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SHACC Algorithms


General Sexual History Taking	Initial Presentation / Roles	History and examination - females	History and examination - males
Sample handling	Result handling	Partner notification	Sexual Assault
How is taking a sexual history for you? When was the last time you took a sexual history? Why did you take it? Was it easy or did you find it difficult? What was the setting? Is there a difference between a GUM clinic and a health centre? Why take a sexual history? What are we trying to find out? How will this affect our management? How is this different from normal history taking? Taking the sexual history in different circumstances Family planning clinic, gynae OPD, on the ward, in general practice, in GUM clinic Objectives identify why to take a sexual history discuss situation when a sexual history may be appropriate identify ways of changing the subject identify the main components of a sexual history practise taking a sexual history How to start the conversation Leaflets and posters Routinely in certain situations/clinics Women smears contraception vaginal discharge & “thrush” Men are more difficult Symptoms Clues from the client “Do you have any other concerns?” Top Taking a sexual history Ensure privacy Be non-judgmental Always explain why you are asking specific questions Only ask relevant questions Back off if interaction is poor Give permission for the client to return to discuss How do doctors make it difficult for patients? Fail to take verbal/non verbal factors into account Use of jargon, inappropriate language Assume everyone is heterosexual Difficulty in dealing with patient’s guilt, anger and fear Communication Good communication skills Eye contact Meet and greet Introductions Body language Vocabulary Open then closed questions Awareness of distress, non verbal clues Problems with communication Deaf Inability to speak English Use of interpreters Family members as interpreters? Language line Top
Initial Presentation Patient asks receptionist for sexual health screening or is referred by single point of access Ask “Have you noticed anything wrong?” And “Has a partner said you need to get checked?” Occasionally they might say “I have been sexually assaulted” If any of above affirmed then book with experienced Nurse/Doctor If all negative then book with Healthcare Assistant (HCA)/Nurse Obtain patient details Name, dob, sex, mobile number, GP, special language needs, etc HCA & the asymptomatic patient Register patient details on computer If sex within 1wk, test and repeat in 2wks Offer chlamydia test First catch urine for men Self administered vaginal swab for women Or urine test if they prefer Offer test for HIV/Syphilis (oral/prick/blood) Explain arrangements for results Opportunistic health promotion/condoms Role of Nurse / Doctor If HCA finds out there are symptoms refer on Nurse works to his/her level of expertise… …Refers to GP who works to his/her level of expertise… …Refers to Dr Cross/Wake for second opinion Can be done by phone or email GUM Clinic as tertiary referral centre Top What does the Health Care Professional (HCP) need to know? What symptoms do you have? Exposure history Use of contraception/risk of pregnancy Other sexual health issues (psychosexual problems) Risk of blood borne viral infections Risky behaviours Presenting complaint Usually vague “I want to be tested” Important to find out why, be curious Specific symptoms in women Discharge, pain, dysuria, bleeding, rash Specific symptoms in men Discharge, dysuria, rash, anal symptoms Specific questions When did you last have sex? Who with? Regular partner, casual contact Do they have symptoms? Previous partners in last X months? What did you do? Did you use condoms? How effectively? Previous sexually transmitted infections Past medical history Medication, history of allergies Contraception, LMP Last cervical smear Intravenous Drug Use Partner from overseas? Tattooing, dental care, blood transfusions, operations overseas Paid for sex Previous STI and HIV testing Previous Hepatitis B vaccination Top
Sexual History – Women Symptoms Vaginal discharge Vulval itching Abnormal bleeding Pain during sex Pain passing urine Skin rash, lumps, ulcers “Is there a chance you could be pregnant?” “Do you also need contraceptive advice?” “Have you been sexually assaulted?” “Have you ever had a sexually transmitted disease?” “When did you last have unprotected sex?” Examination – Women Examine external genitalia Warts Ulcers Lymphadenopathy Speculum examination Take high vaginal swab if discharge (candidiasis, trichomonas or bacterial vaginosis) suspected Swab cervix for gonorrhoea (Stuart’s) Swab endocervix for chlamydia Top
Sexual History – Men Symptoms Discharge Irritation inside penis Discomfort passing urine Skin rash, lumps, ulcers “Do you have sex with men?” “Have you ever had a sexually transmitted disease?” “When did you last have unprotected sex?” Examination – Men Examine external genitalia Warts Ulcers Lymphadenopathy Urethral discharge Balanitis/Posthitis Scrotal contents Take swab from urethral meatus (Stuart’s) to test for gonorrhoea Take swabs from any genital ulcers (Viral Culture Media) to test for herpes Ask man to provide first catch urine to test for chlamydia Offer to test for blood borne viral infections Arrangements for results Top
Doing the tests Keep viral culture media in the freezer before use, put back in fridge after use Endocervical swabs Urethral swabs Men Women Chlamydia – ligase (PCR) DNA tests on urine becoming more available Storing Samples The following will keep over the weekend if kept refrigerated: Viral transport media Clotted blood for HIV & syphilis SDA urine/swabs for chlamydia (48 hours) Stuart’s media will keep gonorrhoea alive for 24 hours (best out of fridge) Top
Results If no mobile or text message not acceptable, make alternative arrangements (letter, email or appointment) Patients with positive test results will receive a text message asking them to contact surgery where testing carried out Patients with negative test results will not receive a text message, but could telephone surgery for results in 2 weeks Patients with infection need a consultation Discuss infection, natural history of disease Partner notification Receive treatment or referral Do they need a test of cure? Top
Partner Notification Contact tracing Traditionally done by health advisers in GUM Recent research shows practice nurses in GP are just as good Depends on quality of information from patient At least get commitment from patient to tell partners to have STI screening Sometimes it isn’t possible as casual partners are often untraceable If patient is reluctant to tell partners to get checked, consider “You have been named...” letter which can be posted to them Should be attempted for partners of patients with TV, gonorrhoea, chlamydia, NSU and HIV Partner Notification – How far back? Chlamydia & NSU Symptomatic – 1 month from symptoms Asymptomatic – 6 months Gonorrhoea Symptomatic – 1 month from symptoms Asymptomatic – 3 months HIV Let the GUM clinic sort this out Top
Rape/Sexual Assault Ask patient if they want to report to the police Juniper Lodge/Solace team can arrange for samples to be taken by experienced forensic MO DNA evidence upto 7 days – don’t wash If patient refuses to contact police, don’t forget emergency contraception, consider blood borne virus prophylaxis Offer to perform STI screening one week and three months afterwards Top

Last modified: 25-09-08