View / Download pdf version of this article

Key reviewer: William Pearce, RN, Christchurch Sexual Health Centre

Why don’t health professionals like talking about sex?

Sexual health is often not discussed during the course of a general practice consultation. Perhaps the most obvious reason is that doctors usually focus on the problem of the day and there is a lack of time to discuss general health issues. However there may be many other reasons for not talking to patients about sex, including embarrassment, fear of alienating the patient, lack of a trusting and comfortable professional relationship with the patient (although a close relationship can also act as a barrier), lack of confidence in speaking about sexual practices and lack of a reason to talk about sexual health.

Given that sexually transmitted infections (STIs) such as chlamydia and gonorrhoea are increasingly prevalent among young people in New Zealand, and patients are often asymptomatic, it is important that health professionals do take appropriate opportunities to talk about sex and don’t wait until the patient raises the topic or presents with an STI.

Barriers to talking about sex

In a study of primary care physicians in Belgium, only 44% regularly provided sexual health information to their patients (asking about sexual history, informing about safer sex and sexually transmitted infections). More than half would not give unsolicited information to an asymptomatic patient with an obvious STI risk. Just under one third of the doctors said that a large age difference between them and their patient was a barrier for speaking about sexual health and patients of the opposite sex were a barrier for 23% of female doctors and 13% of male doctors. Interestingly, a close professional relationship was seen as a barrier for talking about sex for 71% of the surveyed doctors.1 Many patients present at sexual health clinics because they feel unable to discuss their sexual behaviour or genital symptoms with their regular GP.

How to talk to patients about sex

A discussion about sexual health can take place with any patient, however, in particular consider talking to people who:

  • Are in the age group at highest risk for STIs (15 – 25 years)
  • Have had a recent change of sexual partner or relationship break-up
  • Have multiple sexual partners
  • Request a sexual health check
  • Attend for a genitourinary complaint
  • Attend for a cervical smear test
  • Attend for contraception
  • Are pregnant (which may include termination of pregnancy or antenatal advice)
  • Have a condition or are on medication that may inhibit sexual function (e.g. diabetes, beta blockers, SSRIs)

Health professionals may also wish to include a discussion about sexual health as part of a new patient appointment.

Patients often present with other concerns although the main reason for the consultation is a sexual health issue. Consultation skills are important in allowing the patient to discuss the sexual health issue (the “hidden agenda”).

Provide a welcoming and comfortable environment

A consultation setting that is welcoming, comfortable and confidential is more likely to encourage openness when talking about sex. Practices should consider displaying literature in waiting rooms and consultation rooms that stresses the private and non-judgemental nature of their service.2

Explain that talking about sex is a routine aspect of healthcare and ensure that the patient does not feel that they have been singled out or suspected of being likely to have an STI. For example you could say “we ask all our patients about their sexual health…” or “most people are having sex, so we ask about it…”.

Consider developing a practice policy on how to address sexual health issues with patients with communication difficulties e.g. English not first language, hearing impaired, learning difficulties.1 Also consider cultural and ethnic differences and religious beliefs.

Take a sexual history

A sexual history should start with open questions, and then focus on areas of concern. Key skills for effective history-taking include knowing how to address attitudinal issues to sexual behaviour, knowledge about a range of sexual practices and understanding of the need to maintain confidentiality.2

Begin with questions about the patient’s social back-ground. This enables the patient to relax and any problems or risks can be assessed in context. Ask about marital status, duration of relationship with current partner, number of previous partners and their gender, home environment, family support, activities and interests.3

Discussion should also include questions about risk behaviours such as alcohol and illicit drug use, intravenous drug use, sharing of needles, syringes or drug preparation equipment, sexual partners from another country or commercial sex work.

Next, ask more specific questions about sexual practices depending on the patient’s social history. Questions should not be prescriptive and should be tailored to the individual patient and circumstances. Issues that usually should be covered include:2

  • Establish whether sexual activity is taking place
  • Exposure history to determine specific risks and which sites need to be sampled; depending on the gender of partner(s), type of intercourse or sexual practices
  • Use of condoms and other contraception (including correct use and consistency of use)
  • History of previous STIs or STI testing
  • STI history of partner(s) or presence of symptoms suggestive of STIs
  • Assessment of HIV, hepatitis B and hepatitis C risk
  • Discussion of other sexual health issues e.g. erectile dysfunction, premature ejaculation, vaginismus
  • Discussion about sexual abuse and domestic violence

Generally, it is best to use medical terminology when discussing sexual health, however if appropriate, some colloquial language could be used for sexual practices, especially if the medical term may not be understood e.g. cunnilingus vs. oral sex.

Sexual orientation should be discussed as part of a sexual health check

It is important that patients are asked about their sexual orientation or gender of sexual partners, so any specific health issues can be identified and testing targeted. This may include referral for counselling for younger patients who require assistance in exploring their feelings and telling their friends and family. Some younger lesbian, gay, bisexual or transgender people may be at increased risk of depression, suicide, substance abuse and violence.

In a study of 131 people aged 14 to 18 years, who openly identified themselves as lesbian, gay or bisexual, only 35% reported that their doctor knew about their sexual orientation. Almost two thirds (64%) said that their doctor should “just ask them”. Of those who had disclosed their status to their GP, 57% thought that their healthcare had improved as a result.4 Doctors should have some relevant information regarding support groups for young gay, bisexual or lesbian people if they disclose their sexual preference (see list of resources below).

Ask about symptoms

As part of a sexual health discussion, patients should be asked about genitourinary symptoms, regardless of whether this was the reason for their consultation. This may reveal overlooked or ignored problems.2

Ask about:2

  • A recent change in vaginal discharge or urethral discharge
  • Vulval or genital skin problems
  • Peri-anal/anal symptoms
  • Lower abdominal pain
  • Dysuria
  • Changes in menstrual cycle, irregular bleeding or post-coital bleeding

If sexual history or symptom assessment results in laboratory testing, establish how results will be given and discuss any confidentiality issues.

Give advice about safer sex

Based on information gained from sexual history and symptom assessment, individualised advice should be given about practicing safer sex.

The only way to completely prevent STIs and other sexual health issues is to remain abstinent. However by modifying risky behaviours, sex can be made safer.

  • Younger people could be encouraged to express sexual feelings in other ways e.g. massage, mutual masturbation
  • If a person chooses to have sex, consistently and correctly using condoms (or other barrier contraception) is a key safer sex behaviour
  • Even in a monogamous relationship, it may be appropriate to recommend condom use until both partners have had a sexual health check
  • Condoms should always be used for anal sex to protect against STIs and other infections
  • Older people may be less likely to have knowledge about STIs and safer sex methods, so could need extra advice and counselling

Condoms provide protection against most but not all STIs

Condoms should be used for vaginal, anal and oral sex. If used properly, they protect against STIs that are transferred through contact with genital secretions such as gonorrhoea, chlamydia, trichomonias, syphilis, HIV and hepatitis B and C. Protection against diseases such as human papilloma virus, herpes simplex virus, scabies and pubic lice depends on the site of the sore/ulcer or infection and whether this is covered by the condom.5

Condoms are provided free of charge from Sexual Health Centres and Youth Health Centres. They may also be prescribed or obtained by practitioner supply order (PSO). There are a variety of products available in sizes 49 – 60 mm, regular, extra strength or shaped. Choice of product is based on personal preference and self selection of size, however extra strength products are recommended for use during anal sex. It is not necessary to use spermicidal condoms – they are no more effective in preventing pregnancy and can cause vaginal irritation.

PHARMAC is currently consulting on listing a non-latex condom for those with a severe latex allergy.

Condoms should be stored in a cool, dry place and kept away from sunlight. Expiry dates should be checked before use. Only water based lubrication should be used (e.g. KY jelly). Do not use Vaseline, oils (e.g. baby oil) or body lotions.

Best Practice tip: Young people who are resistant to condom use seem to listen more when they are told that condoms protect against eight different infections and pregnancy.

Other barrier methods

Female condoms/femidoms/vaginal liners are available from family planning clinics and offer the same level of protection against STIs as a regular condom for vaginal sex. They are made from polyurethane, with an inner ring to aid insertion and an outer ring that rests on the female genital area. Female condoms can be disinfected after use with household bleach, washed in detergent, dried and re-used approximately five times.

An oral dam (also known as a dental dam) is a thin square of latex that is placed over the vagina or anal area during oral sex. These can be purchased from family planning clinics and some pharmacies or alternatively a cut open latex glove may be used.

Special issues when talking about sex

Same sex partners

Some health professionals may feel uncomfortable or embarrassed asking about a patient’s sexual preference and discussing same sex practices.

A common stereotype is that people with same sex partners have a much higher incidence of STIs due to many sexual contacts and frequent casual or anonymous sex. However, the incidence of STIs is higher in people with multiple sexual partners, regardless of sexual orientation. STIs are transmitted similarly for vaginal and anal sex, although HIV is more easily transmitted through anal sex. Oro-anal sexual contact increases the risk for transmission of pathogens such as giardia and hepatitis A. Bacteria may also cause urethritis in both men and women. Hepatitis B is more common in men who have sex with other men but has not been shown to be spread by any specific sexual practices.6

  • Avoid prejudice
  • Do not presume that all people with same sex partners will engage in the same type of sexual behaviour. Up to one third of homosexual men choose not to practise penetrative anal sex6
  • Anal sex is also practised by heterosexual couples (up to 10% regularly)6
  • If a doctor has personal beliefs about homosexuality, which would compromise the level of care a patient receives, the patient should be referred to another doctor
  • Ensure advice is accurate, it is better to ask for clarification of a certain term or practise rather than to offer misleading advice
  • Sexual orientation is not always fixed – do not presume that a man who has sex with another man is homosexual or that a person who is married cannot be homosexual. Men or women may have a curiosity to experience same gender sex sometimes

Sex in very young people

A particular challenge facing health professionals is how to bring up the topic of sex with very young people, when it is suspected that they may be sexually active.

Young people usually find it difficult to confide to someone about their sexual behaviour. Building trust is extremely important. This is gained by maintaining privacy, confidentiality and a respectful, non-judgemental attitude at all times.

Sometimes a parent or carer will accompany a young person to a consultation and be aware of the reason for the visit. But in most circumstances, accompanying adults should be asked to leave the room, before a discussion about sexual health takes place.

A social and sexual history should be taken and the patient encouraged to talk to a trusted adult. Anything that the young patient discloses must be kept private and confidential from their parent or carer, unless they have consented to discussion.

In some situations, a health professional may judge that further action is required, especially if there are concerns about the maturity and competency level of the young person. Questions which may aid in the decision whether to liaise with a senior colleague, a paediatrician or a child protection team include:2

  • Do parents/carers know about the sexual activity?
  • Do parents/carers know they are attending the doctor?
  • Has the young person had sex against their will?
  • Age of partner – are there any legal ramifications? (The legal age of consent to sexual intercourse is 16)
  • Are there issues of vulnerability (self harm, psychiatric illness, drug or alcohol misuse, internet grooming)?
  • Is the young person under 13?
  • Is the young person being paid/rewarded for sexual activity?

As a general guide, any cases involving non-consensual sex or abuse should be referred immediately to a paediatrician or a doctor with special training (e.g. Doctors for Sexual Abuse Care - DSAC) as well as any relevant authorities (e.g. police).

Cases of people under 16 having consensual sex, should be reported to a public health officer or child protection service, if there is a significant age difference between the young person and their partner, or if there are issues of concern that may place the young person in physical or psychological danger.

Ideas for practice audits

  • Patients asked about gender of sexual partner or if they have ever had a same sex partner
  • Patients asked about condom use and offered condom prescription if appropriate
  • Comprehensive sexual history noted
  • HIV risk assessment performed
  • Updated sexual history taken with new genitourinary complaints
  • Patients asked if they have ever experienced sexual abuse or non-consensual sexual contact

Further reading and resources

Rainbow Youth – an organisation for gay, lesbian and bisexual youth, run by youth.
www.rainbowyouth.org.nz

Ministry of Health “Hubba Hubba” – Safer sex information aimed at youth
www.hubba.co.nz

The Word – Information on sex, life and relationships (Family Planning Association)
www.theword.org.nz

New Zealand Sexual Health Society – resources on safer sex and STIs
www.nzshs.org

List of New Zealand sexual health clinics available from:
www.nzshs.org

References

  1. Verhoeven V, Bovijn K, Helder A, et al. Discussing STIs: doctors are from Mars, patients are from Venus. Fam Pract 2003;20(1):11-5.
  2. French P. BASHH 2006 National Guidelines - consultations requiring sexual history-taking. Int J STD AIDS 2007;18:17-22.
  3. Tomlinson J. ABC of sexual health: taking a sexual history. BMJ 1998;317:1573-6.
  4. Meckler G, Elliott M, Kanouse D, et al. Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian and bisexual youth. Arch Pediatr Adolesc Med 2006;160:1248-54.
  5. Centres for Disease Control and Prevention (CDC). Male latex condoms and sexually transmitted diseases, 2009.
  6. Bell R. ABC of sexual health: homosexual men and women. BMJ 1999;318:452-5.