Sexual Health Workshop. Part One. 3.5 hours. Sexuality, Sexual Health in New Zealand and the Role of the Nurse. First: Ground Rules Ground Rules for Discussion Absolute confidentiality. Respect: demonstrated by Active listening Allowing each person to talk for designated time Respecting differences in cultural and life experiences. Open to learning. May choose same or mixed sex group for discussions. Group Discussion. In Groups of 5-6 • What is appropriate to discuss in my family/culture about sex and sexuality. • What I leaned at home and at school about sex and sexuality. Relates to HEAL6012 Learning Outcome: • Examine concepts of Primary Health Care and apply to community nursing practice. • Demonstrate understanding and application of basic epidemiological concepts to community health. • Demonstrate understanding and application of recent research, including population health statistics, health determinants and appropriate literature in assessing and identifying health issues for individuals and groups in the community. • Critically discuss the role of the nurse within the community, specifically advocacy, enabling and mediation for individuals and groups. Objectives. 1. Discuss in small groups the influence of own cultural and of sexual health teaching in school curricula regarding sex and sexual health education. 2. Outline the concept of sexuality. 3. Outline NZ Government priorities regarding key directions for Sexual and Reproductive Health Strategy (2002). 4. Discuss the Long Term personal and societal outcomes of teenage pregnancies for both mother and the children of teenage mothers. Continued 5. Outline the effects of pornography as an International Public Health Issue. 6. Outline the qualities of effective sexuality education. 7. Outline sexual health screening and barriers to sexual health screening. 8. Discuss the nurses role in relations to stigma and de-stigmatisation in sexual health. Continued 9. Outline recent NZ epidemiology re STIs and abortions. AND 10. Outline general signs and symptoms of STIs, assessment and history taking. 11. Discuss the nurse’s role in health education regarding STIs treatment and prevention. 12. Outline legal aspects and notifiable STI diseases under the Health Act (and Regulations) 1956. 13. Outline the health professional’s role in contact/partner tracing. References Goldberg, S., Adapted by Rolley, J. (2008). Nursing Management: Sexually transmitted infections. (pp.14631479). In: Lewis medical-surgical nursing. Assessment and Management of Clinical Problems. Sydney: Mosby Elsevier. • N.Z Family Planning Organisation has excellent teaching kits you can borrow. Ministry of Health (2001): Sexual and Reproductive Health Strategy. Wellington, NZ: Author. Perrin, P. C., Madanat, H.N., Barnes, M.D., Carolan, A., Clark, R. B., Ivins, N., Tuttle, H.A V., & Williams,. P.N.(2008). Health Education’s role in framing pornography as a public health issue: local and national strategies with international implications. In IUHPEPromotion & Education. Vol. 15, (1) 11-18. References cont. • White, J. Mortensen, A. (2003). Counteracting Stigma in Sexual Health Care Settings. In: The Internet Journal of Advanced Nursing Practice. Vol 6. No. 1. pp 1523-6064 BPAC Setting the scene from Best Practice Advocacy Centre New Zealand Professor Murray Tilyard BSc, MBChB, DipObst, MD (Otago), FRNZCGP (Dist) Editor-in-Chief, Executive Director and CEO, bpacnz (Note his credentials). BPAC NZ. (2013). Sexually transmitted infections in New Zealand. Retrieved from http://www.bpac.org.nz/resources/handbook/st i/sti.asp Obj. 2. Sexuality • Sexuality is the totality of an individuals attitudes, values, goals, and behaviours (both internal and external) based on, or determined by , perceptions of gender. • It is so central to our identity that it permeates nearly every aspect of self-knowledge, self expression and self ideal. • Expression of ones concept of sexuality, is closely related to physical, cognitive and moral development. • See last years notes on gender role, gender identity, sex, gender orientation, masculinity and femininity. (Review Nurs.5061). Objective 3.Health Strategy. Phase One (MOH 2001). • Positive sexuality and healthy sexual reproductive health are Government priorities. As we are sexual beings, positive sexual identity and sexuality are fundamental to our sense of self, self-esteem and ability to lead a fulfilling life. • Govt. focus is on 2 key areas: 1. NZ’s increasing number of sexually transmitted infections (STI’s), particularly chlamydia, gonorrhoea and HIV/Aids. 2. The high level of unintended/unwanted pregnancies. MOH (2002) Sexual/ Reproductive Health Strategic Directions One, Two, and Three pp. 7-10. (15-17 on computer counter) See on-line Strategy at: http://www.health.govt.nz/publication/sexual-andreproductive-health-strategy-phase-one One: Societal attitudes, values and behaviour (Read). Two: Personal knowledge, skills and behaviour (Read) Three: Services (Read this for homework) People with disabilities face specific problems: 1. Acquiring a positive sexual identity 2. In accessing mainstream sexual and reproductive health services. 3. Parents may not see their disabled young person as a sexual being. 4. Common problems in adulthood include inadequate or poor access to information (Braille), services not physically accessible, and many are vulnerable to sexual abuse. Obj. 4. Discuss the possible long term consequences of Sexual Health problems 1. 2. 3. 4. 5. 6. 7. HIV consequence may be death (much better management now) Rates of chlamydia and gonorrhoea have increased over past years, in NZ. Rates disproportionately high for Maori and PI peoples. Antibiotic resistance to standard treatment for gonorrhoea is increasing. STI’s may lead to infertility from pelvic inflammatory disease, cancer, and other chronic diseases. NZ has very high adolescent pregnancy rate. This leads to social and economic problems for mum, and : Increases the child’s risk of poor outcomes in education, health, and welfare. And outcomes of teenage pregnancy for mother and children of teen mothers? What does International Research tell us? Babies: 1. Babies at higher risk of low birth weight 2. Higher rates of infant mortality 3. More likely to grow up in homes that offer lower levels of emotional support and cognitive stimulation. Why?....add you own findings from Readings here. Mothers: 1. Low levels of educational attainment, increased welfare dependency, maternal depression and less competent parenting. Why?.... add you own findings from Readings here What does recent NZ Research tell us? • Results: • Early motherhood was associated with higher levels of mental health disorders, lower levels of educational achievement, higher levels of welfare dependence, lower levels of workforce participation, and lower income. Boden JM; Fergusson DM; John Horwood L • Author's Address: – Christchurch Health and Development Study, University of Otago, Christchurch School of Medicine and Health Sciences, New Zealand. • Source: – Journal Of Child Psychology And Psychiatry, And Allied Disciplines [J Child Psychol Psychiatry] 2008 Feb; Vol. 49 (2), pp. 151-60. Date of Electronic Publication: 2007 Dec What about teenage mothers in Auckland? • ]The Paediatric Society - Auckland District Health Board • Number of Teenage Births in the Auckland DHB Region during 1990-2001. Table 3. ... Teenage Birth Rates by Ethnicity, Auckland DHB 1996-2003. Figure 11. • (See pgs. 12-14 of report) Obj. 5. Discuss Pornography as a Public health Issue. Potential adverse effects. For the user: • Sexual addiction • Sexually acting out • Deviant sexual behaviour • Predisposes or intensifies the predisposition to rape women See Reference. Perrin, P. C., Madanat, H.N., Barnes, M.D., Carolan, A., Clark, R. B., Ivins, N., Tuttle, H.A V., & Williams,. P.N.(2008). Health Education’s role in framing pornography as a public health issue: local and national strategies with international implications. In IUHPE- Promotion & Education. Vol. 15, (1) 11-18. Women and pornography • Higher likelihood to be described in sexualized terms • Forced to participate in violent sexual acts such as rape • More likely to be categorized in traditional gender roles • More likely to experience sex without emotional involvement • Broken marriages Cartoon: Roast Busters' latest victim – The NZ Herald Thursday Oct 30, 2014. Perpetrators are heavy pornograpgy users. Children and pornography • Become victims of sexual interest • Victims of sexual maltreatment and fantasies • Accessibility increases use by child of pornography as source of sex education, which creates future unrealistic and harmful attitudes towards sex and relationships. Teenagers and Pornography • This clip is useful for all teenagers, and especially for young women and parents of teenage girls • http://media.theage.com.au/news/nationaltimes/the-zone-maree-crabbe-4287754.html Obj. 6. Outline qualities of effective sexuality education. (Family Planning 20/9/2011). • International evidence proves, good quality, comprehensive sexuality ed. delays onset of sexual activity, reduces number of partners, frequency of intercourse, and increases condom and contraceptive use. • Programmes are effective when they begin before the young person first has sex. • More effective when home and school contribute. Continued. • Parents are first sexuality educators. Values are ‘taught, not caught’. Role models. • Normalizing sexuality and sexual health education • Young people are maturing earlier, so ed. should start earlier: include attitudes and values, knowledge and skills, communication, negotiation and resisting pressure. • Plethora of overtly sexualised media messages Obj. 7. Outline Sexual Health Screening, and barriers to sexual health screening. Why have a sexual health screen? 1. Start of a new relationship 2. Episode of risk 3. Regular check ups 4. Symptomatic-visible signs of infection Why come to a sexual Health Clinic? 1. Confidentiality 2. Anonymity 3. Specialist Services 4. Free Service Barriers to Sexual health Screening 1. Stigma associated with STI’s • Shame • Embarrassment 2. Poor access to health care • Poverty • Cultural issues • Marginalized groups 3. Bad sexual health consultation experience • Clinician can often ensure a positive outcome Obj. 8. Stigma and destigmatisation. • Historically people with STI have been stigmatized through prejudice and negative social attitudes. • Some health professionals believe clients with STI’s have deviated from the norms of respectable illness. • Polarized ‘them’ (indecent, diseased) and ‘us,’ the decent, clean and healthy. (E.g. women with cervical cancer) The process of destigmatisation. Is…a conscious process of the reversal of the negative cultural message about STI’s Health care practitioners have a key role. • Professional responsibility to change the secrecy, stigma, and silence around sexuality. • Begin with self: exploring and reflecting own attitudes and values (see handout). • Understand the relationship between poor socioeconomic and cultural conditions and poor patterns of sexual and reproductive self-care. Continued • Nurse engages therapeutically with client through, intense rapport building, identification (how he she might feel in same situation), personalization, respect and dignity and client empowerment. Obj.9. Define STIs , outline who gets it, and recent NZ epidemiology of STIs and abortions. • Who gets it? 1. Anyone who has had more than one sex partner ever, or whose partner has had more than one sex partner. 2. Young people between the ages of 15-25 are highest risk. 3. If you don’t ask about sexual health issues, they may not tell you. 4. Even when seeing a young person for another health issue, do ask about their sexual health Obj. 9.a. Recent NZ Epidemiology. Surveillance data from the ESR. • Information from Sexual Health Clinics, (including Student Health Clinics), Family Planning and Laboratory data • Chlamydia • Gonorrhoea • Syphilis • HIV AIDS • http://www.surv.esr.cri.nz/public_health_surv eillance/sti_surveillance.php (see Tables slides).Note, Clinic and Laboratory data and Annual Reports that combine lab and clinic data. Increase of STIs in over 60s. • http://www.nzherald.co.nz/health/news/articl e.cfm?c_id=204&objectid=11276686&ref=rss April 2014 WHO:"Antimicrobial resistance: global report on surveillance" • Treatment failure to the last resort of treatment for gonorrhoea–third generation cephalosporins–has been confirmed in Austria, Australia, Canada, France, Japan, Norway, Slovenia, South Africa, Sweden and the United Kingdom. More than 1 million people are infected with gonorrhoea around the world every day. • http://www.who.int/mediacentre/news/relea ses/2014/amr-report/en/ Abortion Rates • http://www.stats.govt.nz/browse_for_stats/h ealth/abortion/AbortionStatistics_HOTPYeDec 10/Commentary.aspx • http://www.stats.govt.nz/browse_for_stats/h ealth/abortion/ethnic-differentials-in-inducedabortions-in-nz.aspx Congenital syphilis (note on ESR site the rise in cases of syphilis) • SUMMARY POINTS • All pregnant women should be tested for syphilis in pregnancy. • Penicillin is the only antibiotic proven to be effective in the management of gestational syphilis. • Children born to mothers treated with a nonpenicillin regimen should be considered to have been treated inadequately. • Syphilis and HIV coinfection is not uncommon. • All children with clinical or serological evidence of congenital syphilis should be treated with penicillin G for 10 to 14 days. Close clinical and serological follow-up of all children potentially exposed to syphilis in utero is required. Obj. 10. Outline General Signs and symptoms • Common general symptoms: • in females include: purulent discharge, dysuria( painful urination), abnormal bleeding, or pain and bleeding with coitus, lower abdominal pain and in genital warts…horny papules on vulva, vagina, cervix, anal canal, and urethra. In Males • Purulent urethral discharge, dysuria, epididymitis, prostatitis, testicular pain, nonspecific urethritis. • In addition, horny papules anal canal, urethra, glans penis, • For both sexes, flu like symptoms and inguinal canal enlargement. Nursing Management. Begin with Assessment: History taking. Set the scene 1. 2. 3. 4. 5. 6. • • Be aware of your own anxieties (alternative clinician?) Privacy. Other people can hear you. Explain why you want to ask some questions Confidentiality (check if want partner there). Use plain language Explain why you will ask questions specific to sexual activity: Indicates where to take swabs from Indicates what to test for Questions to ask: (some open some closed). • • • • • • Do you have a current partner? Is your partner male or female? How long have you been together? For males, have you ever had sex with a male? For females, pregnancy risk Have you had any other partners in the last 3-6 months? • When was your last sexual contact? (incubation period for STI check-2 weeks) • Sexual abuse? • Drug use? Nursing Management See Book of Readings. (pp….) • • • • Assessment (see previous slides). Nursing Diagnosis (take own brief notes) Planning (take own brief notes) Nursing Implementation: Focus: Health Promotion • Read p. 1475-1476 (in Lewis) now. Note in particular Table 52.10 Patient and Family Teaching Guide. Nursing Management must include: 1. Nurses first responsibility in STI control is educate people in a non-judgemental manner. Build trust and rapport. 2. R.N must confront own feelings and attitudes (see stigmatisation slides). 3. Attend to holistic needs, emotions (guilt, fear, shame), self esteem, physical treatment (must complete medication and have clearance), self care, knowledge of how is spread, responsibilities (letting partner know), hygiene, self examination…etc. (Read pages as above). Treatment • 1. To ensure clients understand the medication given and the need for follow-up to establish the success of treatment I.e. cure. • 2. To assess and refer on to other agencies where appropriate. E.g. counseling, Rape Crisis etc. Obj.11. Evaluation of Client Education See p. 1477-p. 201 of Book of Readings • Expected Outcomes of effective client education are that the client describes: 1. modes of transmission 2. and uses appropriate hygienic measures 3. states that he/she will have no reinfection 4. explains compliance behaviour with follow up protocols. Summary of Main Education Points 1. Acknowledge clients feelings about having STI (most important) 2. To ensure clients have a full understanding of the disease they have and the effects it will/may have on themselves and their partner(s). 3. To discuss with and educate clients about prevention and ensure that learning has occurred. Obj. 12. Legal Aspects of Sexual Health: PERSONS Under Health Act 1956 • Section 88. Persons suffering from veneral disease MUST undergo treatment: • 1. Must be under a medical practitioner and attend for treatment • 2. Must attend for treatment until cured • 3. Person will commit and offence if does not comply with the above. • http://www.legislation.govt.nz/act/public/1956/0065/latest/ whole.html#DLM307283 (see 88 and 89) Legal aspect continued. Section 89 Duty of Medical Practitioner • Venereal diseases: Section 89, requires medical practitioners to educate their patients regarding STI’s about: • 1. the infectious nature of the disease and the penalties under the Act for infecting any other person with the disease. • 2. Warn patient not to have sexual relations until cured of that disease or is free from disease in communicable form • 2. Give written information re treatment of disease and the duties of person suffering from disease. • Regulation 7 (1982) • Any patient who is evading treatment to be referred to the Medical Officer of Health (same with any sexual contacts of this person). Section 92. Infecting any person with veneral disease. • Every person who knowingly infects another person with venereal disease commits an offence and is liable to a fine not exceeding 1,000 or to imprisonment for a term not exceeding 1 year or to both Obj. 13. Contact Tracing/Partner Notification • Health Professional must: 1. Discuss with clients their sexual history, partners, and practices, to ascertain who needs contacting. 2. Negotiate with clients as to who will contact/trace their partners. 3. Advise no sex until partner (and client) has completed treatment and partner tested 4. Stress that partner requires treatment even if tests are negative. 5. Advise that casual contacts should be advised to seek testing and treatment if contactable. General MOH Resources re Sexual Health in variety of Languages • http://www.healthed.govt.nz/resources/searc h-resources.aspx?id=18 NZ Family Planning Resources: (FPA) • http://www.familyplanning.org.nz/ • See Resources Your Teenager and Sexual Health • http://www.healthed.govt.nz/resources/searc h-resources.aspx?id=18 • (see Sexual health left side of screen) Sexuality and Law – Sources of information • Rape Prevention Education - Legal Definitions of Rape and other Sexual Crimes: http://www.rapecrisis.org.nz/content.aspx?id=27 • Community Law Offices. See for: • About Us: Sexual Orientation, Gender Identity and the Law in New Zealand, Youth and the law, and Legal information for pregnant tenagers. Community Law Centres: • hhttp://www.communitylaw.org.nz/search/?q=sexual%20orientation%2 0and%20the%20law.%20http%3A%2F%2Fwww.communitylaw.org.nz%2 F%20%20 Critical thinking (for Revision) • Discuss the current contributing factors related to the current high STI and unplanned pregnancies rates in New Zealand. • (See pg. 1464 in extract in Book of Readings). View the DVD • Sexually Transmitted infections: what we can’t see. • Publisher. VEA (Video Education Australia) Bendigo Vic. Classroom Video • Available in the library: 616:951 For Interest Only. Trans Gender DVD from: The Guardian Newspaper:14 August 2014 • ‘There’s no such thing as a Sex Change’ • http://www.theguardian.com/world/video/20 14/aug/12/transgender-kellie-maloney-lgbtsex-change Using vulgar language to teach sex education to boys? • From The New Zealand Herald • Sex ed for boys needs to be 'vulgar' - expert • 10:20 AM Thursday Oct 24, 2013. • http://www.nzherald.co.nz/yourhealth/news/article.cfm?c_id=1501145&objec tid=11145462 Your Questions • When is it appropriate to engage in sexual practices? For females and males? • When can children come to the clinic • When can children/young people be taught about sex and sexuality? • What is a transgendered person? • (Transgendered =person born with the physical characteristics of one sex who emotionally and psychologically feels that they belong to the opposite sex. ∎ a person who has undergone surgery and hormone treatment in order to acquire the physical characteristics of the opposite sex). (Oxford Dictionary). Your Questions • Is there a link between (chromosome) xxy people and the way they identify? They present as males, but do they ‘feel’ female? • • • • • • There are a number of theories, but as yet, no scientific consensus. Different cultural beliefs and norms about gender (some cultures have more than 2). Biological theories include: XXY and XYY May be considered inter-sex but not identify as transgender Some speculate that hormones and some that brain structure is involved. Clear than some people are aware they are transgender from earliest memories. Your Questions •Sexual health issues for homosexual •How can I talk to an adolescent and transgendered persons •Does sexual orientation contribute to poor sexual health? •What family support available for families with a family member who is gay, lesbian or transgendered. about sexuality and sexual health? •What are different cultures attitudes •What education is given in school and in universities? •How can youth begin to explain to their religious parents about being sexually active? to homosexuality and contraception? •How can we protect ourselves (as •Why are some youth more sexually active than others? Is there a cultural difference? Nurses?) Your Questions •What is safe sex? •How do we solve sexual abuse? •Who decides what is right for someone sexually? •What if it goes against our own beliefs? •Help for youth in incestuous relationships. • What is the prevalence of STI’s amongst hetero and homosexual young people? •Types of contraceptives/options • Sexual health and chronic illness. •How to use a condom. •Sexual violation: what help is available? E.g. CHF, Coronary heart disease, chronic respiratory disease. • What about contraception(See part 2 Thursday).