Chapter 24 Sexual health

Helen Calabretto

KEY TERMS

Abortion

Basal body temperature method

Bisexual

Calendar method

Cervical mucus charting

Condom

Contraceptive implant

Diaphragm

Dyspareunia

Emergency contraception

Female genital mutilation

Fertility-awareness-based methods

Gay

Heterosexism

Heterosexual

Homophobia

Homosexual

Hysterectomy

Injectable contraception

Intersex

Intrauterine device

Lactational amenorrhoea method

Lesbian

LGBTIQSS

Men who have sex with men (MSM)

Menopause

Oral contraceptive pills

Partner

Perimenopause

Queer

Same-sex-attracted

Sexual health

Sexual history

Sexual identification

Sexual orientation

Sexual practices

Sexually transmitted infections

Symptothermal method

Transgender

Transsexual

Tubal sterilisation

Vaginal contraceptive ring

Vasectomy

Women who have sex with women (WSW)

LEARNING OUTCOMES

Mastery of content will enable you to:

• Define the key terms listed.

• Identify personal attitudes, beliefs and biases related to sexuality.

• Discuss the nurse’s role in maintaining or enhancing a client’s sexual health.

• Describe key concepts of sexual development during infancy, childhood, adolescence and adulthood.

• Understand the range of sexualities and sexual behaviour.

• Describe the range of current contraceptive methods in Australia and New Zealand.

• Describe the most prevalent sexually transmitted infections in Australia and New Zealand.

• Identify client risk factors in the area of sexual health.

• Identify and describe nursing interventions to promote sexual health.

• Identify and describe screening for genital cancers.

• Evaluate a client’s sexual health.

• Identify potential referral resources for clients’ sexual concerns outside the nurse’s level of expertise.

• Use critical thinking skills to help clients meet their sexual needs.

Introduction

Social changes in the Western world during the 1960s and 1970s resulted in a change in societal attitudes to sexual behaviour and relationships. Since then there has been a greater acceptance of sex outside marriage, homosexuality and other forms of sexual expression. From 1960 when the oral contraceptive pill was introduced, women have had greater ability to control their fertility. In spite of this, many individuals still feel uncomfortable discussing sexual issues and although there appears to be a plethora of information about sexual matters in the popular media, there is still a lot of misinformation and reluctance to discuss issues related to sexual health. Unfortunately, individuals whose sexual orientation is not heterosexual or who make choices that are not considered ‘mainstream’ may still experience stigma. Registered nurses (RNs) are well placed to assist clients to feel comfortable to ask questions that relate to aspects of their sexuality. In order to do so, RNs need to have an adequate knowledge base regarding sexual functioning and sexual issues particularly as these relate to the specific area of their practice; well-developed communication skills; knowledge of assessment in relation to sexuality; and, importantly, personal comfort in discussing sexuality and a caring, sensitive attitude. These attributes will assist the client to safely raise issues about their sexual health without fear of judgment. This will also be discussed later in this chapter.

It is important to first clarify relevant definitions related to sexual health. Numerous definitions of sexual health exist; however, the following definition from the World Health Organization (WHO, 2006) has been chosen as being a comprehensive definition:

Sexual health is a state of physical, emotional, mental and social wellbeing related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (p. 5)

Sexuality is part of sexual health. As described by Katz (2009), sexuality is an essential part of who we are, and does not depend on engagement in sexual intercourse or sexual fantasy. It encompasses sex, gender, identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Our view of ourselves and others as sexual beings is influenced by cultural, ethnic and religious beliefs and practices as well as our own sense of self (Katz, 2009:8).

Sexual development

As people grow and develop, so does their sexuality. Each stage of development brings changes in sexual functioning and the role of sexuality in relationships.

Infancy

At birth, the infant is identified as female or male. Intersex (ambiguous sex) is further discussed in the definitions listed in Table 24-1, below. According to Erikson, at this stage the infant develops trust (Hoffnung and others, 2010). This includes trust in the self which involves exploration of the body, including pleasant and unpleasant sensations. Exploration includes the discovery of self-soothing sensations, such as touching the genital area. The way in which significant caregivers respond to these exploratory behaviours can influence the infant’s sexual development. Caregivers should be encouraged to accept the infant’s exploratory behaviour as a normal and expected part of development.

TABLE 24-1 DEFINITIONS

TERM DEFINITION
GENERAL
Heterosexism The belief that everyone is or should be, heterosexual and that other sexualities are inferior, unnatural and a threat to society.
Homophobia A person’s or society’s irrational fear, misunderstanding, ignorance of, or prejudice against lesbian or gay people.
Sexual identification Sexual identification is the way in which a person describes his or her sexual self and expresses that self to others. Although this will usually be an expression of the person’s sexual orientation, this may not always be the case when an individual is unable to express their sexual orientation due to fears of rejection, judgment or the need to fit in with family or societal expectations.
Sexual orientation

This is an individual’s emotional and sexual attraction. It may be heterosexual, bisexual or homosexual. It is a consistent pattern of sexual arousal towards a person of the same or opposite sex.

In Australia, a study of men and women aged between 16 and 59 years (Australian Research Centre in Sex, 2003) found that 97.4% of men identified as heterosexual, 1.6% as gay and 0.9% as bisexual. For women, 97.7% of women identified as heterosexual, 0.8% as gay and 1.4% as bisexual. However, 8.6% of men and 15.1% of women reported either feelings of attraction to the same sex or some sexual experience with same sex. Half of the men and two-thirds of the women who had same-sex sexual experience saw themselves as heterosexual. The authors’ conclusion is that same-sex attraction and experience are more common than indicated by the relatively few people who identify as homosexual or bisexual.
Sexual practices Sexual practices are sexual acts with a partner(s) but also include solo sexual behaviour such as masturbation. These behaviours need to be distinguished from sexual orientation and identity. Sexual practices can include kissing, hugging, stroking, penile-vaginal sex, anal sex, oro-genital sex (fellatio, cunnilingus), oro-anal sex (‘rimming’) and mutual masturbation. Oro-genital contact is a common practice and is sometimes not understood or even viewed as ‘sex’, which is often focused on penile-vaginal contact. This puts individuals at risk if they are not aware of the possible transmission of STIs through this route. This also applies to other forms of sexual practices where there is sharing of bodily fluids (semen, vaginal secretions, blood).
DESCRIPTIVE TERMS
Bisexual Men and women who are attracted to both men and women. They may or may not have had sexual relationships with either or both sexes. Some individuals who have sex with both men and women do not consider themselves bisexual.
Gay An individual whose primary emotional and sexual attraction is towards the opposite sex (see homosexual and lesbian). This term is most commonly applied to men; although some women describe themselves as gay, other lesbians may find this term offensive and would prefer to not be described as gay.
Homosexual An individual whose primary emotional and sexual attraction is to the same sex. Individuals who describe themselves as homosexual may or may not have had sexual relationships but are aware of their attraction to individuals of the same sex. Individuals who consider themselves homosexual may also have or have had sexual relationships with the opposite sex.
Heterosexual Men and women whose primary emotional and sexual attraction is to the opposite sex. Another term for heterosexual is ‘straight’. It is important to note that some individuals who consider themselves heterosexual may have had sexual relationships with individuals of the same sex.
Intersex Refers to atypical internal and/or external anatomical sexual characteristics where features usually regarded as male or female may be mixed to some degree. The current recommendation is to avoid genital cutting (surgery), where possible, until a child can fully participate in decision making. (Organisation Intersex International Australia, n.d.)
Lesbian A woman whose primary emotional and sexual attraction is towards other women. Some women who have sex with other women may not call themselves lesbians.
LGBTIQSS

This is one of a range of similar acronyms. This particular one stands for Lesbian, Gay, Bisexual, Transgender/Transsexual, Intersex, Queer and Same Sex attracted individuals.

The National LGBTI Health Alliance uses ‘LGBTI’ as an acronym to collectively refer to a group of identities that includes lesbian, gay, bisexual, trans/transgender and intersex people and other sexuality-, sex- and gender-diverse people, regardless of their term of self-identification (National LGBTI Health Alliance, 2011). While individuals may not want to apply labels to themselves, it is nonetheless important for nurses to appreciate sexual diversity.
Men who have sex with men (MSM) This includes any men who have sex with men who may identify as gay, bisexual, heterosexual or other.
Queer This is a term being used to include alternative sexual and gender identities, including gay, lesbian, bisexual and transgender or gender-questioning people to reclaim what was previously a derogatory term used for homosexuals in particular. It is, however, still a term that is offensive to members of the LGBTIQSS community.
Same-sex-attracted An umbrella term applied to individuals who experience feelings of sexual attraction to others of their own sex. They may be homosexual, bisexual or heterosexual.
Transgender and transsexual This includes people who identify more strongly with the gender other to which they were assigned at birth. They may identify as heterosexual, homosexual or bisexual. Some transgendered people may ‘cross-dress’, but not all do. Transgendered people who undergo treatment to change their bodies are called transsexual. They undertake hormonal therapy and may undergo sexual reassignment surgery.
Women who have sex with women (WSW) This includes any women who have sex with women who may identify as lesbian, bisexual, or heterosexual or other.

Australian Research Centre in Sex Health and Society 2003 Sex in Australia: summary findings of the Australian Study of Health and Relationships. Melbourne, La Trobe University. Online. Available at www.latrobe.edu.au/ashr/papers/Sex%20In%20Australia%20Summary.pdf 25 Apr 2011; National LGBTI Health Alliance 2011 LGBTI. Sydney, National LGBTI Health Alliance. Online. Available at www.lgbthealth.org.au/LGBTI 11 May 2011; Organisation Intersex International Australia (OII Australia) n.d. Position statement on genital cutting. Sydney, OII Australia. Online. Available at http://oiiaustralia.com/18068/on-genital-surgeries 28 May 2012.

Toddler/preschool period

From age 12 months to 5 or 6 years old, the child continues to solidify their sense of gender identity and to differentiate socially defined, gender-appropriate behaviours. This learning process occurs in the course of everyday adult–child interactions, from the toys given to the child, clothing worn, games played and responses encouraged. Children also observe adult behaviour, begin to imitate actions of the same-sex parent and maintain or modify behaviour based on adult feedback. Body exploration continues at this age, and the child may extend exploration to other children. It may extend to role-play games of ‘doctor’ or ‘nurse’ or ‘mummy and daddy’ and exploring each others’ bodies in various stages of undress. Nurses can teach parents that this is a normal aspect of sexual development. Rather than responding with shock or punishment, caregivers can respond by simply redirecting play. It is important from this age onwards that correct names are used to describe body parts and questions related to sexuality are answered in a developmentally appropriately way.

School-age years

Children from 6 to 12 years of age expand their horizons from home to include school and the community. Learning and reinforcement of gender-appropriate behaviour comes from parents and teachers and, importantly, from the child’s peer group. During this time of development, children are likely to continue masturbation as a normal part of development and one which frequently continues as a healthy behaviour throughout life. Teaching children the difference between behaviours that are socially acceptable in public and those that need to be private is appropriate.

By the age of 10 years, many girls and some boys are already beginning to experience some of the changes of puberty. As children enter puberty and their bodies change, they are increasingly modest and their need for privacy should be respected. School-aged children need accurate information from home and school about what to expect as they move into puberty. Knowledge about normal emotional and physical changes associated with puberty may decrease the anxieties as these changes begin to happen. Nurses working with children and young people should be able to assist parents with strategies to talk to their children about pubertal changes and sexual health generally.

At this age, children may assert their independence by testing the limits of appropriate behaviour. Limit testing may be manifested by the use of words or by telling jokes with sexual connotations while watching adult reactions. Limit testing is an important part of developing a sense of independence from the family; however, setting limits in relation to unacceptable behaviours helps children learn about broader societal expectations. Highly sexualised behaviour may be indicative of sexual abuse of the child and will require the nurse to consider all the evidence and, where necessary, act on this information as a mandated notifier of child abuse. This may also apply to sexualised behaviour in younger children. Family Planning Queensland (2006) has developed an excellent publication which will assist nurses to understand normal developmental sexual behaviours and identify, assess and respond to sexual behaviours which are of concern (see Online resources).

Children and adolescents who have a disability, have been abused or have experienced other disruptions to their development or socialisation may be at increased risk of exposure to, or of developing, inappropriate sexual behaviours. Adults who care for these young people have a duty of care to provide relevant information and support.

Puberty/adolescence

The system still frequently used to describe the predictable physical events around puberty for girls and boys was published by Marshall and Tanner (1969, 1970) and is usually referred to as ‘Tanner stages’. These stages are often included on percentile charts for weight and height.

The onset of puberty in girls is usually signalled by breast development (Tanner stage 2) (Rubin and others, 2009). This process may begin as early as age 8 years and may not be complete until the late teenage years. The age of menarche varies widely, but usually occurs around 12 years of age. An Australian study (Tam and others, 2006) found a median age of 12.6 years, which is similar to European studies (Rubin and others, 2009). Although the menstrual cycle is initially irregular and ovulation may not occur at first, fertility should always be assumed unless proved otherwise.

Ejaculation in boys does not occur until the sex organs begin to mature, around the age of 12 to 14 years. Ejaculation may first occur during sleep (called nocturnal emissions or ‘wet dreams’). This may be interpreted as an episode of bed-wetting and even in knowledgeable boys can be very embarrassing. Boys need to understand that although they may not produce sperm with their first ejaculations, they will soon be fertile.

The emotional changes during puberty and adolescence are as dramatic as the physical ones. The adolescent functions within a powerful peer group, with the almost constant anxiety of ‘Am I normal?’ and ‘Will I be accepted?’ Same-sex peers or friends remain influential in defining appropriate behaviour, but the task of establishing a romantic relationship begins. Adolescence is a self-centred, egocentric stage. This introspection is necessary to establish a sense of self within the context of family, community and emotional relationships. Assurance of normalcy in physical and emotional development should be given honestly and often.

The adolescent is faced with many decisions and needs accurate information on topics such as body changes, sexual activity, emotional responses within intimate sexual relationships, sexually transmitted infections (STIs) and pregnancy prevention. Comprehensive sexual health and relationships education which includes topics such as negotiation in relationships (including whether to engage in sexual activity), same-sex attraction, information about contraception and sexually transmitted infections (STIs) is an important part of the school curriculum. A best-practice program will also include activities to facilitate discussion between parents and young people at home.

Factual information regarding sexuality and sexual activity is important, but equally or perhaps more important is guidance in establishing a personal value or belief system to use as a framework for decision making. In healthy family networks, much of this guidance will have been conveyed in the course of child-rearing from early childhood. Parents need to understand the importance of providing information, sharing their values and promoting sound decision-making skills. Parents and significant others need to accept that even with the best guidance and information, adolescents will make their own decisions and must be held accountable for those decisions.

A recent Australian national survey of almost 3000 secondary school students in Years 10 and 12 provides a snapshot of sexual activity in Australian young people (Smith and others, 2008). By Year 12, 44% of female secondary school students and 34% of males had reported having sexual intercourse and 43.3% of Year 10 and Year 12 students had experienced oral sex. Half of the sexually active students always used condoms, 43% sometimes used condoms and 7% never used condoms, which indicates that there is still a lot of unsafe sex occurring.

In this same survey, 91% reported sexual attraction exclusively to the opposite sex, 1% reported exclusive same-sex attraction, 6% reported attraction to both sexes and 2% were unsure of their sexual attraction. Interestingly, in an Australian survey of same-sex-attracted (SSA) young people, one third knew about their sexual difference before puberty (Hillier and others, 2010).

As noted previously, adolescence is a developmental phase during which an individual often explores their primary sexual orientation. It is important for nurses to be aware that there is often an assumption of heterosexuality, and anyone who does not view themselves as heterosexual can feel they are abnormal because of the way others view them. Hillier and others (2010) reported that a number of teenage suicides can be attributed to bullying (verbal, physical or emotional) of SSA young people (Hillier and others, 2010). In this study, 60% of the participants had been subject to verbal abuse, 18% had experienced physical abuse and 69% had experienced other forms of homophobia including exclusion and rumours; 60% of participants had thought about suicide or self-harm, 55% had harmed themselves and 35% had attempted suicide. Suicide Prevention Australia (2009) reports that studies over the last decade reveal that lesbian, gay, bisexual and transgender (LGBT) individuals attempt suicide at rates between 3.5 and 14 times those of their heterosexual peers. It is also believed that most suicide attempts by LGBT people occur while still coming to terms with their sexuality and/or gender identity, and often prior to disclosing their identity to others.

CLINICAL EXAMPLE

You are a graduate registered nurse working with Cody, a 15-year-old male on your adolescent mental health unit, who was recently admitted after attempted suicide and a history of deliberate self-harm. During your assessment, he reveals to you that the reason for this is that he feels he might be gay. He is confused about his sexuality and feels isolated from his peer group at a private boys-only school. He is also concerned about how his family might feel about his sexual orientation. He says he has not told anyone else and is uncertain whether he should tell his parents. How would you respond to this situation?

In the clinical example above, the fact that this young man has revealed this information tells you that he trusts you. How you respond is critical to how he might feel about telling his parents and other important people in his life. You should thank him for placing trust in you and affirm his decision to discuss this with you. You could then suggest that he should only talk to his parents if he feels that they will be supportive and encouraging of his decision to ‘come out’ or if he is ready to cope with a possible negative reaction, and ask who else he has to support him should that be the case. You also need to reinforce to him that he can ask for confidentiality from anyone he comes out to and that he does not need to discuss his sexuality with anyone until he is ready and feels that he can handle both positive and negative responses. It would also be important to provide him with information about services which could assist him if he wanted further support.

Adulthood

The adult has gained physical maturation but is continuing to explore and define emotional maturation in relationships. Intimacy and sexuality are issues for all adults, whether they are in a sexual relationship, choose to abstain from sex, remain single by choice or are widowed. People can be sexually healthy in numerous ways. Sexual activity is often defined as a basic need, but sexual desire can be expressed healthily in other forms of intimacy throughout a lifetime.

As sexually active adults develop intimate relationships, they need to learn techniques of stimulation that are satisfying to both themselves and their sexual partners. Some heterosexual adults may need permission or affirmation that alternative ways of sexual expression, other than penile–vaginal intercourse, are normal. Other individuals may require significant education or therapy to achieve mutually satisfying sexual relationships.

Later in the adult years, individuals may be adjusting to the social and emotional changes associated with children moving away from home. This can be a time of renewed intimacy between partners, or it may be a time when formerly intimate partners realise that they no longer care for each other or have common interests.

At around the age of 50 years women will usually go through the perimenopause and menopause. The perimenopause is the changes that occur for 2–10 years before and 1–3 years after the menopause, which is the last menstrual period. This change occurs as the ovaries cease to respond in a predictable cyclical way to the regular pulses of follicle-stimulating hormone (FSH) and luteinising hormone (LH) from the pituitary gland. Like puberty, this is a normal life stage, yet it can also present challenges for women. Vasomotor symptoms and vaginal dryness are symptoms most consistently associated with the menopausal transition (Nelson and others, 2005). Hot flushes and night sweats (vasomotor symptoms) affect 50% or more of women and may not be manageable (Nelson and others, 2005). The principle of care for women during the menopause is to address symptoms which are interfering with their quality of life and to use this time to address long-term health-promotion goals, including healthy eating and regular exercise.

In addition to concerns about changes in physical appearance, actual physical changes can affect sexual functioning. Decreasing levels of oestrogen may lead to diminished vaginal lubrication and decreased vaginal elasticity. Both of these changes may lead to dyspareunia (painful intercourse). Simple local interventions such as water-soluble lubricants with or without vaginal oestrogen creams or pessaries can be effective measures. Decreasing levels of oestrogen can also result in a decreased desire for sexual activity; systemic treatment with hormone replacement therapy can address this and other symptoms. As men age, they are likely to experience an increase in the post-ejaculatory refractory period, delayed ejaculation and other changes. Anticipatory guidance regarding these normal changes related to ageing can ease concerns regarding functioning. Suggestions such as creating time for caressing and tenderness can help to ease adjustment to normal changes related to ageing. Ageing adults may also need to adjust to the impact of chronic illness, medications and other health concerns on sexuality.

Older adulthood

The capacity for sexuality is lifelong. Theoretically, people can engage in sex and intimacy as far into old age as they choose. However, older adults often face health concerns and societal attitudes that make it difficult for them to continue sexual activity. Although declining physical abilities may make sex as they previously knew it more challenging, learning alternative ways of sexual expression and intimacy can allow for satisfying sexual activity (see Research highlight).

Numerous factors, including lack of a sexual partner or declining health, can affect the sexual activity of the older adult. Nurses working with older adults need to be aware of the sexuality of their clients, assess interest and functioning and plan accordingly (Price, 2009).

Definitions of terms

In the previous section, a number of terms were used in relation to sexuality that require further discussion to assist in your assessment of clients (see Table 24-1). Your understanding of these definitions is important when taking a sexual history. However, it is important to be aware that many individuals do not want to be labelled by their sexual identity or sexual orientation. It is important, therefore, never to assume that a particular sexuality brings a defined range of sexual behaviours.

RESEARCH HIGHLIGHT

Research focus

The sexual narratives of the older person are rarely heard or understood. Myths and misconceptions about sexuality in older age construct the older person as devoid of a sexual identity and situate the older person’s sexual experiences within an area that is largely taboo. This nursing research sought to address this gap in the literature and explore the older person’s experience of sexual desire.

Research abstract

A hermeneutic interpretive study was used to provide a first-hand account of the experience of sexual desire in an ageing context. Audio-taped interviews were conducted with a purposive sample of 11 men and 6 women aged between 62 and 92 years who were willing to discuss their experiences of sexual desire. Participants’ narratives were analysed for emergent themes using a twofold methodology inspired by the philosophy of Paul Ricoeur. Findings revealed that participants identified as sexual beings regardless of age and availability of a sexual partner. Findings also revealed that sexual selfhood was acknowledged through physiological response, that sexual desire could be influenced by sociocultural factors and experienced within an ethical relational domain. Major themes explicated during the study included the experience of health and wellbeing, experience of sexual response, experience of sexual inadequacy, being socialised and re-entering the social scene.

Evidence-based practice

• Many older people remain interested in expressing their sexuality into advanced old age despite prevailing ageist myths that view the older person as asexual.

• Sexual expression incorporates a range of sexual behaviours including sexual intercourse, caressing, stroking, masturbation and other forms of intimacy. Communication is also a component of sexual expression.

• There is increasing recognition by healthcare professionals and policymakers of an important association between human sexuality and physical and psychological health and wellbeing. Australia’s ageing population has the potential to remain sexually active for a longer period of time and to have different expectations in relation to sexual health than any previous generation.

• The need to incorporate sexual health within a holistic healthcare domain will require healthcare professionals to gain awareness and understanding of sexual health requirements and sexual health expectations in relation to the older population. Healthcare professionals will need to overcome barriers to communication with older people by gaining knowledge and expertise in communicating with older people in relation to sexuality and in undertaking a sexual history and sexual assessment when required.

• Sex education is becoming increasingly important for the older person, particularly given the rising incidence of sexually transmitted infections among the older population. Anecdotal evidence suggests an historical lack of sex education provided to older people. The Baby Boomer generation is now moving into the older age demographic and is more likely to engage in risk-taking sexual behaviour and to change sexual partners more frequently than past populations of older people. Healthcare professionals may be the only access that older people have to sex education.

• If older people are provided with opportunities for discussion with a healthcare professional who has a positive attitude towards older-age sexuality and who is comfortable and open to empowering the older person to acknowledge their sexual identity, they will be more likely to engage in communication and to reveal sexual health concerns.

• Empowering the older person to identify as a sexual being may have a positive influence on activities that promote general health, including adopting a healthy lifestyle and adherence with treatment for health conditions that directly or indirectly affect sexual expression.

Reference

Gledhill SE. Desire in the winter’s pale: a hermeneutic interpretation of the experience of sexual desire in older age. PhD thesis, Queensland University of Technology. Online. Available at: http://eprints.qut.edu.au/47987, 2011. 20 Jun 2012.

Pregnancy

A full-term pregnancy is approximately 40 weeks in length and is divided into three trimesters: weeks 1–12, weeks 13–27, and weeks 28–40. The period of pregnancy before birth is known as the antenatal period and the period of 6 weeks after the birth is known as the postnatal period. The birth itself includes labour, during which the cervix dilates up to 10 cm and uterine contractions facilitate the passage of the infant, placenta and membranes through the birth canal. Some births are done by caesarean section. In Australia and New Zealand, registered midwives care for women throughout their pregnancy and in the postpartum period. Women birth in birthing centres which are often part of a hospital (and occasionally at home), where all of the care is provided by midwives or in a hospital maternity unit where midwives work with obstetricians or GPs to deliver babies.

Abortion

Abortions in Australia are performed under individual state laws in public and private hospitals and free-standing abortion clinics. All state and territory laws have been repealed, reformed or modified by parliaments and courts to make provision for some form of lawful abortion. In New Zealand, abortion services are part of the core, publicly funded, healthcare services that the population is entitled to access. Private abortion services are available in New Zealand, but are uncommonly used by women other than non-residents (Silva and others, 2011).

In Australia, it is difficult to obtain accurate abortion statistics because South Australia and Western Australia are the only states to keep accurate abortion statistics. The Victorian Law Reform Commission (2008) notes that the estimated annual number of abortions performed in Australia is between 80,000 and 85,000. The most recent Australian statistics for South Australia (Chan and others, 2009) indicate an abortion rate of 16 per 1000 women, although this may not be representative of the whole of Australia. In New Zealand in 2009, the rate was 19.7 per 1000 women (Statistics New Zealand, 2010).

Nurses need to support women in a non-judgmental way to make their decision about whether or not to have an abortion. Although there is general acceptance of abortion in the community (Victorian Law Reform Commission, 2008), there are anti-abortion groups who actively campaign against abortion and may use violence against women and workers in abortion clinics. Some groups in Australia promote the concept of ‘post-abortion syndrome’ and increased risks of breast and other cancers; however, evidence to support this view is lacking (Russell, 2005).

Abortions are performed surgically, by dilation with or without curettage; or medically using oral mifepristone (RU-486), an anti-progesterone, followed 0–72 hours later by vaginal misoprostol, a prostaglandin analogue. Medical abortion has been available in New Zealand since 2001 and in Australia since 2006. In Australia, mifepristone is currently unlicensed; however, medical practitioners can apply to the Therapeutic Goods Administration (TGA) to prescribe it (Mulligan, 2011). In New Zealand, mifepristone is a medication approved on a restricted basis to institutions licensed to carry out abortions. Most abortions are undertaken in the first trimester, although second-trimester (medical and surgical) and third-trimester (surgical only) abortions are also performed.

Current methods of contraception

This section provides a brief introduction only to the methods of contraception available in Australia and New Zealand. There is no perfect method of contraception. For most methods, effectiveness depends on user compliance, which may be improved by information provision, counselling and the support of healthcare providers (Family Planning Queensland, 2007; see Table 24-2). Moreover, some medical conditions can affect the suitability of a particular method of contraception. Table 24-3 provides a summary of contraceptive methods for women with existing health problems.

TABLE 24-2 COMPARISON OF CONTRACEPTIVE METHODS

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TABLE 24-3 CONTRACEPTIVE METHODS FOR WOMEN WITH EXISTING HEALTH PROBLEMS

CONDITION UNSUITABLE METHODS SUITABLE METHODS
CARDIOVASCULAR DISEASES
Venous thromboembolism

COCs contraindicated

No sterilisation until condition treated and resolved

 Progestogen-only methods, lUDs
Ischaemic heart disease or stroke COCs contraindicated Progestogen-only methods when other methods are not available or acceptable
Valvular heart disease  

Progestogen-only methods

COCs if there are no complications such as pulmonary hypertension, atrial fibrillation or history of subacute bacterial endocarditis
Hypertension

Moderate and severe hypertension complicated with vascular disease are contraindications for COCs

Sterilisation for women increases GA risk, therefore vasectomy could be considered instead

Low-dose COCs for mild hypertension and no additional risk factors (i.e. smoking, diabetes, obesity or age >35 years) when other methods unsuitable or unavailable

POPs, lUDs, implants good choices; DMPA good second choice
Diabetes

Hormonal contraception unsuitable when there are vascular complications

Female and male sterilisation can be performed but with additional precautions to anticipate hypoglycaemia or ketoacidosis and increased risk of infection

Copper IUD with screening and treatment of pre-existing infection prior to insertion, strict asepsis. Prophylactic antibiotics considered

COCs normally contraindicated except where there is no vascular disease

POI (injectables) but only if other methods are not available or acceptable to the client

Hormonal contraception may be used if there are no vascular complications (nephropathy, neuropathy or retinopathy)

POP or Implanon® can be used when there are vascular complications
Convulsive disorders

DMPA and copper or LNG IUD

EC—in the absence of scientific data on how drug interaction affects efficacy, the standard regimen should be used

 All methods are suitable but use of anticonvulsants—phenytoin, carbamazepine, ethosuximide, phenobarbitone and primidone— may reduce the efficacy of COCs, POPs, Implanon
Migraine

COCs contraindicated in focal migraine

Onset or exacerbation of migraine with a new pattern which is recurrent, persistent or severe requires discontinuation of the COC and evaluation of the cause

POPs, DMPA or Implanon are usually discontinued in the presence of headache

For focal migraine, POPs, Implanon® or non-hormonal methods

POIs is last choice in the absence of hypertension

Low-dose COCs for women who have simple migraine without aura
Liver disease COCs contraindicated in active liver disease, severe cirrhosis, or liver tumour

Non-hormonal method should be first choice. Progestogen-only contraceptives may be used if other methods not acceptable or not available

Women who carry hepatitis viruses can use any method of contraception. Mild cirrhosis can generally use progestogen-only contraception, with COCs only as last choice
MALIGNANT DISEASES
Breast cancer or liver neoplasms  

Pregnancy should be avoided in women with a genital tract premalignant or malignant disease. With most genital tract malignancies, the treatment is such that there will be no further pregnancies

Pre-malignant conditions of the cervix—any method is suitable
Breast cancer Breast cancer: copper IUD is a good choice

COCs, POI contraindicated

POPs and LNG lUSs should not be initiated
Endometrial, ovarian, cervical cancer  

Copper lUDs should not be initiated but may be continued if cancer develops during use

Treatment usually causes sterility. If treatment is not available and contraception is needed, COCs, POPs, POI and Implanon® can be used
HAEMATOLOGICAL DISORDERS
Anaemia Copper lUCDs not suitable as they can increase blood flow COCs. Progestogen-releasing IUD, POI can reduce blood loss through menstruation
Sickle-cell disease  

Pregnancy can be life-threatening for women with sickle-cell anaemia, therefore effective method is needed. Long-acting progestogen-only contraceptives should be first choice

COCs and copper lUDs are good second choices
Thalassaemia No methods are contraindicated  
INFECTIOUS DISEASES
Tuberculosis   Efficacy of COCs, POPs and Implanon® is reduced, therefore the woman should be advised to employ a back-up method while taking rifampicin and two weeks after cessation of therapy
Malaria   No contraindications to any method. No known drug interaction between antimalarial medications
HIV infection Spermicide used alone is not adequate Whatever the contraceptive choice, male condoms should also be used. The female condom is less well studied but should also reduce the risk of HIV infection when used consistently and correctly
OTHER
Psychiatric disorders Sterilisation is not recommended for women or men with a psychiatric illness such as depression that may impair informed decision making Methods that do not require strict compliance are more suitable for women with an acute or severe psychiatric disorder for whom making contraceptive choices may be difficult
Mental disability Careful consideration needs to be made to ensure that there is no coercion to use a particular method of contraception. Most methods are suitable and are dictated by the woman’s ability to manage a particular method Sterilisation in the absence of informed consent by the client must involve the legal guardian and team of professionals. The decision must be guided by legislation

COC = combined oral contraceptive; DMPA = depot medroxyprogesterone acetate; EC = emergency contraception; GA = general anaesthetic; HIV = human immunodeficiency virus; IUD = intrauterine device; IUS = intrauterine system; LNG = levonorgestrel; POI = progestogen-only injectables; POP = progestogen-only pill.

Based on World Health Organization (WHO) 2010 Medical eligibility criteria for contraceptive use. Geneva, WHO. Online. Available at www.who.int/reproductivehealth/publications/family_planning/9789241563888/en/index.html 9 May 2011.

Contraceptive prescriptions and advice are most commonly provided by general practitioners (GPs) and by nursing and medical staff in specialised organisations that provide contraceptive services, listed at the end of this chapter. A comprehensive assessment that takes into account the woman’s general health, financial circumstances, lifestyle, cultural and spiritual health and previous experience with contraceptive methods is integral to the selection of the most appropriate contraceptive method for her.

Fertility-awareness-based (FAB) methods

These methods, sometimes called ‘natural methods’ or ‘natural family planning’, use recognition of the changes in a woman’s body at various times of the menstrual cycle. They acknowledge that the estimation of the period of fertility needs to take into account the viability of sperm in the female genital tract—an average of 3–4 days with a theoretical possibility of up to 7 days—and the fertile period of the ovum, which is estimated to be 24 hours (Guillebaud, 2009).

Calendar (rhythm) method

The calendar method is the least reliable of these methods. It is based on the premise that ovulation occurs in the middle of the cycle and the fertile period lasts for six days—the five days before ovulation and the day of ovulation (Jennings and Arevalo, 2007).

Basal body temperature method

The basal body temperature (BBT) method is based on the fact that there is a drop in a woman’s body temperature 12–24 hours prior to ovulation, with a sustained rise for several days afterwards. Knowledge of temperature change is only useful in establishing when ovulation has already occurred over several cycles and thus the infertile period in which safe intercourse can occur.

Cervical mucus charting (ovulation or Billings method)

In this method, the woman is taught to recognise her fertile days by both the appearance and the sensation of mucus at the vulva. The fertile mucus (Spinnbarkeit mucus) assists the sperm to enter the cervix and is produced under the influence of unopposed oestrogen in the follicular phase of the cycle (Guillebaud, 2009). It is likely that ovulation occurs within 1 day before, during or 1 day after the last day of abundant slippery discharge (Jennings and Arevalo, 2007).

Symptothermal method

This method incorporates cervical mucus observation and BBT as described previously, with additional indicators of ovulation. These include symptoms such as the recognition of the softening and lowering of the external cervical os at the time of ovulation by the woman palpating her cervix (Guillebaud, 2009). Additional symptoms which may occur around the time of ovulation include mittelschmerz pain caused by follicular rupture and resulting in symptoms such as dragging pain in the lower abdominal area, and rectal pain which may occur before, during or after ovulation. Other symptoms may include increased libido, mood changes, breast tenderness and tenseness.

Barrier methods

Barrier methods include male and female condoms and diaphragms, and are used only as they are required. Condoms, in addition to their contraceptive value, prevent the transmission of some sexually transmitted infections (STIs), discussed later in this chapter.

Male condom

This is a widely available and popular method of male contraception. Male condoms are one-use-only sheaths most commonly made of latex (rubber). Polyurethane (plastic) condoms are also available but are more expensive than latex condoms. They are thinner and have a higher breakage rate than latex condoms, although they provide a good alternative for individuals with allergies, sensitivities or personal preferences that might prevent the use of latex condoms (Gallo and others, 2006).

It is recommended that lubricants are used with male condoms. Only water-based lubricants should be used with latex condoms. Oils and creams can break down the latex and should not be used—these include vaginal products used to treat Candida albicans as well as oil-based lubricants like Vaseline, baby oil, massage oils and hand and body lotions. Oil-based lubricants can be used with polyurethane condoms. Care must be taken in the handling of all condoms to ensure that tearing does not occur at any time during their use.

Condoms are most effective against STIs to and from the male urethra. These include human immunodeficiency virus (HIV), gonorrhoea, chlamydia, trichomoniasis and hepatitis B. They are less effective against STIs transmitted by skin-to-skin contact or contact with mucosal surfaces, for example genital herpes, human papilloma virus and syphilis, because the infected areas may not be covered by the condom (Warner and Steiner, 2007).

Female condom

The new-generation female condom (FC2) is a loose synthetic nitrile sheath that is inserted into the vagina. It has a ring at one end that fits into the vaginal fornices in contact with the cervix (in much the same way as a diaphragm) and an outer ring that is in contact with the vulva, preventing it from retracting into the vagina. As with male condoms, female condoms afford protection against several STIs (Guillebaud, 2009). Because they are made of synthetic nitrile rather than latex, they can be used with oil-based lubricants. In Australia, women should be referred to their local family planning and sexual health organisation (see Additional resources) for information about availability, which varies from state to state. Female condoms are also available from some online pharmacies. In New Zealand, female condoms are imported by the Family Planning Association and sold through clinics and by mail order.

Diaphragm

A diaphragm is a soft latex or silicone dome with a flexible metal ring encased in the rim. It is inserted into the vagina to cover the cervix (Cook and others, 2003). Diaphragms come in circumferences ranging from 70 mm to 90 mm and must be fitted by a medical practitioner or sexual health nurse. Although use of a spermicide with the diaphragm is recommended by manufacturers, spermicide is not currently available in Australia or New Zealand.

Intrauterine devices

The intrauterine contraceptive device (IUD) is inserted into the uterus and left in situ, and when removed will provide prompt return of fertility. In Australia, the Copper-T 380a™ and Multiload Cu 375™ are available, both of which are copper-bearing. The Copper-T can be left in place for 8 years, and the Multiload for 5 years. In New Zealand, the Multiload Cu 375™ is available. The Mirena™ intrauterine system (IUS), a levonorgestrel (LNG) releasing system, is also available in Australia and New Zealand and has a 5-year life span. It releases 20 micrograms of LNG per day and blocks oestrogen and progesterone receptors, and also reduces sperm penetrability of the uterine fluid and cervical mucus. In addition to its contraceptive action, it is also effective in reducing menorrhagia.

Hormonal methods

Oral contraceptive pills (OCPs)

COMBINED ORAL CONTRACEPTIVE PILLS

Combined oral contraceptives (COCs), commonly known as ‘the pill’, are an effective and popular method of contraception. COCs are a combination of synthetic oestrogen and progestogen in different amounts depending on the brand. COCs are either monophasic (all pills in the packet are identically active with the same strength of oestrogen and progestogen) or multiphasic. Multiphasic pill types include biphasic (two types of active pills in the packet; the oestrogen dosage and type remain constant and the type of progestogen changes between the two last weeks of the active pills) or triphasic (three types of active pills in the packet; the oestrogen level may remain constant or change with the progestogen component, and progestogen has three different levels in the three weeks of active pills) (Nelson, 2007).

Pills are taken each day at around the same time for the 21 active pills in the packet. For the remaining 7 days, which is also called the ‘pill-free interval’ or PFI, either no pills are taken or placebo pills are taken. A withdrawal bleed occurs during that time. An extension of the PFI week risks ovulation and thus the possibility of pregnancy should intercourse occur at that time. This means that every pill in the packet should be taken, and the woman needs to plan ahead so that she has a new packet ready to take at the end of the PFI. If women are hospitalised, they will need to be advised about how to manage their pill-taking to prevent pregnancy if any pills are missed.

PROGESTOGEN-ONLY PILL

The low-dosage progestogen-only pill (POP), also known as the ‘mini-pill’, provides the same amount of one of three progestogens (levonorgestrel, norethisterone or ethynodiol) in each tablet. It is suitable for women in whom oestrogen—and thus COCs—is contraindicated. The POP is taken every day with no PFI. Unlike the COC, which has a 12-hour leeway for the dose of active pills, POPs have to be taken within 3 hours of the same time each day. The action of POPs is via blocking passage of sperm by thickening the cervical mucus, inhibiting ovulation in a variable proportion of cycles, and decreasing endometrial receptivity (Raymond, 2007a). As with the other progestogens, bleeding patterns may be altered during POP use, although amenorrhoea is likely during lactation (Guillebaud, 2009). If women are hospitalised, they will need to be advised about how to manage their pill-taking to prevent pregnancy if any pills are missed.

Hormonal vaginal contraceptive ring

The hormonal vaginal contraceptive ring (NuvaRing™) is the newest method of contraception available in Australia and New Zealand. This form of contraception releases 120 micrograms of etonorgestrel and 15 micrograms of ethinyloestradiol from a soft, flexible plastic ring (outer diameter of 54 mm) inserted into the vagina. Its action is to suppress ovulation, with other likely actions being to increase cervical mucus viscosity and endometrial thinning (Nanda, 2007). The ring is left in situ for three weeks and removed for the fourth week—the ring-free period. The ring is discarded and a new ring used after the ring-free period.

Injectable contraception

Depot medroxyprogesterone acetate (DMPA), known as Depo-Provera™ 150 micrograms, is an intramuscular contraceptive injection that is effective for 3 months. It suits women who prefer a non-coitus-dependent method of contraception, but should be used in conjunction with condoms for women who are at risk for STIs. It is suitable for women who need a method that does not include oestrogen (e.g. a smoker, or where there is a history of thrombosis), women who have oestrogen-related side-effects from COCs or those who are taking medications that are contraindicated with COCs.

DMPA is administered by deep intramuscular injection into the gluteus maximus or deltoid. The woman is given the date for the next injection calculated as 3 calendar months from current injection, although there is a leeway of up to 14 weeks in which the next injection can be administered. The action of DMPA is to suppress ovulation by inhibiting the surge in LH and FSH, thicken cervical mucus to block sperm entry into the upper reproductive tract, slow tubal and endometrial motility and cause thinning of the endometrium (Goldberg and Grimes, 2007).

Contraceptive implant

Implanon™ is a matchstick-sized progestogen-releasing rod, implanted under local anaesthetic parallel to the skin on the inside upper arm. It has a 3-year life span and high efficacy rate, and suits women who want a non-coitus-dependent method that is ‘set and forget’. The action, side effects and precautions related to the use of Implanon™ are the same as for DMPA. Implanon™ contains 68 micrograms of etonogestrel and releases 60 micrograms of progestogen per day. It acts by blocking passage of sperm by thickening the cervical mucus, inhibiting ovulation and making the endometrium atrophic (Raymond, 2007b).

Emergency contraception

Emergency contraception is an important and underused method of contraception that can be used for contraceptive failure (e.g. ruptured or slipped condom, missed pill(s), dislodged diaphragm), non-use of contraception, and sexual assault. It is a method of contraception that should be included as part of counselling for most contraceptive methods as well as be made more widely known about in the community (Calabretto, 2009). Hormonal emergency contraception (EC) is the main approach for EC (although the IUD can also be used). An important multicentre trial led to the current LNG-only method of EC (World Health Organization, 1998). EC is sometimes erroneously thought to be an abortifacient. It is important to understand that EC does not interrupt an already implanted pregnancy (Calabretto and Galloway, 2004). The regimen is 1500 micrograms of LNG in a one-dose pill taken within 120 hours of unprotected sex. The sooner it is taken, the more effective it is. The principal mechanism of action of LNG as EC is to inhibit or delay ovulation, with no demonstrated effect of an implanted ovum (ICEC and FIGO, 2011).

Other contraceptive methods

Lactational amenorrhoea method (LAM)

Breastfeeding can provide a natural contraceptive effect and can be used for contraception when a woman is exclusively or near-exclusively breastfeeding for the first 6 months following a birth, providing 98% protection against pregnancy if the following conditions are met:

• the woman must breastfeed both day and night, providing a minimum of 90% of the infant’s nutritional requirements

• she must be amenorrhoeic, and

• the infant must be under 6 months old (World Health Organization, 2010a).

Spermicides

Spermicides are chemical agents that destroy or immobilise sperm, making them incapable of fertilising an ovum. They are not recommended as a contraceptive alone, but are useful in increasing the efficacy of barrier methods such as diaphragms. Nonoxynol-9 is the active agent in most spermicides, and spermicides are effective against several STIs; however, they are not effective against the acquisition of HIV infection by women from men. Repeated and frequent use of this spermicide has also been associated with increased risk of genital lesions, and may actually increase the risk of HIV (Wilkinson and others, 2007). It is for this reason that condoms which come pre-lubricated with spermicide are no longer recommended; nor is the use of spermicides as a lubricant with condoms.

Vaginal douche

There is an erroneous belief that vaginal douching has a contraceptive effect by flushing sperm out of the vagina. Most sperm are contained in the first few drops of ejaculate, and sperm enter the cervical canal within 90 seconds of the deposit of semen at the cervical os. It is impossible to douche in time to prevent pregnancy, and douching may also cause an increased risk of pelvic infections. This practice should not be recommended (Cates and Raymond, 2007).

Coitus interruptus (withdrawal)

This is a method that requires the man to withdraw his penis from the vagina before he ejaculates. The method may variously be described as ‘withdrawal’, ‘being safe’ or ‘being careful’ or by other euphemisms (Varney, 1997). It is important to be aware of the meaning behind such descriptions when a woman discusses her contraceptive method. It has a low rate of contraceptive efficacy, although when used consistently and correctly it has the same efficacy as barrier methods and therefore should not be dismissed.

Permanent methods of contraception

These highly effective surgical methods block the passage of ova in women and sperm in men. Although reversibility may be possible for some procedures, sterilisation should be considered as permanent, and it is therefore important that appropriate counselling is provided so that expectations are accurate. None of the procedures affect the hormonal levels in the body, and will not diminish but may in fact enhance sexual response because the fear of pregnancy is removed. These techniques do not provide protection against STIs, and so use of condoms is needed for people who are at risk for STIs.

Tubal sterilisation

Female sterilisation, or tubal occlusion, is performed by a gynaecologist under conscious sedation or under general or local anaesthetic. The surgical approaches that may be used are laparoscopy, mini-laparotomy (performed after childbirth) or laparotomy. Once the fallopian tubes have been accessed, they are sealed off with clips, rings or bands applied to the tubes, or diathermy may be used to heat and seal the tubes. The method is effective immediately, and sexual intercourse may be resumed when the woman is ready to do so.

The newest method of female sterilisation—the Essure™ technique—is performed using a cervical block and leaves no abdominal scars. Nickel titanium microcoils are inserted hysteroscopically into the ampullae of the fallopian tubes to cause scarring, and thus blockage, of the tubes. At 3 months, a hysterosalpingogram or ultrasound is performed to confirm the presence and position of the coils (Teoh and others, 2003). Until the blockage is confirmed, another method of contraception must be used. At present in Australia, the Essure™ method is performed in a number of public hospitals under Medicare arrangements. Private health funds will cover the cost of the device and insertion but usually with a gap payment. In New Zealand the procedure can only be undertaken privately. Although it is the least-invasive method of female sterilisation, it is the least-commonly performed procedure at present.

Hysterectomy

Removal of the uterus for obstetric emergencies, cancer or gynaecological problems also confers permanent contraception.

Vasectomy

This is a male method of contraception where the ductus deferens is cut and the end sutured to block the ductus deferens and passage of sperm from the testes. There is local swelling and discomfort for a few days after the procedure. After vasectomy, sperm are reabsorbed. The procedure is usually performed under local anaesthesia, by a urologist, surgeon or GP. Following the procedure, between 15 and 20 ejaculations are needed for the remaining sperm to be expelled from the body, so additional precautions need to be taken until a semen analysis is done to confirm the absence of sperm in the seminal fluid.

Sexually transmitted infections

STIs are caused by bacteria, viruses and parasites transmitted from partner to partner during intimate sexual contact (Temple-Smith and Gifford, 2005). This is most commonly via vaginal intercourse, oro-genital contact or anal intercourse.

Viruses

Herpes simplex virus type 1 (HSV 1) affects the mouth, throat and nose; and type 2 (HSV 2) affects the genitals, although both viruses are capable of infecting the oral or anogenital sites. The virus lies dormant in the nerve root and may be passed on to other people by sexual contact (oral, anal or genital). Transmission can sometimes occur even if the infected person does not have an active outbreak of herpes blisters or ulcers. Half of all new genital herpes infections in adolescents and young adults are with HSV-1, which reflects changed sexual practices where young people are engaging in more-frequent oral sex. They may perceive this activity to be ‘safer’ to prevent pregnancy and STIs or as not being ‘real sex’ so that virginity is preserved. Treatment for genital herpes consists of antiviral medications.

Human papillomavirus (HPV) causes genital warts. Most people will be infected with this virus during their sexual life and although it is usually mild, self-limiting and often asymptomatic, it may also be the cause of cervical and anal cancer. Routine Papanicolaou (Pap) smear screening for women detects early cell changes with HPV infection, allowing early treatment prior to the development of cervical cancer (Department of Health and Ageing, 2011a).

Human immunodeficiency virus (HIV) is one of the retroviruses which leads to the depletion of immune function. Antiviral medications are able to prevent or delay HIV-positive individuals developing acquired immunodeficiency syndrome (AIDS) which is eventually fatal. Only specific fluids (blood, semen, vaginal secretions and breast milk) from an HIV-infected person can transmit HIV. These specific fluids must come into contact with a mucous membrane or damaged tissue, or be directly injected into the bloodstream (from a needle or syringe) for transmission to possibly occur. HIV is transmitted through body fluids by homosexual and heterosexual oral, genital or anal contact or by injecting drug use. It can also be acquired medically, although since 1985 therapeutic blood products in Australia and New Zealand have been screened for HIV and high-risk donors have been excluded from donating blood. Each donor must also sign a declaration stating that she or he does not have any high-risk factors for HIV. Vertical transmission is also possible from mother to fetus during pregnancy; however, with anti-retroviral drug treatment this can be prevented in most cases. Women with HIV are advised not to breastfeed their infants. Both Australia and New Zealand have low rates of HIV (Kirby Institute, 2011; STI Surveillance Team, Population and Environmental Health Group, 2010).

Molluscum is a benign infection caused by the molluscum contagiosum virus, which is transmitted by skin-to-skin contact during sexual contact when there are genital lesions. They are small greyish domes that appear on the genitals and surrounding area. The infection can be self-limiting; it can be actively treated with cryotherapy using liquid nitrogen.

Hepatitis A is mainly not transmitted sexually, but the practice known as anilingus or ‘rimming’ (oro-anal contact) can be a cause of transmission, as can anal intercourse or the poor handling of used condoms after anal sex. Hepatitis B is spread through infective body fluids including sexual activity (vaginal, anal or oral sex), through sharing injecting equipment and vertically from mother to infant at birth. Hepatitis C is transmitted almost exclusively by blood to blood contact but can be transmitted sexually.

Bacteria

Chlamydia is caused by Chlamydia trachomatis, is frequently asymptomatic in women and causes cervicitis and infection of the uterus, fallopian tubes and ovaries. It can result in future increased risk of ectopic pregnancy or infertility. In men it results in urethritis and painful urination; however, as with women, it may be asymptomatic. It is readily detected by a urinary polymerase chain reaction (PCR) test and treated with azithromycin.

Gonorrhoea is caused by Neisseria gonorrhoea and is mainly transmitted sexually, but can also be vertically passed from mother to infant during birth. It results in cervicitis in women and urethritis in men. Transmission can be prevented by using condoms. It is diagnosed with swabs or urinary PCR test and can be treated by a single intramuscular injection of ceftriaxone. Gonorrhoea is 50 times more prevalent in Indigenous populations (Kirby Institute, 2011). Contact tracing is important in limiting the spread of this infection.

Syphilis is transmitted from the skin and mucous membranes of infected people and is easily spread by sexual contact. It is diagnosed by a blood test. If untreated, it can lead to serious heart abnormalities, mental disorders, blindness, other neurological problems and death; however, this is rare today. It is treated with a single injection of a long-acting penicillin, benzathine penicillin G.

Donovanosis is an uncommon genital infection caused by Klebsiella granulomatis. Australia is one of the few countries in which it occurs, and it is most exclusively found in Far North Queensland and the Northern Territory. It persists in these communities because of delayed presentation to healthcare services which are not able to be readily accessed (Temple-Smith and Gifford, 2005).

Parasites

Pubic lice (commonly known as ‘crabs’) is caused by an insect called Phthirus pubis which feeds on human blood and is readily transmitted by sexual contact. Infection results in intense itching of the skin. It is treated with topical permethrin cream.

Scabies is caused by Sarcoptes scabiei, a small mite that burrows into the skin. It is readily spread by skin-to-skin contact and sexual contact is ideal. It is treated with topical permethrin cream.

Trichomoniasis causes profuse, malodorous and frothy vaginal discharge in women. Men are usually asymptomatic, or it may cause mild non-specific urethritis. It is treated with tinidazole or metronidazole.

Prevalence of STIs

The Kirby Institute publishes annual surveillance data on the occurrence of HIV and other STIs in Australia. In 2010, chlamydia was the most frequently reported STI in Australia, with 74,305 cases. Chlamydia rates are rising across all community groups, with the highest being among the age group 15–29 years. Reported infection rates for gonorrhoea were stable from 2005–2009 at 36 per 100,000 total population. The rate of syphilis infections has decreased from 6.6 per 100,000 total population in 2007 to 5.8 per 100,000 in 2009; however, overall an increased number of cases since 2002 has largely occurred among men who have sex with men (MSM). Substantially higher rates of diagnosis of chlamydia and gonorrhoea were recorded among Aboriginal and Torres Strait Islander (ATSI) people compared with non-Indigenous people, and rates of infection are more concentrated in ATSI people living in remote or very remote regions such as central Australia (Kirby Institute, 2011).

An estimated 21,391 people were living with diagnosed HIV infection in Australia at the end of 2010, with an annual number of new cases remaining relatively stable at around 1000 over the past 5 years (Kirby Institute, 2011). Transmission of HIV continues to be mainly through sexual contact between men. The rate of HIV diagnosis was similar between ATSI people and the non-Indigenous population, although a higher proportion of HIV cases among ATSI people were women and attributed to injecting drug use. Of the 1297 new cases of HIV in Australia between 2006 and 2010 for which exposure was attributed to heterosexual contact, 60% were in people from high-prevalence countries or their partners (Kirby Institute, 2011).

In New Zealand, with the exception of HIV/AIDS, STIs are generally not notifiable. Surveillance data are based on voluntary reports from several different sources (sexual health clinics, family planning clinics, student and youth health clinics, and laboratories). Population and disease coverage varies with the data source. Therefore, the data provides some information about the rate and type of STIs but probably underestimates the true burden of disease (STI Surveillance Team, Population and Environmental Health Group, 2010).

The general trend in New Zealand during 2009 indicated that chlamydia was the most commonly reported STI, gonorrhoea was increasing, syphilis showed an increase of 50% from 2008 and was most prevalent among people of European ethnicity. There was a 5.6% increase in genital herpes and a decrease in genital warts and non-specific urethritis (STI Surveillance Team, Population and Environmental Health Group, 2010).

A major problem in dealing with STIs is finding and treating the people who have them. Some people may not even know that they are infected because symptoms are absent or go unnoticed. Because sexual behaviour may include the whole body rather than just the genitalia, many parts of the body are potential sites for an STI. The ears, mouth, throat, tongue, nose and eyelids can be used for sexual pleasure. The perineum, anus and rectum are also frequently included in sexual activity. Furthermore, any contact with another person’s body fluids around the head or an open lesion on the skin, anus or genitalia can transmit an STI.

Sometimes people do not seek treatment because they are embarrassed to discuss sexual symptoms or concerns. They may also hesitate to talk about their sexual behaviour if they believe that it is not ‘normal’ or that they may be judged for revealing information about themselves. Oro-genital sex, anal sex or any sexual behaviour that embarrasses the client may hinder the detection of an STI. By questioning and talking with the client in a caring manner that evokes trust, the nurse can elicit valuable clues about an STI that the client may have missed. The nurse can also begin to assess the client’s attitudes to sexuality and adapt the intervention to make it acceptable to the client’s sexual value system. As an example, a nurse working in a sexual health clinic might ask the following:

• I’d like to ask you some questions about your sexual activity so we can decide what tests to do, is that OK with you?

• Are you currently in a relationship?

• In the last 3 months, how many sexual partners have you had?

• How many partners have you had in the past 12 months?

• Were these casual or regular partners?

• Were your sexual partners male, female or both?

• From today, when was the last time you had vaginal sex/oral sex/anal sex without a condom?

• In the past year, were you ever paid for sex?

• Have you previously been diagnosed with an STI?

• Is there anything else that is concerning you?

• CRITICAL THINKING

You are caring for a 20-year-old woman with cystic fibrosis who tells you that she is sexually active and doesn’t use contraception or practise safer sex because ‘I am going to die young anyway and I’m probably sterile so I can’t get pregnant.’

Think about how you would respond to her. Is she correct in her assumptions about fertility? What health teaching do you need to provide to her in relation to safer sex and pregnancy prevention?

Circumcision

In Australia and New Zealand, the circumcision rate has fallen in recent years. Approximately 10–20% of newborn male infants are circumcised (Royal Australasian College of Physicians, 2010). Although there are medical indications for circumcision, the Royal Australasian College of Physicians (2010) argues that the frequency of diseases modifiable by circumcision, the level of protection offered by circumcision and the complication rates of circumcision do not warrant routine infant circumcision in Australia and New Zealand. It is reasonable for parents to weigh the benefits and risks of circumcision to make the decision whether or not to circumcise their sons (Royal Australasian College of Physicians, 2010).

Female genital mutilation

Female genital mutilation (FGM) involves all procedures where there is removal of part or all of the external female genitalia for non-medical reasons. The WHO states that FGM is ‘recognized internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women’ (WHO, 2010b). In Australia and New Zealand, performance of any type of FGM is illegal and is also prohibited by the Royal Australian College of Obstetricians and Gynaecologists (Mathews, 2011). FMG can result in immediate complications of severe pain, shock, haemorrhage, tetanus, sepsis, urinary retention, open wounds and injury to adjacent genital tissue (WHO, 2010b). In addition to the impact on sexual pleasure, there are also long-term complications including recurrent bladder and urinary tract infections, the development of cysts, infertility, an increased risk of complications during childbirth, and additional surgery to cut open and resuture the vaginal orifice for sexual intercourse and childbirth.

Health promotion activities

Prevention or early detection of some reproductive cancers may be assisted by screening or individual health behaviours.

Testicular cancer

There is no routine screening test for testicular cancer. There is also little evidence to suggest that testicular self-examination detects cancer earlier or improves outcomes (Cancer Council Australia, 2011). A sensible approach is for men to become familiar with the usual level of lumpiness of their testicles and to see their healthcare provider if they notice a change. Men with a family history of testicular cancer (father or brother) or a personal history of absent or undescended testicles, in particular, should regularly check for lumps or swellings on the surface of the testicles.

Prostate cancer

There is no population-based screening test for prostate cancer which is proven to lower the mortality rate (Cancer Council Australia, 2010). Digital rectal examination (DRE) and serum prostate-specific antigen (PSA) are used as screening tests, although the accuracy of these tests is not high. Cancer Council Australia’s (2010) position is that in the absence of direct evidence showing a clear benefit of population-based screening for prostate cancer, a patient-centred approach for individual decisions about testing is recommended. Ideally this takes the form of an informed, shared, decision-making process between the healthcare provider and man, discussing the benefits, risks and uncertainties of testing, and discussion about treatment options and side effects. Screening discussions and decisions should always include and take into account age and other individual risk factors such as a family history of the disease.

Cervix cancer (cervical cancer)

To reduce morbidity and deaths from cervical cancer, the National Cervical Screening Program in Australia recommends 2-yearly Pap smear tests every second year for all women aged over 18 years who have ever had sex, even if they no longer have sex. Routine screening is not required for women under 18 years of age even if they are sexually active. For women who have had a hysterectomy, two negative vaginal vault smears are recommended, after which time Pap smears can be ceased (Department of Health and Ageing, 2011a). In New Zealand, the National Screening Unit advises that all women who have ever had sex should be offered a Pap smear test every 3 years from age 20 to 69 years. If this is the first ever smear, or more than 5 years have elapsed since the previous smear, a second smear is recommended 1 year after the first, with 3-yearly smears thereafter (National Screening Unit, 2008).

The Pap smear test involves collecting cells from the transformation zone of the cervix through a vaginal speculum. The cells are ‘smeared’ onto a slide and sent to the laboratory to be checked for precancerous or cancerous cells. If abnormal changes are found at screening, further tests will be done to see if treatment is needed.

Some strains of HPV which also cause genital warts are commonly linked to cervical cancer. A vaccine has been developed that prevents the types of HPV most commonly linked to cervical cancer. Through their respective national immunisation programs, girls around the age of 12 years in Australia and New Zealand receive a free vaccine for HPV (Department of Health and Ageing, 2011a; National Screening Unit, 2008).

Breast cancer

Breast cancer is the most common invasive cancer in Australian women after non-melanoma skin cancer, and is the most common cancer in New Zealand women. Women are advised to be physically familiar with their breasts, check regularly for any non-hormonal changes and seek advice if they notice any non-normal changes. In Australia mammograms are recommended 2-yearly for women aged 50–69 years but are available to women over 40 years. In New Zealand, mammograms are recommended 2-yearly for women aged 45–69 years. Younger women in high-risk groups may be screened by magnetic resonance imaging (MRI) because mammograms are less effective in younger women because of the increased density of their breast tissue (Brennan and others, 2009).

Ovarian cancer

There is insufficient evidence for population-based screening to detect ovarian cancer (Australian Cancer Network and National Breast Cancer Centre, 2004). Ultrasound (abdominal, transvaginal and Doppler) and serum CA125 have been suggested; however, none of these have the sensitivity or specificity to be recommended as a screening test. Women with a genetic risk for ovarian cancer (an abnormality with the breast cancer genes BRCA1 and BRCA2) need specialist advice.

Talking to clients about sexual issues

Nurses and other healthcare professionals are often reluctant to become involved in taking a sexual history (Wilson and McAndrew, 2000). This may be due to a lack of knowledge about how to introduce the topic of sexual health or not picking up on cues offered by the client during the assessment process. Failing to address these issues leads to missed opportunities for health teaching and appropriate referral. When you work in a particular area of nursing, you will become more familiar with the impact of altered health states on sexuality and will become more confident in discussing this with clients. It is important that you gain confidence in exploring these issues in order to provide holistic care. It also needs to be recognised that the nurse is not expected to have the answers to all sexual issues and concerns identified. This can free the nurse to gather an appropriate sexual history database.

• CRITICAL THINKING

Reflect on the last six clients you have cared for. Were there or could there have been issues related to their sexual health that you could have explored with them? Ask an experienced registered nurse how they would talk to these clients about the impact of sexuality on their health to give you some strategies for your future practice.

CLINICAL EXAMPLE

At the time a person is admitted for major surgery for bowel cancer which will result in a permanent colostomy, s/he may or may not being thinking about the impact of the surgery on future sexuality. However, the topic must be raised before the person is discharged. Here is an example of some possible dialogue you could have with the client at that time, to prompt discussion about their sexual concerns.

• ‘Hello … when I admitted you last Monday, you mentioned to me that you have a partner. Can you tell me if you are sexually active?’

• ‘Now that you are recovering from your surgery, I was wondering how you are feeling about your colostomy and cancer treatment and how this might affect your relationship with your partner?’

• ‘I imagine you might have concerns about sexual intimacy, and perhaps how your partner might react to being sexually intimate with you now.’

• ‘The stomal therapy nurse will be coming today to discuss the management of your stoma when you get home, and she can talk to you about this. Do you want your partner to be involved as well?’

Impact of altered states of health on sexuality

It is beyond the scope of this chapter to discuss all of the possible altered states of health that may affect sexuality, yet nurses need to be aware of this possibility when looking after clients of all ages. Altered states of health may temporarily or permanently affect sexual function. This can include a range of chronic medical and surgical conditions; major trauma; disability; mental health conditions; and the medications that are part of any treatment (see Boxes 24-1 and 24-2). Considering this possibility will be an important part of an initial nursing assessment and also part of the ongoing discharge education.

BOX 24-1 SOME OF THE CONDITIONS THAT CAN AFFECT SEXUALITY

MEDICAL CONDITIONS

Multiple sclerosis, arthritis, cardiac disease, lung disease, diabetes, renal disease, incontinence and obesity, chronic pain

SURGICAL CONDITIONS

Mastectomy, hysterectomy, prostatectomy, colon surgery (from cancer, Crohn’s disease or ulcerative colitis), cardiac surgery, orthopaedic surgery—particularly on the knees and hips

MENTAL ILLNESS

Depression, anxiety, obsessive compulsive disorder, schizophrenia, post-traumatic stress syndrome, substance abuse

INTELLECTUAL DISABILITY

Down syndrome, autism spectrum disorders, developmental disability

TRAUMA

Brain injury, spinal cord injury, burns

BOX 24-2 COMMONLY USED MEDICATIONS THAT MAY AFFECT SEXUAL FUNCTION

Benzodiazepines

Beta-blockers

Calcium channel blockers

Cimetidine

Clonidine

Cyproterone

Digoxin

Finasteride

Haloperidol

Lipid-lowering agents

Lithium

Methyldopa

Monoamine oxidase inhibitors

Neurotoxic cancer chemotherapies

Oestrogens

Opiates (including synthetic opiates)

Phenytoin

Progesterones

Selective serotonin reuptake inhibitors

Thiazide diuretics

Tricyclic antidepressants

In reading the clinical example on the previous page, did you consider the possibility that the client could be gay? If a gay man normally engages in anal sex and has had his rectum removed, this form of sexual behaviour will no longer be possible; and in addition to his further treatment for cancer, this could have a significant impact on his sexuality. If you do not raise this issue and provide appropriate referral, you can imagine how this might affect his future quality of life. Nurses must always be aware that by not discussing particular issues they give a message that the issue is not important. Nurses are conscientious about providing information about medication management, wound management, dietary advice, etc. Sexuality should be given the same consideration.

Sexual history as part of nursing assessment

When taking a nursing history, it is important to include a few questions related to sexual functioning to determine whether the client has any sexual concerns. These questions can be incorporated in the review of systems and covered in a routine, matter-of-fact manner. The nurse needs to understand the reasons why s/he might ask particular questions and be able to provide them to the client on request. As discussed previously, it is important to not assume that the client is heterosexual or exclusively heterosexual (Eliason and others, 2010) and to use the word ‘partner’ which is all-encompassing. The nurse must always be open to the fact that many people are sexually active when they are older, have a disability or have an acute or chronic condition (Gevirtz and Gevirtz, 2008; Hans and others, 2010; McCabe and Taleporos, 2003; Wallace, 2008).

An opening statement such as ‘Sex is an important part of life and can be affected by our health status and vice versa. To better understand your health, it is useful to know ….’ helps move more easily into direct questions such as:

• How do you feel about the sexual part of your life?

• Have you noticed any changes in the way you feel about yourself (as a woman, man, partner)?

• How has your illness, medication or surgery affected your sex life?

• It is not unusual for people with your condition to be experiencing some sexual changes. Have you noticed any changes, or do you have any concerns?

When taking a sexual history from an older adult, it may be relevant to explore the quality of the relationship between partners, the death or loss of a partner, sexual satisfaction and history during middle adulthood, the general health status of both partners, use of prescription and non-prescription medications and current satisfaction with sexual activity.

Additionally, given the prevalence of domestic and other violence, questions relating to abusive relationships can be important. A question such as ‘Are you in a relationship in which someone is hurting you?’ may allow the client to reveal present or previous abuse. An additional question such as ‘Have you ever been forced to have sex you did not wish to participate in?’ may allow the client to discuss their concerns.

When undertaking a sexual history, in many cases it is also relevant to ask about the client’s use of contraception and safe-sex practices. Young people may respond to a comment that allows them to know that being questioned about sexuality is a normal part of assessment. A lead-in could be: ‘Many young people have questions about STIs or whether their bodies are developing at the right rate. Do you have any questions about sex or other things?’ A recent study with young people in an acute children’s hospital concluded that healthcare professionals need to provide young people with a choice to discuss sexual and relationship issues in any healthcare setting (Sanders and others, 2011).

CLINICAL EXAMPLE

A 17-year-old woman with severe genital herpes is admitted to a small community hospital for treatment. Herpes infection does not usually require hospitalisation and is successfully treated with oral antiviral medications. Hospitalisation on this occasion was for pain management and to manage her urinary retention from widespread ulceration of the vulval and perineal areas. Some weeks later, in a case review meeting with all of the RNs, the clinical practice consultant asked who among the group had discussed anything with this young woman about her sexual health. Unfortunately, not one of the RNs had addressed this during the time the young woman was in their care.

Think about why you believe this might have been the case. What opportunities were lost in this situation to provide holistic care for this young woman?

For a female client, other areas that may be included are the date of their last menstrual period (LMP), any history of menorrhagia or dysmenorrhoea, perimenopausal or menopausal symptoms and type of contraception used. Also be aware of the client’s risk for unplanned pregnancy and STIs. This is also relevant for older women.

For all clients it is important to always assure confidentiality (unless the client reveals something that is unlawful and must be reported) and to provide privacy so that other people are not able to overhear the conversation. Be aware that some people are too embarrassed or do not know how to ask sexual questions directly. The nurse may detect clues that a client has unasked questions if they express concern about how their partner may respond now or if the person makes a sexual comment or joke. Looking for and listening to concerns about sexuality takes practice. With experience, the nurse develops skill in clarifying and paraphrasing to help people express sexual concerns. By including sexuality in the nursing history, the nurse acknowledges that sexuality is an important component of health and creates an opportunity for the person to discuss sexual concerns. It also provides the nurse with a range of health teaching opportunities and referral to other relevant healthcare professionals.

KEY CONCEPTS

• Sexuality is related to all dimensions of health; sexual concerns or problems should be considered part of nursing care at all ages and stages of development.

• Attitudes to sexuality vary widely and are influenced by religious beliefs, societal values, cultural beliefs, the media, the family and other factors.

• Nurses’ attitudes to sexuality vary and may differ from those of clients; nurses should be sensitive to clients’ sexual preferences and needs.

• Nurses should use an open and non-judgmental approach when discussing sexual health issues with clients.

• Choice and use of effective methods of contraception are affected by current stage in life; financial status, knowledge, access to particular methods; and existing medical conditions.

• A sexual history should form part of nursing assessment and include questions which will facilitate discussion with the client about relevant sexual health issues.

• Nurses should incorporate knowledge of current common sexually transmitted infections in their client group when undertaking a nursing assessment.

• Many nursing interventions to enhance a client’s sexual health involve the provision of information and education and appropriate referral to other healthcare professionals.

• With their permission, it may be appropriate to include the client’s partner in discussion about issues related to sexual health.

ACKNOWLEDGEMENT

New-Zealand-specific contraceptive information was provided by Dr Christine Roke, National Medical Adviser, Family Planning, Auckland, New Zealand.

ONLINE RESOURCES

Association of Reproductive Health Professionals, www.arhp.org

Australasian Sexual Health & HIV Nurses Association, www.ashhna.org.au

Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists, www.fsrh.org

Family Planning Queensland; Sexual behaviours in children and young people: a guide to identify, understand and respond to sexual behaviours, www.fpq.com.au/pdf/Br_SexualBehaviours.pdf

Royal Australian and New Zealand College of Obstetricians and Gynaecologists, www.ranzcog.edu.au

Royal College of Obstetricians and Gynaecologists, www.rcog.org.uk

The Kirby Institute, www.kirby.unsw.edu.au

World Health Organization; Family planning, www.who.int/topics/family_planning/en

ADDITIONAL RESOURCES

Sexual health and family planning organisations—useful information about clinic locations and services, and contraception, is available from the organisations listed below.

AUSTRALIA

Sexual Health & Family Planning Australia

GPO Box 2138, Canberra, ACT 2601

Website: www.shfpa.org.au

ACT

Sexual Health & Family Planning ACT

Level 1, 28 University Ave, Canberra, ACT 2601

Phone (clinic): (02) 6247 3077

Website: www.shfpact.org.au

New South Wales

Family Planning NSW

State Office, 328–336 Liverpool Rd, Ashfield, NSW 2131

Phone: (02) 8752 4300

Website: www.fpnsw.org.au

Northern Territory

Family Planning Welfare Association of NT

Head Office, Unit 2, The Clock Tower, Dick Ward Drive, Coconut Grove, NT 0810

Phone: (08) 8948 0144

Website: www.fpwnt.com.au

Queensland

Family Planning Queensland

Head Office, 100 Alfred Street, Fortitude Valley, Qld 4006

Phone: (07) 3250 0240

Website: www.fpq.com.au

South Australia

SHine SA (Sexual Health information networking & education SA)

GP Plus Health Care Centre, 64c Woodville Road, Woodville 5011

Phone (general enquiries): (08) 8300 5300

website: www.shinesa.org.au

Tasmania

Family Planning Tasmania

421 Main Road, Glenorchy 7010

Phone: (03) 6273 9117

Website: www.fpt.asn.au

Victoria

Family Planning Victoria

Head Office, 901 Whitehorse Road, Box Hill, Vic 3128

Phone: (03) 9257 0100 or freecall 1800 013 952

Website: www.fpv.org.au

Western Australia

FPWA Sexual Health Services

Head Office, 70 Roe St, Northbridge, WA 6003

Phone: (08) 9227 6177

Website: www.fpwa.org.au

NEW ZEALAND

Family Planning

National Office, Level 6, Southmark House, 203–209 Willis St, Wellington 6142

Phone: (04) 384 4349

website: www.familyplanning.org.nz

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