Sex is a vital part of human life. So, going to a webinar to find out what doctors and other clinicians know about taking sexual histories was exciting. It was a bit mindblowing to me, a practicing clinical sexologist, that people wouldn’t be asking a patient about sex in a routine visit or exam. If we ask people about their diet, why wouldn’t we ask about their sexual behaviors?
Understanding someone’s sexual history, their behaviors, and their histories with sexually transmitted infections (STIs) can help a health practitioner better understand and treat their patient. Ignoring someone’s sexual history can lead to problems down the road, such as a misdiagnosis or improper treatment.
Allison Agwu, M.D., Sc.M., led the session and opened things by saying that sex is “a part of normal life.”
The webinar, offered by the International Antiviral Society-USA, illuminated why taking a sexual history is important regardless of the patient’s age bracket; how to list the most important aspects of a detailed sexual history for adolescents (including sexual and gender minority adolescents) and older adults, including seniors; how to identify the barriers to taking a sexual history; and how to incorporate new skills in taking sexual histories.
The webinar itself was really accessible for everyone. The first question, chosen via poll, asked participants where their level of expertise was in managing HIV infections. There were people from all different levels, ranging from novice to expert; 35% of people who attended were novices, while only 5% were experts.
Here’s what you should know when it comes to taking a sexual history from patients—no matter their age, gender identity, or STI risk.
Why Is Taking a Comprehensive Sexual History So Important?
Because sex is a normal part of human existence, we need to give it the weight it deserves. Taking a complete sexual history is an important first step in providing the necessary advice and treatments a patient may need.
Sexual behaviors have a marked impact on one’s emotional and physical health; therefore, sexuality is an important topic of discussion, regardless of the reason the patient came into the practice. Taking a comprehensive sexual history gives clinicians an opportunity to assess risk, prevent, diagnose, treat STIs, assess medication side effects that may be impacting healthy sexual function, assess emotional and mental health, and better understand a patient’s overall wellness.
Why Are Providers Having Issues With This?
When surveyed, many providers cited a lack of proper training in sexual health, embarrassment, and a fear of offending the patient as their main reasons for not asking thorough questions about a patient’s sexual history.
Even obstetrician/gynecologists sometimes do not take a complete sexual history. A 2012 study from the Journal of Sexual Medicine reported that only 63% of obstetrician/gynecologists routinely assessed patients’ sexual activities, and just 40% routinely asked about sex problems. Only 29% asked about satisfaction, and 28% asked about sexual orientation and identity; 14% asked about pleasure. A full 25% said that they had expressed disapproval of patients’ sexual practices.
With so many doctors offering up judgement rather than education, how can a patient feel comfortable enough to ask questions about sex?
What This Means for Patients
Patients have also shown a reluctance to voice concerns about their sexual health. When you go into a medical practice, there is a notable shift in power. The patient is there to see the doctor—the expert who will tell them what is wrong with them. This dynamic can play a big role in which questions a patient asks.
Patients have expressed a fear of judgement, homophobia, and dismissal of their concerns as some of the chief reasons why they don’t bring up sex to their doctor and other health professionals.
Before we get into how to properly approach a patient about their sexual health and history, let’s get some facts straight on who is having sex and who is at the greatest risk for STI infection.
Adolescents Are Sexually Active—and That Is Just the Truth
Adolescents are having sex, and pretending they aren’t isn’t going to change that. According to a 2017 National Youth Risk Behavior Survey, 40% of teens between ninth and 12th grades have had sexual intercourse. Acting like kids aren’t doing it is irresponsible and can jeopardize their ability to get real, solid health information that they need to protect themselves from unwanted pregnancy and STIs.
According to the survey, 29% of teens had had sex during the previous three months, and, of those, 46% did not use a condom the last time they had sex. And 14% of respondents did not use any method to prevent pregnancy.
When it comes to teens, we shouldn’t be thinking of them as having “underdeveloped” brains. They have growing brains that are doing what they are supposed to be doing. As they age, teens start to desire independence, experience lower levels of emotional regulation, and experience feelings of invincibility. This is a normal way for adolescent brains to develop. It’s important for trying new things and taking risks. These behaviors are a part of growing up.
With all that being said, youths are at a higher risk for STIs and HIV infection. There are lots of reasons for this, both social and biological. Teens lack the immunity required to fight infection in the same way an adult would. They have different anatomy as their bodies are developing. Many social factors also impact the way kids behave, and this type of behavior can result in a greater risk of STI infection.
In teens, STI rates are increasing, while pregnancy rates are decreasing. It’s important to note that sexual minority youths are more likely to have sex by age 13, are more likely to use alcohol, and are less likely to use condoms. When it comes to STIs, this is the highest-risk youth group.
Sexuality in Adulthood
Many life events impact sexual activity. Social factors such as marriage and divorce impact one’s sexual behaviors, as do extramarital affairs, sickness, and other biosocial factors. The median age of marriage has increased, which means that adults are more likley to engage in casual sex over a longer period of time, which in turn leads to increased HIV infections. No matter your age, your sexuality does not disappear. Sex is a normal part of the entire life journey.
Seniors and Sexual Activity
Seniors are not the sexless beings that the media unfairly portrays them as. Lots of seniors are enjoying healthy sex lives and thriving romance. According to AARP, 40% of seniors aged 65 to 80 are sexually active. Of the 72% who have a romantic partner, 54% are sexually active. In this age group, 50% of men versus 12% of women reported being extremely or very interested in sex; 31% of women versus 51% of men reported having sex, and 43% of women versus 31% of men reported being satisfied with their sex lives.
According to the Centers for Disease Control and Prevention, one in six new cases of HIV are among adults 50 and older. This is why talking about sexual health with older adults is so important. Older adults don’t have a risk of pregnancy, decreasing the likeness of condom use. Older adults have also been shown to lack understanding around sexual health and STI risk. Education is crucial, regardless of age.
There are also biological factors to consider. Menopause in older women can lower estrogen levels and decrease vaginal lubrication, making tearing and subsequent STI infection more likely. Older people have age-related immunodeficiencies and often have other underlying health issues that can increase their likelihood of contracting an STI.
What to Ask the Patient
When talking about sex with patients, you want to speak using language that they can understand. Do not use medical jargon, as it can put you in a position of authority in a way that can prevent a patient from feeling comfortable enough to ask important questions. Building a rapport with the patient is crucial in establishing trust. From the minute a patient walks into the office to the minute they leave, you should create a safe space for them.
Questions should be centered around their last sexual encounter, pregnancy prevention, and STI treatment. When asking about number of sexual partners, make it clear to a patient that you are not judging them, but helping to assess their STI risk and condom usage, and to get a better understanding of the person’s sexual behavior in order to adequately help them. More than 60% of Americans haven’t been tested for HIV. Only 15% of U.S. adults aged 18 to 64 have been recently tested. It’s important to tell your patients that condoms are 85% to 95% effective at preventing HIV transmission. If someone is at higher risk of HIV infection, you should suggest pre-exposure prophylaxis (PrEP).
When it comes to pregnancy prevention and birth control, ask what their desires are. What are their goals? Make the advice appropriate. Knowing their goals can help give a framework for the proper medical advice.
Lastly, ask about any problems related to sexual intercourse. This may involve asking questions about sexual abuse, as trauma and psychological issues can manifest as physiological symptoms.
Sample Questions for Practitioners
“Are you presently sexually active?”
“Are you satisfied with your sexual life?”
“Are there problems or worries you’d like to discuss today?”
“Sometimes, people who suffer from X medical condition can suffer from X concern. Are there any concerns you like to discuss with me?”
Having a strategy in place can help when asking these questions. Try connecting it to some other aspect of a patient’s life, rather than simply going right to “Tell me about your sex life.” Knowing about a divorce, menstrual issues, etc. can all help a provider lead a patient into the topic of sex with care.
Don’t make any assumptions about someone’s sex life and behavior, regardless of their sexual identity.
Some Things to Consider: Asking the Difficult Questions
Not every question needs to be asked in a single consultation. This can be a series of discussions, much like “The Talk” parents have with kids about sex. It is an ongoing conversation. If necessary, ask for some follow-up appointments in order to fully address the patient’s concerns and to help them feel safe. Patients are sensitive, and the more comfortable you are, the more comfortable they’ll be.
Be calm. Try to understand your own feelings. The more you practice having these conversations, the easier it will be to communicate with patients. If you are curious about something about a patient’s behavior, ask them about it. Just ask. Ask them the weird or uncomfortable questions. Your patients come first, and their well-being is the most important thing.
If you never ask a patient, you won’t be able to help them.
10 Key Takeaways
- Learn the facts from the patient, and listen.
- Give real, helpful information geared toward your patient.
- Don’t make assumptions.
- Give advice based on sexual history.
- Be sex-positive.
- Ask the harder questions.
- Build rapport and trust.
- Be a safe container for patients for their sexual questions and concerns in order to help them make sexually healthy choices.
- When there is a positive STI result, do not stigmatize. Strategize with your patient on how best to treat the STI.
- It’s OK to be honest if you are confused or if you don’t understand something they’re telling you. Allow the patient to lead you.
This webinar was hosted by the International Antiviral Society–USA (IAS–USA), accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.