Women's sexually transmitted infections in primary care: General practitioners' challenges and strategies - A qualitative study in Germany.
EUROPEAN JOURNAL OF GENERAL PRACTICE
https://doi.org/10.1080/13814788.2023.2190094
ORIGINAL ARTICLE
Women’s sexually transmitted infections in primary care: General
practitioners’ challenges and strategies – A qualitative study in Germany
Pauline Meurer
, Christoph Heintze
and Angela Schuster
Charite – Universit€atsmedizin Berlin, corporate member of Freie Universit€at Berlin and Humboldt-Universit€at zu Berlin; Institute of
General Practice, Berlin, Germany
KEY MESSAGES
STI care is hampered by unclear responsibilities, referral pathways and financial remuneration, by stereotypes and uncertainties regarding diagnostics.
GPs feel responsible for helping; they either rely on referrals, provide care for selected cases, or provide
comprehensive STI care on-site.
GPs with appropriate training and open attitudes provide comprehensive STI care.
ABSTRACT
ARTICLE HISTORY
Background: The incidence of sexually transmitted infections (STI) is rising. Amongst women,
STIs are often asymptomatic and thus likely underreported. STI care in Germany is fragmented.
General Practitioners (GPs) could offer accessible care; however, to which extent GPs provide STI
care and which challenges they face remains unclear.
Objectives: To increase understanding of how GPs provide STI care for women in German highincidence settings and to identify challenges and opportunities for improved care.
Methods: Between 10/20 and 09/21, we contacted 75 practices using snowball and theoretical
sampling. We conducted qualitative guide-assisted interviews with 19 GPs in their practices in
Berlin, Germany. Data were analysed using thematic analysis with grounded theory components.
Results: Responsibilities and financing of STI care services were unclear. Most GPs perceived
specialised doctors to be responsible for STI care in women; however, many non-STI specialised
doctors were the first point of contact for patients and felt responsible to help. (LBTQI) Women
were perceived to have less access to care. Stigmatising perceptions of women with STI-related
needs were common. Doctors immediately referred patients to other providers, offered STI care
for selected cases, or routinely offered primary STI care. GPs’ referral strategies were often unsystematic. Those who offered primary STI care perceived patients’ need for STI care, showed open
attitudes to sexual health, and had undergone further training on STI care.
Conclusion: Training regarding STI care, remuneration, and referral pathways should be provided for GPs. Comprehensive STI care could be offered through the cooperation of GPs and
specialists.
Received 27 July 2022
Revised 1 March 2023
Accepted 3 March 2023
Introduction
Rising incidences of sexually transmitted infections
(STI) are reported in the US and Europe [1,2]. Between
2010 and 2017, the syphilis incidence rate rose by
153% in the UK and by 144% in Germany [3]. The
number of cases is particularly high in urban settings;
in Germany, Berlin is the most affected city [4].
KEYWORDS
STI; women’s health;
primary health care; general
practice; Germany
The most common STI in England and Germany is
chlamydia, with 9% and 5% of 15-24-year-old females
testing positive in screenings in England and
Germany, respectively [5,6]. Chlamydia is asymptomatic in up to 80% of women [7], and the German
screening programme for pregnant persons and
women aged 15–25 reached only 11% of the target
CONTACT Pauline Meurer
Charite – Universit€atsmedizin Berlin, corporate member of Freie Universit€at Berlin and
Humboldt-Universit€at zu Berlin; Institute of General Practice, Chariteplatz 1, 10117 Berlin, Germany
Supplemental data for this article can be accessed online at https://doi.org/10.1080/13814788.2023.2190094
ß 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the
posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
2
P. MEURER ET AL.
group in 2015 [6]. In women, STIs can ascend through
the cervix and into the upper genital tract and cause
serious sequelae such as pelvic inflammatory disease
and infertility [8,9].
Before the 1970s, sexual health care in Europe was
mainly covered by non-governmental organisations
(NGOs). As sexual health was integrated into regular
health care, different providers took on the responsibility: general practitioners (GPs) in the UK and the
Netherlands, community health centres in Sweden and
Portugal, and gynaecologists working at the primary
care level in Germany and Poland. Often, STI care is
separated from family planning, and specialised care
structures have emerged during the HIV crisis [10].
Most people living with HIV in Germany are followedup in HIV-focussed practices, usually led by general
practitioners or internal specialists with an additional
qualification in infectious diseases. They provide both
primary care and specialised care for HIV and STI.
As a result, sexual health care in Germany is fragmented and characterised by a multitude of actors.
Many ambulant services are designed for specific
groups, e.g. men who have sex with men (MSM) or
sex workers. Health services are offered by medical
care providers (gynaecology, urology, dermatology,
general medicine, STI clinics) but also by the local
health authorities and NGOs. The latter focus on populations who experience difficulties in accessing the
regular health system, they offer STI testing at low or
no cost but can’t always provide STI treatment [11].
Patients can freely consult GPs, specialists, or other
providers according to their preferences. Specialised
doctors can be consulted directly; referrals from the
GP are not required.
The guidelines of the German STI Society recommend counselling and diagnostics for either symptomatic patients or according to so-called epidemiological
criteria, which are based on behavioural risks or on
belonging to a population considered at risk [12].
Guidelines provide orientation for care but are not
legally binding. The remuneration of GPs in Germany
is based on a quarterly lump sum per patient, independent of the complexity of provided service. Based
on the number of patients, a laboratory budget is calculated. In specific occasions, including suspicion of
notifiable STI, laboratory tests can be carried out without affecting the budget. Notifiable STIs must be
reported to the Robert Koch-Institute, including syphilis, HIV and gonorrhoea with reduced sensitivities to
certain antibiotics. Other STIs can also be tested
budget neutrally if notifiable diseases are suspected;
laboratory costs are then directly covered by German
compulsory health insurance. Otherwis (...truncated)
