Sexual health and gender diversity

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Sexual health is important for patients of all ages, not just those in their reproductive years. Sexual health is defined as a person’s physical, emotional, mental and social wellbeing in relation to sexuality. It is not merely the absence of disease, dysfunction or infirmity.1

Sexuality encompasses a person’s birth sex, gender, sexual orientation, eroticism, pleasure, intimacy and reproduction.1 While the majority of Australians identify as heterosexual and according to their birth sex, 3.6% of adult males and 3.4% of adult females in Australia identify as lesbian, gay, bisexual, pansexual, asexual or queer.2 Research into the  adolescent population found that 2.3% of Australian senior school students identified as being transgender or gender diverse.3 Limitations exist on the data collected about Australia’s gender and sexually diverse populations.2 Additionally, further research is required for a more complete understanding of an individual’s experience, and the breadth of that experience, of gender, relationships, sexualities and lived experience.4

Sexuality is influenced by many factors, including a person’s culture, religion or spirituality, social, economic and psychological state.1 General practitioners (GPs) therefore need to take a holistic approach to all sexual health presentations and consider:5

  • a person’s sexuality and gender
  • attitudes of a person’s peers and society on sexuality and gender
  • circumstances of the sexual relationships the person may be involved in.

GPs need to be comfortable discussing sex with a wide range of people including those of different ages, genders (eg male, female, transgender, intersex, Sistergirl and Brotherboy), sexualities, Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse people and people with disabilities. It is important to understand the intersectionality of overlapping forms of discrimination and marginalisation for individuals, particularly regarding ethnicity, gender and sexual orientation. Self-reflection and awareness by the GP on their attitude to sexual health, sexuality and gender diversity is vital. The avoidance of assumptions about a person’s sexuality or gender and using gender neutral language (eg ‘partner’ instead of ‘wife’, ’boyfriend’) is paramount in these conversations.6

Some of the more common sexual health presentations in general practice include sexually transmissible infections (STIs), blood-borne viruses (BBVs), pregnancy and patients wanting to prevent unwanted pregnancy through contraception.1,5 Taking a non-judgemental sexual history and identifying individuals at risk of STIs and blood-borne viruses is an important part of general practice. It is also vital for GPs to promote sexual safety and wellbeing through an understanding of the intricacies of sexual consent, safe sex practices and regular testing, particularly for young people and other individuals at increased risk of STIs and BBVs. It is essential for GPs to be well versed in their legislative and public health requirements, particularly regarding notifiable diseases, contact tracing, patient-delivered partner therapy guidelines and mandatory reporting of suspicions of child abuse.

GPs need to be proactive in sensitively raising sexual and reproductive health issues with patients, including:

  • consensual sex and age of consent
  • sexual assault and intimate partner violence
  •  prevention, screening and management of STIs and BBVs
  • prevention and management of unwanted pregnancy (including contraception options for males, females and gender diverse patients, and appropriate counselling and referral for unwanted pregnancies).

GPs have a significant role to play in respecting and acknowledging those who are transgender and/or non-binary through the use of correct names and pronouns and providing gender-affirming healthcare. They also need to understand the barriers to patients in accessing contraception and sexual health services and advocate for inclusive and individually-appropriate healthcare to reduce social and health inequalities experienced by gender-diverse patients, Aboriginal and Torres Strait Islander peoples, patients from diverse cultural, linguistic and religious backgrounds, as well as those who live in rural and remote areas.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • communicate about sexuality and sexual health in a manner that is respectful and responsive to the person’s beliefs, sexuality, gender and culture
1.1.1, 1.1.6, 1.3.1, 1.4.1, AH1.3.1
  • explain why questions including those related to birth sex, gender and sexual orientation are important, and ask questions without bias or judgement
1.1.1, 1.3.1, 1.4.1, 1.4.5, AH1.3.1, AH1.4.1
  • provide patient education about pregnancy prevention, safe sex and consent
1.2.2, 1.2.3, 1.3.2
  • sensitively ask about sexual abuse, including intimate partner violence and child abuse
1.1.2, 1.4.4
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate a respectful and individually appropriate approach to taking a sexual health history
2.1.1
  • perform a physical examination in a respectful manner, checking for understanding and seeking consent prior to examination
2.1.2, 2.1.5
  • undertake relevant procedures for investigating and managing sexual health conditions, including collecting specimens for STI testing and providing contraception
2.1.5, 2.1.6, AH2.1.2
  • diagnose and manage conditions related to sexual health
2.1.6, 2.1.7, 2.1.8, 2.1.9, AH2.1.2
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify and screen patients at increased risk of STI, for example, chlamydia in young people
3.1.1, 3.1.3
  • explain and address the potential impacts of marginalisation, stigmatisation and discrimination on the health of sexually and gender diverse individuals and their access to healthcare
3.2.1, 3.2.2, 3.2.3, 3.2.4, AH3.2.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • reflect on and actively seek to address biases, judgements, assumptions and attitudes regarding sexuality and gender
4.2.2, 4.2.4, AH4.2.2
 
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • maintain patient confidentiality and identify the situations when confidentiality may need to be breached, for example, sexual abuse
5.2.1
  • obtain and document informed consent when performing sexual health investigations
5.2.2
  • implement anti-discrimination practice policies and procedures that promote the health and safety of sexually and gender-diverse individuals
5.2.5
  • arrange for contact tracing and notification of infectious diseases
5.2.3

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Patients presenting to general practice can be diverse in terms of gender and sexual orientation. Using a non-judgemental and gender-affirming approach will help establish rapport and develop trust.
  2. Be open and respectful and ask the questions you need to deliver appropriate care. Do not let your own beliefs, views and biases impact the care you provide to the patient.
  3. Sexual healthcare requires effective history-taking, examination and use and follow-up of appropriate investigations. It is rewarding and makes a difference in the lives of individual patients and in public health outcomes.
  4. Opportunistic sexual health screening can be performed at appointments for contraception, fertility and pregnancy, cervical cancer screening and acute presentations.
  5. Unwanted pregnancies cause significant stress to individuals and the health system. Educating patients about pregnancy prevention and providing suitable and safe contraception is empowering and rewarding.
  6. GPs and practices need to have effective systems to manage abnormal results, notifiable conditions, referral to specialised sexual health services and to recall patients.
  7. Evidence-based guidelines for sexually transmissible infectious and blood-borne viruses, pre-exposure prophylaxis (PrEP) of HIV, post-exposure prophylaxis (PEP) of HIV, and gender affirming healthcare are available and should be used by GPs.
  8. Having an approach to sexual healthcare that is patient-centred and gender affirming allows a GP to tailor their care to individual patients, helps to establish rapport and a trusting therapeutic alliance, and increases patient adherence to healthcare advice and treatment.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Sexual health and gender diversity

Alix, 38, is a transgender female who you have not met before but who has been attending the practice for the past 12 months. She had been under the care of a previous GP registrar before you commenced at the practice. She presents today for a sexual health check.

Questions for you to consider Clinical exam assessment area Domains

What communication strategies would you use to provide a safe environment for transgender and gender diverse patients?

What communication strategies would you use to sensitively take a thorough sexual health history?

How would you approach this consultation if Alix was an Aboriginal or Torres Strait Islander?

What if she was from a different cultural or language group to your own?

  1. Communication and consultation skills
1,2,5

What information would you like from Alix to determine her risk of sexually transmissible infections (STIs) and blood-borne viruses?

If Alix has female partners, what investigations would you order for asymptomatic screening? What if she has male partners?

Would you consider different investigations if either Alix or her sexual partner(s) were Aboriginal or Torres Strait Islander?

  1. Clinical information gathering and interpretation
2   

What diagnoses would you consider if Alix has symptoms such as anogenital ulcers or neovaginal discharge?

How would you determine whether Alix should be offered either pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) for HIV prevention?  

How would you determine if Alix is suitable for on-demand PrEP or continuous PrEP?

  1. Making a diagnosis, decision making and reasoning
2

When would you review Alix to follow up her results?

How would you explain PrEP to Alix: how it works, how to take it, potential side effects and risks and the ongoing monitoring needed?

How would you manage a positive STI result in one of your patients? What about a positive HIV result?

If you diagnose Alix with gonorrhoea, how do you approach contact tracing? What advice would you give her about abstaining from intercourse? When would you review to check for resolution of symptoms and when would you arrange proof of cure testing?

  1. Clinical management and therapeutic reasoning
2   

What vaccinations would you discuss with Alix?

What are the potential barriers for patients with symptoms of an STI seeing a GP or notifying partners of a positive STI result? What additional barriers are there in rural and remote areas?

  1. Preventive and population health 
1,2,3

How can you advocate for appropriate sexual care for your patients? What about for specific patient groups such as adolescents, LGBTIQ+ or Aboriginal and Torres Strait Islander patients?

What if a patient with a positive HIV result would not notify their partner of the result?

How would you manage a positive HIV test result in one of your patients when you look after the patient and their partner?

  1. Professionalism
4   

How can you advocate for appropriate sexual care for your patients? What about for specific patient groups such as adolescents, LGBTIQ+ or Aboriginal and Torres Strait Islander patients?

What if a patient with a positive HIV result would not notify their partner of the result?

How would you manage a positive HIV test result in one of your patients when you look after the patient and their partner?

  1. General practice systems and regulatory requirement
5   

How would you collect samples for STI screening for Alix if she has receptive anal, oral and neovaginal intercourse?

How would this differ for a cisgender female patient having penetrative vaginal sex with male partners?

How would you explain to Alix how to self-collect samples for screening of STIs?

  1. Procedural skills
2   

How would you get extra support and advice to help you manage a patient at high risk of HIV?

What would you do if a patient’s proof of cure testing for ano-rectal gonorrhoea was positive for gonorrhoea?

  1. Managing uncertainty
2   

How would you identify, investigate and manage acute HIV infection?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify five patients at your practice who have had sexual health screening. Audit the notes checking for documentation of:

    1. patient’s sex at birth, gender identity and sexual orientation
    2. sexual and reproductive history, examination findings and investigations ordered
    3. any opportunistic health promotion
    4. if applicable, any management and follow-up, including use of practice software recall system.
  • What were your findings? How could things be improved?
  • Where would you find patient information about sexually transmitted infections (STIs) or blood-borne viruses (BBVs)?
  • What about patient information that is culturally appropriate for: a) Aboriginal or Torres Strait Islander patients or b) patients from a culturally and linguistically diverse background?
  • Where can you find information about notifiable conditions in your state or territory?
  • What guidelines are available to help with contact tracing? What are the ethical and legal implications to consider when a patient with a positive STI or BBV result refuses to notify their partner/s? Who could you ask for advice in this situation?

Identify five patients from your practice who have presented for commencement of contraception for pregnancy prevention. Audit the notes checking for documentation of:

    1. patient’s sex at birth, gender identity and sexual orientation
    2. sexual and reproductive history, any relevant physical examination and urine pregnancy test results and investigations
    3. discussion about contraceptive options, method of action, effectiveness, side effects and risks and contraindications
    4. opportunistic health screening or health promotion
    5. if a contraception was prescribed, documentation of patient education about the contraception.
  • What were your findings? What could be improved? Were you aware of all the contraceptive methods documented in the notes? Are there any contraceptive options that were not documented in the notes you audited?
  • Do you know the indications, contraindications and how to safely prescribe each contraceptive option?
  • Where would you find information about contraception options (including male contraception) – indications, contraindications, and how to safely prescribe? Can you create a table of contraception options, including category, effectiveness/failure rate, side effects, risks, contraindications, special indications, limitations including costs and need for procedure?
  • What is your approach to discussing and prescribing contraception for mature minors? Would this be different if you were looking after a young person in out-of-home care?
  • What health screening and health promotion could you consider discussing at a contraception consultation?
With a supervisor

Make a learning plan specific to your learning needs for this unit. Set achievable goals and timeframes and think about how you can meet these goals. Discuss your learning plan with your supervisor. Arrange to follow up on your learning.

  • What are your learning goals in relation to sexual health and gender diversity? Over what time would you like to achieve your goals? Consider skills in: a) communication, b) taking a history and doing a physical examination and c) practical activities such as collecting samples for STI screening, giving a contraceptive injection, or inserting or removing a contraceptive implant or intrauterine device.
  • What does your supervisor think are the important areas to focus on? Can they suggest opportunities at your practice to develop skills in this unit?

With your supervisor, discuss your practice’s approach to:

    1. recording a patient’s sex at birth, gender, preferred name and pronoun
    2. being inclusive of LGBTIQ+ patients, including transgender and gender diverse patients
    3. addressing potential barriers to patients attending the clinic for sexual healthcare
    4. mature minors and prescribing contraception
    5. child safety concerns related to sexual health
    6. managing abnormal results, including urgent results
    7. notifiable conditions
    8. contact tracing for STIs and BBVs
    9. patient reminders and recalls.
  • What areas is your practice doing well in? What could be improved?
  • What is the age of consent in your state or territory? What are the laws regarding young people consenting to treatment, including contraception?
  • What policies or procedures does your practice have in relation to sexual healthcare?
In a small group

With a colleague, rehearse asking a patient about: a) their gender identity and sexual orientation, b) their current risk of STIs and BBVs and their approach to preventing these and c) their current risk of pregnancy and how they prevent pregnancy, if applicable.

  • Give each other feedback. What was effective? What could be improved?

Rehearse giving instructions to a patient about self-collecting samples for STI screening. Find a patient information resource to help the patient.

  • Give each other feedback. What was effective? What could be improved?
  • Did you find a useful patient information resource? What was it? Were there resources suitable for people whose first language is not English?

Role-play a consultation with a male patient who has sex with males who has presented for a sexual health check-up. With your peers, discuss:

    1. approach to being non-judgemental
    2. approach to taking a comprehensive sexual health history
    3. addressing the patient’s ideas, concerns and expectations
    4. explaining any necessary investigations, giving the patient information about how to collect samples for STI screening and following up results
    5. giving the patient information about STI and BBV prevention and checking patient understanding
    6. giving the patient information about STIs and BBVs.
  • Which communication strategies were effective? Which health promotion strategies were effective? Which patient education strategies were effective?
  • When would you arrange post-exposure prophylaxis (PEP) for a patient? When would you prescribe pre-exposure prophylaxis (PrEP) for a patient? What investigations would you need to do before prescribing?
  • How would you explain to a patient how to take PrEP? What would be your approach to increasing patient adherence with PrEP? How often would you review a patient who was using PREP?
With a friend or family member

Ask friends or family members what they know about STIs. Try to ask people of different ages, cultural backgrounds and genders. Which ones have they heard of? How do they think they are transmitted? Who do they think is at risk?

  • Has this activity changed how you will educate patients about STIs?
  • What non-jargon language would you use when talking to patients about STIs to help them understand?

Ask a friend or family member to share a negative experience of seeing a GP for a sexual health check or to discuss pregnancy prevention. Ask them about any positive experiences such as how a GP built rapport, their communication skills, professionalism, knowledge and skills.

  • Will you change your approach to sexual healthcare based on the experiences of your family member or friend?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

Provide healthcare that is inclusive of and safe for LGBTIQ+ people, including transgender and gender diverse people
  • Understand the terms: sex at birth, gender and sexual orientation.
  • Understand that patients presenting to general practice are diverse and can be cisgender, transgender, gender fluid or intersex, and may be heterosexual, homosexual, bisexual, pansexual or asexual.
  • Understand that LGBTIQ+ people may present to their GP with issues including:
    • physical health
    • mental health
    • sexual and reproductive health
    • alcohol and other substance use
    • domestic and family violence
    • psychosocial stress, including relationship stress, parenting and family stress, work stress, homelessness and financial hardship
    • health screening and preventive healthcare.
  • Understand that stigmatisation, judgement, misgendering patients, homophobia and transphobia by individual healthcare providers and health and other institutions causes significant harm to LGBTIQ+ people and communities and contributes to health inequality and health inequity.
  • Understand that experiencing multiple, compounding social determinants (including being Aboriginal or Torres Strait Islander, being from a culturally and linguistically diverse background, living in rural or remote Australia, having reduced access to education, unemployment, having a disability or being aged) significantly increases health inequity for LGBTIQ+ people.
  • Understand that culture and religious background influence both a patient’s and a GP’s experience of sex, sexuality and gender.
Sexually transmitted infections and blood-borne viruses
  • Through a comprehensive sexual health history, determine and arrange appropriate screening of asymptomatic patients for sexually transmitted infections (STIs) and blood-borne viruses (BBVs).
  • Through a comprehensive sexual health history, perform a physical examination and arrange appropriate investigations, and diagnose and manage patients with:
    • STIs and BBVs presenting with:
      • vaginal discharge, abnormal vaginal bleeding
      • urethral discharge, dysuria, urinary frequency
      • abdominal or pelvic pain
      • genital or anal itch, pain, swelling, skin changes, lesions
      • fever, joint symptoms, rash, nodules
    • STIs and BBVs diagnosed on asymptomatic screening or following assessment of symptoms:
      • chlamydia
      • gonorrhoea
      • trichomonas
      • mycoplasma
      • syphilis
      • genital herpes
      • genital warts
      • hepatitis B
      • hepatitis C
      • human immunodeficiency virus (HIV).
  • Appropriately manage notifiable conditions.
  • Facilitate contact tracing.
  • Provide patient education about prevention of STIs and BBVs.
  • Assess a patient’s risk of HIV and suitability for pre-exposure prevention and post-exposure prevention of HIV and arrange appropriate management.
Pregnancy prevention
  • Through a comprehensive sexual and reproductive health history, determine risk of pregnancy.
  • Provide patient education about prevention of pregnancy.
  • Assess a patient’s current and previous contraception, contraception preferences, and indications and contraindications for particular types of contraception.
  • Understand UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) for use of different types of contraception.
  • Understand the principles of informed consent and confidentiality as applied to sexual health.
  • Understand age of consent in your state or territory.
  • Understand prescribing contraception to mature minors in your state or territory.
  • Understand mandatory reporting in your state or territory.
  • Understand that safe sex discussions should include information about consensual sex, pregnancy prevention, access to emergency contraception and STI prevention.
  • Prescribe contraception:
    • emergency contraception
    • combined oral contraception: combined oral contraceptive pill (COCP), vaginal ring
    • progesterone-only contraception: progestogen-only pill (POP), contraceptive implant, contraceptive injection (Depo), intrauterine devices (IUDs)
    • non-hormonal contraception.
  • Prescribe contraception in specific situations:
    • mature minor
    • patient with contraindications to oestrogen
    • postpartum patient
    • peri-menopausal patient.
  • Provide information about and refer patients for sterilisation:
    • vasectomy
    • tubal ligation or occlusion
    • hysterectomy.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Evidence-based information about screening and treating chlamydia, pelvic inflammatory disease and antimicrobial resistance.
Online resources
Comprehensive evidence-based guidelines on reproductive and sexual health, including contraception. Australian guidelines for the diagnosis and management of STIs in general practice. The Australasian guidelines for partner notification or contact tracing for STIs and blood-borne viruses. Australian guidelines for the use of pre-exposure prophylaxis (PrEP) of HIV.
  • Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). PrEP.
Australasian guidelines for the use of post-exposure prophylaxis (PEP) of HIV. Information about the standard of care and treatment guidelines for trans and gender diverse people, including hormone treatment. Guidelines on the indications and contraindications for different contraception types.
Learning activities
Accredited eLearning activities on sexual health. Free eLearning modules on transgender (including gender diverse and non-binary) mental health care and primary care. A webinar presented by Ruth McNair on supporting LGBTIQ+ mental health. On-demand webinar on sexual and reproductive health. eLearning activity about sexual healthcare in general practice in Australia.
  • The Royal Australian College of General Practitioners. gplearning:
                  check, unit 559, April 2019: Sexual health

This contextual unit covers content that particularly overlaps with the units of Pregnancy and reproductive health, Women's health, and Men's health. Where a topic is mentioned but not covered in detail, or for other related presentations such as sexual dysfunction and contraception, please refer to the Pregnancy and reproductive health, Women's health or Men's health units. 

This unit relates to the other unit/s of:

 

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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/sexual-health-and-gender-diversity 28/06/2022