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Complex Issues in Reproductive and Sexual Health. Charlotte Porter and Fiona Straw C&SH Nottingham. Complicated issues:. Termination of pregnancy Sexual assault Sexual Dysfunction Teenagers Issues of coercion and control Consent. Termination of Pregnancy.

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complex issues in reproductive and sexual health

Complex Issues in Reproductive and Sexual Health

Charlotte Porter and Fiona Straw

C&SH Nottingham

complicated issues
Complicated issues:
  • Termination of pregnancy
  • Sexual assault
  • Sexual Dysfunction
  • Teenagers
  • Issues of coercion and control
  • Consent
termination of pregnancy
Termination of Pregnancy
  • International statistics: every woman of reproductive age has a TOP
  • A woman dies every 15 minutes from complications of illegal abortion
  • In the UK, ¼ women will have a TOP in their reproductive lifetime, and 1/17 every year
  • Annually 800000 deliveries, 200000 TOPs
top nottingham
TOP, Nottingham
  • 2000 terminations per year- UPAC took 2900 referrals in 2007
  • 40-60 per week
  • 8000 deliveries annually
top note audit parity
TOP note audit- Parity
  • 45 women were in their first pregnancy
  • 45 were parous (range 1-7)
  • 20 had had a previous TOP (range 1-2)
  • 23 had had a live birth within the last 12 months
  • 12 had had a non completed pregnancy in the preceding 12 months
  • 4 had had a termination of pregnancy in the previous 12 months
  • Of the under 18s, 4 had children, 1 16 year old reported 3 miscarriages in the preceeding 12 months
top note audit occupation
Top note audit- occupation
  • 20 were students
  • 11 were still at school/college
  • 27 were primarily carers (mother)
  • 33 were employed (semi and non skilled)
  • 3 were unemployed
  • For 3 no occupation was recorded
  • 3 were asylum seekers/refugees
top notes audit 2007 medical history
TOP notes audit 2007- Medical History
  • 3 had BMI >40
  • 2 had IDDM
  • 1 had prior VTE
  • 2 others had significant PMH- pulmonary stenosis, Addison’s Disease.
top legal issues
TOP - Legal Issues
  • TOP = post implantation
  • 5 clauses on ‘blue form’
  • Notification to Department of Health (is the responsibility of the operator)
  • BMA guidelines concerning conscientious objection
other issues relevant to top
Other Issues Relevant to TOP
  • STI
  • Domestic violence (?25%)
  • Inability to access services
  • Gillick / Fraser guidelines, Child protection
  • RCOG guidelines
  • Reducing the rate of unplanned pregnancy
  • Regret
options for top
Options for TOP
  • Medical
  • Surgical
  • Late medical
  • Late surgical
  • Continue pregnancy (?adoption)
medical termination of pregnancy
Medical Termination of Pregnancy
  • 1990, RU 486 used in France
  • Anti progestogen, initially used in the treatment of extradural tumours
  • Mild anti cortico steroid effects
  • Used alone will cause abortion in 1/3 of early pregnancies
  • Use in induction of labour
ru486 mifegyne
RU486 - Mifegyne
  • Initially 600ug dose
  • Increases myometrial tone
  • Priming for prostaglandin action
  • Addition of follow up dose of PgF2a (gemeprost, misoprostyl) increases abortion rate to >95% in women <63 days gestation
current medical regimes
Current Medical Regimes
  • <9 weeks gestation
  • 480 procedures in Nottingham last year
  • 200mg RU486
  • 800mcg misoprostyl 48 hours later
  • 95% complete miscarriage rate
  • 2% failure (locally <1%)
  • 5% ERPOC (locally 1%)
  • 1:2000 needs blood transfusion
  • 50% no analgesia requested
  • 2.5% readmission rate
contraindications to medical top
Contraindications to Medical TOP
  • Ambivalence about TOP
  • Hypertension / cardiovascular disease
  • Smoker >35 years
  • Oral Steroid use
  • Bleeding disorder / anticoagulant use
  • Renal disease
  • *asthma (pg / steroid)
early surgical top
Early Surgical TOP
  • 8-13 weeks
  • Up to 5% re evac rate
  • Post procedure infection (1% readmission rate)
  • 1:500 major (>500mls) blood loss
  • ?1% reduction in fertility
  • Cervical / uterine instrumentation
  • General anaesthesia (or cervical block – and risk of LA toxicity)
top after 12 weeks
TOP After 12 Weeks
  • STOP (dilation and evacuation) offered in some units up to 24 weeks
  • Late medical TOP – traditionally time consuming and invasive (intra / extra amniotic saline / prostaglandin)
  • Combination of RU486 and Pg reduce induction to delivery time and fewer problems than surgical option
sexual assault
Sexual Assault
  • Difficulty assessing the true incidence
  • TOPAZ centre- Nottingham SARC, 180 clients in first year
  • Friday and Saturday nights
  • 5% incidence of pregnancy with rape
  • STI risk varies- (50% for GC, less than 1% for HIV)? Give antibiotics and consider PEPSI/ Hep B prophylaxis
sexual offences act 2003
Sexual Offences Act 2003

Comprehensive review of Sexual Offences

  • Modernise the catalogue of sexual offences
  • Render them appropriate for the 21st century
  • Protect individuals from sexual crime
  • > 70 offences
  • NOT intended to prosecute mutually agreed sexual activity between 2 young people of a similar age unless involves abuse or exploitation
  • Not intended to prosecute health professionals
sexual offences act 200324
Sexual Offences Act 2003
  • Protecting <13 years
  • Intentional
    • penetration of vagina, anus and/or mouth (rape)
      • Max penalty life imprisonment
    • Intentional touching of sexual nature (sexual assault)
      • Max 14 years
    • Causing or inciting sexual activity
      • Charges with specific crime
      • Tougher sentences – max 14 years
  • Absolute offence- Children can NEVER give their consent
sexual offences act 200325
Sexual Offences Act 2003
  • Sexual activity with a child
  • Commits an offence if
    • The girl under 16
    • He intentionally touches (with or without clothes)
    • Or penetrates another person
    • The touching is sexual in nature

Max sentence 14 years

sexual offences act 200326
Sexual Offences Act 2003
  • Engaging in sexual activity in the presence of a child
    • Intentionally engage in an sexual act when you can be seen by a child
    • In order to get sexual gratification
  • Causing a child to watch a sexual act
    • Intentionally cause a child to watch someone else taking part in asexual act
      • Looking at images; videos, photos, webcams
      • In order to get sexual gratification
sexual offences act 200327
Sexual Offences Act 2003
  • Meeting a child following sexual grooming
    • Communicated with a child at least twice (phone or internet)
    • Meet them, or travel to meet them
    • With the intention of committing one of the previously described offences
  • Arranging or facilitating a child sex offence
    • Knowingly arrange or carry out an action which leads to one of the above offences taking place
sexual offences act 200328
Sexual Offences Act 2003
  • Protecting under 18’s
    • Even though age of consent is 16 there are a number of situations where it is important to protect 16-18 yr old girls from abuse
      • Indecent photographs
      • Abuse of children through prostitution or pornography
      • Abuse of positions of trust
      • Abuse by family member
        • Sexual activity
        • Inciting to engage in sexual activity
        • Sex between adult relatives
child sexual abuse
Child Sexual Abuse
  • Always need to be alert
    • Follow ‘Safeguarding Children Board’ guidelines
    • Not always informing the family
    • Joint examination
child sexual abuse30
Child Sexual Abuse
  • Numerous definitions
    • Any use of a child for adult sexual gratification
  • In the UK, by law sexual relationships between children < 16 yrs and adults are always classed as abusive
  • Where abuse of trust, prostitution and sex workers occurs in YP < 18 years
  • Majority abused by carers
  • 1/3 cases involve juvenile perpetrators
  • Sexual Offences Act 2003
  • Working together to safeguard Children 1999
  • Children’s Act 1989
  • Responsibilities of Doctors in Child Protection Cases with regard to confidentiality Feb 2004 RCPCH
    • Chapter 6 Children and Young People presenting to sexual health services
sexual dysfunction






Erectile Dysfunction

Ejaculatory Dysfunction

Decreased libido

Sexual Dysfunction
male sexual dysfunction
Male sexual dysfunction
  • An inevitable complication of ageing?

(the andropause)

questions in the assessment of sexual dysfunction
Questions in the assessment of sexual dysfunction
  • How long?
  • How much distress is it causing?
  • Persistent or situational?
  • Only with intercourse?
  • Partner (+ relationship) problems?


2° sexual characteristics





erectile dysfunction
Erectile Dysfunction
  • The inability to acquire or sustain an erection of sufficient rigidity for sexual intercourse
  • Commonest MSD- difficult to assess incidence? Still relying on the Kinsey report (1948!)
  • Commonly periodic or isolated
  • “impotence” is used to describe those with problems >75% of the time
aetiology of erectile dysfunction
Aetiology of erectile dysfunction
  • Hormonal abnormality
  • Medication
  • Psychological problems
  • Neurological disease
  • Vascular insufficiency
treatment ed
Treatment - ED
  • Restore libido, and improve capacity to achieve and maintain erection
  • PDE5- sildenafil, vadenafil, tadalafil- all CIxn in those taking nitrates
  • Self injectables (alprostadil) and vacuum devices
  • Penile implant
  • Weight loss and exercise
ejaculatory dysfunction
Ejaculatory Dysfunction
  • Prevalence 21-31%
  • Men are least likely to seek help
  • “persistent or recurrent ejaculation with minimal stimulation before, on, or immediately after penetration and before the person wishes it, over which the sufferer has no voluntary control and which causes suffereing or distress to the sufferer and his partner”
aetiology of premature ejaculation
Anxiety, stress, guilt

Early sexual experience

Evolutionary (!)


Genetic predisposition

Hyperexcitable ER

Penile hypersensitivity


Central 5HT receptor dysfunction


Low Mg

CNS problem

Aetiology of premature ejaculation
treatment pe
Treatment (PE)
  • Psychotherapeutic- coping skills and confidence building, communication skills
  • Topical anaesthetic (IELT increase from 1.5 to 8.5 minutes in one study)
  • SSRI (paroxetine)
  • PDE5 (sildenafil)
fsd desire
FSD- Desire
  • 31% of women (NHSLS survey) report hypoactive sexual desire disorder
  • Age and postmenopausal status are risk factors
  • ?role of surgical menopause
  • Depression, anxiety, relationship factors and children living at home
fsd treatment
FSD- treatment
  • Psychotherapeutic
  • Hormonal- oestrogen


sexual arousal disorders
Sexual arousal disorders
  • Inadequate genital lubrication and response
  • Psychological component
  • SSRIs inhibit female sexual responsiveness
sad treatment
SAD- treatment
  • Vaginal lubrication
  • Local oestrogen
  • Vacuum device (USA- only approved therapeutic aproach)
  • PDE5- no clinical evidence
  • Local prostaglandin application
sexual pain
Sexual Pain
  • Dyspareunia
  • Vaginismus
  • Vulvodynia (non localised)
  • Vestibulitis (localised)
  • Non coital sexual pain
cycle of vaginismus
Cycle of Vaginismus

Fear of vaginal penetration

Involuntary muscle spasm

Relationship Breakdown

Sexual Dysfunction in Partner


Avoidance of Sexual Intercourse

& Gynaecological Examinations

Anxiety & Humiliation

  • Psychosexual Medicine – Examination & Exploration of Feelings and Emotions
  • Psychosexual Therapy – Cognitive Behavioural Approach
  • Fenton's Procedure
  • Medication
  • Botox !!
useful tips
Useful Tips
  • Explanation
  • Rationale
  • Vaginal Trainers 1 by 1
  • Lubricant
  • Breathing
  • Pelvic Floor Exercises
  • Feedback and Follow-up
  • Include Partner & Assess Sexual Functioning
motivation and means
Motivation and Means
  • The availability of contraception and education to enable informed and mutually respectful choices
  • A stake in the future, a sense of hope and an expectation of inclusion in an economically advanced society

UNICEF – Innocenti Report

the same as old people
The same as old people?
  • Respect
  • Confidentiality
  • Interest
  • Confidence
  • Honesty
  • Dedicated service
  • Non judgemental
  • Safeguarding

Fraser competence

Child protection

usa youth risk behaviour
USA- Youth Risk Behaviour
  • 70% have tried smoking
  • 50% have drunk alcohol in the last 30 days
  • 47% have used marijuana
  • 50% have had sex
  • 9% have used cocaine
  • 8% had sex before aged 13
  • 17% have carried a weapon in the last 30 days (5% a gun)
  • 19% have considered suicide in past 30 days
percentage of 15 year old girls who have had sexual intercourse by country
Percentage of 15 year old girls who have had sexual intercourse by country

Adapted from Ross J, Godeau E, Dias S. Sexual health. In: Currie et al. Eds. Young people’s health in context. Health behaviour in school-aged children study : international report from the 2001/2002 survey. WHO Europe;2004.p. 153-160.

the legal situation
The Legal Situation

Sexual Offences act 2003

  • Law on sexual offences is not gender specific.
  • S I under the age of 16 is an offence even when consensual or both parties aged under 16.
  • If both under 16, both are committing an offence.
  • Absolute offence if young person under 13.
fraser guidelines
Fraser Guidelines
  • The young person understands the doctor’s advice
  • The doctor cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contraceptive advice
  • The young person is very likely to begin or continue having intercourse with or without contraceptive treatment
  • Unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer
  • The young person’s best interests require the doctor to give contraceptive advice, treatment or both with out parental consent
why do teenagers have sex
Why do teenagers have sex?
  • Young people over-estimate how many of their peers are sexually active
  • Young people have sex in the hope that it will deliver other things
  • Low self esteem
  • Cultural pressure and assumption
  • Lack of SRE from an early age
  • Inability to communicate with parents/carers
  • Home
  • Education
  • Activities
  • Diet/exercise
  • Depression
  • Sex (Drugs, Rock and Roll?)
  • Presenting complaint
  • Age
  • Where they live- who with/support mechanisms
  • School/college/excluded/not attending/YOT
  • Attainment/best friend/what do you want to do?
  • Contact details (? School nurse)
  • Last period (when will they worry about their next period?)
sexual history
Sexual History
  • Coitarche
  • Number of partners (this year?)
  • How long with this partner
  • How old is he/she
  • How many partners has he/she had
  • Issues of coercion
  • Type of sex- don’t assume!
in women peak exposure to human papillomavirus occurs in late teens and early twenties
In women, peak exposure to human papillomavirus occurs in late teens and early twenties

Sanofi Pasteur MSD Data on File 2006 06/004

domestic violence
Domestic Violence
  • 16% of violent crime
  • ¼ women, 1/6 men affected in their lifetime
  • 77% (?89%) victims are female
  • Pre reporting to the police the “average” victim will have been assualted 35 times
  • 2 women die every week
  • 1 report is made every minute
  • 39% involve alcohol
domestic violence government goals
Domestic violence- Government goals
  • Decrease prevalence
  • Increase reporting
  • Increase conviction rate
  • Increase support for victims
  • Decrease the number of deaths

2004 Act- makes common assault an arrestable offence, and made the penalty for breech of a non-molestation order up to 5 years in prison

drugs and alcohol
Drugs and alcohol
  • Class A- Ectasy, LSD, heroin, cocaine, crack, magic mushrooms, injectable amphetamines
  • Class B- amphetamines, ritalin, pholcodeine
  • Class C- cannabis, tranquillisers, some painkillers, GHB, ketamine
drugs and alcohol67
Drugs and alcohol
  • Home office website
  • Talk to FRANK
  • Connections
consent for medical treatment
Consent for Medical Treatment
  • Family Law Reform Act (1969)
    • If sufficient understanding i.e. competence
    • Sufficiently informed
    • Given freely
  • Consent to surgical, medical or dental treatment including venepuncture
  • Parents have legal power to consent on their behalf
consent for medical treatment70
Consent for Medical Treatment
  • Refusal to accept treatment
    • Complex
    • Unlike for competent adults, an adolescent’s rights to refuse treatment is dependent on the circumstances
age of consent for sexual relationship england and wales
Age of Consent for Sexual Relationship England and Wales
  • Sexual Offences Act (1956)
    • A 16 year old girl can consent to heterosexual intercourse
  • Sexual Offences (Amendment) Act 2000
    • A 16 year old boy can consent to homosexual intercourse
gillick case 1982 1985
Gillick Case 1982-1985
  • Mrs Victoria Gillick attempted to make it illegal for health professionals to provide contraception to girls under the age of 16 without their parents consent
gillick case
Gillick Case
  • Lord Fraser Ruling:

It is not unlawful to provide contraceptive advice to a girl under the age of 16 without her parents consent provided that..

gillick case fraser guidelines
Gillick Case: Fraser Guidelines
  • The girl understands the doctor’s advice
  • The doctor cannot persuade the girl to inform her parents or allow him/her to inform them
  • The girl is likely to begin or continue to have sexual intercourse
  • Her physical or mental health is likely to suffer
  • It is in the girl’s best interest
children s act 1989
Children’s Act (1989)
  • Interests and welfare of the child is paramount
    • Providing contraception may be in their best interest
recent high court ruling
Recent High Court Ruling
  • In a recent test case Mrs Axon argued that parents have a right to be notified if a YP under 16 requests a TOP, or has received advice or treatment for an STI
  • 23.01.06 the high court rejected these views and upheld DH guidance re-affirming
high court ruling
High Court Ruling
  • Confidentiality should be maintained
  • Parental consent for a TOP is unnecessary
    • If they are competent to make an informed decision
  • TOP should NOT be available if YP lacked maturity
  • The Law therefore remains unchanged
  • Most important aspect of medical care
  • Duty of confidentiality for any doctor is the same for every patient regardless of
    • competency to consent
    • age
  • Any competent young person can independently seek medical advice and give consent to treatment
  • However confidentiality is not an absolute right
breaching confidentiality
Breaching Confidentiality
  • Based on an individual case
    • Disclosure of abuse
    • Disclosure of current suicidal thoughts or significant self harm
    • Disclosure of homicidal intent
  • In most cases needs to be discussed with the patient
child sexual abuse80
Child Sexual Abuse
  • Always need to be alert
    • Follow ‘Safeguarding Children Board’ guidelines
    • Not always informing the family
    • Joint examination
child sexual abuse81
Child Sexual Abuse
  • Numerous definitions
    • Any use of a child for adult sexual gratification
  • In the UK, by law sexual relationships between children < 16 yrs and adults are always classed as abusive
  • Where abuse of trust, prostitution and sex workers occurs in YP < 18 years
  • Majority abused by carers
  • 1/3 cases involve juvenile perpetrators
case 1 vts3
Case 1 (VTS3)
  • JS, 15 y, local private school, drinking in Park with friend, alleges sexual assault by a stranger in the public toilets
case 2 vts3
Case 2 (VTS3)
  • AC 38y, P0+3 (stop x3 in early 20ies), pain and splitting of forchette with SI, regular partner, 7years, unable to wear trousers, ride a bike, ambivalent re pregnancy- on coc and antidepressants
case 3 vts3
Case 3 (VTS3)
  • NI, 13 years, 6 weeks pregnant by USS, attends UPAC with mum of 17yo partner, parents unaware of boyfriend and pregnancy
case 4 vts3
Case 4 (VTS3)
  • AN, 31yo Somali woman, attends for IUCD check with 7 yo daughter
case 5 vts3
Case 5 (VTS3)
  • RH, 19 y, P2 +2, 7 weeks pregnant, wishes TOP, describe partner as “controlling”. Limited contact with her family, children well cared for.
csae 6 vts3
Csae 6 (VTS3)
  • RG, 17 y, asked to see by receptionist, as complains about consultation with dr in clinic, feels unhappy with contraceptive advice given
case 7 vts3
Case 7 (VTS3)
  • AM, 32 y, HIV positive , for Zimbabwe, no contraception, LMP 16 weeks, Uss 18 weeks pregnant, wishes TOP
case 8 vts3
Case 8 VTS3
  • JB 15 years, vulval soreness 2/7, new partner 3/52 17years, on coc