Engaging in open, nonjudgmental discussions about patients’ sexual health provides an opportunity to assess risk, screen for sexual dysfunction, provide counseling, and offer appropriate vaccinations.
Lifelong Learning in Clinical Excellence | September 18, 2018 | 3 min read
By Helene Hedian, MD, Johns Hopkins University School of Medicine
As a general internist and a physician champion with the Johns Hopkins Center for Transgender Health, I provide primary care for a diverse patient population, including a large number of LGBTQ patients.
Here’s what I’ve learned when it comes to talking about sex with my patients (please note words followed by an asterisk are defined at the bottom of this post):
1.) Most patients care about sex.
In one survey of Americans 25 years or older, 94% of patients agreed that sexual enjoyment adds to quality of life at any age.
2.) Patients may not bring up sex in their doctor’s appointments.
68% of patients were concerned that if they wanted to talk to their doctor about a sexual problem, the doctor would be uncomfortable because the problem was sexual in nature.
3.) Patients want doctors to ask about sex.
In a cross-sectional survey of patients at gynecology and urogynecology practices, 67% of patients agreed that providers should regularly ask about sexual health.
4.) Doctors don’t ask about sex.
Doctors often do not address sexual health proactively with older people. Doctors perceive older patients as asexual, or assume sex is a private topic for older people. This view is based on stereotyped views of aging and sexuality, rather than personal experiences with individual patients.
5.) Here are five medical reasons to ask about patients’ sex lives:
- Identify risk factors for infectious disease
- Screen for intimate partner violence and patient safety
- Establish family planning and reproductive needs
- Screen for sexual dysfunction
- Address health disparities in sexual and gender minority patients
6.) Sex can be an important component of a healthy lifestyle.
Sexual activity in older adults is linked to lower levels of cardiovascular risk in women and lowered inflammatory markers in men and women.
7.) A sexual history followed by an appropriate, targeted discussion about how to stay healthy can enhance the patient-provider relationship.
8.) Implicit bias* against LGBTQ patients is common.
A study of over 4,000 first year medical students demonstrated 46% expressed some degree of explicit bias against LGBTQ individuals. 82% held at least some degree of implicit bias.
Recognizing your own implicit bias* is an important step in providing equitable care to all patients.
Implicit racial bias is shown to predict provider decisions and demeanor with resultant lower quality of care for black patients.
9.) Set the context for your conversation:
For example, you could say, “I’m going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they’re important for your overall health. Just so you know, I ask these questions to all of my adult patients, regardless of age, gender, or marital status.”
Learn more about how to take a sexual history with this great publication: CDC: A guide to taking a sexual history
10.) Be sure to address the five “P”s, which the CDC identifies as the key components to a sexual history:
- Protection from STDs
- Past history of STDs
- Prevention of pregnancy
CDC: A guide to taking a sexual history
11.) Remember that not everyone is cisgender*, heterosexual, or monogamous.
Use the terms each person uses to describe themselves.
Use gender neutral terms like “partner” or “spouse” until you know the gender of a partner.
12.) Sexual orientation is important to know, but sexual behavior is what drives most health risks.
Not everyone who has same-sex sexual partners identifies as gay/lesbian or bisexual.
Helpful definitions from the 2016 UCSF Guidelines:
Transgender: a person whose gender identity differs from the sex that was assigned at birth. May be abbreviated to trans. A transgender man is someone with a male gender identity and a female birth assigned sex; a transgender woman is someone with a female gender identity and a male birth assigned sex.
Cisgender: a non-transgender person may be referred to as cisgender (“cis” means same side in Latin).
Gender identity: a person’s internal sense of self and how they fit into the world, from the perspective of gender.
Sexual orientation: describes sexual attraction only, and is not directly related to gender identity.
Implicit bias: implicit attitudes are automatic responses that often occur outside conscious awareness and are commonly measured using response-latency tasks such as the Implicit Association Test.
Explicit bias: explicit attitudes are consciously controlled and are traditionally assessed using self-report measures such as feeling thermometers.
Institute of Medicine. The Health of Lesbian, Gay, Bisexual and Transgender People. 2011.