Module 3a 2016
Quick clip
 https://www.youtube.com/watch?v=XppEzopIahs
Recap CTG modules 1-2
 Sick notes and benefits
 Calgary Cambridge framework
 Role play - explanation
 Waiting for God – caring for the elderly
• Case scenarios based on EOL care
• Role play – active listening and empathy
Module 3a – 29th November
• Name check and housekeeping.
• Sexual health and sexuality
• Presentation and case discussion
• Coffee
• Case discussion/ role play
• Module 3b
• Case scenarios based on 3a
• Role play – on sexual health/ data gathering.
Closing the Gap 2016
Dr David Anderson
Dr Shazia Akowuah
With thanks to Dr Andy Downs
Aims of 3a
 Improved knowledge of STIs, screening and health
promotion
 Develop skills in sexual history taking in a GP setting
 Improve skills in data gathering, by using cases
involving sexual health.
Video clip
Case scenario
Primary Factors in Taking a Sexual
History
 Ensure privacy and confidentiality
 Establish rapport
 Accurately define the problem(s)
 Ensure successful patient management
 Diagnosis and treat symptomatic disease
 Detect asymptomatic disease
 Prevent serious sequelae, (i.e. infertility in women)
 Promote behavior changes to prevent future infections
Introducing the Sexual History
 Acknowledge personal nature of the subject
matter
 Emphasize confidentiality
 Stress health issues related to sexual behaviors
 Be able to explain how the information will help
you care for the patient
“I’m going to ask some questions about your sexual history.
I know this is very personal information, but it involves important
health issues and everything we discuss is confidential”
Communication Skills to Facilitate
the Sexual History
 Use open-ended questions rather than leading or
“yes/no” questions
 Who, what, when, where?
 “Tell me about…”
 Cone Style of interviewing
 Encourage patients to talk, when needed
 Permission-giving: “Say it in your own words”
 Give range of behaviour (!) and ask for patient’s experience
 Active listening cues to urge patient on
 Eye contact, nodding, “Yes, go ahead”
General Considerations for Taking a
Sexual History 1
 Make no assumptions
 Ask all patient about gender and number of partners
 Ask about specific sexual practices

Vaginal, anal and oral sex
 Be clear
 Avoid medical jargon
 Restate and expand
 Clarify stories when necessary
General Considerations for Taking a
Sexual History 2
 Be tactful and respectful
 Use an unrelated translator whenever possible
 Use accepting, permission-giving language and cues
 Be non-judgmental
 Recognize patient anxiety
 Recognize our own biases
 Avoid value-laden language e.g. (“You should..”, “Why
didn’t you..” “I think you..”)
Sexual History – Content 1
 Chief complaint
 General health history
 Allergies
 Recent medication
 Past STDs
 Women: brief Gynae history
 HIV risk factors (IVDU, partner’s status)
 HIV testing history
Sexual History – Content 2
 Past and current sexual practices
 Gender of partners
 Number of partners
 Most recent sexual exposure
 New sex partners
 Patterns of condom use
 Partner’s condition
 Substance abuse
 Domestic violence issues
Summary: The Five “Ps”
 Past STDs
 Pregnancy history and plans
 Partners
 (Sexual) Practices
 Prevention of STDs/HIV
 There are probably additional questions that you need to
ask appropriate to each patient’s circumstances.
Risk reduction
 If the patient is in a monogamous relationship lasting
more than 12 months, risk reduction counselling may
not be needed.
 However you may need to challenge monogamy,
condom use and perception of risk depending on the
circumstances.
 Remember to reinforce positive behaviour such as risk
reduction, safe sex and contraceptive practice where
appropriate.
STI cases - Ravi
 Aged 22. 4 days of dysuria and no testicular pain.
 Does he have a UTI ?
 Or could it be a STI ?
 What are you going to do
 Increased risk of a STI if under 35, sexually active and recent
partner change. Also MSM and/ or unprotected SI.
Ravi
 Urethral discharge – think chlamydia, gonorrhoea and
NSU.
 Dysuria and discharge. Epididymitis and tender groin
lymph nodes.
 More likely in GC, can be milder or asymptomatic if
chlamydia or another form of non-gonococcal NSU.
 Refer GUM clinic for pre-treatment culture and
partner screening/ treatment
 Gonorrhoea – azithromycin 1 g stat
 Chlamydia - doxycycline 100mg bd
STI cases - Helena
 31 years old lady with recent offensive vaginal
discharge – on the pill after having had 2 children.
 Long term marriage – husband works away a lot.
 Thinks it is thrush again – wanting “cream”
 Is this candidiasis or physiological
 What are the other possibilities ?
Helena
 Physiological discharge is white/ clear and non offensive,
alters with menstrual cycle.
 Candidal infections are common and probably over
diagnosed and over treated. Itch due to overgrowth causing
vulvo- vaginitis – thick, white dx which is non-offensive
and can cause soreness and dysuria/ dyspareunia.
 10-20% women are asymptomatic
 Bacterial vaginosis is more commonly seen in sexually
active women but is not a STI – thin profuse fishy smelling
dx without itch/ soreness.
Helena (2)
 STIs.
 Chlamydia – can cause copious purulent vaginal dx but




asymptomatic in 80% of women
Gonorrhoea – purulent vaginal dx but asymptomatic in
50% of women
Trichomonas vaginalis – offensive yellow dx which is frothy
and often profuse – causing vulval itch and soreness,
dysuria and superficial dyspareunia. Common in young women
Remembering risk of pregnancy.
Refer GUM clinic – screening for above, HIV and syphilis.
STI top tips
 Urethral dx – think STI, especially if under 25 yrs.
 Acute vulval pain – think HSV
 Genital ulcers – think herpes simplex or syphilis
 Arthritis – think chlamydia/ GC
 Viral illness with rash – think primary HIV, especially
MSM.
 Lower abdo pain – exclude ectopic/ appendix. Think PID.
 Swollen painful testes in young man – exclude torsion, then
think STI
 Vaginal dx in young women – think BV if odour, no itch.
 welcome back
 https://www.youtube.co
m/watch?v=mxlZD3oEfs
U&list=PLzmtTg5wGBW
XwezQxPkpYEskce1prAi
VJ&index=56
Role play
 Small groups of 3
 One to act as observer
 Work through the following case(s)
 Feedback as a whole group
Case 1 - Ben
 An 16 yr old man attends. He tells you that he has been
‘passing razor blades’ for the last few days and has a
discharge from the end of his ‘willy’.
 Discuss!
Case 2 - Debbie
 Case – a 25 yr old woman attends. She tells you that
she has had unprotected sex 2 nights ago and would
like the morning after Pill. You recall that you referred
her husband for a vasectomy last year.
Case 3 - Ryan
 A 26 yr old man attends, who has not attended often at
all in the past. The only 2 consultations in the last 5
years were for a wrist injury & a sore throat.
 He tells you that he booked the appointment today as
he has had problems with maintaining an erection
ever since his 1st sexual encounter. He tells you that he
is heterosexual.
 Discuss
Discuss the following cases?
 Or would you like to do more role play?
Case 4 – Nicola
 A 35 yr old woman attends.
 She tells you that she is finding sex very painful for
the last 9 months. She is now finding it difficult to
relax when she has sex, and is avoiding it whenever
possible.
 She tells you that she had pelvic inflammatory disease
some years ago, but that the problem seems to be more
at the opening now.
 Discuss
Case 5 - Chloe
 A 24 yr old woman attends.
 From the notes you can see that she has had 2 TOPs in
the last 3 years. There is a previous history of
chlamydia infection last year. You note from the
records also, that there has been no consultation for
contraception in the last 9 months.
 After the usual introductions, she tells you that she
has come today to request an “abortion”.
 Discuss
GMC guidance 1
Personal Beliefs and Medical Practice core guidance:
 You must make the care of your patient your first
concern
 You must treat your patients with respect, whatever
their life choices and beliefs
 You must not unfairly discriminate against patients by
allowing your personal views to affect adversely your
professional relationship with them or the treatment
you provide or arrange
GMC guidance 2
 If carrying out a particular procedure or giving advice about
it conflicts with your religious or moral beliefs, and this
conflict might affect the treatment or advice you provide,
you must explain this to the patient and tell them they have
the right to see another doctor. You must be satisfied that
the patient has sufficient information to enable them to
exercise that right. If it is not practical for a patient to
arrange to see another doctor, you must ensure that
arrangements are made for another suitably qualified
colleague to take over your role
 You must not express to your patients your personal beliefs,
including political, religious or moral beliefs, in ways that
exploit their vulnerability or that are likely to cause them
distress
Other situations where doctors’
personal beliefs may affect care
 Care of patients pre- and post-termination of
pregnancy. However, in England, Wales and Scotland
the right to refuse to participate in terminations of
pregnancy is protected by law.
 Clothing and other expressions of religious belief or
culture
 Completion of cremation forms
More situations where personal
beliefs should not affect patient
care
 Adult patients who have capacity to make decisions about
their care have the right to refuse any medical treatment
 The GMC’s guidance 0-18 years: Guidance for all doctors
deals with making decisions where the patient is a child or
young person, including issues such as capacity to consent,
parental responsibility and refusal of treatment.
 Female genital mutilation - sometimes referred to as
female circumcision - is a serious crime and a child
protection issue, whether undertaken in the UK or abroad
(see the Female Genital Mutilation (England, Wales and
Northern Ireland) Act 2003 and the Prohibition of Female
Genital Mutilation (Scotland) Act 2005)
The Equality Act 2010
 consolidates the complicated and numerous array of
Acts and Regulations, which formed the basis of antidiscrimination law in Great Britain
 protecting against discrimination in employment on
grounds of religion or belief, sexual orientation or age
 requires equal treatment in access to employment as
well as private and public services, regardless of
characteristics of age, disability, gender reassignment,
marriage and civil partnership, race, religion or belief,
sex, and sexual orientation
Using GMC guidance & the law 1
 Case – a 28yr old man attends. He tells you that he has
been uncomfortable with his sexuality since he was a
teenager, and wants to take the steps to change. He
has researched this & knows of a clinic for transgender
patients to which he would like to be referred.
 Taking into account what we have discussed, how
would you approach this situation?
Using GMC guidance & the law 2
 A 30 yr old woman attends with a friend, who she
explains is her partner. She would like to be referred
for artificial insemination by donor.
 Taking into account what we have discussed, how
would you approach this situation?
Good book for patients and us !
Close
 Any further thoughts?
 Feedback?
CTG modules 4-6 – provisional dates
 Module 4. 7/8 th March
‘A different planet’ - teenagers/adolescents
 Module 4b Sharing management
 Module 5. 28/29th March.
‘Walked into the door’ – Domestic Violence
 Module 5b Dealing with Uncertainty
 Module 6.
9/10th May.
‘They are different to us’. Learning disability and Vulnerable adults.
 Module 6b Medical Ethics