Speaking of Sex: Creating a Safe Place for Open Discussion

It is one of the great ironies of a sex-drenched culture that sex, if it is spoken of at all, is too often described with code words and cute metaphors or, in health care settings, sometimes barely mentioned. Both practitioners and patients can be reluctant to speak frankly and this can impact both the quality of health information, as well as good decisions about healthy sexual practices. Health care providers need to take an honest look at their ability to be comfortable with sexuality and discussions of sex.

Many patients, despite an abundance of experience, don't feel very competent with one important component of sex: speaking about it. There are many situations in which this can be a problem. Couples often have trouble communicating frankly with each other about their sexual needs or concerns in their relationship. Revealing serostatus to a date or sex partner is a big concern for many HIV-positive persons. And others, even after seeking out a provider they assume to be "culturally competent" (such as a gay man finding a gay physician), are reluctant to talk about their sexual practices honestly with that provider, which jeopardizes their health. I have had patients report that they prefer to get tested and treated for sexually transmitted infections at an anonymous clinic rather than at the office of their HIV doctor. This is not for insurance reasons, but because they are embarrassed about their sexual behavior.

Sex is still wrapped in shame for many people. This is true of professionals, as well. I have had patients who completed inpatient substance abuse programs tell me that while in treatment they never spoke of their sexual practices, most of which were critically linked to their drug use. Why wasn't this discussed? In many cases, it was because the counselor was uncomfortable speaking about sexual practices. When I train other therapists, we pay close attention to their sexual competence: the ability to be comfortable speaking about sexual concerns and make it safe for their clients to do so as well.

Both patients and health care providers need to be mindful about the communication of sexual concerns. Here are some concepts to discuss with your patients that may help them speak up about sex:

• Feeling devalued impacts sexual decisions
  Marginalized people (including LGBT [lesbian, gay, bisexual and transgender] and/or HIV-positive men and women) need to work at self love even harder than society at large simply because they are consistently bombarded with negative messages, both overt and covert. Remind them they have a right to their feelings, a right to speak up and to be heard, and a right to have their sexual limits honored.
• Shame inhibits frank discussion
  The potential for embarrassment or shame needs to be minimized when speaking about sexual needs, concerns or problems. Point out to your patients that they are not the first to have such feelings and that not speaking up could have fatal consequences. This is especially true for discussions with health care providers. I know one man who didn't want to speak to his physician about his anal warts, which consequently went untreated and developed into rectal cancer.
• Open conversation requires emotional safety
  Whether it's HIV status, the need to use condoms, or concern that one's sex life is a little out of control, everyone needs to be able to speak their truth. Many patients evaluate their physician's comfort level with various topics and seek permission to bring up difficult, sexual topics. Consciously promote open communication, remembering that frank discussion is based on trust and may require direct questioning.

It is up to the health care provider to create a safe and accepting environment in which sexual topics can be freely discussed. Maintain an awareness of your own facial expressions or body language that convey even subtle judgment and possible shaming of your patient. If issues come up that increase your discomfort or challenge your knowledge, consult and/or refer. It is essential that patients frankly discuss sexual practices and concerns in a safe, non-judgmental atmosphere. Remind them that there are no bad questions and that even if they want to ask what they think is a naive question, they should speak up. Remind them that you have probably heard it before.

When discussing something as important as sexual needs or sexual health, everything should be on the table. Lives depend on it.