NHS-funded cosmetic surgery on female genitalia increased from 400 to 1,100 procedures between 2002 and 2008. Most operations were to reduce protuberance of labia minora from between the labia majora. Morphology of female genitalia may vary. A woman may be aware of such variability from seeing other people’s bodies or looking at pictures and films. These may contribute to a concept of what is normal and in part to women’s anxieties about their own bodies. The authors looked at differences in female genitalia from three genres of imagery: online pornography, textbooks and feminist publications. Dr Richard Ma comments: 'GPs may be used to dealing with men who present with anxieties about erectile difficulties and penis size; however, we may be less able to deal with women with anxieties about genital morphology as they tend not to present as often. This paper helps us to understand some of the causes of these anxieties and aids our own understanding of the norm.'

The vast majority of the population in England live within 30 minutes of their nearest GUM clinic, only 3% have to travel further. However, there is a wide variation in geographical distribution with more difficult access in the South West and eastern regions.  Writes Richard Ma: 'Despite apparently good access to sexual health services for the majority of the population, levels of STIs, unplanned pregnancies and HIV remain high. According to this paper, no one in London has to travel more than 30 minutes to a GUM clinic and yet it has high rates of unplanned pregnancies, STIs and HIV. One explanation is that even if a clinic is within 30 minutes’ travelling time, those who need the service most may not access it; also, someone who may benefit from a sexual health screen may not travel to a GUM clinic. It remains inequitable that some GPs offer a full range of sexual health services whereas others do not. Although timely access and close proximity may address sexual health needs, commissioners may need to work on improving the coverage of sexual health services in non-GUM settings such as general practice, community contraceptive clinics, youth services and pharmacies, where people are more likely to be offered a check-up opportunistically when they attend for another reason.'

The prevalence of Neisseria gonorrhoeae (GC) in young people, aged 15-24, was found to be 0.47% in a study carried out in the community.

Although not part of the National Chlamydia Screening Programme (NCSP), some areas under the programme provide screening for gonorrhoea as well. The number of tests for Chlamydia trachomatis (CT) and GC were obtained from five NCSP areas providing dual testing. Four areas introduced testing in 2007 and the fifth in 2008. Two of these areas were outside London and the rest within Greater London. The period of data collection was not stated. A total of 219,412 samples were tested from the five programme areas. The percentage of CT-positive samples ranged from 2.7% to 9.2%, GC positivity ranged from 0.2% to 2.1% which is consistent with other prevalence studies. CT positivity was higher outside London but that of GC varied; one London programme area consistently had the highest CT and GC positivities.

GPs who are under 35 and working in metropolitan areas are more likely to offer HIV tests, a study from Australia has found. Patients deemed to be at risk by their GP or who present for screening are most likely to be tested. The study used data from a cross-sectional, national survey of GP activity called BEACH (Bettering the Evaluation and Care of Health). This database has been running since 2000; each year, approximately 1,000 GPs from a national, rolling sample are recruited. Dr Richard Ma comments, 'There are two messages in this paper which to me might suggest potential strategies to improve HIV testing. Working on the supply side by focusing on GPs who are less likely to offer tests, and on the demand side by encouraging more people to ask for HIV testing; the latter seems to be one of the reasons for testing being carried out.' 

Patients who present to general practice with a suspected STI expect to be offered tests, given information and a formal referral to a GUM clinic if care is not offered on site. However, a qualitative study found that these expectations were often not met and many would prefer to be treated at a GUM clinic in future. 'It is refreshing to see that the public chose to see their GP in the first instance for sexual health matters. They expected their sexual histories to be explored, genital examinations to be done, and tests for STI and HIV to be offered. It is unfortunate, however, that some of the patients did not get what they wanted from general practice. It feels to me that we as GPs sometimes create barriers so that people do not get the care they need and it doesn't just apply to sexual health. It is the old chestnut: PUNs and DENs - patients' unmet needs might be doctors' educational needs. Let's try to do something about it.'

Anonymity and confidentiality are the key priorities for young people using contraceptive health services, a systematic review has found. Non-judgemental staff and accessibility are also deemed important. This systematic review examined selected qualitative research that looked at views of young people and providers in the UK regarding contraceptive services. Quality of papers was assessed using NICE criteria for qualitative studies. Data from each paper were extracted to establish core themes, which were further analysed and synthesised using a constant comparison method.

 Young age, having sex more than once with the infected partner, and a greater number of partners are all risk factors for chlamydia in contacts, a study from a GUM clinic has shown. A questionnaire-based, cross-sectional study was carried out using contacts of chlamydia cases attending a GUM clinic in Leicester. Only those who were verified as a contact case and willing to have a chlamydia test were included. 'This study is too small to trigger any changes to current practice. Larger studies are needed to weigh up the risks and benefits of switching to a policy of offering epidemiological treatment just to high-risk contacts, the researchers conclude. However, this study helps to reinforce the importance of partner notification as an important tool to reduce onward infection of STIs such as chlamydia. Not only do we need to convey the importance to the index case that their partners need testing and treatment, but we also need to remember to test and treat the partners if they present to us in general practice.'

There is a one in five risk of  men who have sex with men (MSM) being treated for HIV passing on the infection to their male partners if they do not use condoms. Using data from a cohort of MSM in the Netherlands, researchers used mathematical modelling to predict the probability that a man will infect his uninfected male partner over the course of first-line antiretroviral treatment. Three clinical situations were used: viral suppression achieved with good adherence to treatment; suppression achieved but adherence poor; suppression not achieved.'There are two very important messages: condoms remain the best way to reduce the risk of HIV transmission but their efficacy is not 100%; and risk of HIV transmission reduces with more frequent monitoring as this guards against risk of viral load increasing since the last measurement, i.e. decisions on condom use can be made based on a recent viral load measurement taken three months before rather than six months or longer. This paper provides a good rationale for any practitioner who sees MSM who are HIV positive and ask about risk of transmission to their uninfected male partners. They should always use a condom regardless of viral load and get the viral load checked regularly at their HIV clinic.'

Many men presenting with epididymo-orchitis in general practice are being prescribed antibiotics but not undergoing investigation, a large UK study has found. Information from the General Practice Research Database (GPRD), which contains anonymised longitudinal patient records from 460 general practices, was used to estimate the incidence of epididymo-orchitis in primary care between 2003 and 2008 and examine the management of patients with this condition. Men aged 15-60 years presenting with a first episode of epididymo-orchitis between 30th June 2003 and 30th June 2008 were included. Aspects of management assessed included: testing for STIs or UTIs, treatment using specific antibiotics for epididymo-orchitis, evidence of referral for further care or management only within the practice. A total of 12,615 patients, median age 37 years, with a first episode of epididymo-orchitis were identified. The incidence was highest in 2004-2005 and declined in the later years of the study. The fall in incidence coincided with the roll out of the National Chlamydia Screening Programme but a causal link cannot be substantiated by this study. 'The incidence of acute epididymitis, with or without testicular involvement, is estimated to be around 40/10,000 person years in the UK. In men under 35, the likely pathogen is an STI such as chlamydia or gonorrhoea; in older men, this is likely to be due to non-sexually transmitted infections. Just under half of cases may have no identifiable cause. Effective treatment is important to avoid complications such as infertility, prostatitis and urethral strictures. Cases related to STIs present opportunities for partner notification.'

Although the management of pelvic inflammatory disease (PID) is improving in general practice, most patients are still failing to be treated according to national guidelines, a UK study has shown. The British Association of Sexual Health and HIV (BASHH) has published guidelines for the management of PID which includes tests that are routinely available in primary care and antibiotics that are easily obtained from community pharmacists. The investigators used information from the General Practice Research Database (GPRD), a database of anonymised longitudinal patient records from 460 general practices. 'A total of 3,797 women were coded as having a first episode of PID during the study period; the incidence appeared to decrease from 19.3 to 8.9/10,000 person-years. The National Chlamydia Screening Programme had just been rolled out at the beginning of the study period; in theory, screening and treating for chlamydia may prevent cases of PID but this relationship cannot be substantiated from this study alone.'

The attitude of doctors and healthcare administrative staff is a greater obstacle to extending HIV testing than that of patients, a study has found.This paper set out to explore the attitudes of patients to being offered HIV testing in Cornwall where the prevalence is reported as 32 per 100,000 population. Patients attending six GP practices and selected hospital outpatient clinics, between November 2008 and January 2009, were enrolled in the study. They were given a short information sheet on HIV and asked to respond to a series of statements about HIV testing. 'This study was carried out in an area in the UK with relatively low HIV prevalence so the findings may not be transferable to urban areas with higher prevalence and, presumably, greater awareness. However, this is an assumption and the negative attitudes to HIV testing expressed by some individuals working in secondary care is extremely worrying. It appears the public are broadly in favour, it's the medical profession that is the barrier to increasing testing.'

Point of care (POC) diagnostic tests for chlamydia have low sensitivity and positive predictive value, a study from the Netherlands has found. The researchers evaluated the diagnostic performance of three POC tests: Handilab-C, Biorapid CHLAMYDIA Ag test and QuickVue Chlamydia test comparing them with the nucleic acid amplification test (NAAT), the gold standard for diagnosing chlamydia. All the POC tests were commercially available and had a CE mark (Conformitée Européene). 'The authors described these tests as having ‘alarmingly poor performance' particularly in terms of sensitivity and positive predictive value; they also state that these tests are not ready for widespread use. Clearly in practice, this would result in infections being missed and unnecessary treatment for those with false-positive results.'

Giving antiretroviral therapy (ART) to patients with HIV-1 could reduce transmission rates in the population. The Partners in Prevention HSV/HIV Transmission Study enrolled heterosexual adults from seven African countries (Botswana, Kenya, Rwanda, South Africa, Tanzania, Uganda and Zambia) co-infected with HIV-1 and herpes simplex virus type 2 (HSV-2), along with their HIV-1 seronegative partners. The study was a randomised, double-blind, placebo-controlled trial of aciclovir HSV-2 suppressive therapy. A post-hoc analysis of data from this original study was undertaken with the aim of assessing the effect of ART use by HIV-1 infected participants on the risk of HIV-1 transmission to their uninfected partners. The majority of HIV infections in the world are due to HIV-1 which means these findings are still generalisable even though the study took place in Africa.

Computer-assisted interviewing can encourage the disclosure of sexual risk-taking behaviour, a study has found. However, this approach was not accompanied by an increase in STI diagnoses. A total of 2,351 patients over the age of 16 with a new clinical episode attending two large sexual health clinics in central and SW London were enrolled in the trial. Patients were randomised into three arms: computer-assisted self-interview (CASI) with a touch-screen computer in private, after which a clinician assessed a computer printout of the history; computer-assisted personal interview (CAPI) where patient and clinician view the screen together but the data is input by the clinician, using the same interview schedule as in CASI; pen and paper interview (PAPI) with a clinician as per usual care completing a proforma. In the third group, data from clinic notes were transferred into same electronic format as CASI and CAPI.  'Embarrassment is a huge barrier for both doctors and patients in general practice which gets in the way of good sexual healthcare. It appears the use of computers to take sexual histories can yield more sensitive sexual behaviours, but whether patients are willing to disclose these to their GP and have them recorded in their notes might be a different matter.'

'While the POPI study does not prove beyond doubt the effectiveness of a chlamydia screening programme, it does prove there is some evidence that it can reduce incidence of PID. Also of interest is that it helps clinicians not to dismiss taking a sexual history in a woman who has had a chlamydia test as she might have been exposed to risks since the last test.'

Current UK national guidelines recommend an increase in HIV testing in primary and secondary care settings to improve early diagnosis. However, I think for this to be successfully rolled out in primary care, there need to be adequate incentive structures in place to encourage uptake, and effort should be concentrated in areas of high HIV prevalence such as London, Brighton and other urban areas.