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7 Genitourinary Medicine
Services
A Renton, S Hawkes, M Hickman, E Claydon, H Ward, D Taylor-
Robinson
1 Summary
This chapter addresses the need for genitourinary medicine (GUM) services, the promotion of sexual health
and diagnosis and treatment of sexually transmitted diseases (STDs), excluding HIV and AIDS.
Sexually transmitted diseases – categories and definitions
A wide range of conditions present to GUM clinics. These conditions may be classified according to the
symptoms and signs (syndromically), according to causative agents (for infectious STDs) and according
to the long-term sequelae of the conditions.
The most useful existing classification scheme is that used to report clinic activity to the Department of
Health on the KC60 statistical return. This scheme uses information describing syndromic features and
causative organisms to classify cases. The scheme is especially useful for infectious conditions. However a
substantial proportion of individuals presenting to GUM services do not have an infectious condition.
These individuals may be attending, for example with psychosexual problems, or merely for a check-up.
Although within some clinics there is provision for allocating separate KC60 codes to different
non-infectious conditions and thus disaggregating this important area of activity, these codes vary from
clinic to clinic.
Incidence and prevalence of genitourinary conditions and risk behaviours
for acquisition of sexually transmitted infections
The principal source of information on the frequency and occurrence of STDs is derived from a
statistical return from GUM clinics to the DOH (KC60). Other possible information sources are
described – but none offer data that can be used at a local level.
Allocation of individuals attending STD clinics to district of residence data is not easy as the KC60 does
not record district, and because extensive cross-boundary flows may occur. The paucity of information
attributable to district populations is highlighted throughout this chapter and urgently needs to be
addressed.
During 1993/94 over 45 000 new episodes were recorded at 225 STD clinics in England and Wales –
corresponding to one in 50 of the population aged 16–64.
Most GUM clinics are small – over half record less than 1500 episodes a year and 90% recording less than
5000. There is considerable variation in attendance rates between regions, with the highest rate in clinics
located in the North Thames RHAs, approximately three times that found in the West Midlands. While
the majority of DHAs have one local GUM clinic, there are still a few districts without a GUM clinic.
The difference between regions varies less generally for the viral and chronic infections, such as genital
warts and herpes simplex virus. Very large differences occur between DHAs in rates of initial contacts.
However these largely reflect differences in the location of clinics.
About one-third of all new contacts in GUM clinics are classified as D category under the KC60 scheme.
This represents individuals attending for one or more of the many different services or problems catered
for by GUM services, such as counselling, treatment of rare conditions, sexual health screening, or family
planning. It is important therefore that providers are aware of the different types of services offered by
the local GUM clinic and of which types are included in the ‘catch-all codes’ in order to interpret the
activity data. The breakdown of GUM clinic activity in the UK in 1990/91 is shown in Figure 1.
Proportion of all first contacts by STD group
Other untreated 24%
Referred elsewhere 2% (^) Gonorrhoea 3% (^) Chlamydia 6% Trichomonas and Candida 11%
Anaerobic infections 6%
Warts 12%
Herpes Non-specific genital infection 3% 19%
Other STDs 2%
Other treated 12%
Figure 1: Breakdown of GUM clinic activity in the UK in 1990–91 across KC60 categories.
The reported incidence of STDs has changed markedly over time. Gonococcal infections were declining
in importance over the period 1976 to 1986, the decline accelerating in 1985/86. It is important to note
that the fall in gonorrhoea pre-dated recognition of HIV infection. In women Trichomonas vaginalis
infections also declined. Over the same period the number of diagnoses of genital warts or genital herpes
increased substantially. Several explanations can be offered for these trends, including improved
diagnosis and treatment of bacterial STDs, changes in sexual behaviour and greater ascertainment of
asymptomatic disease. However the extent to which these different explanations account for the observed
trends is not known.
Sexually transmitted diseases mostly affect young people with the bulk of cases occurring in women aged
16 – 24 years and in men aged 20–29 years. In women the rates of initial contacts among those below 16
years (age of legal consent) are higher than rates in women over 45 years. It follows therefore that GUM
services must be acceptable to young sexually active people and that other services sought by young
people need to provide advice and information on sexual health and the availability of GUM services.
People with STDs presenting to GUM clinics may represent the tip of the iceberg of sexually transmitted
infection. Unfortunately most available prevalence surveys have small sample sizes and the samples were
not selected randomly from the population. They do suggest however that young age is associated with an
increased risk of infection and that the difference between asymptomatic and symptomatic infection can
be large. Of course not all asymptomatic infection will lead to complications but clearly if untreated the
probability of transmission to others remains. Further investigation of STD prevalence via the use of
local surveys is needed.
Models of care
There is one basic model of care that covers the whole of GUM services in the UK; the provision in each
district of at least one specialist GUM clinic within an acute unit or, less frequently, attached to a
community unit.
In recent years there has been a shift away from a disease based approach (which underpins GUM)
towards the broader concept of sexual health. This shift has yet to be fully reflected in the provision of
services. A few districts have integrated sexual health services where GUM, family planning, termination
of pregnancy, psychosexual counselling and related services are provided in one clinic. In other areas
there is no unified service but greater links are being established between community gynaecology and
GUM. Family planning clinics can also provide screening for sexually transmitted organisms, such as
Chlamydia trachromatis.
There is a clear case for better planning of services and liaison between sectors. Primary prevention
including health education, condom distribution and hepatitis B vaccination is carried out within GUM
clinics but also needs to be co-ordinated across other services within the district. This reflects the
widening role of GUM into sexual health which must be carried forward into district models of care
where either GUM clinics are integrated with other sites in the delivery of services, or the management of
sexual health services is integrated through common protocols and shared care schemes.
The potential role of GUM services in wider community based screening for STDs needs to be
considered. In the first instance questions relating to the potential value of extending screening beyond
individuals who present themselves to clinics will need to be addressed at the national rather than district
level.
Outcome measures and targets
National targets for a reduction in gonorrhoea incidence were set in the Government’s strategy The
Health of the Nation and have been achieved.
Further development of appropriate outcome measures and targets will require the enhancement of
surveillance and information systems from GUM clinics and laboratories. The installation of GUM
clinic computers provides the opportunity for collating data at a population level and several regions are
piloting new information systems.
Information and research priorities
Information systems require further development to allow geographical attribution of individuals with
STD infections.
Currently little is known about the amount of STDs diagnosed and treated outside GUM. This must
change as districts develop more integrated sexual health services and more extensive screening of people
in other settings is carried out.
Information derived from clinic activity will need to be supplemented by the findings of new sample
surveys which establish the prevalence of STDs in different populations.
Studies are needed into the benefits and effectiveness of selected preventive interventions, including
population screening or universal screening for STDs in asymptomatic women.
Models of shared care and education and the cost-effectiveness of treating chronic viral STDs (excluding
HIV) outside GUM clinics needs to be assessed.
Hepatitis B is currently the only sexually transmitted virus for which an effective vaccine is available but
there is evidence that coverage is low. Studies are required to explain why vaccination is not reaching
those people who are at highest risk of infection, and to make practicable proposals on how this can be
changed.
Sexual health services are becoming integrated. It is important to establish what role GUM physicians
have in the education of other health care workers in the recognition of STDs and the development of
local algorithms for the management of STDs outside GUM clinics. Also whether there is scope for
managing chronic STDs in primary care with the advice of GUM consultants, following a similar model
of other chronic diseases.
2 Introduction
Genitourinary medicine is one part of the services concerned with the sexual health of the population and is
one of the key Health of the Nation areas. Sexual health like the WHO definition of health is not merely the
absence of disease and any definition must recognize both the positive and negative consequences of sexual
activity. Sexual health can be regarded as:
the enjoyment of sexual activity of one’s choice without causing or suffering physical or mental harm.
The undesired results of sexual activity include unwanted pregnancies and the transmission of STDs, which
if untreated can have long-term consequences such as infertility, ectopic pregnancy and genital cancers.
Health authorities implementing the Health of the Nation strategy will need to plan integrated and
complementary services and to develop alliances to promote sexual health across traditional boundaries.
Genitourinary medicine services will play a key role within this strategy and it is important to be aware that:
an integrated sexual health services package incorporates other health care providers (e.g. family
planning, obstetrics and gynaecology, general practice), local government (e.g. health education in
schools and management of social services homes) and voluntary organizations (e.g. provision and
targeting of sex education in the population)
complementarity between GUM and other sexual health services must be a primary concern of those
commissioning services.
Though the models of care section focuses on sexual health services, the role of non-GUM services in the
delivery of sexual health must be the subject of other needs assessment exercises. Moreover planning the
future delivery of sexual health services has been addressed by a joint working group.
GUM services have a split role and responsibilities. First they have a responsibility for the alleviation of
disease in individuals. Second they fulfil an important public health function to control sexually transmitted
infections in the population, through the rapid diagnosis and treatment of symptomatic individuals,
screening and treating individuals for asymptomatic infection, contact tracing, diagnosis and treatment of
infection in sexual partners and provision of health education materials and advice on prevention. Third they
Table 2: Important sexually transmitted pathogenic organisms
Type of organism Name (disease)
Bacteria Treponema pallidum (syphilis) Neisseria gonorrhoeae Chlamydia trachomatis
Viruses Herpes simplex Human papilloma (warts) Hepatitis B
Ectoparasites Phthirus pubis (crab louse) Sarcoptes scabiei (scabies)
Protozoa Trichomonas vaginalis
Fungus Candida albicans
In addition STDs may lead to chronic symptoms or complications if untreated. The main complications
which may also have a non-infectious cause are shown in Box 1.
Box 1: Common long-term complications of STDs
Tubal infertility Miscarriage Ectopic pregnancy Ano-genital cancer Chronic hepatitis
A more complete list of STD organisms, together with a description of the common features of acute
infection and chronic sequelae, is given in Appendix VI.
Classification of presenting conditions
The principal source of information on GUM clinic activity and STD incidence in England and Wales
combines data on syndrome, organism, plus treatment of suspected disease (i.e. clinical diagnosis without
microbiological confirmation). Known as the KC60 it is a statistical return made quarterly to the DOH from
each GUM clinic. An abridged list of the main conditions are shown in Table 3. A complete list with the
recent revisions is shown in Appendix II.
If a patient is admitted into hospital with an STD or genitourinary condition the diagnosis will be coded
under the ICD classification system. The hospital information system (HIS) will be less useful for assessing
the STD related health service activity because only a small fraction is dealt with in the inpatient setting. A
list of relevant ICD 10 codes is given in Appendix I, in the event that health care commissioners or providers
wish to monitor GU related hospital inpatient activity.
Much of the information presented on the frequency of occurrence of these infections in section 4 will be
based on this summary KC60 classification. The KC60 also provides data on whether selected STDs were
acquired homosexually. However not all GUM clinics submit data on acquisition and a review of those that
did submit data found it to be highly variable and unlikely to be accurate. The KC60 data on homosexual
acquisition, therefore, have not been used. Commissioners and providers wishing to monitor STDs by sexual
acquisition will need to review data quality in their local GUM clinic and establish the policy on sexual
history taking and routine data collection.
Table 3: The KC60 classification of STD workload
KC60 code Condition Description a^ Intensity b
A1– 9 Syphilis genital ulcers plus complex multi-system chronic sequelae
B1.1–4a,5 Gonorrhoea urethritis in men, vulvovaginitis in women 1
C4a–e Chlamydia cervicitis and vulvovaginitis in women (though usually asymptomatic), urethritis in men
C4h–i Non-specific genital infection urethritis of unknown cause in men only (though Chlamydia may not be tested for)
C6a, C7a Trichomonas and Candidosis vulvovaginitis 1
C6b–c,7b Vaginosis and other anaerobic infections
mostly vulvovaginitis (some infection in men) 1
B1.4b–c, C4f–g Pelvic inflammatory disease (PID)
pelvic pain with or without discharge of gonoccocal, chlamydial or unknown origin
C11a–b Genital warts 2
C10a–b Herpes simplex ulceration 2
C13a–b Hepatitis serologically confirmed 3
C1–3, C5, C8– 9 c^ Other specific STDs and complications
ulcers, infestation and other complications 1/
D2 Any other condition requiring treatment
D3 Other episode not requiring treatment
D4 Other conditions referred elsewhere a (^) See Table 1. b (^) ‘Intensity’ refers to service need: 1 on the spot diagnosis, antibiotic treatment, and contact tracing;
2 multiple outpatient visits; 3 may require inpatient management. c (^) Chancroid, donovanosis, scabies, pediculosis, LGV (lymphogranuloma venereum) or sexually acquired
arthritis.
4 Incidence and prevalence of genitourinary conditions
and risk behaviours for acquisition of sexually
transmitted infections
In 1993/94 over 45 000 new episodes were recorded at 225 GUM clinics in England and Wales. Roughly this
corresponds to one in 50 of the 16–64 year-old population attending a GUM clinic. Even though over
one-third of people who attend are found not to have a STD, treatable STDs at GUM clinics represent only
the tip of the iceberg of sexually transmitted infections. Most GUM clinics are small – with over half
recording less than 1500 episodes a year and 90% recording less than 5000. The number of GUM clinics in
X
X X
1976
0
20 000
X (^) X (^) X (^) X (^) X X (^) X (^) X X X (^) X X X X
40 000
60 000
80 000
100 000
120 000
1977197819791980198119821983198419851986198719881989199019911992
Syphilis Gonorrhoea Non-specific gen. inf. Herpes Warts Other not treated
X
Population
Figure 2: Initial contacts seen in GUM clinics in the UK 1976–92: selected diagnoses: male.
X (^) X X
X X
1976
0
10 000
X X (^) X (^) X (^) X (^) X X X X X
20 000
50 000
60 000
70 000
90 000
1977197819791980198119821983198419851986198719881989199019911992
X X
X
30 000
40 000
80 000
Syphilis Gonorrhoea Trichomonas Herpes Warts Other not treated
X
Population
Figure 3: Initial contacts seen in GUM clinics in the UK 1976–92: selected diagnoses: female.
Infectious syphilis is very rare. Gonococcal infections were declining in importance over the period 1976 to
1986 and the decline accelerated in 1985/86. In women trichomoniasis infections also declined. Over the
same period the number of initial contacts in whom a diagnosis of genital warts or genital herpes was made
increased substantially. Concomitant increases in non-specific genital infection in males (mainly non-
gonococcal urethritis) and patients attending with other conditions for which no treatment was required also
increased.
Several explanations can be offered for these trends. Bacterial STDs can be controlled effectively through
the early diagnosis and effective treatment of index cases and their sexual partners. It may be therefore that
improved clinical services throughout the 1970s led to a reduction in the average duration of infectivity of
this group of STDs with a consequent decline in incidence. In addition bacterial STDs have declined in
incidence as a consequence of changes in sexual behaviour within the population, in particular in response to
AIDS awareness, and campaigns promoting safer sex. Indeed this notion has been enshrined within the
Health of the Nation strategy setting a target for a reduction in gonorrhoea incidence within the population.
This target was set, not to reflect the public health importance of gonorrhoea itself, but because gonorrhoea
incidence nationally was measurable, and in the belief that gonorrhoea incidence provided a good indicator of
underlying ‘unsafe’ sexual behaviour within the population. It is important to note that the beginnings of the
decline in gonorrhoea predated the recognition of AIDS/HIV infection by several years, although the
response to the latter may be responsible for the acceleration in decline.
The apparent rise in incidence of warts and genital herpes over the time period is clearly not explicable by a
move towards safer sex within the population. Initial contacts with untreated non-STD conditions show a
similar pattern suggesting that at least for some of these diseases the increase might be accounted for by
ascertainment of asymptomatic disease among the increasing overall number of attenders, a feature of greater
access to GUM services. Attendance increased by roughly 50% in men over the time period and effectively
doubled in women. However an increase in attendance of the order of 50–75% may not explain entirely the
four- to five-fold increase in genital warts or the rise in genital herpes seen over the period, although it may
explain the increase in non-gonococcal urethritis.
Two further explanations have been offered for the rise in incidence of the viral STDs. First that the
different STDs are associated with different types of sexual behaviour, which if they change in frequency
will not have any significant effect on the occurrence of other STDs. Second that the viral diseases are in an
epidemic phase and have not yet reached a stable endemic equilibrium incidence within the population. The
extent to which these different explanations account for the observed trends is not known.
Incidence estimates for genitourinary conditions based on GUM clinic attendance
Estimates of the crude incidence of the important KC60 based groupings of genitourinary conditions
averaged for the years 1990 and 1991 are shown in Table 4. An overall attendance rate of over 2% (one in 50)
is seen for men and women aged 16–64 years in the UK in 1991 and 1992. There is considerable variation in
attendance rates between regions, with the highest rate in clinics located in the North Thames RHAs,
approximately three times that found in the West Midlands. It is important to remember that variations
between RHAs reflect cross-boundary flow, the number of clinics located within the region and differences
in diagnostic or coding practice. The difference between regions varies less for the viral and chronic
infections, such as genital warts and herpes simplex virus. The relative frequency of the different conditions
in the UK is shown in Figure 1, page 398.
Two of the largest categories of patients are those classified as having other untreated conditions, or
treated for any reason other than those classified in the STD categories. Thus one-third of all new contacts in
GUM clinics are unspecified, though they could refer to the many different services or problems catered for
by GUM, such as counselling, treatment of rare conditions, sexual health screening, family planning, etc. It
is important therefore that providers are aware of the different types of services offered by the local GUM
clinic and of which are included in the ‘catch-all codes’ in order to interpret the activity data.
The most common specific diagnoses (excluding non-specific genital infections in men) are candidal
infection and warts. In the case of chlamydiae infection it is important to appreciate that the proportion of
initial contacts to whom this diagnosis is assigned will be greatly influenced by the availability and extent of
testing for Chlamydia trachomatis in clinics.
Variation between districts within regions
It is difficult on the basis of current knowledge to explain the observed regional variation. It may reflect real
differences in the geographic incidence of specific STDs. Alternatively regional differences may reflect
differences in the availability and location of clinics, or health seeking behaviour across the country. Very
large differences occur between DHAs in rates of initial contacts. This is shown for a single RHA in Table 5
and largely reflect differences in access and clinic location. The differences cannot be used to reflect
differences in population incidence of STD; although STD incidence is likely to be geographically
heterogenous it is not possible to say by how much.
Districts with relatively low contact rates will need to establish whether these rates reflect problems of access.
In addition districts will have to collaborate with their neighbours and the nearest inner-city GUM clinics in
order to establish the distribution of clinics serving their population.
Age distribution of initial contacts
The age distribution of individuals with new episodes of STDs is shown in Table 6. A characteristic pattern
is seen: the bulk of cases in women occurs in those aged 16–24 years. In men the distribution is shifted to the
right by about five years; the bulk of cases occurring in those aged 20–29. In women the rates of initial
contacts among those below 16 years (age of legal consent) are higher than the rates in women over 45 years,
for all the diagnoses shown.
This has important implications for service configuration. Genitourinary medicine services must be
acceptable and accessible to young sexually active people. Equally services sought by young people such as
school nurses, primary health care team, family planning, accident and emergency (A and E) and social
services, need to be co-ordinated in order to advise individuals (who may still be at school) of the availability
of GUM services and to encourage them to attend clinics where appropriate.
Table 6: Age-specific rates per 100 000: initial contacts with GUM services by diagnosis in the UK 1990/
Infection Females Males
rate per 100 000 rate per 100 000
< 16 16 – 19 20 – 24 25 – 34 35 – 44 >=45 < 16 16 – 19 20 – 24 25 – 34 35 – 44 >=
Syphilis 0.2 0.6 1.7 1.1 0.5 0.1 0.1 0.7 2.1 2.9 1.3 0.
Gonorrhoea 7.7 156.0 128.0 43.0 7.2 0.6 3.0 101.0 216.0 126.0 26.9 0.
Herpes (first attack) 5.0 105.0 136.0 62.9 17.5 2.6 0.9 28.0 97.7 73.3 28.0 5.
Warts (first attack) 19.7 549.0 514.0 160.0 41.2 5.6 4.9 219.0 624.0 286.0 72.5 12.
Chlamydia 17.4 393.0 380.0 113.0 18.5 1.8 2.5 123.0 294.0 151.0 35.6 4.
Clearly the age-specific rates of STD occurrence in the peak age groups are several times that for the whole
population aged 16–64. Because the KC60 data are contact rather than person based, it is difficult to estimate
the incidence rate of any STD. However there is little doubt that it exceeds 1% per year. The data are not
generalizable to individual districts, nor are they available for individual DHAs.
KH09 data
As with other outpatient clinics, GUM clinics collect information on the number of clinic sessions held and
the total number of attendances: the KH09 statistical return. KH09 could serve to interpret the KC
activity between clinics, for example, by comparing the ratio of total KC60 contacts to the overall number of
attendances. However in a recent study commissioned by the DOH and carried out by the Policy Studies
Institute 3 there were many problems found in comparing KH09 data between clinics. Clinic sessions were
defined in different ways: some recorded male and female clinics running concurrently as one session, whilst
others recorded it as two clinic sessions and in some clinics telephone consultations were included in the
overall workload returns. When districts are assessing the workload of clinics in their area it will be
imperative for them to know the method by which the workload is measured before valid comparisons can be
made. The KH09 for GUM clinics is not published separately but aggregated with other hospital outpatient
returns. Districts therefore must arrange with their local providers for access to this data source.
Sexually transmitted diseases prevalence surveys
While KC60 data provide reasonable estimates of the incidence of symptomatic disease, they provide little
information on the population incidence and prevalence of total infection (asymptomatic and symptomatic)
with sexually transmitted pathogens. Estimates of STD prevalence in a district can be gleaned from
information already collected in ad hoc surveys of STD prevalence which have been carried out both in STD
clinic and non-clinic settings. The results of the most recent of these surveys are presented in Table 7.
It cannot be assumed that these figures are universally valid since the sample sizes are small and not
randomly selected from the population but it is of note that many of the surveys give very similar prevalence
rates for the asymptomatic carriage of sexually transmitted pathogens. The most common finding in all the
surveys is that young age is associated with an increased risk of infection, with the highest prevalence
consistently found in young sexually active teenagers.
The difference between asymptomatic and symptomatic infection can be large, suggesting that a very large
proportion of the total burden of sexually transmitted infection may remain undiagnosed and asymptomatic.
For example approximately 20 000 incident cases of Chlamydia trachomatis infection are recorded in the UK
annually. Even if it is assumed that all chlamydial infections diagnosed in the clinics occur in women aged
16 – 30, the figure still represents only three per 1000 women, which in turn represents only 6% of the total
caseload (if we assume 5% of women are infected).
Of course not all asymptomatic infection will leading to complications but clearly if untreated the
probability of transmission to others remains. Further investigation of STD prevalence via the use of local
surveys is needed.
Laboratory reports
Other measures of the prevalence of STDs in a particular district can be compiled from laboratory reports.
The only STD which is notifiable under the infectious disease legislation is ophthalmia neonatorum. This
was commonly caused by gonococcal disease, transmitted vertically from the mother to child, starting as
conjunctivitis in the new born and sometimes leading to blindness. During the 19th century ophthalmia
neonatorum occurred in 1 to 15% of infants born in US and European hospitals. However the district
prevalence rates for this condition now are so low as to be meaningless for planning services, or for
monitoring the prevalence of STDs.
There is a system of voluntary reporting of laboratory data to the PHLS Communicable Disease
Surveillance Centre (CDSC) and through the 53 area and regional laboratories which constitute the Public
Health Laboratory Service. These collect data on the prevalence of extra-genital N. gonorrhoeae and together
with the Gonococcus Reference Unit at Bristol carry out specialized typing of strains of gonococci and
determine resistance patterns. It must be remembered however that this is a voluntary reporting system and
it is recognized that the data set is incomplete and does not refer to district populations. In a recent survey of
one region only half of the eligible NHS laboratories reported regularly to the CDSC and samples from
one-third of the GUM clinics were tested at laboratories which did not report at all (unpublished).
However steps are being taken to improve laboratory reporting by developing and implementing
electronic means of capturing the relevant data from the pathology computer and transferring it to the CDSC
(M Catchpole, personal communication). In 1995 the PHLS STD/HIV/AIDS Committee recommended
that all gonococcal infection diagnosed by laboratories be reported to the CDSC, in order to provide a more
complete picture. The success of this initiative however will depend on the programme to introduce a
computerized reporting system.
The data are used by the CDSC in their reports on the epidemiology of STDs nationally. It is not
published on a regular basis by area of report, though the CDSC can provide data to individual districts.
Districts should check whether their local laboratories are contributing to this surveillance system and
identify how much infection is diagnosed outside the local GUM clinic.
The PHLS is currently implementing a system of sentinel surveillance for STDs. At present this involves
just three clinics (two in London and one in Sheffield) but there are plans to extend and expand this to 15
clinics in 1996/97. This surveillance system may provide useful data on the epidemiology of sexually
transmitted infections in England and Wales and will be available for district planners to use when assessing
GUM service requirements in their area. The CDSC is also planning to set up a collaborative system to
monitor the incidence and distribution of congenital syphilis in England and Wales.
General practice morbidity survey
The Office of Population, Censuses and Surveys (OPCS) has recently published preliminary findings from a
national survey on patient visits to GPs. 17 This survey takes place once a decade, the most recent being
November 1991 to end of October 1992, in 60 volunteer practices in England and Wales. The results are
published as numbers of patients consulting per 1000 person–years at risk. The rates for diseases which may
be sexually transmitted were 0.6 for syphilis and other venereal diseases, 8.1 for herpes simplex infections
and 31 for candidasis.
Whilst it is difficult to comment in detail on these figures, as they are not specific for individual conditions,
it would appear that GPs see a substantial number of women whom they diagnose as having candidal
infection (thrush) and not many other sexually transmitted diseases. The OPCS will publish further details
of the study and its results, including tables of prevalence, incidence and service utilization for the whole
study population and for people with different socioeconomic characteristics.
The CDSC in collaboration with the Royal College of General Practitioners is currently looking more
closely at the presentation and management of people with STDs in general practice. Through a nationwide
network of GPs who are collaborating in this research, information will be available on the specific rates of
presentation, and diagnoses and management strategies used by GPs. The results of this survey will be
published by the CDSC.
Sexual behaviour surveys
The final source of information relevant to GUM service provision is provided by the surveys of sexual
behaviour. The recently published National Survey on Sexual Attitudes and Lifestyles (NSSAL)^18 has, for
the first time, provided epidemiologists and planners with detailed information on the sexual behaviour of
the UK population. It is planned that information from the NSSAL survey will be presented to district
health authorities by standard area in 1995/96 for their own assessments of need.
As shown in Table 8 on average men report more partners than women, and men and women living in
Greater London tend to report larger numbers of partners. If ‘risk of STD acquisition’ is defined as having
had more than one partner then about 15% of males and 10% of females aged 16–59 are at risk.
In Table 9 the distribution of reported numbers of lifetime sexual partners is presented; there again being a
remarkable similarity across the regions, apart from Greater London. If we define ‘lifetime risk of STD
acquisition’ as having had more than two lifetime partners, then about 50% of males and 40% of females
might be deemed to be at risk.
Table 8: Distribution of number of sex partners in previous year of respondents to NSSAL: broken down by standard region
Males Females
Region n 0 1 2 3 – 4 5 – 9 10+ n 0 1 2 3 – 4 5 – 9 10+
% % % %
Northern 427 11 77 5 5 1 1 565 15 80 4 1 0 0
North Western 857 11 74 9 3 2 0 1165 14 81 4 1 0 0
Yorkshire/Humberside 638 13 73 8 4 2 0 869 12 82 4 2 0 0
West Midlands 761 12 76 7 3 1 0 904 15 79 5 1 0 0
East Midlands 603 11 76 8 4 1 0 673 11 80 7 2 0 0
East Anglia 316 15 76 5 3 0 1 358 12 83 3 2 0 0
South Western 622 12 76 7 6 0 0 793 10 81 6 2 0 0
South Eastern 1715 12 74 10 3 1 0 1975 14 79 5 1 0 0
Greater London 1059 13 65 11 7 3 1 1243 16 75 5 3 1 0
Table 9: Distribution of lifetime number of sex partners of respondents to NSSAL
Males Females
Region n 0 1 2 3 – 4 5 – 9 10+ n 0 1 2 3 – 4 5 – 9 10+
% % % %
Northern 426 6 22 9 24 16 24 565 6 50 18 13 10 3
North Western 854 5 21 9 19 20 26 1165 5 41 19 19 11 4
Yorkshire/Humberside 636 7 20 11 20 18 24 866 5 40 17 18 14 6
West Midlands 759 8 21 12 19 19 21 902 7 40 15 20 13 5
East Midlands 600 6 24 13 13 19 24 674 5 39 19 19 12 6
East Anglia 316 7 24 14 14 19 21 358 6 44 16 15 14 5
South Western 621 5 22 9 19 21 24 791 3 38 17 19 15 8
South Eastern 1704 6 20 10 18 23 23 1969 6 37 16 20 14 8
Greater London 1053 6 13 11 18 19 34 1240 7 28 15 18 18 14
Table 10 shows the number and proportion of respondents in the sample in each standard region who
reported ever having attended a GUM clinic. The figures are shown for the whole sample and separately for
those individuals who reported more than two partners in the previous year and more than five lifetime
partners. It can be seen that larger proportions of individuals with larger numbers of partners report having
attended a GUM clinic at least once, though the proportion only reaches greater than one in four for people
living in Greater London. Differences between regions in GUM clinic attendance are likely to represent
differences in availability and accessibility of services, which should be noted and acted upon by those
commissioning and delivering services.
Following publication of the Monks report the DOH has issued yearly executive letters which request
health authorities to give an update of progress in implementing the recommendations of the report.
By now most if not all districts should have a local GUM clinic, or be opening one shortly. If not then need
is being almost certainly unmet and serious consideration should be given now to funding a new GUM clinic.
In 1990/91 the DOH commissioned a second study carried out by staff from the Policy Studies Institute. 3
Both reports found considerable variations in the work done by members of staff in different clinics and no
clear guidelines with respect to working roles. The main recommendations of the second study are given in
Appendix IV. The ability of staff to fulfil the multiple functions within GUM will vary widely depending on
the patient workload, clinic opening hours and number of trained staff within each department.
The size of individual clinics varies enormously between districts. However because services are open
access and little is known about the population prevalence of STDs, it is not possible to determine the
appropriate size, or ‘norms’ of a local service. Instead districts need to obtain knowledge about their own local
services and determine where else their population seek treatment and advice for STDs before comparing
service provision with other commissioning agencies.
The basic facilities which should be on offer within every clinic follow.
Primary prevention
The epidemiological shift away from curable STDs and towards the diagnosis of a greater number of chronic
and incurable viral infections has been accompanied by the realization that a mainstay of public policy
towards these diseases should be primary prevention. Thus it has been recognized that education about
sexual health plays a vital role in promoting sexual wellbeing and hence in avoiding the risks posed by unsafe
sexual activity.
Education is carried out by both local health promotion departments and within clinic settings (especially
by health advisers). While in an ideal world every health care professional in a GUM clinic will endeavour to
incorporate messages about primary prevention and safer sexual practice time constraints often preclude
this. As a result most GUM departments currently employ health advisers whose principal role is generally
split between providing education and information to patients, with contact tracing and counselling. A
review of the work undertaken by health advisers found that:
many had received no training in GUM related topics
increasing amounts of their time is being spent on HIV-related issues (mainly pre- and post-test
counselling but also in dealing with HIV-positive patients in some clinics) thus leaving less time for
discussing other STDs or for partner notification work.
However the work of health advisers and the primary prevention services offered by GUM departments
should encompass the following.
Health education
This is aimed primarily at the provision of information about health risks and their prevention through the
development of an individual’s skills in making choices and hence changing sexual behaviour and activity. 19
Promotion of safer sexual activity and the maintenance of healthier lifestyles are messages that health
advisers must make available and acceptable to all sections of the client population. Depending on the
demographic mix of the local population, health education material will need to be targeted specifically at
certain groups who are either at potentially higher risk of STDs or less likely to utilize services effectively.
Some groups, who may need special consideration include:
gay men and men who have sex with men
injecting drug-users
adolescents and young people
commercial sex workers (male and female)
people from ethnic minority groups.
Clearly health education is not limited just to those people who present to GUM clinics but is also targeted at
those who may be at higher risk of infection and reluctant to attend GUM clinics (or asymptomatic and hence
unaware of their STD). While the majority of work in the area of promoting safer sexual practices in the
general community and increasing the uptake of sexual health screening facilities, is carried out by people in
health promotion departments, health advisers from GUM clinics also play a significant role in this area. In a
number of districts health advisers go out into the community, for example into schools and youth groups
and either undertake health education themselves or are involved in the education of peer educators in each
community.
Provision of free condoms
The question of resource allocation to establish and maintain this service is something which often requires
negotiation at a local level as it can become a significant part of the purchasing budget of a clinic.
Hepatitis B vaccination
At present (1997) hepatitis B virus is the only sexually transmitted pathogen against which there is a safe and
effective vaccination (although currently there is research on the development of vaccines against both
Chlamydia and Herpes simplex virus). In 1983 Adler et al.^20 concluded that screening and vaccination of
homosexual men against hepatitis B is cost-effective in reducing the incidence of the disease and its
potentially lethal sequelae. In 1989 a survey by Loke et al.^21 found that of 121 clinics in the UK, 81% offered
screening for hepatitis B surface antigen but only 30% were able to offer the vaccine itself. Each district
should assess the prevalence and uptake of hepatitis B screening and et al .Avaccination programmes in its
own area.
Contact tracing
Largescale programmes for contact tracing (partner notification) for STDs have been in operation in the UK
for over 40 years 22 with the intention of:
preventing re-infection of the index case
controlling community spread (as it allows the identification and treatment of asymptomatic and
pre-symptomatic individuals who otherwise may not seek treatment)
providing health education about STDs to the individual.
A description of partner notifications is provided by the World Health Organization. Recently there has been
a concerted shift of emphasis from provider to patient referral, i.e. it is the index patients themselves who are
encouraged to notify their sexual contacts.
