When should you take a sexual health history?
Questions about sexual health should be routinely included as part of a general history for all patients seen in primary
care. The purpose of taking a sexual health history is to assess risk of STIs, identify problems with sexual function,
identify issues of past sexual abuse or risk of future abuse, and to assess overall sexual wellbeing and knowledge.3
In general, a sexual health check should be undertaken:
- As part of a routine preventative healthcare check-up in all sexually active people (particularly those aged under
- For sexual contacts of someone with a bacterial STI, pelvic inflammatory disease or epididymo-orchitis
- For people who have had a recent partner change or multiple partners
- For females attending for routine contraceptive or cervical screening visits
- Prior to intrauterine device (IUD) insertion
- During routine antenatal testing
- Before termination of a pregnancy
- For people presenting with specific anogenital symptoms
- For people who have been sexually assaulted
- For people who request a sexual health check
How to open a dialogue about sexual history
Ensure that the patient feels comfortable and able to speak openly. It is important that practitioners are also comfortable
with asking questions about sexual health in order to help put patients at ease. It should be clear from the outset that
the consultation is confidential, and the tone of the conversation should aim to normalise the clinical encounter, e.g.
“We routinely discuss sexual health with all our patients, is it ok if I ask you some questions?” or: “Chlamydia is very
common in sexually active young people, so can I ask you some questions to see if you need a check-up?”
General points for taking a sexual history
All questions in the sexual history should be gender neutral until the gender of sexual contacts is known. Avoid using
the term “partner” (or husband/wife) unless the person has stated they are in a relationship.
It is important to discuss confidentiality, and its limitations, in case any significant safety issues are identified.
It may be helpful to briefly explain why each question is being asked and that the questions are routine, e.g. “We ask
everyone the same questions, they may seem intrusive but I’m just trying to find out risks and what tests you may need.”
It may not be possible to take a full sexual history at the initial presentation, especially if this was not the primary
reason for the visit. The most relevant information is whether the patient is currently symptomatic, whether any test
is indicated at that visit, whether they are at risk of unwanted pregnancy and whether they have risk factors for HIV,
syphilis, hepatitis or other infections. Asymptomatic, young people can be referred to the Practice Nurse for a more in-depth
sexual health history and testing if there is insufficient time during the consultation, or be encouraged to return for
an additional consultation. New Zealand research shows that nurse-led education and self-collection of samples is an effective
strategy for increasing uptake of opportunistic chlamydia testing in people aged 16 – 24 years.5
The range of questions that may be included as part of a complete sexual history are:3
- Do you have any specific problems or symptoms? Mention specific symptoms such as, for females: unusual vaginal discharge,
lower abdominal pain, abnormal bleeding, urinary symptoms and dyspareunia; for males: dysuria, penile discharge; and
for both sexes: genital itch, rashes, sores or blisters, anorectal symptoms.
- Are you sexually active at present? Are you in a relationship?
- When was the last time you had sex? (important to establish whether it is an appropriate time to test)
- Was this with a regular or casual sexual contact/partner?
- Was this sexual contact/partner male or female?
- Do sexual encounters usually include vaginal, oral or anal sex?
- How many sexual contacts/partners have you had in the previous two months? (important for partner notification purposes)
- Do you use condoms – always, sometimes or never?*
- For females – when was your last period? Do you use hormonal contraception? When was your last cervical smear?**
- Have you ever had any STIs before?
- Have you had all your routine recommended vaccinations? e.g. Hepatitis B, HPV?**
- Do you ever have sex while under the influence of alcohol or other drugs? Have you ever injected drugs?
- Have you ever traded sex for money or drugs?
- Have you ever had any unwanted sexual contact?
- Have you ever been afraid in a relationship, or been hurt by a partner?
- Have you ever had a non-professional tattoo, genital piercing, or received medical or dental treatment overseas in
a developing nation? (important to assess risk of blood-borne viruses)
Once relevant information has been gathered, ask again if the patient has any questions or if they want to add anything
before assessing their risk of infection.
* Modify to “protection” for women who exclusively have sex with women
** If thorough patient notes are available, hormonal contraception use, cervical smear information and
vaccination questions may be skipped
Assess the patient’s risk profile for STIs
The key behaviours that increase risk of any STIs are:6
- Misuse of alcohol or other recreational drugs
- Early onset of sexual activity
- Inconsistent condom use
- Multiple or frequent change of sexual contacts (more than ten in the previous six months)
- A history of sexual assault or intimate partner abuse
- Commercial sex work (if not using condoms consistently), or having unprotected sex with a commercial sex worker
- The key groups at risk of HIV are:6
- Men who have sex with men (MSM)
- People from a country where there is a high HIV prevalence, e.g. Sub-Saharan Africa, South-East Asia, India, Eastern
Europe, South America
- Injecting drug users
- Sexual partners of people in the above categories
- People at increased risk of blood-borne infections, e.g. hepatitis C, include:3
- Injecting drug users – past or present
- HIV positive MSM
- People who have received medical or dental treatment in a developing nation
- People who have had non-professional tattooing or piercing
Physical examination and appropriate testing
The information gained from the sexual history will guide the extent of physical examination and laboratory testing
Generally, routine STI testing should occur annually where appropriate, but this depends on risk factors. Testing should
be repeated more frequently (i.e. three to six monthly) if the patient’s history suggests higher risk sexual behaviours.
If there is a specific sexual event that the patient is concerned about and they are currently asymptomatic then it
is recommended that testing be deferred until two weeks after the event. If they are unlikely to come back for testing
or if they have current anogenital symptoms then testing should be done at the time of presentation.
Any patient with atypical anogenital ulceration should be referred to or discussed
with a sexual health physician ( for further information see New Zealand Sexual Health Society genital ulcer disease summary: www.nzshs.org).
STI test availability varies throughout New Zealand, and testing should always be guided by local laboratory recommendations.
Most laboratories now offer combined nucleic acid amplification tests (NAAT) for chlamydia and gonorrhoea on a single
PCR swab or urine specimen (talk to your laboratory about the preferred specimen collection swab/receptacle).
Ideally, an examination should be performed as part of a sexual health check-up, and samples for testing taken during
the examination. However, self-testing is a safe and effective method for opportunistic testing in asymptomatic patients
or those who decline examination.8, 9
It is important to tell patients how and when they will be notified of test results. For low-risk patients it is usually
appropriate to tell them that they will only be contacted if there are any abnormal results. For higher risk patients,
e.g. MSM having unprotected anal sex, it is recommended that they are asked to re-attend to discuss their results in person.
Routine examination and testing for females should include:3
- Physical examination of the vulval and perianal skin, inguinal nodes, vestibule, introitus, cervix and vagina, looking
for skin lesions, rashes, ulceration and abnormal vaginal discharge
- If requiring speculum examination, i.e. symptomatic or a contact of a person with gonorrhoea:
- Endocervical swab(s) for chlamydia and gonorrhoea testing (one swab if the laboratory offers combined NAAT testing)
- If a sexual contact of someone with gonorrhoea an additional endocervical swab for culture and antibiotic susceptibility
testing should be taken*
- High vaginal swab for bacterial vaginosis, candida, and trichomoniasis
- Serology for hepatitis B (if not immunised), syphilis and HIV
- Hepatitis C serology if the patient has risk factors
- Viral swab for herpes simplex virus if ulcers are present
A self-collected vaginal swab is appropriate for opportunistic testing for chlamydia in an asymptomatic female, or if
a genital examination is declined. Instruct the patient to remove the swab from its container, insert it approximately
4 cm into the vagina, rotate and then replace in the swab container.
A first void urine (first 30 mL of the stream) is not the first-line recommendation for chlamydia testing in women as
it has lower sensitivity than a vaginal swab, but is useful if the patient declines examination and does not want to self-collect
Routine examination and testing in males should include:3
- Physical examination of the genital and perianal skin, inguinal lymph nodes, penis, scrotum, and testes looking for
skin lesions, urethral discharge, rashes and genital ulceration
- First void urine for chlamydia testing (and gonorrhoea if the laboratory offers combined NAAT testing)
- If symptomatic with dysuria, urethral itch or discharge, or urethral discharge is noted on examination or a contact
of a person with gonorrhoea:
- Take a urethral swab for gonorrhoea culture,* using the smallest available bacterial culture swab (e.g. thin, blue
per-nasal swab inserted approximately 1 cm into the urethral canal)
- Serology for hepatitis B (if not immunised), syphilis, and HIV
- Hepatitis C serology if the patient has risk factors
- Viral swab for herpes simplex virus if ulcers are present
N.B. Urine samples do not have to be early morning urine. Ideally the patient should not have passed urine in the previous
two hours, however, if the patient is unlikely to return for testing, a specimen should still be collected and tested.
A study has shown that the voiding interval does not significantly alter results of the Cobas PCR assay when testing for
chlamydia in males.10
Men who have sex with men (MSM)
Testing as recommended for all males should be offered at least annually, depending on sexual history. Additional tests,
regardless of stated sexual practices, should also be included for MSM.
N.B. MSM with anorectal symptoms should be referred to, or discussed with, a sexual health physician.
Additional tests (i.e. also follow recommendations for all males) for MSM include:3
- A pharyngeal NAAT test for gonorrhoea
- An anorectal NAAT test for chlamydia and gonorrhoea. Anorectal swabs should be collected by inserting the swab 4
cm into the anal canal, rotating and replacing in the swab container. If the patient is a sexual contact of a person
with gonorrhoea, an additional anorectal swab for gonorrhoea culture* and antibiotic susceptibility testing should be
- Hepatitis A serology (if not immunised) – offer vaccination if susceptible (not funded; once a patient is recorded
as having been vaccinated, annual testing is no longer required)
*Discuss with laboratory as swabs for gonorrhoea culture are not always processed (or are subject to specific
N.B. NAAT tests are now recommended for testing rectal and pharyngeal infection in MSM. A positive NAAT test from an
extra-genital site needs to be confirmed by supplementary testing, which is done automatically by the laboratory.11
Best Practice Tip: Test kits can be bundled up and tied with a band in groups
for a “male check-up”, “female check-up” and “MSM check-up” to help speed up the testing process and ensure that all
the necessary tests are done.
Treatment of common STIs
Treatment should be initiated if testing reveals a positive result for an STI, or if there is a high index of suspicion,
e.g. signs and symptoms or contact with a person with a confirmed STI.
Patients should be advised to avoid unprotected sexual intercourse until seven days after treatment has been initiated
for any STI, and at least seven days after sexual contacts have been treated, to reduce risk of re-infection. Partner
notification should be discussed at the time of treatment (see “Partner notification”).
All patients should be routinely followed up one week after treatment to check adherence, symptom resolution and whether
partner notification has occurred. This role is often undertaken by the Practice Nurse. Re-treatment is necessary if there
has been unprotected sex with untreated sexual contacts during the week after treatment initiation. Patients should be
advised to have a repeat sexual health check in three months, as reinfection is common. Entering a recall in the practice
management system can be helpful.
Partner notification, or contact tracing, is the process of identifying sexual contacts of a person with a STI and
ensuring that they are aware of their possible exposure. This helps to prevent reinfection in the index case, and allows
identification of undiagnosed STIs and prevention of possible complications in their contacts. Partner notification should
be discussed at the time of treatment for a STI and is recommended when the following conditions are identified: chlamydia,
gonorrhoea, trichomoniasis, non-gonococcal urethritis, pelvic inflammatory disease and epididymo-orchitis. Partner notification
is not necessary for people diagnosed with genital warts or genital herpes although regular sexual partners may benefit
from an assessment and a routine sexual health check. Management of partner notification for syphilis or HIV is more
complex and referral to, or discussion with, a sexual health physician is recommended.
The most common method of partner notification is for the index case to notify their sexual contacts themselves.13 All
sexual contacts in the previous two months should be notified.13, 14 Discuss with the patient how they will
notify their contacts, e.g. in person or over the phone, email or text, and provide them with the information that they
will need, such as fact sheets and suitable websites on the condition and advice on returning for testing.13
If the patient does not wish to notify their contacts due to concerns about confidentiality or safety, e.g. there are
issues of partner violence, notification can be done by clinical staff, with every effort to maintain confidentiality
of the index case. If a patient attends as a contact of someone who has been infected, the index case must not be identified
to the contact. Referral to appropriate agencies should be facilitated if there is ongoing risk of violence from a current
The General Practitioner, or usually the Practice Nurse, should follow up with the patient after one week to confirm
that relevant sexual contacts have been notified, as well as to check symptom resolution, adherence to medication and
whether there has been any unprotected sex.13
Sexual health clinics can assist with partner notification if required.
Referral may be necessary
Referral to, or discussion with, a sexual health physician is recommended for patients with:12
- Recurrent urethritis
- Genital warts (difficult or resistant cases)
- Suspected or confirmed syphilis
- Suspected or confirmed HIV
- Any STI during pregnancy
- Problematic, recurrent or chronic vaginal discharge
- Chronic genital pain or sexual dysfunction
Referral is also needed for patients who require specific sexual health counselling, or for follow-up of patients or
contacts who fail to attend for treatment.
In New Zealand some conditions must be reported to the Medical Officer of Health, including acute hepatitis A, B and
C and AIDS (but not HIV).
For more detailed information on the treatment of STIs, refer to the New Zealand
Sexual Health Society Best Practice Guidelines, available from: www.nzshs.org
The first-line recommended treatment for people with chlamydia (and males with non-gonococcal urethritis), and their
sexual partners is azithromycin 1 g, stat, or alternatively (if not pregnant), doxycycline 100 mg, twice daily, for seven
Azithromycin is safe for use in women who are pregnant (category B1*),15 and has better efficacy than alternatives.
*Therapeutic Goods Administration Australia pregnancy category
Patients with a symptomatic rectal chlamydia infection, should be referred to, or discussed with, a sexual health physician.16
All patients treated for chlamydia and gonorrhoea should be advised to have a repeat sexual health check in three months,
as re-infection is common. A test of cure is unnecessary, except in women treated during pregnancy or if a non-standard
treatment has been used. This should be carried out five weeks after treatment was initiated.16
The first-line recommended treatment for people with gonorrhoea, and their sexual partners is ceftriaxone 500mg, IM,
stat (make up with 2mL lignocaine 1%, also see “Updated guidance on using ceftriaxone”), plus azithromycin 1g, stat. Co-infection
with chlamydia is very common, and azithromycin should always be co-administered, even if the chlamydia test is negative
as the medicines act synergistically and reduce the risk of development of resistance.17
If the isolate is known to be ciprofloxacin sensitive, a 500 mg stat dose of ciprofloxacin can be used instead of ceftriaxone
(but not in women who are pregnant).
A test of cure for gonorrhoea is not usually required unless there is a risk of re-exposure, symptoms do not resolve
or a non-standard first-line medicine has been used (test in five weeks). Patients should be encouraged to return in three
months for a sexual health check.17
Updated guidance on using ceftriaxone to treat gonorrhoea
Ceftriaxone injection is used for treating gonorrhoea if the antibiotic susceptibility is unknown, if the isolate is
ciprofloxacin resistant, and for females who are pregnant or breast feeding (ciprofloxacin is contraindicated in pregnancy).
The recommended dose of ceftriaxone for the treatment of gonorrhoea has increased from 250 mg ceftriaxone IM, to 500
mg IM stat.17
This increase in the dose for ceftriaxone has been recommended to overcome emerging cephalosporin resistance in Neisseria
gonorrhoeae. Although the relevant subsidy requirement for ceftriaxone is "treatment of confirmed ciprofloxacin-resistant
gonorrhoea", the prevalence of ciprofloxacin resistance is as high as 54% in some areas in New Zealand, and treatment
where susceptibility is not known should be with ceftriaxone.17
The first-line recommended treatment for people with trichomoniasis, and their sexual partners is metronidazole 2 g,
stat, or alternatively if not tolerated, metronidazole 400 mg, twice daily, for seven days. Metronidazole may be given
to women who are pregnant (category B2) or breast feeding, but they should be advised to avoid breast feeding for 12 –
24 hours after the dose.18 Ornidazole 1.5 g, stat may be used instead of metronidazole, but is not recommended
in women who are pregnant as no study data is available.
A test of cure for trichomoniasis is not usually required unless there is a risk of re-exposure. Culture of urethral
swabs is rarely positive in males, due to low sensitivity, therefore empirical treatment of male partners is recommended
without testing for trichomoniasis. Male contacts should, however, have a routine sexual health check for other STIs.18
Women with bacterial vaginosis are often asymptomatic. It is not usually necessary to treat bacterial vaginosis unless
symptoms are present or an invasive procedure is planned, e.g. insertion of an IUD or termination of pregnancy.
If treatment is required, first-line is metronidazole 400 mg, twice daily, for seven days.19 Metronidazole
2 g stat, may be given if adherence is an issue, however, the stat dose is thought to be associated with a higher rate
of relapse in women with bacterial vaginosis. Ornidazole 500 mg, twice daily, for five days, or 1.5 g, stat, is an alternative
if metronidazole cannot be tolerated.
Treatment of male sexual partners of women with bacterial vaginosis is not usually necessary.
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is usually caused by a STI, particularly in women aged under 25 years, women who have
had recent change of sexual partner or women with a previous history of gonorrhoea or chlamydia. Diagnosis of PID is clinical,
taking into account the history, clinical findings and results of tests. However, STI tests will often be negative and
a low threshold for treatment is appropriate, given the potential long-term consequences of infection and diagnostic uncertainty.
Treatment should cover infection with gonorrhoea, chlamydia and anaerobes.
First-line treatment is ceftriaxone 500 mg, IM, stat plus doxycycline 100 mg, twice daily, for 14 days plus metronidazole
400 mg, twice daily, for 14 days. Metronidazole can be discontinued in women with mild PID symptoms, if it is not tolerated.20
Note: If adherence is in doubt, azithromycin 1 g stat, with a repeat dose in seven days, may be used
instead of doxycycline.20 Ornidazole may also be considered as an alternative to metronidazole, if it is not
Epididymo-orchitis may occur due to a variety of pathogens. STI pathogens are more likely in younger males (< 35
years) with a history of more than one sexual partner in the past 12 months and urethral discharge.21 It is
important to test for STIs prior to initiating antimicrobial treatment.
If STI pathogens are suspected as the cause, first-line treatment is ceftriaxone 500 mg IM, stat, followed by doxycycline
100 mg, twice daily, for 14 days. If symptoms are severe, refer immediately to hospital.21
If UTI pathogens are suspected as the cause, first-line treatment is ciprofloxacin 500 mg, twice daily, for 10 days
or (if contraindications to quinolones) amoxicillin clavulanate 500/125 mg, three times daily, for 10 days.
Patients should be reviewed within 24 – 48 hours to assess response to treatment, and should be referred to hospital
(urology) if signs and symptoms are worsening or do not improve.21
Lesions (genital ulcers, sores or fissures) may be detected during the physical examination. If there is uncertainty,
refer to, or discuss with, a sexual health physician. Referral is recommended for women who have their first clinical
episode during pregnancy as serology may be required. A viral swab of lesions for herpes simplex should be taken, but
a negative result does not exclude infection.22
The recommended first-line treatment is aciclovir 200 mg, five times daily, or 400 mg, three times daily, for five days
(safe to use during pregnancy).15 Lignocaine gel 2% may be given for topical analgesia (not subsidised), but
oral analgesia may be required, particularly if symptoms are severe.22
For further resources on managing herpes, including in women who are pregnant,
Lesions can be identified on clinical examination. If warts are extensive, atypical, intravaginal/cervical or if there
is uncertainty about the diagnosis, refer to, or discuss with, a sexual health physician.23
Treatment is mainly for cosmetic purposes, and may not be desired in all cases, e.g. if the warts are not visible externally
and not extensive.
Podophyllotoxin solution 0.5%, twice daily, for three consecutive days per week, for five weeks, is appropriate for
lesions which can be easily seen, e.g. pubic or penile shaft warts. It is not recommended to use podophyllotoxin for females
with vulval warts or for people with perianal warts, as misapplication will cause significant irritation.
Imiquimod cream 5%, once daily, three times per week, for up to 16 weeks, is fully subsidised with Special Authority,
for patients with warts not responsive to podophyllotoxin or for use in more sensitive areas, e.g. vulval or perianal
warts or warts under the foreskin.23
Cryotherapy, laser, diathermy or surgical excision may be options if other treatments are not effective.23
N.B. The HPV vaccine prevents infection with HPV types 6 and 11 which cause 90% of anogenital warts.23
For further resources on managing HPV, including in women who are pregnant, see: www.hpv.org.nz
It is recommended that all patients with suspected syphilis be referred to, or discussed with, a specialist sexual health
service if the practitioner does not have experience in managing syphilis.
For further information see: “Syphilis:
testing for the great imitator”, Best Tests (Jun, 2012).
What to do if other sexual health issues are raised
Occasionally in the course of a sexual health consultation a patient may state or indicate that they have sexual health
issues beyond disease or infection.
Sexual dysfunction such as erectile dysfunction or loss of libido, are likely to be the most common non-STI issues encountered
in primary care. A key requirement for the evaluation of sexual dysfunction is to determine whether the issue is associated
with stress or anxiety. The presence of any serious medical condition is likely to impair sexual function not only because
of the condition itself, but also due to the associated impact on psychological wellbeing.
For further information on sexual dysfunction in women, see “Selected
topics in women’s health”, Best Tests (Sept, 2010).
For further information on sexual dysfunction in men, see “Selected
topics in men’s health”, Best Tests (Sept, 2010).
Sexual violence is common in New Zealand. Most offenders are known to the victim and there is a high rate of intimate
partner violence in New Zealand. Identifying people who are currently experiencing abuse or have been recently abused
is likely to be difficult and will rely on interpreting the person’s responses to sexual history questions and explicitly
asking about abuse. These people will usually require referral to the appropriate services and if there are children in
the household who are witnessing violence then referral to Child Youth and Family Services (CYFS) is required.
It is important to be aware of what counselling support services are available locally. Counselling may be funded by
ACC. People who disclose a recent sexual assault may wish to report it to the police and a forensic examination may be
required. Doctors for Sexual Abuse Care (DSAC) is an organisation that provides advice and support on the management of
sexual abuse to New Zealand doctors. DSAC provides guidelines and an educational service, as well as patient information.
For further information, see: www.dsac.org.nz
Selected topics in sexual health
Special consideration for people who are lesbian, gay, bisexual and transgender
Lesbian, gay, bisexual and transgender (LGBT) people have different risks from those seen in the majority of patients.
There is a large body of evidence that LGBT people are likely to report greater perceived barriers to quality healthcare
as a direct result of their sexual or gender identity.24 Asking about sexual preference during a sexual health
consultation provides an ideal way in which to broach the subject in order to offer better care.
The uptake and frequency of cervical cancer screening is significantly lower in females who identify as lesbian or bisexual
(ten times less likely to have had a test in the previous three years) than in heterosexual females.24 Cervical
cancer is caused by sexually transmitted high-risk HPV types, and there may be a false perception among both patients
and healthcare providers, that women who do not have penetrative sex with males are not at risk from cervical cancer.
However, there is significant clinical evidence that HPV is easily transmitted by oral sex and digital penetration. Health
care providers should encourage cervical screening in all females aged 20 years and over, regardless of sexual preference
or identity, and routine STI testing should be offered to all sexually active women regardless of sexual preferences.
Men who have sex with men have different sexual health risk factors than exclusively heterosexual men. HIV and syphilis
are more common in MSM, and STIs such as gonorrhoea and syphilis can easily be transmitted by oral sex. Encouraging the
use of condoms, and assessing recreational drug and alcohol use in this group is particularly important. Regular testing
for STIs is recommended at least annually, with more regular testing depending on sexual history, rate of partner change
and consistency of condom use.25 Frequent testing (three to six monthly) is recommended for men reporting
regular, unprotected anal sex, more than ten sexual partners in six months, engagement in group sex or use of recreational
drugs during sex.25, 26 Testing for syphilis at least annually is recommended in HIV-positive MSM.25
Some patients may express concern over certain problems believed to be related to anal sex, such as piles and anal fissures;
however, these issues are no more common in MSM than in heterosexual people.27 These problems are usually
related to straining at stool or constipation, and should be managed within this context. Faecal-oral spread of illnesses
such as giardiasis and hepatitis A can occur via oral-anal sexual contact. Episodes of diarrhoea may be due to faecal
exposure via oral-anal contact with another person, but are usually self-limiting. If diarrhoea persists, stool culture
should be requested to identify any potential bacterial cause.27 STIs such as chlamydia, gonorrhoea, herpes
and syphilis may cause symptoms of proctitis (anal bleeding, discharge and tenesmus) even if there is no history of receptive
anal intercourse. Therefore it is recommended that all MSM with anorectal symptoms be referred to or discussed with a
sexual health physician.
Homosexuality and bisexuality, of both men and women, has been associated with higher rates of psychological and behavioural
disorders, including depression, anxiety, mood disorders, suicidal ideation and planning, eating disorders, alcohol and
substance abuse, and tobacco use.28 While these issues are not exclusively related to sexual health, identifying
a same-sex or bisexual sexual identity in a sexual health consultation presents an opportunity for the practitioner to
discuss these other significant issues.
Ensuring the safety and health of sex workers
Sex workers, both male and female, have high-risk lifestyles and, as a group, are often marginalised by society. In
general, sex workers exhibit higher than average knowledge about STI and HIV transmission.29 Sex workers self-report
an overall high adherence rate to condom-use, safe sex practices and health-seeking behaviours.29 However,
sex workers often have poor control over work-place safety and may not have complete control over safe-sex practices;
condom use may be poor in certain circumstances, particularly where there is concurrent drug or alcohol use.29 In
addition, rates of abuse, sexual assault and psychological issues are higher among sex workers than in the general population.29
When assessing the health of sex workers, include questions about intravenous drug use and exposure to abuse.
Six-monthly screening for STIs and HIV is sufficient for sex workers; more regular testing does not increase STI prevention
if condoms are used consistently.30
Assessing the mental health of sex workers is important, both directly and indirectly as a method of preventing further
sexual health issues. Sex workers who are psychologically distressed or have identified mental health issues report less
consistent condom use, riskier behaviour and fewer sexual health checks-ups.29
For further information and a resource to which sex workers can be directed, see: www.scarletalliance.org.au and www.nzpc.org.nz
For further information on what to do in the case of sexual abuse or exploitation,
Genital piercing and STIs
Performing a sexual health check-up in a person with a genital piercing may be difficult: physically, it may be complicated
to obtain urethral swabs, and certain piercing locations may increase the risk of blood borne infection.
Male genital piercing, most commonly through the glans penis and external urethra, known as a “Prince Albert”, can cause
scarring and urinary problems. As urethral swabs in males are inserted one centimetre into the urethra, some piercings
may affect testing. First void urine is unlikely to be affected. Female genital piercing is usually through the clitoris,
clitoral hood or labia, and it is therefore unlikely to impact on examination or swab collection.
Genital piercing, like any procedure that penetrates the skin, can lead to a viral or bacterial infection. Post-procedural
infection with bacteria, such as Staphylococcus aureus, pseudomonas and group A streptococcus, is common.31 There
is limited evidence as to whether the prevalence of STIs is increased in people with genital piercings. In general, genital
piercing in females, unless at a non-typical site, is unlikely to directly affect STI prevalence or exposure. However,
there is case study evidence that the prevalence of genital warts is higher in males with genital piercings.31 This
may be causative, as the trauma and epithelial damage from piercing may increase the ease of transmission of high-risk
HPV strains, or correlative, in that males with genital piercing may be prone to higher-risk behaviours.31
Important information may be revealed by enquiring about the reason for getting a piercing. Genital piercing in females
has been linked with an increased incidence of past physical, emotional and sexual abuse (this link has not been studied
in males).32 In many of these females, genital piercing was viewed as a way to reclaim their bodies or their
sexuality.32 While the absolute number of females with genital piercing who have been exposed to abuse is
likely to be low, the relative number appears to be high compared to the overall population.