Dyspareunia - understanding sexual pain

Lynda Carlyle

This is an important component of the sexual health work done at the Townsville Sexual Health Unit - unlike other sexual health services there is not many others that have the capacity, capability or willingness to talk about sexual function, pain and good sex with their clients.  Townsville works within a sexual 'health' model - a wellness model - and therefore having an enjoyable sex life is just as important as ensuring that the client is disease free.

Dyspareunia is a major issue with many women (and men) and the 'pyscho-sexual' issues can be overwhelming for some people who suffer pain with sex.  Learning how to help people with sex pain isvital for sexual health practitioners - there are no sex therapists  in the regional and remote areas (generally) - there are none that I know of in Townsville.  It was therefore really important for sexual health clinicians to  learn from the 4 speakers and the chair of this session on Wednesday (8th Nov).

one area that struck a cord with me was the model of bad sex  and how it can be reversed.  Many clients have sex out of 'duty' which leads to anxiety, tension, lack of arousal and painful sex.  As a clinician giving the client 'permission' to say no to sex for a time frame where some pain relief strategies can be in place or developed with the client and their partner was really important.  Many clients may not

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Associate Professor David Whiley, Principle Research Fellow, Pathology QLD and the University of QLD, Australia looked at the different Neisseria Gonorrhoeae (NG) genotypes within NSW and in particular the genotypes associated with MSM and the heterosexual community.  David’s team collected samples over a period of time and applied NG genotyping and whole genome sequencing to the NG isolates, using MassARRAY iPLEX technology. Amongst many interesting findings the majority of isolates collected from female patients of all ages belonged to 1-5 clusters.

Having an understanding of the NG genotypes is fascinating, especially in the face of antibiotic resistance. Following on from Davids presentation, Dr. Eric Chow, senior research fellow, Melbourne Sexual Health Centre, VIC, Australia then presented an interesting session on Risk Factors for NG in heterosexuals. As it stands NG is the second most prevalent STI, which has been attracting a lot of media attention due to the first line antibiotic resistant strains.

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Dr. Chow looked at a number of risk factors associated with the increase. The risk factors included condom use, dating apps, bisexual sex, alcohol use and international travel. Increased International travel seemed to be the most feasible risk associated with the increase. The take home message from this; always ask clients about overseas travel and to educate them on safe sex abroad. 

The trainees presentations were a highlight of the conference for me - some fascinating cases, presented superbly with an audience including some great HIV clinicians made for a stimulating and highly educational session. It would have been easy to continue the discussion on any of these cases for a good few more hours. 

The first case, from the Alfred Hospital was of a young man recently arrived in Australia who presented with a rash and pulmonary infiltrates. The rash was eventually found to be histoplasma - an important diagnosis to consider, although much more common in other parts of the world, locally acquired cases have been reported.

The next case, from Perth, was of another visitor, this time from Zimbabwe, who was diagnosed with HIV after presenting with sinus pain. Investigations found haemophagocytic lymphohistiocytosis, and she was diagnosed with orbital NK/T cell lymphoma. Due to her status as a visitor, there were issues associated with payment. Whilst her HIV care was paid for as an STI according to a state government undertaking, therapy for the cancer proved an entirely different matter. She was given second line therapy in order to contain costs. On her return to Zimbabwe, again HIV treatment was easily available, however the treatment of the cancer was again not possible and she died 3 months after her return.

A case of gummatous tertiary syphilis, presenting as lesions on the back and arm was presented from inner city Sydney. Again, advanced HIV, known this time for a number of years but untreated, was present, however in this case, syphilis had also been diagnosed on numerous occasions over recent years but remained only partially treated. The case presented numerous issues including diagnosis and management of tertiary syphilis, the difficulties in managing patients with psychiatric comorbidities as well as complex social circumstances and itinerancy. This was a sobering reminder of the difficulties that are faced in clinical practise, and the presentation ended with the case being unresolved (patient absconded with partial syphilis treatment and having not picked up ongoing HIV medication scripts).

Finally, from the Royal Melbourne Hospital, another late presenting individual with advanced immunosuppression, newly diagnosed with HIV and started on treatment, presented to hospital with cryptococcal meningitis, and, despite treatment, deteriorated with multiorgan failure and decreased conscious state in ICU. Fortunately, he recovered to be discharged well form hospital a number of weeks later. The analysis focused on the reasons behind the deterioration in health after treatment commencement, with the most likely explanation believed to be unmasking cryptococcal IRS. An important question about whether rates of IRS are increased on INSTi was raised, with George Behrens- guest from Germany and one of the judges of the session, announcing an impending clinical trial in severely immunocompromised new presenters starting on treatment , comparing rates of IRS on treatment with PIs compared with integrase inhibitors.

In addition to the medical complexities of the cases, common themes including late presentation, still a not infrequent problem, and the difficulties in management associated with challenging socio-demographic circumstances, including itinerancy, psycho-social issues, and medicare -eligibility. 

Plenty to think about.

Day 2: Afternoon Session Joint Symposium

Chaired by Teddy Cook and Ange Davidson.

So I'm going to be jotting ideas and themes as I go, paraphrasing.

Trans populations are and are becoming more so a at risk population in multiple areas, including violence, socioeconomic disadvantage, but also within HIV and sexual Health.

Teddy goes to say that despite your personal thoughts towards trans and gender diverse people, today is about your clinical practice, and this is what counts. "Lets consider this a call to action" "Because we need you. We have been erased over the last 30 years. We are not considered as a priority population in any state and except for the most recent statement".

The capture of data using sex, gender or identity is has been holding back ability to identify and treat. This has become so that people consider rates of trans and gender diverse people within risk populations to be low. This is false and unless people identify or area identified within data, we cannot make decisions on providing services to this population.

Furthermore, within the grouping MSM, trans men or trans masculine have been forgotten and erased.

Trans and gender diverse (GD) people area a VERY diverse group. Some define themselves within a multitude of different ways, a handful of examples being Trans, non--binary, brother-boys and sister-girls, queer... I could go on.

Trans men are men, and trans women are women. I would qualify this statement however trans and GD people do have some particular needs met (such as identifying that trans men may still need pap tests or trans women will need to consider prostate checks as they age).

Teddy asks, Will you stand with us to stand with us to move toward meaningful steps towards trans inclusion and recognition in this area of clinical care?

Panel Members (apologies if I don't go into everyone's CV's, believe me they've an interest and investment in this area).

Ange Davidson is a Sexual Health Nurse at Gateway in Wodonga, Victoria

Mish Pony, Gender Diverse and Trans sex worker representative for Scarlett Alliance, Australian Sex Worker Association

Dr Ayden Scheim, Global Public Health at University of California

Lisa O'Brien, Sistergirls and Brotherboys Australia, NSW

Jeremy Wiggins, Victorian Aids Council, EQUINOX Clinic, Vistoria

Dr Stuart Aitken, Sexual Health Physician, Gold Coast, Qld.

Dr Vincent Cornelisse Sexual Health Physician, HIV, PrEP and Transgender medicine, Melbourne SH Centre

Q: What does trans and GD inclusive clinical care look like to you?

The underlying theme here is that currently, in Australia, trans and GD people have fragmented care. Multiple panelists recognised this and that integration within primary care is needed to provide holistic care to this population.

Specific healthcare needs such as ARV treatments may be attended by GP's with experience and knowledge in this area, much in the same way as hormone therapy for trans people. The specific need to see an endocrinologist is not always necessary and some panelists make reference to "gatekeeping" within the medical profession, where patients require clinicians approval and guidance in this area, which may not always be the case.

Another theme that arose was the lack of experienced clinicians in rural or remote areas, even in cities outside the East Coast, meaning that people seeking medical transition (ie. hormone therapy) will need to travel for these healthcare needs, often away from their families and communities. In particular this is raised as a potential issue with Aboriginal or Torres Straight Islander people away from their mob, moving to larger centres or cities and the increased risk of socioeconomic disadvantage when moving to areas of higher cost, less support and increased isolation.

Another point made by the panelists is that there is significant difference from state to state (or territory) in regards to models of care, legality, requirements in particular to gender marker recognition. Informed consent is a healthcare model that removes particular onus from clinicians and allows trans and GD people to engage in their own healthcare and needs. It is not always necessary that someone be deemed "Trans" by a psychiatrist or psychologist before being allowed to commence on hormone therapy.

One great quote was "We don't send gay people off for sexuality assessments anymore, why should we do so for trans people?".

Q: Trans-specific healthcare is not specific healthcare, it is general, simple healthcare. How does this play out in your practice?

One panelist referred to their own practice and the normalisation of providing care to trans and GD people is paramount, that many of the clients they see have grown up in a society and culture hostile towards them and historically a medical model pathologising them. From a social justice point of view, one panelist made the statement that workings with trans and GD people was "very clinically satisfying" for these reasons, helping people through providing comprehensive general practice care.

One idea that was brought forward, that the concept of Evidence based practice is particularly binding to us as clinicians. Not all areas are so bound to the requirement that we must have hard available evidence in studies before we change practice. This in my opinion is an interesting concept, as on one hand I agree that we must be guided by scientific methodology that has been proven to be what makes "best practice" however the thought from the panelist(s) that we should strive to be more open to other forms of practice whilst evidence and studies are conducted in this area.

Q: In regards to HIV and Sexual Health care, where does this place trans and GD people?

Not all panelists agree that TGD people should be a priority population for HIV! Controversy!

One panel member refers to data showing that approximately half tans women in the last 12 months were not sexually active. Although limited accurate data exists, there is evidence that trans and GD people are both at higher risk and not at higher risk of HIV.

The panel then discussed how appropriate training for care of trans or GD people can and should be implemented. A general concensus that training should commence early in the career, preferably at university, to explain the basics of transgender and GD persons and their healthcare needs. There is experience within the trans and GD community that when meeting a practitioner who has a gap in experience or knowledge that they then need to themselves educate the practitioner in "trans 101" type information and this is not seen as ideal, particularly when a client themselves is not in a position to do so.

Final Thoughts, in no particular order.

- Training to include trans and GD issues, particularly for specialists

- Changes to data collection to include trans and GD persons

- Trans healthcare is simply healthcare. It should not be only for Psychiatrists or Sexual Health practitioners.\

- Increase in culturally appropriate healthcare for trans and GD persons

- Opportunity for trans and GD inclusive programs for Sexual Health and HIV medicine.

- That systems can and should change to adapt to new models of care (for screening, SH and HIV care and general healthcare for trans and GD persons).

As the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) draws to a close I am reinvigorated and ready to implement changes in my own practice.

I was privileged to visit a local health facility and impressed by their ability to treat so many with limited resources. 

Despite the differences, there are many similarities in the emerging health needs of PLHIV and hepatitis C.

• Ageing populations calls for teams of primary healthcare workers.
• Hep C treatments are rapidly expanding across the Asia Pacific but barriers remain. Primary care seen as important in delivery of treatment in Australia.
• Hep C testing and treatment needed in communities with access to at risk populations.
• PrEP is emerging as the preventative health priority. Innovative approaches being used.
• Stigma and discrimination remains a barrier to access to care.
• Dual therapy ART looking more likely to be effective than not.
• Long acting ART development continues.
• Multiple new DAAs for hepatitis C on the horizon.

I have just finished an APACC promotional video and can recommend this conference to my Australian colleagues for next year.