Sexual health

Recent legal changes are negatively affecting provision of timely medical care to Australian transgender youth

Fiona Kelly · Simona Giordano · Michelle M Telfer · Ken C Pang

Religious LGBTQA+ conversion practices cause significant mental health harms. The health sector needs to recognise, support and respect survivors in ways that are affirming of sexual and gender diversity.

Jennifer Power · Timothy W Jones · Tiffany Jones · Nathan Despott · Maria Pallotta‐Chiarolli · Joel Anderson

The laws governing treatment consent in gender dysphoria have rapidly evolved in the past two decades, with the uncertainty, and at times confusion, regarding the law resulting in volatility in clinical practice

Calina Ouliaris

Whether the U=U message is received with scepticism or not, it is clear it is radically challenging the stigma associated with HIV

James H McMahon · Brent Allan · Daniel Grace · Nic Holas

Removing MBS rebate restrictions for telehealth consultations would enhance sexual and reproductive health services access

Yan Cheng · Clare Boerma · Lucy Peck · Jessica R Botfield · Jane Estoesta · Kevin McGeechan

Laws requiring doctors to report consensual adolescent sexual activity present legal, clinical and ethical problems Many Australian teenagers engage in consensual sexual intercourse with similar aged peers.1 They require confidential medical care, including contraception and sexually transmitted infection testing. However, adolescents’ rights to access medical care may confront legal barriers. In several Australian states and territories, new criminal laws require adults to report sexual offences against children. Other criminal laws make it an offence for adolescents aged under 16 years to engage in sexual intercourse. Accordingly, a question for clinical practice is whether the new criminal law reporting duty applies to adolescents’ confidential communications regarding consensual sexual activity. Law, ethics and practice must protect children, but must not criminalise consensual peer sexual activity or compromise clinical care. Here, we review literature regarding adolescents’ lived experience, findings from developmental science, and analyses of consensual and lawful sexual activity. We conduct a comparative analysis of Australian criminal law reporting duties for child sexual offences. We identify situations where laws inappropriately require clinicians to report adolescent sexual activity, and we make recommendations for reform. Background A 2018 national survey found 47% of 14–18‐year‐olds engaged in vaginal or anal intercourse, including 34% of those in Year 10.1 For most Year 10s (aged 14–16 years), the most recent sexual partner was a peer aged under 17 years (92%). However, 6.5% of sexually active Year 10s reported their most recent partner was aged 18–19 years. Of Year 10 females, over one‐third (37%) had engaged in intercourse, and for 10% of these their most recent partner was aged 18 years or older. General practitioners were the most trusted source of sexual health information, from whom 40.6% of females sought clinical advice.1 Clinician engagement was further evidenced by 43.5% of females using the contraceptive pill. However, adolescents experience multiple barriers in accessing health services, including perceived lack of confidentiality, and youth friendly service guidelines recommend confidential care approaches.2,3,4 The Lancet commission on adolescent health acknowledged the complex interplay of adolescent neurodevelopment and legal principles of capacity.5 Australian legal milestones differ, indicating how laws attempt to attain policy goals while grappling with scientific knowledge: 10‐year‐olds can be liable for criminal offences; 15‐year‐olds can obtain a Medicare card; and 17‐year‐olds can drive. Developmental neuroscience has shown adolescents aged 15–16 years possess adult‐like cognitive ability,8,9 while psychosocial and neurobiological maturity continues into the mid‐20s.8 It has been shown that, especially when in “calm and emotionally‐neutral contexts”,5 adolescents possess cognitive capacity to weigh costs and benefits and make reasoned judgements about courses of action, including about consenting to medical treatments involving contraception and sexual health.6,7 Much consensual peer sexual activity occurs in such settings; even in more emotionally “hot” circumstances, the capacity to consent to sex with similar aged peers is consistent with findings from developmental neuroscience. Legal requirements for consent, and the age of consent Lawful consent to sex requires full, free and voluntary agreement, and the absence of threat, intimidation and abuse of power (Box 1). Social science models of child sexual abuse are similarly premised on consent requiring full, free, voluntary and uncoerced participation.10 Laws must navigate a tension between protecting the developing adolescent and respecting and promoting their capacity and autonomy.11,12 In this setting, legislatures, as the bodies in each state and territory able to pass and amend criminal laws (legislation), must protect children and youth from sexual abuse, while allowing consensual peer sexual activity in both heterosexual and same‐sex relationships. Currently, the legal age of consent prohibits intercourse with minors under a specified age, presuming that children under this age lack capacity to provide true consent. This age is 16 years in most jurisdictions (Box 2). Legal defences embody legislatures’ acknowledgement that sex between adolescents may be consensual and permissible. Criminal laws in five jurisdictions provide a close‐in‐age defence to offences where the act involves consenting people who are both minors aged under 16 years or are similar in age (Box 2). Prosecution guidelines Similarly, official guidelines in every jurisdiction13,14 regarding prosecution of criminal offences recommend against prosecuting consensual activity between minors. These guidelines acknowledge it is against the public interest to prosecute these cases, because of the oppressive consequences, and the trivial and merely technical nature of any breach. Victoria’s guidelines are particularly strong, and specifically refer to situations where both adolescents are under 16 years of age, and where they are aged 15 and 18 years: a prosecution is contraindicated where a young person “has committed an offence in the context of a consenting sexual relationship with another young person [including] sexual penetration of a child under 16 where the offender is 18 and the complainant is 15”.13 In such cases, prosecutors should consider: the adolescents’ ages and maturity; whether they are in a relationship; whether they consented; and whether the person wishes a prosecution to proceed.13 In our hypothetical clinical case of Anna and David (Box 3), a prosecutor should conclude that despite technical commission of an offence (due to Anna and David being 15 and 18, respectively), prosecution should not occur because they are mature, near aged peers in a consenting sexual relationship with no coercion. They were responsibly acting to obtain contraception and advice from a medical practitioner, and Anna would not want David prosecuted. Prosecution is against the public interest for reasons including adverse effects on adolescents’ willingness to seek medical advice, which may result in further consequences including unintended pregnancies, sexually transmitted infections, and effects on education, employability and health. Criminal law reporting duties Child protection legislation has long required professionals to report sexual abuse to child welfare agencies.15 Recent inquiries into institutional abuse and cover‐ups catalysed recommendations for new reporting duties in criminal law, applied to all adults.16,17 Victoria, New South Wales, the Australian Capital Territory and Tasmania have since enacted new reporting duties in criminal law, advancing social norms to protect children.15 Queensland has recently enacted a duty, which has not yet commenced. (Supporting Information, Table 1). These laws require adults to report information to police about a sexual offence committed against a child. To accommodate exceptional circumstances and navigate ethical tensions, exceptions apply to requests of non‐disclosure, and confidential disclosures (Supporting Information, Table 1). Comparative analysis: six dimensions of legal inconsistency and uncertainty The relevant laws differ between jurisdictions, and exceptions are of uncertain application. Comparative statutory analysis reveals that for medical practitioners treating adolescents in consensual peer relationships, the laws present six problems. First, only NSW expressly excludes medical practitioners from the duty to report sexual offences against children (Supporting Information, Table 1). This creates a clear inconsistency: NSW practitioners are exempt from the duty, while their counterparts elsewhere are not. However, exempting NSW practitioners may mean sexual offences are less likely to be reported. Second, three jurisdictions apply the duty to report sexual offences both to situations involving two minors aged under 16 and to situations involving a minor and an adult. In contrast, Victoria only applies the duty to situations involving a minor and an adult. Accordingly, Victoria’s duty is narrower, acknowledging that otherwise it may inappropriately embrace consensual behaviour; yet it is important not to discourage Victorian practitioners from reporting non‐consensual sexual offences between minors, so this limit may be suboptimal. The problem elsewhere is that the duty may capture consensual peer activity. Third, only Victoria excludes the duty where the adolescent “victim” aged 16 or 17 requests non‐disclosure. Elsewhere, this exemption applies only to requests by victims aged 18 or over. This creates inequality in recognising adolescent capacity and autonomy. Fourth, the concept of a “reasonable excuse” for non‐reporting is not exhaustively defined (Supporting Information, Table 1). It is unclear whether a reasonable excuse for non‐disclosure includes a medical practitioner’s choice not to report a confidential disclosure in a therapeutic setting of consensual acts constituting a sexual offence. This leaves practitioners in all jurisdictions unsure whether they would be legally protected for not reporting. Fifth, Victoria, NSW and Tasmania enable prosecution only if approved by the Director of Public Prosecutions. This suggests multiple situations do not warrant prosecution. However, it is not clear when approval would be given, leaving clinicians in doubt about exemptions to the duty. The ACT lacks this mechanism, indicating higher likelihood of prosecution. Sixth, health professionals may be exempt from the duty where a patient confidentially discloses a sexual offence (Supporting Information, Table 1). This exemption is founded on the concept of professional confidential relationship privilege. However, these exemptions are unclear, rely on networks of laws, and apply to different practitioners. Tasmania and the ACT lack clear confidentiality exceptions (Supporting Information, Table 2). NSW has a clear exemption. Victoria has an express exemption if the information is a “confidential communication” as defined by other legislation (Box 4). However, in Victoria, the exemption applies only to communications from the younger adolescent (Box 4). In Anna’s hypothetical case, David attending the consultation would technically trigger the GP’s duty to report (Box 3). Discussion The new duties in criminal law to report sexual offences against children are consistent with policy values in protecting children, and with bioethical principles of justice and beneficence. Requiring adults to report child sexual offences is justified by diminishing harm to individuals, and by enhancing community protection and a protective social fabric for vulnerable children.18 Sexual activity between adults and children should generally be considered abusive, due to absence of consent and presence of coercion.10 However, legislatures must ensure an appropriate balance between protecting children and youth from sexual offences, and recognising their capacity and promoting autonomy, privacy and freedom of expression.11,12 Genuinely consensual sexual activity between under‐aged minors is not abusive.10 In addition, a grey zone of cases may involve two adolescents aged almost 16, and 18. Here, where sexual activity may be genuinely consensual, ethical analysis, findings from developmental science, and clinical needs all suggest the duty should be moderated by nuanced individual consideration by clinicians (Box 3). In our view, the central concept that should inform legal principles and practice is consent, and its presence or absence in circumstances which do not involve threat, intimidation or abuse of authority. On our analysis, three conclusions seem clear. First, legislative reforms are required so that disclosures in therapeutic contexts of clearly consensual sexual activity between similar aged peers under 16 are expressly exempt from the reporting duty. This is consistent with policy animating Victoria’s law reform requiring adults to report “a serious indictable offence involving the abuse of a child”,16 and Royal Commission recommendations.17 If protected by such an exemption, clinicians consulting with adolescents who are having sex with similar aged peers can be unhindered in providing preventive health interventions including contraception for mature minors, and screening for sexually transmitted infections.18 Clinicians routinely enquire about age of sexual partners and otherwise consider risk of abuse and patient capacity when providing treatment.7 If they reasonably conclude the adolescents are consenting, confidential treatment should be provided and this is clearly incompatible with reporting to police. Such an exemption also allows clinicians to create a safe environment to encourage adolescent help‐seeking, check for other health risks,19 explore family dynamics, and connect the adolescent with parents or others to benefit wellbeing.18,19 Second, this legislative exemption could extend to clearly consensual activity between adolescents aged 15 and 18. Legal attribution of capacity to consent to sex using simple age cut‐offs is convenient, but sometimes incongruent with developmental science, lived experience and clinical scenarios.9 In situations of clearly consensual activity, a margin of error should favour patient autonomy and clinical care. This is consistent with prosecutorial guidelines and Tasmania’s similar age exemptions. Clinicians would prefer this slight extension of the exemption so they can promote health and encourage future help‐seeking. Our hypothetical patients Anna and David would be unwilling to seek future care if the GP reported David to police. Third, the different models for exempting clinicians as recipients of confidential information are complex, uncertain and unsatisfactory. Legislative reforms are required to create a clear, unified approach. Any legislature that seeks to include an exemption for confidential disclosures about abusive incidents made to medical practitioners within therapeutic contexts should enact a specific exemption, using the NSW model. This would solve difficulties ascertaining whether this constitutes a “confidential communication” or is protected by privilege. It would also solve problems in the requested non‐disclosure exemptions; for abusive incidents, application only to those over 18 is inconsistent with developmental science, which suggests Victoria’s age 16 is justifiable, and could be extended to those aged 15. This three‐pronged approach aligns with clinicians’ duty of confidentiality in codes of ethics,20 and organisational policy on sexual and reproductive health.21 National principles recognise medical practitioners’ central role in supporting sexual and reproductive health through confidential care, with youth a priority population.18,21 This medico‐legal context is increasingly complex. Our analysis has focused on adolescent peers in genuinely consensual relationships whose ages mean technically they are committing an offence, exemplified by peers aged 15 and 18 years (Box 1). We unequivocally support duties to report child sexual abuse,15,22 and do not here consider other situations where different outcomes may transpire. We also caution that where disclosures of abusive incidents may be exempt from the criminal duty, a clinician may have a separate overriding legal duty to report. For example, Victorian doctors may be exempt under s 327(7)(c) of the Crimes Act 1958 from disclosing a 10‐year‐old’s confidential disclosure of sexual assault, but must report under child protection legislation.15 Health practitioners therefore need to know their responsibilities under different laws, and need ongoing professional education to promote legal literacy. Progress towards reform may require several steps. Since legislative limitations differ, agencies representing medical practitioners could urge reform at state and territory level, informed by research and clinical experience. However, ideally, a harmonised national approach should be adopted. National medical regulatory bodies and government ministries could mobilise to support a single model law that balances the need to protect Australian children from sexual offences, while promoting adolescents’ rights to consensual sexual activity. Box 1 – Requirements of consent to sexual intercourse, by Australian states and territories Conditions for consent to sexual intercourse Jurisdiction Free and voluntary agreement Not by threat, intimidation, or abuse of authority Australian Capital Territory Crimes Act 1900, s 67 (not expressly defined) s 67(1): consent to sexual intercourse with another person is negated if that consent is caused: “(a) by the infliction of violence or force on the person, or on a third person …; or (b) by a threat to inflict violence or force on the person, or on a third person …; or (c) by a threat to inflict violence or force on, or to use extortion against, the person or another person; or (d) by a threat to publicly humiliate or disgrace, or to physically or mentally harass, the person or another person; or … (h) by the abuse by the other person of his or her position of authority over … the person” New South Wales Crimes Act 1900, s 61HE(2): “A person ‘consents’ to a sexual activity if the person freely and voluntarily agrees to the sexual activity” s 61HE(5)(c): A person does not consent to a sexual activity if the person consents “because of threats of force or terror (whether the threats are against, or the terror is instilled in, that person or any other person)” s 61HE(8): “The grounds on which it may be established that a person does not consent include … (b) if the person consents to the sexual activity because of intimidatory or coercive conduct, or other threat, that does not involve a threat of force, or (c) if the person consents to the sexual activity because of the abuse of a position of authority or trust” Northern Territory Criminal Code Act 1983, s 192(1): “consent means free and voluntary agreement” s 192(2): “Circumstances in which a person does not consent to sexual intercourse … include circumstances where: (a) the person submits because of force, fear of force, or fear of harm of any type, to himself or herself or another person” Queensland Criminal Code 1899, s 348(1): “consent means consent freely and voluntarily given by a person with the cognitive capacity to give the consent” s 348(2): “consent to an act is not freely and voluntarily given if it is obtained—(a) by force; or (b) by threat or intimidation; or (c) by fear of bodily harm; or (d) by exercise of authority …” South Australia Criminal Law Consolidation Act 1935, s 46(2): “a person consents to sexual activity if the person freely and voluntarily agrees to the sexual activity” s 46(3): a person does not freely and voluntarily agree to sexual activity if “(a) the person agrees because of (i) the application of force or an express or implied threat of the application of force or a fear of the application of force to the person or to some other person; or (ii) an express or implied threat to degrade, humiliate, disgrace or harass the person or some other person” Tasmania Criminal Code 1924, s 2A(1): “‘consent’ means free agreement” s 2A(2):”a person does not freely agree to an act if the person … (b) agrees or submits because of force, or a reasonable fear of force, to him or her or to another person; or (c) agrees or submits because of a threat of any kind against him or her or against another person; or … (e) agrees or submits because he or she is overborne by the nature or position of another person” Victoria Crimes Act 1958, s 36(1): “consent means free agreement” s 36(2): ”Circumstances in which a person does not consent to an act include, but are not limited to, the following—(a) the person submits to the act because of force or the fear of force, whether to that person or someone else; (b) the person submits to the act because of the fear of harm of any type, whether to that person or someone else” Western Australia Criminal Code Compilation Act 1913, s 319(2)(a): “consent means a consent freely and voluntarily given” s 319(2)(a): “a consent is not freely and voluntarily given if it is obtained by force, threat, intimidation, deceit, or any fraudulent means” Box 2 – Close‐in‐age defence for sex with a minor under the legal age of consent, where intercourse is consensual Jurisdiction Legislation Age of consent Express defence for intercourse with someone under the legal age of consent if similar in age, and consent is provided Australian Capital Territory Crimes Act 1900, s 55(2) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 10 or over: s 55(3)(b) New South Wales Crimes Act 1900, s 66C(3) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 14 or 15: s 80AG Northern Territory Criminal Code Act 1983, s 127(1) 16 No Queensland Criminal Code Act 1899, s 215(1) 16 No South Australia Criminal Law Consolidation Act 1935, s 49(3) 17 Yes — if accused was under 17, and child was 16: ss 49(4)(a) and (4)(b)(i) Tasmania Criminal Code Act 1924, s 124 17 Yes — age gap not more than 5 years, if child was aged at least 15: s 124(3)(a); and age gap not more than 3 years, if child was aged at least 12: s 124(3)(b) Victoria Crimes Act 1958, s 49B 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 12 or over: s 49V Western Australia Criminal Code Act 1913, s 321(2) 16 No Box 3 – Hypothetical clinical case study Anna is 15 years of age and in Year 10 at a co‐educational high school in Victoria. She has been getting good grades and has a part‐time job at a supermarket. David is 18 years of age, in Year 12 at Anna’s school, and works at the same supermarket. They have been dating for 3 months. Anna presents to her general practitioner for contraceptive advice. She has become sexually active with David and wants contraception additional to condoms. Her GP confirms Anna is a mature minor, since she understands fully the range of contraceptive options open to her, how they work, and their side effects. She has carefully considered all options with David, and has chosen a long‐acting reversible contraceptive implant. She intends to inform her mother, but she is not quite ready yet. She is certain she does not want to experience an unintentional pregnancy. Anna describes her relationship with David as very positive. She feels completely safe with him and under no coercion. She feels she could stop the relationship at any time if she wanted to, and so could he. The age of consent for sexual intercourse in Victoria is 16. Where sex involves a minor aged 12–15, no offence is committed if the other person is less than 2 years older than the minor, and the sex is consensual. Technically, David is committing a sexual offence by having sex with Anna, because he is 3 years older than her; if he was 17 there would be no offence. However, the GP is satisfied this relationship is consensual, and previously would not have reported this situation under either criminal law or child protection law. However, the criminal law on failure to disclose that commenced in Victoria in 2014 has now presented a dilemma for the GP. These laws aim to protect children from sexual abuse and require adults to report knowledge of a sexual offence with a child under 16 years to police. Anna has not expressly stated to the GP that she does not want the situation reported to police, since it has not occurred to her that anything wrong has happened. The GP studies the government website on the new laws to understand what she should do. She is relieved to learn health practitioners are exempt from the criminal law duty to report if they are told about the offence in the course of a confidential consultation. However, because of other legal definitions (Box 4), this exemption only applies if consulting exclusively with the person against whom the offence has been committed. The next day, Anna and David consult the GP together for a baseline sexually transmitted infection screen. The GP was happy to see them, but was perplexed that the exemption did not apply if consulting with the offender, in this case David. She was very reluctant to call the police about David and Anna, due to her knowledge about the consensual nature of their relationship, and their responsible behaviour in obtaining contraception. The GP also understands that other adults who know about the situation, such as Anna’s and David’s parents and school teachers, would appear to be required to report by the criminal law duty, since no clear exemptions apply to them. Box 4 – Health Practitioner Regulation National Law: definitions and application In Victoria, a “confidential communication” is “a communication, whether oral or written, made in confidence by a person against whom a sexual offence has been, or is alleged to have been committed to a registered medical practitioner or counsellor in the course of the relationship of medical practitioner and patient or counsellor and client”: Evidence (Miscellaneous Provisions) Act 1958, s 32B. Under the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5, “health practitioner means an individual who practises a health profession”. A “registered health practitioner means an individual who (a) is registered under this Law to practise a health profession, other than as a student; or (b) holds non‐practising registration under this Law in a health profession”. A “health profession” is defined to include a list of 15 professions (including recognised specialties in these), and most relevantly here includes the following professions: medical, nursing, pharmacy, and psychology. In Victoria, a “registered medical practitioner” under the Health Practitioner Regulation National Law is defined through the application of the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5. Victoria incorporated the Queensland Act into Victorian law, through the Health Practitioner Regulation National Law (Victoria) Act 2009, s 4 (Application of Health Practitioner Regulation National Law). The Health Practitioner Regulation National Law is also incorporated into other jurisdictions’ laws: Health Practitioner Regulation National Law (Tasmania) Act 2010, s 4; Health Practitioner Regulation (Adoption of National Law) Act 2009 (NSW), s 4; Health Practitioner Regulation National Law (ACT) Act 2010, s 6.

Ben Mathews · Lena A Sanci

The medical profession has the opportunity to prevent further harm to patients and damage to public trust

Cherrie Ann Galletly

Understanding the multiple identity groups of Aboriginal and Torres Strait Islander LGBTQ+ young people can assist in meeting their health care needs Where does a young, LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other non‐heteronormative or non‐binary sexual and gender identities, including asexual) Aboriginal and Torres Strait Islander person go for health care in Australia? Do they attend an Aboriginal community controlled health organisation in search of culturally sensitive care? Or do they visit an LGBTQ+‐friendly health service to access staff trained in sexual and gender diversity? Is there a space for them, and other LGBTQ+ Aboriginal and Torres Strait Islander young people, in the Australian health care landscape? These questions are being posed by Indigenous LGBTQ+ health advocates.1 Recent national policy documents outline the need for comprehensive health care for Aboriginal and Torres Strait Islander LGBTQ+ young people.2,3 Despite this identification in policy, limited information is available to health practitioners on working with Aboriginal and Torres Strait Islander LGBTQ+ young people (Box 1). Practitioners are limited by the absence of an integrated framework as well as a dearth of research into these young peoples’ health needs and service preferences. Intersectionality theory highlights that individuals can face multiple structural inequalities within each of the social groups that they occupy, which also affect their access to health, social and economic resources.4 We suggest intersectionality theory as a guiding principle for research and practice with Aboriginal and Torres Strait Islander LGBTQ+ young people. An intersectional approach means recognising that patients belong to multiple identity groups, such as sexual orientation and cultural groups, which are socially constructed and which affect their social positioning and subsequent treatment, such as discrimination, within health care systems.4 The health and wellbeing of Aboriginal and Torres Strait Islander LGBTQ+ young people Aboriginal and Torres Strait Islander LGBTQ+ young people occupy three intersecting identities, which, when considered separately, are each linked to risks for poor health. The risks for poor physical health and social emotional wellbeing among Aboriginal and Torres Strait Islander peoples are well documented.5 Within Australia, LGBTQ+ individuals experience heightened suicidality, serious assault, homelessness and psychological distress6,7 compared with their heterosexual, cisgender peers. These increased health risks do not indicate inherent vulnerability but rather are outcomes of discrimination, marginalisation, racism, transphobia and homophobia.15 Young people not only experience health risks associated with their development phase — for example, heightened risk of psychopathology, physical injury and emotional dysregulation9,10 — but are also often unaware of health services available to them or have fears around confidentiality.11 LGBTQ+ young people, in particular, report feeling isolated from health services.6 Health practitioners may therefore see Aboriginal and Torres Strait Islander LGBTQ+ young people in a variety of settings, including in suicidal crisis, seeking care after a serious assault or injury, or counselling for prolonged psychological distress. Although health care workers may be aware of the health risks associated with being Aboriginal and Torres Strait Islander, LGBTQ+ or young, the health outcomes for someone with these intersecting identities remain largely unknown. Emerging literature has begun to identify the health concerns of people who are both Aboriginal and Torres Strait Islander and LGBTQ+, although this work is thus far limited to adults.12,13,14 Consistent with research into these groups separately, findings suggest that suicidality, substance misuse and homelessness are primary health concerns for Aboriginal and Torres Strait Islander LGBTQ+ people. However, the evidence in adults also points to a set of health‐related concerns which are unique to being Aboriginal and Torres Islander and LGBTQ+. For example, some individuals move off Country in search of more accepting communities or to access gender‐affirming care.13,14 However, moving off Country can lead to feelings of dislocation due to loss of connection to Country, which can then precipitate illness. Arguably, Aboriginal and Torres Strait Islander LGBTQ+ young people find it harder to move off Country because of reduced financial and personal resources. Support and service in remote areas are also scarce.14 An inability to express gender or sexual identity is another health‐related concern for Aboriginal and Torres Strait Islander LGBTQ+ people. Some people report feeling pressure to suppress their sexual or gender identity when they are in Indigenous communities.12 Exclusion of gender diverse individuals from men's or women's business can negatively affect social and emotional wellbeing.13 Contemporary culture‐based wellbeing programs often continue this practice of providing support along binary gender lines. Some of the authors’ own experiences reiterate this unintentional bias; Indigenous health care providers use terms such as “sis”, “brother” or “sistergirl” when answering the phone, which can mean that people are misgendered. Although we acknowledge that these terms carry meaning to the Indigenous community, they can be problematical for trans and non‐gender‐conforming young people. There is therefore scope to develop a culturally sensitive way to bypass the use of these gendered terms until a young person's pronouns have been established. Intersectionality theory as a guiding framework International models8,15 provide a useful footing on which to consider intersectionality in the Australian health context. These models demonstrate how societal oppressions of racism and heterosexism within health care systems influence internal (eg, an individuals’ self‐concept) and external (eg, lack of LGBTQ+‐specific services, stigma toward multiple minority groups) risk factors. Importantly, the impact of these risk factors resulting from societal oppressions is not simply a multiplicative effect. Rather, individuals living within multiple minority groups face health disadvantage because of their unique social positioning. Common across these models is an emphasis on the social context of health outcomes because membership in multiple minority status groups can be associated with increased stresses and barriers impeding an individual's coping efforts. Further, when practitioners do not consider how a patient's gender, social class, ethnicity and sexual orientation influences their care needs, patients who experience multiple oppressions can become invisible by being left out of health research or ignored in policy and health promotion efforts, leading to delays in seeking care. Such invisibility in health care is a reported concern among Aboriginal and Torres Strait Islander LGBTQ+ people.12 Health care at the intersection: implications for health research and practice Adopting an intersectional approach to health care requires practitioners to consider the relationship between multiple structural inequalities faced by Aboriginal and Torres Strait Islander LGBTQ+ young people, and downstream consequences for this group's wellbeing. Doing so will likely require additional training and professional development. As Box 1 outlines, although not health providers per se, services and supports led by Aboriginal and Torres Strait Islander LGBTQ+ people have emerged in response to the multiple barriers presented by existing health services. These services provide a space for Aboriginal and Torres Strait Islander LGBTQ+ people to discuss intersecting identities. For example, the Gar'ban'djee'lum Network offers a space in which to celebrate sexual and cultural identity, and Black Rainbow partners with an online newspaper to publish content by Aboriginal and Torres Strait Islander LGBTQ+ authors, providing a platform for voices from people living at this intersection. Service providers can increase their awareness of the contemporary issues faced by Aboriginal and Torres Strait Islander LGBTQ+ young people by accessing online information from these organisations. Moreover, concrete steps which practitioners can follow can be guided by an awareness of intersecting categories, diversity of knowledges, power and multilevel analysis, reflexivity, time and space, and equity and social justice.8 Actions that practitioners can take which are consistent with these domains are outlined in Box 2. The increased focus on Aboriginal and Torres Strait Islander LGBTQ+ young people, led by and advocated for by Aboriginal and Torres Strait Islander LGBTQ+ community members and researchers, is a welcome step towards ensuring safe and effective health care for all Australians. However, there has been little guidance for practitioners on how best to work with this patient group. Health services wanting to support Aboriginal and Torres Strait Islander LGBTQ+ young people can: include an LGBTQ+ status question on intake forms; services can also use an open‐ended question format for young people to describe their gender, rather than tick‐boxes of “male”, “female” or “other”; provide visual displays of support in waiting rooms, such as displaying a rainbow pride flag and other pride flags alongside Aboriginal and Torres Strait Islander flags; and establish mechanisms for Aboriginal and Torres Strait Islander LGBTQ+ young people to provide service feedback (eg, asking patients from this group how the service can best meet their needs). Further, although there are increasing calls to apply an intersectional approach in health care — none more powerful than those of Aboriginal and Torres Strait Islander LGBTQ+ young people themselves — research has yet to systematically evaluate treatment outcomes for patients when such an approach is applied. Future research should measure treatment outcomes in services where staff apply an intersectional lens. The omission of young people from previous research into the health and wellbeing of Aboriginal Torres Strait Islander and LGBTIQ+ people also remains a pressing concern. Further research with young people is needed if practitioners and services working with young people are to effectively and appropriately work within an intersectional framework. Box 1 – Current services available for Aboriginal and Torres Strait Islander LGBTQ+ people* Organisation name Description Website Black Rainbow Advocacy for Aboriginal and Torres Strait Islander LGBTQ+ suicide prevention Support for homelessness, domestic violence, and people involved in the justice system http://www.blackrainbow.org.au/ Tekwabi Giz Provides support to the National LGBTI Health Alliance for Aboriginal and Torres Strait Islander LGBTQ+ people, specialised knowledge, advocacy https://lgbtihealth.org.au/tekwabigiz/ IndigiLez Women's Leadership and Support Group Special focus on Indigenous lesbians and same sex‐attracted women Advocacy for Aboriginal and Torres Strait Islander LGBTQ+ people, cultural retreats, safe sex workshops, family days, workshops, social activities, self‐defence workshops https://www.facebook.com/IndigiLez/ Sisters and Brothers NT Social change, advocacy, support, consultation, resource creation, and research, and awareness for sistergirls, brotherboys, and Aboriginal and Torres Strait Islander LGBTQ+ people https://www.facebook.com/SistersBrothersNTCelebratingDiversity/ First Nations Rainbow Acceptance, celebration, raising community awareness, improving wellbeing, and reducing stigma and discrimination https://www.firstnationsrainbow.org.au/ Yarns Heal Suicide prevention among Indigenous peoples, including sistergirls, brotherboys and LGBTQ+ individuals https://www.yarnsheal.com.au/ Gar'ban'djee'lum Network Support, advocacy, information on healthy lifestyles, social events, fundraising, and celebration of sexual and cultural identity https://www.afao.org.au/article/us-mob-garbandjeelum-network/ Blaq Aboriginal Corporation Celebration, representation and increased visibility of Aboriginal and Torres Strait Islander LGBTQ+ community members https://www.blaq.org.au/about-about * This list of organisations in not exhaustive but provides a starting point for practitioners wanting to learn more about Aboriginal and Torres Strait Islander LGBTQ+ health. Information in the table is taken from the organisations’ websites. None of the organisations listed are young people‐specific, although some make note of the importance of young people. Box 2 – Next steps in health care provision for Aboriginal and Torres Strait Islander LGBTQ+ young people Domain8 Next steps for research and practice Intersecting categories: health professionals should consider that patients likely occupy multiple social positions, not just the identity which appears most dominant Develop LGBTQ+ health information guides that are culturally sensitive to Aboriginal and Torres Strait Islander patients and easily accessible to young people Display the Aboriginal and Torres Strait Islander flags alongside the pride flags at health services Including LGBTQ+ status options on patient intake forms Because experiences of discrimination based on sexual and gender diversity among Aboriginal and Torres Strait Islander people can occur within the context of pre‐existing trauma,12 consider applying trauma‐informed care models when working with this patient group Specific health promotion efforts and programs targeted at Aboriginal and Torres Strait Islander LGBTQ+ young people Primary research into the social emotional wellbeing of Aboriginal and Torres Strait Islander LGBTQ+ young people Primary research into experiences and preferences of Aboriginal and Torres Strait Islander LGBTQ+ young people in the health system Diversity of knowledges: consider Indigenous and queer ways of knowing and being Seek Aboriginal and Torres Strait Islander LGBTQ+ young peoples’ perspectives on their health issues Assess whether Aboriginal and Torres Strait Islander LGBTQ+ young people have a culturally specific understanding of their health and wellbeing, which may differ from dominant, medicalised explanations Primary research into how Aboriginal and Torres Strait Islander LGBTQ+ young people conceptualise health and wellbeing Power and multilevel analysis: health professionals hold greater power than Aboriginal and Torres Strait Islander LGBTQ+ young people due to their positions in society; health issues for this patient group occur across multiple levels of society Reducing power differentials in the healing relationship by using less medicalised language with patients and asking them how to best cater to their specific needs Ensuring young people understand limits of confidentiality so that they can trust practitioners with disclosing their LGBTQ+ status Practitioners attend professional development opportunities that promote appropriate ways of working with Aboriginal and Torres Strait Islander LGBTQ+ young people (such training is currently provided by some organisations listed in Box 1). Primary research into the impact of various societal oppressions on Aboriginal and Torres Strait Islander LGBTQ+ young peoples’ wellbeing Primary research into enablers of effective service delivery in this patient group Reflexivity: consistent reflection on practice decisions and how they relate to patients’ social positioning Practitioners regularly reflect on assumptions they may hold about Aboriginal and Torres Strait Islander LGBTQ+ young people and the root cause of their health problems Discussions with LGBTQ+, Indigenous and mainstream health care providers around attitudes toward Aboriginal and Torres Strait Islander LGBTQ+ young people Time and space: patient needs and preferences are not static, and vary with social positioning Practitioners remain up to date on social trends which may affect this patient group (eg, recent legalisation of same sex marriage, release of the Uluru Statement from the Heart) Practitioners ask individual patients about their experience of living at this intersection, and not assume a universal experience Primary research into health care needs and preferences across the life course in this patient group Equity and social justice: advocating for increased inclusion of Aboriginal and Torres Strait Islander LGBTQ+ young people Health professionals can use their positions of social power to advocate for the needs of Aboriginal and Torres Strait Islander LGBTQ+ young people within their collegiate relations, workplaces and the broader health sector

Bep Uink · Shakara Liddelow‐Hunt · Kate Daglas · Dharma Ducasse

Objectives: To assess the numbers of notifications to health regulators alleging sexual misconduct by registered health practitioners in Australia, by health care profession. Design, setting: Retrospective cohort study; analysis of Australian Health Practitioner Regulation Agency and NSW Health Professional Councils Authority data on notifications of sexual misconduct during 2011–2016. Participants: All registered practitioners in 15 health professions. Main outcome measures: Notification rates (per 10 000 practitioner‐years) and adjusted rate ratios (aRRs) by age, sex, profession, medical specialty, and practice location. Results: Regulators received 1507 sexual misconduct notifications for 1167 of 724 649 registered health practitioners (0.2%), including 208 practitioners (18%) who were the subjects of more than one report during 2011–2016; 381 notifications (25%) alleged sexual relationships, 1126 (75%) sexual harassment or assault. Notifications regarding sexual relationships were more frequent for psychiatrists (15.2 notifications per 10 000 practitioner‐years), psychologists (5.0 per 10 000 practitioner‐years), and general practitioners (6.4 per 10 000 practitioner‐years); the rate was higher for regional/rural than metropolitan practitioners (aRR, 1.73; 95% CI, 1.31–2.30). Notifications of sexual harassment or assault more frequently named male than female practitioners (aRR, 37.1; 95% CI, 26.7–51.5). A larger proportion of notifications of sexual misconduct than of other forms of misconduct led to regulatory sanctions (242 of 709 closed cases [34%] v 5727 of 23 855 [24%]). Conclusions: While notifications alleging sexual misconduct by health practitioners are rare, such misconduct has serious consequences for patients, practitioners, and the community. Further efforts are needed to prevent sexual misconduct in health care and to ensure thorough investigation of alleged misconduct.

Marie M Bismark · David M Studdert · Katinka Morton · Ron Paterson · Matthew J Spittal · Yamna Taouk

Sexual dysfunction is a frequent, potentially distressing, adverse effect of antidepressants and a leading cause of medication non‐adherence. Sexual function should be actively assessed at baseline, at regular intervals during treatment, and after treatment cessation. Trials comparing the risk of sexual dysfunction with individual antidepressants are inadequate, but it is reasonable to conclude that the risk is greatest with selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), less with tricyclic antidepressants (except clomipramine) and mirtazapine, and least with moclobemide, agomelatine, reboxetine and bupropion. Management of antidepressant‐induced sexual dysfunction requires an individualised approach (eg, considering other causes, dose reduction, addition of medication to treat the adverse effect, switching to a different antidepressant). Post‐SSRI sexual dysfunction has been recently identified as a potential, although rare, adverse effect of SSRIs and SNRIs. Consider the possibility of post‐SSRI sexual dysfunction in patients in whom sexual dysfunction was absent before starting antidepressants but develops during or soon after antidepressant treatment and still persists after remission from depression and discontinuation of the drug.

Jody Rothmore

A 39-year-old woman was referred for colposcopy with a positive human papillomavirus (HPV) type 16 infection result on a self-collected HPV vaginal swab

Monica FG McGauran · Adam Pendlebury

M ost cervical cancers can be prevented with HPV vaccination and screening

Julia ML Brotherton · Alison C Budd · Marion Saville

Gender details must be better captured to facilitate appropriate planning of sexual health services

Denton Callander · Teddy Cook · Phillip Read · Margaret E Hellard · Christopher K Fairley · John M Kaldor · Emanuel Vlahakis · Alisa Pollack · Christopher Bourne · Darren B Russell · Rebecca J Guy · Basil Donovan

Increasing numbers of TGD individuals are seeking health care in Australia; new guidelines will help clinicians provide appropriate gender-affirming care

Ada S Cheung · Katie Wynne · Jaco Erasmus · Sally Murray · Jeffrey D Zajac

Treatment of erectile dysfunction with pharmacotherapy alone or in combination with graded psychosexual therapy is effective in improving and/or restoring sexual function in most men

Christopher G McMahon

There have been many advances in sexual and reproductive health and rights in Australia but we must also recognise the gaps that affect our most vulnerable populations

Deborah J Bateson · Kirsten I Black · Shailendra Sawleshwarkar

Lack of national abortion data impedes development of sexual and reproductive health care policies and programs for young Australians

Jennifer L Marino · Susan M Sawyer

Recent legislative and policy measures aim to raise awareness of the needs of older LGBTI people

Carmelle Peisah · Kim Burns · Samantha Edmonds · Henry Brodaty

An update on the evidence, and implications for the medical community

Ken W Knight* · Sarah EM Stephenson* · Sue West* · Martin B Delatycki · Cheryl A Jones · Melissa H Little · George C Patton · Susan M Sawyer · S Rachel Skinner · Michelle M Telfer · Melissa Wake · Kathryn N North · Frank Oberklaid

Interpreting positive cytomegalovirus serology requires caution, and follow-up testing is important

Alana Christensen · Anushia Ashokan · David L Gordon

Identifying and removing barriers to completing the vaccination course in schools is proving successful

Julia ML Brotherton · Karen L Winch · Lisette Bicknell · Genevieve Chappell · Marion Saville

If high vaccine coverage is sustained, the higher rates of HPV-related cancer rates in Indigenous women should also decline

Hammad Ali · Hamish McManus · Catherine C O'Connor · Denton Callander · Marlene Kong · Simon Graham · Dina Saulo · Christopher K Fairley · David G Regan · Andrew Grulich · Nicola Low · Rebecca J Guy · Basil Donovan