3 The standard clinic process and sexual health in primary care

It is estimated that 1 in 7 adults over the age of 16 in the UK has attended a GUM clinic at least once. Many who attend may not harbour an active sexually transmitted infection (STI) but wish to exclude one. The ‘GUM patient’ does not fit a single stereotype. While it may be more common for young people to attend, a wide age range from <16 to >60 are seen. Their demographic characteristics vary, depending on the risk factors of the local and commuting population and the acceptability and accessibility of GUM services to potential users. Slightly more ♂ than ♀ attend, with sexuality and ethnicity varying geographically. The following groups of people are more likely to attend:

While most patients attending may feel anxious and embarrassed, some are intensely distressed. The psychological responses to STIs or risk of such include severe anxiety, depression, a strong sense of stigma, shame, feelings of guilt, low self-esteem, and anger. Strong negative responses such as these may hamper communication and lead to apparently irrational behaviour. It is necessary to understand and appraise the emotional state of the patient when providing optimum care. If a patient is aggressive, the priority should be safety while attempting to de-escalate the situation.

( Chapter 5, Children p. 108)

Adolescents <16 years attending GUM have a high incidence of STIs and report a low use of reliable contraception. Some may also have suffered sexual abuse.

( Sexual assault: general principles p. 102)

May attend for sexual health screen and STI risk assessment and due consideration should be given to any post-traumatic stress that may dominate the patient’s mood and emotions.

The following risk factors have been noted in various epidemiological studies. They are likely to vary over time and across different geographic regions but are useful in planning local service provision and targeting specific sexual health promotion. Clinically they are useful in risk assessment.

Certain types of physical contact carry higher risks for certain infections, e.g. penetrative sex and HIV, orogenital contact and anogenital herpes.

Knowledge of the wide range of sexual practices and the vocabulary in use is of value in advising those at risk of STIs.

Arousal from kissing (basoexia), manual genital stimulation (mutual masturbation and heavy petting), body rubbing (frottage and ‘dry rooting’), rubbing buttocks (pygotripsis), feet (podophilia), kneading flesh (sarmassophilia); tickling (titillagnia), lap dancing (squatting above a sitting person and non-genital rubbing).

Penile positioning into the axilla (axillism), between breasts (coitus a mammilla and mazophallate), between legs (coitus interfermoris), between knees (genuphallation).

Examples: caning/flagellation (using cane/whip), bondage/strangulation (physical restraint/constriction), electrophilia (arousal from electricity), meatotomy (urethral dilation).

Bestiality, zoophilia. Specific examples include cynophilia (dogs), entomophilia (insects), ophidiophilia (snakes), felching (inserting animals into vagina or anus).

Taking a sexual history and discussing sexual health issues are vital elements of the consultation, eliciting essential information on the STI risk. It must be non-judgemental and empathic, thereby promoting effective patient participation. When taking a sexual history:

Pro formas ensure a systematic approach to history-taking (Algorithm 3.1). Asking when last sexual intercourse took place is a useful way to start the sexual history (details of sexual partners, contraception, and sexual risks). Presence of a third person, especially sexual partner, may inhibit this. Types of sexual practices reported can help in planning which specimens to obtain. Obtain any information patient has on the nature of sexual partner’s infection(s). Where mother-to-child transmission is relevant enquire about clinical presentations in the children.

Conducting the consultation through an interpreter or when cross-cultural issues are relevant may be difficult. It is preferable to use an unrelated interpreter but sometimes this may not be possible.

Prior to the examination the patient should be given an explanation and his/her agreement obtained. Certain procedures require written consent (e.g. local anaesthesia, minor surgery, and clinical photography).

The examination room should be warm and comfortable with a screened area allowing privacy while the patient undresses. An examination couch with good lighting is required (with stirrups/leg rests for ♀ to allow examination in the semi-lithotomy position).

The patient should undress below the waist and be provided with drapes or gowns. Irrespective of the gender of the patient or the examiner, a chaperone must be offered ( GMC Guidance 2001, p. 25), who may also be able to assist in the collection of specimens and reassure the nervous patient. The acceptance or refusal of a chaperone should be documented in the patient’s notes. Chaperones should sign to confirm their attendance during the examination. Although the GMC suggests that a patient’s friend or relative could act as a sole chaperone, this is not advised in GUM as it may compromise confidentiality and the provision of relevant information to the healthcare professional (HCP).

The examination trolley should be set up prior to the examination. Specula should be pre-warmed in water, which also acts as a vaginal lubricant. Lubricating gels should be avoided whenever possible as they may inhibit the growth of Neisseria gonorrhoeae. The use of lubricants cannot be avoided for proctoscopy, but care should be taken to ensure that swabs are not contaminated. During examination the patient should be kept informed of progress, but unnecessary or facetious comments must be avoided. Convenient facilities should be available to obtain urine specimens.

A venous blood sample for syphilis and HIV should be taken with consent from patients at risk of an STI. Because of the sensitivity arising from HIV testing and the implications of a positive result, additional discussion may be required to ensure fully informed consent ( HIV pre-test discussion p. 436). Testing for hepatitis B and C virus may also be required.

Skin rashes/lesions, generalized lymphadenopathy, hair loss, jaundice, mucosal lesions (orogenital), conjunctivitis/uveitis, and arthritis may arise from STIs, and genital problems may be features of dermatological or systemic diseases.

In those at risk, especially MSM, proctoscopy and screening for N.gonorrhoeae and C.trachomatis (if NAAT is available) should be offered, remembering that infection may occur without penile penetration. The anal canal and distal 5cm of the rectum should be examined with a proctoscope to check for pus (which can be sampled and prepared as a Gram-stained smear) and other lesions (e.g. warts). This also minimizes faecal contamination when taking swabs. Lubricants should be used with care around the anal sphincter to avoid rectal contamination as they may impair the isolation of N.gonorrhoeae.

Rectal testing for N.gonorrhoeae should also be offered to ♀ at risk (e.g. with symptoms, urogenital gonorrhoea, contacts of gonorrhoea, and following sexual assault). Chlamydia screening may also be considered.

Swabs for N.gonorrhoeae should be offered to those at risk especially if symptomatic, gonorrhea found at other site(s), contacts of gonorrhoea, MSM, and those sexually assaulted.

At the end of the consultation the patient will require further advice and information on their condition or situation, its management, and the need, when relevant, for further follow-up which may include repeat or additional tests. It is important to make these recommendations clear and explicit with the provision of written information.

Ideally medication should be dispensed, free of charge, to the patient while he/she is in the clinic.

Treatment of STIs excluding HIV/AIDS (but including initial diagnosis of and counselling support for HIV) is free without any prescription charge to all attendees at GUM clinics irrespective of their nationality. HIV/AIDS management after the initial diagnosis and counselling is subject to the standard regulations concerning entitlement to NHS hospital treatment ( Asylum seekers and refugees p. 36).

Primary Care Trusts (PCTs) have principle responsibility for:

Sexual health services are divided into levels as outlined in the National Strategy for Sexual Health and HIV (Box 3.1).

If a primary care practice is unable to provide Level 1 service it should be made clear in the practice information and explicit arrangements made for their patients through other practices or community services. PCTs should identify and support primary care teams with special interests in sexual health which can provide locally enhanced services to a high standard. GPs and nurses need to undertake specific training to develop and maintain skills required. These services can be offered to unregistered patients or those registered with other practices. PCTs should develop provision of a full range of Level 2 services (Box 3.2) in collaboration with GUM and Community Family Planning to meet local needs and fill gaps in existing service provision.

For extensive testing refer to local GUM service and contact local laboratories regarding test methods and arrangements.

Test patients at high risk (under-25s and new partner in preceding 12 months).

If local prevalence exceeds 2 in 1000 (local PCT data) all men and women registering with a general practice should be offered an HIV test. Otherwise a risk assessment should be performed ( Chapter 38, p. 436). Positive test: refer to GUM.

Consider sexual and contact history. If positive syphilis serology, refer to GUM. If positive hepatitis B serology, refer to gastroenterology. If patient at risk of hepatitis B administer hepatitis B vaccination ( Chapter 24, p. 296).