Women’s Sexual Health- History Taking and Risk assessment Dr Mo Kawsar Consultant GUM 27th Feb 2018

Objectives Approach to taking a sexual health history Phrases you might use to explore the sexual history What challenges you might face in avoiding assumptions Making an appropriate risk assessment Determine if there are issues she feels unable to discuss Apply knowledge to investigation and treatment Determine safely if she is at immediate risk of harm

Principles of Sexual History taking Confidentiality Components Risk assessment

Confidentiality General Medical Confidentiality All NHS employees are expected to adhere to Caldicott Principles Guidance from the General Medical Council and Nursing & Midwifery Council General health confidentiality in the UK is a common law duty The duty of confidentiality to the patient is absolute except in very specific circumstances, such as when it is in the patient’s or public’s interest

Sexual health clinic &confidentiality The NHS Code of Confidentiality applies to services managing STIs in England and Wales, with an additional duty of enforcement of confidentiality required by the NHS Trusts (Sexually Transmitted Diseases) Directions 2000 This means that services managing STIs must operate systems for clinical record management that does not allow disclosure Identifying information is not shared except for the purpose of treatment of STIs or for the purpose of prevention of infection

Environment for sexual history-taking welcoming, comfortable, confidential physical environment is likely to encourage openness and candour when discussing sensitive issues, such as sexual behaviour Non-judgemental way Consultations should take place in private settings & in a soundproof room Requests for clinician gender on the basis of culture, religion or personal preference should be accommodated where possible

BASHH recommendations Confidentiality policy should be displayed in the waiting area or otherwise made available to patients All patients should be offered a chaperone for any intimate examination in accordance with GMC guidance All patients should be offered a clinician of their preferred gender where possible The utmost care should be taken to preserve the confidentiality of patients and their sexual contacts during the consultation

Components of a sexual history A careful assessment of symptoms to guide the examination and testing An exposure history to identify which sites need to be sampled and the STIs to which the patient may be at risk An assessment of contraception use and risk of pregnancy . Assessment of other sexual health issues including psychosexual problems Assessing HIV, hepatitis B and C risk for both testing and prevention Assessment of risk behaviours, which will then facilitate health promotion activity including partner notification (PN) https://www.bashhguidelines.org/media/1078/sexual-history-taking-guideline-2013

Minimum sexual history Symptoms/reason for attendance Date of LSC, partner’s gender, anatomic sites of exposure Condom use and any suspected infection, infection risk or symptoms in this partner Previous sexual partner details, as for LSC, if in the last three months Total number of partners in last three months if more than two Previous STIs Last menstrual period (LMP) and menstrual pattern, contraceptive and cervical cytology history Pregnancy and gynaecological history Past medical and surgical history Medication history and history of drug allergies Agree the method of giving results Establish competency, safeguarding children/vulnerable adults Asymptomatic patients Confirm lack of symptoms Date of LSC and number of partners in the last three months Gender of partner(s), anatomic sites of exposure, condom Use and any suspected infection, infection risk or symptoms in partners Previous STIs last menstrual period (LMP), contraceptive and cervical cytology history Agree the method of giving results Establish competency, safeguarding children/vulnerable adults

Sexual history-cont. Last sexual contact/intercourse (LSC/LSI): The gender of partner(s)- to identify same sex partner The type of sexual contact/sites of exposure (oral, vaginal, anal)-for sampling Condom use/barrier use- condom promotion/risk assessment The relationship with the partner (live-in, regular, casual partner, etc.), duration of the relationship and whether the partner could be contacted- facilitate PN The time interval since the LSI- window periods, PEP,EOC Any symptoms or risk factors in the partner- identify STI in partner Previous sexual contact/inter course (PSI) last three months as a minimum Blood-borne virus risk assessment and vaccination history for those at risk Recommend/consider Recognition of gender-based violence/intimate partner violence(IPV) women may be asked whether they have ever exchanged money in return for sex Alcohol , smoking and recreational/ chem sex drug history HPV vaccination for women after 1995

Risk assessment for blood-borne viruses Current or past history of history of injecting drug misuse; sharing of needles, syringes or other drug preparation Discussion of injecting drug misuse in sexual partners Sex with a partner from or in a country with a high HIV, hepatitis B or Hepatitis C prevalence (NICE guidance) HIV testing history Hepatitis B risk and Hepatitis B vaccination history

Risk assessment in Children & Adolescents <18 yrs Fraser competency/Guidelines for under 16s The young person understands the health professional’s advice. The young person is aware that the health professional cannot inform her parents that she is seeking sexual health advice without consent, nor persuade the young person to inform her parents The young person is very likely to begin having, or continue to have, intercourse with or without contraceptive/sexual health treatment. Unless she receives contraceptive advice or treatment the young person’s physical or mental health, or both, are likely to suffer The young person’s best interests require the health professional to give contraceptive advice, treatment, or both without parental consent Child Sexual exploitation (CSE) risk assessment Spotting the signs- BASHH/Brook preformat https://www.brook.org.uk/attachments/Spotting-the-signs-CSE-a_national_proforma_April_2014_online.pdf

CSE proforma

Professional analysis of CSE risk Is there evidence of any of these within their relationship? Coercion Overt aggression (physical or verbal) Suspicion of sexual exploitation/grooming Sexual abuse Power imbalance Other vulnerabilities If you have identified risks or concerns please discuss with your CSE or Safeguarding Lead and follow your own child protection policy and procedure

Summary Sexual history is fundamentally important to assess the sexual health of women Detailed risk assessment is need for vulnerable females