Consultation skills - Talking about sexual health

Tried and tested methods make raising the topic of sexual health less daunting.

Advise young people to use a condom with a new partner, especially until they have been tested for STIs
Advise young people to use a condom with a new partner, especially until they have been tested for STIs

The UK has high rates of teenage conception and rising rates of STIs, especially chlamydia, with consequent adverse health and socio-economic outcomes.

The DoH has launched a number of initiatives to tackle these problems including the national chlamydia screening programme, the teenage pregnancy strategy and the national communication campaign, Sex: worth talking about.

All emphasise the importance of engaging and communicating with young people to provide them with accurate information about sexual health and contraception.

It is a common misconception that talking about sex and relationships will increase early experimentation.

Rather it empowers young people to make well-informed choices, which may include delaying first sex and practising safe sex.

Barriers to discussion
GPs regularly see young people: 60-70 per cent of 15- 25-year-olds attend for an appointment at least once a year. General practice is therefore an ideal place to target young people about their sexual health.

Raising the subject in this familiar setting also serves to normalise it. So if it is a good place to talk about sexual health, what are the barriers to GPs doing so as routine?

Time constraints are a factor but even a brief intervention is beneficial. The foundations laid by doing so make it more likely a young person will come back, confident that it is acceptable to talk to you about their sexual health concerns.

Fear of upsetting or causing embarrassment may be a concern. The evidence from surveys of young people shows they are happy for their GP to raise the subject, provided it is done confidentially, with respect and in a non-judgmental manner.

Initiating the discussion is therefore best done with the young person alone and confidentiality should always be discussed first.

If attending with someone else, such as a parent, it is good practice to request a few minutes alone at the end of a consultation. This will help the young person to feel confident accessing services independently in the future.

Raising the subject
It is easy to talk about sexual health in a GUM clinic but more challenging when sexual health is not on the patient's agenda.

Using tried and tested opening strategies and questions suitable for different situations is advisable. Tips for initiating a conversation on sexual health include:

  • Depersonalise the situation. Say the computer has flagged up that they are in the age group where we routinely ask about sexual health.
  • Give a positive health message. Say you are running a health promotion scheme for young people in your practice, that it is for all young people who have had a sexual partner, and offer them a simple urine test for chlamydia.
  • Ask an open question such as: 'What do you think about relationships and sex?' This is a good way to establish current knowledge, attitudes and concerns.
  • Use something that has been happening in the news or a TV soap to begin the discussion.
  • Make no assumptions.

For example, if a patient's symptoms raise the possibility of an STI or an unrecognised pregnancy, first establish their sexuality and if they are sexually active.

  • You can't cover it all in one consultation - offer a follow-up consultation, signpost to other agencies and/or provide written information as appropriate.

Risk-taking behaviours
If a young person is not yet sexually active there is still much to be gained from the intervention. It is a chance to begin to build a relationship of trust and to explore other issues, such as worries about sexuality and risk-taking behaviours such as alcohol and recreational drug use.

For the sexually active, just a few questions can elicit a lot of information and flag up high-risk behaviour.

'Have you got a regular partner and how long have you been together?'

'Have you recently changed partner?'

'How many partners have you had in the past three months?'

'Have your partners been male or female or both?'

'Do you use contraception?'

It is important to have knowledge of protocols and referral pathways should serious issues, such as alcohol and drug dependence, mental health problems, abuse or prostitution, be identified.

Key messages
Have a few key messages. Information empowers young people to make responsible choices, where lecturing and imposing our own standards usually fails. Key messages include:

  • Most teenagers do not have sex until they are at least 16.
  • It is OK to say no.
  • It is good to talk to your parents and partner about sex and relationships.
  • Drinking too much alcohol can lead to unplanned and unprotected sex.
  • If planning to embark on a sexual relationship, be responsible: use contraception and condoms.
  • There are many methods of contraception. Use an effective method and consider a long-term one.
  • Have few partners and do not overlap partners.
  • Chlamydia is invisible, serious and easily spread. All sexually active patients should be tested annually for chlamydia and after each new partner. One in 10 people under 25 years have the infection. The test is a simple and painless urine sample and treatment is a single dose of antibiotics.
  • Use a condom with a new partner until you have both been tested, and consider a full sexual health screen.

Dr Kibirige is a GPSI in sexual health in Middlesbrough and a local champion for the National Chlamydia Screening Programme

Learning points

Sexual health
1. Always try to see the young person alone, even if only for a few minutes at the end of a consultation.

2. Establish a rapport: be open, honest and non-judgmental.

3. Have a few tried and tested phrases to introduce the subject of sexual health.

4. Assess current knowledge, dispel myths and discuss social norms.

Dr Janice Kibirige recommends

Teenage Health resource centre

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