In this issue
=============


## Complications of gender reassignment surgery may present in the sexual health clinic

Male-to-female transsexuals (trans women) often undergo vaginoplasty, either alone or as part of gender reassignment surgery. As only three centres perform this in the UK, patients may live far from the centre where their surgery was performed, and may present to local sexual health clinics with complications. Suchak and colleagues describe the management of four such cases, stressing that confidentiality and a holistic approach are especially important for this group. ***See [page 245](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-101091)***

## Ethnic minority women decline cervical screening because they underestimate their risk

Attracting ethnic minority women to attend for cervical screening can be challenging. Using in-depth interviews Marlow *et al.* show that emotional barriers such as shame, fear of cancer, and the interactions they have with health professionals may stand in the way of screening uptake. But in addition, Asian women perceived that they were at a low risk for cervical cancer as they associated this with sex outside of marriage. The authors argue that this group would benefit from more education and support in relation to cervical cancer. ***See [page 248](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-101082)***

## HPV vaccination status may be a proxy for wider sexual health risk

Women vaccinated against human papillomavirus (HPV) vaccination have been said to display higher levels of preventative behaviours and more positive attitudes to sexual health than unvaccinated individuals. Comparing indicators of risk and preventative behaviours among young women attending genitourinary medicine (GUM) clinics, Sadler *et al.* found that unvaccinated women displayed more high-risk sexual behaviour, leading the authors to suggest that routine assessment of HPV vaccination status may act as a surrogate marker for risk, and allow targeting of health promotion in the unvaccinated population. ***See [page 255](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-100896)***

## Self-testing for HPV may be more acceptable to lesbian and bisexual women

HPV testing now plays an essential role in the prevention of cervical cancer, either in conjunction with cervical cytology or as a stand-alone test. But lesbian or bisexual women, who are at risk of HPV-related disease even though they may not have engaged in heterosexual intercourse, may miss out on conventional screening. Self-testing has been proposed as an approach to testing that is potentially attractive to this group. In a survey of over 400 women in the USA, Reiter *et al.* found that just over half would be prepared to self-test. The authors suggest that providing better information to overcome women's concerns might increase the proportion who would participate in a screening programme. ***See [page 259](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-101004)***

## Awareness campaigns are needed to tackle cervical cancer in resource-poor settings

Cervical cancer remains a major cause of cancer mortality in poor regions. In Georgia, more than half of new cervical cancer cases are detected too late to offer effective treatment. Poor awareness of screening, of the role of HPV infection, and of preventive strategies such as HPV vaccination may contribute. Surveying attendees at four women's consultation centres in Georgia, Butsashvili *et al.* found that despite a clear desire for more information on HPV and cervical cancer prevention, current awareness is poor. The authors call for more comprehensive public awareness campaigns. ***See [page 265](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2013-100833)***

## Women with IBD are concerned about pregnancy but undeterred

Inflammatory bowel disease (IBD) affects women in the prime of their fertile years. These women may be concerned about involuntary childlessness, medication teratogenicity, pre-term delivery, low birth weight or miscarriage, to the point where some choose not to attempt pregnancy. A telephone survey of 129 women with IBD in the USA takes a contemporary look at risk perception in fertile women with IBD. They find that while women with Crohn's disease were more anxious about adverse pregnancy outcomes than those with ulcerative colitis, fewer than 3% allowed their IBD-related concerns to impact upon their intended family size. ***See [page 272](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-101000)***

## Sex after surgery for severe endometriosis

Deep infiltrating endometriosis (DIE) is a crippling condition, affecting all aspects of life including sexual function. The role of surgery is controversial. In a non-randomised study from a specialist centre in Bologna, Italy, Di Donato and colleagues prospectively compared 250 women with DIE with 250 matched controls. Sexual activity questionnaires before and after their surgery showed a significant improvement in self-reported sexual function post-surgery, with 6-month scores comparable to those of the healthy women. Interpreted cautiously, these non-randomised medium-term findings may offer some hope of symptom reduction while conserving fertility in a condition that is difficult to live with and to treat. ***See [page 278](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-100993)***

## Ambulatory hysteroscopy has a place in the investigation of abnormal bleeding

Abnormal uterine bleeding is a distressing and occasionally ominous symptom which can present in sexual health settings, either because it relates to contraception, or simply because women may find it easier to discuss this problem in this setting. In the second part of a series of ambulatory hysteroscopy in reproductive health, Cooper *et al.* review its use in the diagnosis and treatment of abnormal bleeding. Reducing the need for hospital admission, ambulatory procedures offer potential benefits for both patients and health services. ***See [page 284](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-100872)***

## Clinicians do not record women´s own reasons for stopping contraception

Sexual and reproductive healthcare is at its best patient-centred and respectful of individual understandings and preferences – but not always, as a review of literature on contraceptive method change or discontinuation shows. Assessing whether the reasons documented by clinicians for stopping a method actually reflected women's experiences, Inoue and colleagues found they did not. Instead, a predominance of categoric medical terminology predominated, with little reference to women's specific reasons or own words. The authors argue that the medical literature needs to document women's subjective experiences. ***See [page 292](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2014-100976)***

## Using online counselling allows a one-stop IUC fitting visit and reduces wait times

Increasing uptake of long-acting reversible contraception (LARC) is a national priority, but in NHS Lothian has led to long waits. Multiple visits for counselling and fitting are known to reduce uptake. This ‘Better Way of Working’ article investigates a ‘one-stop’ service using an 11-minute online film and required online questionnaire to counsel and prepare women for intrauterine contraception (IUC) insertion. A retrospective computer case note review found the initiative was associated with fewer clinical contacts before IUC insertion with no loss in the number of women able to have the IUC fitted as planned. The IUC insertion service was achieved within existing 30-minute appointments. Evaluation from the woman's perspective is currently ongoing but verbal feedback was positive. ***See [page 300](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2015-101223)***

## Twenty-five years on, the international debate about the place of sexual health continues

In his regular comparison of this Journal's content a quarter of a century ago with today's issues, our International Advisory Editor draws attention to concerns in 1990 about the impending harmonisation of standards across the 12 countries of the European Community. Could British family planning services serve as a model for the other European countries? Or would they wither because of feared budget cuts? Twenty-five years later the importance of sexual health has been recognised on the international stage, with the hope that it will be accorded its proper place in the United Nations post-2015 Development Agenda, despite continuing sensitivities in some parts of the world. ***See [page 303](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2015-101297)***

## A contraception clinic in an integrated sexual health service: back to the future or a backward step?

The first winner of the *Anne Szarewski Journal Memorial Award*, Laura Percy, describes the establishment of an open-access, walk-in, nurse-led contraception-only clinic within an integrated sexual health service, to provide an easily available facility for clients with straightforward contraceptive needs such as continuation of an established method. While this may appear to be a reversal of recent progress in integration of sexual health services, it certainly seems to be popular with the clients. However, in her accompanying **Mini Commentary,** Sharon Moses gives reasons for caution in adopting this approach and suggests that the need expressed by Dr Percy's clients could more reasonably be met by improving the effectiveness of Level 1 providers. This is a discussion that will surely continue. ***See [pages 309](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2015-101280)*** and ***[312](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2015-101335)***

## Resources for women with infertility are needed, and are improving

In a year that has seen a 65-year-old German mother with 13 children expecting quadruplets, a media storm over the testing of new reproductive techniques on actual human pregnancies, and the autobiography of the first test-tube baby, Louise Brown, it seems pertinent for our Consumer Correspondent to explore the issue of not being able to have a child. Re-interviewing women she first interviewed in 2008, Susan Quilliam highlights how individual women overcome the distress and challenges of infertility, and how support for such women has improved. While acknowledging the deep and lasting shadow that infertility can cast, the author summarises resources now available for such women. ***See [page 314](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2015-101331)***

## Crocodile forceps may also help removing ‘missing’ IUDs

What's the best instrument for removing ‘missing’ intrauterine devices (IUDs) under ultrasound control? The Journal recently published a paper describing the use of hysteroscopic grasping forceps for this purpose, but two letters written by Mary Pillai and Abha Govind in response make a case for the use of ‘crocodile’ forceps. Ultrasound visualisation and effective instruments should greatly reduce the need for hospital referral for IUD removal. ***See [pages 316](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2015-101317)*** and ***[317](http://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2015-101254)***