Sexual health

Sexually transmissible infections (STIs) are hyperendemic in some remote Indigenous populations in Australia. Screening programs have had some success in reducing the prevalence of STIs in specific populations, but there has been little overall improvement in the past 10 years. We question the usefulness of current practice and urge consideration of a new and radical approach. Instead of a “screen, treat and contact trace” strategy, we suggest adopting the same approach as currently accepted for trachoma control: populations reaching a threshold prevalence for a set of marker STIs (identified through sentinel surveillance) should be offered a treatment program aimed at the entire sexually active population. We also recommend a parallel program of health promotion and “life skills” education and outline the arguments for such a departure from currently accepted public health policy.

Francis J Bowden FRACP, FAChSHM, MD · Katherine Fethers MB BS, FAChSHM, MMed(STD/HIV)

Objective: To determine whether asking general practitioners to offer chlamydia screening at the same time as Pap screening increases chlamydia screening rates.Design: A pragmatic cluster randomised controlled trial.Participants and setting: Doctors from 31 general practices in the Australian Capital Territory performing more than 15 Pap smear screens per year, and all women aged 16–39 years attending those practitioners between 1 November 2004 and 31 October 2005.Intervention: Doctors in the intervention practices were asked to routinely offer combined chlamydia and Pap screening to eligible women; doctors in the control practices were asked to implement screening guidelines based on a risk assessment of the individual patient (ie, usual practice).Main outcome measure: Chlamydia screening rate per visit.Results: There were 26 876 visits by eligible women during the study period: 16 082 to intervention practices and 10 794 to control practices. Chlamydia screening occurred during 6.9% (95% CI, 6.5%–7.3%) of visits to intervention practices and 4.5% (95% CI, 4.1%–4.9%) of visits to control practices. After controlling for clustering and potential confounders, there were twofold greater odds of chlamydia screening occurring during a visit by an eligible woman to an intervention practice than to a control practice (adjusted odds ratio, 2.1 [95% CI, 1.3–3.4]).Conclusion: Combining chlamydia and Pap screening increases the rate of chlamydia screening in general practice. Implementing this approach would require little additional infrastructure support in settings where a cervical screening program already exists.

Francis J Bowden FRACP, FAChSHM, MD · Marian J Currie RN, RM, PhD · Helen Toyne MB BS, DipRACOG · Clare McGuiness MB BS, PhD · Lynette L Lim MSc, PhD · James R Butler MPolEcon, PhD · Nicholas J Glasgow MB ChB

Chlamydia screening programs overseas have failed to reduce chlamydia prevalence despite screening 20%–30% of young sexually active women. The Australian federal government announced in 2005 that it would provide $12.5 million for chlamydia control. Policymakers must look to chlamydia screening programs in other countries to learn from their experience. Australia has an excellent primary health care system and a strong track record in establishing highly successful public health programs. This experience places it in a strong position to design and implement an innovative chlamydia screening program to reduce chlamydia prevalence.

Jane S Hocking MPH, MHthSc(PHP), PhD · Jennifer Walker BAppSc, MPH · David Regan BSc(Hons), PhD · Marcus Y Chen MRCP, FAChSHM, PhD · Christopher K Fairley PhD, FAFPHM, FACSHP

Clinical records Patient 1 A 55-year-old man presented with tenesmus, rectal bleeding and discharge of 3 weeks’ duration. He had a past history of treated syphilis and anal warts. High-resolution anoscopy, performed by a sexual health physician, revealed an extensive anterior ulcer distal to the dentate line, suggestive of anal carcinoma (Figure A). However, histological examination of repeated rectal biopsies revealed non-specific ulceration, with chronic inflammation in the adjacent rectal glandular mucosa. Patient 2 A 54-year-old man with previously treated syphilis presented with a 2-week history of per-rectal bleeding, pain and associated fevers. Colonoscopy, performed by a gastroenterologist, revealed extensive rectal ulceration. Histological examination of a biopsy from the ulcer revealed ulceration with mixed acute and chronic inflammatory cells and a lymphoid infiltrate, suggestive of a lymphoma (Figure B). A sigmoidoscopy was performed 7 days later, when the patient re-presented with worsening rectal pain and bleeding. Repeat rectal biopsies confirmed non-specific inflammation with atypical Epstein–Barr virus-associated lymphoid proliferation rather than lymphoma. Patient 3 A 43-year-old man with previous Kaposi’s sarcoma presented with a 2-month history of per-rectal bleeding and diarrhoea. Colonoscopy, performed by a surgeon, showed multiple rectal ulcers suggestive of Crohn’s disease (Figure C), but biopsies showed non-specific acute and chronic inflammatory infiltrates only. All three patients were HIV-infected men who have sex with men. They were receiving highly active antiretroviral therapy, with good virological control and CD4+ T cell counts. All were investigated for a broad range of diagnoses, including inflammatory bowel disease, colorectal malignancy, lymphoma and sexually transmitted infections; all underwent one or more invasive procedures by various specialists before being referred to our infectious diseases outpatient clinic between 2005 and 2006. After assessment at the clinic, the aetiology of the anorectal condition was determined in all cases by a simple rectal swab. The swab was initially tested for Chlamydia trachomatis using a routine nucleic acid amplification method. As these tests were initially positive, the samples were further analysed by sequencing of the outer membrane protein gene. This confirmed, in all three cases, that the strains were of the lymphogranuloma venereum (LGV) 2b serovar, which is commonly associated with LGV. Screening for other sexually transmitted infections was negative. All patients made a full clinical recovery after treatment with doxycycline 100 mg twice a day for 3 weeks. Patient 2 underwent a repeat colonoscopy 2 months later, which revealed complete resolution of the ulcer. Chlamydia trachomatis is a human pathogen and a common cause of sexually transmitted infections, including lymphogranuloma venereum (LGV).1 LGV was previously confined to endemic areas in tropical regions — principally Africa, India and northern South America. However, since 2003, LGV has emerged as an increasingly important infection worldwide, with outbreaks occurring in communities of men who have sex with men (MSM) in The Netherlands, Belgium, France, Germany, Sweden, the United Kingdom and North America.2-6 Risk factors identified in these outbreaks include HIV seropositivity, previously diagnosed sexually transmitted infections, concurrent ulcerative disease, and unprotected receptive anal sex with casual partners. In Australia, there have only been two previous reported cases of LGV. Both patients were MSM. One patient presented with inguinal lymphadenopathy acquired in Melbourne,7 while the other had anorectal LGV acquired after sexual exposure in Europe.8 Unlike other chlamydial infections, which are generally restricted to epithelial surfaces, LGV is invasive and causes severe inflammation, often with systemic symptoms and with a preference for lymphatic tissue.1 The manifestations of LGV infection vary depending on the site of inoculation, presenting either as a painful unilateral inguinal syndrome or an anorectal syndrome. Lessons from practice Lymphogranuloma venereum (LGV) is an invasive inflammatory disease of the urogenital tract caused by infection with Chlamydia trachomatis. LGV is an important cause of anorectal disease in men who have sex with men. Anorectal LGV may masquerade as inflammatory bowel disease, colorectal malignancy, lymphoma or other ulcerative rectal sexually transmitted infections. Diagnosis requires a high index of suspicion. It is important to take a detailed sexual history and conduct specific microbiological testing for C. trachomatis. Screening for coinfection, contact tracing, general education and health promotion are important public health components of managing LGV. LGV infection is characterised by three stages. In the first stage, the primary lesion is usually an asymptomatic small genital ulcer that heals spontaneously. This is followed by a painful inguinal lymphadenopathy associated with systemic features. Lymph node inflammation may progress to involve the surrounding subcutaneous tissue, causing an inflammatory mass (bubo) and/or abscess. Complications occur in 30% of cases as a result of bubo rupture and/or sinus tract or fistula formation. In anorectal disease, acute haemorrhagic inflammation of the colon and rectum is associated with involvement of perirectal lymphatic tissue.1,9 The third stage is characterised by chronic granulomatous inflammation leading to lymphatic obstruction, fibrosis and stricture formation.1 Clinical proctitis is a common problem in MSM, and C. trachomatis is one of the most frequent infectious agents found in this population. When suspected, C. trachomatis infections can be quickly identified and treated. However (as was the case with the patients described here), infected people may present to non-sexual-health practitioners (eg, gastroenterologists or colorectal surgeons) for persisting symptoms.9 Endoscopic features are non-specific, with a wide range of differential diagnoses including Crohn’s disease, lymphoma, anorectal carcinoma and other sexually transmitted ulcerative infections (eg, syphilis, herpes).3,4,9 Biopsies typically show only non-specific inflammatory features. C. trachomatis is divided into 15 serovars, labelled A, B, Ba, C–K and L1–L3, based on analysis of the major outer membrane protein. The various serovars are associated with specific disease manifestations: serovars A, B, Ba and C cause trachoma; serovars D–K are associated with urogenital infection; and serovars L1–L3 cause LGV.10 The L2 serovar can be further separated into L2, L2', L2a or L2b according to minor differences in their component amino acids.9 The commonly used commercial diagnostic tests for C. trachomatis are nucleic acid tests that can be performed on urine and on cervical and urethral swabs. Although not currently licensed for use on rectal swabs, the test may be used “off licence” and is the investigation of choice. Alternative tests, such as culture, are slow to perform and less sensitive, while serological tests cross-react with other Chlamydia species and can not distinguish between previous infection and current infection on single specimens. As commercial nucleic acid tests can not distinguish between uncomplicated rectal chlamydial infections (serovars D–K) and LGV (serovars L1–L3), directed testing is required (eg, outer-membrane protein sequencing). Therefore, to make a diagnosis of LGV, it is important at the outset to discuss the optimum specimen collection technique with a microbiologist at the laboratory to which the specimen will be sent. Two dry swabs should be sent with a specific request for LGV testing. This is a reference laboratory test and is offered by only a few public laboratories. The charge for the test is under the Medicare nucleic acid rebate, with no gap amount charged to the patient. The laboratory turnaround time for such a specimen is typically about 2 weeks from receipt. The correct diagnosis is essential, as treatment regimens recommended for LGV infection are much more prolonged than those for uncomplicated genital chlamydial infections — for example, a patient may receive 3 weeks’ treatment with doxcycline 100 mg twice a day or azithromycin 1 g weekly. However, good clinical trial data are lacking, and inadequate therapy may be associated with progressive disease and tissue destruction. Careful follow-up of the index patient is therefore essential. As with other sexually acquired infections, rigorous contact tracing is important to prevent further spread within the community. Counselling about healthy sexual practices is an important public health component of management, and patients should be alerted to the increased risk of HIV transmission associated with genital ulcer disease. A. Patient 1 — high-resolution anoscopy showing extensive ulceration distal to the dentate line. B. Patient 2 — biopsy from a rectal ulcer showing a lymphoid aggregate with a germinal centre (arrow) (haematoxylin and eosin stain; original magnification 3100). C. Patient 3 — colonoscopy showing multiple ulcerative lesions in the anorectal area.

Sebastiaan J van Hal MB ChB · Richard Hillman MD, FRCP · Damien J Stark BSc, PhD · Jock L Harkness FRCPA · Debbie Marriott FRACP, FRCPA

Is it me or my hormones? Understanding midlife change. 2nd ed. Margaret Smith, Patricia Michalka. Sydney: Finch Publishing, 2006 (278 pp). ISBN 187645174 2. We’ve all seen them in our practices: anxious women, bewildered or even frightened by the signs of the menopause transition. Perhaps they’re carrying the burden of family folklore; perhaps they’ve somehow managed to insulate themselves — even through pregnancy and childbirth — from a proper understanding of their own bodies; perhaps they’re shocked by these intimations of mortality. Hot flushes, night sweats and mood swings may have taken them by surprise. The loss of sexual desire or the experience of discomfort during intercourse may be evoking confused responses, ranging from self-doubt (“Am I still an attractive woman?”), to worry about the state of the relationship with their partner. For some women, patient listening and an assessment of their physical state (including, in appropriate cases, hormone therapy) may provide all the reassurance they need. For others, though, something more comprehensive is called for. For women who need detailed information — physical, emotional, sexual, social and even spiritual — about the menopause transition, this book is a godsend. Margaret Smith, a gynaecologist specialising in the menopause, and Patricia Michalka, a psychotherapist, have distilled their combined wisdom into a book that addresses one of the most fundamental questions raised by menopausal women: “Is it me or my hormones?” In a genuinely holistic approach, the authors explore the many symptoms and issues that sometimes confuse menopausal women to the point of despair. The case-study approach is handled warmly and with compassion: worried women will find it easy to identify with the stories in this book. We all know that the “one size fits all” approach flies in the face of common sense and our experience of the uniqueness of each patient’s situation. Is it me or my hormones? emphasises the need to take an individual approach, and to recognise that symptoms are rarely a sign of only one thing.

Sheila O’Neill

To the Editor: We read with interest the article by Couper et al on the psychosocial impact of prostate cancer (PCA) on patients and their female partners.1 We agree that involvement of partners in the research pro-cess is pivotal to understanding the relational dimension of how PCA is both understood and approached by men and their partners.2 However, this could be extended to consider the unique experiences of gay men diagnosed with PCA and their partners. Heteronormative viewpoints are commonplace in PCA research. This bias is unfortunate, as there is a 28% possibility that one of the men in a gay relationship will develop PCA over the course of his lifetime.3 While it is probable that gay men and their partners have some of the same concerns regarding PCA as heterosexual couples, there are also unique concerns that are specific to gay men and their partners. Such considerations may include (but are not limited to): the prostate gland as a site of sexual pleasure and the associated implications of being able to engage in penetrative anal sex after prostate surgery;4 homophobia and/or disregard for sexuality within the health care system5 when being diagnosed with and treated for PCA; and the impact of polygamous (open) relationships and the ambiguous position of gay partners having to care for their mates.4 At this stage, the above concerns are purely speculative, as there is a paucity of literature on gay men and PCA.4,6 We believe future research on the psychosocial impacts of PCA should consider the experiences and special concerns of gay men with PCA, as well as those of their partners.

James A Smith · Shaun M Filiault · Murray J Drummond · Robert J Knapman

In reply: We thank Smith et al for their acknowledgement of the importance of the relational dimension to understanding how prostate cancer (PCA) is understood and approached by men and their partners. The psychosocial implications of prostate cancer for same-sex couples are important and need specific investigation. However, there are methodological difficulties in attempting to quantify the impact of PCA on same-sex couples and in comparing their experience with other couples. In our review of the literature,1 we discovered that where previous researchers had included same-sex partners in their studies, insufficient numbers were recruited for meaningful quantitative statistical comparisons. For example, Perez and colleagues,2 Neese and colleagues3 and Davison and colleagues4 each recruited only one same-sex couple into their studies of 134, 164 and 74 couples, respectively. We believe that a qualitative approach is needed, specifically seeking out and examining the experiences of a group of same-sex couples and comparing and contrasting their experiences with those of a group of male–female couples. This is an approach we are considering in future studies to help us develop and refine an effective but broadly applicable couple-focused psychosocial intervention for PCA.

Jeremy W Couper

In Australia, about 150 000 men aged 16–59 years identify as gay or bisexual, while a similar number identify as heterosexual but have some history of same-sex sexual contact. Pitts, Couch and Smith advise that the clinical implications for these men include more than sexual health concerns. They suggest several consultation skills that can help doctors to recognise these men and better meet their needs. Human sexual practice is diverse. In response to the need to better understand that diversity in the face of the HIV epidemic, a fact became widely known that had previously been understood by few: a significant population of men who do not self-identify as “gay” or “bisexual” sometimes have sexual contact with other men. It was recognised that a descriptor for behaviour, rather than an assertion of social identity, was needed, and the term “men who have sex with men”, and its acronym MSM, came into being. We believe there are “definitional” challenges associated with this term, as well as clinical and practical implications when working with men to whom such a descriptor might be applied. What's in a definition?It is rare for medical journals to include sexuality and sexual behaviour as important components of men’s health and wellbeing. It is even more unusual to acknowledge MSM outside the context of HIV. Use of this acronym in a men’s health context both illuminates and challenges. MSM is a behavioural definition; it does not imply an identity, and it does not consider sexual attraction. We prefer the term “male-to-male sexual practices” (MMSP), as it explicitly acknowledges that the sexual practices, rather than the person, are at issue. The choice of “practices” in the plural also signals that male-to-male sex may incorporate a range of sexual behaviours which may, or may not, include oral and anal sex. How many men fit the definition?The Australian Study of Health and Relationships in 2001 surveyed a nationally representative sample of 19 307 Australians aged 16–59 years. These included 10 173 men, of whom 97.4% identified as heterosexual, 1.6% as homosexual or gay, and 0.9% as bisexual, while 0.1% were undecided or “other”. A lifetime history of sexual attraction that included other men was reported by 6.8%, and sexual experience with other men by 6.0%. Of the men who identified as heterosexual, 2.7% reported having had sex with at least one other man. By extrapolation to the general Australian population, this suggests that there are about 158 000 men aged 16–59 years who identify as heterosexual but have some history of same-sex sexual contact. This is in addition to the 148 000 men who identify as gay or bisexual.1 What are the clinical implications?Sex, risk and MSMWhat does it matter that the patient, whatever his sense of identity, has anal sex with men, and perhaps also has penetrative sex with women? The international medical literature on MSM builds a picture of a risk-taking and at-risk group. They are particularly, if not exclusively, considered in the context of HIV risk, and to a much lesser extent are known to be at risk of other sexually transmitted infections (STIs). We recently completed a study of the knowledge and attitudes of gay men towards anal cancer and human papilloma virus (HPV).2 We know that anal sex carries a high risk of HPV transmission, particularly for men who are HIV-positive, but our study showed that very few gay men had even heard of HPV, and most were not aware of its association with sexual practices. In this regard, they differ little from women, who are at similarly high risk — of cervical cancer — through HPV exposure. MSM are at greater risk of gonorrhoea or syphilis than are other men. However, most consultations with MSM are for issues other than STIs and reflect the profile of health conditions experienced by Australian men. Substance useCertainly, if a category or group is defined only in terms of sexual activity, it is unsurprising that STIs feature large. However, there is some evidence of health risks other than sexual health risks in MSM, which nevertheless derives from HIV studies. These indicate a higher than expected rate among some MSM subcultures of alcohol use, and injecting and other illegal drug use. Men in the Australian Study of Health and Relationships who identified as bisexual were eight times more likely to report a history of injecting drug use, and gay men were twice as likely, as those who identified as heterosexual.3 However, they were no more or less likely than other men reporting a history of injecting drug use to report sharing needles or injecting paraphernalia. In Private lives, our national online survey of health and wellbeing among gay, lesbian, bisexual, transgender and intersex Australians, we found that 38.3% of gay-identifying men reported tobacco use on more than five occasions in the previous month,4 which compares with 26% for Australian men in general.5 Mental healthFindings about MSM are mixed in the area of mental health. Numerous studies have indicated higher rates of depression and anxiety in gay men. A 5-year study in South Australia reported 30% of homosexually active men met the criteria for a major depressive episode, as measured by the Primary Care Evaluation of Mental Disorders screening tool.6 Twenty-seven per cent of the men in the survey were diagnosed with dysthymic disorder on enrolment, while the survey indicated a lifetime prevalence of a depressive disorder of 48%. This is five times the rate for all men reported from primary health care clinics in the United States where the survey instrument was validated.7 In Private lives, which involved 3429 gay men from all Australian states and territories, we found that the prevalence of depressive disorders was high, with 48.7% of men scoring on at least one of the two criteria for a major depressive episode. Nearly a quarter of respondents (23.8%) met the criteria for a major depressive episode, with a similar proportion reporting experiencing depression (24.2%). It is of particular concern that 15.7% of gay men indicated suicidal ideation in the 2 weeks before completing the survey. While the causes are not easily identified, it is probable that living in a society characterised by homophobia is a contributing factor.4 What are the practical implications?Recognition of MSMHow does one recognise MSM? Would the behavioural question be: “Have you ever had sex with a man?” or “Have you had sex with a man in the past year?” and/or “Have you also had sex with a woman?” And how would the word “sex” be interpreted? Presumably, the narrowest definition of MSM would be a man who has experienced anal sex (insertive or receptive) on at least one occasion in his life. However, it is not surprising that publications on MSM almost never offer a definition or, if they do, proceed to bundle MSM with gay, bisexual and other homosexually active men into a single analysis. MSM and their health needs are most likely to evade recognition because of the heteronormative nature of most clinical practice — based on the assumptions that, until proven otherwise, all people have a simple sexual identity, and that it is heterosexual. A gay man who is “out” about his sexuality to his doctor (67.2% of men in the Private lives survey had told their doctors) may find his general health concerns sometimes overshadowed by concerns about sexual health. This may be understandable, given the relatively high rates of HIV and other STIs among these men. However, STIs or any other single issue should not become an overriding focus of any clinician–patient relationship. When, how, and what to ask a man about sex? Simply put, when and if you consider it matters, avoiding a default assumption that the man is heterosexual, even if he is married, partnered with a woman or has children. MSM have wives and children too! In most cases, the need to ask is determined by the presenting condition, and it may not matter so much to whom a man is attracted, or what he identifies as his sexual identity, as what his recent sexual practices have been. So, ask questions about the sex he does, rather than about what he is. Of course, if the presenting problem has to do with a complicated life course perhaps including mental health issues, then questions about sexual attraction and identity could well be the important ones. The case scenarios (Box) show the differing process and outcomes when a doctor recognises, or fails to recognise, the possibilities. For new patients, it may be easy to indicate that a full sexual history is a usual part of an initial consultation, whatever the presentation. For existing patients, sexual history may be best approached indirectly. A statement that hepatitis B vaccination is freely available and recommended for all men who have had sex with another man can be mentioned in the context of reminding all male patients of vaccination schedules. If a clinician (or a practice) takes a “no default assumptions” approach to sex, then the move into questions of sexual attraction, identity and practice will happen when, and if, they matter. Finally, we are confident that it is rare that health articles define the population in terms of a single behavioural characteristic. To think analogously, would we not shrink from referring to WWR (women who reproduce), PWJ (people who jog), or indeed MSW (men who have sex with women)? Is it so surprising that we would prefer the term “male-to-male sexual practices” or MMSP? Case scenarios Scenario 1 — MSM not recognised Rob is a 36-year-old man who lives in a regional town. He is married with three young children and is feeling guilty and highly anxious following an unsafe sexual episode with another man a while ago. He feels he will be able to relieve his anxiety only by having an HIV test. He goes to a local doctor he does not know, as he does not want to use his family doctor, who also treats his wife and children. On the information form, he states that he is married. In the consultation, Doctor A invites him to discuss his presenting problem, and Rob leads into it by saying he is very embarrassed because he has been unfaithful to his wife. Doctor A, sensing his embarrassment, tries to help by asking whether the woman is someone he is having an ongoing affair with and whether he feels she might have had an STI. Not knowing how to get round this, Rob says that he is worried about STIs. Doctor A ends the discussion, which is clearly becoming more uncomfortable, by ordering a series of STI checks and suggesting the affair has been a bad idea and should end. The tests do not include an HIV test. Rob has gained nothing from the visit; he does not return for the test results. Scenario 2 — MSM recognised Rob, still anxious, goes to another doctor in the town to try to have an HIV test. This time he notices a health promotion poster for same-sex attracted people (Figure*) in the waiting room and so feels more confident. He completes the information form again to say he is married but notes an option for “same sex relationship”. These signals lead him to feel safer about discussing his concerns. Doctor B asks why he has come, and he says he has had unsafe sex with someone other than his wife. “Was that with a male or a female partner?” asks Doctor B. He then asks what Rob actually did with that partner. Rob and Doctor B agree that an HIV test is necessary and discuss other STI tests as well. Hepatitis B vaccine is also discussed, along with the levels of anxiety Rob has been feeling. Doctor B takes the opportunity for a reminder about the importance of practising safe sex in the kind of situation Rob describes, but acknowledges that is not always easy. He will see Rob again for his test results, and makes sure he will return by telling Rob he is pleased to have met him and that he would be happy to see him any time he needs to talk about things. When his test results come back negative, Rob and Doctor B use the feeling of relief to talk through some of his health risks and to plan strategies to avoid anxiety in the future. After the consultation, Rob feels less guilty and more in control of his life, and less likely to take risks with his own health and the health of his wife in the future. * This poster and other useful resources are available at http://www.glhv.org.au/ MSM = men who have sex with men. STI = sexually transmitted infection.

Marian K Pitts PhD, AFBPS, MAPS · Murray A Couch BA(Hons) · Anthony M A Smith PhD

John W Orchard Visiting Fellow, South Sydney Sports Medicine, University of New South Wales, 111 Anzac Parade, Kensington, NSW 2033. johnorchardATmsn.com.au To the Editor: I congratulate Harris et al1 on conducting a survey that identified aspects of specialty training that are difficult for female doctors and doctors with partners and/or children. However, there are some omissions in their article, which, although small, illustrate further ways in which “specialty” training is unfriendly to the aforementioned groups. The authors purported to survey all medical graduates registered in 2002 “with a clinical college training program”. It appears that registrars on the Australasian College of Sports Physicians (ACSP) training program were not included. This training program has been in place since 1992, has been recognised by the Health Insurance Commission since 1999, and is most definitely a “clinical college training program”. Although similar in structure, there are two major differences between the sports physician training program and most other “specialty” training programs; namely, that the training is almost entirely non-hospital based and that the resulting qualification (the FACSP) is not recognised as a “specialty” in Australia. In 2002, I believe that the Australasian College of Sexual Health Physicians was in a similar position to the ACSP, administering a “non-specialty” clinical college training program (which is now under the auspices of the Royal Australasian College of Physicians). The recognised specialties in Australia, with the major exception of general practice, almost all conduct most of their training in hospitals. Not only are these hospital-based positions relatively “female-unfriendly” and “parent-unfriendly”, they don’t adequately train specialists for the majority of doctor–patient interactions, which do not actually take place in hospitals. They also contribute to the reality that our “health” system is focused on treatment of disease rather than prevention.2 Areas such as women’s and men’s health, travel medicine and dietary medicine also exist within our health system.3 Ideally, if we want a health system that is better at actually promoting health, these areas should also have formally recognised training programs. The conservatism of both the Australian Government and the medical profession is reflected in the process for recognising new specialties, which has severely discouraged community-based specialties from being developed. The “choice” of specialty training that Harris et al examined in their study was limited by what was officially sanctioned in 2002. If it were accepted that there should be more recognised specialty postgraduate training positions in community-based fields of medicine, then not only would our medical system start to address its deficiencies in health promotion, but there would be far more attractive training opportunities for doctors who don’t wish to pursue full-time hospital-based positions.

John W Orchard

Specific priority actions and screening programs should target sexually active young people The incidence of sexually transmitted infections (STIs) is increasing in many parts of the world including Australia,1 and the release of the first Australian National Sexually Transmissible Infections Strategy to deal with STIs is timely.2 Three very appropriate priority areas have been identified: Aboriginal and Torres Strait Islander sexual health, STIs in men who have sex with men, and control and prevention of infection with Chlamydia trachomatis among young people. Given that an implementation plan is under development, it is timely to comment on the Strategy, pointing out its strengths and weaknesses, so as to ensure that an effective, comprehensive approach is implemented. Experience from the United Kingdom, where a national STI strategy was developed in 2001,3 suggests that this is the first stage of a long, difficult and contentious process to improve sexual health within the community. The control of STIs involves a range of activities. As well as research, surveillance, and adequate training and support of professional staff, it is essential that we not only increase access to health care (including screening, treatment and contact tracing), but that we also promote health and educate the young about sex. While the Strategy satisfactorily covers surveillance, service provision and research, sex education and behavioural prevention are not adequately addressed, except with reference to gay and other homosexually active men. There are no specific priority actions focusing on sexually active young people, and a lack of clarity with regard to the targeting of screening programs for young people. The Australian Study of Health and Relationships, a recent survey of the sexual relationships and practices of 19 307 people aged between 16 and 59 years, showed that the median age of first intercourse among Australians aged between 16 and 19 was 16 years, and that the reporting of multiple sex partners was significantly associated with younger age and with identifying as bisexual or homosexual.4,5 As the authors noted: “This early onset of sexual activity indicates that it is important to ensure that all young people have information about contraception and disease prevention before they begin their sexual careers and not simply in their final years of schooling.”5 Health promotion, including mandatory sex education, is essential for all young people, male as well as female, and those under as well as those over 16 years of age. A study comparing sexual health outcomes in young people in the context of sex educational policies in the Netherlands, the United States, France and Australia found that in France and the Netherlands, where there is mandatory secondary school sex education, there are fewer STIs than in Australia and far fewer than in the US, where sex education is patchy.6 Increasing access to health care is not enough. There is also evidence that school-based education is likely to be more effective if it is sex positive, that is, if education does not focus solely on delaying or abstaining from sex.6 In the UK, where STI rates are at an all-time high, a survey of young people’s experience of sex education came to the conclusion that such education was “too little, too late and too biological.”7 We should learn from such experience. The Strategy refers to raising awareness of STIs among sexually active young people and recommends that there be a national health promotion campaign. However, the approach is coy. Although safer sex is mentioned, the only mention of condoms occurs under the action plan for gay men, where the Strategy mentions “reinforcing safer sex and condom use.” The consistent use of condoms is a highly effective method of reducing the risk of acquiring STIs, in particular the bacterial infections (gonorrhoea, chlamydia and syphilis) and HIV.8 Condoms have been and continue to be a major factor in the reduction in the incidence of HIV in homosexually active men in Australia. Widespread condom use is also the single most important factor in the continued low incidence of all STIs in commercial sex workers in Australia.9 Young sexually active people need to be aware of the risk of STIs and use condoms to prevent their transmission. The continued promotion and widespread availability of condoms must be one of the key elements of any successful STI strategy. The incidence of chlamydia infection in Australia is increasing and has more than doubled between 2000 and 2004 with over 35 000 notifications, with the largest increases noted in women aged 15–19 and 20–29 years.1,10 In the Minister for Health’s press release, which accompanied the launch of the Strategy, funding of $12.5 million over 4 years was announced for increased awareness, improved surveillance and a pilot testing program for chlamydia infection,11 and this is very welcome. However, while the Strategy highlights the need to develop “a chlamydia screening pilot targeting sexually active young adults”, the Minister’s press release had a different spin, suggesting that the pilot testing program for chlamydia will target women aged 18–30 years. However, younger women and men, particularly young men, who seldom seek health care, should also be the target for the pilot.12,13 In the US and Sweden, where national chlamydia screening policies based largely on opportunistic screening of women have been in place for several years, rates of chlamydia infection remain high.14 There are many long-term physical consequences of STIs, in particular, pelvic inflammatory diseases and consequent infertility, and cervical and other genital tract tumours. In addition, STIs are often associated with psychological morbidity. The release of the Strategy provides a unique opportunity to reduce the prevalence of STIs and their consequences. We must ensure that we make the most of this opportunity.

Adrian Mindel MD, FRACP, FRCP · Susan Kippax BA(Hons), PhD, FASSA

After “unprotected” sexual encounters, sexual history guides risk assessment and testing for sexually transmissible infections (STIs). Chlamydia trachomatis infection is the most prevalent bacterial STI. Sexually active young people (aged < 25 years) should have annual chlamydia testing. Opportunistic STI testing is indicated for population groups at increased risk of STI, including young people, gay and other homosexually active men, and Indigenous people. Gay and other homosexually active men should be regularly tested for HIV, syphilis, chlamydia and gonorrhoea. Indigenous people should be regularly tested for syphilis, chlamydia and gonorrhoea. Postexposure antiretroviral prophylaxis may be indicated after high-risk sexual encounters.

Deborah L Couldwell MB BS, MM, FAChSHM

When I was asked to take on writing for Dolly magazine’s “Dolly Doctor” column in 1993 I was more excited than if I’d won a Dolly total hair, body and personality makeover at age 13. This was a unique opportunity, which would not come along very often, to enter part of an adolescent’s world on her terms. The first question asked of me by anyone (including teenagers) about Dolly Doctor is, “Are the questions made up?” The answer is a resounding “No!”. In 1993, the magazine received 1000 letters a year to its health and sex columns. Today, it receives 1000 emails every 3 weeks, and the occasional mailed letter. And it keeps growing. A few years ago, the magazine expanded its health section, calling the whole segment Dolly Doctor, rather than just the one-page medical column. There is now a psychologist who answers questions about mental health issues, relationships and feelings. There are feature articles as well as personal stories, and earlier this year I began answering boys’ questions as well. Being a Dolly Doctor hasn’t always been easy. Sometimes I just don’t know the answer. For example, what is the green ointment that’s supposed to remove moles but instead caused a scar after 2 weeks and “didn’t work much”? Or, could the 3 cm piece of long dangly skin hanging from the vulva actually be a Bartholin’s gland, and if not, then what is it? Perhaps all this terminology is just too confusing. It’s clear that too much information can also mix health messages, such as the letter from the girl who “can’t stop masturbating” and is terrified because she doesn’t want to have a Pap smear yet. And what do I say to a 13-year-old whose best friend and she share the same crush, but one has taken the trouble to write and ask for advice about torn loyalties while the other has doubtless just “gone in for the kill”? Maternal responsibilities and Dolly Doctor have also caused consternation. I wouldn’t allow my children to read the magazine when they were prepubertal, but they were permitted to tear out wall posters to decorate their bedrooms (does anyone else remember “Hanson”?). One day my then 8-year-old son, playing at a friend’s house, told the mother that he’d like a “condom on his sandwich please”. In Year 4, he started a “sex club” at school, a fact I discovered when the mother of another boy approached me in the playground to express her concern about the pernicious effect my work was having on my family. (I should add that being in the sex club involved walking around saying “we’re in the sex club” and nothing more.) This same son (now 16) and my 15-year-old daughter seem to know the answers to all the questions I receive, and more besides. My daughter recently laughed at my ignorance of a (supposedly) common word used to describe a particular phallic shape. Only after she explained this to me was I able to answer the question correctly. All makes for interesting dinnertime conversation too. The number of Dolly magazines lining my bookshelves outnumbers my peer reviewed journals by about 10 to 1. So, as much as Dolly Doctor was my guide to life, as it has been for many teenagers since the magazine started in 1970, it now helps to guide my life as an adolescent-health professional. For every “desperate” teenager writing to Dolly Doctor each month, for every straightforward or heart-wrenching, amusing, bizarre or even downright ridiculous question that comes my way, there is some poignant reminder of what is so wonderful about adolescents.

Melissa S-L Kang MB BS

Fighting the current epidemic requires intensive education of clinicians and men who have sex with men, as well as targeted screening A research article (page 179)1 and a letter to the editor (page 218)2 in this issue of the Journal should leave you in no doubt that syphilis is back. After falling precipitously with the onset of the HIV epidemic in the early 1980s, syphilis infection rates are rising dramatically in Australia and the developed world among men who have sex with men.3 Why has this occurred, and what can be done about it? Australia’s response will determine if the current syphilis epidemic is remembered as an isolated epidemic or the return of endemic infection. The prevalence of a sexually transmitted infection (STI) is determined by three factors: the probability of transmission per partnership, the rate of partner change, and the duration of infectiousness. The particular importance of the duration of infectiousness is illustrated by the dramatic 100-fold fall in the prevalence of syphilis following the introduction of antibiotics.4 Another example is in situations where access to health care is poor and duration of infectiousness is therefore prolonged, as in isolated Indigenous communities in Australia. In such communities, both syphilis and gonorrhoea are common, despite rates of partner change being similar to those in the rest of Australia.5 In contrast, gonorrhoea or syphilis struggle to exist in communities with adequate access to health care, unless the rate of partner change is high. What then has changed among men who have sex with men to cause this sudden rise in syphilis infections in New South Wales and Victoria? Sexual behaviour has changed, with rates of any unprotected anal intercourse among men who have sex with men having increased by 50% in Australia over the last 10 years — this was also a strong risk factor for incident syphilis in the Health in Men (HIM) study6 mentioned in the research article by Jin et al.1 Oral sex is also transmitting syphilis, despite being considered relatively safe in terms of HIV transmission. Over half of the men in Jin et al’s cases series believed they had contracted syphilis through oral sex,1 and oral sex has been reported as the sole risk factor in up to 50% of cases reported overseas.3 HIV-positive men who have sex with men appear to be at increased risk of syphilis in Australia, representing between 40% and 54% of the cases reported by Jin et al1 and Guy et al.2 In addition, unprotected anal intercourse with an HIV-positive man was a strong risk factor for incident syphilis among HIV-negative men in the HIM Study.1 These findings are consistent with overseas reports that syphilis is more commonly diagnosed in HIV-positive men.3 The critical issue is what can be done now to control this epidemic. Clearly, increasing the use of condoms is important, particularly for anal sex. It is unlikely, however, that condoms will be widely used for oral sex, even though this practice is transmitting syphilis. In addition, reducing the rate of partner change is important, but it has been difficult to demonstrate large effect sizes in controlled studies.7 Substantially reducing the duration of infectiousness may be possible through educational campaigns, increased screening and enhanced contact tracing. Intensive educational campaigns for clinicians and men who have sex with men are fundamental for promoting early diagnosis and treatment, and screening high-risk individuals. Remember, most doctors under the age of 45 have not seen a case of syphilis, and young men are also less likely to be aware of the symptoms and clinical presentation of the infection. Educational campaigns that use the Internet can be relatively cheap and effective. For example, one banner advertisement on gay websites resulted in 32 270 click-throughs to public health websites with syphilis information.8 The cost per “click” varied from $0.05 to $10.8 Increased screening is the only way to detect asymptomatic infection; up to 33% of infections reported by Jin et al in the syphilis case series and the HIM study were asymptomatic.1 Guidelines suggest yearly testing for syphilis for any man who has had sex with another man in the past 12 months.9 This is easily justifiable given the syphilis incidence rate of 0.78 per 100 person years among men in the HIM study, but not necessarily easy to implement because it involves reaching all men who have sex with men, not just those attached to the gay community.1 Screening at every clinic visit for syphilis among HIV-positive homosexually active men may be necessary in view of the higher incidence of syphilis in this group. STI control is most cost effective if programs are focused on core group members who have large numbers of sexual partners. In the syphilis case series, up to two-thirds of the men had attended sex-on-premises venues or saunas where rates of STI infections have been previously reported to be extremely high.1,10 Contact tracing is an essential part of effective STI control but is difficult among men who have sex with men, whose partners are often anonymous. Nevertheless, innovative programs can prove effective. One study found that contact tracing was relatively effective even though the only identifying information available to public health officials were the “screen names” used in internet chat rooms. In this study, 41 of the 97 contacts of men infected with syphilis were traced through their “screen names”.8 Lastly, information about the epidemic, including the typical clinical features, who is affected, and risk factors for infection, is critical to inform intervention, as indeed both Jin et al1 and Guy et al2 have shown. For example, Jin et al provided much needed information about the usual clinical presentation of syphilis, finding that rash was the most common symptom (42%), but an ulcer or sore was also common (40%).1 As the rash of secondary syphilis is extremely infectious, identifying such cases early will significantly improve control. Australia’s response will determine if the current syphilis epidemic is remembered as an isolated epidemic or the return of endemic infection. Endemic syphilis will be expensive; both in human and financial costs, not least because it promotes HIV transmission. We need to learn from Australia’s effective and early response to the HIV epidemic that was characterised by community partnership, bipartisan government support, a commitment to harm minimisation and dynamic, original strategies.

Christopher K Fairley MB BS, PhD, FRACP · Jane S Hocking MPH, MHlthSc, PhD · Nicholas Medland MB BS

Objectives: To describe trends in the notification of infectious syphilis in New South Wales, the characteristics of homosexually active men recently notified with early syphilis, and the seroprevalence and incidence of syphilis, as well as associated risk factors, in a Sydney cohort of HIV-negative homosexually active men.Design, setting and participants: Secondary analysis of New South Wales infectious syphilis surveillance data from 1998 to 2003; a case series of 57 homosexually active men diagnosed with early syphilis in inner Sydney from December 2002 to January 2004; and a prospective cohort study of syphilis among 1333 HIV-negative homosexually active men in Sydney recruited from June 2001 to December 2003.Main outcome measures: Rates of notification of infectious syphilis in New South Wales and in areas of inner Sydney; behavioural and clinical features of men with syphilis in the case series; and incidence of syphilis and hazard ratios (HRs) associated with sexual behaviours in the cohort study.Results: Infectious syphilis notifications in inner Sydney rose more than 10-fold (from 6 in 1999 to 162 in 2003), and the increase was confined to men. Of 57 men with early syphilis in the case series, 54% were HIV-positive and 32% reported no symptoms of syphilis. These 57 men were highly sexually active and likely to report recreational drug use. In the cohort study, 1292 men (97% of participants) consented to syphilis testing; the incidence of syphilis was 0.78 per 100 person-years, and risk factors included reporting unprotected anal intercourse with HIV-positive partners (HR, 5.31; 95% CI, 2.00–184.93) and insertive oral sex (HR, 4.55; 95% CI, 1.14–18.18).Conclusion: Syphilis has been re-established among homosexually active men in Sydney, and HIV-positive men are over-represented. Frequent screening is needed in this population to curb the transmission of both syphilis and HIV.

Fengyi Jin MPH · Garrett P Prestage PhD · John M Kaldor PhD · Andrew E Grulich PhD, FAFPHM · Susan C Kippax PhD · Catherine M Pell MB BS · Basil J Donovan MD, FAChSHM

Rebecca J Guy,* David E Leslie,† Kleete Simpson,‡ Beth Hatch§ Jennie Leydon,¶ Margaret E Hellard,** Heath A Kelly†† * Epidemiologist, ** Head, Centre for Epidemiology and Population Health Research, Macfarlane Burnet Institute for Medical Research and Public Health, GPO Box 2284, Melbourne, VIC 3001; † Microbiologist, ¶ Senior Serologist, †† Head, Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC; ‡ Surveillance Manager, § Partner Notification Officer, Blood Borne Viruses and Sexually Transmissible Infections Program, Department of Human Services, Melbourne, VIC. Rebecca. GuyATburnet.edu.au To the Editor: In Victoria, notifications of infectious syphilis infection (primary, secondary and early latent [< 2 years’ duration]), reported by the Department of Human Services, have increased more than fivefold in the past decade, from 16 in 1995 to 85 in 2004 (Box). An increase in notifications has also been observed in Sydney.1 Whereas previously in Victoria, very few infectious syphilis notifications were reported among men who have sex with men (1 of 16 cases in 1995), in 2004, 63 of a total of 85 cases (74%) were in this group (68% of these were acquired in Victoria). The Victorian Infectious Diseases Reference Laboratory (VIDRL) conducts testing for sexually transmitted infections (STI) and HIV for three Melbourne sexual health clinics with a high proportion of patients who are men who have sex with men. In 2004, 62 male patients tested positive for infectious syphilis, and 40% of these were HIV-positive. This is similar to the situation in Sydney, where in 2003, 54% of infectious syphilis cases were reported among HIV-positive men who have sex with men.1 Syphilis outbreaks among men who have sex with men have been reported elsewhere in recent years. There was an outbreak of syphilis in this group in Greater Manchester; between 1999 and 2002, and 37% of cases were in HIV-positive men.2 In this population, syphilis infection was associated with unprotected oral sex with high numbers of partners, seeking sexual partners at venues (darkrooms, cruising areas and saunas) and use of drugs (GHB [gamma hydroxybutyrate] and poppers [amyl nitrate]).3 A San Fransisco study in 2000, performed in response to a syphilis outbreak among men who have sex with men, reported that meeting sexual partners through use of the Internet was a factor significantly associated with syphilis infection.4 It is likely that some or all of the factors reported in these outbreaks overseas are contributing to the sustained increased in infectious syphilis notifications in Victoria, but it is important to have local data to ensure interventions are targeted appropriately and cost effectively. In Victoria, responses to the increase in syphilis notifications have already included an alert to general practitioners to encourage men who have sex with men to have syphilis testing and individual counselling, and syphilis testing of men who have sex with men at a popular sex-on-premises venue over a 4-week period. Depending on further studies in this population in Victoria, other responses could include enhancing outreach at Internet chat rooms, intensive counselling of HIV-positive men who have sex with men, and education interventions such as peer-led community-based strategies for countering unsafe sex and substance-use behaviours. Finally, it is vital that interventions are multidisciplinary, collaborative and evidence-based. Infectious syphilis notifications by year, Victoria Data from the Notifiable Infectious Diseases Surveillance System Database, Communicable Diseases Section, Victorian Department of Human Services.

Rebecca J Guy · David E Leslie · Kleete Simpson · Beth Hatch · Jennie Leydon · Margaret E Hellard · Heath A Kelly

To the Editor: Lymphogranuloma venereum (LGV) is an uncommon sexually transmitted infection caused by Chlamydia trachomatis serovars L1–3. LGV is not endemic in Australia, and rare Australian cases of LGV have been seen in patients who have either acquired the infection while travelling overseas in an endemic area, or have had local contact with an imported case. Currently, there is an outbreak of LGV in western Europe (in particular, The Netherlands) and the United States.1-4 A case of LGV in an Australian man with no history of overseas travel was managed recently. A 42-year-old bisexual man with previously treated early syphilis and hepatitis C infection presented to a Melbourne hospital in August 2004 complaining of 3 months of tender right inguinal lymphadenopathy. An excisional biopsy showed the formation of necrotising granuloma indicative of LGV. He had no history of penile ulceration, urethritis or proctitis. The surgical wound healed normally. The patient gave a history of attending sex-on-venue premises (“gay saunas”) and “beats”. He reported having oral sex with men, and recently having non-insertive sex involving masturbation with an unknown casual male contact who was apparently an overseas visitor. The patient had a female sexual partner with whom he had irregular, unprotected vaginal intercourse. The diagnosis of LGV was confirmed by polymerase chain reaction (PCR), which detected C. trachomatis, identified as serovar L2 by nucleotide sequencing, from the excised lymph gland. IgG and IgA antibodies to C. trachomatis were demonstrated by enzyme-immunoassay. Tests for other active sexually transmitted infections were negative. The patient was treated with doxycycline (100 mg twice daily for 3 weeks). His asymptomatic female partner was also treated. LGV is endemic in developing countries in our region, but occurs only sporadically in industrialised countries. The first stage of disease consists of a papule or ulcer that may occur on the penis, urethra or cervix. Proctocolitis may also be present, mimicking inflammatory bowel disease. Regional lymphadenopathy develops in the secondary stage of disease when there may be systemic symptoms. Fistula formation at these sites can be prevented by early recognition and treatment. Late, severe genital ulceration is rarely seen. Confirmation of a diagnosis of LGV requires showing C. trachomatis serovars L1–3 by serological tests or PCR on genitourinary specimens. Lymph node resection is not favoured because of the possibility of sinus formation. Prolonged treatment with doxycycline or roxithromycin for 3 weeks is required for affected patients. Asymptomatic contacts are treated with doxycycline for 1 week or a single dose of azithromycin. This case of locally acquired LGV highlights the features of this progressive disease that may now be recognised more frequently in Australian men who have sex with European or North American men. Histological section of the lymph node showing the thickened node capsule and necrotising granuloma Image courtesy of Dr Malcolm Buchanan, Department of Anatomical Pathology, Royal Melbourne Hospital.

Damon P Eisen

We know what to do, but doing it is the challenge In 1992, the late Fred Hollows warned of the catastrophic effects that HIV would have in remote Indigenous communities. His trademark candour caused considerable stir, and a number of important initiatives were implemented, such as the Tri-state HIV/STI Project in Central Australia and the National Indigenous Australians’ Sexual Health Strategy. However, it would be hard to argue that HIV is widely believed to be a priority in Indigenous health 13 years later. Health-seeking behaviour based on the presence of genital symptoms or awareness of risk is limited in many Indigenous communities . . . Until now, the prevalence of HIV in the Indigenous community has been considered similar to that in the non-Indigenous community.1 In this issue of the Journal (page 124), Wright et al present evidence of a higher rate of HIV among Indigenous people in Western Australia than in the non-Indigenous population.2 They report that, while the rate of HIV notifications in the non-Indigenous population declined between 1985 and 2002, it increased in the Indigenous population. The difference in risk for Indigenous women was striking — 39% of all female HIV notifications in WA since 1994 have been for Indigenous women, giving an Indigenous : non-Indigenous age-standardised rate ratio of 18. In contrast, the rate ratio for Indigenous males was 2. Wright et al also confirmed the marked differentials in risk of other sexually transmitted infections (STIs) in the Indigenous population — with Indigenous : non-Indigenous age-standardised rate ratios of 242 for syphilis, 77 for gonorrhoea and 16 for chlamydia. The data in this study are likely to predominantly reflect the situation in rural and remote regions of WA, and the authors acknowledge the difficulties of interpreting surveillance data. Nevertheless, the findings demand attention. Health-seeking behaviour based on the presence of genital symptoms or awareness of risk is limited in many Indigenous communities: the concept of “sexual health” is a construct usually confined to well-resourced urban populations. Few Indigenous children in remote areas complete high school and, as a result, there are few reliable means of informing young people about health risks. Although many Aboriginal Health Services have instituted local programs of distribution, condom use appears to be uncommon,3 and there is anecdotal evidence of an increase in injection drug use in remote areas. In settings of social disruption and dislocation, such as among individuals who congregate on the fringes of major urban areas, sex is often exchanged for favours, alcohol and other substances. Not surprisingly, reinforcement and maintenance of health messages and wide implementation of interventions are difficult to achieve in these settings. It is not entirely clear why the prevalence of HIV has remained low in remote Aboriginal Australia; however, this might be explained by the structure of local sexual networks. In simple terms, the sexual network identifies who is having sex with whom, how often and where. Individuals in a sexual network operate in a social space, not necessarily a geographic space. Because of the sensitivity surrounding this issue, there has been very little published on the complex sociocultural factors that determine the structure of Indigenous sexual networks in remote Australia. It is known that Indigenous people living in remote areas may travel extensively across the country, but are likely to choose partners they already know and who share the same background. This has been termed “assortative” partnering, and has been observed in other populations.4 The absence of HIV from a network protects all its members — it is only when an HIV-infected individual enters the network that transmission occurs. Such individuals may have travelled to large urban areas and contracted HIV through injection drug use or homosexual contact. As a result, a substantial proportion of the members of the sexual network will become infected, although in small communities the absolute numbers will remain low. This implies that control of HIV in the Indigenous population will require multiple small interventions that target individual sexual networks, as well as reflecting the local sociocultural conditions. In the 1990s, the rates of curable STIs (chlamydia, gonorrhoea and trichomoniasis) were found to be many times higher in the Indigenous population in the Northern Territory, compared with the non-Indigenous population. However, the rate of a non-curable, viral STI (human papillomavirus) was higher in the non-Indigenous than in the Indigenous population. This suggested that a major reason for the disparity in rates is the limited access to and use of clinical services in remote areas, rather than differences in average rates of partner change.5 Health professionals who have worked in remote health settings know how hard it is to do more than simply react to the patients who walk through the clinic doors with an acute problem. Maintaining population health programs, such as immunisation, health promotion and risk factor modification, is always difficult in these settings, and these programs are first to suffer when a medical crisis occurs. The opportunity costs of a local HIV epidemic are considerable: HIV does not just affect the individual who is infected — sexual partners are also at risk, and transmission can occur antenatally and during breastfeeding. Ongoing risk behaviour after a diagnosis of HIV is documented, driven by psychiatric and substance abuse-related factors. The medical system is compelled to react to the presence of HIV infection in a particular community. In one remote community, this required an increase in the staff of the local public health unit from three to eight, and other programs fell by the wayside (unpublished data). This migration of resources may be one of the major costs of an HIV epidemic in remote Indigenous Australia. Evidence from Africa suggests that STI control early in an HIV epidemic may be effective in limiting the spread of HIV,6 but this strategy is less useful once the HIV epidemic is established. Good STI control requires a coordinated program that addresses health promotion, diagnostic and screening services, rapid access to appropriate treatment and locally appropriate contact tracing. This is not easy, nor cheap, but it is possible — as seen with a successful program in Central Australia.7 Others have also implemented relatively effective programs.8 Primary care providers can use a new Medicare rebate item (item 710) to screen for STIs in Indigenous people as part of a broader preventive health assessment. The new National Aboriginal and Torres Strait Islander Sexual Health and Blood Borne Virus Strategy, to be announced later in the year, will provide a useful review of existing programs, and recommendations for specific action. HIV testing is central to HIV control: it determines the extent of the epidemic and helps plan local interventions. Antenatal screening and antiviral treatment of an HIV-infected mother can almost eliminate the risk of transmission of HIV to the neonate; appropriately timed therapy has obvious benefits for the individual in terms of morbidity and mortality, and successful treatment reduces the viral load and decreases the risk of transmitting HIV through sexual contact. There is no need to reinvent guidelines for testing in Indigenous settings — they already exist. Sustainable implementation is the challenge that faces primary care providers. The data from Wright et al provide a compelling reason for meeting this challenge now.

Francis J Bowden FRACP, MD

Erectile dysfunction and related disorders. William Alexander, Culley Carson. London: Mosby, 2003 (vi + 152 pp). ISBN 0 7234 3327 5. Understanding of erectile dysfunction has progressively increased over the years due to the development of new treatments. Much of the information available today to medical practitioners is provided by the pharmaceutical industry, particularly when a new product appears on the market. This book provides up-to-date and independent information to any medical practitioner who has an interest in assessing and treating erectile dysfunction. The book’s authors are experienced practitioners in this field and the book itself comes in the neat, pocket-size format usually reserved for emergency handbooks, although it is more likely that it would sit on a desk as a reference. The first chapters, covering anatomy, diagnosis and treatment, would suffice for most doctors’ needs. There are straightforward tables, figures and illustrations supporting the written information. The section on treatment is up-to-date and includes all the current products in the UK market, although not all are available in Australia. I particularly liked the emphasis on the psychological component of erectile dysfunction, a common secondary issue that is often overlooked. Other, more detailed issues, such as ejaculatory disorders and andrology, are well covered and relevant to those with an interest in sexual medicine. The list of resources and web sites is European based. I refer Australian readers to our local resource, Impotence Australia (www.impotenceaustralia.com.au. Phone 1800 800 614). With the increasing recognition of sexual dysfunction as a medical condition, I recommend Erectile dysfunction and related disorders as an excellent publication. Michael P LowyGeneral Practitioner Sydney Centre for Men’s Health Bondi Junction, NSW

Michael P Lowy

A previously well 30-year-old man presented with severe progressive back pain, joint pain and fever. Magnetic resonance imaging confirmed an epidural abscess. A sexual history revealed both risk factors for and previous symptoms of a sexually acquired infection. Neisseria gonorrhoeae was isolated from a rectal swab and from a wrist aspirate, consistent with disseminated gonococcal infection. The epidural abscess resolved clinically and radiologically after treatment for N. gonorrhoeae with ceftriaxone. Localised back pain and fever are important symptoms, which may indicate an epidural abscess or vertebral osteomyelitis. In assessing such a patient, a sexual history is often omitted, but it can provide useful information, as illustrated here. Clinical recordPresentation (Day 0): A 30-year-old man presented to hospital with an 8-day history of progressive severe thoracic back pain and a 5-day history of left knee pain. The back pain had occurred suddenly after lifting weights, and radiated to the right chest wall. Chiropractic manipulation and paracetamol had been unsuccessful in relieving the pain. His family history in relation to rheumatological or inflammatory disorders was unremarkable, and he had never used intravenous drugs. He had no symptoms of fever, conjunctivitis, urethritis, rash, early morning joint stiffness or neurological dysfunction. On initial examination he looked well but had a slightly raised temperature (37.8°C). There was tenderness over the fifth to the seventh thoracic vertebrae, and his left tibiofibular joint was erythematous and warm. Examination of the skin and of musculoskeletal, neurological and genitourinary systems showed no abnormalities. Initial investigations revealed a neutrophil leukocytosis of 9.5 × 109/L (reference range [RR], 1.7–7.0 × 109/L) and raised inflammatory markers: C-reactive protein, 73 mg/L (RR, < 3 mg/L); and erythrocyte sedimentation rate, 47 mm/h (RR, 0–10 mm/h). Test results for haemoglobin concentration, platelet count, serum electrolytes, renal and liver function, rheumatoid factor and antinuclear antibody were within normal limits. Blood cultures were negative. The patient was admitted to hospital after a magnetic resonance imaging scan of the thoracic spine revealed an epidural mass at T6/T7 level (Figure A, B). Day 1: A computed-tomography-guided biopsy of the epidural collection was undertaken. This revealed an acute inflammatory exudate with neutrophils. Cytological examination did not detect malignant cells, and no organisms were seen on Gram stain. The patient’s left wrist became painful, red and swollen, and an infectious diseases consultation was arranged. A sexual history revealed that the patient had experienced mild anal pruritis associated with a white anal discharge 3 months before presentation. This occurred after he had had sexual intercourse with multiple male partners, and it resolved without treatment. Microscopic examination of the fluid aspirated from the wrist joint revealed numerous pus cells and gram-negative diplococci on Gram stain (Figure C). Urethral, rectal and throat swabs were taken. A provisional diagnosis was made of disseminated gonococcal infection with an epidural abscess. Therapy was initiated with ceftriaxone 2 g intravenously twice a day. A single dose of 1 g azithromycin orally was also given to treat possible associated Chlamydia trachomatis infection. Serological tests for sexually transmitted diseases, including syphilis, HIV and hepatitis B virus infection, were negative. The patient’s regular sexual partner was treated with ceftriaxone 250 mg intramuscularly and azithromycin 1 g orally. Further contact tracing was not possible as the identity of other sexual partners was unknown. Day 3: Culture of the wrist aspirate and rectal swabs isolated Neisseria gonorrhoeae that was fully sensitive to ciprofloxacin and ceftriaxone, but resistant to tetracycline and penicillin. The urethral swab, throat swab and the epidural aspirate were sterile. Most of the patient’s symptoms resolved 48 hours after starting ceftriaxone. Course: The patient was discharged from hospital after 7 days and instructed to take oral ciprofloxacin 500 mg twice a day for 4 weeks. At review 1 month later: The patient’s symptoms had completely resolved and a repeat magnetic resonance imaging scan revealed total resolution of the epidural collection. The patient elected to go to his local doctor for follow-up serological testing. DiscussionEpidural abscesses are rare and in most cases are caused by Staphylococcus aureus.1 To our knowledge, this is the first reported case of disseminated gonococcal infection presenting as an epidural abscess. With an increasing incidence of N. gonorrhoeae infection in our community, clinicians need to be aware of the manifestations of disseminated gonococcal infection, and to consider it in the differential diagnosis of inflammatory syndromes in sexually active patients. Disseminated gonococcal infection is an uncommon manifestation of N. gonorrhoeae infection. It most commonly follows asymptomatic mucosal infections and is more common in women (female : male ratio, 3 : 1).2 The reported incidence of disseminated infection ranges from 0.5% to 3% of mucosal infections,3 and its incidence in Australia is increasing (predominantly in men who have sex with men).4 Patients typically present with either a triad of tenosynovitis, dermatitis and polyarthralgia without purulent arthritis, or purulent arthritis without skin lesions.2 These two syndromes are not exclusive and some overlap can occur. The most commonly involved joints are the knee, the elbow, and the joints distal to these. Other reported complications are rare and include osteomyelitis,5 meningitis,6 and overwhelming sepsis.7 The bones typically involved in gonococcal osteomyelitis are those adjacent to the sites of gonococcal arthritis, as the organism spreads through the synovium into the adjacent bone. In our patient, N. gonorrhoeae was isolated from the wrist and rectum, confirming disseminated gonococcal infection, which was temporally associated with an epidural abscess. Although N. gonorrhoeae was not isolated from the site of the abscess, complete symptomatic and radiological resolution followed antimicrobial therapy directed against N. gonorrhoeae. For the investigation of symptoms of localised back pain and fever, magnetic resonance imaging is the investigation of choice.8 Appropriate microbiological sampling is essential to determine the aetiological agent and guide antimicrobial therapy. Our case illustrates the importance of obtaining a sexual history, both for the differential diagnosis and for selecting investigations to perform. The recommended empirical treatment for N. gonorrhoeae infection in Australia is ceftriaxone, as more than 5% of isolates are resistant to penicillin, ciprofloxacin and tetracycline.9 Screening for other sexually transmitted infections, and contact tracing and treatment of sexual partners are important to control epidemics. A: T1-weighted sagittal magnetic resonance imaging scan through the cervical and thoracic spine shows an epidural abscess lying posteriorly to the T6 vertebral body (arrow). B: T1-weighted axial magnetic resonance imaging scan at T6 level shows a poorly defined extradural space-occupying lesion, extending through the right neural exit foramen (arrow) with a small paravertebral component. There was an associated effusion within the facet joint (not shown) and no evidence of bony erosion, destruction or oedema. C: Gram stain of wrist aspirate, revealing numerous polymorphs and gram-negative intra- and extracellular diplococci.

Sebastiaan J van Hal MB ChB(Hons) · Jeffrey J Post MB BS(Hons), FRACP

Donna B Mak,* Graeme H Johnson,† Lewis J Marshall,‡ Jacqueline K Mein§ * Public Health Physician, Department of Health Western Australia, 189 Royal Street, East Perth, WA 6000; † Medical Officer, Derby Aboriginal Health Service, Derby, WA; ‡ Head, Sexual Health Service, Fremantle Hospital, Fremantle, WA; § Public Health Medical Officer, Kimberley Population Health Unit, Broome, WA. makhoATbigpond.com To the Editor: We were pleased to read Chen and Donovan’s editorial which highlighted sex-based inequalities in control of genital chlamydial infection and argued for more screening of men for this infection.1 In the Kimberley region of Western Australia, where rates of genital chlamydial infection are among the highest in Australia, control strategies encompass both sexes.2 Although chlamydial infection was not notifiable in WA until 1993, it has been part of the sexually transmitted infections (STI) control program of the Kimberley Public Health Unit (now the Kimberley Population Health Unit) since the 1980s. Since 1989, regional STI management guidelines have recommended that testing for chlamydial infection (and gonorrhoea, syphilis, hepatitis B and HIV infection) be offered to all patients presenting with STI symptoms or as a sexual contact of an STI patient, and as part of antenatal, prison and well-person’s screenings.3,4 In 1996, empirical treatment for chlamydial infection with single-dose azithromycin (funded by the Kimberley Public Health Unit) was added to the standard treatment regimen, and antibody testing and culture were replaced by nucleic acid testing, which is more transport-robust and sensitive. This led to the introduction in 1997 of active health-service-initiated contact tracing for chlamydial infection (ie, sexual contacts reported by patients with chlamydial infection are actively sought by health staff and offered an STI consultation and empirical treatment). Between 11 June 2001 and 29 June 2002, WA Health Department staff (who contribute over 70% of the region’s STI notifications) notified 94 cases of chlamydial infection in female patients and 56 in male patients.5 Coinfection was common, with 61 patients (41%) also having gonorrhoea and four (3%) also having syphilis. Of the female patients, 30% were tested for chlamydia because they had self-presented with STI symptoms, 32% as part of antenatal or well-person’s screening, 36% because they had been reported as a sexual contact of a patient with STI, and 2% for unknown reasons. The corresponding proportions in male patients were 45%, 7%, 45% and 4%, respectively (Pearson χ2 = 12.6, df = 3; P = 0.006). Prevalence of chlamydial infection in the Kimberley antenatal population (69% of whom are screened for chlamydia) is 3% (95% CI, 2%–6%).6 Prevalence in 93 Kimberley men screened consecutively on admission to prison during 18 weeks in 1998–1999 was also 3% (95% CI, 1%–9%). During this same period, prevalence among 59 Kimberley men and 68 women presenting consecutively as STI contacts was 19% (95% CI, 11%–31%) and 22% (95% CI, 14%–33%), respectively (Mak DB, unpublished data). These data demonstrate that contact tracing contributes significantly to chlamydial case-finding, and support the addition of azithromycin to the Kimberley’s empirical STI treatment regimen. Empirical treatment and contact tracing for gonorrhoea over more than 15 years have been associated with decreases in the rate of gonorrhoea and the male : female ratio of cases in the Kimberley (Box). Seven to 8 years after introducing empirical treatment and contact tracing for chlamydial infection, rates have increased in both sexes, as has the proportion of male notifications (Box). Further progress in control of chlamydial infection requires continued provision of STI screening, treatment and contact-tracing services that are acceptable and accessible to both men and women. Notifications of chlamydial infection and gonorrhoea in the Kimberley region, 1993–2002

Donna B Mak · Graeme H Johnson · Lewis J Marshall · Jacqueline K Mein

Caring for lesbian and gay people: a clinical guide. Allan Peterkin, Cathy Risdon. Toronto: University of Toronto Press, 2003 (xii + 378 pp). ISBN 0 8020 4857 9. One of the unintended consequences of the gay liberation movement of the seventies and beyond has been the myth that lesbians and gays are "bullet-proof". Evelyn Hooker's1 work from the 1950s is often misinterpreted to suggest that lesbians and gays are so mentally and physically robust that the effects of childhood parental disapproval, adolescent social exclusion and a lifetime of discrimination and victimisation just "bounce off". This was meant to leave us just as healthy as members of the advantaged mainstream. The notion of the "pink dollar" — which implies that all gay men (and, to a lesser extent, lesbians), despite widespread discrimination at work, are rich urban professionals with expensive cars — is another facet of this mythology. Peterkin is a psychiatrist and Risdon a family physician (an unfortunate term alienating to many gays and lesbians). They are part of a welcome movement that is dismantling this myth and recognising that lesbian, gay, bisexual and transgendered people, like members of other persecuted groups, may require special consideration in redressing the health consequences of social disadvantage. Their book is clinically practical, well researched and a reliable guidebook for the primary health care practitioner. It is inclusive of the issues of people who are multiply disadvantaged, although it betrays its North American origins in the section focusing specifically on the concerns of gay and lesbian Native Americans. This is only partially applicable to the care of gay Indigenous Australians. Bisexuals might find the book's title exclusive. The authors could also be criticised for uncritically accepting an "identity" view of sexual diversity that ignores the last 20 years of academic writing on "queer theory", and the social construction of homosexuality. Its main purpose, however, is a desktop guide for clinicians, which it does very well. Gary D RogersDirector, Health in Human Diversity Unit Department of General Practice University of Adelaide, SA 1. Dr Evelyn Hooker was an American psychiatrist who published the first empirical research to challenge the then prevailing psychiatric assumption that homosexuality was a mental illness. Her groundbreaking work ultimately led to the removal of "homosexuality" from the Diagnostic and Statistical Manual of Mental Disorders.

Gary D Rogers

Sexuality is intrinsic to a person’s sense of self and can be an intimate form of communication that helps relieve suffering and lessens the threat to personhood in the face of life-limiting illness. Health professionals struggle to accept that people with life-limiting illness, especially older people, continue to be sexual beings. People facing life-limiting illness may appreciate the opportunity to discuss issues of sexuality and intimacy with a trusted health professional. Practical strategies to assist health professionals to communicate effectively about sexuality and intimacy include creating a conducive atmosphere, initiating the topic, using open-ended questions and a non-judgemental approach, and avoiding medical jargon.

Amanda J Hordern BN, MEd · David C Currow MPH, FRACP

Sex remains an important contributor to quality of life in many patients with chronic illness and their partners. The effects of chronic illness on sexuality are multifactorial and can impact on all phases of sexual response. Sexual dysfunction and dissatisfaction in chronically ill patients are underdetected and undertreated because of barriers to doctor–patient discussion about sex and lack of medical training in human sexuality. For doctors to become more motivated to broach the topic of sex, they need to recognise that people may be sexually interested even though they are old, ill or disabled. The PLISSIT model provides a graded counselling approach that allows doctors to deal with sexual issues at their own level of expertise and comfort.

Rosemary A McInnes MB BS, FACSHP

Australia is lagging behind other developed countries in efforts to control chlamydial infection Australian politicians are concerned about the falling fertility rate and are debating measures, such as cash incentives and paid maternity leave, to reverse the “baby bust”.1 If enacted, these measures are expected to cost several hundred million dollars per year — perhaps several thousand dollars per extra baby. Yet, Australia is at high risk of — if not already undergoing — a silent epidemic of preventable infertility and foetal loss through ectopic pregnancy caused by Chlamydia trachomatis infection. This condition can be detected by a $24 test and effectively treated with a single dose of antibiotics. Some commonly held assumptions about chlamydial infection in men need to be addressed. Chlamydial notifications have increased fourfold over the past decade (Box). However, as most infections are asymptomatic, the 26 000 cases reported in 2002 probably represent only a fraction of the true incidence and prevalence.2-4 This trend may be partly due to a reporting artefact or greater numbers or sensitivity of tests.5 Yet, if these factors were the complete explanation, the graph of notifications should have plateaued long ago. The passage of time and enhanced surveillance data6,7 indicate that most of the increase is real. The proposed National Sexual Health Strategy was shelved before the last federal election, and state-initiated Chlamydia programs designed to enhance case-finding through selective testing by general practitioners (and, therefore, Medicare) were discouraged. Australia is overdue to follow the lead of other developed nations by getting serious about controlling chlamydial infection.8 Because infected women are usually asymptomatic, and because they incur the bulk of the serious morbidity, Chlamydia programs have traditionally focused on screening women.9 Selective testing criteria for women include combinations of age under 25 years, reported change of sexual partner, non-use of condoms, unintended pregnancy, and an inflammatory Pap smear result. However, this testing is only secondary prevention — some women identified in this way will already have silent damage to their fallopian tubes and their fertility. True primary prevention mandates that women never acquire chlamydial infection. As there is no vaccine, this means avoiding infection either by behavioural means (use of condoms, non-penetrative sexual practices or sexual abstinence) or by having male partners who are not infected. In this light, some commonly held assumptions about chlamydial infection in men need to be addressed. The first is that men are less likely to be infected than women. Recent population-based surveys in Scandinavia, the United Kingdom and the United States have consistently shown similar chlamydial prevalences among heterosexual men and women.3,4,10 Higher notification rates for women (Box) probably reflect more testing of women than men.7,11,12 Longer duration of infection in women could also be part of the explanation, although how long untreated chlamydial infection can persist in either sex remains uncertain.13 Another apocryphal belief is that the bulk of men with chlamydial infection present for treatment, driven by genital symptoms.9 However, studies in the community have revealed that most men with urethral chlamydial infection, like women, are symptom-free3,4,10 — perhaps as many as three-quarters10 — and that asymptomatic men are less likely than asymptomatic women to present for testing.10 Although there are few data on the duration of chlamydial infection in men,13 it may be months or years. A better understanding of the duration of infection would enhance our ability to model potential interventions. Sweden has a long and much-acclaimed history of screening women for chlamydial infection. This has reduced the prevalence of chlamydial infection and the incidences of both pelvic inflammatory disease and ectopic pregnancy. However, these successes have begun to reverse recently, with the suggestion that Sweden’s failure to test men is a significant reason.8 Since the advent of urine tests for chlamydia, screening men has become feasible and potentially cost effective (using US parameters).12 Without this screening, the success possible with interventions aimed exclusively at women may be limited.8 To determine whether screening of men is justified, more population-based research is required on chlamydial infection in Australian men. The prevalence of infection in different subpopulations would help determine where future screening initiatives are most needed and provide a baseline for evaluating control measures. Factors associated with infection should be identified and assessed as criteria for selective screening. Studies on the natural history of infection and the cost-effectiveness of interventions would also be of global interest. While definitive screening guidelines cannot be promulgated without such data, clinicians could be remiss if a urine test for C. trachomatis was not part of the routine assessment of a young man who reports unprotected sex with a new sexual partner (female or male), regardless of symptoms. More generally, we should be asking what other factors are contributing to the re-emergence of chlamydial and other sexually transmissible infections in Australia. We also need to debate whether single-sex health models can sometimes ultimately harm women. Most women live in an environment that is also populated by men. Chlamydia trachomatis notifications in Australia Source: National Centre in HIV Epidemiology and Clinical Research (http://www.med.unsw.edu.au/nchecr/)

Marcus Y Chen MRCP, DTM · Basil Donovan MD, FACSHP

The sexual health needs of teenagers differ from those of adults. Young sexually active teenagers are at high risk of Chlamydia trachomatis genital infection and its complications. Teenage pregnancy continues to be a problem in Australia. Current preventive strategies and clinical services in this domain of adolescent health in Australia are deficient. Australia can learn from the innovative and effective strategies developed in various countries for preventing high-risk sexual behaviours in teenagers.

S Rachel Skinner MB BS, PhD, FRACP · Martha Hickey MRCOG, FRANZCOG, MD