AKT – Sexual health and gender diversity

Trent Wallace, aged 29, presents with a 2-week history of painless ulceration on the shaft of his penis. He is otherwise well, denies dysuria or discharge, and is sexually active with multiple male partners. He uses condoms inconsistently. He has not travelled overseas. No significant past history. No current medications or allergies.

On examination, there is a single, well-demarcated, non-tender ulcer with a clean base. Inguinal lymph nodes are enlarged but non-tender.

What is the MOST appropriate next step in management?

Miranda Xu, aged 17, presents with heavy menstrual bleeding and dysmenorrhoea. She reveals during the consultation that she identifies as non-binary and prefers the pronouns ‘they/them’. They are sexually active with male and female partners and do not use contraception. They feel distressed by their periods and request to stop them.

Medical history: nil significant. No allergies. Not on any medications.

What is the MOST appropriate next step?

Jordan Evans, aged 22, presents to discuss pre-exposure prophylaxis (PrEP). He is a cisgender male who has sex with men. He reports multiple partners and occasional recreational drug use. No regular partner. No history of STIs. No medications. He is not circumcised.

Examination is unremarkable. You counsel him about safe sex and he is keen to commence PrEP.

What investigation MUST be performed before prescribing PrEP?

Nina Hirst, aged 37, presents requesting screening for STIs. She is a transgender woman who has been on feminising hormone therapy for 2 years and underwent gender-affirming vaginoplasty last year. She has a monogamous male partner and uses condoms inconsistently. She is asymptomatic. She wants to know what screening is needed for her anatomy and risk factors.

What is the MOST appropriate set of screening tests for Nina?

Isaac Peters, aged 45, presents with rectal bleeding and mucous discharge. He has a history of receptive anal sex with casual male partners and was treated for chlamydia proctitis 18 months ago. He reports tenesmus and some loose stools but denies fever. He is HIV negative and takes PrEP. On rectal examination, there is mucosal inflammation with tenderness.

What is the MOST appropriate next investigation?

Eliza Maher, aged 35, presents requesting contraception. She has recently commenced testosterone as part of gender-affirming hormone therapy and now identifies as a transgender man. He is sexually active with a cisgender male partner and is uncertain if he can still become pregnant.

He is amenorrhoeic for 4 months. No medical comorbidities or current contraception. He is unsure if he wants children in the future.

What is the MOST appropriate next step?

Matthew Kline, aged 46, presents with new-onset genital ulcers. He has a history of HIV, well-controlled on ART with recent undetectable viral load. He reports unprotected anal and oral sex with new male partners overseas. He is febrile, and on examination has multiple shallow ulcers with grey bases on the glans penis and tender inguinal lymphadenopathy.

What is the MOST likely diagnosis?

Aleena Jaffari, aged 32, presents seeking screening before starting a new relationship. She is a cisgender woman who has sex with women (WSW) and is currently asymptomatic. She is not on any regular medications and has no significant medical history. Her last cervical screening test was 5 years ago. She is not using contraception.

What is the MOST appropriate screening strategy?

Joel McGregor, aged 38, presents with rectal pain, discharge, and tenesmus. He identifies as a gay man and has had multiple recent anonymous partners. Examination reveals mucopurulent rectal discharge and erythematous mucosa. NAAT is positive for Chlamydia trachomatis, and genotyping confirms LGV strain.

What is the MOST appropriate treatment?

Kai Ng, aged 19, presents to discuss their gender identity and ongoing distress about body changes since puberty. They describe persistent discomfort with their assigned gender (female at birth), have socially transitioned and request a referral to begin gender-affirming hormones. They have no mental health diagnoses and no self-harm history. Supportive family.

What is the MOST appropriate next step?

Amina Farah, aged 26, presents with a 4-day history of vulvar pain and dysuria. She has had three sexual partners in the last 2 months and uses condoms inconsistently. She is otherwise well and not on any medications. On examination, there are multiple small, shallow ulcers on the labia and tender bilateral inguinal lymphadenopathy.

What is the MOST appropriate next step?

Noah Fitzgerald, aged 52, presents for follow-up after a recent diagnosis of HIV. He is in a new relationship and is concerned about transmission. He is otherwise well and has commenced antiretroviral therapy (ART) with good adherence. His viral load is now undetectable at 6 months.

What is the MOST appropriate advice regarding risk of transmission to his partner?

Emily Hwang, aged 31, is a transgender woman who presents requesting cervical screening. She has not had gender-affirming surgery but is concerned about HPV and wants to know what screening she needs. She has regular receptive anal intercourse with her male partner and no symptoms.

What is the MOST appropriate cervical screening recommendation?

Jacob Riley, aged 21, presents with testicular pain and swelling. He reports urethral discharge earlier this week and has a male sexual partner. On examination, he has tender swelling of the left epididymis and mild scrotal erythema. His urine NAAT returns positive for Chlamydia trachomatis.

What is the MOST appropriate treatment?

Lucia Gianni, aged 42, presents for review of her cervical screening history. She has been with female partners exclusively for 15 years. She believes she no longer needs screening. She has no symptoms and is otherwise well. Her last cervical screening test was over 5 years ago and was normal.

What is the MOST appropriate advice regarding cervical screening?

Sara Holmes, aged 24, presents with recurrent candidiasis and vulvar discomfort. She also discloses distress about body image and expresses a desire to explore gender identity. She has not disclosed this to any other health professional. She is tearful and unsure what she wants to do next.

What is the MOST appropriate next step?

Dominic Chan, aged 28, presents with a painless genital lump noticed during showering. He is in a monogamous relationship with a male partner. On examination, there is a single, firm, non-tender papule on the shaft of the penis with a central dimple and pearly edge.

What is the MOST likely diagnosis?

Casey Nguyen, aged 34, is a non-binary person using they/them pronouns. They present to discuss starting testosterone as part of their gender-affirming care. They have no medical conditions and are not on any medications. They ask what effects they can expect from testosterone therapy.

Which of the following is the MOST likely long-term irreversible effect of testosterone therapy?

Liam Cook, aged 19, presents after being contacted by a partner who tested positive for gonorrhoea. Liam is asymptomatic but concerned. He has had unprotected oral and anal sex with male partners in the last month. He is otherwise well and takes PrEP regularly.

What is the MOST appropriate next step?

Helena James, aged 61, is a cisgender woman in a same-sex relationship. She presents for routine health check and states she hasn’t seen a doctor in years. She has never had a cervical screening test, assuming it wasn’t necessary as she only has sex with women. She has no symptoms and takes no medications.

What is the MOST appropriate management?

Freddie Lang, aged 44, presents with rectal bleeding and discomfort. He is a gay man and recently returned from overseas. He reports proctitis symptoms and discloses that his most recent partner was diagnosed with monkeypox. On examination, there is perianal erythema, ulceration, and inguinal lymphadenopathy.

What is the MOST appropriate next step?

Isabella Cruz, aged 16, presents with low mood and distress about body changes. She was assigned male at birth but identifies as female. She has socially transitioned and is supported by her family. She requests puberty blockers. She is otherwise healthy with no psychiatric history.

What is the MOST appropriate next step?

Tyler Adams, aged 30, presents with dysuria and urethral discharge. He is a gay man with multiple partners and takes PrEP. On examination, mucopurulent discharge is seen. Urine NAAT is positive for gonorrhoea, and rectal swab is pending. He is allergic to penicillin (anaphylaxis).

What is the MOST appropriate treatment?

Melanie O’Donnell, aged 48, presents for a sexual health check. She discloses a history of sexual trauma and expresses anxiety about examinations. She has never had a cervical screening test. She is in a stable relationship with a woman and otherwise well.

What is the MOST appropriate approach?

Zane Keating, aged 39, presents for discussion of fertility. He is a transgender man who stopped testosterone 3 months ago and has resumed menses. He is in a relationship with a cisgender female partner and they wish to conceive using donor sperm.

What is the MOST appropriate next step?

Anthony Russo, aged 27, presents after developing a painful inguinal mass and fever. He is a man who has sex with men and had unprotected receptive anal sex while overseas. He reports rectal pain and discharge. Examination reveals tender unilateral inguinal lymphadenopathy and mucopurulent proctitis. NAAT returns positive for Chlamydia trachomatis.

What is the MOST likely diagnosis?

Rebecca Tran, aged 33, presents for sexual health screening. She is a transgender woman who has undergone vaginoplasty. She is sexually active with men and concerned about her HIV risk. She is interested in pre-exposure prophylaxis (PrEP).

What is the MOST appropriate initial step?

Leo Grant, aged 22, presents with new genital warts. He is otherwise healthy, has sex with men, and has not received the HPV vaccine. He is distressed and wants to know if the vaccine is still worthwhile.

What is the MOST appropriate advice?

Jordan D’Souza, aged 29, presents with painful urination and urethral discharge. He is in a monogamous relationship with a female partner. NAAT returns positive for Mycoplasma genitalium. He is allergic to macrolides (rash) and has no other medical issues.

What is the MOST appropriate treatment?

Sienna Varga, aged 25, presents for review of gender-affirming hormone therapy. She has been on estradiol patches and spironolactone for 3 years. She is concerned about long-term effects. Blood pressure is 110/70 mmHg, BMI 23, and recent oestradiol level is therapeutic. No signs of adverse effects.

What is the MOST appropriate management?

Anthony Russo, aged 27, presents after developing a painful inguinal mass and fever. He is a man who has sex with men and had unprotected receptive anal sex while overseas. He reports rectal pain and discharge. Examination reveals tender unilateral inguinal lymphadenopathy and mucopurulent proctitis. NAAT returns positive for Chlamydia trachomatis.

What is the MOST likely diagnosis?

Rebecca Tran, aged 33, presents for sexual health screening. She is a transgender woman who has undergone vaginoplasty. She is sexually active with men and concerned about her HIV risk. She is interested in pre-exposure prophylaxis (PrEP).

What is the MOST appropriate initial step?

Leo Grant, aged 22, presents with new genital warts. He is otherwise healthy, has sex with men, and has not received the HPV vaccine. He is distressed and wants to know if the vaccine is still worthwhile.

What is the MOST appropriate advice?

Jordan D’Souza, aged 29, presents with painful urination and urethral discharge. He is in a monogamous relationship with a female partner. NAAT returns positive for Mycoplasma genitalium. He is allergic to macrolides (rash) and has no other medical issues.

What is the MOST appropriate treatment?

Sienna Varga, aged 25, presents for review of gender-affirming hormone therapy. She has been on estradiol patches and spironolactone for 3 years. She is concerned about long-term effects. Blood pressure is 110/70 mmHg, BMI 23, and recent oestradiol level is therapeutic. No signs of adverse effects.

What is the MOST appropriate management?

Hayley Singh, aged 35, presents with concern about a new sexual partner. She is a cisgender woman who has recently started a relationship with a bisexual man who is HIV positive and has an undetectable viral load. They are considering stopping condom use. She is otherwise healthy and not on any medication.

What is the MOST appropriate advice?

Nicki Talbot, aged 40, presents with chronic pelvic pain. She is a cisgender woman in a long-term same-sex relationship. She has a history of endometriosis and multiple prior laparoscopies. She is distressed and asks about non-hormonal options.

What is the MOST appropriate next step in management?

Zac Holden, aged 29, presents for STI screening. He is a sex worker who has multiple male and female partners. He uses condoms most of the time but reports occasional breaks. He is HIV negative and takes daily PrEP. He has no symptoms today.

What is the MOST appropriate screening frequency for Zac?

Anna Papadopoulos, aged 46, presents with vaginal atrophy symptoms. She is a cisgender woman in a new relationship with another woman. She is postmenopausal and not on HRT. She experiences pain with sex and feels embarrassed discussing it.

What is the MOST appropriate initial management?

Kai Tan, aged 23, presents for advice about on-demand PrEP. He is a cisgender man who has sex with men, mostly on weekends. He has no chronic illnesses and takes no regular medications. He has heard about ‘2-1-1’ dosing and wants to know if it is suitable for him.

What is the MOST appropriate response?

Louise Carmody, aged 58, presents with concerns about sexual dysfunction. She is a transgender woman who transitioned 10 years ago and has been in a long-term monogamous relationship. She is on estradiol and spironolactone. She reports low libido and difficulty with orgasm. Her hormone levels are within target ranges.

What is the MOST appropriate initial management step?

Adrian Watts, aged 25, presents with recurrent urethritis despite previous treatment. He is a gay man who uses condoms inconsistently. Current symptoms include dysuria and scant discharge. NAAT is negative for chlamydia and gonorrhoea, and urethral swab shows elevated leukocytes.

What is the MOST likely cause?

Emma Ritchie, aged 30, presents with concerns about fertility. She is a transgender woman who has not undergone genital surgery. She has been on hormone therapy (estradiol and spironolactone) for 6 years. She is considering stopping hormones to attempt biological parenthood.

What is the MOST appropriate advice?

Lara Nguyen, aged 20, presents requesting emergency contraception after a condom broke last night during sex with her partner. She has a BMI of 38 and is otherwise well. She is not using regular contraception.

What is the MOST effective emergency contraception option for her?

Dev Patel, aged 36, presents with scrotal swelling and discomfort. He is a cisgender man in a monogamous relationship with a male partner. He reports no urinary symptoms but mentions recent fever. On examination, he has tender swelling of the left testicle and epididymis. Urine NAAT is negative for STIs.

What is the MOST appropriate next investigation?

Olivia Webb, aged 47, presents for cervical screening. She is a cisgender woman who had her last CST 6 years ago. She reports a new sexual relationship with a woman after years of abstinence. She is unsure whether she still needs screening after menopause.

What is the MOST appropriate next step?

Riley Matthews, aged 17, presents to discuss gender identity. They report feeling distressed when referred to as female and want to start transitioning. Their parents are supportive, and they are otherwise well with no mental health issues.

What is the MOST appropriate initial step in management?

Marcus Young, aged 42, presents for STI screening. He is in a polyamorous relationship and has male and female partners. He uses condoms inconsistently and is interested in doxycycline as post-exposure prophylaxis for STIs.

What is the MOST appropriate advice regarding doxycycline prophylaxis?

Aleks Petrovic, aged 50, presents with persistent anal pain and discharge. He has a history of receptive anal intercourse. Examination reveals a perianal ulcer and granulation tissue. Swabs for common STIs are negative. Biopsy reveals squamous cell carcinoma in situ.

What is the MOST important risk factor in this case?

Samira El-Khoury, aged 29, is a cisgender woman who has sex with women. She presents for routine STI screening. She is asymptomatic and last tested 18 months ago. She has had two new partners in the past year and uses barrier protection inconsistently.

Which of the following should be included in her STI screen?