Handbook of Contraception and Sexual Health

Suzanne Everett

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429819735
• Edition: 4
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Offering a comprehensive guide to contraception and sexual health, the new edition of this practical handbook has been fully updated with the latest clinical guidance, research and methods, including new technologies.

Giving clear and detailed information about all contraceptive methods, including how to use them, contra-indications, interactions and common patient anxieties, this guide takes an integrated approach to sexual health. It includes updated chapters on the consultation, person-centred care, anatomy and physiology, and sexually transmitted infections. The new edition adds content on pharmacology for independent prescribers, pornography, trafficking, female genital mutilation (FGM) and other issues related to safeguarding, LGBT sexuality, and new technologies such as apps, online screening kits and SH24.

With plenty of self-assessment exercises, question and answers, and case scenarios, the Handbook of Contraception and Sexual Health is an essential read for all nurses, midwives and allied health professionals working in community health and primary care settings.

1The consultation

• History taking
• Sexual history taking
• The client
• The nurse–client relationship
• Confidentiality and ethics
• Grooming
• Clinical guidance
• United Kingdom Medical Eligibility Criteria (FSRH, 2016)
• Off-label prescribing
• Quick starting
• Bridging
• Useful resources

During a consultation you are in a unique position to give men and women the opportunity to talk about intimate areas of their sexual life and anxieties they may have. However, this will happen only when a client feels they are free to discuss any anxiety or problem. Sometimes clients will give you clues of a problem as they have their hand on the handle of the door and are about to leave the room. Sometimes we miss these clues because we are in a rush or fail to recognise the significance of the clue and only realise its meaning on reflection. In some situations, we may neglect a statement because we have become caught up in our own agenda. Clients may tell you information about themselves which may be upsetting and shocking to you; if your body language, tone of voice or expression shows this, then they will feel that they are unable to disclose any further information for fear of being reproached and judged. It is important never to assume that all clients are heterosexual: reproductive sexual health is not just about preventing pregnancy but about disease prevention, health promotion and education.

During a consultation, ensure that you are free of interruptions and that total privacy is maintained. Give clients the opportunity to ask questions. Try and ask open-ended questions, for example, ‘do you ever have pain or any difficulties during sexual intercourse?’ rather than a closed question, such as ‘you don’t have any pain during intercourse?’ which only offers the client the opportunity to say ‘no’. Open-ended questions give clients room to bring up problems associated with the area of questioning. Open-ended questions allow clients to express problems which may in fact be common place; sometimes clients can feel that they are the only one having difficulties with, for example, a method of contraception, and knowing that they are not alone can be reassuring.

When undertaking any procedure involving a client, it is important to obtain their consent. For a client to give informed consent you should explain carefully why this procedure is necessary and what it involves. When performing intimate examinations such as vaginal or testicular examinations, you should maintain the client’s privacy, allowing them to feel safe without fear of being interrupted by your colleagues or viewed from windows by strangers. Discuss with your client whether they would like a chaperone for any intimate examination.

If you give clients freedom to talk in a non-judgemental environment, then even if they choose not to disclose a problem at an initial consultation, they may return in the future knowing they can feel safe to talk freely.

It is always a good idea to speak to your clients on their own; this ensures that you are gaining their consent and that they are not being coerced into a decision. With young people, this has always been incorporated into the consultation that at some point, their consultation is on a one-to-one basis. This is to ensure that they are not being groomed or pressurised into sexual intercourse and that you are giving the best possible care with all the information available. Increasingly all consultations are on a one-to-one basis and this should be promoted, as clients do not always divulge full information about their sexual histories in front of sexual partners or relatives. By seeing men and women individually, we ensure that a full history is obtained and can address issues of sexual abuse and domestic violence. Relatives who interpret for clients may not fully understand the relevance of questions asked and may not translate all questions and answers completely; as a result, we may not be able to ensure full consent has been obtained from them. Following the introduction of the Mental Capacity Act in 2007, it is vital that full consent has been gained; to ensure that this happens then qualified interpreters and signers should be used if needed to attain that the client understands and has the mental capacity to consent.

Case study 1.1

A 34-year-old woman attends with her husband for contraception. The husband walks in to the consultation room, and you ask him to wait outside. He appears cross and says his wife wants him in the room; you explain that it is your department’s policy* to see clients individually, and he relents and leaves the room. When the woman and you are alone, she says that she did not want him in the room, as he does not want her to use contraception and wants her to get pregnant, which she does not want at the moment. You discussed whether she is being emotionally or physically abused, and this does not appear to be the case and you offer help if this changes. You are then able to discuss why she is unable to express herself fully with him and you offer her contraception.

(*Not all sexual health departments have this policy, so it is important to ascertain what is the practice in your area; if there is not one, you may wish to discuss how you all ensure a complete history has been taken.)

History taking

At initial consultations with clients, a full medical history should be taken and updated at regular intervals, which must be dated and documented in the notes for future reference. A complete history includes the general health of the client in the past and present, their gynaecological and sexual health, contraceptive history and the health of their immediate family. Clients can feel threatened by personal questions, especially if they are asked immediately on arrival; try and establish a rapport by finding out the reason for their attendance. Often by finding out why a client is attending, other questions that you need to know will be answered as a by-product. However, you will need to ask questions which should be open-ended such as ‘do you ever have any pre-menstrual symptoms?’ or ‘do you ever have migraines?’ If a client does have a problem, then you will need to find out more details: for example, if a client has migraines ask her to describe them and the frequency. You will still need to ask specific questions to eliminate contraindications to different methods of contraception such as ‘when you have a migraine do you ever see flashing lights or have loss of vision?’ Taking a detailed history can take time but can help nurture a good relationship between you and your clients. It can also create the opportunity for them to discuss issues for which insufficient time was given previously.

During the consultation, you should address allergies and medications. Clients often do not consider some over-the-counter and herbal remedies as medications. So, it is important that you really find out what people may be taking as this may affect the efficacy of hormonal contraception that is prescribed; an example of this is St John’s Wort. Increasingly men and women are obtaining drugs through the internet, so this is another area you should consider with the people you see.

Sexual history taking

Increasingly contraceptive and genitourinary medicine services are combining or offering similar care to streamline services to clients. With the incidence of sexually transmitted infections rising, it is important to discuss sexually transmitted infections with men and women. Many clients believe that they will know if they become infected, and do not realise that they may be asymptomatic. In the Face of Global Sex report (Durex, 2010), the Durex network looked at 15 European countries giving KAP score to represent young people’s knowledge, attitudes and practices. It was found that for every year in delay in starting sexual health education, there was a drop in KAP score. This corroborates with earlier Face of Global Sex work which shows that increasing numbers of sexual partners are linked to adverse sexual health. This highlights how little young people know about sexual health and how important it is to promote safe sex practices. We should always try to encourage women and their partners to go for screening once they commence a new sexual relationship, and also when they have had unprotected sexual intercourse. Increasing knowledge in sexual health was seen in the Face of Global Sex report (Durex, 2010) to correlate with delayed commencement of sexual intercourse and a decreased number of sexual partners. As health professionals, we need to be accessible to clients and help empower them with knowledge of sexual health and contraception.

The client

Clients who attend for advice on contraception can vary not only in the cultural and religious beliefs they hold but can also have very different attitudes and values about relationships and sexuality. The decisions and problems a client will encounter will depend on where they are in their life: for example, an unplanned pregnancy may be a disaster to a client aged either 15 or 50 for very different reasons, and the decision they make about the pregnancy will be from different perspectives.

Clients who are under 16 years of age may have taken some time to gain enough courage to attend a family planning clinic and, as a result, may feel embarrassed and awkward. Often younger clients may attend with a friend, and there may be anxiety over confidentiality, especially if the client is under the age of 16 (see confidentiality page 6). They may have already commenced sexual intercourse and require emergency contraception or already be pregnant. Research (Smith, 1993) has shown that the teenage pregnancy rate is higher in deprived areas, but the abortion rate is higher in affluent areas. The abortion rate may be higher in affluent areas for a number of reasons such as social and parental pressure, or that girls from these areas may know how to access abortion services and have the support of their parents. They may have career plans and see a future ahead (Simms, 1993), whilst teenagers living in deprived areas may decide to continue with a pregnancy because of lack of access to abortion services. They may not have career plans and see a pregnancy as their future.

Older clients may feel just as awkward as younger clients but for different reasons. They may not have discussed intimate areas of their sexual life with anyone and may find the situation embarrassing. Society tends to portray clients over the age of 65 as disinterested in sexual intercourse; however, research shows this is far from the truth (Steinke, 1994). Nevertheless, with increasing age, clients may need to adapt their sexual relationship depending on their health and may wish to discuss this. Often the impact of chronic diseases and medications on sexuality is not fully discussed with clients and their partners. It may take clients some time before they are able to pluck up the courage to discuss these implications or are given the opportunity by professionals to discuss them.

The nurse–client relationship

During a consultation, a relationship develops between the nurse and the client where feelings and emotions may be expressed. Many clients who consult have no problems and attend for contraceptive advice and supplies; however, other clients may have anxieties and problems that take a great deal of courage to discuss. It is during consultations where there are problems that the recognition of feelings evident within the consultation can help illuminate these problems. This can be sufficient to relieve an anxiety or may bring a hidden problem out into the open, where it can be looked at more closely.

Recognising the type of emotion expressed in a consultation can be difficult, and sometimes you may only be able to recognise on reflection once a client has left. Reflection and psychosexual seminar training can help improve and increase your skills in this area. There are several reasons why we may fail to recognise feelings or acknowledge a problem. Sometimes we lack the confidence to discuss intimate areas with clients and need a great deal of courage to pursue an issue, but this does become easier with practice. On other occasions, our minds may be fixed on our own agenda that will stop us from listening to the client. For example, there may be a very busy clinic and you may feel pressurised to ‘hurry things along’ or something the client says may trigger a ...