Let’s Talk About Sex
Sexual Histories & Patient Centered Risk Reduction
Case 1: Norma
63yo F with PMH of poorly controlled T2DM and HTN who presents for DM fu.
You have been seeing this patient every 1-3 months for the last two years while attempting to control her DM.
As you stand up to leave from today’s appt, Norma mentions that there is one other thing she would like to discuss: she is not interested in sex any more.
You are behind schedule with three patients already waiting. You tell Norma that you agree this is an important topic and would like to give it the time it deserves. You propose scheduling a follow up appointment in a few weeks to discuss further.
Morning class! Welcome to sex education.
Let’s face it. Sex ed sucks.
Yes. There is a study for that.
A meta-analysis of 48 studies from 10 different countries (including the US) published in the BMJ found that high school students believed their sex ed to be:
Pound, Pandora, et al. “What Do Young People Think about Their School-Based Sex and Relationship Education? A Qualitative Synthesis of Young People’s Views and Experiences.” BMJ Open, vol. 6, no. 9, Sept. 2016, p. e011329, 10.1136/bmjopen-2016-011329.
Embarrassing…
A study in 1990 looking for reasons why providers still did not take sexual histories in spite of the growing AIDS epidemic showed providers reported:
MERRILL, JOSEPH M., et al. “Why Doctors Have Difficulty with Sex Histories.” Southern Medical Journal, vol. 83, no. 6, June 1990, pp. 613–617, 10.1097/00007611-199006000-00004. Accessed 21 Sept. 2021.
Burd, Irina D., et al. “ORIGINAL RESEARCH—EDUCATION: Impact of Physician Gender on Sexual History Taking in a Multispecialty Practice.” The Journal of Sexual Medicine, vol. 3, no. 2, Mar. 2006, pp. 194–200
Loeb, Danielle F., et al. “Patient, Resident Physician, and Visit Factors Associated with Documentation of Sexual History in the Outpatient Setting.” Journal of General Internal Medicine, vol. 26, no. 8, 27 Apr. 2011, pp. 887–893
Turns out, our patients want to talk about sex.
A survey of 1452 patients at a general medical practice found that:
Meystre-Agustoni, G, et al. “Talking about Sexuality with the Physician: Are Patients Receiving What They Wish?” Swiss Medical Weekly, vol. 83, no. 6, 8 Mar. 2011, 10.4414/smw.2011.13178. Accessed 28 Mar. 2021.
And yes, I know not everyone here is a primary care provider
For our specialist colleagues this is still relevant:
Oncologists - consider HPV exposure in the throat or anus
General surgeons - recognize dyspareunia as a long term surgical complication due to abdomino-pelvic adhesions
Palliative - assess sexual health as a component of quality of life
Rehab medicine - discuss adaptations for sex just like other daily activities
So, what is sex anyway?
So much more variety than just “men, women or both.”
So, what is sex anyway?
I have sex using my In contact with my partner(s)’s
vagina vagina
penis penis
mouth mouth
anus anus
toys toys
other ________ other ________
(connect all that apply)
So, what is sex anyway?
Kasotakis, G., et al. “Rectal Foreign Bodies: A Case Report and Review of the Literature.” International Journal of Surgery Case Reports, vol. 3, no. 3, 2012, pp. 111–115, 10.1016/j.ijscr.2011.11.007. Accessed 4 May 2022.
CDC: 6 Ps
Open ended -> specific
Eg. “What types of sex do you have?” Then, “Have you had any anal intercourse?” If yes, “Was it receptive? Insertive? Was a condom always used?”
Mcvay, Ryan, and Division of STD Prevention, CDC. US Department of Health and Human Services Centers for Disease Control and Prevention a Guide to Taking a Sexual History Taking a Sexual History. 2008.
AAFP: “Proactive Sexual Health History”
Sexual Health Screening Questions Questions for a Detailed Sexual History
Are you currently sexually active? Have you ever been?
Are your partners men, women, or both?
How many partners have you had in the past month? Six months? Lifetime?
How satisfied with your (and/or your partner's) sexual functioning are you?
Has there been any change in your (or your partner's) sexual desire or the frequency of sexual activity?
Do you have, or have you ever had, any risk factors for HIV? (List blood transfusions, needlestick injuries, IV drug use, STDs, partners who may have placed you at risk.)
Have you ever had any sexually related diseases?
Have you ever been tested for HIV? Would you like to be?
What do you do to protect yourself from contracting HIV?
What method do you use for contraception?
Are you trying to become pregnant (or father a child)?
Do you participate in oral sex? Anal sex?
Do you or your partner(s) use any particular devices or substances to enhance your sexual pleasure?
Do you ever have pain with intercourse?
Women: Do you have any difficulty achieving orgasm?
Men: Do you have any difficulty obtaining and maintaining an erection? Difficulty with ejaculation?
Do you have any questions or concerns about your sexual functioning?
Is there anything about your (or your partner's) sexual activity (as individuals or as a couple) that you would like to change?
Preventive Sexual Health Questions
How do you protect yourself from HIV and other STDs?
Have you ever been tested for HIV? Would you like to be?
Do you use anything to prevent pregnancy? Are you satisfied with that method?
Have you ever been immunized against hepatitis? Would you like to be?
P.L.I.S.S.I.T. Model for Approaching Sexual Health Problems
Permission: (1) For physician to discuss sex with the patient; (2) for patient to discuss sexual concerns now or in the future; and (3) to continue normal (i.e., not potentially harmful) sexual behaviors.
Limited Information: Clarify misinformation, dispel myths, and provide factual information in a limited manner.
Specific Suggestions: Provide specific suggestions directly related to the particular problem.
Intensive Treatment: Provide highly individualized therapy for more complex issues.
Savoy, Margot, et al. “Sexual Health History: Techniques and Tips.” American Family Physician, vol. 101, no. 5, 1 Mar. 2020, pp. 286–293, www.aafp.org/afp/2020/0301/p286.html. Accessed 27 May 2021.
Fenway Institute/Harvard: Affirming Sexual Histories
1. Make it routine, confidential, and free of assumptions related to age, anatomy, gender, ability.
2. The more often you take the sexual history, the easier it will become.
3. Explain to patients why it is important.
4. Ask about sexual function and satisfaction, not just STI risk.
5. Ask open ended questions, at least initially.
6 . Normalize “less desired” responses: “Many people do not use condoms every time they have sex. How often do you use condoms?”
7. Mirror patients’ language, if possible.
8. Don’t be so concerned about asking something in the “right” way that the conversation becomes a robotic rather than a professional but natural interaction.
9. Consider giving patients the option to answer questions indirectly: “I recommend screening for gonorrhea and chlamydia at all sites that might have been exposed. For example, if someone puts their mouth on another person’s penis, I would test the mouth…Which of these sites should you have tested today?”
10. Tone and rapport matter as least as much as the questions themselves.
Ard, Kevin. Taking an Affirming Sexual History. https://fenwayhealth.org/wp-content/uploads/10.-Taking-an-Affirming-Sexual-History-Ard.pdf
Why talk about risk reduction as part of a sexual history?
Screenings without interventions use valuable time without significant impact.
Bearing in mind, it’s still valuable to open the door for future discussion, even if patients are not ready for discussion now.
Sexual health is important!
Identification of STI and HIV risk & and offer STI/HIV prevention
Opportunities for preventive care (vaccines, PrEP)
Opportunities to discuss reproductive health concerns
What is risk anyway?
If sexual health is fulfilling and safe sexaul activity, sexual risk is anything which is not that
Case 2: Emily
17yo F with PMH of irregular and painful periods. She has never been sexually active.
She has tried OCPs before but would often miss doses and so still had irregular bleeding. The patch caused a local skin reaction. You discuss other options including an arm implant, but she is on the wrestling team and worries the implant could be damaged or displaced.
She ultimately considers the vaginal ring vs an IUD. However, in both cases she is worried about the pain of placing them as she has never inserted anything vaginally. She opts to start with the vaginal ring but returns a month later stating that she has tried many times and has not been able to insert it due to pain. She still wants to use the vaginal ring but feels that she will never be able to do so. She is also considering engaging in receptive vaginal-penile intercourse is is worried that this will hurt.
Risk reduction resources
STIs: Not just condoms - frequent testing, PrEP or PEP, etc.
Contraceptives: RHAP Birth Control Options Fact Sheet; bedsider.org
Consent: Yes, No, Maybe Inventories
Painful sex: Mayo Clinic resources; ISSWSH
BDSM/Kink safety: San Francisco Aids Foundation S&M and Kinky Sex Resources; NCSF Kink Aware Professionals Directory
Legal: National Coalition for Sexual Freedom Incident Report; safewordtax.com
Case 2: Micah
24yo M who was assigned female at birth. He is currently taking testosterone and has no past surgical history. He otherwise has no pertinent PMH.
Micah presents to the clinic for STI testing and you ask a detailed sexual history. He reports that he is in several open relationships which are sexually fulfilling and include receptive vaginal-penile, receptive oral-vaginal, and penetrative vaginal intercourse with a strap on. He consistently uses condoms and dental dams, and sanitizes his toys.
He comes to the clinic for comprehensive STI testing every three months and requires the same of his partners. He has never had oral STI testing and do this today.
You ask about his pregnancy preferences and he reports that he does not want children and takes Plan B whenever he engages in receptive vaginal-penile intercourse. You discuss Plan B efficacy as well as other contraceptive options. He chooses a Mirena IUD and you are able to place it at the visit.