For many of us, while in medical school and residency, sexual health history was mostly taught from a disease standpoint. If a patient had a complaint about sexual dysfunction, had a symptom or concern about a sexually transmitted infection, needed contraception, or had specific questions related to the reproductive system, then we took a sexual history. Sexual health history taking in many programs is limited to an elective in the STI clinic or when rotating through the infectious diseases service. Our students and residents are comfortable with the routine of past medical history, past surgical history, social history, and family history before they launch into the physical examination. In that social history, we routinely ask about alcohol, tobacco, and illicit substance use, but we skip over a sexual history.
Sexual health profoundly influences a person’s physical and psychological well-being, yet sexual health history is often not taken or is poorly taken in clinical settings. When we take a complete sexual health history, it allows us to do a couple of things: enhance screening, diagnosis, and treatment of sexually transmitted infections, including HIV, but more importantly, provides prevention education. We can talk to our patients about prevention options (not just pregnancy prevention), including immunizations, HIV pre-exposure prophylaxis, and post-exposure prophylaxis. In this age of mass misinformation on the internet, we can address misconceptions and provide accurate information to our patients. As sexual health conversations become routine, the stigma around the topic is reduced When we look at sexual health history taking from a pro-sexual wellness standpoint, we’re more likely to prioritize and incorporate it into our routines.
So why are we, as physicians in training and practice, not routinely taking a sexual history? In conversations with colleagues and reviewing the literature, the top reasons are time constraints, lack of adequate training to do it well, not a priority, documentation fatigue, our own biases or discomfort in talking about sex, biases about age (my patients are too young or too old to be sexually active), not having the resources to address concerns that are raised, waiting for patients to raise issues about their sexual health, and not finally wanting to offend patients. So, living in the fear of non-perfection, we don’t do it.
How do we then move sexual health from a place of disease management to a place of wellness promotion? We routinize sexual health history taking, and we do it in a way that is open-minded and non-judgmental. We put our patients at ease, ensure privacy and reassure them of confidentiality. We let our patients know that we ask these questions of everybody, so they don’t feel singled out or targeted. We seek out training to get better at it as resources are available on how to do this well, even when you have just a few minutes (see the National Coalition for Sexual Health). We learn about the five Ps: partners’ practices, protection from STIs, history of STIs, pregnancy desire or prevention, and then the sixth P, pleasure. We practice, practice, practice. We understand that practice makes progress, and progress beats waiting for perfection. The more routine we make it, the more it becomes an expected part of a clinical encounter. Our patients will expect these questions that are proactive about their sexual wellness. I think rather than being offended, our patients will thank us.
As physicians, let’s commit to embracing sexual health as a vital aspect of our patients’ lives.
For those leading training programs teaching students and residents, let’s model best practices and incorporate them into curricula and into our EMR templates. By doing this, we can empower the next set of physicians and health care providers on routinizing and being comfortable with taking a sexual health history.
For those of us already in practice, let’s practice asking about sexual health during our clinical encounters. Start with those patients you have established relationships with; soon enough, it will become routine. Let’s get out there and have those conversations in a pro-sexual health and wellness manner. We’re all thinking about it (sex) and talking about it (sex) anyway, so let’s discuss this with our patients. We can provide accurate information on how to prevent sexually transmitted infections, including HIV, help them optimize their sexual health, promote wellness and bring an important aspect of their lives to the exam room. Taking a sexual health history is an important part of overall health. Sexual health is health.
Toyin M. Falusi is an infectious disease physician.
