Biomedicine is improperly imbued with a nomothetic methodology, which views 'disease' in a similar way to other 'natural' phenomena. This arises from a 300-year history of a positivist domination of science, meaning that objectivist research (e.g. randomized controlled trials or biochemical research) attracts more funding and is more readily published than 'softer' qualitative research. A brief review of objectivism and subjectivism is followed by a definition of an emerging medical paradigm. Current 'inappropriate' medical practices become understandable in this broader context, and examples are given. A constructivist paradigm can continue to incorporate 'objective' clinical findings and interventions, as well as the recent evidence for the doctor-patient relationship as a major contributor to patient outcomes.

While the complaints process is intended to improve healthcare, some doctors appear to practise defensive medicine after receiving a complaint. This response occurs in countries that use a tort-based medicolegal system as well as in countries with less professional liability. Defensive medicine is based on avoiding malpractice liability rather than considering a risk-benefit analysis for both investigations and treatment. There is also evidence that this style of practice is low quality in terms of decision-making, cost and patient outcomes. Western medical practice is based on biomedicine: determining medical failure using the underlying, taken-for-granted assumptions of biomedicine can potentially contribute to a response of shame after an adverse outcome or a complaint. Shame is implicated in the observable changes in practising behaviour after receipt of a complaint. Identifying and responding to shame is required if doctors are to respond to a complaint with an overall improvement in clinical practice. This will eventually improve the outcomes of the complaints process.

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Summary: This guideline provides evidence-based guidance on the content of safer sex advice and the provision of brief behaviour change interventions deliverable in genitourinary (GU) medicine clinics. Much of the advice is applicable to other healthcare settings including general practice and clinics providing HIV care. Advice on condom use and effectiveness, oral sex and other sexual practices, testing for sexually transmitted infections (STI) and partner reduction is provided. Advice specific to the transmission of HIV infection including seroadaptive behaviours and negotiated safety is also included. An accompanying review of the evidence supporting the guideline with a complete reference list is available online. A patient information leaflet based on the advice statements developed is also available through the BASHH website.Keywords: sexually transmitted diseases, safe sex, risk reduction behaviour, condoms, HIV infections SCOPE AND PURPOSEThe objective of this document is to provide guidance for practitioners in Level 3 genitourinary (GU) medicine services (Tier 5 in Scotland) on safer sex advice provided in sexually transmitted infection (STI) and HIV management consultations. The guideline consists of: † Recommendations on the format and delivery of brief behaviour change interventions deliverable in GU medicine clinics; † Recommendations on the content of safer sex advice given to individuals at continued risk of STI; † Additional advice to be provided for those living with HIV, or from groups with higher rates of HIV incidence.Much of the guidance is applicable in other sexual health and general practice settings, including HIV care services. The evidence base for the recommendations is summarized in an accompanying online document. Issues relating to implementation of behaviour change interventions in clinics, such as designing service structures and care pathways or the competencies required in different multidisciplinary staff groups, will be addressed in British Psychological Society (BPS) Good Practice Guidelines.1 Safer sex advice and individual behaviour change interventions provided within clinics are elements of a combination prevention approach to STIs and HIV 2,3 that may also include group and community-based behavioural interventions, structural and social changes and for HIV, biomedical interventions including postexposure prophylaxis for HIV following sexual exposure (PEPSE), pre-exposure prophylaxis (PrEP) 4 and the early initiation of antiretroviral therapy (ART). IDENTIFYING CANDIDATES FOR SAFER SEX ADVICE AND OTHER PREVENTION INTERVENTIONSNo systematic reviews, meta-analyses or original studies describing methods to systematically target potential candidates for interventions were found. The selection of patients for advice and behavioural interventions should be based on demographic group and individual history taking to identify recognised risk factors. 5,6 Guidance on eliciting risk factors is detailed in the BPS guidelines.1 Those at increased risk may include: † Adolescents...

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