During the 1914–18 World War there was an alarming increase in legally defined venereal diseases (VDs): syphilis, gonorrhoea, and chancroid. A Royal Commission produced the Venereal Disease Regulations (1916), specifying that local authorities should provide clinics which:
• could be accessed directly (without general practitioner referral)
• enabled voluntary attendance
One-hundred-and-thirteen clinics were established in 1917.
During the 1939–45 World War there was a concern that troops were being incapacitated by infection, with a core group of individuals acting as a reservoir. Therefore, doctors began to question patients about their sexual partners. An individual named by more than one person could be compelled to have treatment; failure to comply could lead to imprisonment (Defence of the Realm Act 33B 1942). This regulation was subsequently repealed in 1947, but led to the introduction of voluntary partner notification (PN) in the uk, a vital tool in the control of infection.
In the uk, there are now over 260 clinics led by consultants specializing in GUM, covering a wide range of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) and other genitourinary conditions or problems. Their name has evolved from ‘VD Clinic’, ‘Special Clinic’, or ‘Sexually Transmitted Diseases Clinic’ to ‘Genitourinary Medicine Clinic’, ‘Sexual Health Clinic’, or an eponymous name, and many are integrated with sexual and reproductive health (SRH) services, previously known as contraception, family planning, or contraception and sexual health services.
STIs and genitourinary conditions present in a variety of guises to different specialties (e.g. dermatology, gynaecology, urology, and infectious diseases). Therefore, cross-referral is common and allows for the establishment of multidisciplinary clinics, e.g. for vulval disorders.
The National Strategy for Sexual Health and HIV (2001) identified wide-ranging differences in the provision of sexual health services throughout England. Concerns that such inequalities might adversely affect the government’s attempts to 
the number of teenage pregnancies and rates of STIs resulted in the concept of ISH services. GUM and SRH services, which in the past have traditionally operated as separate entities, are now working closely together to provide high-quality easily accessible ISH services for all.
Robust joint training initiatives for both medical and nursing staff have resulted in dual-trained clinicians able to deal with all aspects of routine sexual health care. Specialist clinicians deal with complex STIs and contraception, medical gynaecology, psychosexual problems, erectile dysfunction and HIV care and treatment. Patients now have the opportunity to self-refer for termination of pregnancy (TOP) and information about this service must be made readily available to attendees.
The continued 
in infections and unwanted pregnancies may be addressed by the provision of high-quality easily understandable health promotion together with the opportunity to undergo testing in alternative locations. Point-of-care testing allows immediate results and undoubtedly encourages those who may not otherwise attend conventional sexual health services to be screened.
The ultimate goal of GUM and ISH is to STIs within the community. This is achievable by delivering accessible and non-judgmental services, which provide free and immediate diagnosis and treatment to those who think they may have, or be at risk of having, an STI. Epidemiological control of infection remains essential to the sexual welfare of the community. However, clinics must reconcile confidentiality with a need for both 1° care and hospital services to be aware of serious chronic health problems in the individual. Health advice with good community links is important for ensuring that PN issues are dealt with efficiently and sensitively, reducing the continued transmission of STIs.
Comprehensive national surveillance programmes are essential when formulating strategies for national screening and treatment policies. Surveillance data inform clinical practice, allow the planning and allocation of resources, and help identify at-risk populations. This is largely achieved by the collection of reliable data from GUM/ISH clinics, as information on infection managed elsewhere, including 1° care, is limited.
The core function of GUM is to provide screening, surveillance, diagnosis, treatment, and PN for STIs including HIV. This is combined with sexual health promotion, teaching, training, and research.
In addition some services provide specialized clinics at their main location or at outreach venues (e.g. prisons). These are established and resourced to meet local need and may include sessions for:
• chronic or recurrent conditions, e.g. HIV, warts, herpes
• problems involving different specialties, e.g. vulval conditions, sexual assault (providing both forensic examination and infection screening), one-stop sexual health service
• related problems where service need is identified, e.g. psychosexual and sexual dysfunction
• special groups, e.g. young people; lesbian, gay, bisexual, or transgender people; ethnic minorities; commercial sex workers.
GUM/ISH is a consultant-led service with a dedicated higher medical training programme for specialty registrars from specialty training years 3–6 (ST3–ST6). There are also training posts at the more junior levels of foundation year 2, and general practice specialty training years 1 or 2. Many non-consultant career-grade doctors, who are known as associate specialists or specialty doctors, are working either exclusively in GUM, ISH, or in association with SRH, 1° care, etc.
The role of the nurse within GUM/ISH has continued to evolve, with specialist (and consultant) nurses now the norm. Nurse-led clinics run alongside conventional medically led services, with nursing staff working independently, taking responsibility for total patient care, including the examination of new patients under protocol and providing medication through patient group directions. No uniform model of care exists; individual centres implement their own preferred methods.
In the UK, HAs are employed within GUM/ISH services. Their primary public health role is PN, which is the identification and management of partners who may have been exposed to STI(s). Their role also includes work at community and population levels, identifying local sexual health needs and ensuring that services are accessible to those with the greatest need by effective targeting and the development of innovative practice approaches. They act as advocates for health gain and work collaboratively with others to tackle the wider determinants of health (Box 1.1).
Box 1.1 Role of HAs (varies between clinics)
• Providing a holistic approach to patients, with information, education, treatment, and support.
• Comprehensive needs assessment of index patients (IPs) and other vulnerable groups (e.g. young people, ethnic minorities, those sexually assaulted), including associated social, emotional, or sexual difficulties.
• Effective PN ensuring the attendance and treatment of sexual contacts, including settings outside GUM/ISH, e.g. 1° care.
• Establishing and maintaining care pathways for patients in primary/acute care diagnosed with STIs.
• Pre- and post-test HIV discussion.
• Counselling, information, and support to patients, including those with HIV infection and their partners, friends, and relatives.
• Sexual health education provision within GUM/ISH and the community, liaising with statutory and voluntary services.
• Research, audit, and service development.
• Support of clinical outreach in non-clinical settings to targeted groups, e.g. increasing the uptake of HIV testing in those most at risk, hepatitis B vaccination for men who have sex with men, STI screening for sex workers.
• Tackling the stigma and discrimination and prejudice often associated with sexual health.
• Helping people make informed decisions about relationships, sex, and sexual health.
• Preventive interventions that build personal resilience and self-esteem and promote healthy choices.
The majority of patients seen in GUM or ISH, either self-refer or are seen as a result of PN. 2° referrals are seen, especially from 1° care, SRH, and rape crisis organizations, with tertiary referrals from gynaecology, dermatology, infectious diseases, urology, etc. These may be formal, with a letter, or based on verbal advice. By common acceptance, there is no correspondence unless the patient has been referred by letter. However, in certain situations, it may be in the patient’s best interests for there to be an exchange of medical information between professionals providing care, but this should have the patient’s agreement.
Easy and timely access to the clinic should be available. When the clinic is closed, a pre-recorded telephone message detailing clinic opening hours, together with the telephone number for other local GUM/ISH services, Accident and Emergency, or NHS Direct is of benefit to anyone with an urgent problem. Appointment availability should be linked to staff numbers and experience. Ideally, patients should be seen within 48 hours. However, testing too soon after an infection risk may produce false-negative results (e.g. 2 weeks for chlamydia); therefore, this period should be extended (unless prophylactic treatment is required), or clear information should be given to patients regarding this possibility and re-testing at the appropriate time offered. If this is not possible, careful use of triage may help identify those with urgent problems.
All services should review their location and opening hours to match the needs of the local population. Some clinics provide open access without prior booking, although most utilize some form of appointment system.
In clinics operating by an appointment system, a robust triage system should be available for urgent situations. Trained staff should be able to assess and prioritize the patient’s condition, including advice on optimum screening time intervals following an infection risk, and then arrange the appropriate attendance. Use of digital technology for triaging and some aspects of clinical consultation with home testing or self-testing is a recent development. Some services have introduced these to address the increasing demands for the services; further developments could see wider application of such new technology.
Any assistance required by the disabled should be highlighted when making an appointment, but accessibility facilities, such as wheelchair access, disabled toilets, minicom systems, etc., should be in place.
Most hospitals are able to provide an accredited interpreting service, but will need time to arrange an interpreter of the appropriate language. Alternatively, a telephone system can be used (e.g. Language Line). If possible, avoid family members, friends, or relatives acting as interpreters, as information may be withheld by the patient under these circumstances.
Patients should be allowed privacy during registration by ensuring that they cannot be overheard while providing information, or by the use of self-completed registration forms or digital interface. Help must be available to those with difficulties in completing such forms or digital portals. The amount of information required at registration will differ from clinic to clinic. However, collection of the data shown in Table 1.1 may assist the clinic to contact the patient if required and help with service planning, statistics, and surveillance.
Table 1.1 Useful information for registration
| Name | Nationality |
| Address | Country of birth |
| Date of birth | Ethnicity |
| Telephone number(s) | Area of residence |
| General practitioner | Referral source and documentation |
| Employment status | Name of partner (if attending) |
Patients who refuse to give any information about themselves may attend. The right to anonymity is accepted within GUM/ISH. The patient should be issued with an individual clinic identification (ID) number, which should be used on all specimens and request forms. They should be encouraged to provide at least their date of birth, which can be used with the ID number as an additional reference when confirming identity, test results, etc.
Appointment cards showing the patient’s ID number and all booked appointments should be issued at the time of registration. Details of the clinic opening times and telephone numbers should be clearly printed on the card. These administrative processes can be digitized, and some services have already introduced digital systems as the main or an additional option.
Waiting areas are inevitably areas of stress for those wishing to remain anonymous. Issuing patients with a welcome leaflet on arrival explaining how the clinic operates will hopefully anxiety. Those who are acutely distressed should be moved into a private area. The use of a television or music system in the waiting room may help to distract the anxious patient and also reduce the risk of sensitive information being overheard.
Soundex codes (Table 1.2), together with dates of birth, are commonly used within GUM/ISH to provide clinical information, while protecting individual confidentiality.
Table 1.2 The Soundex code
|
The Soundex code contains four characters, with the first being the first letter of the surname. The remaining three are numbers derived from the name. When the adjacent letters are from the same category, the second is disregarded. The letters A, E, H, I, O, U, Y, and W only contribute if they start the name. An empty space is represented by a zero. Once the four-character limit has been reached, all remaining letters are redundant. |
|
| Category | Letter |
| 1 | B, P, F, V |
| 2 | C, S, K, G, J, Q, X, Z |
| 3 | D, T |
| 4 | L |
| 5 | M, N |
| No code | A, E, H, I, O, U, Y, W |
Letters confirming attendance for a clinic or hospital appointment should be made available for the patient to present to their employer using hospital-headed notepaper without reference to GUM/ISH. This letter should state the date and time of the visit together with the date and time of any further appointments.
Patients attending GUM/ISH clinics may reclaim their travel expenses upon receipt of bus/train tickets if the distance travelled is >15 miles from home. Legislation is unclear about those who travel less than this distance. Therefore, it is suggested that discretion be used in such cases. This facility is offered to patients irrespective of individual financial circumstances (Department of Health NHS Charges HC11 2002).
Patients leaving the area can be issued with a summary of investigations and treatments carried out while attending the initial clinic. This allows subsequent clinics to assess the need for further management.
Various systems are employed throughout the country to provide test results and include:
• returning in person or telephoning for all results
• contact by the clinic (letter, phone, text message, e-mail, secure online portal).
Informing patients that if they are not contacted the results are –ve or normal (‘no news is good news’) is considered poor practice. Some patients, including those working in the sex industry, may request written proof of the test result. When provided, it must be made clear that this may not cover recently acquired infections (e.g. within ‘window’ periods). Patients must produce a photographic identification before issue of such results.
A digital system aids the process of recall. Patients are generally reviewed for the following reasons:
• to be given positive test results and treatment
• further management (e.g. ongoing treatment, PN).
Recall usually takes the form of a letter requesting that the patient contacts the clinic, but may also be by telephone, e-mail, or text-messaging.
PN (see Table 1.3) is the process of contacting the sexual partners of an individual with a STI, including HIV, to advise them of their exposure to infection, and encourage them to attend for counselling, testing, treatment, and other prevention measures. PN is an essential component of STI management and control, protecting patients from re-infection, partners from long-term consequences from untreated infection, and the wider community from onward transmission. First introduced as ‘contact tracing’ in the 1940s in the UK, to identify, diagnose, and treat contacts of VDs, PN now applies to all sexually transmitted infections as an essential part of infection control. Guidelines produced by the World Health Organization endorse PN as an essential component of prevention and control of STIs. In the UK, PN is undertaken primarily by HAs, employed within GUM/ISH services. The guidance document, Sexual Health Advising – Developing the Workforce (DoH/SSHA/Unite 2008) recommends a robust programme to prepare the future HA workforce and to strengthen the public health role of HAs. This was an aim of the National Strategy for Sexual Health and HIV (DH 2001).
Table 1.3 Partner notification
| Infection | PN method | Trace period s = symptomatic as = asymptomatic |
|
| Patient | Provider | ||
| Cervicitis (mucopurulent), PID, epididymitis | ✓ | ✓ | Current sexual partners |
| Chancroid | ✓ | ✓ | 10 days from disease onset |
| Chlamydia | ✓ | ✓ | 4 weeks (s), 6 months (as), or last partner if longer |
| Donovanosis | ✓ | ✓ | 40 days from disease onset |
| Gonorrhoea | ✓ | ✓ | 2 week (s) males, 12 weeks (as) males, and all females or last partner if longer |
| Hepatitis A | ✓ | ✓ | 2 weeks prior to and 1 week after onset of jaundice |
| Hepatitis B | ✓ | ✓ | 2 weeks prior to onset of jaundice or based on risk |
| Hepatitis C | ✓ | ✓ | Based on risk assessment |
| Anogenital herpes | × | × | Offer advice and STI screening |
| HIV | ✓ | ✓ | Risk assessment informs PN for as cases (If 1o infection—3 months) |
| Lymphogranuloma venereum | ✓ | ✓ | 30 days from disease onset |
| Non-gonococcal urethritis | ✓ | ✓ | 4 weeks (s), 6 months (as), or last partner if longer |
| Pediculosis | ✓ | × | 12 weeks: current partner |
| Scabies | ✓ | ✓ | 8 weeks: current partner, household members |
| Syphilis (early) | ✓ | ✓ | 12 weeks (1°), up to 2 years (2o, early latent) |
| Syphilis (late) | ✓ | ✓ | 10 years; vertical transmission possible for a decade post-infection; therefore, includes children born to infected mothers |
| Trichomoniasis | ✓ | × | Current partner |
| Anogenital warts/molluscum | × | × | Offer to screen current partners |
The ultimate aim is to break the chain and transmission of STIs and rates of infection by:
• Stressing the importance of PN to those diagnosed with certain STIs.
• Providing them with information on the nature, exposure, and risk of infection. The need to have sexual partners appropriately managed before sexual intercourse resumes must be emphasized.
• Identifying, contacting, and screening sexual partners of the IP, providing information and offering treatment if appropriate.
PN should be conducted so that all information remains confidential and the process is voluntary. Consultation with the HA should take place in an appropriate soundproofed environment, free from interruption.
• Patient referral: IP with an STI is encouraged to notify their sexual partner(s) of any infection risk. HAs can help the IP to decide what information should be passed on to partners and how best to do this. The process is facilitated by the issue of contact slips bearing the IP ID number, name of infection (usually in a coded form), and details of the issuing clinic. Use of digital technology for PN is a recent development.
• Provider referral: these are offered to those IPs who do not wish to inform their sexual partner(s) themselves. The IP provides partner details to the HA after reassurance that confidentiality will not be compromised. HAs make direct contact with at-risk sexual partner(s) based on information provided by the IP. Evidence demonstrates that provider referral is more effective than partner referral.
• Contract referral: this allows the IP and HA to negotiate an acceptable time span in which the IP will attempt to contact sexual partner(s). If unsuccessful, provider referral may follow by agreement.
• No referral: where PN is impractical (involves careful risk–benefit analysis), e.g. when there is insufficient information or a threat of violence to the IP or HA.
While partner notification remains a voluntary activity within the UK, countries such as Sweden and certain states of the usa have made it a legal requirement.
Sexual health promotion is an activity that proactively and positively supports the sexual and emotional health and well-being of individuals, groups, communities, and the wider public, and reduces the risk of HIV transmission. The key aim is to inequalities in sexual health.
• Transmission of HIV and STIs (advice on safe sex)
• prevalence of undiagnosed HIV and STIs by encouraging testing
• education to bring about stigma of STIs and HIV.
Objectives include raising awareness, education and provision of information, and service-provider development.
These should be carefully chosen to match the needs of the target group. They can be divided into direct and indirect methods.
• National and local media health campaigns to public awareness.
• Individual one-to-one work in a sexual health setting (HAs, nurse specialists).
• Condom distribution, e.g. in youth clinics, GUM/ISH/SRH clinics and primary care.
• Screening for STIs and HIV in a variety of easily accessible settings.
• Promoting self-care, e.g. over-the-counter emergency contraception, pregnancy testing, advice on testicular self-examination.
• Targeted community work, particularly with marginalized and vulnerable groups (outreach, street, and group work).
• Dissemination of information via digital media or using materials such as leaflets, posters, and magazines which also inform clients about local sexual health services.
• Sex and relationship education in formal and informal educational settings.
• Training courses and workshops for those involved in sexual health work. Digital media can be used to support these.
• Conferences where research and best practice can be shared.
• Development of policies and strategies, including local needs assessment.
• Inter-agency working, especially within the voluntary and community sector (e.g. Terrence Higgins Trust).
• Support and advice to groups developing sexual health services.
• Discussion with health commissioners to enable funding and provision of services.
Can be widespread in diverse settings by trained staff from different disciplines, including:
• Further education, training colleges, and universities.
• Pubs, clubs, and recreational settings (e.g. gyms), including poster and leaflet displays, condom machines in toilets, etc.
• Residential care: for people with disabilities or learning difficulties, older adults, hostels for people seeking asylum, refuge from abuse, and people lacking permanent accommodation.
• Prison and young offenders’ institutions.
• Drug and alcohol services: needle exchanges and methadone clinics.
• Sex venues, such as saunas and cruising areas.
• Community centres, including youth clubs and faith groups.
• Workplaces, including armed services (barracks, etc.), pharmacies, NHS.
• Clinic settings: GUM/ISH, 1° care, SRH, TOP clinics.
Accurate information should be provided that is clear, easily accessible, and up to date. It should be offered in a non-judgemental way, be sensitive and respectful to the diversity of individual and community beliefs and attitudes. Misconceptions should be challenged, and stigma and prejudice should be actively discouraged. This information should empower individuals to make responsible decisions about their sexual health. Information should be evidence based. Discussion should be encouraged to explore ideas, thoughts, and feelings. Support should be available to all, but particularly those who are vulnerable and marginalized.