Table of Contents
Genital Examinations and Sexual Health for Vulnerable Communities is written by Cara Taheny. Full in-depth original article available here. Below is the abridged version.
Read other CPD articles here
Introduction
Cara is a Nurse Practitioner with a speciality area of practice in Sexual & Reproductive Health. Originally from Adelaide, SA, Cara has worked rural/remote in NSW & WA as well as in the cities of Adelaide & Perth. Cara has worked mainly in the community, including working with people living with HIV, men who have sex with men, Indigenous people, sex workers, CALD communities, young people & people who identify as either LGBTIQA+.
What is sexual and reproductive health nursing?
For me, S&RH nursing is broad and includes working with people from puberty through to older age. In the earlier age group, it can be more basic work such as talking about our bodies, what our reproductive systems are and what changes are happening so that young people understand this process. It can also incorporate discussing private areas on our bodies and sexual safety so that young people have the knowledge and ability to talk to someone they trust if they feel unsafe. So, this aspect of S&RH nursing isn’t about sex, but it is about setting up good foundations for young people so that when and if they choose to have sex that they feel empowered and in control of what choices they make.
Most of my work is usually working one on one with clients who are or have had sex and they are seeing me for certain aspects relating to this. It might be to do with:
- Contraception;
- testing for sexually transmitted infections (STIs);
- treatment for STIs;
- cervical screening;
- genital examination to diagnose a problem or to reassure someone that their anatomy is normal
- listening to someone who shares an experience of sexual abuse or assault;
- general counselling about relationships and wellbeing (including intimiate partner violence, family & domestic violence; sexual problems within relationships, etc)
- prescribing PrEP (pre-exposure prophylaxis to prevent HIV)
- referring clients to specialists or alternative services for follow up
- period problems (eg. Painful periods, absent periods, irregular periods)
- genital problems (such as abnormal genital discharge, itch, lumps/bumps)
- immunisation (Hep A, Hep B, HPV, Monkeypox)
- advice/education
- pregnancy testing
- pregnancy planning or early antenatal care and referral
- unplanned pregnancy information and pregnancy choices (including medical and surgical termination) – I’ve worked within the abortion care space in the past but currently would see people and do initial diagnostic testing and refer on
- recommend or dispense emergency contraceptive pill (ECP)
- drug use including drugs having a negative impact on sex as well as injecting drug use and how to inject safely
- menopause management (hormonal changes experienced by women when transitioning to having no periods in their 40’s-50’s)
- sexual dysfunction and referral (painful sex, erectile dysfunction, premature ejaculation, etc)
Approach to nursing different groups?
My general approach to anyone who walks in (no matter which subheading they fall under) is to humanise the experience, normalise the person and just don’t be a dick! And if I am a dick at any point (eg. Use an incorrect term or word) I apologise and move on.
People living with HIV
Within this space, it’s more about understanding where HIV is at in 2022. Most People Living With HIV (PLHIV) are taking medications to suppress the virus. When the virus is suppressed enough it is undetectable. Undetectable = untransmissible. U=U is a phrase common in this space. That means they can’t pass on the virus to someone. That isn’t common knowledge to most people and yet it’s the reality of HIV management today.
A lot of work is about reducing stigma. Also it’s about knowing when their HIV is relevant to the consult you are having with them. Eg. I saw someone recently for immunisation and part of the workup asked if they were on any medication. They mentioned a HIV medication, which I knew was for HIV treatment. All I needed to know was if they had an undetectable viral load because if they did, I knew (1) that their HIV was being managed and (2) their immune system was fine. End of story. I didn’t need to change lanes and start focusing on their HIV. I did their immunisation and focussed on that.
Men who have sex with men
For me it’s about having the awareness that not all men are heterosexual and that not all men who are having sex with other men identify as ‘gay’. I might be seeing a man who is married with kids but has sex with men outside of this marriage. It’s about asking questions.
I see a lot of MSM who have been having testing with their GP and only ever being offered a urine test for chlamydia and gonorrhoea. Not once have they been asked about who they are having sex with and what type of sex they are having. By asking the questions I can talk about risk reduction as well as offer suitable testing (i.e. rectal and/or throat swab for chlamydia and gonorrhoea).
It’s also about picking up on a client’s body language. Just recently I saw an older guy and I could tell straight away he was uncomfortable. I mentioned that straight away (he was a new client to the service) and he admitted he didn’t realise he was seeing a woman clinician. There were legitimate reasons that explained him being uncomfortable about this but immediately I responded “you don’t have to see me, I’ve got a male nurse here who can see you instead if you’d prefer”. He did, and we had great health outcomes for him.
Indigenous people
It’s all about context. I’ve worked across 3 different states in Australia including urban, rural and remote areas and every experience is different. It’s about having cultural understanding and reading body language. Talking to people and building rapport is important. Utilising your colleagues and networks to ensure you’re practising safely. I worked on Ngaanyatjarra Lands and had some tremendous experiences where I provided education to women in ways that suited the women. So having the flexibility to try different ways of working is important. I provided women’s health education on the floor with props to explain what I was talking about. I’ve also had older women or support staff translate what I’m saying into their language so that there was a better understanding of what was being said.
In a remote clinic with no male clinicians, I managed to provide culturally safe sexual health care to an Indigenous man. I changed my practice in order to be culturally safe. This client had what potentially sounded like a syphilis chancre (sore) but I respected his wish for me to not examine this when I discussed his options. I wasn’t able to provide a male clinician that day to do this part of the consult and so had to change my ways in order to still provide a culturally safe service that still had excellent clinical outcomes.
Sex workers
Understanding different ways of working in this industry is important (eg. Brothel, independent, street-based). There is also stigma experienced within this community and so empowering and supporting sex workers to work safely is part of this work. In NSW I worked with SWOP (Sex Workers Outreach Project) and built rapport with the manager of a local brothel in the town I worked in. This resulted in providing an evening clinic on site so that workers could access confidential STI screening. This also built rapport with workers and our service so that workers felt safe to access our drop in clinic on a Friday at our community health centre for continued sexual health care.
Culturally & Linguistically Diverse Communities (CALD)
Interpreters and Google Translate can be very helpful. I’ve used face to face and phone interpreters with great success. Sometimes people’s conversational English is good, but it might be the occasional medical term that isn’t known. That’s where I find Google Translate can be helpful if it’s just occasional.
Otherwise, a longer appointment with a phone/face-to-face interpreter provides a much better understanding. Also, just having awareness into cultural differences can be helpful as there might be sexual practices a client is doing that wouldn’t be supported by their community. This can impact on safety and risk taking as well as negatively impact on their mental health if it is in conflict with their upbringing.
Young people & people who identify as either LGBTIQA+.
Giving them a voice and allowing them to have some decision-making on their health is important. Knowing your state-based legislation is vital to working with young people. For instance, I’ve worked in areas where I can talk to a young woman (underage) without a parent (their choice) and provide S&RH services. That might be providing contraception or STI screening for example. It infuriates me when I hear of health workers telling young people “if you want that then you’ll have to come in with your parent”.
Of course, I love it when a parent is supportive and involved. But this doesn’t happen for everyone and young people need to know their rights so that they can be empowered and reduce their risk and increase their sexual safety.
For people who identify as LGBTIQA+ it’s about listening and not assuming. Use pronouns they prefer. Be cautious about words you use if someone is dysmorphic about their genitals. I think health workers get scared they’ll stuff up but my experience is that if you are non-judgemental and willing to adapt to the person in front of you, then you’ll be fine.
If you say something that you realise is offensive (i.e. Saying he instead of she for a trans woman) then just correct yourself and move on. You don’t have to spend 5 minutes dribbling on about how sorry you are. The fact that you’re trying and learning is often more than what most people do in this person’s life.
Genital examinations
I always explain to the client why I may need to do a genital examination. I talk about if I was to do one what it might tell me to help with diagnostics and treatment. But also if I don’t do one how that may impact on the management pathway. Then it’s up to the patient to consent. I’ve had some young girls who the thought of a vaginal examination (often for the first time ever) is too much.
They may be seeing me to do with a possible vaginal thrush or abnormal vaginal discharge. In this scenario, rather then they say no and I get no sample, I’ll negotiate and say how about you take the swab yourself behind the curtain and pass it to me so I can prepare a slide and sample that way. Sometimes the examination isn’t 100% necessary.
Of course, best practice may be to do one but sometimes there are work arounds that ensure the client is happy and safe. My experience working with vulnerable populations is that rapport is a better long term outcome rather than strongly encouraging an examination that they don’t want and then they never come back to see you again.
Hot tip 1
As a junior, the Family Planning organisations in Australia offer clinical courses where you can practice consults and examinations and I strongly encourage this. It’s all about practice. I still remember doing some of my first cervical screenings and being so fixated on finding a cervix I’d forget there was a person attached to it. And as junior staff (or even senior staff who don’t do genital exams often) we are guilty of this. Now I can chat and be totally engaged with the person and pick up on the non-verbal cues while examining.
Hot tip 2
My other hot tip is to talk through what you are doing with the client. It provides 2 purposes. 1) it is informing the client on each stop you are doing (i.e. I’m just going to touch your labia now) and so the client feels involved and can match what they are feeling with what you are doing; and 2) it is breaking up the examination in your head to the steps you need to take. When you’re new this process of talking through what you’re doing is very helpful to you and makes it all manageable without being so overwhelming.
Courses or CPD people can do
