Common barriers to taking an appropriate sexual history include time restraints, lack of confidence, not wanting to embarrass the patient and fear of intrusion. Age, sex and cultural background of the patient relative to that of the GP may also present a barrier to the patient disclosing their sexual history. Lines of enquiry regarding sexual coercion, unwanted sex or assault may often be avoided because of a GP’s lack of confidence in managing the outcomes of such enquiries.
It might be advisable for GPs to first examine their own comfort levels, beliefs and biases. If, for example, the GP feels uncomfortable taking a sexual history then the patient is unlikely to feel comfortable either. A useful strategy is to keep questions matter-of-fact and in simple language, and practice them. Rehearsing in a mirror or role playing with a colleague or supervisor can help normalise the issues that need to be discussed with the patient. Due to their cultural or religious background, a doctor may hold beliefs about sex, pregnancy or sexuality that preclude a nonjudgemental and helpful sexual health consultation. In such instances, referral to another GP or health professional is advisable.
Consent and the GP’s responsibilities
It is important to know and understand the relevant state laws governing consent. Information about the age of consent to sexual activity in each state and territory of Australia is available on the Australian Institute of Family Studies website (https://aifs.gov.au/cfca/publications/age-consent-laws) as well as comprehensive information about mandatory reporting of suspected sexual abuse of a minor, which also varies slightly from state to state (https://aifs.gov.au/cfca/publications/mandatory-reporting-child-abuse-and-neglect).
When providing sexual health advice to a person under 16 years of age, be it providing contraception advice or advising on STI management, it is best practice to follow the Fraser guidelines (which classify the young person as ‘Gillick competent’ or not).3 A useful checklist derived from the guidelines is provided in Box 3. It can be helpful to keep a record of the responses to this checklist in the patient’s clinical notes. As long as it has been assessed and recorded that the young person is ‘Gillick competent’, the doctor can, for example, prescribe an oral contraceptive pill.
Screening young people for STIs
Important questions to ask when assessing the risk of STIs in a young person are listed in Box 4. These include questions about frequency of sexual contacts and condom use. Young people may feel embarrassed to admit that they do not feel confident using condoms. A helpful website to refer young people to is Body Talk (https://bodytalk.org.au). Often young people are frightened of what is involved in an STI screen, but a simple explanation can quickly allay this fear.
The NSW Sexually Transmissible Infections Program Unit (STIPU) Testing Tool provides a clear summary of what to test for, how to test, the required frequency of testing and how to trace contacts.4 This testing tool is consistent with the Australian STI Management Guidelines, and although designed by NSW Health it can be adapted for clinicians nationwide.
All sexually active young people should have annual chlamydia testing. In young women testing of a self-collected vaginal swab or a first-void urine sample is preferable. In young men a first-void urine should be collected. It is important to determine a young person’s immunity to hepatitis B if their immunisation history is unclear. HIV and syphilis serology should be performed according to the young person’s risk and the local HIV and STI prevalence. Additional testing is required in young men who have sex with men. This includes testing for gonorrhoea, chlamydia, syphilis and HIV at least annually, with the frequency based on the person’s risk. Testing involves collecting swabs for polymerase chain reaction testing for rectal gonorrhoea and chlamydia, urine chlamydia and throat gonorrhoea. It is also important to establish the person’s immune status with regard to hepatitis A and hepatitis B viruses.
Underuse of effective contraception
Many young people continue to use either no contraception or unreliable means of contraception including the withdrawal method (used by 10% of Australian young people).5 Most pregnancies in adolescents in Australia are unintended, and about half of these pregnancies are terminated.6 Teenage pregnancy is of significant concern due to the associated poorer health, educational and socioeconomic outcomes in the mothers and children.5