Witnessing an HIV boom in the 1980s
A sexual health doctor
Angela Robinson is a consultant in sexual health and HIV medicine. She studied medicine at the University of Newcastle, and qualified in 1980. After training in general medicine, Dr Robinson obtained her MRCP in 1983. She was appointed to a consultant position at University College Hospital in London in 1989 and became honorary senior lecturer at University College London in 1995
Why did you choose to work in sexual health? 1
Genitourinary medicine has a lot of different facets, including public health, epidemiology, clinical medicine, microbiology, virology, and also psychosocial aspects. Originally, I had been working in haematology but I decided that I preferred more patient contact. Sex and sexual activity is fundamental to the species and it seemed to me that it was often ignored in medicine. We look after individuals but also look after the public health and—although it might seem simple on the exterior—sexual health is fundamental to life and requires a unique skills set.
What effect did HIV have on sexual health services?
In 1985 when HIV was in the ascendance, I was looking after the patients with haemophilia in Cardiff. Once the HIV antibody test became available we soon realised that we had been looking after many HIV positive patients.
Before HIV, pursuing a career in genitourinary medicine was seen as somewhat of a last resort as if you weren’t able to succeed in other medical branches. This was for most, untrue but with the advent of HIV, the specialty gained more respect and became more challenging
The arrival of HIV changed the landscape of basic scientific research, with advances in immunology and molecular biology which can now be applied to other medical fields. The partnership between scientists and drug industry has resulted in development of highly active drugs and understanding of viral resistance, which is applicable to other viruses.
Why do you think genitourinary medicine was originally ignored?
A lot of clinicians didn’t want to venture into any discussions about sexual health and felt ill equipped to do so. Sex was not mentioned and its consequences not dealt with, even though sex is an integral part of life. It’s a specialty that not everybody feels comfortable doing. Some people find it difficult to ask intimate questions. I think this has changed with better undergraduate education and of course there has been a cultural change in how society views sex. In fact that pendulum might have swung too far the other way—where sex is sensationalised in the media with the potential for distorted expectations.
How do you think sexual health is represented in the media?
There’s a lot of ignorance around sexual health with a lot of misinformation. Sex and sexually transmitted infections are good for business and responsible journalism can be hard to find. In terms of helping people to look after their sexual health, I still think we are doing young people a disservice. Personal social health and economic education is not always well taught at some schools.
There is an expectation that teachers are able to talk to pupils about sexually transmitted infections, sexual health, and relationships without adequate training. We probably don’t give enough support to teachers. The evidence base suggests if you give accurate information people are more knowledgeable—this doesn’t necessarily change peoples’ sexual behaviour to become more sexually active. In Holland and Scandinavian countries, outcomes suggest that there is a delay in sexual debut, and fewer sexually transmitted infections and unwanted pregnancies. This might depend on the different cultural approach, with the family as central. Generalising, parents are able to talk about sex with their children whereas in the UK this is often not the case and many children find out information about sex from their peer group or from the media.
What’s the most common challenge you have to deal with on a day to day basis?
One of the most exciting aspects of this job is that every person you see has their own story to tell, so it’s the challenge of supporting each individual sitting in front of you. Although the diseases might be the same, how someone came to acquire them and their impact manifest differently. The challenge is to get an immediate rapport with a patient, be able to talk about intimate details, make them feel comfortable and that they are not being judged and dealing with their anxieties.
What changes have you seen throughout your career?
There are more sexually transmitted diseases around now than there were in the 1990s. We’re seeing a broader range of infections with improved diagnostic techniques and the resurgence of infections that were becoming quite uncommon like syphilis, for example. You wouldn’t have seen much in the late 1980s and early 1990s because sexual behaviour changed with the arrival of HIV/AIDS but now you’re seeing primary and secondary syphilis certainly in London clinics on a regular basis and the re-emergence of lymphogranuloma venereum.
The next major change will be the fall in numbers of patients with genital warts, one of the commonest conditions seen in clinic, when the human papilloma virus vaccine is rolled out starting from 2013.
How should sexual health services be run in this new era of clinical commissioning groups?
The crucial element we need to control infection is rapid access to services that are experienced with diagnosis, treatment, and partner management of sexually transmitted infections and HIV. Our open access clinics, which do not require GP referral, allow people to attend promptly. Some people do not want to disclose their problems to GPs or find GP services difficult to access. Secondly, services must be confidential. If people feel their information is not being handled confidentially then the problems go “underground,” people don’t present as they are scared of consequences if others get to know. This results in onward transmission if patients are infected or ongoing unnecessary anxieties if people feel unable to come forward for testing. Any commissioning must keep these fundamental aspects of services and the well developed networks otherwise there is a risk of worsening sexual health outcomes and higher financial costs.
What skills are needed to succeed when working in sexual health services?
You have to like speaking to people and you can’t be judgemental. You have to be comfortable talking about sex and be able to facilitate others to divulge very personal information. I always say it’s where the bedside manner really counts. If the patients aren’t comfortable with you, then they won’t talk to you and won’t come back. The specialty requires a training in general medicine, but although it’s a medical specialty, you have to have training in some aspects of gynaecology and public health. Also, communication skills, empathy, and an interest in the psychological-pathological and epidemiological-clinical-lab interfaces are important.Matthew Billingsley, editorial assistant, doc2doc and specialty portals
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Cite this as: Student BMJ 2012;20:e602