1. Taking a sexual history Dr Kate Armitage June 2016 SHA conference, Leeds

2. Biography GP at Leeds Student Medical Practice since 2008-Partner since November 2014 Staff grade in GUM before becoming a GP in 2007 Honorary Secretary, Faculty of Sexual and Reproductive Health since June 2015

3. Disclosure of interests Bayer since 2010 Investigator sponsor study/speaker fees/attending conferences MSD since 2010 Investigator sponsor study/speaker fees Pfizer 2013 Speaker fees Hon Sec role at FSRH in education and training

4. And you?.... Who in the room is a GP? Nurse? Any other staff group?

5. Some sobering thoughts… Sexual health of the UK population is in decline UK has highest teen pregnancy rate in Western Europe TOP rates have increased over recent years Anecdotal evidence that many women not offered a range of contraceptive options especially LARC

6. And there is more… Rates of STIs are increasing Burden in under 25s, urban areas

7. HIV in the UK-situation report 2015 2015 approx 103,000 people living with HIV 1.9 per 1000 adults ( over 15) Approx 18,100 of these unaware of status (17%) Men who have sex with men (MSM) age 15-44: 1 in 20 living with HIV 2014: 69% of eligible GUM attendees tested for HIV Document advocates ‘ask your GP for a HIV test’ Home testing for HIV www.freetesting.hiv

8. NatSAL National survey of sexual attitudes and lifestyles 1990 2000 2010

9. NatSAL-1 2000-over 11,000 respondents 16-24 yr olds had highest rates of new partners 1/3 rd men and 1/10 th women had at least 10 lifetime partners 4.3% men have paid for sex 5.4% men and 4.9% women had same sex contacts

10. NatSAL-1 and -2 Comparing 2000 to 1990 figures Earlier age of first sexual intercourse Increased number of lifetime partners Decline in marriage, growth in cohabitation Increased partner change Decreased condom use

11. NatSAL-3 2010

12. Taking a sexual history

13. Sexual health care Includes Risk assessment Prevention, diagnosis and treatment of STIs Contraception Management of unplanned pregnancy

14. Barriers to delivery of sexual health care in general practice ? Time Other priorities Confidence Knowledge and skills Technical issues ( access to tests/labs etc) Confidentiality/anonymity Partner notification Conflict between public health and that of individual

15. Remember… Most STIs are asymptomatic Risk assessment is the key to management History taking is the key to risk management

16. So-before you start.. Consider Physical environment Privacy Confidentiality

17. Communication Clinic literature- advertising the need for sexual history taking-this may improve acceptability Communication skills of clinician including attitudes and beliefs-use non judgemental inclusive language Communication issues for patient such as access to interpreters

18. What do you think is the most difficult question to ask/subject to raise during sexual history taking? A moment to give it some thought and write it on a post it note. You can discuss with your neighbour if you wish!

19. Components of a sexual history Symptoms-to guide examination and tests Exposure history Contraception use/pregnancy risk Other sexual health issues ( including psychosexual issues) HIV/ HepB/HepC risk assessment for testing and prevention Assessment of risk behaviours, leading to partner notification and sexual health promotion

20. Reason for attendance Symptoms No symptoms-why today? Contact? Response to media article? Etc etc

21. Symptoms Women Change to discharge Change to bleeding Dysuria Abdominal pain Pain with sex Genital skin problems Men Urethral discharge Dysuria Testicular pain Genital skin problems Perianal/anal symptoms

22. Core component of sexual history Last sexual intercourse (LSI) Partner gender/sites of exposure*/condom use Previous sexual partner (PSP) as for LSI Women: LMP/contraception/cytology HIV risk history Hep B and C risk assessment Any child protection concerns? Access to results * most practitioners worry about asking this

23. How to ask…. May use ‘warning shot’ ‘I am going to ask you some personal questions, these are all for a reason, and they are all confidential-is that ok with you?’ Don’t apologise…

24. How to ask….. ‘when did you last have sex/sexual contact?’ ‘was that with a regular or a one-off partner?’ ‘ was it someone you know or didn’t know?’ ‘was that a male or female partner?’ What kind of sex was it? Was it vaginal/oral/anal sex’ ‘Did you use condoms? Do you use condoms always, sometimes or never?’ ‘does that person have any symptoms?’

25. How to ask… ‘When was the last time you had sex with somebody different?’ ……as for last sexual intercourse

26. How not to ask.. No closed questions to start ‘Are you married?’ ‘Are you in a stable relationship?’ ‘Are you sexually active?’ ‘are you homosexual?’ Want questions that are precise and useful without being blunt, that are understood by both patient and clinician

27. Sexual history Should include all partners within past three months as rough guide ‘How many sexual partners have you had in the past three months?’ If not already established with male patients, ‘have you ever had sex with another man?’

28. Also relevant.. Past history of STIs including details of treatment and compliance/follow up Past medical and surgical history Drug history/allergies Contraceptive and reproductive health history Asking men what contraception their female partner is using?

29. HIV risk assessment Current/past use of injecting drugs, personal history or that of partners SI with anyone from abroad SI with men/bisexual partner Medical treatment abroad SI with HIV positive partner Sex work History of HIV testing

30. HIV risk assessment ‘Have you ever injected drugs? Or had sex with anyone who injected drugs?’ ‘Have you had sex with someone born outside the UK?’ (Country/dates) ‘Have you had any operations or blood transfusions abroad?’ ‘Have you ever had sex with another man?’ ‘Have you had sex with a man who had sex with men?’

31. HIV risk assessment (2) ‘have you had sex with anyone you knew to have HIV?’ ‘Have you ever paid for sex, or been paid for sex?’ If the answer is yes to any of the above, they are in a higher risk group ‘Have you ever had a test for HIV? When/where/what was result?’

32. HIV testing discussion Compare your objective risk assessment as clinician with subjective risk assessment of patient Further discussion if patient is high risk Discussion may also occur if mismatch in risk assessments

33. HIV testing discussion What do you think the result will be?’ ‘Have you given any thought to how you may feel if the result is positive?’ ‘Who will you tell/what support have you got if the result is positive?’ Discuss what would happen in event of positive result-repeat testing/HIV care under GUM Arranging to give result -in person if high risk

34. Blood borne viruses (BBV) Hepatitis B and C Risk assessment broadly similar to HIV In high risk groups- Consider Hep B vaccination history +/- starting vax course Consider Hep B and C testing

35. Other risks Alcohol and drugs Useful to ask as can give idea of patients approach to risk taking behaviour, or whether they are taking risks with sex when under the influence Though can be distractors from focus when taking sexual history, taking time to discuss but may not influence management on this occasion ( revisit at later consults)

36. Other risks Mental health issues Mania Disinhibition Hypersexuality

37. Access to results Important to clarify with patient at time of testing In person? Phone message for patient note? Phone call with clinician? Many different approaches taken in GUM services, for example Text ‘No news is good news’? What do you think of this approach?

38. To recap……. Components of a sexual history Symptoms-to guide examination and tests Exposure history Contraception use/pregnancy risk Other sexual health issues ( including psychosexual issues) HIV/ HepB/HepC risk assessment for testing and prevention Assessment of risk behaviours, leading to partner notification and sexual health promotion

39. Child protection issues Under 16s Some laws relevant to under 18s such as grooming/exploitation and sex work Assessing competency to consent to history taking and examination, documenting this Fraser guidelines

40. Child protection issues Relevant to establish & document include Age of partner/s Age at sexual debut Parents/carer awareness of sexual activity Parents/carer awareness of clinic attendance Coercion Transactional sex Educational venue/attendance Vulnerability

41. Child protection issues Discuss with colleagues Child protection training Local child protection leads/named GP and nurse

42. After taking a history Access to results (see previous slide) Explaining examination, investigation and management Documentation of history (proformas/templates?)

43. Follow up Sexual histories are dynamic and can change within days Low threshold for retaking history and re- examining

44. Scenarios 4 to consider Spend a minute thinking what you would ask this patient/discuss with your neighbour before I reveal the relevant details

45. Scenario 1 Amit Age 22 Pain passing urine What do you ask?

46. Would you have established that.. Amit was born in India, been in the UK 4 months He has had pain passing urine for 2 weeks He has regular female partner of 4 years ( his wife) and does not use condoms He has never had any other lifetime partners

47. Scenario 2 Amit Age 22 Pain passing urine What do you ask?

48. Would you have established that.. Amit was born in Bradford Amit has had pain passing urine for 7 days He last had sex a week ago with his regular female partner of 7 months, intermittent condom use for VI, no OI He last had sex with someone different on holiday in Tenerife a month ago, she was from UK, no condoms used

49. Scenario 3 Amit Age 22 Pain passing urine What do you ask?

50. Would you have established that.. Amit is from Kenya, studying in the UK He has had pain passing urine for 7 days He has been in the UK for 6 months His last sexual contact was when he paid for oral sex 2 weeks ago in London

51. Scenario 4 Amit Age 22 Pain passing urine What do you ask?

52. Would you have established that.. Amit is a first generation Ghanaian Indian, who has been in the UK since October 2010 He has had pain passing urine for the past 7 days He has had 10 male partners in the past three months, he has had anal sex without condoms He last had sex with a woman 4 months ago

53. Key points Risk assessment is the key to management History taking is the key to risk assessment Don’t apologise for asking Don’t make assumptions

54. Role play If we have time!

55. Role play Tim Age 24 Registered today Jane Age 20 Registered today

56. Role play Tim age 24 Dysuria 5 days Some testicular pain One off SI with FP on holiday in Ibiza 2 FP on holiday-5 partners in 3 months No condoms, drinks 30 units a week No SI with men Concerned is ‘thrush’, never had any tests Low risk for HIV on questioning

57. Role play Jane age 20 Vaginal discharge 2 wks, not itchy Small sore on vulva today, painful Last SI 3wk ago with reg MP one year Previous SI 4 wk ago with one off MP Implant one year, no condoms Never had STI testing Low risk for HIV on direct questioning

58. Further reading http://www.bashh.org/documents/Sexual% 20History%20Taking%20guideline%20201 3.pdfhttp://www.bashh.org/documents/Sexual% 20History%20Taking%20guideline%20201 3.pdf 2013 UK national guideline for consultations requiring sexual history taking BASHH-British Association for Sexual Health and HIV

59. Further training in Sexual and Reproductive Health RCGP Introductory Certificate in Sexual Health http://www.rcgp.org.uk/substance_misuse/sex__drugs_and_hiv_group/i ntro_cert_in_sexual_health.aspxhttp://www.rcgp.org.uk/substance_misuse/sex__drugs_and_hiv_group/i ntro_cert_in_sexual_health.aspx FSRH- Diploma/DFSRH New course-SRH essentials for Practice Nurses BASHH- STIF training ‘Core’ and ‘plus’ course Clinical competencies assessments

60. Thank you Any questions? Catherine.armitage@nhs.net