Serious conversations about sex are difficult for most us; health care providers are no exception. As a 1997 Institute of Medicine report titled "The Hidden Epidemic" noted, "Ironically, it may require greater intimacy to discuss sex than to engage in it."
So it's no surprise that providers often avoid talking about sexual health with their patients because they don't feel comfortable asking what they perceive to be sensitive and potentially embarrassing questions. In a busy health care practice it's not uncommon for providers to skip questions about sexual health unless a patient has signs or symptoms of sexually transmitted diseases (STDs). Or providers may be operating under the incorrect assumption that they don't need to discuss sexual health with the octogenarian widow or the wheelchair-bound veteran in their exam rooms.
But learning about the sexual health and behavior of patients is a critical piece of providing high-quality, patient-centered, accessible, and efficient health care -- and in many instances patients want to talk about sex with us. In a survey of 500 men and women over age 25, 85 percent of respondents expressed interest in talking about sexual concerns with their doctors, even though 71 percent thought their provider would likely dismiss their concerns.
Knowledge of a patient's sexual history gives us opportunities to educate and counsel them about HIV, STDs, and viral hepatitis. Without taking a sexual history, it's difficult to know what tests or vaccinations are needed. These mostly "silent" diseases can go unnoticed for long periods of time until they lead to more serious illness. Without treatment, they can also spread to other partners and increase disease in the community.
There are new federal government programs and initiatives that have the goal of greatly reducing HIV, STDs, and viral hepatitis in the U.S. health care system. Community health centers and other health care practices that care for underserved and vulnerable populations are essential to reaching these goals because their patients are often most at risk.
In an effort to foster productive conversations between providers and patients about healthy sexual function, behavior, and satisfaction, the National LGBT Health Education Center collaborated with the National Association of Community Health Centers on the toolkit "Taking Routine Histories of Sexual Health: A System-Wide Approach for Health Centers." The publication is an A to Z guide to the best practices for establishing the routine collection of sexual health histories during a primary care visit, from recommended screening questions and subsequent risk assessments, to information on coding and billing, and recommendations for implementing the taking of routine sexual histories in your organization. While the toolkit was designed for community health centers, it can be easily adapted for use in other health care settings. It goes beyond a focus on risk, and suggests engaging in conversation with patients to learn about sexual satisfaction, desires for parenting, domestic violence, and situations where one's situation may lead them to trade sex for money.
The toolkit shows providers that gathering information about their patients' sexual behavior can be done thoroughly and efficiently by starting with three basic questions related to behavior and risk:
- Have you been sexually active in the last year?
- Do you have sex with men only, women only, or both?
- How many sexual partners have you had in the last six months?
These questions give a sense of a person's sexual behavior and sexual risk, and make it easier for providers to tailor broader and deeper discussions to the needs of individual patients. It's important that providers assure patients that this is something they do routinely with all patients, and that it is not based on assumptions about a particular patient's behavior, identity, or life circumstances. Context is key for facilitating open and honest discussion with patients about their sexual lives.
This is particularly true for high-risk populations who've been historically marginalized or oppressed. Our toolkit includes information about unique considerations when working with transgender women or men who have sex with men (MSM), two groups at high risk for HIV, STDs, and viral hepatitis. Additionally, transgender men, most of whom do not do not undergo complete sex reassignment surgery or undergo total hysterectomy later in life, are also 10 times more likely to have an inadequate Papanicolaou (Pap) test compared to female patients, as my Fenway Health colleague Jennifer Potter, MD recently showed in a study published in the Journal of General Internal Medicine.
In order to better serve these populations, it's important for sexual histories to be sensitive to and inclusive of these patients. We answer important questions, such as:
- How often should people be tested for HIV and STDs?
- What vaccinations should be offered to whom
- Why are some MSM at higher risk for HIV and STDs?
The toolkit offers important tips for talking with transgender patients, who frequently forgo routine health care due to a lack of culturally competent providers. Points to keep in mind include:
- Use the patient's preferred name when talking to them -- it will not necessarily be the same name that is on insurance and medical records.
- Ask what pronouns your patients prefer to use for themselves. Many transgender people prefer that you to use the pronoun that matches their gender identity.
- Like anyone else, a transgender person may have partners who are male, female, or transgender.
It may take time to feel completely comfortable communicating with patients about their sexual health, identities, behaviors and desires. There was a time when people only whispered the word "cancer," and only in recent decades have we begun to break down the stigma of depression and other mental illness. But the more we can engage in honest conversations about sex and sexuality -- inside and outside of the health care setting -- the healthier and happier our communities will be.
For the health of all communities, opening the door to talking about intimate issues of concern including sexual health will take us along the road to better health.