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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Sexual health

Definition

The general practice management of sexual health covers physical, emotional, mental and social wellbeing in relation to sexuality, and not merely the absence of disease, dysfunction or infirmity.

Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. According to the World Health Organization working definition, for sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.1 2

As community based health practitioners, general practitioners are vital to the maintenance of individual sexual health.

Curriculum in practice

Typical cases that illustrate how the sexual health curriculum applies to general practice include:

  • Luci was at a wedding last weekend and drank far more than usual, perhaps in excess of 15 standard drinks of mixed spirits and champagne. It was a warm night and several of the guests then wandered down to the beach with a couple of bottles of champagne. She comes to see you for something to settle her stomach but also for the 'morning after' pill as she has had unprotected intercourse. What is your management? Three days later Luci has developed a slight discharge and lower abdominal pain. A pelvic examination finds extreme adnexal tenderness and cervical excitation. What organism is most likely and what treatment should you use?
  • Carol and her partner Kate have been in a relationship for 8 months and are contemplating moving in together. Carol has a long history of depression and self harm following a brief, previous relationship that was troubled by intimate partner abuse. She has been much happier since meeting Kate. The two share a love of hiking and spend their weekends bushwalking in the local national park. Carol is worried that once they live together it will be harder to keep her sexuality a secret and wants advice on how to raise the subject with her elderly parents. She is also worried that she may lose her job at the private school where she works, which has an exemption from anti-discrimination laws. In reviewing her record, you also realise Carol has missed several appointments and is well overdue for a Pap test.

Rationale and general practice context

Sexuality is a basic human attribute and, as such, is a vital part of human health and wellbeing. According to the World Health Organization working definition1:

'Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors'.

Attending to sexual health and its problems is a basic task of primary healthcare and a core part of general practice in Australia.

Sexual health presentations are common in Australian general practice. According to BEACH activity data, 5.1 out of every 100 patient encounters in general practice were for issues regarding the female genital tract (including Pap tests/check ups and menstrual problems), 3.7 out of 100 encounters were for pregnancy and family planning issues (including oral contraception and pre- and postnatal check ups), 2.8 out of 100 encounters were urological, and 1.4 out of 100 encounters were for the male genital system.3 This does not include encounters for relationship counselling or other sexual health concerns.

Unsafe sex was estimated to cause 0.6% of the burden of disease in Australia in 20034 and the rates of sexually transmissible infections (STIs) continue to rise, especially in young people.5 Sexual contact can transmit infections such as chlamydia, herpes simplex, human papilloma virus, hepatitis B, gonorrhoea, human immunodeficiency virus (HIV) and syphilis. Sexual activity has also been associated with an increased risk for specific cancers such as cervical and anal cancer.

While in recent times sexual health services in Western countries have been provided by sexual health centres, family planning clinics and other facilities, there has been a global trend to integrate sexual health services into primary care.6 This aims to improve antenatal, perinatal, postpartum and newborn care; provide high quality services for family planning, including infertility services; eliminate unsafe abortion; combat STIs including HIV, reproductive tract infections, cervical cancer and other gynaecological morbidities; and promote sexual health.

Due to the diverse nature of sexual practices, clinicians also need to be comfortable with discussing sex with a wide range of people including those of different ages, gender (male, female, transgender), sexual preference, culturally and linguistically diverse backgrounds, and people with disabilities.

The Australian Study of Health and Relationships (ASHR), in a population based sample of males and females aged 16-59 years, indicated that over 7% of women and 6% of men had had sexual experiences with people of the same sex. Approximately 90% of women and 95% of men indicated that they were exclusively attracted to the opposite sex. Males who identified themselves as homosexual reported a higher number of lifetime sexual partners than lesbians or heterosexuals respectively.7 8

In addition, the ASHR8 indicated that the median age of reported first intercourse was 16 years of age. About 40% of males and one-quarter of females reported having had intercourse when they were below the age of 16 years, and so GPs must be able to manage sexual health concerns in young people where risks of unplanned pregnancy and STIs are high. Issues of nonconsensual sexual activity can also emerge at this time. General practitioners should be able to elicit this history and be aware of available support services and resources.

Sexual health in general practice also involves a working knowledge of legislative public health requirements of STIs and mandatory reporting. This includes a working knowledge of disease and partner notification.

Related curriculum areas

Refer also to the curriculum statements:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

SEHT1.1

Communicate effectively when talking about sex and sexual health, and display confidence with language and cultural sensitivity.

SEHT1.2

Take an adequate sexual history in a nonjudgmental manner from various patient groups, including young people, people in same-sex relationships, older patients, people from culturally and linguistically diverse backgrounds, people with disabilities, injecting drug users and sex workers.

SEHT1.3

Counsel on sexual health issues appropriate to the level of training including normal sexual activity, sexual aging, contraception, safer sex education, sexual rights, sexual diversity, contact tracing, gender sexual assault and abuse and sexual dysfunction.

SEHT1.4

Explain to patients the importance of taking a sexual history as part of general healthcare.

SEHT1.5

Provide competent pretest counselling and education for all STIs, in particular for HIV and hepatitis C.

2. Applied professional knowledge and skills

SEHT2.1

Incorporate sexual history taking into the general medical history, including recognising clinical presentations of potentially high sexual health morbidity and mortality.

SEHT2.2

Assess the competency of young people in making their own health decisions regarding their sexual health, including contraception.

SEHT2.3

Perform appropriate genital examinations in a sensitive manner, recognising common normal variants and being respectful of cultural concerns.

SEHT2.4

Understand developmental sexuality including the physical, emotional and social changes of puberty in girls and boys.

SEHT2.5

Understand the psychology relating to sexuality and management of sexual abuse and violence.

SEHT2.6

Understand STIs from bacterial/viral/fungal/protozoal infections including their epidemiology, basic microbiology and signs and symptoms of disease.

SEHT2.7

Understand sexual health pathology testing, results, interpretation and principles and regional/jurisdictional knowledge of contact tracing requirements.

SEHT2.8

Know sexual health treatments and test of cure or test of re-infection (when applicable).

SEHT2.9

Know cervical screening and management guidelines.

SEHT2.10

Know contraception including pharmacology, use, cost effectiveness, accessibility and patient concordance issues for both genders.

SEHT2.11

Know genital dermatology and common gynaecological/urological problems.

SEHT2.12

Understand sexual dysfunction as a common issue and have the ability to discuss this with patients.

3. Population health and the context of general practice

SEHT3.1

Know the prevalence of common STIs such as human papilloma virus, herpes simplex virus and chlamydia and how to access local and national information on these infections.

SEHT3.2

Be aware of changing incidences of STIs within certain population groups, eg. chlamydia in people under 25 years of age, STIs in men who have sex with men, infections acquired overseas and in the indigenous population.

SEHT3.3

Provide opportunistic STI testing to patients at risk, eg. chlamydia testing for people under 25 years of age and those who have recently changed sexual partners, in accordance with RACGP preventive screening guidelines.

SEHT3.4

Understand the key concepts of working with the Aboriginal community to promote indigenous sexual health.

SEHT3.5

Understand the GP's, or other health practitioner's, role in contact tracing and follow up after an STI diagnosis.

SEHT3.6

Promote safer sex practices including condom use when appropriate, to both young people and to adults with a recent change in sexual partner.

SEHT3.7

Be aware that sexual dysfunction can be caused by physical and psychological conditions and is a common adverse effect of frequently prescribed medications, and be able to discuss this with patients.

SEHT3.8

Appreciate the prevalence of sexual assault and abuse within the community and be aware of how this affects your own patient population.

4. Professional and ethical role

SEHT4.1

Understand the heightened concerns for confidentially with regard to sexual healthcare, eg. a person at high risk of HIV may prefer to have testing done within a facility that allows coded testing, such as a sexual health centre.

SEHT4.2

Maintain confidentiality of adolescent patients seeking sexual health and other advice as limited by duty of care.

SEHT4.3

Establish and maintain professional boundaries.

SEHT4.4

Work effectively with local networks to support complete sexual healthcare including sexual health clinics, family planning centres and viral hepatitis clinics.

5. Organisational and legal dimensions

SEHT5.1

Understand and comply with legal requirements with regards to HIV pretest counselling and notification of results according to the stage of training and the legal jurisdiction where the clinician practises.

SEHT5.2

Understand the medical practitioner's and the patient's role in contact tracing, according to the stage of training and the legal jurisdiction where the clinician practises. Be aware of notification requirements and procedures and compliance with these.

SEHT5.3

Be able to coordinate contact tracing and notification using local services acceptable to the patient, noting your legal obligations according to the stage of training and the legal jurisdiction where the clinician practises.

SEHT5.4

Understand and comply with legal issues surrounding termination of pregnancy, according to the stage of training and the legal jurisdiction where the clinician practises.

SEHT5.5

Understand and comply with issues relating to sexual assault, according to the stage of training and the legal jurisdiction where the clinician practises.

SEHT5.6

Understand legal issues surrounding treatment of minors, age of consent and notification of young people at risk of harm, according to the stage of training and the legal jurisdiction where the clinician practises.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

SEHLM1.1

Describe the role of tolerance and acceptance of difference and how this affects communication skills.

SEHLM1.2

Demonstrate how to take a sexual history as part of a medical history, according to level of training.

2. Applied professional knowledge and skills

SEHLM2.1

Outline the range of normal sexual activity, fertility control and genital infection control.

SEHLM2.2

Demonstrate appropriate confident and respectful clinical examination skills.

SEHLM2.3

Describe the clinical investigations/tests available for the investigation of genital infection, specifically STIs.

3. Population health and the context of general practice

SEHLM3.1

Describe the factors influencing the transmission and impact of STIs using the basic sciences of microbiology, anatomy, pathology, pharmacology and psychology.

SEHLM3.2

Describe the principles and importance of education and contact tracing in patient care.

SEHLM3.3

Describe the public health issues related to the management of STIs, both in Australia and overseas.

4. Professional and ethical role

SEHLM4.1

Reflect on own personal knowledge and beliefs regarding sexuality, culture and health, and be aware of how these beliefs have the potential to affect sexual health management.

SEHLM4.2

Demonstrate a developing understanding of ethical practice, confidentiality issues and the requirements for notification of certain STIs.

5. Organisational and legal dimensions

SEHLM5.1

Describe the legal requirements regarding disease notification and laws relating to discrimination that apply to people with HIV and other infections.

Prevocational doctor

1. Communication skills and patient-doctor relationship

SEHLP1.1

Demonstrate the ability to take an appropriate sexual history.

SEHLP1.2

Demonstrate developing confidence in approaching discussion of sexuality/sexual problems/sexual assault.

SEHLP1.3

Demonstrate developing confidence in talking about sexual issues and using language that specifically relates to a range of sexual activities and practices.

SEHLP1.4

Demonstrate the ability to provide accurate safer sex information and to understand the barriers to safer sex practice.

2. Applied professional knowledge and skills

SEHLP2.1

Demonstrate the ability to confidently examine patients with STIs.

SEHLP2.2

Describe the range, epidemiology and prevalence of STIs commonly encountered, or infrequently encountered but dangerous to miss, in the general Australian community.

SEHLP2.3

Describe the appropriate investigations for STIs.

SEHLP2.4

Describe the range of management options for the treatment of common STIs.

SEHLP2.5

Demonstrate knowledge of the interface between sexual and reproductive health and how sexual behaviour may influence contraceptive options.

3. Population health and the context of general practice

SEHLP3.1

Describe the differences in the patterns of STIs and the specific health issues that may exist within different groups in the Australian community, eg. men who have sex with men, Aboriginal and Torres Strait Islander people, recently arrived refugees, youth, the culturally and linguistically diverse, women who have sex with women, sex workers and intravenous drug users.

SEHLP3.2

Describe the extent of HIV in Australian community with regard to case identification and management within a hospital environment.

4. Professional and ethical role

SEHLP4.1

Demonstrate developing ability to handle complex medical and psychosocial issues in a nonjudgmental way relating to sexual health.

SEHLP4.2

Demonstrate increasing awareness of cultural, age related and gender differences in the approach and reaction to STIs.

SEHLP4.3

Reflect on the diversity of sexual experience based on personal experience and undergraduate training, which has encouraged an open approach to such diversity through patient and peer contact and appropriate teaching.

5. Organisational and legal dimensions

SEHLP5.1

Identify resource groups and individuals who can assist and advise with the management of sexual health issues.

SEHLP5.2

Describe ethical clinical practice, notification, public health acts and contact tracing with regard to sexual health.

SEHLP5.3

Describe mandatory reporting regulations with respect to STIs and their implementation.

Vocational registrar

1. Communication skills and patient-doctor relationship

SEHLV1.1

Demonstrate openness to diversity through patient and peer contact and confidence in basic clinical and interpersonal skills in the provision of sexual healthcare.

2. Applied professional knowledge and skills

SEHLV2.1

Demonstrate the ability to assess, examine and investigate patients presenting with sexual health problems, including possible infection.

3. Population health and the context of general practice

SEHLV3.1

Describe the principles and practices of contact tracing and how they apply to the community that the practitioner is working in.

SEHLV3.2

Demonstrate the ability to function independently in community practice with reference to appropriate sexual health screening and public health measures.

4. Professional and ethical role

SEHLV4.1

Demonstrate continual development and awareness of how personal attitudes and experiences may affect clinical practice.

SEHLV4.2

Demonstrate the ability to practise in a manner in which confidentiality is maintained within the legal obligations, especially of contact tracing.

SEHLV4.3

Describe the ethical implications of sexual health issues.

5. Organisational and legal dimensions

SEHLV5.1

Describe the legal implications of sexual health issues.

Continuing professional development

1. Communication skills and patient-doctor relationship

SEHLC1.1

Demonstrate the ability to raise the issue of intimate partner violence or unwanted sexual experience in the context of routine sexual healthcare enquiries and develop a planned approach to the management of disclosure.

2. Applied professional knowledge and skills

SEHLC2.1

Demonstrate commitment to continue exploring the field of sexual health and the challenges within your own practice.

SEHLC2.2

Demonstrate commitment to providing best practice in sexual healthcare provision.

3. Population health and the context of general practice

SEHLC3.1

Describe and demonstrate the ability to manage the particular sexual health needs of various subpopulations at risk, eg. Aboriginal and Torres Strait Islander people, young people, gay, lesbian, bisexual, transgender, intersex patients, patients from culturally and linguistically diverse backgrounds, and people with disabilities.

4. Professional and ethical role

SEHLC4.1

Reflect and act on clinician professional development needs in sexual health medicine including quality assurance and continuing professional development activities.

5. Organisational and legal dimensions

SEHLC5.1

Demonstrate a willingness to tailor practice to encourage clients from diverse backgrounds to attend for sexual health services.

SEHLC5.2

Regularly review clinical practice in relation to the major issues in sexual healthcare provision and changes that may occur within own community (eg. chlamydia in young people).

References

  1. World Health Organization. Gender and human rights. Available at www.who.int/reproductivehealth/topics/gender_rights/sexual_health/en.
  2. World Health Organization. Defining sexual health. Report of a technical consultation on sexual health. 2006. Available at www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf.
  3. Britt H, Charles J, Henderson J, et al. General practice activity in Australia 2009?10. Canberra: Australian Institute of Health and Welfare; 2010.
  4. Australian Institute of Health and Welfare. The burden of disease and injury in Australia 2003. 2007. Available at www.aihw.gov.au/publication-detail/?id=6442467990.
  5. Australian Institute of Health and Welfare. Australia's health 2010. Canberra: Australian Institute of Health and Welfare; 2010.
  6. Department of Reproductive Health and Research. World Health Organization. Integrating sexual health into primary care services. Progress in reproductive health research. No 67. 2005. .
  7. Australian Research Centre in Sex Health and Society. Latrobe University. Summary. Australian Longitudinal Study of Health and Relationships. 2005. Available at www.latrobe.edu.au/alshr/papers/wave1_summary2005.pdf.
  8. Smith AM, Rissel CE, Richters J, Grulich AE, de Visser RO. Sex in Australia: the rationale and methods of the Australian Study of Health and Relationships. Aust N Z J Public Health 2003;27:106-17.

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