Enhancing sexual health care for IMGs
Jasmine
Welcome to tonight's webinar, Enhancing Sexual Healthcare Delivery, Supporting International Medical Graduates in General Practice. We are joined tonight by speakers Dr Rohan Bopage and Dr Mahalekshmi Selvanathan. Our GP facilitator is Dr Natasha Feingold. My name is Jasmine and I am your RACGP representative for this evening. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening. I would like to introduce you to our presenters for this evening. Rohan is a Consultant Physician and specialist in infectious diseases and sexual health medicine. His journey in medicine began in Sri Lanka where he graduated from the University of Colombo. He then gained foundational experience as a junior doctor in the UK's National Health Service before moving to Australia in 2006 as an international medical graduate. Maha is a GP who has a particular interest in sexual and reproductive health, family planning and women's health and is experienced in providing contraception, counselling and safe sex education to schools and community groups. In addition to her clinical work, Maha is a passionate advocate for international medical graduates in Australia and currently serves as chair of the Federal AMA IMG Committee. Dr Natasha Feingold is a GP from Sydney who has recently moved to the Gold Coast, Queensland. She is committed to the quality medical education of junior doctors and worked for many years as a lecturer at the University of Notre Dame School of Medicine. I will now hand it over to Natasha who will go through the learning objectives this evening.
Dr Natasha Feingold
Thank you much, Jasmine. We have a lot to get through tonight. I might just jump right into the learning objectives. Tonight, we are going to, number one, identify current Australian STI and HIV guidelines that inform testing, diagnosis, prevention, and treatment. We will also describe evidence-based strategies for managing common and emerging sexual health presentations in general practice. We will also apply a patient-centred contraception consultation framework that incorporates shared decision making, and finally, we will select and use practical tools, digital resources and referral pathways to support efficient patient-centred sexual health care. We are so lucky tonight to have two experts in our field. I will be managing the Q&A box. If there are any questions that you have during the presentations, go ahead and write them down, and if I can interrupt the speakers, I will, but otherwise we will also save the Q&As for the end and hopefully we can have a great chat with our expert presenters. With that, I will pass it on to Rohan. Thank you much.
Dr Rohan Bopage
Thank you, Natasha. It is great to be here, especially as a fellow international medical graduate and to talk to our general practice colleagues. What I am hoping to do over the next 20 minutes, first 10 minutes, I am going to give you a very rapid update around the epidemiology. Then you will understand why this is current, what is the relevance. Then we will go to a more practical stuff around history taking, some of the challenges, how do you make sexual health history easier for you, and also we will have quick cases at the end, and I am going to focus mainly on the male sexual health and Maha will focus more on the female sexual health. All right, let us start some of the epidemiology. Syphilis. Now, as you probably had heard a lot about syphilis. In this graph, we are showing the data and notification of early syphilis, what is called infectious syphilis over the last decade. As you can see, that is continuing to increase and there is a rapid increase happening from 2019. What that actually means, a decade ago, something like congenital syphilis is extremely rare. People have not seen it. Now we see that every year. I mean, this year again, we have seen a couple of cases already in Western Sydney as well. That is a big issue. Babies are born with congenital syphilis or some are having bad outcomes as a result of increasing number of infectious syphilis. This graph is going to show what the difference in the sex specific infectious syphilis in New South Wales. As you can see, it is largely in men, and in this increase in men, predominantly is gay bisexual men or men who have sex with men, but also quite interestingly, we start to see heterosexual men also representing increasing proportion. Look at the females. Even though the relative numbers are small, and if you look at the notification rate back in 2015, it is 0.5. In 2023, it almost reached 6, significant increase in infectious syphilis in female population. As a result, in last year, you probably have seen Chief Health Officer in Australia has declared syphilis is infection of national significance because we are seeing clinical syphilis in this country as a developed nation that is a public health crisis. Why syphilis readily crosses the placenta and this infect the infant and can lead to foetal death and neonatal complications. As doctors, I think we have a very important role now in terms of how we curb this increasing syphilis epidemic and having adverse outcomes. It starts with the testing, thinking about how we actually identify syphilis. In the majority of the cases, syphilis is asymptomatic and you pick up on testing and the testing guidelines has recently been changed. Every woman when they are pregnant in their first antenatal visit, you should test for syphilis and we do not stop there, and we will do another test in the second trimester around 26 or 28 weeks, and also, we do another test closer to the birth, and if there are increasing risks, I will come back to that, we will actually do more testing. The next slide will show you, this is the policy document from New South Wales Health. As you can see, all pregnant women, at the screen at first contact, then we will do the second contact in the second trimester, but if they are identified at increased risk, what are the increased risk? If the woman has previous syphilis, who had any other STIs in past 12 months, as you know, the same mode of transmission. If somebody had chlamydia, gonorrhoea, then they are more likely to have syphilis as well, and when we look up our cases with congenital syphilis for last 12, 13 months, then a couple of things comes up over and over again. One thing is the substance use, particularly methamphetamines and also associated mental health issues, and other things like homelessness and etc. These are psychosocial conditions where people become quite vulnerable, and also if the woman during their pregnancy has new partners or recent partners. All their male partners are gay bisexual men. These are the things that would put that woman at increased risk of having infectious syphilis during pregnancy, and you should try and opportunistically test at every occasion because these are challenging cases. They will not be necessarily come into the appointments. They might come in for the reason and you take that opportunity to opportunistically test for syphilis.
Let us move on to gonorrhoea. Similar to syphilis, we are seeing a much bigger problem now with gonorrhoea. As you can see, since 2015 to 2024, there is steadily increase. There is a dip in where the COVID epidemic happened, but we are continuing to see that. Over the last decade, in 2024, we have seen the highest number of notifications across New South Wales, and if you look at the actual numbers, they are still on the metropolitan, but relative numbers look at, we see the largest increase in far west, northern Sydney and also western Sydney where I was. Next slide please. This is the sex specific. Similar to syphilis, we are seeing increase in men and these are largely still gay bisexual men, but also we are starting to see that in heterosexual men as well, and again, similar to female, if you look at the sex specific rate, in 2015 22.6, now is closer to 65, 67, significant increase starting to see in women as well. Next, look at the AMR gonorrhoea. AMR stands for antimicrobial resistant gonorrhoea. As you know, gonorrhoea treatment you give in current guidelines recommendation is you give dual therapy, you give half a gram of Ceftriaxone intramuscular, and also you give at least 1 or 2 g of Azithromycin only depending on the site. What is AMR referred to? When you see a high level of resistance, MIC to Azithromycin or decreased sensitivity to Ceftriaxone, that is the MIC is creeping above 0.124. As you can see, they are not very common, they are rare, but you will see they are at increasing numbers we start to see, and this is 2023 to 2024 data, but we also start in 2025 data, and also recently, we are also starting to see increasing number of gonorrhoea. What is really interesting is, Azithromycin resistant gonorrhoea largely seen in, gay bisexual men, but when you see the Ceftriaxone decreased susceptibility, that is very concerning because that is our last resort at this stage. They are mostly in heterosexual population, and also some of these conditions are actually travel related. As you know, when people go travel, people do have sex and that is the reality, and particularly in our neighbouring countries, South Asia, East Asia, Vietnam, Taiwan, China, these countries have a very high rates of Ceftriaxone decrease sensitivity to gonorrhoea, and when they go have sex, they can bring it back to the country and also give it to their partners here. I think as general practitioners, we are doing a really important role because these AMR testing are done by the swabs that you have sent. When you see somebody with gonorrhoea, you take a swab and send it to culture and the lab monitor that. That swab is really critical part. If you do not send it, actually we are not going to find that out. Unfortunately, since the Trump administration, what has happened is there is a lot of funding cuts and our neighbouring countries, particularly Vietnam, China, Southeast Asia, their surveillance program has been stopped. We now really do not know what is happening in our neighbouring countries, and only way to find out is to keep up with the program and the surveillance at this stage. Let us look at M-pox. M-pox previously used to call monkeypox. We now cannot use that word monkey because it is stigmatising. Please use the word M-pox. It is a viral illness, and in the last couple of years in 2022 and 2024, we saw quite big outbreaks of M-pox. There are two types of M-pox. What is endemic in Africa, that is Clade 1. What we are talking now in Australia and some of the other developed countries is Clade 2, and there has been a increase in 2024 and 2022, but due to the vaccination rates, the rates has now come down, but still, we start to see M-pox, and anybody can get M-pox, but still, we see largely concentrated on gay bisexual men, and also, we start to see some heterosexual, particularly, around sex workers, and it is a self-limiting illness, but in some people, it starts with the prodromal symptoms like fever, fatigue, lymphadenopathy, then develop quite a painful, people describe as rash, then it turns into blisters and then ulcerate, and these lesions can go through sometimes two to three weeks, and there are some complications, but they are rare, and testing is very easy. When you see something possibly related syndrome, to take a dry swab and then sent to the lab and they have a multiplex testing for M-pox.
All right, I only have one slide HIV, this is like a one hour lecture that we talk about, but HIVs, I mean, Australia is leading the world. We are actually trying to come to a stage in the future that we might have a virtual elimination. You will see our numbers are coming down, but now we are starting to see some shifting happens. Those who are born in Australia, who are connected to the community, connected with the health seeking behaviour health service, we see less and less HIV. The more HIV we are now seeing, people are overseas born, particularly overseas born gay bisexual men who come to this country, not engaged for various reasons, stigma, religion, culture, etc. They are not engaging. They are not on plan, they are not getting the messages, and they are the one who are getting HIV. In the group, those who are migrated from other countries, and particularly late diagnosis of HIV who end up having complications, they have probably acquired HIV in their home country, and nearly did not test it until they become really at risk, and sometimes unfortunately end up having horrible complications. This is the change in epidemiology. Think about that, particularly those who are working in regional and rural general factories, you might have these patients with you. They might not come out to you and say, they are bisexual, I have sex with men or I use drugs and have multiple partners or I have condomless sex. They are the one now getting HIV. I have come to the point about that I can check and also uptake of HIV antiretroviral treatment has changed the dynamic of epidemiology.
I am talking about PrEP. PrEP stands for HIV pre-exposure prophylaxis, highly effective. If people take it properly, we are talking about high 95 to 99. Essentially people who take it properly, they do not get HIV. This is what we are seeing particularly in metro cities. If you take the Sydney, Southeastern Sydney in the Western countries, gay bisexual men who are on PrEP, do not get HIV anymore, and Australia has done incredibly well in terms of PrEP update, but there are a lot more work to do, particularly for you as general practitioner. Sexual health services alone cannot do that, particularly in the regional, rural and non-metro areas. There are people who benefit from PrEP and that will change our goals to our HIV epidemiology, probably virtual elimination, and PrEP is easy to do. You manage lots of other complicated diseases. It is very, very simple to do. You do not need special accreditation. Any general practitioner can prescribe PrEP. In the interest of time, I will just quickly move into the next topic. About STI testing. There are two groups of testing when you do. You test somebody when somebody present with symptoms and signs suggestive of an STI syndrome. Other big and important group is, you test somebody when they do not have any symptoms, but you do opportunistic testing. I have highlighted some of the symptoms, that is in your primary care STI guidelines. The link is there where you have ano-genital lumps, ulcers, other symptoms like ano-rectal symptoms, patient has pain, discharge from the rectum, vaginal discharge, or other conditions, rare ones like sex-associated diarrhoea. In these cases, you do test because person has STI symptoms, and depending on the condition, I will talk about what sort of testing you will do when we talk about the case studies, but the really important thing when I want to talk to you about the screening, when the person comes in for something else, they are aware, if they have any of these other risk factors, it is a really good opportunity that you should try and do testing. Is this population Aboriginal and Torres Strait Islander people, men who have sex with men, sex workers, people who use drugs, particularly people who use methamphetamines, gender diverse people, people being in adult prisons, or people who come from high prevalent countries. Another important thing, as I mentioned, in gonorrhoea, the travellers, and also people, mobile workers. Sometimes they do fly-in, fly-out workers, and they maybe have an engagement in sexual activity there. Sometimes they go back to different countries, and finally, again, importantly we talked about pregnant people.
Going to sexual history. This terminology can be confusing. In this context, what sex actually means in here is the physical sexual characteristics. When baby is born, they will be assigned to either male or female, and at times they might have ambiguous genitalia or might have both male and female, then it would intersex. Gender is very different to sex. Gender is how you express yourself, your identity, a sense of self, where your masculinity, femininity, and some people identify as non-binary people, and according to that, they might use particular pronouns, he, she, they, other, and sexuality is also very different to sex gender because it is how you are attracted to, what is your sexual attraction. Is it more masculine people or with feminine people, and they might identify as gay, straight, queer, bi and there might be different other terminology, and again when you talk to sexual activity, that is also quite different. For example, one person might be assigned sex as a male, identify themselves as a female. Their pronoun may be gay, and they might be saying they are queer, bi or straight. In their sexual activity, they might have a vagina or they may have underwent gender assignment surgery and might instead of having a penis now have a vagina, they might have vaginal sex, or they might not have vaginal sex, they might elect to have anal sex, and also they use sex toys, and also word chem sex, they might use some drugs during sexual activity that will enhance their sexuality and also make them more at risk with STIs and HIV.
Sexual health history taking. As an IMG, I think we all dreaded when we come to sexual history, but I would like to assure that as a general practice, you have done lot more complicated discussions. When you come to sexual history, if you follow a pattern and if you do some practice, these are actually quite easy. Important thing is how do I do? I start with the confidentiality and privacy. Every time I see a patient, first thing I will say in Australia, there is a very good privacy levels, protect your confidentiality and reassure the patient and that will make the trust and make the patient comfortable. Other important thing is be mindful about your body language. If you are not comfortable, patient will pick that up and it will not go very well and probably you might not be able to do a good job, and also how we normalise that. That means you will say the same thing and say, I am going to ask some very personal questions. The reason I am asking, these questions determine what I am going to do, what sort of test, and it is going to help me and I am going to help you to find out what is going on, and I am going to ask these questions everybody and also tell that these are common conditions. There is nothing shameful about it. It does not define who you are. In most of the STIs have no symptoms. If I do not know what test to do, you are not going to find out and most are treatable, and majority are very curable and manageable easily. Do not make any assumptions because most of the time you will get it wrong if you make assumptions, and also we all have our values, systems, our attitudes, but when you come to these conversations, in any conversation in medicine, I think we have said this, and have an open mind and put the patient in their best interest. The way I do, I start, I go back to when was your last sexual contact, and then I will ask a little bit about, is that with a man, is that with a woman, or is it with a group sex, or is it with a trans person, and what sort of a sex did you have? Was it oral sex, or was it deep kissing? Did you have anal sex? Especially if it is to man and a woman, and to men, I will ask whether you are top, bottom, are you insertive or receptive partner, was there ejaculation? Did you use condoms, or did you use drugs, etc, etc? And there is a really good section around STI guidelines that can be seen here. This section actually came directly from there. Take home message here, if you practice having your own way of systems, and then use the same thing over and over again, then you will do it very well, and there are no hard and fast rules around it. This is the way that I started, and how I teach to my juniors.
We have four cases, but they are very rapid cases. I am not going to spend too much time around each, maybe one or two minutes. What I am trying to do is in these four cases, I want to think what are the DDs, what tests, and what treatment you are going to do. First case is Jake. He is a young 26-year-old Aboriginal man who, who identifies as gay, come to you with a urethral discharge. He is saying discharge is like a greenish. One of the most common DDs here is gonorrhoea, chlamydia, obviously there are a lot of other things. What is important thing I mentioned here is, you need to examine the person. When you see the discharge, you take a swab for gonorrhoea culture, remember, and you do a first pass urine for chlamydia and gonorrhoea, and you could stop there because he identifies as a gay man. He might have oral sex, anal sex. You need to swab their pharynx and also anus. And what about serology? HIV, syphilis is very important, and also hepatitis B, do not forget about that and then in this case, what test you have talked about and then one of the treatment empirically you will do, you will give Ceftriaxone, Azithromycin. If you are thinking, they may have a coinfection of chlamydia, you might give doxycycline as well.
Next case, Mike. Mike is a 55-year-old man. He identified as straight, and he thought it is really embarrassing because something in his bottom, he got multiple lumps. When we see this patient, this straight man who has something in their bottom, it is really embarrassing. I think it is quite a stressful conversation to have. I think it is important to reassure you do not need to have anal sex to get things in your bottom because this is proximity area. If you get some infection elsewhere, it can easily spread to your perianal area. This could be warts, could be herpes, could be many other DDs. I think in this case, what I really wanted to highlight, to reassure that person. Particularly, this is why straight men avoid coming to the clinic, see their doctor. They are worried they get labelled as gay men or having sex with them or having anal sex. It is not the case.
Next case is Wei. She is a 32-year-old and identifies as a trans female and she comes and says, I got a penile rash. Again, trans female, understand some of them have a penis, some of them have a vagina, and some of them even though have elected to have vaginal sex or may have anal sex. In case rash could be very different for different people. That is why examining is really important. In this case, the rash is very painful ulcers. Most differential diagnosis is herpes, M-pox, and sometimes even syphilis, even though classically they are painless, it could be syphilis.
Last case is Ramesh. He is 42-year-old man. He is identified as straight, but occasionally, he goes and has sex with men, but he is a very rare occurrence and he identified as a straight man and he will know about PrEP. What do you do? It is really good opportunity for you to talk about because these are the people now they are getting HI. They are not connected. They are isolated. They are stigmatised. They are not reaching out. They are not on PrEP. Ask him questions about what sort of sex when you are having sex, do you have anal sex? When do you have sex and what sort of risky sex? And the PrEP again as a general practitioner, you can easily provide PrEP and there are ways to take PrEP on demand in certain conditions, particularly like Ramesh, where not having lots of casual sex, occasional sex, he could do PrEP on demand where you take two tablets before at least two hours, then one 24 hours, one 48 hours. Again, I am just going to highlight in my last minute, there is a lot in general practice that you could do particularly these are challenging cases, and if you apply the same principle and have a non-judgmental attitude, you will be able to get a history and identify what are the tests you will do and offer treatment and also preventative methods. Thank you. I will stop there and then hand over to Maha. Thank you.
Dr Mahalekshmi Selvanathan
All right. Thank you. When I first started in general practice as an international medical graduate, I wish I had understood just how broad our human sexual and reproductive health truly really is. I come from an Asian country, it was quite mind blowing. People have sex across entire lifespan from very young adult right through to their seventies, eighties. No, they have sex. People have sex. That is normal. It is our responsibility to ask without judgment and listen without assumption. Termination of pregnancy is a patient's choice. It is not a moral debate. Our role as general practitioner is to provide accurate information, compassionate care support, even though our personal beliefs differ. Now, not all vaginal ulcers are sexually transmitted infection, and if you anchor too quickly, it will lead to misdiagnosis and broken trust. Now we have got really one of the best cervical screening program in the world, and you need to know how to explain it clearly and respectfully. It is vital, especially for patients that are coming with fear, with trauma, cultural hesitation. Now, a patient's sexual orientation is their choice to disclose. It is not ours to presume, and yes, same-sex couples, they do have babies in many different ways. Now, probably go to the next slide. Like Rohan said, I think one of the hardest things for new doctors, especially IMGs is knowing how to start a conversation about sexual health. Now the key is to raise it at any opportunity, make it feel normal. Do not make it feel awkward. Okay. I usually have a simple hook, like a single neutral sentence that opens the door. Sometimes I just tell my patient, look, I asked all my patient this because it is an important part of your overall health, and that one line is enough to reduce the stigma. It gives the patient permission to speak. Now, sexual health discussion does not have to sit in isolation. They can come naturally as a part of any other consultation. It can be during a reproductive consult, mental health consult, contraception, fertility, alcohol, drugs, anything. All these overlaps with your sexual well-being. Now, sometimes if you are lucky, it is quite straightforward, the patient may directly ask you, can I have an STI screen? When that happens, it is our job to respond calmly without surprise or judgment. You create a space where that honesty feels safe. Okay. When you start normalising conversation, patients start opening up and that is where good medicine begins. Now I will move to the next slide. As I said, this is the same thing. Easiest way to normalise sexual history is to include it in your lifestyle question. I always say, look, I am going to ask you a few questions that I usually ask all my patients. When you frame it this way, as I mentioned, you like you request, you reduce your stigma, encourage honesty, you make safer, more informed clinical decision. Really important here, Now with the next slide. Sexual history. When you are taking a sexual history, especially in general practice, I always tell people, like for me, I have a clear a gynaecological framework, you can make up a template or a shortcut. This is so important so that nothing important is missed. I usually start with menstrual history. You ask about the usual cycle patterns, the flow, the regularity. Red flags should always be explored. You want to know intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding. Do not forget dysmenorrhoea, dyspareunia, which can significantly impact quality of life. Then you go with contraception. You can ask the patient, are you thinking of using something? Are you using anything? Are you consistent? Does it suit their need at that stage of their life? Then you go through a past gynaecological history, conditions, ovarian cysts, PCOS, any previous gynaecological surgery. Now all this is important because it completely changed risk assessment and management. Always ask about cervical screening history. When it was last done, were the results normal? Cover a bit of obstetric history, pregnancy, births, complication. Then you just ask any other background history. When you go in a structured approach, you keep the consultation safe, efficient, and patient-centred. For male patient, I will just add on, do you have any discharge, any dysuria, ulcers, rashes, pain? Talk about erectile dysfunction. Again, normalise it. Libido changes, any ejaculation issues.
I am a bit passionate about this slide. If you Google up in gender bias survey, you can actually read the whole survey. We need to talk about this uncomfortable truth. In that survey, it says that two-thirds of women report feeling unheard or dismissed by their GP, and women are twice as likely as men to feel dismissed by a doctor. For many, this dismissal does not look dramatic. It actually sounds quite familiar. It sounds quite subtle. Being told that pain is in your imagination, this is normal or you just have low pain tolerance or their symptoms are simply due to stress. These words really matter. They do not just minimise symptoms. They delay diagnosis, they erode trust. They teach patients to stop advocating for themselves. We see the consequences later. Endometriosis diagnosed years too late, autoimmune disease missed, mental health, suffering alongside with physical symptoms. As GP, our power is not just investigation and referral. It is listening, validating and believing. When we do not have answers, acknowledging a patient's experience just changes the whole perspective of their care. Sometimes, I run out of words and I just say that I hear you and that is all that matters.
When you actually discuss sexual health, we must always lead with safety and comfort. How you start the conversation will determine whether a patient will open up or shut down. Normalise early, I usually normalise early, signposts clearly. I always say, lots of patients experience this, it is quite a routine part of healthcare. Again, that one sentence would reduce shame and reassure patients that they are not alone. Confidentiality, as Rohan said, should be explained upfront, especially for our younger patients because understanding privacy is so essential for honest disclosure. The trust is built through transparency. I always explain why I am asking this question. I always say that, look, I am asking this question because your answer will determine when is the testing, what testing should I do? Everyone is asked the same question and some questions will feel personal. Of course, always ask for explicit consent, offer a chaperone, explain that the chaperone is actually for patient's comfort and safety, not because of suspicion and discomfort. Finally, of course, reassure them that STI is quite common. Many have symptoms. Most are actually quite easily treatable. Wen the patient feels safe, informed, respected, they engage. That is really important. One thing that I stress all the time is that, as an IMG doctor, no matter what your background is, no matter what your religion is, no matter what your faith or personal beliefs are, you leave them at the consult room door. The moment you walk into that room, you are not there as an individual with opinions. You are a GP. Being a GP means practicing medicine without judgment, without assumption, without allowing your personal belief to influence care. Our patients do not come to us to be assessed morally. They come to be treated medically, safely and respectfully. They deserve evidence-based care. They deserve clear information and advocacy in their best interest, not ours. That does not mean that you have to abandon who you are. It means understanding that professionalism requires boundaries. It means recognising that our role is not to direct choices, but to support informed choice because that one moment when a patient feels judged, they will stop being honest. When honesty is lost, safety is lost.
This is just a simple example, some patients get very embarrassed, like when they come back with chlamydia positive. I always say, look, it is okay. People of all background get STI. It does not say anything about you as a person, just let us get you sorted here. This is what I recommend or I thank them for being responsible for even coming for an STI check.
The language, for a lot of ING doctors that are working, we have worked across cultures Language in sexual health is very crucial. How people define sex is different. It is really important to have clear, neutral, inclusive language. For example, I say that when I ask about sex, I am talking about any sexual contact. Again, I normalise it by saying, I ask everyone the same question. You always allow the patient to clarify in their own word, you avoid assumptions about partners. I do not say, do you have a husband or do you have a boyfriend? I always ask, do you have a partner? What types of sexual contact do you have? Let the patient talk.
This is really important, especially for our Oasis doctors here. For doctors, especially IMG doctors working in Australia, asking a patient about their Aboriginal or Torres Strait Island status is our clinical and cultural responsibility. It ensures the care and services you provide are safe, effective and culturally respectful. You can ask neutral, respectful questions, like we ask all patients whether they identify as Aboriginal or Torres Strait Islander patient and this helps us make sure the care and support we provide meets your needs and are culturally appropriate. Then you record. Accurate recording is really important because it is for data quality. It is really important because we can provide communities with timely relevant health information and monitor, evaluate our health outcomes, programs and funding. For our IMG doctors, the key is to ask without assumption or judgment. You normalise the question again, you reassure confidentiality and doing so will improve trust, health equity and ensure that all patients receive care that respects their culture and identity. You do this for every client. regardless of their appearance, regardless of their country of birth, whether the staff know them or their family background. This will avoid assumptions and also ensure equity.
This is quite interesting. We have got a 22-year-old female, Hannah, with a possible pregnancy, mouth sores. She is a known patient since childhood, sexually active with a regular male partner for the last 12 months and a brief breakup six months ago and last period was a while ago. Think what's your plan? How will you frame this consult? What are the issues here? The first thing is that, of course, you want to establish pregnancy. You can establish using urine pregnancy test, that is your office test, or a beta-HGT, or ultrasound. I am just cutting short. I mean, I am sure that there will be a lot of questions we want to ask, but I am just going to go with what is really important here. The further history I want to know about the sore, duration, onset, how did it start to look like at the beginning? First of all, make sure, it an ulcer? Is it a vesicle? Then maybe just ask her, has she had this before? Has she been diagnosed with anything before? Then you want to examine the mouth, you want to examine the lymph nodes, genitals with chaperone and consent, and the skin for rash as well. Then you can also think about all your antenatal bloods, including STI screening, other screening like chlamydia, gonorrhoea, syphilis, HIV, hep B, hep C, depending on the sexual history and symptoms. Of course, the next one would be swabs. What are you going to swab? What swabs are we going to take? I am assuming here the patient that the sore has been there for about two weeks. I am thinking of syphilis, okay. What swabs we are going to take? The first thing you need to do is swab from the base of any ulcer using a PCR swab. You can also do a PCR for HSV as well. Then syphilis serology and the diagnosis is done in combination of serology, PCR of the lesion, history and clinical assessment. Let us say if it is positive, do not panic. As I said, I have only seen one syphilis in pregnancy all this while. Do not panic. I you do not know what to do or you do not know how to interpret the results, you contact your local public health unit and seek help. Here you want to get the regular male partner in and test him and treat him. As I said, if it is positive, pregnant women always seek urgent specialist advice.
Quiz time. Hannah is 12 weeks pregnant on dating scan. How often would you test Hannah for syphilis during this pregnancy? Okay, excellent. Everyone paid attention to Rohan in the beginning. Three times, yes, because she is high risk of reinfection. Booking in 28 and 36 weeks. Here Hannah has issues in that screening period. That is the correct answer.
How are we going to start talking about contraception? When you open the conversation about contraception, you always create a safe, non-judgmental environment. You assess the knowledge and the past experience. You can ask the patient, what do you know about different contraception methods available? Have you used any contraception before? What type? How did it go for you? Any side effects, any satisfaction? Were there difficulties? Was there excess issues? Was there any problem with costs or clinic availability? Those kinds of things. Then you can also go on to start narrowing it down. What is important to you right now regarding the contraception? This part here, you are thinking the pregnancy intention, lifestyle, health conditions, those kinds of things. Then you can move on to trying to clarify the information and address the misinformation. An example is, you can say, look, some people think the pill causes infertility, but evidence shows fertility returns quickly after stopping. That opens a bit of conversation, always provide evidence-based, culturally sensitive guidance. You can give written resources or point them to any reliable websites, if appropriate. Then, I always ask them, who else is involved in this decision about contraception? That is really important. The last one, want to screen for reproductive cohesion. You can say that, sometimes partners and family may try to control contraception or pregnancy decision. Has anyone pressured you about this? You want to look for these signs. If the patient is missing pills due to partner interference or if there is any pressure to use or avoid contraception, or sometimes fear of attending appointments alone. This is where you can pick up a lot of things as well. I always screen for domestic violence during this conversation. Then you can just summarise.
You want to explore the motivation and fertility intentions early. Recognize that many patients are unsure about timing of pregnancy. I always say that, are you thinking about becoming pregnant in the next year? When you use motivational technique of interviewing, you can actually approach the goals and values without any judgment. You can ask, does the patient want to avoid, delay or achieve pregnancy? Again, that will guide you into a consult, whether this is a contraception consult or preconception counselling. Then you can also say, would you like to become pregnant in the next year? As this slide says, mixed results in primary care, but it can actually prompt meaningful conversation.
As I mentioned earlier, how to narrow down. I always give that option. What do you know about contraception? What matters to you the most? You give a brief overview of all relevant options, especially if the patient wants to see a full range. Then you talk about Implanon, Mirena, all those things. Then you start narrowing down. You aim to focus two to three methods quickly that matches the patient's priority, like the effectiveness, convenience, health, lifestyle. This allows more detailed discussion that you can talk about the pros, the cons, the practical concentration around this. Let us say the patient is presenting for a specific need, for example, if the patient comes up and say, oh, I am just here for a repeat of my pill script, you can check the knowledge of the chosen method, you can offer additional information or other options, if they want to talk about it, keeping the patient informed, but do not overwhelm them. Then you can move on to shared decision. As we spoke about discussions of pros, cons, side effects, lifetime fit, then you incorporate patient's motivation. What is their fertility intention? Is there someone talking to them, asking them to do this? Then you make that decision together. Once the decision has been made, it has been started, you always follow back. You can give them the information, hand them paperwork and say, why do not you decide and come back? Sometimes you just have to do the quick start method. Again, you work together with the patient in all of this.
Think of what are the important factors when people are choosing a contraception method? What do you think? Just think for a while, what are the most common things that patients decide when they want to think about starting contraception. Of course, how reliable is the method to prevent pregnancy? Then you want to think about bleeding impact, how is this choice of contraception going to affect my menstrual pattern? Is it going to be heavier? Is it going to be lighter? Is it going to be irregular, absent periods, those kinds of things. Then you also have to think about medical conditions, the safety consideration, thinking on the other health issues like patients with hypertension, which would be suitable, patients with clotting disorder, patients with migraines with aura, those kinds of things. Then you also think, some patients think about non-contraceptive advantages, like this might help me reduce cramps, this might make my acne feel better, look better, and also protection against certain cancers. Then you think about other things like age, reproductive stage, the patient's fertility goals, is the patient perimenopausal or is it postpartum? These things will influence choices, and patients think about the access to it, costs, oh, I want a Mirena, who is inserting it. How much is it going to cost? The convenience of obtaining that certain method. I see a lot of patients that are influenced by others. Oh, my friend has a Mirena or my friend has an Implanon, so influence of others, like especially from partners, from family, from friends that can affect decision making. An ethical and spiritual belief, what does the person believe cultural or religious values that will guide what methods are being acceptable.
Finally, this is just a review. You talk about the contraceptive options, then you move on to discuss methods, specific issues, as I mentioned just now, then you do not bombard them or throw everything to them. You allow time for questions. I usually use from Family Planning New South Wales, you can always give them printed material according to their language, according to their literacy level. Then, for example, if you want to do a Mirena insertion, you plan or you refer or you insert, one of it. I am not going to go into the quick start method, but that is when the next step comes in.
Dr Natasha Feingold
Thank you so much. I do not think we have ever finished on time. You guys are amazing. If there is anybody who has any burning questions, feel free to put them in the Q &A box. I might just start out with asking some questions to both of you in terms of working in Australia. What have been the differences between working in your home countries and working in Australia in sexual health, reproductive health, can you chat about some of the interesting things, the challenging things that you have come across?
Dr Rohan Bopage
I will give an example, Natasha. When I was training, I saw a case where a man in his 40s, executive, has a wife and two young kids, who went to multiple doctors, GP specialists with a sore eye, ended up getting blind on one eye. They ended up having nephrotic syndrome and had biopsies, and after multiple consultations, ended up in our hospital in Sydney and having syphilis in the eye. Nobody took a sexual history. These are not just general practice, these are specialists, one after the other. He ended up having syphilis and HIV. We talked to him, he occasionally goes overseas, has sex with men. Because we assumed he has a wife and two young kids, he does an executive job and a suit, I think that sort of assumptions that we make, we always do that. I think when it comes to sexual health, if you leave these assumptions out and say that I am going to ask these questions because that is in the differential diagnosis. One thing I can get my head around that it is actually easy when you start to think about that. You leave your judgements, your values, your religion, what you say and how you agree. You just make it as normalised. I am going to ask everybody. If this patient comes to me with a red eye, if I have the slightest doubt this could be syphilis, I am not going to have that assumption that he is a man in a suit with a wife and a kid. I think that is something that always stays with me throughout my career.
Dr Natasha Feingold
Was it different in your home country dealing with that?
Dr Rohan Bopage
It is very different. We did not talk about it. Also, the stigma and the judgment. I think one thing here is because the health services, we get to learn about this here, even in med school back home in Sri Lanka, we have very little, now we talk about sex. It is a taboo topic and we do no learn. I think we understand that we can learn and we can get trained. If you are not good at it, you can practice and you can seek help.
Dr Natasha Feingold
Maha, what about you?
Dr Mahalekshmi Selvanathan
One thing that I remember the most is that when I was in ED and back home in Malaysia, this girl came in, she was, 8 cm dilated, she was pregnant and kept denying that she had sex. The moment she delivered the baby, they were hitting her. She is young, she is 17, but it is something that is not spoken about. We have got such a big population. Everybody has sex, but it is something that is never spoken because it is a stigma. for example, I do not think when I was doing my internship, a sexual check, even in the OBG department, are you okay? How is sex? Are you experiencing pain? Nothing. There was no discussion, and I remember I was quite rebellious for an Asian girl to go and ask, is sex painful? It is so important because it tells us so much. I find that only now slowly, I have seen myself back home and even in Australia, and that is why I talk about this a lot. I have seen doctors who judge you so fast, they go like, oh, okay, yeah, right, STI. You cannot do that. Patients will not come back. I get that back home quite a bit, the judgment, the stigma is still there.
Dr Natasha Feingold
It is all relative because even as Australian trained doctors, there is a lot missing in our education and feeling prepared to take sexual histories. It is getting better, but it is interesting, it can be the same here. Somebody in the chat box just mentioned that, there is no difference in the terms of taking sexual histories, but the language can be quite difficult. Do you have any advice around that? Rohan, we talked about some of the language that you taught us tonight, or any resources, maybe general resources as well.
Dr Rohan Bopage
I think sometimes using the anatomy. It is a part of the body. Think as if I am describing something in my face, I think you use the same thing, it is a part of the body, use the anatomy, and also use a picture, sometimes I have pictures, I have some models and I show the patient, point where things are. Particularly sometimes conversations might not go very well and they are embarrassed to do the examination. I will say, draw me, show me where things are. If you use the anatomical term, it makes it a lot easier, and if you think this is a part of the body.
Dr Mahalekshmi Selvanathan
I also think that there is nothing to be hidden. As I said in my slide, if you are nervous, they will feel it. They will be like, oh, should I say something? Should I not? Just ask directly, are you having sex? Are you insertive or are you receiving, normalise the language. There is no correct language. For me, I feel, English easy, ask directly, but I always reassure confidentiality. I always say, look, if you do not feel comfortable, you do not have to tell me. You can tell me later when you feel comfortable, reassure that, and then you say that, it stays confidential. You create that space and then you just use your normal language. I have come to a point where my patients come in and say, oh, Dr Maha, I have got chlamydia again. I do not have to ask, and they were like, oh yeah, I know, I know, it will normalise along the way.
Dr Natasha Feingold
I think using the same language that the patient uses sometimes, because even there are a of people that do not know their own anatomy either, sometimes using and educating the patient is a great point. There were some questions about resources. We are going to send you quite a few resources and links and websites to those of you who have signed up to the webinar. Do not worry, there will be lots of great info there that, if you do have an interest in this or want to learn more, there will definitely be some great points of contact that you can look at.