What are the best practices?

Key takeaways:

• Patients benefit from talking with PCPs about their sex lives, but few PCPs initiate the conversations, leading to gaps in care.
• A speaker here discussed the best practices for taking modern sexual histories.

NEW ORLEANS — Discussing sexual health is beneficial for patients, but the burden often falls on them to bring up the sensitive subject and, thus, many do not, according to an expert at ACP’s Internal Medicine Meeting.

It is important for primary care providers to ask about a patient’s sexual history for multiple reasons, like assessing their sexual function, risk for STIs and desire for pregnancy, Richard E. Greene, MD, MHPE, FACP, a professor of internal medicine at New York University’s Grossman School of Medicine, said during his presentation. But another major factor is that patients may not know what to share in a clinical setting.

“Anywhere between 20% to 50% of our patients have some form of sexual dysfunction, but if we don’t ask, they often don’t share that with us,” he said. “So, we could have the opportunity to bring them in to have these conversations and provide life-saving information.”

In another study Greene referenced, just 17% of older adults sought out a health care provider when they had a distressing sexual complaint, and more than half had to initiate the conversation themselves.

“We’re putting a lot of burden on them to sort of show up and talk to us about things that we don’t always invite,” Greene said. “But here’s what I want you to take home: in … these studies, the patient reported that when they talked to us about their distressing sexual complaint, that speaking to us was actually helpful. We are good at this when we engage in it, but we sometimes don’t open the door and allow our patients to talk to us about these things.”

He also acknowledged that it can be challenging to have these conversations. And although he has heard many different reasons why this might be the case, what he has found over the years is that it all ultimately boils down to shame.

“It’s really hard because we have all the stigma around talking about sex,” he said. “We were raised in the same culture they were. We were told what was appropriate and not appropriate to talk about with people. And then we became doctors, and we’re supposed to have these conversations.”

Greene said there is often a moment during visits when bringing up sexual histories feels uncomfortable. If the provider does not challenge that feeling, “it’s really easy to skip over” the line of questioning. Then, if a patient does not bring it up themselves, the practitioner thinks they have not missed anything. But this can create a large gap in care.

“What we know from the literature is that we actually do miss things,” he said.

To avoid missed or misdiagnosis, Greene recommended some best practices, like:

• use accessible, non-stigmatizing language;
• create a safe environment;
• give space for traumatic experiences patients may have had (Greene said this can be “really common,” so it is important to recognize the signs); and
• consider the identities of both parties and how that may affect the interaction.

“There’s not one way to ask about sexual history because people’s sex lives look very different,” he said. “Who we are and what we bring into the room really matters with what our patients will feel comfortable telling us.”

Another tip Greene offered was to explain why the questions are being asked and then allow why you are asking to guide how you ask about it.

“Context is everything. I always, always, always tell people why I’m asking the questions I’m asking,” he said. “I’m not just curious. I’m trying to protect your health.”

For example, Greene shared the story of a patient who had a sore throat. For 2 years, they thought it was a case of allergic rhinitis, “until I did a better sexual history and found out that the patient actually … had gonorrhea, and we don’t know for how long they’d had it,” he said.

Greene also provided a few quotes that PCPs struggling with finding the rights words for these interactions can use in their practice:

• “Tell me about your sex life,” or “Are you currently having sex? If no, have you ever been sexually active?” or “Are you in an intimate relationship with anyone?” as an opening line;
• “I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are personal, but they are important for your overall health.”
• “Certain medical conditions are linked to sexual practices.”
• “I ask these questions to all of my adult patients, regardless of age, gender or marital status. These questions are as important as the questions about other areas of your physical and mental health. Like the rest of our visits, this information is kept in strict confidence.”
• “At our next visit, I’d like to spend some time talking about your sexual history and current sexual practices, as this is an important part of your health. Would you be open to that?”

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