Achieving the Comfort and Competence to Discuss Your Patients’ Sexual Health: Achieving the Comfort and Competence to Discuss Your Patients’ Sexual Health Community and Public Health Action Committee, 2001-2002 American Medical Student Association


Today’s goals: Today’s goals Sexual health—what is it and why is it so important to discuss with our patients? What’s the buzz?…or Where’s the buzz?: Exploring the barriers to discussion Practical techniques for guiding sexual health discussion Putting theory into practice: Let’s talk about sex!


Dusk, A vignette: Dusk, A vignette It was that time of evening, just before dark. The house was empty except for the two of them. As they lay together entwined in a warm embrace, this room, this bed, was the universe. She stroked the nape of his neck. He nuzzled her erect nipple, first gently with his nose, then licked it, tasted, smelled and absorbed her body odor. It was a hot and humid August day, and they had been perspiring. Slowly he caressed her breast as he softly rolled his face over the contours of the other. He pressed his body close against her, sighed, and fully spent, closed his eyes and soon fell into a deep, satisfying sleep. Ever so slowly she slipped herself out from under him, for fear that she would disturb him; she cradled him in her arms and then moved him to his crib. Having completed his 6 o’clock feeding, the 4-month-old had just experienced another important step toward his sexual development. EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002].


Defining our terms: Defining our terms Sexuality: Begins before birth and lasts a lifetime Shaped by our values, attitudes, beliefs, behaviors, physical appearance, personality, spirituality Involves giving and receiving sexual pleasure, as well as enabling reproduction Sexuality is a total sensory experience, involving the whole mind and body—not just the genitals. EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002].


Defining our terms, cont.: Defining our terms, cont. Sexual Health: The integration of the physical, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication, and love. WHO Technical Report Series #572 The ability to express one’s sexuality free from the risk of sexually transmitted infections (STIs), unwanted pregnancy, coercion, violence, and discrimination. EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002].


Why discuss sexual health?: Why discuss sexual health? Foster comfort and trust between doctor and patient Explore underlying issues that affect patients’ health needs and quality of life Support the community’s knowledge and influence to maintain healthy sexual and reproductive behaviors Help patients negotiate safer sex behaviors, and prevent infection and unwanted pregnancy Help them address sexual concerns Help them understand changes in their bodies throughout their life cycle Improve their satisfaction with health services EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002].


Sexual health and quality of life: Sexual health and quality of life 91% married men and 84% married women ranked satisfying sex life as important 94% all polled said sexual enjoyment added to quality of life at any age 50% said sexual problems should not be accepted as consequence of aging. Marwick. JAMA. 281:23, 1999.


…YET: …YET 71% thought doctor would dismiss concerns they would bring up about sexual problems 68% were afraid of embarrassing their physicians by discussing sexual dysfunction Marwick. JAMA. 281:23, 1999.


…So…: …So… Are they right?


Your dual perspective:: Your dual perspective: List 3 reasons why you, as a patient, would and/or would not discuss your sexual health with a physician. List 3 reasons why you, as a physician, would and/or would not discuss your patients’ sexual health with them.


From the beginning!: From the beginning! 350 senior medical students surveyed 93% believe knowledge of patients’ sexual practices is important to medical history BUT 50% felt poorly trained to take sexual history 25% felt embarrassed to ask necessary questions Merrill et al. South Med J, 1990.


Doctors face barriers: Doctors face barriers Female and male physicians report significantly less comfort obtaining sexual history from patients of opposite sex Lurie et al. Arch Fam Med. 7:2, 1998.


Don’t ask, don’t tell…don’t know!: Don’t ask, don’t tell…don’t know! 64% women 18-44 said it’s up to health professional to initiate conversations about STDs YET… Only 10% said physician raised subject of STDs other than HIV/AIDS Only 3% brought up STDs themselves Larkin. JAMA Women’s Health Newsline, Background Briefing, posted July 13, 1998.


Teens NOT talking about sex!: Teens NOT talking about sex! Only 43% teenaged girls and 26% teenaged boys discuss pregnancy prevention or STDs with physicians during routine exams. Younger teens less likely than older or sexually experienced peers to discuss STDs and/or pregnancy with physicians Marchione. Milwaukee Journal-Sentinel, 12/07/00.


Why don’t doctors break the silence?: Why don’t doctors break the silence? Lack of provider comfort and knowledge Provider biases Fear of offending patients Time limitations/institutional requirements ???


A practical approach to discussing sexual health: A practical approach to discussing sexual health


Reviewing the sexual history discussion guide: Reviewing the sexual history discussion guide Principles: Create comfortable environment Avoid assumptions Use clear language Be patient, thorough, and culturally sensitive Conduct complete history and physical


When facing very reluctant patient: When facing very reluctant patient Discuss in office setting vs. exam room, so patient can be dressed/present self on more even terms Assess WHO is in room. How does patient respond to family/ friends, other health providers, other patients being present? If still reluctant, try to engage brief discussion to set stage for later encounters AND/OR Ask if patient would be more open to another interviewer (same sex, etc.)


Building the Necessary Vocabulary: Building the Necessary Vocabulary


What is SEX?: What is SEX? Hugging Kissing Masturbating Manually stimulating your partner Vaginal penetration Anal penetration Vaginal or anal penetration with objects Oral-genital stimulation Sexual excitement while looking at or reading pornography Telephone or 'cyber' sex Dressing up in 'sexy' clothes Other EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002].


When is it SEX?: When is it SEX? When done by: Man and woman Two people of the same sex Groups of people Young married couple Old married couple Unmarried people Strangers People of different ages When done: For emotional reasons For money/drugs/ resources In a public place In a private place WHEN THE PATIENT DEFINES IT AS SEX! EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002].


Understanding our patients as individuals: Sex: biological characteristics—anatomical, physiological, and genetic—as a female or male. Gender: what a person, society, or legal system defines as 'female' or 'male.' Cultures define gender roles, or appropriate male/female attitudes, behaviors, and responsibilities. EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002]. Understanding our patients as individuals


Understanding our patients as individuals, cont.: Gender identity: the personal conviction each individual has about being 'feminine' or 'masculine.' Sexual orientation: the erotic or romantic attraction for sharing sexual expression with members of the opposite sex, same sex, or both sexes. EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002]. Understanding our patients as individuals, cont.


Understanding our patients as individuals, cont.: Sexual behaviors: actions (touching, kissing, and other stimulation of the body) done to express sexuality Sexual practices: activities performed habitually or repeatedly (although some use the terms 'sexual behaviors' and 'sexual practices' interchangeably). EngenderHealth. 2002. Sexuality and sexual health [Online minicourse.] Available: EngenderHealth Web site, www.engenderhealth.org [March 4, 2002]. Understanding our patients as individuals, cont.


Reviewing the sexual history discussion guide: Reviewing the sexual history discussion guide Framing the encounter Timing Transitioning Normalizing Opening Closing


Optimizing your interviewing style: Optimizing your interviewing style Higher patient comfort levels with ubiquity or bridge vs. direct introduction: Ubiquity: I routinely ask all my patients about their sexual history…I’m now going to ask you some questions about your sexual activities. Lifestyle bridge: You’ve told me about your lifestyle, your occupation, exercise, and diet. Now I’m going to ask you some questions about your sexual activities. Direct: I’m now going to ask you about your sexual activities. Floyd et al. Arch Fam Med. 8:3, 1999.


Optimizing your interviewing style, cont.: Optimizing your interviewing style, cont. Higher comfort levels when interviewer addressed patients’ feelings before sexual history vs. no assessment How do you feel about answering some questions about your sexual activity? Floyd et al. Arch Fam Med. 8:3, 1999.


Optimizing your interviewing style, cont.: Optimizing your interviewing style, cont. More comfortable with patient-centered technique than open-ended when interviewer collected information on sexual practices/risk Patient-centered: Please describe your understanding of how sexual activities affect health and how that relates to your own situation. Open-ended: Please describe your sexual activities. Floyd et al. Arch Fam Med. 8:3, 1999.


Reviewing a sample sexual history discussion guide: Reviewing a sample sexual history discussion guide Assessing Risk Addressing Concerns Fertility Issues Talking Points


Now, let’s put it into practice!: Now, let’s put it into practice!


Further Resources: Further Resources Planned Parenthood Federation of America, www.plannedparenthood.org Sexuality Information and Education Council of the United States, www.siecus.org AMA, www.ama-assn.org AMWA, www.amwa-doc.org The Coalition for Positive Sexuality, www.positive.org American Association. For Sex Educators, Counselors, and Therapists, www.aasect.org American Social Health Association, www.ashastd.org


Contributors: Contributors This program was designed by Erica Schockett and the AMSA Community and Public Health Action Committee, 2001-2002. Many thanks to EngenderHealth for allowing the adaptation of parts of their online curriculum for the purposes of this project.


Questions?: Questions? Comments?