Grand Rounds at Sutter Santa Rosa Regional Hospital: Let's Talk about Sex (MacArthur 5/4/2022)

Big thanks to Dr. Sophie MacArthur for her excellent presentation on a topic that we could ALL use a little education on-- Sex. And specifically how we talk about it with patients.

The recorded presentation is available HERE.

Link to her slides is HERE.

My notes:

The Sex Ed most of us had in school wasn't any good

a meta-analysis of 48 different studies in 10 countries (including US) in BMJ found high school students believed their sex ed to be impractical, out of touch, sexist, heteronormative, and embarrassing

And. .. let's face it. Physicians aren't very good at talking about sex with patients.

While 88% of primary care physicians say they take a sexual history, only 25% of charts have said history recorded
A study from the 1990s-- height of the AIDS epidemic-- found providers didn't take sexual history because they didn't feel it was relevant, didn't feel well-trained, and felt embarassed
We are inadequately trained
We tend to discuss sex only when patients ask

But. . .patients want to talk about sex!

In one large study from Europe, 91% of patients want their physicians to ask about their sexual history and sexual health
Even of the 15% who would feel embarrassed talking about sex, 75% still wanted their doctor to ask

As part of sexual history and STI screening, many of us were trained to ask the following question: "Do you have sex with me, women or both?"

Dr. MacArthur asked us to consider a better question: "When you have sex, what parts of your body come in contact with what parts of someone else? And how?"

Two reasons this question is a better question than the men, women or both question:

it is not heteronormative
it allows us to screen people for STIs at appropriate sites (e.g. for rectal, oral GC/CT)

There are several different ways we can approach the topic of discussing sex with our patients. All of them promote using open ended questions.

3 options:

1) CDC "6Ps"

Permission ("May ask you a few questions about your sexual health and sexual practices?")
Partners ("Do you have any new partners in the last 12 months? How many? Do your partners have any risk factors?"
Practices ("When you have sex, what parts of your body come in contact with what parts of someone else? And how?")
Protection from STIs ("Do you and your partners discuss protection from STIs? "What methods do you use? How often do you use them?")
Past history STIs ("Have you ever been tested for STIs? Have you ever had an STI?")
Pregnancy intention ("Do you think you would like to have (more) children some day?")

2) AAFP "Proactive Sexual Health History" (2020)

3) Fenway Institute/Harvard: 6Ps + Guidance: Taking an Affirming Sexual History

Ask routinely, confidentially and free of assumptions
Do it often (you will get better at it)
Explain why it's important to know what you are asking
Ask about function and satisfaction (not just about STI risk)
Use open ended questions (e.g. "what types of sex do you have?"), at least initially
Normalize less desired responses (e.g. many people don't consistently use condoms; how often do you find yourself not using a condom?")
Mirror patient's language if possible
Make the interaction as natural as possible (not robotic)
Give patients the option to answer questions indirectly (e.g. I recommend screening for GC/CT in all the sites that may have been exposed; for example, the throat, the anus, the penis, the vagina. Which of these sites should you have tested today?)
Tone and rapport matter, at least as much as the questions

Risk reduction is an important part of sexual history, but risk extends beyond our traditional view of STIs and unwanted pregnancy.

Risk=anything that is not sexual health and/or sexual well-being

This can include non-consensual sex, painful sex, bad sex, legal repercussions of sexual behavior (e.g. consent is not sufficient to protect someone), nerve damage (S&M practices)