Sexual Health for GPs: Complete Survival Guide

❤️

Sexual Health for GPs: Your Complete Survival Guide

From awkward conversations to confident care - comprehensive, inclusive, evidence-based

Tea-Friendly Learning For GP Trainees Short on Time Red Flag Focused 🏳️‍🌈 LGBTQIA+ Inclusive 📚 Exam Ready

Date Updated: February 8, 2026

What This Page Covers:

• Consultation Mastery: Setting up safe spaces, taking inclusive histories, and intimate exams
• Diagnostic Pathways: When to test, treat, or refer for STIs and other conditions
• Differential Diagnosis: Symptom-led frameworks for common presentations
• Common Conditions: Confidently managing infections, contraception, and sexual dysfunction
• Red Flags: Safeguarding, emergencies, and serious pathology you must not miss
• Exam Relevance: How this is tested in AKT, RCA, and WPBA assessments

⚡ Quick Facts at a Glance:

99%

PrEP reduces HIV risk by 99%

Almost 0%

HIV transmission risk from HIV+ person on antivirals with undetectable viral load

1 in 4

Teens will have an STI before age 18

70%

Reduction in genital warts since HPV vaccine introduction

Quick Navigation

Downloads & Resources

path: SEXUAL HEALTH

hiv counselling.doc

hiv post exposure prophylaxis guidelines (BAASH).pdf

hiv pretest discussion.pdf

lgbtq - avoiding heterosexual bias in language.doc

lgbtq - avoiding heterosexual bias in language.ppt

lgbtq - gay men and their sexual health.doc

lgbtq - gay people and productivity - stonewall report.pdf

lgbtq - gay sexual slang.ppt

lgbtq - heterosexual questionnaire.doc

lgbtq - sexual orientation  - a practical guide for the nhs.pdf

lgbtq - working with gay people.pdf

lgbtq - working with trans people.pdf

lgbtq -gay slang explicit.doc

osce station - chlamydia.doc

postcoital bleeding.doc

setting up a sexual health service.ppt

sexual and psychosexual problems in gp - a tutorial plan.doc

sexual health - and being a gp lead.ppt

sexual health case and resources.doc

sexual health cases.doc

sexual health of the young.pdf

sexual health promotion.pdf

sexual health.doc

sexual history - basic rules.ppt

sexual history - how to take one.pdf

sexual history taking and common sti.ppt

sexually transmitted infections.pdf

Web Resources

Brainy Bites: Essential Sexual Health Wisdom

Key Questions for Data Gathering

Partners, Practices, Protection, Past STIs, Pregnancy intentions. Tailor to time available

Sample phrases:

• "Can you tell me about your sexual partners in the last few months?"
• "What types of sexual activity do you engage in?"
• "How do you protect yourself during sexual activity?"
• "Have you ever been diagnosed with a sexually transmitted infection?"
• "Are you trying to get pregnant, or trying to avoid pregnancy?"

"How has this affected your relationship/self-esteem?" Context matters as much as the symptom

Sensitive approaches:

• "This must be quite worrying for you..."
• "How is your partner feeling about this?"
• "Has this changed how you feel about intimacy?"

Red Flags – What Not to Miss!

Torsion is a surgical emergency. Assume it's torsion until proven otherwise

• Acute onset (<24 hours)
• Severe pain, nausea/vomiting
• Elevated testis, absent cremasteric reflex
• Same-day urology referral essential

PID can cause tubal damage rapidly. Don't delay treatment

• Lower abdominal pain + cervical motion tenderness
• Fever, abnormal discharge, raised inflammatory markers
• Broad-spectrum antibiotics immediately
• Urgent referral if systemically unwell

FGM, child sexual exploitation, domestic violence. Know your mandatory reporting duties

• FGM in girls <18: Mandatory police reporting within 1 month
• Unexplained STIs in children
• Signs of coercion or abuse
• Document carefully - may be used in court

Common Sexual Diseases for GPs

Sexual Orientation, Sexual Practices, Language and Anatomy

💬

Based on American Psychological Association guidelines: Language shapes care quality and patient comfort.

✓ Inclusive Language

• "Are you in a relationship?" (not "Are you married?")
• "Tell me about your partner" (not "boyfriend/girlfriend")
• "Do you have sex with men, women, or both?" (not assumptions)
• "Sexual orientation" (not "sexual preference")
• "Same-gender sexual behavior" (not "homosexual behavior")
• "What pronouns do you use?"
• "What name would you like me to use?"

✗ Avoid These Terms

• "Homosexual" (use "gay" or "lesbian")
• "Sexual preference" (implies choice)
• "Opposite sex" (use "other gender")
• "Normal" relationships (implies others abnormal)
• Assuming marital status indicates sexual activity
• "Lifestyle choice" (regarding sexual orientation)
• "Sexual deviant" or pathologizing language

Key Principles

• Use people-first language: "people who are gay" rather than "gays"
• Include diverse examples in health education
• Don't assume pregnancy risk from all sexual activity
• Use parallel terms when comparing groups
• Avoid stigmatizing language and stereotypes

LGBTQIA+ Explained

L - Lesbian: Woman SEXUALLY ATTRACTED to and WANTING ROMANTIC RELATIONSHIP with another woman
G - Gay: Man SEXUALLY ATTRACTED to and WANTING ROMANTIC RELATIONSHIP with another man (or umbrella term)
B - Bisexual: SEXUALLY ATTRACTED to and WANTING ROMANTIC RELATIONSHIP with male or female gender
T - Transgender: Gender identity differs from birth sex

Q - Queer/Questioning: Umbrella term or exploring identity
I - Intersex: Born with atypical sex characteristics
A - Asexual: Little to no sexual attraction
+ - Plus: Includes all other identities

Common Orientations

Heterosexual/Straight: SEXUALLY ATTRACTED to and WANTING ROMANTIC RELATIONSHIP with the opposite gender
Gay/Lesbian: SEXUALLY ATTRACTED to and WANTING ROMANTIC RELATIONSHIP with the same gender
Bisexual: SEXUALLY ATTRACTED to and WANTING ROMANTIC RELATIONSHIP with either male or female gender
Pansexual: SEXUALLY ATTRACTED to and WANTING ROMANTIC RELATIONSHIP with anyone, regardless of gender
Asexual: Little to no sexual attraction

Behavioral vs Identity

MSM: Men who have Sex with Men (behavior, not identity) - usually want relationship with females, and sexually attracted to females, but also like sexual acts with men, even though they usually dont find men particularly attractive nor do they want a relationship with them.
Heteroflexible: Mostly heterosexual (sexually attracted to & want relationship with opposite sex) but sometimes have other-gender attraction.
Homoflexible: Mostly homosexual (sexually attracted to and want relationship with same sex), but sometimes have different-gender attraction
Note: Behavior ≠ Identity. Some MSM don't identify as gay/bisexual

Gender Identity

Cisgender: Gender identity matches birth sex
Transgender: The person feels deeply inside that they are different from the gender they were born with. Imagine what you are now and tommorrow, you wake up inside the body of the opposite sex? How would you feel? This is exactly how trans people feel, although they did not wake up overnight with it.
Non-binary: A person does not relate to feeling male nor female
Gender fluid: Somedays a person feels male, other days more female, and possibly other days, something else.
Agender: Someone does not particularly feel male or female or anything else.

Important Distinctions

Transgender vs Transvestite: The first is to do with identity, the transgender person feels deeply inside of a gender different to what they were born with. A transvestite is a person who is comfortable with the gender they were born with, but prefers to wear clothing of the opposite gender usually for sexual gratification or expression.
Binary vs Non-binary: Binary - means a person relates to being male or female. Non-binary - a person does not relate to feeling male nor female.
Pronouns: Most cis-males and trans-males prefer to be called he/him. Most cis-females and trans-females prefer to be called she/her. Most non-binary prefer to be called they/them. The latter might sound odd to you, but it is only because you are not used to saying it. Grammatically it is correct and not wierd. If you feel it feels weird to you, it means you have some learning and development needs.
Intersex: Born with atypical sex characteristics (formerly "hermaphrodite" - outdated term)
Note: Always use person's chosen name and pronouns

ℹ️

Understanding diverse sexual practices helps provide appropriate risk assessment and harm reduction advice.

Practice	Description	STI Risks	Harm Reduction
Oral Sex	Mouth-to-genital contact	HSV, HPV, gonorrhoea, syphilis, chlamydia	Condoms, dental dams, avoid if oral lesions
Anal Sex	Penetration of anus	Highest HIV risk, all STIs, hepatitis	Condoms, PrEP if high risk, adequate lubrication
Vaginal Sex	Penetration of vagina	All STIs, pregnancy risk	Condoms, contraception, regular testing
Rimming	Oral-anal contact	Hepatitis A/B, parasites, bacterial infections	Dental dams, hepatitis vaccination, hygiene
Fisting	Hand/fist insertion into vagina or anus	Trauma, blood-borne viruses, bacterial infections	Gloves, adequate lubrication, gradual progression
Sex Toys	Use of objects for sexual pleasure	Cross-contamination, trauma if inappropriate objects	Clean between partners, condoms on toys, body-safe materials
Chemsex	Sex under influence of drugs	Increased risk-taking, sharing equipment	Harm reduction services, addiction support, regular testing
Poppers Use	Alkyl nitrites inhaled for anal muscle relaxation but others use it for a little "high" sexual feeling.	Increased risk-taking, potential for trauma	Avoid with erectile dysfunction medications, use in ventilated areas
Group Sex	Multiple partners simultaneously	Multiple exposures, cross-contamination	Fresh condoms between partners, regular testing
Polyamory/Throuples	Multiple romantic relationships (this is becoming more common)	Network transmission risks	Communication, testing agreements, barrier methods

Clinical Approach

• Ask about specific practices, not just "sexually active"
• Tailor STI screening to practices engaged in
• Provide non-judgmental harm reduction advice
• Consider extra-genital testing (throat, rectum) for MSM
• Discuss PrEP for high-risk individuals

Penis Size: Facts for Patient Reassurance

Average Measurements

• Flaccid length: 9.16 cm (3.6 inches)
• Erect length: 13.12 cm (5.17 inches)
• Erect circumference: 11.66 cm (4.59 inches)
• Normal range: 10-18 cm when erect

Key Messages

• Size does NOT determine sexual satisfaction
• Technique and communication matter more
• Most vaginal nerve endings in outer third
• Reassure patients about normal variation

Data-Gathering & Examination Tips

Under-16s: Fraser Guidelines

Apply Fraser guidelines (Gillick competence). Confidentiality can be maintained if the young person:

• Understands the advice and its implications
• Cannot be persuaded to involve parents
• Is likely to have sex without treatment/advice
• Their physical/mental health would suffer without advice

Essential Elements

• Chaperones: Always offer for intimate examinations. Document offer and response
• Inclusive Language: Ask about preferred name and pronouns
• Documentation: Clear, factual notes. Include relevant negatives
• Safety-netting: Clear advice on when to return

What to Say

• "Everything we discuss is confidential..."
• "I'd like to offer you a chaperone for the examination"
• "What name would you like me to use?"
• "What pronouns do you use?"

STI Risk Assessment (The 5 P's)

Partners: Number, gender, concurrency
Practices: Vaginal, anal, oral
Protection: Condom use consistency
Past History: Previous STIs, tests
Pregnancy Intention: Contraception needs

Sample Questions:

• "How many sexual partners have you had in the last 3 months?"
• "What types of sexual activity do you engage in?"
• "How often do you use condoms?"
• "Have you ever had an STI?"

Contraception Consultation Structure

• Medical eligibility (UKMEC criteria)
• Efficacy, advantages, disadvantages
• Patient preferences and lifestyle fit
• Follow-up and troubleshooting plans

Key Questions:

• "What's most important to you in contraception?"
• "How do you feel about daily methods?"
• "Any concerns about procedures?"

Unwanted Pregnancy Approach

• Explore sensitively: preferences, safety, immediate risks
• Safeguarding assessment (coercion, abuse)
• Non-directive counselling on all options
• Clear signposting to appropriate services

Always obtain explicit consent and offer a chaperone for intimate examinations.

Female Genital Examination

Indications:

• Abnormal bleeding, discharge, pain
• Suspected PID, foreign body
• Contraceptive device issues

Approach:

• Explain each step clearly
• Visual inspection first
• Speculum if needed
• Look for: discharge, lesions, ulcers, warts, atrophy, FGM

Vaginal pH Testing & Swabs

• pH >4.5 suggests bacterial vaginosis or trichomoniasis
• Self-taken vulvovaginal swabs acceptable for chlamydia/gonorrhoea
• Clinician-taken swabs needed for microscopy

Common pitfall:

Using lubricant on swabs can affect test results

Key Phrases for Sensitive Sexual Health Enquiries

"I'd like to ask you some questions about your sexual health. This is a routine part of healthcare, and everything we discuss is confidential."

"These questions might seem personal, but they help me provide you with the best care possible."

"I ask all my patients these questions - it's nothing to be embarrassed about."

"Are you currently in a sexual relationship?"

"Can you tell me about your sexual partners in the last few months?"

"Do you have sex with men, women, or both?"

"How would you describe your sexual orientation?"

"What types of sexual activity do you engage in?"

"This includes vaginal, oral, or anal sex - I need to know to provide appropriate testing."

"Do you use any sex toys or engage in other sexual practices?"

Diagnostic Approach & Investigations

Investigate vs. Treat vs. Refer - Navigating the "what next" after a sexual health presentation

Opportunistic Screening (NICE NG221 recommends):

• All sexually active under-25s annually (chlamydia)
• New sexual partners or change in partner
• Men who have sex with men (MSM) - 3-monthly if high risk
• Pre-conception or antenatal booking
• HIV testing in high prevalence areas (>2/1000) offered to all new registrants

Symptomatic Testing Indications:

• Abnormal vaginal/urethral discharge
• Dysuria, frequency, urgency
• Genital ulcers, lumps, or lesions
• Pelvic pain or abnormal bleeding
• Partner notification from STI diagnosis

Testing Frequency for High-Risk Groups:

Gay Men & MSM:

• HIV, syphilis: Every 3 months
• Chlamydia, gonorrhoea: Every 3 months
• Hepatitis B: Annually (if not immune)
• Include throat and rectal swabs

Women at Higher Risk:

• Multiple partners: Every 6 months
• Sex workers: Every 3 months
• Partner of MSM: Every 6 months
• Cervical screening as per guidelines

Presentation	First-line Tests	Additional Tests	When to Refer
Abnormal discharge	pH, microscopy, chlamydia/gonorrhoea NAAT	Trichomonas PCR if high risk	Recurrent symptoms, treatment failure
Fishy odour	pH, microscopy (clue cells)	Whiff test (KOH)	Recurrent BV (>3 episodes/year)
Cottage cheese discharge	pH, microscopy (spores/hyphae)	Candida culture if recurrent	Recurrent thrush (>4 episodes/year)
Frothy yellow discharge	Trichomonas PCR, chlamydia/gonorrhoea	Full STI screen	Always refer for contact tracing

Available Self-Testing Options:

HIV Self-Testing:

• Oral fluid or fingerprick tests
• Results in 15-20 minutes
• Window period: 12 weeks
• Reactive results need confirmation

STI Postal Testing:

• Chlamydia/gonorrhoea: Urine or swab
• Syphilis/HIV: Fingerprick blood
• Available through SH:24, local services
• Results via text/online portal

ℹ️

Patient Counselling: Explain window periods, limitations, and importance of professional follow-up for positive results.

Same-Day Referrals:

• Suspected testicular torsion
• Severe PID with systemic symptoms
• Suspected sexual assault (within 72 hours for forensics)
• Paraphimosis or severe balanitis
• Suspected ectopic pregnancy

Urgent (within 48 hours):

• Suspected gonorrhoea (high resistance rates)
• Primary syphilis (infectious)
• Suspected herpes in pregnancy
• Complicated STI in immunocompromised
• Safeguarding concerns

Differential Diagnosis Frameworks

Symptom-Led Differentials - Pattern recognition for common sexual health presentations

Condition	Discharge Characteristics	Associated Symptoms	Key Diagnostic Features
Bacterial Vaginosis	Thin, grey, fishy odour	Usually asymptomatic, mild itch	pH >4.5, clue cells, positive whiff test
Candida	Thick, white, cottage cheese	Intense itch, dysuria, dyspareunia	pH <4.5, spores/hyphae on microscopy
Trichomoniasis	Frothy, yellow-green, offensive	Dysuria, frequency, strawberry cervix	pH >4.5, motile organisms on microscopy
Chlamydia	Mucopurulent or absent	Often asymptomatic, dysuria, bleeding	NAAT positive, cervical friability
Gonorrhoea	Purulent, yellow-green	Dysuria, pelvic pain, fever	NAAT positive, gram-negative diplococci
Physiological	Clear/white, cyclical variation	No itch, odour, or pain	pH 3.8-4.5, normal lactobacilli

Clinical Pearls:

• Mixed infections are common - test for multiple causes
• Absence of symptoms doesn't rule out STIs
• Consider atrophic vaginitis in post-menopausal women
• Foreign body (retained tampon) can mimic infection

Condition	Ulcer Characteristics	Pain	Associated Features	Diagnosis
HSV (Primary)	Multiple, shallow, vesicles → ulcers	Very painful	Fever, malaise, lymphadenopathy	PCR swab, serology
HSV (Recurrent)	Fewer, smaller ulcers	Mild-moderate pain	Prodromal tingling, shorter duration	Clinical, PCR if atypical
Primary Syphilis	Single, indurated, clean base	Painless	Regional lymphadenopathy	Dark field microscopy, serology
Behçet's Disease	Deep, well-demarcated	Very painful	Oral ulcers, eye symptoms, arthritis	Clinical criteria, exclude infections
Aphthous Ulcers	Shallow, yellow base, red halo	Painful	Recurrent, stress-related	Clinical, exclude other causes
Trauma	Variable, history of injury	Variable	Clear precipitant	History, exclude infection

⚠️

Red Flag: Any persistent, non-healing genital ulcer should be biopsied to exclude malignancy.

Superficial Dyspareunia (Entry Pain)

Infections: Candida, HSV, bacterial vaginosis
Dermatological: Lichen sclerosus, eczema, contact dermatitis
Anatomical: Tight hymen, vaginal stenosis
Hormonal: Atrophic vaginitis (menopause, breastfeeding)
Psychological: Vaginismus, anxiety, trauma history

Deep Dyspareunia (Deep Pelvic Pain)

Gynaecological: Endometriosis, ovarian cysts, fibroids
Inflammatory: PID, chronic pelvic pain syndrome
Anatomical: Retroverted uterus, pelvic adhesions
Bowel: IBS, constipation, inflammatory bowel disease
Urological: Interstitial cystitis, urethral syndrome

Assessment Approach:

• Detailed sexual history including timing, triggers, positions
• Relationship factors, psychological wellbeing, trauma history
• Examination: external genitalia, single-finger examination first
• Consider Q-tip test for vulvodynia/vestibulodynia
• Pelvic examination if tolerated - assess for masses, tenderness

Bleeding Pattern	Common Causes	Key Features	Initial Management
Post-coital bleeding	Cervical ectropion, polyps, cancer, infections	Bleeding after intercourse	Speculum exam, cervical screening, STI testing
Intermenstrual bleeding	Hormonal contraception, polyps, fibroids, cancer	Bleeding between periods	Pregnancy test, pelvic exam, consider imaging
Heavy menstrual bleeding	Fibroids, adenomyosis, endometrial pathology	>80ml/cycle or subjective heaviness	FBC, TFTs, consider transvaginal USS
Post-menopausal bleeding	Atrophy, HRT, endometrial cancer, polyps	Any bleeding >12 months post-menopause	Urgent 2-week wait referral
Breakthrough bleeding	Missed pills, drug interactions, infections	Bleeding on hormonal contraception	Review compliance, STI screen, consider change

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Red Flags: Post-menopausal bleeding = cancer until proven otherwise. Urgent referral required.

Treatment & Prevention

STI Treatments, Contraception & Prevention Strategies

Updated 2026: Treatment recommendations based on latest BASHH guidelines. Always check local antimicrobial resistance patterns.

Condition	First Line Treatment	Alternative	Notes
Chlamydia (uncomplicated)	Doxycycline 100mg BD × 7 days	Azithromycin 1g day 1, then 500mg × 2 days	Test of cure not routinely needed. Partner notification essential
Gonorrhoea	Refer to GUM	If urgent: Ceftriaxone 1g IM + Azithromycin 1g PO	High resistance rates - culture essential. Always dual therapy
Syphilis (early)	Refer to GUM	Benzathine penicillin 2.4MU IM (single dose)	Partner notification essential. Follow-up serology needed
HSV (first episode)	Aciclovir 400mg TDS × 5 days	Valaciclovir 500mg BD × 5 days	Start within 72 hours. Extend to 10 days if severe
HSV (recurrent)	Aciclovir 800mg TDS × 2 days	Suppressive therapy if ≥6 episodes/year	Patient-initiated therapy. Start within 24 hours
Bacterial Vaginosis	Metronidazole 400mg BD × 5-7 days	Metronidazole gel 0.75% × 5 days	Avoid alcohol during treatment. Partner treatment not needed
Candida (uncomplicated)	Fluconazole 150mg single dose	Clotrimazole pessary 500mg single dose	Topical treatments safe in pregnancy
Trichomoniasis	Metronidazole 2g single dose	Metronidazole 400mg BD × 7 days	Always treat partner. Test of cure at 4 weeks

Important Treatment Principles:

• Always treat sexual partners for STIs (except BV and candida)
• Advise abstinence until treatment completed and symptoms resolved
• Follow up positive results and ensure treatment completion
• Consider expedited partner therapy where appropriate
• Document partner notification attempts

Infection	Discharge Appearance	Odour	pH	Itch/Pain	Other Features
Bacterial Vaginosis	Thin, grey, homogeneous	Fishy, especially after sex	>4.5	Minimal itch	Clue cells, positive whiff test
Candida	Thick, white, cottage cheese	Yeasty/bread-like	<4.5	Intense itch, burning	Vulval erythema, satellite lesions
Trichomoniasis	Frothy, yellow-green	Offensive, musty	>4.5	Itch, dysuria	Strawberry cervix, motile organisms
Chlamydia	Mucopurulent or none	None or mild	Variable	Often asymptomatic	Cervical friability, bleeding
Gonorrhoea	Purulent, yellow	None to offensive	Variable	Dysuria, pelvic pain	Cervical inflammation, systemic symptoms
Normal	Clear to white, cyclical	None or mild	3.8-4.5	None	Lactobacilli predominant
Atrophic Vaginitis	Scant, may be bloody	None	>4.5	Dryness, dyspareunia	Pale, thin vaginal walls

Clinical Pearls for Recognition:

• Fishy odour + grey discharge = BV (most reliable combination)
• Cottage cheese + intense itch = Candida (classic presentation)
• Frothy + offensive = Trichomoniasis (always STI screen)
• No symptoms ≠ no infection (chlamydia often asymptomatic)
• Mixed infections common (test for multiple causes)
• pH testing is quick and helpful (normal <4.5)

LARC (Long-Acting Reversible Contraception) - First Choice

Method	Efficacy	Duration	Key Benefits	Main Considerations
Mirena IUS	>99%	5 years	Reduces menstrual bleeding	Initial irregular bleeding
Copper IUD	>99%	10 years	Hormone-free, immediate fertility return	May increase bleeding/pain
Implant	>99%	3 years	Convenient, reversible	Unpredictable bleeding patterns
Depo injection	>99%	12 weeks	Private, reduces periods	Delayed fertility return, bone density

Emergency Contraception

Levonorgestrel (Levonelle):

• 1.5mg single dose
• Up to 72 hours post-UPSI
• Less effective after 24 hours
• Available over-the-counter

Ulipristal (ellaOne):

• 30mg single dose
• Up to 120 hours post-UPSI
• More effective than levonorgestrel
• Prescription only

Copper IUD: Most effective emergency contraception up to 5 days post-UPSI or ovulation

Barrier Methods & Safer Sex

Male Condoms:

• 98% effective when used correctly
• Protect against most STIs
• Use with water-based lubricant
• Check expiry dates and storage

Female Condoms & Dental Dams:

• Female condoms: 95% effective
• Dental dams for oral-genital/anal contact
• Can be inserted up to 8 hours before
• User-controlled protection

Vaccination Programs

HPV Vaccination:

• Routine at age 12-13 (both sexes)
• Catch-up to age 25 for MSM
• Protects against cancer-causing types
• 70% reduction in genital warts

Hepatitis B:

• Routine in infancy
• Offer to high-risk adults
• MSM, sex workers, multiple partners
• Check immunity before vaccination

Harm Reduction Counselling

• Risk reduction: Fewer partners, mutual monogamy, regular testing
• Substance use: Avoid chemsex, don't share equipment
• Communication: Discuss STI status with partners
• Regular screening: Tailor frequency to risk level
• Treatment as prevention: Undetectable = untransmittable (U=U)

Red Flags & Conditions Not to Miss

Safeguarding and Emergencies

Mandatory Reporting Requirements

• FGM in girls <18: Report to police within 1 month (mandatory)
• Child sexual abuse: Any STI in prepubertal child
• Sexual assault: Recent assault requiring forensic examination
• Trafficking: Multiple STIs, signs of control/coercion

Warning Signs to Recognize

Domestic Violence:

• Controlling partner behavior
• Unexplained injuries
• Fear of partner's reaction
• Isolation from support networks

Sexual Exploitation:

• Multiple STIs in young person
• Older partner with significant age gap
• Gifts, money, accommodation provided
• Substance use, missing from home/school

Documentation & Action

• Document concerns clearly and factually
• Use patient's own words in quotes
• Body maps for injuries (if consent given)
• Know local safeguarding procedures
• Involve safeguarding lead/social services
• Consider safety planning with patient

Presentation	Key Features	Immediate Action	Timeframe
Testicular Torsion	Sudden severe testicular pain, nausea, high-riding testis	Urgent urology referral	Same day (<6 hours optimal)
Severe PID	Pelvic pain + fever + systemic symptoms	IV antibiotics, urgent gynae referral	Same day
Paraphimosis	Retracted foreskin causing constriction	Attempt reduction, urgent urology if fails	Same day
Fournier's Gangrene	Necrotizing fasciitis of genitals	IV antibiotics, emergency surgery	Immediate (life-threatening)
Ectopic Pregnancy	Pelvic pain + bleeding + positive pregnancy test	Urgent gynae assessment	Same day
Sexual Assault	Recent assault (<72 hours)	SARC referral, forensic examination	Immediate (evidence preservation)

🚨

Remember: When in doubt, refer urgently. Better safe than sorry with potential emergencies.

2-Week Wait Referral Criteria

Gynecological Cancers:

• Post-menopausal bleeding
• Unexplained vulval lump/ulceration
• Persistent pelvic mass
• Cervical mass on examination

Urological Cancers:

• Testicular lump (any age)
• Penile lesion/ulceration
• Persistent scrotal swelling
• Unexplained hematuria

HPV-Related Cancers

• Cervical: Regular screening, investigate abnormal bleeding
• Anal: Consider in high-risk MSM, HIV+ patients
• Oropharyngeal: Increasing incidence, especially in men
• Vulval/Vaginal: Persistent lesions, especially in older women
• Penile: Any persistent lesion, especially if ulcerated

Clinical Examination Red Flags

• Hard, fixed lumps: Suggest malignancy
• Non-healing ulcers: Biopsy required
• Irregular bleeding patterns: Investigate thoroughly
• Unexplained weight loss: Consider systemic disease
• Lymphadenopathy: May indicate metastatic spread

How This Topic Is Tested - Exam-Focused Preparation

High-Yield Topics for AKT

Clinical Knowledge:

• STI treatment regimens (especially chlamydia)
• Contraception efficacy rates and UKMEC criteria
• Emergency contraception timeframes
• Cervical screening guidelines
• Fraser guidelines for under-16s

Guidelines & Evidence:

• NICE guidelines on STI reduction
• BASHH treatment recommendations
• FSRH contraception guidance
• Safeguarding procedures
• Partner notification requirements

Sample AKT-Style Questions

Q: A 19-year-old woman has a positive chlamydia test. What is the first-line treatment?

A: Doxycycline 100mg BD for 7 days

Q: A 15-year-old requests contraception. Under Fraser guidelines, you can provide this without parental consent if:

A: She understands the advice and cannot be persuaded to involve parents

Communication Skills Assessment

Data Gathering:

• Use inclusive, non-judgmental language
• Explore ICE (Ideas, Concerns, Expectations)
• Take comprehensive sexual history (5 P's)
• Address confidentiality early

Clinical Management:

• Explain examination process clearly
• Discuss treatment options and side effects
• Address partner notification sensitively
• Provide clear safety-netting advice

Common RCA Scenarios

• Young person requesting contraception
• Patient with STI symptoms needing testing
• Contraception counseling and method selection
• Breaking bad news (positive STI result)
• Emergency contraception consultation
• Sexual dysfunction or relationship problems

Case-Based Discussion (CBD) Topics

• Complex contraception cases (multiple comorbidities)
• STI contact tracing and partner notification
• Safeguarding concerns in sexual health
• Managing treatment failures or complications
• Ethical dilemmas (confidentiality vs. public health)

Clinical Observation Tool (COT) Skills

Consultation Skills:

• Establishing rapport and trust
• Sensitive history taking
• Appropriate examination technique
• Clear explanation of findings

Professional Skills:

• Maintaining confidentiality
• Recognizing limitations
• Appropriate referral decisions
• Documentation standards

Recommended Learning Opportunities

Clinical Attachments:

• GUM clinic sessions
• Family planning clinics
• Young people's sexual health services
• Gynecology outpatients

Skills Development:

• IUD/IUS insertion training
• Contraceptive implant procedures
• Cervical screening updates
• Safeguarding training

Portfolio Evidence

• Significant Event Analysis: STI outbreak, safeguarding case
• Audit: Contraception prescribing, STI testing rates
• Quality Improvement: Improving sexual health services
• Learning Log: Reflect on challenging cases
• Patient Feedback: Sexual health consultation experiences

HIV: What GPs Need to Know

HIV Disease Stages & Symptoms

Early HIV (Seroconversion Illness) - 2-6 weeks post-infection

Common Symptoms (50-90%):

• Fever, malaise, fatigue
• Maculopapular rash (trunk, face)
• Lymphadenopathy
• Sore throat, mouth ulcers
• Headache, myalgia

Less Common:

• Diarrhea, nausea, vomiting
• Genital ulceration
• Neurological symptoms
• Thrombocytopenia

Key: Often mistaken for flu/glandular fever. High viral load = highly infectious

Chronic HIV (Asymptomatic Phase) - Years to decades

• Usually asymptomatic
• Gradual CD4+ T-cell decline
• May have persistent generalized lymphadenopathy
• Increased susceptibility to infections
• Without treatment: CD4 count falls ~50-100 cells/year

Advanced HIV/AIDS (CD4 <200 cells/μL)

Opportunistic Infections:

• Pneumocystis pneumonia (PCP)
• Candida esophagitis
• CMV retinitis
• Toxoplasmosis
• Mycobacterium avium complex

AIDS-defining Cancers:

• Kaposi's sarcoma
• Non-Hodgkin lymphoma
• Cervical cancer
• Primary CNS lymphoma

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GP Role: Early recognition of seroconversion illness, appropriate testing, and prompt referral to HIV services.

HIV Treatment: GP Knowledge Level

Modern HIV Treatment Principles

• Start immediately: Treatment recommended for all HIV+ patients regardless of CD4 count
• Combination therapy: Usually 3 drugs from 2+ classes (HAART)
• Goal: Undetectable viral load (<50 copies/mL)
• U=U: Undetectable = Untransmittable (no sexual transmission risk)
• Adherence crucial: >95% adherence needed to prevent resistance

Drug Class	Common Examples	Mechanism	Key Side Effects	GP Monitoring
NRTIs (Nucleoside RTIs)	Zidovudine (AZT) Tenofovir Emtricitabine	Block reverse transcriptase	Lactic acidosis, lipodystrophy, renal toxicity	FBC, U&Es, LFTs
NNRTIs (Non-nucleoside RTIs)	Efavirenz Rilpivirine	Block reverse transcriptase	Rash, CNS effects, hepatotoxicity	LFTs, psychiatric symptoms
Protease Inhibitors	Ritonavir Darunavir Atazanavir	Block viral protease	GI upset, lipid abnormalities, diabetes	Lipids, glucose, drug interactions
Integrase Inhibitors	Dolutegravir Raltegravir Bictegravir	Block integration into host DNA	Generally well tolerated, weight gain	Weight, mood changes

GP Role in HIV Care

Shared Care Responsibilities:

• Routine health maintenance
• Cardiovascular risk assessment
• Cancer screening (enhanced)
• Mental health support
• Drug interaction checking

When to Involve Specialist:

• Treatment failure or resistance
• Significant side effects
• Opportunistic infections
• Pregnancy planning
• Complex drug interactions

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Drug Interactions: HIV medications have numerous interactions. Always check before prescribing new medications.

PrEP, PEP & DoxyPEP: Complete Guide

2026 Update: DoxyPEP now recommended by BASHH for high-risk individuals. PrEP access expanded across the UK.

PrEP Regimens & Efficacy

Regimen	Dosing	Efficacy	Best For
Daily PrEP	Tenofovir/Emtricitabine daily	99% reduction in HIV risk	Regular sexual activity, all genders
Event-based PrEP	2-1-1 dosing around sex	86% reduction (MSM only)	Infrequent sexual activity, MSM

PrEP Eligibility Criteria

• MSM with condomless anal sex in last 6 months
• Heterosexual men/women from high-prevalence areas
• People who inject drugs sharing equipment
• Sexual partners of HIV+ individuals not on treatment
• Sex workers at ongoing risk
• Transgender individuals at high risk

PrEP Monitoring Requirements

Before Starting:

• HIV test (4th generation)
• Hepatitis B surface antigen
• eGFR and urinalysis
• Full STI screen

Ongoing (3-monthly):

• HIV testing
• STI screening
• Renal function
• Adherence support

PEP Urgency & Timing

• Start within 72 hours of exposure (ideally <24 hours)
• 28-day course of combination antiretrovirals
• Risk assessment essential - not indicated for all exposures
• Follow-up testing at 6 weeks, 3 months, 6 months

Exposure Type	Risk Level	PEP Recommendation	Additional Considerations
Receptive anal intercourse	High	Recommended	Highest transmission risk
Insertive anal intercourse	Moderate	Consider	Assess source viral load
Receptive vaginal intercourse	Moderate	Consider	Higher risk if menstruating
Insertive vaginal intercourse	Low-moderate	Consider	Risk varies with viral load
Oral sex	Very low	Not usually recommended	Consider if oral ulceration
Needlestick injury	Low	Consider	Assess needle type and source

PEP Regimen (Standard)

• Tenofovir/Emtricitabine (Truvada) 1 tablet daily
• Plus Raltegravir 400mg twice daily
• Duration: 28 days exactly
• Side effects: Nausea, diarrhea, headache, fatigue
• Adherence crucial: Missing doses reduces efficacy

🆕

New 2026: DoxyPEP now recommended by BASHH for preventing bacterial STIs in high-risk individuals.

DoxyPEP Protocol

• Dose: Doxycycline 200mg single dose
• Timing: Within 24-72 hours after condomless sex
• Maximum: Once daily (don't repeat if multiple exposures same day)
• Efficacy: ~65% reduction in chlamydia, gonorrhoea, syphilis

DoxyPEP Eligibility

Recommended For:

• MSM with recent bacterial STI
• MSM on PrEP with high STI risk
• Transgender women with high STI risk
• Consider for other high-risk groups

Contraindications:

• Doxycycline allergy
• Pregnancy/breastfeeding
• Children under 12 years
• Concurrent tetracycline use

DoxyPEP Considerations

• Resistance concerns: Monitor local resistance patterns
• Not effective against: Herpes, HIV, hepatitis
• Side effects: GI upset, photosensitivity, esophagitis
• Regular STI screening still essential
• Counseling: Not a substitute for safer sex practices

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You've Got This! 💪

Remember: You don't need to be a sexual health specialist to provide excellent sexual healthcare. You just need to know when to worry (red flags), when to treat (primary care management), and when to refer (specialist services).

Key Takeaways:

• Create a safe, non-judgemental space using inclusive language
• Use structured approaches for history-taking (5 P's framework)
• Know your safeguarding duties and mandatory reporting requirements
• Understand the common conditions you can manage and when to escalate
• Sexual health conversations get easier with practice - your inclusive approach makes a difference

Now go reward yourself with that well-deserved coffee ☕