Sexual health 13,14
Whether or not sexual health screening is undertaken in primary care, GPs have an important role to play, particularly in identifying patients with unmet needs given that stigma and discrimination often hinder uptake of services of this kind.
Disparities of healthcare access are reflected in in global data which reports an HIV prevalence of 19.1% among transgender people, with trans women (particularly women of colour) estimated to be 49 times more likely to have HIV than compared to the background population15. Trans men who have sex with men are often grouped into the MSM (men who have sex with men) cohort and as a consequence are often under-represented in the data.
Any patient, regardless of their gender identity, who has sex in situations where condoms are not used and who is HIV negative is a suitable candidate for HIV PrEP (pre-exposure prophylaxis) 16.
Be alert to the contribution of mental health vulnerabilities and of drug and alcohol use in this context.
In the UK, all trans people accessing sexual health services are offered an HIV and syphilis test, and some provide HIV PrEP.
Any person under 45 years old who has a risk similar to MSM is eligible for the quadrivalent HPV vaccine. HPV vaccination is also important for AFAB people with a cervix.
It is helpful to know if your patient has undergone any genital surgery, and to involve their surgeon if discharge symptoms develop in the first 6 months following a procedure. For example, vaginal discharge in a trans woman who has undergone vaginoplasty surgery could be related to excess granulation tissue or a vaginal stenosis and shouldn’t assumed to be an STI.
Knowing if genital surgery has taken place and what was undertaken also ensures that the appropriate swab sites are selected. For example, in the UK, a neovagina is usually constructed using penile skin, making it less susceptible to STI acquisition. A focus of infection might be missed if only a vulvo-vaginal swab were only to be taken in this case.
Similarly, some trans men who have undergone genital surgery will have a urethra constructed from grafted skin. For others, buccal tissue is used, eg: in metoidioplasty, where the hypertrophied clitoris is fitted with a mucosal-lined urethra.
Hormone use can also influence the presentation of a sexual health symptom. For example, testosterone-associated atrophic vaginitis can, when severe, present with vaginal discharge in the absence of an STI.