Talking to patients about sex

A recent study out of France showed that patients wanted to be asked about their sexual lives by their doctors, more than the physicians expected. Patients didn’t find it intrusive, as some doctors feared. The study reflects the reality that some physicians are cautious or uncomfortable about broaching matters of sexuality. This can be especially true around sexual identities and orientations, as well as STIs and unwanted pregnancies. Sherbourne Health, a community clinic in downtown Toronto serves a diverse population. Dr. Laura Pripstein, medical director there, and staff physician Dr. Larisa Eibisch answered our questions about how to talk to patients about their sexual lives and health, and how to create a trusting open environment that facilitates the best sexual care. Q: A recent study out showed that patients actually want to be asked about their sexual lives by their doctors, more than doctors would think. Has this been your experience? Dr. Pripstein: 100%. I think clients want to have a safe space to have open conversations about their sexual lives. As long as the conversation/questions are framed in a non-judgemental, respectful way, without assumptions. It is important for clients to know they have someone they can trust to answer questions and get evidence-based information about sex. Dr. Eibisch: Absolutely! Opening a conversation about sex takes the pressure off the patient to do so and normalizes the conversational environment. I imagine that bringing up issues related to sex to their doctor could provoke uncomfortable thoughts and emotions (e.g., “Will my doctor think I’m weird for doing xyz?” “Is my doctor accepting of my sexual orientation?” “My sexual practices?” “Will I feel shamed?”). By asking, we show that we are open, knowledgeable and welcome this information-sharing as part of their healthcare. Q: What should doctors be particularly sensitive to when talking to patients? (for example, patients’ sex, age, cultural background, etc.) Dr. Pripstein: If doctors are initiating conversations about sexual practices, it is important to ask open-ended questions that allow the client to guide how they would like to speak about these matters. If someone is young, it is still important not to assume they are not engaging in sexual activity and/or that they may have questions if considering having sex for the first time. Sometimes initiating these conversations may be difficult but they are important. “Are you sexually active?” is usually a good start so that if they say, “No,” you can let them know if they are thinking about engaging in sex for the first time you can speak with them about how best to protect themselves from STIs and whether they are interested in fertility, and if not, how to protect from unwanted pregnancy. If clients aren’t comfortable speaking about this with you, at least you have brought up the topic so that they know you are open to having this conversation. Q: Sexual orientation: How can doctors speak to patients in a way that is inclusive, doesn’t assume someone is heterosexual, and conveys openness and acceptance? Dr. Pripstein: Asking questions that do not assume heteronormative sexual practices is important. Asking, “Are you sexually active?” “Are your partners cis male/cis female/trans/all of the above?” Using language that indicates you are aware of the various gender orientations and that it is possible not to fit into one particular box can make clients feel more comfortable opening up about their sexual orientation. Dr Eibisch: With expansive pronouns becoming the norm, knowing what to say can feel overwhelming, especially if you don’t have many patients who identify outside of a binary lens (male/ female, he/she). With any new patient, I ask what pronouns they use. When broaching discussions of sex, I let them know that I am aware that sexual practices are equally expansive, and I would like to learn more about what they do, so that I can better understand and care for them. Q: What if someone is at a stage of questioning their gender or a doctor thinks they might be. How could a family physician broach the subject, make someone feel comfortable, and possibly get them the support they need? Dr. Pripstein: The decision to transition is a deeply intimate and personal decision. I’ve never had a situation in which I have been the one to bring it to a client’s attention. I feel that clients will broach this with their provider when they feel safe and ready. To set the stage for disclosure, clients need to be aware that they are in a positive space with regards to gender orientation. Having rainbow stickers/ trans posters in your office is one way that indicates to a client you are open to having these discussions and can work with clients who are starting to question their gender. Q: Are there other areas physicians should be particularly sensitive about broaching (unwanted pregnancy/abortion, sexual difficulties, STDs, etc.)? Dr. Eibisch: The decision to abort a pregnancy, wanted or unwanted, often comes with mental and emotional anguish. I have learned to temper my reaction to a patient’s disclosure of pregnancy, to pause and ask first how they feel about it before I congratulate or commiserate with them. I also ensure to spontaneously include therapeutic abortion in my presentation of choices so that they know it is something I have knowledge of and am comfortable talking about. Erectile or sexual dysfunction has a similar associated stigma. Being direct with patients and asking them questions about ED, premature ejaculation, anorgasmia, etc., establishes the ground rules that these are topics of which you have knowledge and are comfortable talking about. Q: In your opinion, what is the most important thing physicians should keep in mind when discussing sexual issues with a patient? Dr. Pripstein: Don’t make assumptions! If a client is sexually active, it is important when reviewing their history to make sure you are complete when working up for STI testing. If people are having protected penetrative sex they still may be having unprotected oral sex. Complete STI testing includes oral swabs, rectal swabs (if appropriate) as well as urine and blood work for STIs. Matter-of- fact questions such as: “Do you have any receptive anal sex?” “Do you use condoms all the time, some of the time?” “Do you have oral sex?” “Do you use condoms when having oral sex?” Based on the answer, it is reasonable to swab these orifices in addition to urine and blood tests. Dr Eibisch: When talking to patients about any sensitive issues, be prepared. Be prepared by knowing the topic, whether it be STI risks and the appropriate investigations; which antidepressants are associated with anorgasmia; or how to work up erectile dysfunction. Also be prepared to not know and to temper your reaction. A patient recently asked for HIV testing and in our ensuing discussion, disclosed a high-risk sexual practice I was not familiar with. It took everything I had not to show my shock, and model empathy and acceptance instead. Having knowledge means not being surprised.

Talking to patients about sex

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