Reproductive and Sexual Health Handbook

This chapter provides guidance for ensuring a patient-centred approach to reproductive and sexual health consultations and associated clinical examinations, with particular reference to marginalised populations who may be vulnerable to poor reproductive and sexual health outcomes. 

Gender-neutral language has been used throughout the Handbook where possible; however the terms ‘women/female’ and ‘men/male’ are also commonly used for ease of reference and succinctness. 

Optimal sexual health is ‘…a state of physical, emotional, mental and social well-being in relation to sexuality; it is 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. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled’.⁽¹⁾ While distinct from reproductive health, sexual health and reproductive health are also closely linked.⁽²⁾

This Handbook aims to support clinicians in providing best-practice reproductive and sexual health care to Australia’s geographically and socio-culturally diverse populations. In order to uphold the principles of optimal reproductive and sexual health, it is important to understand people’s attitudes, behaviours and practices relating to reproductive and sexual health matters. Research and data collected from large national representative surveys not only shapes health policy but also provides valuable insights into current practices and trends relating to sexual behaviours and attitudes.

The 6th National Survey of Australian Secondary Students and Sexual Health, which surveyed 6,327 year 10, 11 and 12 students from Government, Catholic and Independent schools in Australia, reported

Taking an effective history from a patient is an essential skill that can be mastered with practice. Depending on the context of the consultation and the needs of the patient, the history may be brief or more detailed. The taking of a focused history from a patient with new onset pelvic pain will differ in scope from opportunistically enquiring about their sexual health during a cervical screening consultation; however both share the same principles, as outlined below.

It is also important to be aware that patients seeking reproductive and sexual health care may have experienced, or be experiencing, domestic or gender-based violence. Be alert to and aware of cues and indicators of this, which may include psychological and mental health issues as well as physical injuries. The Domestic Violence Toolkit for GPs provides a useful framework for supporting and managing disclosures of domestic violence in the primary care setting ⁽⁸⁾ (also see section on Safety Planning and Referral in Chapter 16: Management of Sexual Assault and Domestic Violence in Primary Health Care). Be aware that past sexual abuse or sexual violence may increase a patient’s difficulty in seeking help for sexual issues and that ‘routine’ reproductive

Having a structured approach to history taking facilitates continuity of care and clinical handover. Below is a guide to key points to be included when taking a history.

The clinical examination will be informed by a clinical history and any symptoms of the person presenting. Patients may feel anxious, fearful or embarrassed about having an examination. Any procedure being undertaken should be explained to the patient, along with a demonstration on a model if required and possible. Verbal consent must be obtained before conducting any procedure. Check if the patient would like anyone else to be present during the examination.

Your patient mix is likely to be very diverse – including young people, older people, lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) people, Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse (CALD) backgrounds, and people with a disability – all may require particular awareness and sensitivity. Clinicians often feel that consultations can be additionally challenging due to a lack of knowledge of their patient’s cultural, social or family background, because of language and communication difficulties, or because of age differences. It is essential not to make assumptions about patients or force your own values onto them, but rather to provide information in a sensitive and appropriate manner to enhance understanding and ensure they are making informed decisions. It is also important to remember that every person is an individual and will have their own beliefs, values and customs.

 

KEY POINT

It is important not to impose your own values onto the patient, but to listen carefully and provide information in a sensitive and appropriate manner to support understanding and informed shared decision-making about the presenting issues of concern.

World Health Organization (WHO). Defining sexual health: report of a technical consultation on sexual health [internet]. Geneva: World Health Organization; 2006. Available from: https://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf?ua=1. World Health Organization (WHO). Sexual health and its linkages to reproductive health: An operational approach [internet]. Geneva: World Health Organization; 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/258738/9789241512886-eng.pdf;jsessionid=406DCA227A86231A2574790D0EC9DFA0?sequence=1. Fisher C, Waling A, Kerr L, Bellamy R, Ezer P, Mikolajczak G, et al. 6th National Survey of secondary Students and Sexual Health 2018. [Internet]. Bundoora: La Trobe University; 2019. Available from: https://latrobe.figshare.com/articles/6th_National_Survey_of_Australian_Secondary_Students_and_Sexual_Health_2018/7806812. de Visser R, Richters J, Rissel C, Badcock P, Simpson J M, Smith A, et al. Change and stasis in sexual health and relationships: comparisons between the first and second Australian studies of health and relationships. Sex Health 2014;11(5):505-9. Richters J, Rissel C, de Visser R, Grulich A,. Australian study of health and relationships 2: sex in Australia summary Second Australian Study of Health and Relationships (ASHR) 2015. Australian Commission on Safety and Quality in Health Care (ACSQHC). 2nd edition National Safety and Quality Health Service Standards (NSQHS) [internet]. 2019. Available from: https://www.safetyandquality.gov.au/our-work/assessment-to-the-nsqhs-standards/nsqhs-standards-second-edition/. Medical Board of Australia. Sexual boundaries in the doctor-patient relationship [internet].  Medical Board of Australia; 2018 [updated 2018 Dec 12]. Available from: