Part 2: Taking a Sexual History Talking with Patients about Sex Curriculum Kenneth Schwartz Foundation

1. Part 2: Taking a Sexual HistoryTalking with Patients about Sex CurriculumKenneth Schwartz Foundation

2. This Section Addresses… • What we need to know • Whom we should ask • How we should ask • What questions to ask • When we should ask • This curriculum was guided by the voices of 100 male and female outpatients who were surveyed in an internal medicine clinic

3. Q1: What do we need to know?

4. What Do We Need to Know? “There’s a lot we need to know. Is a patient comfortable with their sexual identity and orientation? What kinds of sexual behavior are they engaging in? Are they at risk for unintended pregnancy or sexually transmitted diseases? What is the quality of their relationships? Are they able to communicate openly with their partners? Are they happy with their sexual lives?”

5. Sex and GenderTraditional Dichotomous View Man / Woman Masculine / Feminine

6. Sex and GenderNew Models Reflect Complexity • Sexual identity: • Biological status (M, F, intersex) • Sexual orientation: • Focus of attraction (same-sex, opposite sex, trans men / women) • Sexual expression: • Choice of sexual partner, sexual practices • Gender identity: • Subjective sense of self (masculine, feminine, androgynous, neuter • Gender expression: • Social presentation (clothing, hair, mannerisms, speech)

7. ‘Transgender’ = Umbrella Term • People whose feelings or behaviors do not match their assigned gender: • Cross-dressers • Transmen, transwomen • MTF and FTM transsexuals • People who consider themselves to have no gender or multiple genders: • Genderqueer, androgyne, beyond binary, gender-bender, polygender

8. Points that Deserve Emphasis • Sexual identity  gender identity • Sexual orientation  sexual behavior • Gender identity  sexual orientation / behavior

9. Summary:What Do We Need to Know? • Sexual knowledge, attitudes, skills • Sexual and gender identity • Sexual orientation and behavior • Level of self-acceptance • Past experiences (good/bad; abuse?) • Satisfaction: desire, arousal, orgasm, intimacy • Risk for unintended pregnancy • Risk for sexually transmitted diseases

10. Q2: Who should we ask?

11. Patient Quote “It’s really important to ask all of your patients about sex. Basically, if you assume your patient isn’t having sex, you’re living in a bubble”

12. Adolescenceand Young Adulthood

13. Young Adults are Sexually Active(Clinician Quote) “We did an informal survey of sexual activity at the college where I work. We were astounded by the wide variety of sexual practices the students engaged in, including: abstinence, frottage, vaginal intercourse, anal intercourse, water sports, solo, partner and group masturbation, cunnilingus, fellatio, shared and unshared sex toy use, S&M, and piercing tongue, nipples, and genitalia.”

14. Teens are also Sexually Active(Data on Intercourse) • 61% of Black students • 48% of Hispanic students • 43% of White students Have had sexual intercourse by age 19. Grunbaum J et al. Youth Risk Behavior Surveillance- United States, 2001. In: Surveillance Summaries June 28, 2002, MMWR 2002;51:1-64.

15. Teens are also Sexually Active(Data on Other Sexual Behaviors) • Teen ‘virgins’ (no intercourse) often engage in other forms of sexual behavior: • 30%: mutual masturbation • 10%: fellatio/cunnilingus • 1%: anal intercourse Schuster MA et al. The sexual practices of adolescent virgins: genital sexual activities of high school students who have never had vaginal intercourse. Am J Pub Health 86:1570-76.

16. Unsafe Sex is CommonAmong Youth • 7% have had intercourse before age 13 • 14% have had  4 lifetime partners • 63% used a condom and 17% used birth control pills during last sexual intercourse • 25% were under the influence of alcohol or drugs before last intercourse • 4% had been pregnant or gotten someone else pregnant 2003 Youth Risk Behavior Survey: www.cdc.gov/yrbss

17. As Clinicians, We Have a Responsibility to Educate Young Patients about Sex “I worry a lot about the young people we see in our clinic, because they take a lot of risks. As health care providers, it is our duty to provide sexual health education and guidance to these young people, who frequently receive little to no information from their families of origin. If we don’t do it, who will?”

18. Midlife and Beyond

19. Myths about Sex in Mid-Older Life(Clinician Quote) “There are an awful lot of myths about sex in mid-to-older life. These include things like: older adults aren’t attractive or desirable, or older adults aren’t interested in sex or able to have enjoyable sex any more. There’s also the idea that older people don’t have to worry about getting sexually transmitted diseases.”

20. Myths about Sex in Mid-Older Life(Patient Quote) “When you get to be my age… nobody expects you to be interested in sex or even care about it… it is something that you should discuss, its supposed to be over but it really isn’t”

21. Myths about Sex in Mid-Older Life(Patient Quote) “Back a decade ago before it was public knowledge & before anyone talked about it I think we men and our women suffered in silence and just didn’t bring up the subject. It was like the subject of masturbation, or condoms, or abortions, or any of the things American society just didn’t talk about, they just didn’t talk about what men were facing and what their partners were facing. So to bring things out to the table and have something to do about it is just magic.

22. Fact: Sex Remains Important(Data) 74% of men / 66% of women ages 45 – 59, 61% of men / 48% of women ages 60-74, and 50% of men / 44% of women  age 75 believe that a satisfying sexual relationship is important to their relationship. American Association of Retired Persons (AARP) Modern Maturity Sexuality Study of 1,384 Americans 45 years of age and older (www.siecus.org).

23. Fact: Older People are Sexually Active (Data) • 71% of men / 51% of women in their 60s, 57% of men / 30% of women in their 70s, and 27% of men / 18% of women  80 engaged in sexual activity once a month or more during the past year. National Council on Aging (NCOA) Healthy Sexuality and Vital Aging Study of 1,292 Americans 60 years of age or older.

24. Fact: Older People Contract STDs(Data) • 10% of HIV-infected people in the US are aged 50-plus • Older women have higher incidence rates than older men • Persons of color are particularly at risk National Association on HIV Over Fifty (www.nahof.org)

25. We Need to Ask Older People(Clinician Quote) “I think we’re often pretty good at asking younger populations sexual histories, but it is always important to ask even the geriatric population…it might feel funny for you to ask someone who is the age of your grandparents but, you know they are at risk for STDs. They were young at an age when we weren’t that concerned about safe sex. So it is always important no matter what the age to ask in a respectful manner. Go ahead and find out what you need to know.”

26. We Need to Ask Older People(Patient Quote) PT: “I am here for a checkup” DR: “Okay, what has been going on since your last checkup a little over a year ago? PT: “Well I have this vaginal discharge and it seems kind of different and well I think my husband may be having an affair DR: “I am so sorry to hear that…”

27. We Need to Address Safer Sex(Clinician Quote) “It’s especially important to discuss safer sex with older people, who, due to loss of a long-term partner, may be re-entering the dating world after many years in a monogamous relationship. Many of these individuals have little knowledge of safer sex methods, and little to no experience having frank discussions about sexual safety with prospective partners. Women sometimes feel particularly uncomfortable initiating these kinds of discussions.”

28. Sex and Illness / Disability

29. Sex and Cancer(Patient Quote) “I really appreciated the fact that my post-transplant homecare packet included instructions about when it was safe to resume sexual activity, and how to cope with new problems like vaginal dryness. Just because I had leukemia didn’t mean I was no longer sexually active. In fact, because my partner and I were so terrified that I was going to die, physical intimacy, including being close sexually, probably became even more important to us during and after my illness than ever.”

30. Sex and Heart Disease(Patient Quote) “After I had my heart attack I worried that I wouldn’t be able to get it up any more because of all the new medicines, or that it wouldn’t even be safe to try to have sex. My cardiologist was great. He told me it was OK to have sex since I passed my stress test, and that we’d do everything we could to work around any side effects of my medications.”

31. Sex and Disability(Patient Quote) “It’s really amazing, the kinds of things people will assume. Just because someone has a disability, you can’t assume they’re not having sex. People are very creative. People with wheelchairs have sex. People with quadriplegia have sex. Certainly people who are blind like me have sex!”

32. Sex and Illness / Disability(Data) • Patients with illness/disability may become less sexually active because of misconceptions about their ability to have sex, the safety of having sex, body image concerns, and grief related to functional losses. • Emotional and physical intimacy provide comfort and aid adjustment. • Pleasurable sex is achievable with appropriate adaptations even when disability is significant. Nusbaum. Chronic illness and sexual functioning. Am Fam Phys 2003;67:347-54.

33. Summary: Who Should We Ask? • Girls / boys, men / women • Young, middle-aged, elderly • Single, partnered, widowed, divorced • People with illness and disabilities • EVERYONE

34. Q3: How should we ask?

35. One Person’s View: Just Ask!(Patient Quote) “Just ask! This sends the message that ‘sex can be spoken here,’ and gives patients an opportunity to discuss any concerns they may have.”

36. Many people we surveyed stressed the importance of non-verbal cues that demonstrate openness and lack of judgment

37. Non-Verbal Messages (1):Visual Cues in the Waiting Room • Posted non-discrimination policy: • We do not discriminate on the basis of … • Educational brochures that address: • A range of sexual practices (oral, vaginal, anal) • Specific populations (heterosexual, LGBT)

38. Non-Verbal Messages (2):Inclusive Language on Forms • ‘M / F / Other’ • ‘Legal Name’ and ‘Preferred Name’ • ‘Partner,’ ‘Spouse,’ ‘Living Together’ • ‘S / M / W / D / Other’

39. Non-Verbal Messages (3):Calm, Cool, Collected Clinician Manner “It’s always embarrassing to talk about sex. If the provider is calm, cool, collected, and matter of fact, I feel a lot more comfortable.”

40. Survey respondents suggested a number of tips to facilitate more comfortable discussion

41. Respect Dignity and Modesty(Patient Quote) “If possible, conduct the interview while the patient is clothed.”

42. Respect Privacy & Confidentiality(Patient Quotes) “Don’t try to ask about abuse if the patient’s parent, significant other, or caretaker is in the room.” “It’s best to interview partners in a couple separately, not together.” “I don’t think a history of sex needs to be repetitiously repeated in files, since it may cause bias in care.”

43. Explain the Context

44. Explain the Context “You really have to introduce the topic with a statement about why it’s important to ask. Otherwise you hit people with questions about sex that seem like they’re coming out of the blue, and they may feel embarrassed and not really understand why the questions are relevant.” “I think health providers should always explain why they’re asking certain questions--- especially ones that might take people by surprise. I think most patients are willing to discuss pretty much anything with their provider if they know that it’s pertinent to the visit and the doctor isn’t just being nosy.”

45. Be Clear about What You’re Asking(Patient Quotes) “I wish the nurse had explained the meaning of ‘had sex,’ as being a very Catholic girl, the term ‘had sex’ meant even someone touching your breast, or anywhere above the knee and below the shoulders.” “You’ve really got to be specific: some people don’t think oral sex is sex. Other people don’t think you’re sexually ‘active’ if you only do it once a month.”

46. ‘Sex’ and ‘Sexual Activity’ Mean Different Things to Different People • Sex with a partner, but not masturbation • Penile-vaginal penetration, but not oral or anal sex • Aggressiveness during sexual encounters • Recent sexual contact (yesterday, last week), but not more remote activity (last month, last year) • Multiple sexual partners • Frequent sexual activity

47. BeCarefulwith Language(Patient Quotes) Use of language Use of language

48. BeCarefulwith Language(Patient Quotes) “Minimize communication barriers by using a professional interpreter, if necessary.” “Don’t use slang– use medical terms to discuss sexual activities.” “Beware of labeling. For example, some men who have sex with men describe themselves as ‘gay,’ while others do not like that word.”

49. Common Terms Straight Gay Lesbian Bisexual Transgender Transsexual Queer Sexual minorities For self-identification only: Highly personalized meaning Some embrace; others shun Presentation/openness vary: ‘Masculine’ vs.‘feminine’ ‘Out’ vs. ‘in the closet’ Choice of partner(s) diverse: Men, women, both, neither Use the Patient’s Language

50. Behavioral DesignationsMore Accurate, Less Stigma • WSW: • Women who have sex with women • MSM: • Men who have sex with men