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					Sexual
Health
Awareness


Sexual Health
Awareness
in custodial
settings
A self-directed workbook
Name:

Establishment/ Unit/ Department:




                         1
Sexual
Health
Awareness                                                                                                                                          CONTENTS

INTRODUCTION .......................................................................................................................................................................... 3
    INTRODUCING THIS WORKBOOK .................................................................................................................................................... 4
    AIMS OF THE WORKBOOK ............................................................................................................................................................. 4
    HOW TO USE THIS WORKBOOK ..................................................................................................................................................... 4
MODULE 1 – DEFINING SEXUAL HEALTH ............................................................................................................................... 6
    SEXUAL HEALTH......................................................................................................................................................................... 6
    DEFINITIONS OF SEXUAL HEALTH ................................................................................................................................................. 7
    HOLISTIC MODEL OF SEXUAL HEALTH .......................................................................................................................................... 9
MODULE 2 – SEXUAL HEALTH INFORMATION                                                       PART 1 ....................................................................................... 13
    SEXUAL ANATOMY .................................................................................................................................................................... 13
    SEXUALLY TRANSMITTED INFECTIONS (STIS) .............................................................................................................................. 14
    THE SEXUAL TRANSMISSION OF HIV & VIRAL HEPATITIS .............................................................................................................. 20
    RISK REDUCTION AND SEXUALLY TRANSMITTED INFECTIONS ........................................................................................................ 23
    CONDOMS AND DENTAL DAMS ................................................................................................................................................... 23
MODULE 3 – SEXUAL HEALTH INFORMATION                                                       PART 2 ....................................................................................... 26
    CONTRACEPTION CHOICES ........................................................................................................................................................ 26
    CHOICES FOR UNPLANNED AND UNWANTED PREGNANCY ............................................................................................................. 29
    OTHER SEXUAL HEALTH ISSUES FOR MEN .................................................................................................................................. 30
    OTHER SEXUAL HEALTH ISSUES FOR W OMEN ............................................................................................................................. 32
MODULE 4 – TALKING ABOUT SEX, SEXUALITY AND SEXUAL HEALTH ......................................................................... 35
    DEFINITIONS OF SEX, SEXUALITY AND SEXUAL ORIENTATION ........................................................................................................ 35
    ATTITUDES AND VALUES TO SEX AND SEXUAL EXPRESSION .......................................................................................................... 36
    VALUES AND ATTITUDES AND W ORK IN CUSTODIAL SETTINGS ....................................................................................................... 39
    TAKING ABOUT SEX .................................................................................................................................................................. 40
    PROFESSIONAL BOUNDARIES..................................................................................................................................................... 41
    SUPPORT AND SUPERVISION ..................................................................................................................................................... 41
MODULE 5 – SEXUAL HEALTH IN CUSTODIAL SETTINGS ................................................................................................. 42
    SEXUAL HEALTH IN CUSTODIAL SETTINGS................................................................................................................................... 42
    SECURITY ISSUES VS PRIVACY ................................................................................................................................................... 43
    CONFIDENTIALITY ..................................................................................................................................................................... 43
    CONTINUITY OF HEALTHCARE .................................................................................................................................................... 44
    PEOPLE WITH SUBSTANCE USE PROBLEMS ................................................................................................................................. 44
    MANAGEMENT OF BLOOD BORNE VIRUSES (BBVS) ..................................................................................................................... 44
    RELIGIOUS AND CULTURAL FACTORS .......................................................................................................................................... 45
    SAME SEX RELATIONSHIPS ....................................................................................................................................................... 45
    WORKING WITH SEX OFFENDERS ............................................................................................................................................... 46
    RAPE & SEXUAL ASSAULT ......................................................................................................................................................... 46
MODULE 6 – REFERRING ON ................................................................................................................................................. 48
    RECEPTION AND INDUCTION ...................................................................................................................................................... 48
    WHEN TO REFER AN INDIVIDUAL ................................................................................................................................................. 50
    HOW TO REFER ........................................................................................................................................................................ 50
    FOLLOW-UP OF REFERRAL ......................................................................................................................................................... 50
    DISCHARGE ............................................................................................................................................................................. 51
TAKING LEARNING INTO WORK PRACTICE ......................................................................................................................... 52
FURTHER INFORMATION ........................................................................................................................................................ 53
    REFERENCES ........................................................................................................................................................................... 53
    USEFUL W EBSITES/CONTACTS .................................................................................................................................................. 53
GLOSSARY ............................................................................................................................................................................... 54
NOTES ....................................................................................................................................................................................... 56
ACKNOWLEDGEMENTS .......................................................................................................................................................... 60




                                                                                              2
Sexual
Health
Awareness
INTRODUCTION
Sexual health is something that is a part of all our lives - whether we are currently in a relationship or not or
whether we are, in fact, actually having sex or not.

There are many factors that can contribute to poor sexual health or, indeed, to good sexual health. These include:
access to information, support and resources, experience of poverty and social deprivation, the impact of
oppression and discrimination, our relationships with our families, friends and peer networks, our experience of
current or previous sexual relationships, our mental health and emotional well-being and our relationships with
drugs and alcohol. In terms of sexual health and prisoners, we need to acknowledge that they are a
disadvantaged group which is often affected by all the risk factors associated with poor sexual health.

In England and Wales, since 1995 we have seen a significant increase in the diagnosis of most Sexually
Transmitted Infections (STIs) including the sexual transmission of HIV and viral hepatitis (Health Protection
Agency, 2007). Teenage pregnancy rates and the general numbers of unintended pregnancies continue to
remain at worryingly high levels.

We all worry about sexual health from time-to-time, but for those in prison or other custodial settings these worries
are often magnified. If we have lots of time to dwell on anxieties and concerns then we can feel particularly
vulnerable and this can have an enormous impact on our mental health and could even contribute to either
thoughts or, in extreme cases, actions of self-harm or suicide.

However, being in prison can provide a real health care opportunity. Working with offenders on their sexual health
can have an impact not only on their health and well-being, but also on that of their current and future partners
and, therefore, on the wider community. Prisoners are members of the general population and come from and
usually return to the community.

For those of us who do not work in the sexual health field, discussing issues of sexual health and sexuality can
feel difficult and perhaps embarrassing or awkward. We may not feel comfortable in responding to questions,
concerns or anxieties that may arise from conversations about sex or know how or when to refer someone to
specialist services. Working in a custodial setting presents its own difficulties and dilemmas. We may feel that in
terms of our priorities, sexual health is way down on the list.

It is hoped that this workbook will provide you with an increased awareness of sexual health and help you to
consider that the sexual health of the prison population is in all our interests. It will give you the information and
knowledge to inform and improve your working practice in managing the daily needs of people under your care
and supervision. It will also help towards creating a whole prison approach to building the physical, mental and
social health of prisoners as detailed in Prison Service Order 3200 – Health Promotion.




                                                          3
Sexual
Health
Awareness
Introducing this workbook
This workbook has been written for anybody who works with offenders within custodial settings. It is an
introductory workbook that will help participants to further enhance their work practice and develop an holistic
approach to managing individuals in their care. It will also help in the referral of offenders to the correct healthcare
professional(s).

This workbook is not written specifically for those who work in prison health care settings or already have a sexual
health role within their work remit – although these staff may find it useful as a tool to develop a greater
understanding of, and a commitment to, providing sexual health care for those currently in custodial settings

What the workbook does not cover is how to develop or run sexual health services within custodial settings. It
does not aim to tell you what you should be doing or how to do it but will, hopefully, generate thoughts and ideas
that can be put into practice within your own establishment or unit.

Aims of the workbook
This workbook aims to help you:

           Develop a basic understanding of sexual health, sexuality and sexual expression
           Understand the factors that can contribute to poor and to good sexual health
           Identify the particular sexual health issues that being in a custodial setting brings
           Feel more comfortable and confident in talking about sex and sexual health within the professional
            boundaries of your role
           Develop an understanding of the importance of referral to specialist sexual health/ health care and
            identify appropriate routes of referral for the individuals you are working with

This workbook will not:

            Enable you to identify or diagnose sexual health problems
            Replace the need for referral to specialist health care services

Note: This workbook is not intended to give you anything more than a basic awareness of sexual health
issues. It should, hopefully, give you the information and knowledge to enhance your skills in managing
individuals in your care, but will not enable you to replace the need to include or refer to specialist sexual
health services.

How to use this workbook
This workbook is divided into six modules (or sections).

Module 1            -       Defining Sexual Health
Module 2            -       Sexual Health Information Part 1
Module 3            -       Sexual Health Information Part 2
Module 4            -       Talking About Sex, Sexuality and Sexual Health
Module 5            -       Sexual Health in Custodial Settings
Module 6            -       Referring On

Each of these modules will take a different amount of time for you to complete and, whilst you need to complete
each module in order, they have been designed to allow you to work through them at your own pace and on
separate occasions. In total, the workbook should take you about ten to twelve hours to complete.




                                                             4
Sexual
Health
Awareness
In each module there are questions for you to answer and exercises to complete. It is important to finish these
fully before progressing with the workbook.

At the end of each module there is an opportunity for you to reflect on the learning points for you and to record
your thoughts on any follow-up action or to identify further learning opportunities.

This workbook is about your own learning and, therefore, is not assessed or contributes to any academic
standards. It will, however, hopefully give you a greater understanding of sexual health with particular relevance
to custodial settings, give you the confidence and information to include sexual health issues with offenders you
work with in your establishment and encourage you to explore options for further training/ self-development in this
area.




                                                        5
Sexual
Health
Awareness                                                                                  MODULE 1

MODULE 1 – DEFINING SEXUAL HEALTH

 Module Aims:

 By the end of this module you will have:

        Considered definitions of sexual health
        Developed an awareness of the factors that can impact on our sexual health
        Identified how these factors can relate to the sexual health of people in custodial settings
        Demonstrated a basic understanding of the meaning of sexual health




Sexual Health
The term sexual health is widely used as a general term, but when we consider what this term really means it can
be difficult to explain.

Exercise 1
What does the term sexual health mean to you? Write down below how you would describe good sexual health.
If forming your thoughts into one sentence proves difficult, make a short list of what you believe to be the key
elements of good sexual health.

Good sexual health is




When we hear the term sexual health, the things that most probably spring to mind are: avoiding sexually
transmitted infections or unwanted pregnancy, not suffering from sexual dysfunction (being physically unable to
have sex) and having a fulfilling and enjoyable sex life. All these things are an important part of good sexual
health, but there is so much more to sexual health that we need to consider.
Here are some definitions of sexual health. After reading them, write down your first thoughts about them.




                                                         6
Sexual
Health
Awareness                                                                                    MODULE 1
Definitions of Sexual Health
1)    Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality: it is not
      merely the absence of disease, dysfunction or infirmity.

      Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as
      the possibility of having pleasurable and safe sexual experiences which are free from coercion,
      discrimination and violence.

      For sexual health to be attained and maintained, the sexual rights of all persons must be respected,
      protected and fulfilled.

                                                                                        (World Health Organisation)

2)    Sexual health means enjoying the sexual activity you want without causing yourself or anyone else
      suffering, physical or mental harm. It is not just about using contraception or avoiding infections.

                                                                                  (fpa – Family Planning Association)

Exercise 2
Write down your thoughts about these definitions. Are they helpful? Do they say enough for you?




It may be useful to unpick these definitions of sexual health and list all the things they cover.

Having good sexual health means:

 Having sex that is consensual, mutual, equal and legal *

 Feeling good about ourselves as a sexual being and how our bodies can give and receive sexual pleasure

 Knowing that we all have the right to be sexual and the right to sexual pleasure

 Not being forced or manipulated into having sex that we do not want

 Not forcing or manipulating others into having sex that they do not want




                                                           7
Sexual
Health
Awareness                                                                                    MODULE 1
 Feeling comfortable about and receiving affirmation of our sexual orientation – whether we are gay, lesbian,

   heterosexual or bisexual

 Being free from sexual disease and infection

 Knowing how to protect ourselves from being infected with, or infecting others with, sexually transmitted

   infections

 Deciding when to get pregnant and being supported in avoiding unintended pregnancy

 Having the right to choice when pregnant – including access to safe, timely and supportive abortion services

 Having access to good sexual health information and services

 Being able to use our bodies sexually and being supported emotionally and physically to achieve this **

 Not having anything done to our bodies that will negatively affect our emotional or physical well-being or our

   ability to have sex ***



 Notes

 *        The age of sexual consent in England and Wales is 16. This is an equal age of consent for all –
 whether gay, lesbian, heterosexual or bisexual. However, there is a specific section of the Sexual Offences
 Act that makes it illegal for adults in a position of trust (e.g. teachers, youth workers, probation officers, prison
 workers etc.) to have sex with anyone under the age of 18 who is, or has been, in their care.

 **       In order to achieve a satisfying and enjoyable sex life, some people will need psychological support in
 the form of psychosexual counselling or therapy. Others may have physical difficulty in having sex and may
 need support in the form of aids or adaptations to help them achieve sexual relationships or medical support
 (e.g. prescribing viagra/ erection aids/ treatment for haemorrhoids/ lubrication for vaginal dryness)

 ***     This covers the impact of rape, sexual assault and sexual torture. It also refers to practices such as
 female genital mutilation (FGM) – sometimes referred to as female circumcision. This practice is now illegal in
 England and Wales (The Female Genital Mutilation Act 2003).




                                                          8
Sexual
Health
Awareness                                                                            MODULE 1
Holistic Model of Sexual Health
There are many factors that impact on our sexual health. Factors that can promote and help achieve good sexual
health. Factors that can also have a negative and damaging effect on our sexual health.

The following model provides a framework for identifying the areas of our lives that contribute to our sexual
health.



                                              Sex and
                                              Sexual
                                              Practice


                                                                      Life Experiences
           Political Factors




                                                                                    MODULE 1
                                              Sexual
       Spirituality                           Health                                Self Image




                           Social                              Emotions
                        Relationships




                              Adapted from a model by Jo Adams & Carol Painter
                                        Centre for HIV & Sexual Health




                                                      9
Sexual
Health
Awareness                                                                                  MODULE 1
Sex and Sexual Practice

This refers to the actual sex we are having (or not having) and who with. Is it mutual, equal and consensual, is it
pleasurable, are we enjoying it and is it what we want? Are we taking the right precautions to avoid unintended
pregnancy and sexually transmitted infections?

What messages do we receive about the value of exploring our own bodies sexually, do we feel comfortable with
masturbation. What do we hear from the media and peer groups about the type of sex we should be having and
how often. How does this make us feel about our own sexual practice?

Are we currently celibate and is this by choice or by circumstance e.g due to illness or to being in prison?

Life Experiences

Our experiences of life events impact not only on our mental and emotional health but can also affect our sexual
health. Some experiences have obvious links to sexual health – for example rape and sexual assault, experience
of sexual torture, childhood sexual abuse, accidents/ injury to sexual organs, illness and even pregnancy and
childbirth.

Other life experiences such as poverty, growing up in a neglectful or abusive family environment, relationship
breakdowns, experience of domestic violence, a history of substance misuse and our experiences of spending
time in a custodial setting can also have a negative effect on how we feel about ourselves, our relationships and
our sex life.

Self Image

How we feel about ourselves, the way we look, our size and shape, the ageing process all have a huge impact on
our sexual health. If we generally feel good about ourselves and have high self-esteem then we are going to feel
good about our sexuality and sexual expression and how our bodies can give and receive sexual pleasure.

However, there are many things that can have a detrimental effect on our self-image. The media, for instance,
gives out very powerful and damaging messages about how we should look and what we should wear in order to
be sexually attractive. Basically, the messages we could be receiving are that we should be young, tall, slim, able
bodied and absolutely flawless. If we feel that we can’t live up to these images and messages (and let’s be
honest, not many people can!), we are more likely to suffer from low self-esteem and to enter relationships with a
need for reassurance, affection, neediness and feel inferior to our sexual partners. In summary we are more likely
to give away our sexual rights and, therefore, feel less than great about our sexual health.

For people who have a chronic disease (e.g. HIV, hepatitis C, cancer etc.) the potential detrimental effect on self
image and self worth can also have a negative impact on their feelings of sexuality and on their sexual
expression.


Emotions

We cannot separate our emotional well-being from our sexual well-being. They are connected and affect each
other. Emotions are feelings and sex without feeling is mechanical, dislocated and lacking in intimacy. For some
people this may actually be their experience of sex. For example, some women (and men) involved in prostitution,
people in abusive relationships and people forced into having sex they do not want. This can have a huge impact
on their current and future sexual health.

Casual sex can sometimes be regarded as sex without emotions, but for some people it is an informed choice
that can avoid the potentially threatening emotions such as fear of abandonment, dependency, jealousy etc. And
for some, it involves the same range of emotions that people feel in an established sexual relationship. In fact,
people who are ‘in love’ generally take greater risks and are more likely to have unprotected sex for ‘bonding’
reasons, to achieve greater intimacy or as a gesture of trust.




                                                         10
Sexual
Health
Awareness                                                                                   MODULE 1
Our ability to feel the full range of emotions and feelings and to be able to express and feel these within our
sexual relationships is central to good sexual health. This includes emotions such as love, desire, pleasure and
happiness as well as emotions that can be perceived as negative like anger and jealousy – these are emotions
we all feel from time to time, it’s what we do with these and how we communicate them that can have a positive or
negative effect on our sexual relationships.

Social Relationships

Our experience of our wider relationships, not just our sexual relationships, is another factor that can influence our
sexual health. What are some of the early messages that we get from our parents, teachers and other family
members about sex? Are they affirming and accepting or negative and condemning – leaving us feeling guilty,
secretive or even dirty about sex? What are the messages we received about masturbation for instance?

The influence of our social relationships with our friends and other important figures in our lives continue to affect
how we feel about sex and, therefore, impact on our sexual health throughout our lives. The messages we all give
out (whether verbal or non-verbal) about sex and sexual practice can help people feel good about themselves
sexually or make them feel ashamed, inadequate or unequal.

Spirituality

For many people their beliefs and values are shaped by their spirituality, which is often (though not always)
aligned to religion. Having faith and being part of a religious community can give people a deep sense of comfort,
self-worth and belonging which can only help them to achieve good sexual health.

However, for some people, the messages they receive about sex and sexual practice from religious leaders can
have devastating impact on their ability to feel good about their sexuality and sexual expression. For example –
being gay and told that homosexuality is against gods will, being told that all forms of contraception (including
condoms) are forbidden, believing that it is wrong for a woman to refuse her husband sexually or that
masturbation is a sin and a weakness. These messages can, and do, have a detrimental effect on sexual health.

Political Factors

Many people in society experience discrimination, prejudice and harassment simply because of the community
they are part of. The messages these people receive about their value as members of society and about their
sexual relationships are often negative, dismissive or even hostile. Being in receipt of these messages can
damage feelings of positive sexuality and self-worth.

Some examples of how being part of a group experiencing discrimination can impact on sexual health are:

 Gay men, lesbian and bisexual people hearing homophobic views about the value of their partnerships,
  stereotypical images about the sex they have and being seen as sexually deviant.
 Women who carry condoms and initiate sexual relationships being labelled as immoral or promiscuous.
 People in prison being expected to suppress their sexual feelings and even refrain from masturbation
 Older people and people with disabilities having their sexual needs ignored or seen as insignificant by the
  medical profession.




                                                         11
Sexual
Health
Awareness                                                                                  MODULE 1
Exercise 3
Thinking about the people in your care, identify factors in their lives that may have a damaging effect on their
sexual health.




This holistic model helps us to not only understand the various factors that impact on our sexual health but also
demonstrates that work that we are doing with people in our care in areas that are not obviously about sex and
sexuality can, and do, have an impact on their sexual health.

Based on this model, examples of work that can contribute to good sexual health are:

   Providing timely access to good quality, confidential sexual health information and services
   Arranging counselling and therapy to work through negative life experiences
   Sexual risk reduction counselling
   Self esteem workshops
   Anger management classes
   Encouraging supportive peer and social networks
   Allowing people to have the space and time to explore their religious and cultural beliefs
   Challenging homophobic comments and remarks

Module Reflection
My three main learning points from this module are:

    1.


    2.


    3.

My three ideas for how this module can improve my working practice are:


    1.


    2.


    3.



                                                         12
Sexual
Health
Awareness                                                                                  MODULE 2

MODULE 2 – SEXUAL HEALTH INFORMATION
           PART 1
 Module Aims:

 By the end of this module you will have developed a basic awareness of:

        Sexual anatomy
        Sexually Transmitted Infections (STIs)
        The Sexual transmission of HIV & Viral Hepatitis
        Risk reduction and STIs
        Condoms and dental dams

 Note: This module is not intended to give you anything more than a basic awareness of sexual
 health issues. It should, hopefully, give you the information and knowledge to enhance your skills in
 managing individuals in your care, but will not enable you to replace the need to include or refer to
 specialist sexual health services.




Sexual Anatomy
This module gives information about Sexually Transmitted Infections (STIs), contraception and other sexual
health issues that can affect men and women. As it is predominantly the genitals, reproductive system and urinary
tract that are affected by STIs, feature in our contraception choices and are core to our sexual and reproductive
health, it is important that we start with making sure we are familiar with the terms used to describe these areas of
our bodies. We also need to acknowledge that some people have anal and/ or oral sex – areas of our bodies that
can also be affected by STIs and other sexual health issues.


Female Reproductive System

The female reproductive system is mainly internal and its function is to make hormones, produce eggs, provide
space for eggs to be fertilised by sperm and to feed and protect developing babies before birth.



   Uterus/Womb                                                                                          Clitoris
                                     Fallopian
                                     tube                                                               Labium
                                                                                                        majora
                                           Ovary
                                                                                                        Urethral
    Cervix                                                                                              opening


                                                                                                        Vaginal
                                                                                                        opening

             Vagina    Vulva                                                                     Labium
                                                                          Anus                   minora




                                                         13
Sexual
Health
Awareness                                                                                    MODULE 2
Male Reproductive System

The male reproductive system is mainly external and its function is to make hormones and produce sperm.

              Bladder

                                                                                           Prostate Gland
               Urethra



                Penis
                                                                                               Rectum



              Foreskin
                                                                                                Anus


                                 Glans      Testicle       Scrotum           Vas Deferens
                                                                             (sperm tube)



Sexually Transmitted Infections (STIs)
STIs are infections that can be passed from one person to another person during sexual activity. There are over
30 different infections that can be passed on sexually. Some of these really can only be passed on during sex,
some can be passed on in other ways and some develop in our own bodies and then can be passed on sexually.
Basically, sex involves getting close and intimate with other people and this is what allows the infections to
spread.

STIs can be passed on through vaginal sex, anal sex, oral sex and mutual masturbation/ fingering.

At best, STIs can cause discomfort, embarrassment and irritation. They can, however, have long-term effects on
our health including infertility (unable to have children), impotence (unable to have an erection), life-long illness or
even death. Some STIs that can cause long-term damage have no symptoms at all.

STIs roughly fall into one of three categories – bacterial infections, parasitic infections and viral infections.


Bacterial Infections

Bacteria are very small single-celled life forms that live in and around us and can reproduce quickly. While not all
bacteria are harmful (in fact our bodies need some forms of good bacteria) some cause disease and illness. In
order to survive and develop, most bacteria use organic matter as food and warmth. Therefore, if we think about
the warm, moist parts of our bodies (vulva, vagina, penis, rectum and throat) they are the ideal places for bacteria
to thrive and grow.

The following table details some of the main sexually transmitted bacterial infections, their possible symptoms and
effects and treatments available.




                                                          14
Sexual
Health
Awareness                                                                           MODULE 2
Chlamydia    Chlamydia is the most common form of bacterial STI that can easily be passed on during
             vaginal, anal or oral sex. Depending on where a person becomes infected with Chlamydia, it
             can be found in the vagina, rectum, urethra or throat.

             Even though Chlamydia may be present, many people do not have any symptoms at all,
             although some people may experience an unusual discharge from the vagina or penis, pain
             when urinating or having sex or bleeding after sex.

             If not detected and treated, chlamydia can have long-term effects on our health.

             In women, the infection can lead to Pelvic Inflammatory Disease (PID) and could also
             spread throughout the reproductive organs and cause permanent blockage of the fallopian
             tubes – meaning that it could be difficult or impossible to conceive (have a baby) without IVF
             treatment.

             In men, the infection could spread up the urethra and into the testicles – causing pain and
             swelling of the testicles or block the vas deferens (the tube which sperm leave the body
             from).
                                                                                    MODULE 2
             Treatment for Chlamydia consists of a course of antibiotic tablets. This is a very effective
             treatment for most people, but they should refrain from having sex until they (and their
             partner – if they have one) have completed treatment.
Gonorrhoea   Gonorrhoea is another common bacterial STI (sometimes called the Clap) that is very
             similar to Chlamydia in how it is transmitted and the areas of the body it affects.

             However, unlike Chlamydia, the majority of males will experience symptoms, but the
             majority of women will not. These could include:
              an unusual white, yellow or green discharge from the penis or vagina
              pain when urinating or having sex
              irritation, discharge or itching in the rectum

             If not detected and treated, gonorrhoea can also have long-term effects on our health. It can
             affect fertility in both men and women and could cause abdominal pain.

             Treatment for Gonorrhoea consists of a single high dosage of antibiotic tablets. This is a
             very effective treatment for most people, but they should refrain from having sex until tests
             show that the treatment has worked.

Syphilis     Syphilis is a much more complicated bacterial STI. It can be spread by intimate close body
             contact and during all forms of sexual intercourse. Until recently, cases of Syphilis in England
             and Wales had become very rare but there has been a dramatic increase in the number of
             cases detected at sexual health clinics.

             If left untreated, Syphilis can have serious effects on our health and could eventually (many
             years from infection) lead to the breakdown of many of our major organs – even resulting in
             death.

             There are three stages to the development of Syphilis in the body.

             Primary stage Syphilis – one or more painless sores or ulcers appear (usually around the
             point of genital contact with the sores of an infected person). These could be external (on the
             vulva, penis, anus or mouth) or internal (in the vagina, rectum, tongue or throat). These sores
             are very infectious but usually disappear after a few weeks.
                                                                                  MODULE 2
             Secondary stage Syphilis – the bacteria enters the bloodstream and over the next one to
             two years, infected people will have other symptoms:
                                                                                  MODULE 2

                                                  15
Sexual
Health
Awareness                                                                              MODULE 2
                  a rash that is non irritating that can be anywhere on the body – but typically on the torso,
                   hands and feet, . This rash will come and go and unless it appears in the mouth, is not
                   infectious.
                  white patches in the mouth
                  mild flu-type symptoms
                  wart-like growths around the vulva and anus or mouth

                 Tertiary stage Syphilis – after many years, the bacteria begins to affect all the major organs
                 in the body and the central nervous system leading to brain damage, heart failure, liver
                 failure and eventually death.

                 Syphilis is usually detected by having a blood test for the bacteria, though if in the early
                 stages where sores or ulcers are present, these can be swabbed to detect the bacteria.

                 Treatment at any stage of this infection is by a course of antibiotics (normally penicillin
                 based). These will be administered either by injection into the buttocks or orally depending
                 on a sexual health clinic’s practices.

Thrush           Thrush is a common yeast infection that many women (and some men) are susceptible to.
                 This yeast (called candida) lives in all our bodies but is usually kept in check by naturally
                 occurring bacteria.

                 Symptoms for women can include irritation, swelling and soreness around the vagina and
                 vulva, a thick, white, cheesy discharge and pain when urinating or having penetrative sex.

                 Symptoms for men can include irritation, itching or redness under the foreskin, a thick
                 cheesy discharge from under the foreskin and pain when urinating or ejaculating

                 Possible causes are:
                  a reaction to antibiotics
                  having sex with someone who has thrush
                  a reaction to some perfumed soaps, vaginal cleansing products
                  wearing tight nylon or lycra underwear

                 Treatments
                  an anti-fungal cream or vaginal pessaries (e,g. canesten)
                  anti-fungal tablets taken by mouth
                  advising people to avoid overusing deodorants, perfumed soaps and toiletries in the
                    genital area and avoid synthetic or tight underwear
                  for some women, using sanitary pads instead of tampons during menstruation (periods)
Gut Infections   Some bacteria that can live in our stomach and intestines can also be passed on sexually.
                 Bacteria such as Giardiasis, Amoebiasis and Salmonellosis cause stomach cramps and
                 diarrhoea and weight loss.

                 If we come into contact with the rectal area or faeces of an infected person – through anal
                 sex, handling sex toys that have been used in the rectum or by fingering the anal area– and
                 the bacteria gets from our fingers into our mouth then we could also get these gut infections.
                 Another sexual practice that could transfer these bacterial infections is oral-anal sex
                 (sometimes called rimming).

                 Treatment for these gut infections is by taking appropriate antibiotics. The type of antibiotic
                 prescribed depends on the type of gut infection detected.




                                                     16
Sexual
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Parasitic Infections

A parasite is an animal or plant that lives in or on a host (another animal or plant). They obtain nourishment from
the host without benefiting or killing the host.

Parasitic infections that can be passed sexually can also be passed on in other ways, but getting close and
intimate with someone who has one of these infections is an ideal way for a parasite to move from one person to
another.

The table below details some of the main sexually transmitted parasitic infections, their possible symptoms and
effects and treatments available.

Pubic Lice         Pubic Lice are sometimes referred to as Crabs. They are tiny insects similar to head lice
                   that feed off us by sucking our blood. They generally live in any body hair apart from on the
                   head. This could be in pubic hair, chest hair, underarm hair, eyebrows and eyelashes.

                   Pubic lice travel around our bodies by crawling from hair to hair and lay their eggs at the
                   shaft of hairs. They cannot jump or fly so transmission is by close body contact. Sexual or
                   close bodily contact is the most likely route of transmission though it is possible to become
                   infected by sharing bedding, towels or clothes with an infected person. It is extremely unlikely
                   that you could pick them up from a toilet seat or sitting next to someone on the bus.

                   Symptoms typically include:
                    itching, irritation and scratching
                    black powder from insect droppings in underclothes and bedding
                    visible insects in body hair

                   Although very easy to pick up, they are also relatively easy to treat. Treatment involves
                   applying a lotion over the whole body (these can be bought from pharmacies or prescribed
                   from health care centres). These lotions need to be left on for about 12 hours before washing
                   off and this will kill the insects and their eggs. Bedding and clothes should also be washed on
                   a hot 50 degree cycle.

                   It is possible for itching to continue for a week or two even if the treatment has been
                   successful – calamine lotion can help to relieve this itchiness.
Scabies            Scabies is another tiny parasitic insect that feeds on blood but this insect actually burrows
                   under the skin. They can live on any part of our bodies but tend to prefer the more fleshy
                   parts such as between our fingers and toes, wrists, inside of elbow and knee joints,
                   underarms, abdomen, bust, buttocks and genital area.

                   These insects are passed from person to person through close and sustained bodily contact
                   including sexual contact. It is possible though not common to be infected by sharing bedding,
                   towels, clothing or by handshakes and similar social contact.

                   Symptoms typically include:
                    itching, irritation and scratching
                    a rash of tiny spots
                    raw broken skin from intense scratching
                    tiny lines or track marks where the insect has burrowed

                   Treatment for scabies is the same as for pubic lice - a lotion that needs applying over the
                   whole body (bought from pharmacies or prescribed from health care centres) which needs to
                   be left on for between 12 and 24 hours before washing off. This will kill the insects and their
                   eggs. As a precaution it is also advisable to wash bedding and clothes on a hot wash cycle.




                                                        17
Sexual
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Awareness                                                                               MODULE 2

Threadworm         Threadworms are small worms that look like threads of white cotton. People develop these
                   worms when the eggs of the worm get onto their fingers and then into their mouth. The
                   worms live inside the rectum and around the anus causing itchiness and irritation.

                   Threadworms are a very common infection in children (but also adults) who usually come
                   into contact with the eggs whilst playing on areas covered in grass or on bare soil. They are
                   treated with tablets or powders bought over-the-counter at chemists or prescribed by
                   medical centres.

                   Threadworms can be passed on sexually by coming into contact with the rectal area or
                   faeces of an infected person – through anal sex, handling sex toys that have been used in
                   the rectum, by fingering the anal area and from oral-anal sex.


Viral Infections

A virus is an infectious agent that invades and takes over cells within our bodies and cause disease and illness.
There are many forms of viral infections that can be passed from one person to another – measles, mumps,
influenza, chickenpox etc.

Some viral infections are classed as STIs because this is the way they are mainly contracted. In the table below,
two of the main sexually transmitted viral infections are detailed.

We would also include HIV and some forms of Viral Hepatitis in this category, but these are discussed in detail
later in this module.

Genital Warts      These warts are caused by the Human Papilloma Virus (HPV) and although they can
                   appear anywhere on the body, when they are in or around the sexual organs are known as
                   Genital Warts. They are the second most common STI detected and treated at sexual
                   health clinics.

                   These warts are fleshy growths (a bit like cauliflower florets in shape). They can appear in
                   and around the vagina, the anus, the penis or on the scrotum. Usually, they are not painful
                   but can cause irritation. They are passed on by skin-to-skin contact with the warts.

                   Once somebody is infected with HPV, they will always have the virus (which lives under the
                   skin) even if they have warts or not. People are only infectious when they have the warts.

                   Warts can be treated in one of four ways:
                    cryotherapy – freezing the warts using liquid nitrogen
                    painting the warts with an anti-wart liquid
                    hyfrecation – burning the warts off with an electric current
                    laser treatment

                   This treatment may take weeks or months to clear the warts.

                   Once treated some people will have further outbreaks of warts from time-to-time whilst others
                   will not. Therefore, a regular check-up is recommended, not least because there is also a
                   possible link between Genital Warts and Cervical and Anal Cancer




                                                        18
Sexual
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Genital Herpes       Genital Herpes is caused by a form of the Herpes Simplex virus that can also be
                     responsible for the cold sores that can appear around your mouth.

                     Once infected with the virus, sores or blisters can appear at the point of infection – this could
                     be in the genital area, around the anus, around the mouth or even around the eyes. These
                     blisters are highly infectious but usually disappear after 2 – 3 weeks.

                     Even though the blisters disappear, the virus will still be present in the nerve endings.
                     Whether someone has subsequent outbreaks of blisters depends on how efficiently their
                     immune system is working. Things that affect our immune system can promote a new
                     outbreak of herpes – tiredness, stress, alcohol and drug use, periods of ill health can all
                     contribute to herpes blisters reappearing for some people.

                     Treatments available do not attack the virus itself but aim to relieve the symptoms of the
                     blisters or stop the blisters from developing. They take the form of creams and ant-viral
                     tablets. Unlike treatments for cold sores, there are no over-the-counter remedies available for
                     genital herpes.



Exercise 4
Most custodial settings have access on-site (usually through healthcare units) for people to access testing and
treatment for STIs. Find out what services are available in your establishment for the screening, diagnosis and
treatment of STIs and record your findings here.

Some questions you might ask are:

   Is there an on-site sexual health service?
   Who runs it (a visiting sexual health team or prison health staff)?
   When and how often is it available?
   How would a prisoner access the service
   Is there a waiting list?
   How confidential is it?




                                                          19
Sexual
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Awareness                                                                                  MODULE 2
The Sexual Transmission of HIV & Viral Hepatitis
HIV and AIDS – an overview

HIV stands for Human Immuno-deficiency Virus. It is a viral infection that can be transmitted sexually. In fact, of
the 40 million people infected with HIV in the world the vast majority were infected from having sexual intercourse
with another person with the virus.

Once the HIV virus enters the body it attaches onto cells in our immune system that help protect us and keep us
healthy. It eventually kills off these cells weakening the immune system so that it is unable to fight off infections
and other illnesses.

A person who has been infected with HIV and has the virus is said to be HIV positive. Someone who has been
tested for HIV and does not have the virus is HIV negative. Most people, however, are HIV status unknown – that
is they have not been tested so cannot say with certainty what their HIV status is.

Once the immune system is weakened by HIV, illnesses that would otherwise be easily fought off can take hold
and affect us (these are called opportunistic infections). These include rare kinds of cancers, pneumonia and
brain diseases amongst many others. If someone who has the HIV virus develops some of these rare illnesses
then they are said to have AIDS. AIDS stands for Acquired Immune Deficiency Syndrome. HIV and AIDS are
not the same thing.

A person who is HIV positive can live for many years before being affected by the illnesses that might give them
an AIDS diagnosis. In England and Wales there are very effective treatments that work for many people. They
help to keep the amount of HIV in someone’s body at a manageable level and help the immune system stay
stronger for longer. These drug treatments do have side effects that can be difficult to live with and the treatments
need to be taken regularly and at certain times of the day in order to be effective. If treatment is suspended or
interrupted, someone may develop a drug resistant form of HIV.

Recent developments in treatment of HIV include Post Exposure Prophylactic treatment (PEP). If someone has
been at risk of being infected with HIV (e.g. by having unprotected sex with someone who is HIV) they can take a
3 month course of HIV drug treatments that start within 72 hours of possible exposure to the virus, which can stop
HIV taking hold in the body and prevent HIV infection.

However, the outlook has never been better for HIV positive people in the UK. Life expectancy for people with HIV
who start treatment before there is too much damage to the immune system is now similar to that of people who
do not have the virus. This is not the case in some parts of the world where access to treatment is limited or non-
existent and where people are still dying of an AIDS related illness every day.

Transmission of HIV

When a person is infected with HIV, the virus can be found in many of their bodily fluids. However, in fluids like
saliva, sweat and urine the levels of virus are so low and the quality of virus so poor that there is absolutely no
chance of being infected with HIV by coming into contact with them.

The only bodily fluids where the level and quality of HIV is high enough to be infectious are:

   Blood
   Semen
   Vaginal Fluids


    Anal Mucus
    Breast Milk
                                                                                           MODULE 2
Coming into contact with these bodily fluids is not in itself a risk in terms of infection. There has to be route of
transmission for these fluids to get into our blood stream.
                                                                                           MODULE 2

                                                         20
Sexual
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Many of the high-risk activities in terms of possibly becoming infected with HIV are sexual activities. Particularly
high-risk activities are vaginal penetrative sex and penetrative anal sex – where the penis enters the vagina or
rectum. This applies to both men and women, gay or straight and whether you are the person being penetrated or
the person penetrating (the giver or receiver). Oral sex carries some risk of infection but this is much lower than
penetrative sex. The factor that could increase the risk of infection from oral sex is the general state of the mouth
and throat. If there is damage from bleeding gums, mouth ulcers or from a bacterial STI (e.g. gonorrhoea) than
the risk is increased. Oral sex performed on a man (fellatio) is higher risk than oral sex performed on a woman
(cunnilingus).

The following table gives examples of those activities that are no risk in terms of HIV infection; those where there
is some risk but it is unlikely that someone will be infected by taking part in these activities; those considered low
risk activities and those activities where there would be a high risk of infection.


No Risk                      Very Small Risk               Low Risk                      High Risk

Kissing                      Sharing a toothbrush          Oral sex – fellatio           Penetrative vaginal sex
                                                                                         without a condom
Shaking Hands                Sharing razors                Penetrative vaginal sex       Penetrative    anal   sex
                                                           using a condom                without a condom
Hugging                      Oral sex – cunnilingus        Penetrative  anal   sex       Sharing needles for IV
                                                           using a condom                drug use
Sharing cups and glasses     Oral sex – anal lingus                                      Breast feeding a baby
                             (rimming)
Being spat at                Sharing        sex  toys
                             (vibrators/dildos)
Being bitten                 Needle-stick injury

Sharing a toilet             Being bitten – if skin is
                             broken
Massage                      Blood transfusion in the
                             UK
Mutual masturbation

From swimming pools


In terms of high-risk activities, if we are working with an offender who is HIV positive, the table above
demonstrates that occupational exposure to HIV and the risk of infection is rare with only needle-stick injuries
being a matter for concern. Prison Order 3845 gives details on the management of blood borne and
communicable diseases.                                                                      MODULE 2
Viral Hepatitis – an overview

Hepatitis literally means disease of the liver. Many factors can lead to liver damage or Hepatitis – including
alcohol and drug use. However, there are also a number of viruses that can also cause liver damage. These are
referred to as Viral Hepatitis.

There are many types of Viral Hepatitis, some affect us more than others, some have a vaccine to prevent
infection of these types of Hepatitis, some can be transmitted from sexual activity and some can lead to long term
and chronic illness – even death.

Our liver is an extremely important organ that helps the body to:
 Process food and clear toxins from the body
 Store energy for when we need it



                                                         21
Sexual
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Awareness                                                                                  MODULE 2
Symptoms of hepatitis infection could, therefore be:
 Extreme tiredness
 Aches and pains
 Loss of appetite
 Jaundice (yellowing of the skin/whites of the eyes)
 Nausea, sickness and diarrhoea
 A bad reaction to alcohol

Treatment really depends on the type of Hepatitis we have contracted, how long we have been infected and our
general level of health. For some people, rest and a healthy diet is enough to help the body naturally clear the
virus, others will need drugs (Interferon) to do this and, for some, having Hepatitis will be a lifelong illness that
could eventually require a liver transplant.

Types of Viral Hepatitis

The following table details the different types of Viral Hepatitis, the bodily fluids that are infectious in someone
with each type, how sexual transmission may be possible and whether a vaccination is available.

 Type    Bodily fluids that are     Possible routes of sexual transmission                           Vaccination
         Infectious                                                                                  available?
 A       Faeces (shit)              Oral-anal sex (rimming)                                          Yes
                                    Penetrative anal sex
                                    Fingering the rectum
                                    Using anal sex toys
 B       Blood                      Penetrative vaginal sex                                          Yes
         Semen                      Oral sex – cunnilingus
         Vaginal fluids             Oral sex - fellatio
         Saliva                     Penetrative anal sex
         Breast Milk                Rimming
 C       Blood                      Small risk of sexual infection if blood is present in sexual     No
                                    fluids
 D       Blood                      Penetrative vaginal sex                                          No
         Semen                      Oral sex – cunnilingus
         Vaginal fluids             Oral sex - fellatio
         Saliva                     Penetrative anal sex
         Breast Milk                Rimming
 E       Faeces (shit)              Oral-anal sex (rimming)                                          No
                                    Penetrative anal sex
                                    Fingering the rectum
                                    Using anal sex toys
 F       See notes below
 G       Blood                       Small risk of sexual infection if blood is present in sexual No
                                     fluids
Note: There is no Hepatitis F. Researchers at one stage thought they had identified a new type of Hepatitis and
named it ‘F’ – this was later disproved.

We will be looking at the management of HIV, Viral Hepatitis and STIs within custodial settings in Module
5.




                                                         22
Sexual
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Awareness                                                                                MODULE 2
Risk Reduction and Sexually Transmitted Infections
STIs are extremely common infections – many of us will come into contact with at least one of these at some part
in our lives. They are also extremely easy to pass on from one person to another through all types of sexual
activity. But there are a number of things we can do to reduce the risk of being infected with STIs.

 Use condoms for penetrative vaginal or anal sex and for fellatio. Condoms are an effective barrier for most
  (though not all) STIs.
 Use dental dams (a flavoured latex barrier) for cunnilingus.
 Have a regular sexual health check up at a sexual health clinic (GU Clinic). This could be every year, every 6
  months or every 3 months dependent on our sexual activity and the number of sexual partners we have.
 Seek prompt medical attention for any symptoms of STIs
 Refrain from sexual activity while undergoing any treatment for an STI
 Regularly check our genitals for signs of infection

Condoms and Dental Dams
Condoms

If used correctly and consistently, condoms are an effective barrier to most STIs. Yet there are still a lot of
reasons that people give for not wanting to use them. Some of the reasons you may have heard are:

   They are a passion killer – they spoil the moment
   If I carry a condom people will think I’m easy
   It makes sex less intimate
   It’s like having a bath with a raincoat on
   It doesn’t feel natural
   I mean to, but get carried away with the moment
   I can’t get hold of them when I need to use them
   I can’t seem to keep an erection when wearing one
   They don’t fit, they are too tight

However, knowing you and your partner are less likely to get an STI (or get pregnant) can help give you peace of
mind. Condoms can be fun to use if part of the whole sexual experience. There are many different condoms
available that have different textures, are thinner, non-latex, flavoured and even one that includes a local
anaesthetic to help men delay ejaculation. It can be enjoyable finding out which one you prefer using!

For condoms to be effective they need to be used correctly. The majority of condom failure is down to incorrect
usage. It might seem straightforward – you get a condom, put it on, have sex, then throw it away. However, there
are some golden rules of condom use that should be followed. These are given on the next page.




                                                        23
Sexual
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Awareness                                                                    MODULE 2
Condom Use

             Step 1
             Before opening the condom packet, check that it is still in date. Condoms have an expiry
             date and shouldn’t be used after this date. Check that the type of condom has been given
             a Kite-Mark or CE mark (European quality standard), (a mark to show it is of an
             acceptable standard. Also check that the package has not been damaged).



             Step 2
             When opening the package, do this carefully It is best to squeeze the condom away from
             where you are tearing the packet open. Watch out for nails and jewellery that could tear
             the condom. Never open the packet using your teeth.




             Step 3
             Check that you know which way the condom will unroll so that you don’t try to put it on
             inside out, pinch the end of the condom to make sure there is space for the semen to
             collect and place the condom at the head of the erect penis.




              Step 4
              Roll the condom down to the base of the erect penis.
              If you want to use a lubricant, make sure you use a water based one* that will not
              damage the condom. Lubricants are essential for anal sex as the rectum does not have
              natural lubricant like the vagina, but you may also want to use lubricant for vaginal
              penetration. Only put lubricant on the outside of the condom when it is fully on – never
              inside as it may slip off.

              Step 5
              Have sex! During sex you should check from time-to-time that the condom is still in
              place and has not been damaged. If you are having a particularly long session it is
              advisable to stop and change the condom.


             Step 6
             After ejaculation, hold the base of the condom so that it doesn’t come off during
             withdrawal. Then carefully remove the condom to avoid spillage, wrap it in tissue and
             throw it in the bin. Do not flush them down the toilet.

              Notes : * oil based lubricants such as baby oil, vegetable oil and Vaseline can
              damage latex condoms and make them more likely to split. Non-latex condoms that
              can be used with oil based lubricant are available.
                                                                             MODULE 2
              Using two condoms together does NOT make sex safer. The friction actually makes
              them both more likely to split

              Condoms should only be used once.


                                           24
Sexual
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Awareness                                                                              MODULE 2
Dental Dams



                                 Dental dams are sheets of flavoured latex that can be used as a barrier to
                                 prevent infections from vaginal oral (cunnilingus) and anal oral (rimming) sex.

                                 They are placed over the entire vaginal or anal area and held in place whilst
                                 oral sex takes place. Like condoms, dental dams should be thrown in the bin
                                 after use and only used once.




 Exercise 5
 The provision of condoms and/ or dental dams in custodial settings is dependent on the individual
 establishment. Find what the arrangements are for condom or dental dam distribution within your establishment
 (if any) and record your findings here.




Note: Prison doctors or their deputies have a duty to make condoms, dental dams and water based lubricants
available to any prisoner, irrespective of age, who requests them. If they are not made available, prisoners may
resort to using less reliable methods including using latex gloves as condoms.
Module Reflection
My three main learning points from this module are:

    1.


    2.


    3.

My three ideas for how this module can improve my working practice are:


    1.


    2.


    3.




                                                      25
Sexual
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Awareness                                                                                MODULE 3

MODULE 3 – SEXUAL HEALTH INFORMATION
           PART 2
 Module Aims:

 By the end of this module you will have developed a basic awareness of :

    Contraception choices
    Options for unintended and unwanted pregnancy
    Other sexual health issues for men
    Other sexual health issues for women




Contraception Choices
There are many different methods of contraception available to women (and men). Different methods suit different
people at different times in their lives. The methods of contraception available in England and Wales are detailed
below.

Most contraceptives will not, however, protect against STIs and, therefore, it may in addition be advisable
for people to use one of the barrier methods of contraceptive (condoms or femidoms – the female
condom).

Type of Contraception      Diagram                        Description
Oral Contraceptive Pill                                   Contraceptive pills contain hormones that help to
                                                          prevent pregnancy by either:
                                                           Stopping eggs being made
                                                           Thickening cervical mucus to prevent the sperm
                                                              meeting an egg
                                                           Thinning the womb lining to stop eggs implanting in
                                                              the womb
                                                          There are two different types of pill available – the
                                                          progestogen only pill (mini-pill) which is taken every
                                                          day and the combined pill which is taken 3 weeks out
                                                          of 4.

                                                          The oral contraceptive is over 99% effective if taken
                                                          according to instructions, though vomiting and
                                                          diarrhoea can affect this, as can some medicines.
Injectable                                                An injection of hormones is given every 8 or 12
Contraception                                             weeks. This slowly releases the hormone into the
                                                          body and works in a similar way to the contraceptive
                                                          pill: It:
                                                           Thickens cervical mucus to prevent sperm meeting
                                                               an egg
                                                           Thins the lining of the womb to stop eggs
                                                               implanting
                                                           Stops eggs being released

                                                          Contraceptive injections are over 99% effective as
                                                          long as the injections are kept up-to-date. It may take
                                                          a woman some time to regain fertility after she stops
                                                          using this method of contraception.



                                                       26
Sexual
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Awareness                                               MODULE 3

Contraceptive Implant        This is a small flexible rod that contains hormones
                             that are slowly released into the body. It is
                             inserted, by a doctor or nurse, under the skin of
                             the arm and works for 3 years. It:
                              Stops eggs being made
                              Thickens cervical mucus to prevent sperm
                                  meeting an egg
                              Thins the womb lining to stop eggs implanting
                             Implants are over 99% effective, though some
                             medicines can stop them from working.
Contraceptive Patch          These patches look similar to nicotine patches and
                             release hormones that:
                              Stop eggs being made
                              Thicken cervical mucus to prevent sperm
                                  meeting an egg
                              Thin the womb lining to stop eggs implanting
                             A new patch is used each week for 3 weeks out of
                             every four. They are over 99% effective if used
                             correctly, though they are not suitable for women
                             over 35 years old, for smokers or for women who
                             weigh more than 90kg.
Intrauterine Device          An IUD is a small plastic and copper device that is
(IUD) or Coil                fitted in the womb by a doctor. It works by
                             changing the chemical make-up of the womb and,
                             therefore, stops eggs from implanting. This device
                             can stay in place between 3 and 10 years
Intrauterine   System        depending on the type, but can be taken out by a
(IUS)                        doctor at any time and is immediately reversible.

                             An IUS is a similar device, but contains slow
                             release hormones that:
                              Thicken cervical mucus to prevent sperm
                                 meeting an egg
                              Thin the womb lining to stop eggs implanting
                             An IUS works for 5 years, but can be removed by
                             a doctor at any time.

                             Both these devices are over 99% effective.
                             Women are taught how to regularly check that the
                             IUD & IUS are correctly sited.
Diaphragms and Caps          These come in a variety of different shapes and
                             sizes and are basically a latex or rubber device
                             that provides a barrier to stop sperm from entering
                             the womb. They are filled with a spermicidal jelly
                             or cream and inserted into the vagina and placed
                             so they cover the cervix. They can be put in place
                             any time before sex but need to be left in place for
                             at least 6 hours after sex before removing.

                             Most diaphragms are washable and reusable, but
                             as the size and shape of each woman’s cervix
                             differs (and will change over time due to weight
                             change, pregnancy etc.) a doctor will need to
                             examine and measure the cervix before
                             prescribing. Diaphragms and caps are between
                             92% and 96% effective.


                        27
Sexual
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Awareness                                                                          MODULE 3
Male Condom                                            Latex or non-latex. Covers the penis during sexual
                                                       intercourse and prevents sperm from entering a
                                                       woman’s vagina.

                                                       If used correctly is 98% effective.




Female Condom                                          Like the male condom, the female condom
                                                       (femidom), acts as a barrier to prevent sperm from
                                                       entering the vagina.

                                                       The female condom has an internal ring that is
                                                       placed over the cervix, the condom lines the
                                                       vagina and the opening lies just outside.

                                                       If used correctly, this condom is 95% effective.

Natural Family                                         This form of contraception involves taking bodily
Planning                                               measurements to indicate when a woman is fertile
                                                       and unfertile. It means that a woman will not have
                                                       to take hormonal contraception but will need to
                                                       know her body well and keep records of indicators
                                                       of fertility.

                                                       Natural family planning can involve keeping
                                                       records of bodily temperature, measuring the
                                                       thickness of vaginal fluids.

                                                       It is a 98% effective method if followed correctly,
                                                       but does involve either not having sex during fertile
                                                       times or using condoms
Female Sterilisation                                   This is a permanent and irreversible method of
                                                       contraception. It involves a surgical operation
                                                       under general anaesthetic to place clips on the
                                                       fallopian tubes. This prevents eggs from getting
                                                       into the womb.

Male Vasectomy                                         This is a surgical operation performed under local
                                                       anaesthetic. The vas deferens (the tubes that
                                                       carry sperm) are cut and this stops sperm being
                                                       released when a man ejaculates.

                                                       It should be considered as a permanent solution to
                                                       contraception, but can be reversed in some cases.

                                                       After the operation, it will take time for a man to
                                                       clear the remaining sperm in the tubes and until a
                                                       man has had two clear sperm tests another
                                                       method of contraception should be used.

Only the male and female condom provide an effective barrier to help prevent STIs as well as unplanned
pregnancy.




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Emergency Contraception

If contraception has not been used during sex or contraception has failed (e.g. a condom has split), there are two
options available to help prevent an unwanted pregnancy from taking place.

1. Progestogen-only emergency pills

This pill contains a hormone that will stop eggs being released or stop a fertilised egg implanting in the womb. It
should be taken within 72 hours of unprotected sex – though the sooner it is taken, the more effective it is likely to
be. It is still advisable for a woman to take a pregnancy test 2 weeks later to make sure that this pill has worked.

2. Intrauterine device (IUD)

If an IUD (described earlier in this module in Contraceptive Choices) is fitted within 5 days of unprotected sex it
can stop any eggs being fertilised or fertilised eggs from implanting in the womb. After fitting, the IUD can be kept
in place as a long term method of contraception or can be removed as soon as a woman is sure she is not
pregnant.

Choices for Unplanned and Unwanted Pregnancy
Sometimes, if contraception fails or contraception has not been used, an unplanned or unwanted pregnancy can
occur. If this happens, there are basically three options available:
 To have the baby
 To have the baby and have it adopted
 To have an abortion

Abortion

Abortion in Great Britain has been available since the passing of the Abortion Act 1967, amended 1990. Abortion
is generally safe with risks increasing as the pregnancy increases. If an abortion is being considered, the sooner it
is carried out the better. Ideally, it should take place within the first three months as this reduces the likelihood of
side effects or complications, although, abortions are legally available up to 24 weeks into pregnancy. Very few
abortions take place after 20 weeks (less than 2%).

Two forms of abortion are available and which method used mainly depends on how many weeks pregnant a
woman is.

1. Medical abortion

This involves taking two separate drugs, two days apart at the hospital or specialist clinic. The first stage of the
treatment involves taking an oral tablet. The second stage involves either another oral tablet or the insertion of
vaginal pessaries (tablets put into the vagina). For the majority of women this will terminate the pregnancy. This
method is generally available up to 63 days into the pregnancy.

2. Surgical abortion

This form of abortion is generally available up to 15 weeks into the pregnancy and is carried out under general
anaesthetic where the foetus is surgically removed. At earlier stages (before 8 weeks) surgical abortion is
sometimes available under local anaesthetic.

Later abortion (more than 15 weeks into the pregnancy) can be done through medical or surgical procedures
dependant on local practice and facilities available.




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Before an abortion takes place, an ultrasound scan will be done to determine how long the woman has been
pregnant. Counselling will be offered to help the woman decide the most appropriate form of abortion and whether
abortion is the option she wants to take. Post abortion counselling is also available. This can be a time of distress
for the woman and every effort should be made to minimise this. The majority of women deal with abortion but
some may need additional counselling before abortion and afterwards. Some women will be relieved that they are
no longer pregnant, but others may experience difficult feelings, guilt or confusion and need this post-abortion
support.

Other Sexual Health Issues for Men
Balanitis

Balanitis is a condition where the end of the penis (or the glans) becomes inflamed, leading to redness, irritation
and soreness. Men who experience this can sometimes mistake this for symptoms of an STI.

Possible causes of balanitis are:

   a build up of yeast infection, urine, sweat or other debris under the foreskin
   an allergic reaction to some soaps, washing powders or cleansing products
   an allergic reaction to condoms
   phimosis – a condition where the foreskin is tight and does not pull back over the glans
   another sexually transmitted infection

Treatments depend on the cause of balanitis, but could include:

   an anti-yeast cream or tablets (e.g.canesten)
   a steroid cream to reduce inflammation
   advising the use of non-latex condoms
   circumcision (if the man has phimosis)
   regular washing of the glans with water and a bland soap
   treatments for any STIs present

Testicular Cancer

This is the most common form of cancer affecting young men between the ages of 15 and 40. Men with an un-
descended or partially descended testicle (one or both testicles don’t come down into the scrotum) are more likely
to develop testicular cancer as do men with a family history of this cancer. Symptoms usually consist of a lump,
growth or ongoing pain in the testicles. Men could also notice blood when they urinate.

If detected early enough, testicular cancer is easily treated with a cure rate of about 90%. Men should, therefore
be encouraged to regularly check their testicles for unusual lumps and given information on how to do this.

Torsion of the Testes

Torsion of the testes is a condition where the testes (or testicles) twist around in the scrotum and the spermatic
cord also twists blocking the blood supply into the testicle. This is a very painful condition and if the testicle is not
untwisted and the blood supply restored within 6 hours of torsion happening, the testicles will become damaged
and may ‘die’. This condition should, therefore, be treated as a medical emergency and requires an operation to
untwist the testes. If this operation is too late, the testicle will have to be removed.

Whilst this condition is uncommon in men over the age of 25, it can occur at any age.
                                                                                              MODULE 3
Prostate Cancer

The prostate gland is only found in men and helps to make semenal fluid. It lies just below the bladder and is
about the size of a chestnut. The prostate gland can be felt through the walls of the rectum and when stimulated



                                                           30
Sexual
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Awareness                                                                                   MODULE 3
this way (through anal sex, fingering or the use of a dildo or vibrator) can produce intense sexual pleasure for
some men.

Prostate Cancer occurs when malignant cancer cells form within the prostate. These cancerous cells can develop
and spread to other areas of the body. Although most cases of Prostate Cancer develop in men over the age of
65, it can affect younger men.

Symptoms may include:
 A poor or weak urine stream – it takes longer to empty your bladder
 Dribbling of urine from the penis after urinating
 Needing to go to the toilet more urgently
 A more frequent need to urinate
 Pain at the base of the penis

An early diagnosis of Prostate Cancer is a major key to successful treatment. This can be done by examining the
prostate gland (the doctor will insert a finger into the rectum and feel the gland for lumps or enlargement) and by a
blood test.

Treatment for Prostate Cancer depends on the size of the cancer and whether it has spread or not. It can range
from treatment to control the cancer or to ease the symptoms. The prostate might be removed or hormones given
to slow down the growth of the cancer both of which could cause erectile dysfunction (impotence) and a man
might need medication or other support in order to get and maintain an erection.

Bacterial Prostatitis

This infection of the prostate is caused by a bacterial infection. Usually the cause is bacteria that lives in the
bowel being transferred to and travelling up the urethra and irritating the prostate. Other causes could be a side
effect of having kidney stones or after having a catheter fitted. Sexually transmitted infections are rarely the cause
of prostatitis.

Men can have an acute infection (which happens suddenly) or a chronic infection that occurs gradually over time.
Symptoms can be a sharp pain at the base of the penis or in the testicles, pain when going to the toilet, pain when
ejaculating and general aches, pains and fever.

A urine test can normally detect the presence of bacteria that may be causing the prostatitis, but an x-ray might
be required to check for other problems with the urinary tract. If this condition is confirmed, a 4-week course of
antibiotics is needed plus painkillers to ease any pain and fever. Laxatives can also help by making faeces softer
and taking pressure off the prostate when going to the toilet.

Anal Fissure

This is a small tear of the skin of the anus that can be caused by constipation or through anal sex. This can be
very painful and the pain can feel worse after going to the toilet when you pass faeces or after anal sex – often
followed by bleeding from the anus. In most cases, fissures heal themselves after time, but some people will
need cream, ointments and painkillers to help with healing. Avoiding anal sex until the fissure heals is also
recommended.

Sexual Dysfunction

Sex can sometimes be difficult for men for a number of reasons. This could be problems getting and maintaining
an erection, ejaculating too soon or not at all, loss of interest in sex or obsessive/compulsive sexual thoughts.

Lots of things can contribute to sexual dysfunction including stress, anxiety, the effects of alcohol or recreational
drugs and traumatic life experiences. Some men may need psychosexual counselling in order to resolve their
difficulties in having sex. Others may need medical intervention – prescribing viagra, implants to achieve an
erection etc.




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Sexual
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Other Sexual Health Issues for Women
Cervical and Other Gynecological Cancers

Cervical cancer can affect any woman who has been sexually active with a man, woman or with both. It is usually
triggered by infection with a type of human papilloma virus (HPV). There are many different types of HPV and
they are passed on by close skin to skin contact. The viruses that affect the genitals are passed on by sex. A
different type of HPV causes genital warts.

After the age of 25, women should be encouraged to have regular smear tests (sometimes called PAP tests). A
smear test involves a medical practitioner inserting a speculum into the vagina and wiping the cervix with a small
brush to gather some cells that are later analysed in a laboratory. This may feel uncomfortable, but should be a
painless procedure. These tests should take place every 3 years and can detect abnormal cells in the cervix
before they become cancerous.

Endometrial Cancer – or cancer of the lining of the uterus - mainly affects women after the age of 50 who have
never had children, are overweight or are diabetic. Symptoms can include unusual bleeding from the uterus which
should be reported to a medical expert right away.

Ovarian Cancer is also more likely to affect women as they get older and is more likely in women who reach
menopause after 50 and who have never had children. Symptoms can include swelling of the stomach, unusual
vaginal bleeding, pelvic pain or digestive problems. Women who experience any of these symptoms should seek
medical advice as early detection improves survival rates.

Breast Cancer

Breast cancer can affect women at any age in their lives, but some risk factors increase the chances of
developing this including a history of cancer within the family, being overweight, alcohol use and women who
have either never had children or had their first child after the age of 30.

As with most cancers, early detection and treatment greatly increase the chance of cure and survival. So, women
should be educated to check their breasts for irregular lumps, other changes in breast tissue, unusual discharge
from the nipples and seek medical advice if they notice any of these symptoms. The majority of breast lumps are
not cancerous, but getting advice quickly to make sure is essential.

Treatment for breast cancer will depend on the type of cancer and how far it has progressed, but could include
radiotherapy, chemotherapy or mastectomy (removal of one or both breasts). For women undergoing this
treatment, counselling and support is offered. Specifically, women who have a mastectomy may experience
issues of low self-image and self worth and this can have a devastating impact on how they feel as a sexual being
and on their longer-term sexual health.

Bacterial Vaginosis (BV)

BV is a very common vaginal infection that occurs when bacteria alter the pH balance of the vagina – changing it
from acidic to alkaline. Women with BV (men cannot get BV) may experience:
     A thin, watery vaginal discharge
     A strong fishy smell from the vagina – particularly after sex

BV can be caused by a number of things including douching or washing the genitals with scented soaps or bubble
bath, using strong detergents to wash underwear, use of vaginal deodorants or, sometimes, a reaction to semen
in the vagina.

Treatment is usually by a course of antibiotics in tablet form or as a cream applied to the vagina.




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Cystitis

Cystitis means inflammation of the bladder. Symptoms can include:
    A burning sensation when passing urine
    Cloudy looking urine that may contain blood
    An urgent need to urinate frequently
    A high temperature

A bacterial infection is the usual cause of cystitis in women and antibiotics can help treat the infection, though
most women can self-treat the symptoms by:
    Drinking plenty of water/ clear fluid
    Drinking cranberry juice

If symptoms persist for more than 2 days, medical advice should be sought.

Anal Fissure

This is a small tear of the skin of the anus that can be caused by constipation, after childbirth or through anal sex.
This can be very painful and the pain can feel worse after going to the toilet when you pass faeces or after anal
sex – often followed by bleeding from the anus. In most cases, fissures heal themselves after time, but some
people will need cream, ointments and painkillers to help with healing. Avoiding anal sex until the fissure heals is
also recommended.

Menopause

The menopause is the end of a woman’s menstrual cycle where hormone production drops below the level
required to continue her periods. It is a natural occurrence linked to ageing and marks the end of a woman’s
reproductive years. It tends to take place between the ages of 45 and 55 (with an average of 51). Before the age
of 45, if a woman reaches menopause, this is called premature menopause.

Symptoms of the menopause include:
 Hot flushes                                                     Weight gain
 General aches and pains                                         Itchy skin
 Tiredness                                                       Bladder problems
 Anxiety/ Panic attacks                                          Depression
 Night sweats

Women who are going through the menopause can take Hormone Replacement Therapy to help reduce the
unpleasant side effects, but adopting a healthier lifestyle with balanced diet, exercise and help to stop smoking
can also help.

The menopause does not, however, mean an end to sex. Some women may find their sex drive is lower but most
remain sexually active.

Although contraception is no longer required for women who have been through the menopause, other sexual
health risks (including STIs and HIV) remain and access to condoms and dental dams, screening for STIs etc. are
still necessary. Access to water based lubricants can also help with vaginal dryness related to the menopause
and help make sex more comfortable and less painful.




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Awareness                                                                                  MODULE 3
Sexual Dysfunction

Sex can sometimes be difficult for women for a number of reasons. This could be problems in having penetrative
sex, inability to achieve orgasm, loss of interest in sex or obsessive/compulsive sexual thoughts.

Lots of things can contribute to sexual dysfunction including stress, anxiety, the effects of alcohol or recreational
drugs and traumatic life experiences. Some women may need psychosexual counselling in order to resolve their
difficulties in having sex.

 Module Reflection
 My three main learning points from this module are:

     1.


     2.


     3.

 My three ideas for how this module can improve my working practice are:


     1.


     2.


     3.




                                                         34
Sexual
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Awareness                                                                                MODULE 4

MODULE 4 – TALKING ABOUT SEX, SEXUALITY
AND SEXUAL HEALTH
 Module Aims:

 By the end of this module you will

  Be able to define sex, sexuality and sexual orientation
  Recognise how our attitudes and values can affect work with people in our care
  Have explored your own attitudes and values to sex and sexual practice
  Have considered the factors that can help or hinder when talking about sexual health with people in our
   care
  Recognise the importance of professional boundaries, support and supervision in sexual health work


Definitions of Sex, Sexuality and Sexual orientation
Before you proceed with this module, it is important to be clear about what we mean by sex and sexuality. These
terms are often confused with each other and with sexual orientation. When talking about sex and sexuality, it can
help to define these.


 Sex                       Refers to the biological gender of people – whether male or female. It can also
                           mean sexual activity – the type of sex we have or don’t have.

 Sexual Intercourse        Sexual activity that involves vaginal, anal or oral penetration. There are many other
                           sexual activities that do not involve penetration – these are not referred to as
                           intercourse.

 Sexuality                 Often confused with sexual orientation, sexuality is the expression of sexual
                           sensation and related emotional intimacy between human beings – it involves the
                           whole mind and body and not just the genitals. We all have a sexuality, whether we
                           are currently having sex or not.

 Sexual Orientation        The direction an individual’s sexuality based around the sex and gender that
                           individual finds attractive.

                            Gay men are emotionally and/ or physically attracted to men
                            Lesbians are emotionally and/ or physically attracted to other women
                            Bisexual men and women are emotionally and/or physically attracted to
                             members of both sexes
                            Heterosexual (or straight) men and women are emotionally and/or physically
                             attracted to members of the opposite sex

                           Being lesbian, gay, bisexual or heterosexual is about more than the sex we have. It
                           is about our interests, likes, dislikes, friendships, partnerships and attitudes. It
                           shapes the way we live our whole life.




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Attitudes and Values to Sex and Sexual Expression
Our own attitudes and values towards sex and sexual expression will differ to those of other people – they are
individual and unique to us. These attitudes and values are shaped from an early age and are influenced by a
number of factors – our parents, education, friends, the media etc. Our life experiences will continue to challenge
and question these values and attitudes and, as a result, we may or may not change or develop these.

Exercise 6
The early messages we receive about sex and sexuality are often the messages that stay with us and shape the
values and attitudes we have to sex and sexual expression. What are the early messages about sex that you
can recall? Was sex talked about at home, at school, with friends?:

Messages from your parents/ guardians




Messages from your school/ your teachers




Messages from your friends




Messages from the media/ television




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Awareness                                                                                   MODULE 4
These early messages are particularly powerful in shaping our attitudes in later life, not only to our own sexual
relationships, but to those of other people and, in the context of this resource, to the sexuality and sexual health of
people we work with and who are in our care.

For instance:

 If the messages were that sex is not talked about then we may feel it is a very private matter that we never
  discuss.

 If the messages were that sex was about reproduction, then we might have difficulty in accepting that sex is
  also about pleasure

 If we were made to feel guilty about masturbation then we may feel secretive about sex and feel that sex is
  ‘dirty’ or it is wrong to feel sexual desire

 If we were only told that sex should only happen between a man and a woman then we may feel that being
  gay, lesbian or bisexual is wrong and something to be ashamed of.

Our attitudes, values and beliefs about sex and sexuality do impact on our behaviour towards others. It is,
therefore, essential when we are considering work we may be doing around sexual health in custodial settings
that we do reflect on and consider what our values, attitudes and beliefs are.

It may be helpful to explore what we mean by the following terms: values, attitudes, beliefs and behaviours.

Values
A value is a type of belief about how one ought or ought not to behave. They are individual to us and are formed
in the home, at school, from peer groups, from the communities we belong to, in our workplaces, in religious
settings and through the media. Examples of a person’s values might be:
 People should wait until they are married before having sex
 Anal sex is an unnatural act
 Abortion is a choice that should be available to all women
 As long as sex is consensual, mutual and equal, everyone should be free to have the sex they want with who
    they want

Attitudes
An attitude is how we evaluate other people in a favourable or unfavourable manner way based on our value
base. Examples of attitudes could be:
 Heterosexual people are superior to homosexual people
 People who are sent to prison should forfeit their human rights
 Young people are more promiscuous than previous generations were

Beliefs
A belief is something we believe or accept as true. They are informed by what we are told, what we hear or read.
Sometimes these beliefs can be false beliefs, such as:
 All STIs can be cured
 Homosexuality is illegal in the UK
 Giving out condoms/ dental dams in prison encourages prisoners to have sex with each other

Behaviours
A behaviour is the way we conduct ourselves and communicate our values and attitudes to others. Examples of
behaviours are:
 Referring to people who have casual sex as ‘slags’ or ‘tarts’
 Taking part in homophobic attacks (sometimes known as ‘queerbashing’)
 A look of disgust when someone asks for flavoured condoms for oral sex




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Exercise 7

Think about your values towards sex and sexuality and place the following activities into the box that most
reflects your own values.

If you are unsure of the terminology, please refer to the glossary at the end of this workbook.


Bisexuality                              Swapping sex for cash/                    Oral sex
Masturbation                             drugs                                     Anal sex
Threesomes                               Sharing sexual fantasies                  Vaginal sex
Internet Sex                             with your partner                         Dogging
Non-monogamy                             People with HIV having sex                Cruising
Sex between a man and a                  Monogamy                                  Sex in prison
woman                                    Pornography                               Using sex toys
Sex between a 35 year old                Abortion                                  Voyeurism
and a 17 year old                        Celibacy                                  S & M sex
Sex between two 13 year                  Sex outside marriage                      Cross Dressing
olds                                     Sex between 2 women                       Casual sex
Sex between a 60 year old                Sex between 2 men
and a 20 year old                        Having sex using drugs

I value this for myself                I value this for others but not for    I do not value this for anyone
                                       myself




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Sexual
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Values and Attitudes and Work in Custodial Settings
Our values and attitudes can, and often do, impact on the relationships with people we work with. In particular,
consider which activities you placed in the ‘I do not value’ column in the previous exercise. If these are activities
that we are either uncomfortable with, or have strong negative reactions to, how will we feel if they are raised in
conversations with prisoners?

   If you placed abortion in this column and a woman in your care, who has recently arrived in your
    establishment, confides in you that she thinks she may be pregnant - how would you react? Would you be
    able to impartially talk through the options available to her, including her right to access safe and supportive
    abortion services?

   If sex between men is something that you do not value (or sex in prison), how do you feel about working with
    gay prisoners or male prisoners that you know are having sex with each other? Would you feel comfortable in
    talking to them about their sexual health support needs?

   What might happen if you were asked questions about the sexual health risks associated with oral sex if you
    do not value this activity? Would you react in a way that demonstrated your values on this activity?

Exploring our own values about sex is not about saying that we need to change our beliefs around the activities
that we do not value, but is about being aware of these so that we do not communicate them verbally or non-
verbally in our interaction with people in our care. If we are aware of the areas of potential difficulty for us, then we
will be better placed to respond if they are raised in our work with others and in a way that does not communicate
any feelings of judgement, condemnation or distaste.

We can separate our personal values from our professional work. This is something that everyone who works in a
custodial setting is already used to doing. People in our care will be there for a number of offences that we do not
value – and in terms of sexual values, this will include people convicted of sexual offences against children and
other adults. None of us should value any sexual activity that is not consensual, mutual or equal. But we work with
these issues on a daily basis – hopefully not bringing our personal values into our work. We can apply this
principle to our work around sex and sexual health.

This way, we can make sure that the support, advice and guidance on issues of sexual health is impartial,
appropriate and supportive.

In summary, we need to be aware that:



                                           Our attitudes about sex



                                             Affect our behaviour



                                  Affect our relationships with people



                                     Affects the quality of the service

                                                           39
Sexual
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Taking About Sex
Talking about sex with our partners and friends can be difficult for a host of reasons. We can feel embarrassed or
awkward about doing this or may cover up these feelings by being loud and full of bravado. Talking about sex with
the people we work with can feel even more difficult to do.

There are additional factors to consider when talking about sex with people in custodial settings that may make
this feel more difficult to do. Some of your concerns may be:

 A woman officer talking to men about sexual health may lead to hostility and sexual remarks – and a male
  officer may also receive this response when talking to women
 Prisoners using this as an opportunity to make an officer feel embarrassed
 Colluding with non-consensual sexual fantasies
 A hostile reaction from prisoners to any suggestion that sex may be happening within the prison
 Prisoners offering to engage in sexual behaviour with staff as a wind up
 Prisoners using the opportunity to ‘get off’ on talking in detail about sex
 Prisoners talking about their sexual fantasies
 The possibility of sexual assault on prison staff

Staff who work in a custodial setting have a very difficult job to do with lots of conflicting pressures and dilemmas
to deal with on a daily basis. The need to manage security issues and, at the same time, promote the health and
well-being of the people in our care can feel a difficult balance to achieve. However, supporting people to access
sexual health support services will contribute to an improvement in the overall health of the prison population and,
therefore, the general physical and emotional health within your establishment.

There are a number of basic factors that can help us to effectively discuss with a prisoner the sexual health
concerns or worries they might have. And there are factors that can be unhelpful.



 What Can Help                                              What Can Hinder

    Keeping a neutral tone of voice                         A tone of voice that communicates disinterest,
    Maintaining an open posture                              shock or judgement
    Keeping good eye contact                                Harsh facial expressions
    Sticking to factual information                         Being too ‘jokey’/ laughing/ smirking
    Asking questions that are only necessary to give        Entering into detailed conversations about sex
     you the information you need                            Talking about your own sexual health
    Using good listening skills                             Talking about your own sex life
    Maintaining your own personal space                     Offering a suggested diagnosis/ your own opinions
    Having a good awareness of sexual health issues         Not taking someone’s concerns about their sexual
    Acknowledging that you are not a sexual health           health seriously
     expert                                                  Being dismissive
    Knowing ‘how to’ and ‘where to’ refer for specialist    Promising to get information or to refer on and
     support, information and guidance                        then not doing so
    Acknowledging that talking about sexual health is       Using jargon, complex or medical language –
     difficult for most people                                without explanation
    Acknowledging that sexual health is an important
     issue for everyone – even when in prison




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Professional Boundaries
When working with prisoners around their sexual health needs we need to be mindful of our own professional
boundaries and in particular the boundaries of our own work roles.

Whilst we can play an immensely important role in raising awareness of sexual health and sexual health services/
support, we should not step outside the role of facilitating access to these services.

We should not:
 Offer suggested diagnosis of symptoms of sexual health problems
 Tell people that we think they have nothing to worry about
 Deny referral to sexual health services

Other things to consider that will help to ensure that we maintain a professional relationship with the people in our
care are not sharing information about our own sexual health, talking about our personal experiences of sexual
health problems or talking about our own sexual relationships.

Support and Supervision
Sexual health is something that can and does affect us all. If we are working with people in our care on their
sexual health issues and concerns, it can bring up issues that we react to personally (either from past experience
or from a concern we currently have about our own health).

We may have had a difficult conversation where we feel we were being manipulated into colluding with sexual
fantasies or were being deliberately set-up for the amusement of other prisoners.

We may not know how best to support someone who has disclosed information about a sexual health problem or
where best to take this.

It is important that we know where to take any difficulties or dilemmas that arise in our work. We could:
 talk through issues with senior officers during supervision
 ask for advice or support from prison healthcare workers
 if appropriate, ask colleagues for advice on how to proceed
 consider whether another officer is better equipped to work with a particular prisoner
 consider if it would be more appropriate for someone of the same gender to pick up this issue
 access workplace counselling support
 access sexual health services in the community to address our own sexual health problems
Module Reflection
My three main learning points from this module are:

    1.

    2.

    3.

My three ideas for how this module can improve my working practice are:


    1.

    2.

    3.


                                                         41
Sexual
Health
Awareness                                                                                  MODULE 5

MODULE 5 – SEXUAL HEALTH IN CUSTODIAL
SETTINGS
 Module Aims:

 By the end of this module you will have:

  An understanding of the context of sexual health work in custodial settings
  An awareness of the additional factors of working with sexual health issues in custodial settings



Sexual Health in Custodial Settings
Prison populations contain an over-representation of members of the most marginalised groups in society. These
include: people with poor health and chronic untreated conditions, mental health problems, the vulnerable and
those who engage in activities with high health risks such as injecting drugs and commercial sex work.

Women in prison are particularly vulnerable as they come in disproportionate numbers from backgrounds of
violence and abuse. (International Centre for Prison Studies, 2004). They are likely to have additional and
different needs with respect not only to maternity care and gynaecological health but also to psychological health
and a greater incidence of past or recent abuse, whether physical, emotional or sexual in nature (Working With
Women Prisoners, HM Prison Service, 2003).

Every setting presents its own problems and challenges – whether it is for men, women or young offenders –
whether it is an open or closed establishment – whether it is a local prison with high turnover (and more issues
around aftercare) or a high security or training prison with a more settled population (with more longer term
interventions required).

Health Care Standard 6 and Health Services for Prisoners Standard require all prisons to provide health
education and support around the following subjects:
 Coronary heart disease
 Cancer
 Mental health
 Substance misuse
 HIV/ AIDS
 Sexual health

Work on sexual health issues is, therefore, seen as a relevant health priority for all custodial settings. The sexual
health of the prison population has a direct impact on the sexual health of the whole population. Sexual health is
an issue for people entering custody, during custody (whether someone is having sex or not) and on release and
beyond.

There is also the concept of prison sexuality to consider. The term ‘Prison Sexuality’ refers to sexual relationships
between confined individuals. Since prisons are separated by gender this means with a same-sex partner, often
in contradiction to a prisoners’ sexual orientation prior to entering custody.

The sexual health needs of and sexual health problems encountered by the prison population are broadly the
same as for the general population. This includes the need for screening and treatment for STIs, education and
awareness on safer sex, access to sexual health resources and support, contraception advice and information
and treatment for other sexual health problems.

However, there are a number of additional factors that those working on sexual health issues within custodial
settings need to consider. Some of these are discussed in the next part of this module.



                                                         42
Sexual
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Awareness                                                                                   MODULE 5
Other Factors and Issues about Working with Sexual Health Issues in Custodial Settings

Security Issues vs Privacy
Custodial settings need to be secure and procedures need to be in place to protect the safety of the general
population, of prison staff and of the prisoners themselves. This can lead to a tension between the need to
enforce security and restrict freedom and autonomy on the one hand while also enabling individuals to exercise
more control over, and improve their health, on the other.

Security issues mean that any right to privacy is something that once in a prison environment is rarely an option.
Sharing cells with ‘pad-mates’ further restricts personal space and privacy. An obvious impact of this is difficulties
in finding the space and time to masturbate uninterrupted. Masturbation is, for many, the only sexual activity they
will engage in during custody. Masturbation in private is a healthy release of sexual tension and desire and
contributes to feelings of emotional and physical well-being. When this is frowned upon or discouraged it can lead
to a build up of negative emotions such as hostility and aggression as well as feelings of guilt over what should be
seen as a natural and normal expression of sexuality.



Confidentiality
All medical records should remain confidential within medical services. People who can freely access GU Clinics
are guaranteed complete confidentiality under the Venereal Diseases Act of 1958 *. People in prison however,
do not have this right to absolute confidentiality – for both security and safety reasons.

This can prove to be a barrier when seeking support or treatment on sexual health issues. For example, some
prisoners will not present for outside hospital visits because they know they will be escorted and the majority of
time will have officers present when having intimate or personal internal examinations. Others may fear that by
seeking treatment from prison healthcare facilities for symptoms of an STI everyone on their wing will get to know
and they may fear they will be ridiculed or condemned by their fellow prisoners. Prisoners should be fully informed
of the limitations of confidentiality before invited to discuss sexual matters.

Therefore, all staff should be mindful of confidentiality sensitivities and think about who needs to know this
information. For instance, who really needs to know which prisoners are HIV positive and why. We also need to
think about what is entered on any paper or electronic records (e.g. LIDS, OASyS etc.) and again ask if it is
relevant and appropriate to record this.

There are some things that may breach sexual health confidentiality inadvertently. How do we explain why one
prisoner is getting additional food, rest and treatment breaks etc. without others knowing or suspecting that they
have HIV or Hepatitis C?




The law on confidentiality in relation to STIs outlined in the Venereal Diseases Regulations 1974 and the NHS
and Primary Care Trusts STD directions 2000 state:

- information capable of identifying an individual examined or treated for an STI shall not be disclosed except -

a) for the purpose of communicating that information to a medical practitioner in connection with the treatment
   of persons suffering from such disease or the prevention of the spread thereof, and
b) for the purpose of such treatment or prevention




                                                         43
Sexual
Health
Awareness                                                                                   MODULE 5
Continuity of Healthcare
Approximately 140,000 prisoners pass through the custodial system each year and 80% of those people in prison
are there for only 6 months or less. Add to this prisoners who are transferred between establishments and we
have a carousel of endless movement that can impact on the continuity of healthcare including sexual healthcare.

Continuity of healthcare is key to the success of clinical interventions and treatment. Problems in achieving this
continuity may include:
 Someone being transferred to another prison in the middle of treatment (though transfer of a prisoner awaiting
   urgent cancer referral, for example, is rare but may happen for security reasons)
 Getting results of tests to someone (e.g. smear test results, STI results, prostate blood checks) when they
   move establishment or have left prison
 Ensuring completion of a course of antibiotic treatment for a bacterial STI and arranging follow up tests to
   show the infection has been cured

There is, therefore a need for full and well thought out through-care on sexual health issues. On release, or
discharge, it is important that the need for continuity of care is communicated, with the prisoners consent, to his or
her GP or local sexual health service.

For more information on continuity please refer to PSO 3050 – Continuity of Healthcare for Prisoners

People with Substance Use Problems
Prisoners generally come from the least healthy sections of the population with around 90% of those entering
custodial settings having a mental health or substance misuse problem. Research tells us that people with
substance use problems are more likely to have engaged in other risk taking behaviour, including risky sexual
health behaviours (Tapert et al, 2001).

Prisons also see a high proportion of people who have at some time used, or who are currently using, drugs that
are injected (e.g. heroin, crack cocaine). It is estimated that around 25% of prisoners report having injected drugs
and roughly 20% of these have Hepatitis B and 30% have Hepatitis C (Health Promoting Prisons: a shared
approach, 2002).

Many prisoners will revert to drug taking on release. So the time spent in prison provides an ideal opportunity for
prisoners to receive interventions that enable them to make informed choices regarding behaviours that impact on
their health. Working with someone on their drug or alcohol addiction can have a knock-on effect to improving
their sexual health and well-being and to reducing the effects of unhealthy or high risk behaviours.

Management of Blood Borne Viruses (BBVs)
The rates of HIV and Viral Hepatitis in prisoners are much higher than in the general population. Current
estimates are that:
 8% of prisoners have Hepatitis B
 7% of prisoners have Hepatitis C
 0.3 % of men and 1.2% of women in prisons have HIV

                                                          (Health Promoting Prisons: a shared approach, 2002).

Prisons can be the ideal environment for the spread of HIV and Viral Hepatitis and it is important that there are
procedures in place for the prevention, control and management of all communicable diseases including Blood
Borne Viruses.

The main risks in terms of the transmission of BBVs in prison are from unprotected sex and sharing needles. This
includes needles and other equipment used as ‘home made’ tattoo kits (broken cassette/ CD parts etc).




                                                         44
Sexual
Health
Awareness                                                                                   MODULE 5
In terms of transmission of HIV from prisoners to staff, this cannot occur in ordinary circumstances. There is a
possibility of infection from being stuck with a contaminated needle, but even if this happens the risks are very
low. Another theoretical risk is from blood getting into a wound during a fight, but infection by this route is
extremely rare (infection is not known to have occurred in this way in any prison staff).

The transmission of Viral Hepatitis from prisoners to staff should not occur in ordinary circumstances. However,
there is a risk from being stuck with a contaminated needle, from being bitten, and dealing with bloody fights.
Particular care is also needed when working with violent or self harming prisoners or attending to suicide
attempts.

Vaccination against Hepatitis A and Hepatitis B is available for all staff working in custodial settings and all staff
are strongly encouraged to be immunised. There is no vaccine for Hepatitis C. Vaccinations are also available to
prisoners through prison health care settings.

We need to remember that the chance of staff working in custodial settings acquiring any serious
infection are extremely small and adherence to recommended procedures will make them even smaller.


 For more detailed information on the Management of HIV & Viral Hepatitis in custodial settings please refer to
 the following Prison Service Orders/ Instructions:

 PSO 3845         –        Blood Borne and Related Diseases
 PSO 8900         –        Occupational Health
 PSI 12/1999      –        Communicable Diseases
 PSI 50/2001      –        Hepatitis C – Working With Drug Users




Religious and Cultural factors
The people currently residing in custodial settings will come from a very diverse range of backgrounds and within
this there will be people from a wide range of religious and/ or cultural backgrounds. The values and messages
about sex and sexuality from differing religious and cultural reference points need to be acknowledged in every
aspect of prison life. This includes our work around sexual health issues

We need to be mindful of how we talk about sex and sexual health, make sure information is available in a range
of formats/ languages that reflect the population of the establishment we work in and acknowledge that some
people will be particularly hesitant in seeking advice and support because their religion or culture has strong
messages about monogamy, being faithful, homosexuality etc.

Same Sex Relationships
For most people in custodial settings (and this includes those that are gay, lesbian and bisexual), sexual
relationships and expressions of sexual desire are suppressed during their time in custody. For others, sexual
relationships between men and sexual relationships between women will happen. There are many reasons why
sexual relationships may develop:

 Because prisoners are gay, lesbian or bisexual
 For comfort and companionship – most people who form relationships based on these principles will revert to
  heterosexual relationships on release
 In exchange for goods/ favours
 For personal safety reasons
 By force or coercion

Sexual activity between consenting adults in their own cells is not an illegal act. Though different
establishments might have different views and guidance on the issue of sex within prisons.



                                                         45
Sexual
Health
Awareness                                                                                   MODULE 5
If we accept that some same sex activity does take place in prisons, as they do in every sector of society, then we
need to respond by giving prisoners the information and support to maintain good sexual health and avoid being
infected with STIs – including HIV.

At present, prison doctors or their deputies have authority to make condoms, dental dams and water based
lubricants available to any prisoner irrespective of age who requests them. By going through this process,
however, it means disclosing that you are or may be having same sex relationships. The fear of stigma and
possible harassment may be a barrier to seeking support to reduce sexual risk taking.

Gay men and lesbians might also want to keep their sexual orientation secret for fear of abuse, taunts and
assault. The National Gay Prisoner Support Service offers advice, guidance and support to any member of
LGBT community from arrest to completion of their sentence.

Working with Sex Offenders
Around 8% of people in prisons are sex offenders – people convicted of sexual murder, rape, sexual assault and
sex offences against children – of which the vast majority are male. These offenders should be engaged with
initiatives such as the Sexual Offender Treatment Programme ( SOTP).

Working around sexual health issues with people who have a history of sex offending might feel inappropriate.
We may feel that it will fuel or facilitate thoughts of deviant sexual fantasy and arousal, contribute to their sexual
preoccupations or counter work being done through the treatment programmes.

The key here is that basic, factual sexual health information and support should be made available to all. Any
discussions must be based on the value that sex should be mutual, consensual, equal and legal. Conversations
that steer away from this basic principle should be brought back to this premise and staff should be careful of
being manipulated or colluding with offenders’ sexual fantasies. If this proves difficult to manage then requests for
sexual health information should be referred to specialist workers.

Rape & Sexual Assault
It is not known how much coercive sex and rape actually occurs within custodial settings but we do know it
happens. Coercive sex (or being forced to have sex) may be a significant source of HIV transmission in custodial
settings.

There are many myths and fallacies around about rape and sexual assault – you may have heard of some of
these. Myths include:
 men can’t be sexually assaulted if they don’t want to be
 a woman can’t sexually assault another woman
 heterosexual men don’t get raped
 tall, strong ‘masculine’ men won’t be raped

Women and men who have experienced rape or sexual assault may react in many different ways. Many people
feel guilty or ashamed about what has happened, that they should have been able to stop it from happening. They
may feel shocked, distressed, angry or maybe completely numb.

Some people who have been raped may be confused about physical reactions they may have experienced whilst
being raped or assaulted. Getting an erection and ejaculating, or having an orgasm during sexual assault does
not mean you ‘really wanted it’ or consented to it – it is a normal reaction to stimulation even if this was against
your will.

When this happens to someone in a custodial setting, these feelings will be heightened and there will be added
factors to consider including possible repercussions of reporting the incident by the perpetrator or from other
inmates. For all these reasons, the actual levels of rape and sexual assault in custodial settings are likely to be
under reported.




                                                         46
Sexual
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Awareness                                                                                MODULE 5
 Exercise 8
 What are some of the signs that might tell you that someone in your care may have been the victim of sexual
 assault?
 Where could you get support from within your establishment on issues of rape and sexual assault?




People who have been raped or sexually assaulted may immediately have worries about STIs including HIV and
will need referral to sexual health services to check these concerns out. Longer-term implications to consider are
the impact on mental health, self-esteem and self worth, suicidal thoughts or suicide attempts and the impact on
current and future relationships. Specialist counselling and therapy services would, therefore, need to be involved
in supporting someone through an experience of rape or sexual assault.



 Module Reflection
 My three main learning points from this module are:

     1.


     2.


     3.

 My three ideas for how this module can improve my working practice are:


     1.


     2.


     3.




                                                        47
Sexual
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Awareness                                                                                   MODULE 6

MODULE 6 – REFERRING ON
 Module Aims:

 By the end of this module you will be aware of:

    When to refer an individual who has concerns or worries about their sexual health
    Who to refer an individual to in your establishment
    How to refer an individual with sexual health support needs
    The importance of follow-up support after referral


The prison service, in partnership with the NHS, has a responsibility to ensure that prisoners have access to
health services that are broadly equivalent to those that the general public receives from the NHS – including
sexual health services (PSO 3200).

Providing sexual health services and working with people in custodial settings to access these services (by
increasing awareness of sexual health issues and appropriate referral) is a real healthcare opportunity. It can help
build the physical, mental and social health of prisoners, prevent the deterioration of health whilst in custody and
help prisoners adopt healthy behaviours that can be taken back into the community upon release and, therefore,
has a positive impact on the sexual health of their partners and on the wider community.

All staff working in custodial settings can contribute to this goal. If given appropriate training and support, Wing
based staff - for instance - are ideally placed to carry out basic sexual health promotion tasks. By raising general
awareness of sexual health issues staff can help increase referral to and take-up of prison healthcare and
specialist sexual health promotion services.

Reception and Induction
All prisoners receive a health assessment at first reception to identify any immediate health needs. Priority is
given to:
 immediate physical health problems
 immediate mental health problems
 significant drug or alcohol abuse
 risk of suicide and/ or self harm

It may be that some sexual health issues, concerns or worries may be discussed at this stage (e.g. someone who
is on anti-retroviral treatment for HIV), but the real emphasis of reception is about keeping the new arrival safe
from immediate harm.

During the week immediately following reception, a general health assessment is taken which is more likely to
include questions on sexual health - including STI screening, HIV and Hepatitis testing and vaccination.

New arrivals will be given a prison healthcare leaflet that should talk about the provision of sexual health services
within that establishment – this may also contain advice on, for example, advice on avoiding STIs, Hepatitis
immunisation, testicular or breast self examination and even safer sex. The Prisoners’ Information Book also
gives information about HIV/ AIDS but currently not about other STIs.

Not all sexual health worries and concerns will be picked up during reception and the General Induction is another
opportunity for staff involved in this process to raise awareness of sexual health services and support within your
establishment. During induction, staff must be alert to the individual and particular needs that prisoners might
have which have not already been picked up via the healthcare and reception process – this could include sexual
health needs. Induction is the ideal opportunity to raise issues of sexual health with prisoners, to ‘plant seeds’ for
future interventions, give options for consideration and help prisoners access the help they need.



                                                         48                               MODULE 5
Sexual
Health
Awareness                                                                                    MODULE 6
After induction, prisoners may still need referral to specialist sexual health services. By being aware of sexual
health issues and by being open to discuss sexual health with people in your care, this will not only help with
referral but will greatly increase the chances that someone will raise anxieties, worries or concerns with you and,
therefore, get help and support they might not otherwise access. In turn, this will improve their overall physical
and emotional health - and that of their partners and the wider community/ general population.

The important thing is that you are aware of the referral systems in your own work setting, know how to refer,
when to do so and how to do so.

 Exercise 9
 The provision of sexual health advice, information and support (including testing and treatment for STIs and
 wider sexual health issues) is different in each custodial setting. In terms of referral it is essential that you are
 aware of what systems and facilities are available in your establishment. Find out about referral for sexual
 health issues in your work setting and record your findings here.

 What referral systems are used within your establishment?




 What sexual health services are available within your establishment?




 What sexual health issues would require a referral outside of the establishment?




 Who are the contacts for referral about sexual health issues in your establishment?
 Who are the contacts for referral about sexual health issues outside of your establishment?




                                                          49
Sexual
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Awareness                                                                                  MODULE 6
When to refer an individual
Unlike referrals on mental health issues or around suspected substance misuse when we may use observation
techniques to identify behaviours that might lead to a referral, sexual health referrals are more likely to be in
response to disclosure by the prisoners themselves.

We may:
 observe signs of swelling, soreness or discharge around the genital areas during strip searches
 notice someone is itching or uncomfortable with something around the genital, rectal or pelvic area
 see prisoners having sex with each other whilst conducting wing checks
 overhear conversations that could suggest that someone has been taking sexual risks in the past

However, it is much more probable that a prisoner will approach you to ask for a referral to healthcare and women
in custodial settings are more likely than men to ask to see a doctor.

We do need to remember that many STIs will have no immediate symptoms, so raising general awareness about
sexual health through health fairs, newsletters, notices and in our general conversations with prisoners can lead
to referral opportunities that might otherwise be missed. Also, just because someone has had a full sexual health
check during induction, doesn’t mean that they do not need a further check up whilst in prison.

How to refer
How to refer someone to sexual health support services varies in each establishment, but basic principles of all
referrals are:

 Getting the information needed to make the referral and only the information you need to do this (e.g. name,
  age, prison number, relevant offending history, reason for referral).
 Not asking for information that is not required for you to refer and that will be obtained by sexual health
  services (you do not need to know a prisoners sexual health history, the number of sexual partners he or she
  has had or a full list of symptoms etc.)
 Not offering your own opinions (to healthcare staff or to the prisoner) on probable diagnosis or treatment
  solutions
 Avoiding the use of jargon or clinical terminology, with the prisoner or in your verbal/ written referral
 Communicating whether the referral was requested by the prisoner or suggested by a prison officer
 Never denying someone a referral to sexual health services because in your opinion it is not warranted

Follow-up of referral
After referral, you may want to know the outcome of your referral or get feedback on what happened as a result.
Whether you will officially receive this from the healthcare team really depends on practice and policy within your
establishment. This may depend on:
 Whether you need to know the outcome – what will be gained by you having this information? Prisoners are
   entitled to a confidential service and prison staff do not have a right to know a person’s diagnosis
 Are there any security issues raised by this referral that you need to be aware of
 Are there mental health issues that are causing concern – is the prisoner at risk of harm to themselves or to
   others
 Does the prisoner need to take ongoing medication or attend for further tests or treatment
 Does the prisoner need a referral to an outside agency that will necessitate arranging escorts etc.
 Does information need to be recorded for inclusion in a discharge plan

It may be that none of the above apply and you receive very little information from your referral. You may,
however, want to ask the prisoner directly how the referral went. This really depends on the individual
circumstances of each referral. If this is to show interest in the health and well-being of the prisoner in your care
and is done sensitively and appropriately this may be justified, but consider why you would ask, what you would
get from asking, what do you want to know and whether you really need to do this.



                                                         50
Sexual
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Awareness                                                                                  MODULE 6
 Appropriate Practice                                      Inappropriate Practice

    How did that go for you?                               So what’s wrong with you then?
    Was it helpful?                                        Come on spill the beans.
    Are you still worried about anything?                  Look, I pulled out all the stops for you – the least
    Are you happy with the referral?                        you can do is tell me what happened.
    Do you want to talk about it?                          Is it catching?
    Is there anything I need to know?                      What did they do to you?
                                                            That’ll teach you to be more careful in future.


Discharge
 From the beginning of a prisoner’s sentence, consideration shall be given, in consultation with the appropriate
 after-care organisation, to the prisoner’s future and the assistance to be given him/her on and after his/her
 release (The Prison Rules 1999).

Sexual health issues should be considered in all discharge plans for prisoners. It may be that someone is
receiving treatment or support for a sexual health problem at the point of discharge or maybe the need to continue
risk reduction behaviour in terms of sexual health has been identified as a priority for that individual.

Prison health care services are the key referrers to primary care in advance of prisoners release and should
ensure that release plans are inclusive of sexual health issues. Release packs should also include information on
both local and national sexual health support along with condoms and health promotion material. These need to
be inclusive of different languages and reflect an awareness of levels of literacy within the prison environment.

Where a prisoner is receiving medical care that needs to continue after discharge, it is important, as set out in the
Transfer and Release section of the Health Services for Prisoners Standard, that information to ensure
continuity of care is communicated, with the prisoners consent, to his/ her GP and/or other responsible community
agencies on discharge. This is particularly important for prisoners who are receiving treatment to ensure that
there is no treatment break caused by delays in communication between prison health and GPs etc.

 Module Reflection
 My three main learning points from this module are:

     1.


     2.


     3.

 My three ideas for how this module can improve my working practice are:


     1.


     2.


     3.




                                                         51
Sexual
Health
Awareness                                                                MODULE 6

TAKING LEARNING INTO WORK PRACTICE
Thinking about this workbook and your learning:

What 3 things will you immediately change in your work practice?

1.


2.


3.




What 3 changes will you make to your work practice in the longer term?

1.


2.


3.




What support do you need in order to make these changes and who from?

1.


2.


3.




What do you need to do in order to make these changes?

1.


2.


3.




                                                  52
Sexual
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Awareness

FURTHER INFORMATION
The following are useful documents/ resources/ on-line resources/ contacts for further information on issues of
sexual health that have been addressed in this workbook.

References
Effective Sexual Health Promotion Toolkit              Department of Health, June 2003
Health Promoting Prisons – A Shared Approach           Department of Health, 2002
Prison Health Handbook                                 Department of Health, HM Prison Service, Jan 2003

Tackling Blood Borne Viruses in Prison –               National AIDS Trust (NAT), April 2007
A Framework for Best Practice in the UK

The National Strategy for Sexual Health & HIV          Department of Health, 2001




Useful Websites/Contacts
www.bassh.org                                  British Association for Sexual Health and HIV

www.dh.gov.uk                                  Sexual health information

www.fpa.org.uk                                 Sexual health and contraception information

www.patient.co.uk                              Health information

www.aidsmap.com                                Information about HIV / AIDS

www.tht.org.uk                                 Information about HIV / AIDS

www.plusve.org                                 Information about HIV/AIDS and STIs

www.britishlivertrust.org.uk                   Information on liver diseases /viral hepatitis

www.brook.org.uk                               Sexual health and young people – under 25

www.bpas.org                                   British pregnancy advisory service

www.abortion-help.co.uk                        Marie Stopes – information on abortion

www.efc.org.uk                                 Pregnancy/abortion information – young people

www.hmprisonservice.gov.uk                     HM Prison Service

www.hpa.org.uk                                 Health Protection Agency

www.rapecrisis.co.uk                           Rape Crisis Federation

www.survivorsuk.co.uk                          For men who have experienced rape/sexual assault

www.cancerresearchuk.org                       Cancer Research




                                                      53
Sexual
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Awareness
GLOSSARY

                          The insertion of the penis, or sex toy (vibrator, dildo etc.) into the rectum through
Anal Sex
                          the anus.

Antibiotic                A drug that kills bacteria and other germs.

Blood Borne Virus (BBV)   A kind of germ that lives in the blood stream.

Celibacy                  Abstinence from all sexual activity and sexual relations.

Coercion                  The act of forcing a person to do something against his or her will.

                          All parties involved within a sexual activity have given their consent based upon a
                          full appreciation and understanding of the facts and implications of any actions,
                          with the individual being capable of giving consent (over 16 years of age and
Consensual
                          mentally capable) and that his or her judgment is not being impaired at the time of
                          consenting (by sleepiness, intoxication by alcohol or drugs, other health problems,
                          etc.).

Contraception             The prevention of conception by the use of birth control devices or agents

                          The act of walking or driving about a locality in pursuit of a partner for (often quick
Cruising
                          and anonymous) sex.

Cunnilingus               When a person kisses, licks or sucks on a female's genitals.

                          Any environment that requires managing individuals or groups of people within a
Custodial Setting         confined and secure setting to maintain the safety of those individuals or the
                          general public.

                          Having sex in a public place – typically a park or car park – where other
Dogging
                          consenting adults are invited to observe.

Fellatio                  When a person kisses, licks or sucks on a male’s genitals.

                          Genitourinary Medicine Clinic – a clinic that specialises in dealing with sexually
G U M Clinic
                          transmitted infections and many other genital and sexual problems.

                          The state or condition in which the body (or part of the body) is invaded by an
Infection                 infectious agent (eg, a bacterium, fungus or virus), which multiplies and produces
                          an injurious effect (active infection).

                          Using the Internet for sexual pleasure. This could be consensual sexual
                          discussion on–line for the purpose of achieving arousal or orgasm (including
Internet Sex
                          visual connections via web-cams) or using the Internet to arranging to meet
                          sexual partners.

Masturbation              Manual stimulation of the genital organs for sexual pleasure.




                                                     54
Sexual
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Awareness
Monogamy               The practice of having sex with only one partner.

                       The practice of not being exclusive to one sexual partner. There may or may not
Non-Monogamy
                       be more one sexual relationship happening at the same time.

                       The use of the mouth and/or tongue to stimulate another person's genital or rectal
Oral Sex
                       area.

Reproductive System    The bodily systems of women and men that regulate sexual functioning.

                       When a person kisses or licks or sucks another persons’ anus and surrounding
Rimming
                       area.

                       Sado-masochism . Obtaining sexual pleasure or gratification by inflicting pain and
S & M Sex              suffering on another person (sadism) or by being sexually humiliated or receiving
                       pain (masochism).

                       How a person feels about him/ her self - feelings of self worth, of being valued and
Self Esteem
                       of pride in oneself.

Sexually Transmitted
                       An infection that can be acquired through sexual contact.
Infection (STI)

                       Sex involving three people at the same time. This may be 3 men, 3 women, 2
Threesomes
                       men and a woman or 2 women and a man.

Vaginal Sex            The insertion of the penis, or sex toy (vibrator, dildo etc.) into the vagina.

                       A person derives sexual pleasure from watching others nude or having sexual
Voyeurism
                       intercourse (often, though not always, without their knowledge).




                                                  55
Sexual
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Awareness
NOTES




            56
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Health
Awareness
NOTES




            57
Sexual
Health
Awareness
NOTES




            58
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Health
Awareness
NOTES




            59
Sexual
Health
Awareness




ACKNOWLEDGEMENTS
This workbook is based on the format of the self-directed workbook Mental Health Awareness in Custodial
Settings written by Offender Health Care Strategies and produced by the Department of Health and HM Prison
Service.

Written and compiled by:

Tony Atkin                             Centre for HIV and Sexual Health, Sheffield


The following people helped to inform, shape and produce this resource:

Kate Henderson-Nichol                  Department of Health (Primary Care Lead for Sexual Health)

Steve Slack, Anthony Bains,
Anne Shutt, Matt Harrison              Centre for HIV and Sexual Health, Sheffield

Gill Bell                              Sheffield Royal Hallamshire Hospital

Rachel Payling                         Wakefield District PCT

Amy Johnson                            Phoenix Family Services

Dee Jones                              Durham & Chester-le-Street PCT

Alison Woodland                        HMP Moorlands

Dr Tim Moss                            Doncaster Royal Infirmary

Dr Tracey Dibble                       Central Health Clinic, Sheffield

Dr Eamon O’Moore                       Central Thames Valley Health Protection Unit




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