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Leaving judgement at the door

Cate Swannell
Med J Aust
Published online: 18 August 2014

Sexual health physicians talk about sex all day, meet society’s most marginalised people, and thrive with a good sense of humour. They’re also at the forefront of the battle against HIV/AIDS, hepatitis and genital warts

Sexual health physicians are generally a happy bunch.

“Why wouldn’t we be happy?” Dr Darren Russell, director of sexual health at the Cairns Hospital, says. “We get to talk about sex all day and many of our patients can be helped relatively easily.

“There aren’t too many areas of medicine where you can cure the patient’s problem quickly, and they’re very grateful.

“They come in suffering both physically and psychologically and we can help them, often just by listening and not judging them. It’s wonderful.”

Sexual health medicine was only gazetted as a specialty in 2009 and there are just 137 fellows and 20 trainees in Australia and New Zealand, according to Dr Lynne Wray, president of the Royal Australasian College of Physicians’ Australasian Chapter of Sexual Health Medicine (AChSHM).

Most work in the public system and many are general practitioners or former GPs who crossed over into specialising in sexual health.

“There’s a strong primary care focus and that’s appealing to many”, Dr Wray tells the MJA.

“A lot of the work is educational, supplying information about safe sex practices, as well as diagnosis and management of sexually transmissible infections and HIV, so there’s a public health and preventive health aspect as well.”

Strong communication skills and the ability to leave judgement outside the consulting room are vital parts of the sexual health practitioner’s repertoire.

“Being non-judgemental goes with the territory”, Dr Wray says.

“Life isn’t about what we think is right. Our role is to make sure the patient is seen by someone who can help them.”

Patients with sexual health problems are often young members of marginalised communities, anxious about their sexuality, sexual practices and possible exposure to infections.

Professor Basil Donovan, a pioneer of sexual health medicine who was instrumental in establishing Australia’s first sexual health clinic in Sydney in the mid 1980s, says it was the patients who attracted him to the specialty.

“I liked the patients”, he tells the MJA.

“They tend to be inherently charming and they are inclined to get up to more mischief than most.

“I had a sheltered country childhood and doing this work I got to meet people who I had never had a chance to meet before and I found them to be perfectly normal.”

It was, he says, “frustrating” in the early days of sexual health medicine in Australia as there was no training available and an establishment resistance to any ambitions of being recognised as a specialty in its own right.

By contrast, sexual health medicine in the United Kingdom has been recognised as such since 1916.

Troops spending their World War I furloughs in the brothels of Paris and then crossing the Channel to nearby England prompted fast action in the campaign against venereal diseases and in prophylaxis, Professor Donovan says.

“Australia didn’t get epidemics of venereal disease after the First or Second World Wars”, he says.

“By the time the troops got back from Europe to Australia they were no longer infectious, so it wasn’t a big priority.”

That changed forever when the AIDS epidemic rose in Australia in the early 1980s.

Professor Donovan and four others, including Dr Robert Finlayson, now with the Taylor Square Clinic in Sydney, founded the first private sexual health clinic in the country in 1981 and then took themselves off to London to complete a diploma in venereology at the University of London.

On his return, Professor Donovan established the pioneering Master of Sexual Health program at the University of Sydney, the first such degree course in the country.

Many enter sexual health medicine because their general practice features a large proportion of that type of case and they gravitate more and more towards it.

Dr Finlayson was one such convert.

“I was a paediatric dermatologist”, he tells the MJA. “I was asked by a colleague to do a locum in a government sexual health clinic, and that was it.”

Dr Alison Rutherford, a final-year trainee worked in public health for about 10 years before deciding to take on the formal sexual health postgraduate training.

“It was interesting to me to be able to combine both clinical work and public health”, she tells the MJA.

“It’s incredibly satisfying work.

“Patients walk in embarrassed and sometimes ashamed and it may have been a long journey for them to walk through the door and, within half an hour, they can be feeling much better.”

Dr Rutherford says the training program is “great”.

“It’s based on adult learning principles and you get some retrospective credit for work you’ve already done, so it caters for where your deficiencies are.

“For example, I’d done a lot of work in family planning but hardly anything in HIV/AIDS, whereas others have concentrated on infectious diseases but haven’t focused at all on reproductive health.”

While the core of the training is sexually transmitted infections and HIV, she says, there are units on sexual assault, contraception, sexual dysfunction, reproductive health and gender identity issues.

Sexual health medicine, like most specialties, has its hot button issues and, with the conclusion of the International AIDS Congress in Melbourne last month, the future of HIV/AIDS treatment and prevention is top of the list.

Clinical trials investigating the benefit of pre-exposure prophylaxis (PrEP) and home HIV testing are strongly supported by the AChSHM, Dr Wray says.

“PrEP is an option for people who are not able to sustain safe sex practices”, she says. “Most of them are not looking to use them for 5 or 10 years, but see them as a short-term option in a specific situation. PrEP is an important pillar of ending HIV progression.

“We’re supportive of home testing because there are people who prefer the privacy of their own home. This could be particularly so in rural and remote communities where people may know their GP on a social level. It can be confronting to have to discuss issues about our sexual practices.

“It’s about access to choices and having good education about home tests and instructions for use and follow-up of reactive results.”

Opposition to home HIV testing reminds Dr Wray of an earlier breakthrough moment — when women could first access home pregnancy tests.

“The question was ‘Can we trust women to do the right thing?’ and this debate is ringing the same kind of bell for me”, she says.

Many of the leaders in sexual health medicine are closing in on their retirement and question marks remain about where the next generation of senior specialists will come from.

And although there has been great progress in the HIV/AIDS arena, there are growing concerns about the rise of viral hepatitis, chlamydia, gonorrhoea and Mycoplasma genitalium — a bacterium that infects the mucous membranes of the urethra, cervix, throat and anus.

Perhaps the most spectacular change in sexual health medicine has come since the advent of the human papillomavirus vaccine, which has caused a dramatic drop in the incidence of genital warts.

“Half my life used to be spent on my knees freezing warts off people’s buttocks”, Dr Russell says. “I rarely see them any more, thank goodness.”

“But there is no end of work for sexual health physicians, nevertheless.”

As in the case of many specialties, access to sexual health practitioners outside urban areas is problematic.

Dr Wray sees the growth of dual training as the key to meeting the needs of remote and rural patients.

“Just as it’s hard to find a consultant cardiologist in a country town, there’s a shortage of sexual health specialists as well”, she says. “But if GPs and general physicians can extend their skills into the area of sexual health then that has to be of benefit for rural areas.”

For more information about postgraduate training in sexual health medicine, visit the AChSHM’s education website at https://www.racp.edu.au/page/australasian-chapter-of-sexual-health-medicine

  • Cate Swannell


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