Download Introduction Talking with Patients about Sex Curriculum Kenneth

Introduction
Talking with Patients about
Sex Curriculum
Jennifer Potter MD
Acknowledgement
Kenneth B. Schwartz
Center Mission
To support and advance compassionate health care
in which caregivers, patients and their families
relate to one another in a way that provides hope to
the patient, support to caregivers and sustenance to
the healing process
This Curriculum Addresses
the Following Questions…
• Why should we talk to patients about sex?
• Who, what, and when should we ask?
• How can we respond productively?
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Part 1: Introduction
Part 2: Taking a Sexual History
Part 3: Providing Risk Reduction Counseling
Part 4: Assessing and Addressing
Satisfaction
Multiple Sources of
Information
• Clinician voices…
• Patient voices…
• Peer-reviewed literature…
Lets Talk
about Sex
Sex Is Normal
Sex is Healthy
Sex is Important to Patients
• In a survey of over 27,500 people in 29
countries, the majority of male (83%)
and female (63%) respondents
described sex as “extremely”, “very”,
or “moderately” important in their lives.
Nicolosi A et al. Sexual behavior and sexual dysfunctions after age 40:
the global study of sexual attitudes and behaviors. Urology
2004;64:991-997.
Clinician Goal:
Help Patients Achieve Sexual Health
• Avoidance of unwanted pregnancies
• Absence of sexually transmitted
diseases
• Sexual expression without exploitation,
oppression, or abuse
• Sexual satisfaction or sexual
contentedness
It’s Not a Perfect World…
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Unintended pregnancy
Sexually transmitted diseases (STDs)
Sexual assault / abuse
Sexual difficulties / dysfunction
Cultural taboos
When patients run into trouble,
it’s usually because of…
• Misconceptions and lack of knowledge
about sexuality and sexual function
• Poor communication with partners
about contraception, safer sex, and
sexual needs
When clinicians run into trouble,
it’s usually because of…
• Misconceptions and lack of knowledge
about sexuality and sexual function
• Poor communication with patients
about sexual history, safer sex, and
sexual problems
Consider the Impact of Culture
Common Cultural Taboos
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Masturbation
Sex before marriage
Sex outside of marriage
Sex between close relatives
Sex with children
Same-sex sexual activity
Use of contraception
Non-intercourse activities (oral, anal sex)
Sex during menstruation, pregnancy, or
during the postpartum period / lactation
Sex and Gender Differences
• Sexiness criticized in women; admired in men:
– ‘Slut’ vs. ‘stud’
• Premarital / extramarital sex unacceptable for
women; condoned in men:
– Intact hymen, chastity belt
• Sexual pleasure valued less / taboo for women:
– ‘My husband’s needs come first’
– Female genital circumcision
• Stigma greater for older women than men:
– ‘All dried up’, ‘withered’ vs. ‘he’s a real Don Juan’
Culture Impacts Function
• Sex is not discussed 
– Ignorance re: anatomy, function, technique
• Sense of self ≠ societal expectations 
– Anxiety, confusion, shame, isolation
– More depression, substance abuse, unprotected sex
• Gender role inequities 
– Poor communication re: safer sex, sexual needs
– Sexual inhibition/avoidance after sexual trauma
Clinician-Patient Relationship:
Also Impacted by Culture
Consider Conception / Pregnancy
Misconceptions
You Can’t Get Pregnant If…
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It’s your first time
You have your period
You do it standing up
The woman is on top
You douche afterwards
The guy ‘pulls out’ before he ejaculates
www.siecus.org
Facts about Conception
• 49% of pregnancies are
unplanned
• US rates are higher than in other
developed countries
Unintended pregnancy rates: Henshaw SK. Unintended
pregnancy in the United States. Fam Plann Perspect
1998;30:24-9.
Consider Sexually Transmitted Diseases
STD’s: If I can’t see it, I don’t have one, right?
Misconceptions:
You Can’t Get Infected If…
• You’re on the pill
• You have sex with only one partner
• Both partners say they are virgins
• Your partner has no symptoms
• You eat a lot of hot peppers
www.siecus.org
Facts about STDs
• 1 in 3 Americans infected by age 24
• Often asymptomatic
• Sequelae can be severe:
• Pelvic inflammatory disease, ectopic
pregnancy, infertility, cervical dysplasia,
cervical cancer, HIV/AIDS, chronic illnesses
(eg. hepatitis B)
www.plannedparenthood.org
Consider Abuse and Assault
Sexual Abuse: A Definition
• An act of violence or aggression that occurs
when a person is forced, threatened, or
coerced into sexual contact without their
consent
• Examples: rape, fondling, indecent
exposure, peeping Toms, obscene phone
calls, childhood sexual abuse, sexual
harassment
Misconceptions
Sexual Abuse & Assault
• The primary motive for rape is sexual
• People who are raped ‘ask for it’ in some way
• A person can prevent an assault by resisting
• Women report rape to get revenge / attention
• Women owe men sex in some circumstances
• Women say ‘no’ when they really mean ‘yes’
• It only happens to the young / beautiful
Facts about Abuse / Assault
• Affects 1 in 5 women over the lifespan
• Rarer, but still occurs in men
• 80% of all assaults are committed by
someone the victim knows (family
member, spouse, friend, date,
coworker, personal care attendant)
Acierno et al. Health impact of interpersonal violence: prevalence
rates, case identification, and risk factors for sexual assault, physical
assault, and domestic violence in men and women. Beh Med
1997;23:53-63.
Effects of Abuse and Assault
• Health sequelae can be severe:
– Psychological:
• PTSD
• Substance abuse
• Suicide attempts
– Interpersonal:
• Isolation, dysfunctional relationships
– Physical:
• STDs, pelvic inflammatory disease, chronic pelvic
pain, sexual difficulties, headaches, eating disorders,
irritable bowel syndrome,  frequency many chronic
medical conditions
Last but not Least…
Consider Sexual Satisfaction
Misconceptions of
Sexual Function & Satisfaction
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Men want sex more than women
Women care about intimacy more than men
If you love your partner, sex will be wonderful
My partner should know what I want
Good sex is spontaneous
Movies and TV portray sex as it really is
Bigger is always better
Facts about Sexual Function
• Both women and men enjoy sex / intimacy
• Fulfilling sex often requires planning / effort
• Changes in function occur with life stress,
aging, illness, and many medications
• Lifestyle adaptations preserve sexual
satisfaction in many circumstances
Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the
United States: prevalence and predictors. JAMA
1999;281:537-544.
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We Can Make a Difference
By Talking about Sex
Taking a Comprehensive
History
• Discuss sexual identity/orientation:
– Assess level of self-acceptance
• Identify risk behaviors for:
– Unintended pregnancy
– Sexually transmitted diseases
• Ask about sexual abuse
• Ask about sexual satisfaction
Providing Pertinent Counseling
• Basic sexuality education:
– Pregnancy, STIs
– Sexual response, changes with aging
– Lifestyle modifications to enhance pleasure
• Risk reduction strategies:
– Contraceptive options, safer sex methods
• Support and referral for patients who:
– Are confused about their identity / orientation
– Disclose a history of abuse
– Request evaluation / treatment for sexual problems
Unfortunately…
We Don’t Do a Very Good Job
“I don’t take a
sexual history,
as often as I
should”
We Don’t Ask
• Less than 40% of primary care
clinicians obtain a sexual history
routinely in new adult patients
• We ask even less often during
successive visits
Diamant et al. 2000
They Don’t Tell
• A survey of adults > 25 showed that
85% would like to discuss a sexual
problem with their physician, but 68%
were reluctant to ask, and 71% thought
their concerns would be dismissed.
Marwick C. Survey says patients expect little physician
help on sex. JAMA 1999;281:2173-4.
It’s Important that We
are the Ones to Raise
the Topic
Clinician Clip
“I think it is important for us as providers to bring
it up to them, because often patients come in &
they aren’t comfortable raising the issue. But, if
we as providers approach it first, I think often it
opens up a lot & people feel much more
comfortable & know that they can trust you &
talk to you about it”
Patient Clip
“I really wish they had asked…Its
really hard for a patient to bring it
up…afraid of being dismissed…”
What We
Want to Avoid…
Don’t Ask
Don’t Care
Why don’t we ask?
Clinician Clip
“I think early on it was much more awkward. I
can remember as a 2nd year student doing a
mock interview, when you were taking a sexual
history, how uncomfortable & nervous I was.
But as time has gone on I have become more
comfortable with it. I think I do a better job with
it because I am more comfortable & my patients
more comfortable to.”
Clinician Clip
“I know when I first started I worried people
would get angry & be like how dare you suggest
I would do X, Y, or Z & I have never had that
happen. Sometimes with older patients they
chuckle and be like, I don’t do that, but not in an
angry sort of way & some patients are thankful
that you ask & say thank you for not assuming
one thing or another”
Clinician Clip
“My comfort level varies quite a bit …the most
recent experience was working with a gay man
around his methamphetamine abuse & some of
his sexual practices that have been
accompanied by that… there was stuff that I had
never heard of before so I think I probably
blushed, felt a little embarrassed,, a little thrown
off not knowing exactly how to talk about it with
him until I had a chance to process it a bit.”
Embarrassment
We Don’t Ask Because Of…
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Personal embarrassment
Lack of knowledge re: clinical relevance
Ignorance re: who, when, how, or what to ask
Concern re: not knowing how to answer questions
Concern re: becoming aroused/uncomfortable
Concern re: appearing seductive/intrusive
Uncertainty about legal issues
Time constraints
Lack of Sexuality Education
Lack of Sexuality Education
• A survey of 125 United States and 16
Canadian medical schools revealed
that the majority of undergraduate
medical programs provide less than
10 hours of education on human
sexuality.
Solursh DS, Ernst JL, Lewis RW. The human sexuality education of
physicians in North American medical schools. Int J Impot Res 2003;15
(Suppl 5):S41-45.
How can we do a
better job?
Clinician Clip #1
Quote:
(1) Examine our biases
(2) Listen to our patients
(3) Be willing to practice
Clinician Clip #2
“As a clinician it is important to never make
assumptions about your client’s sexual history &
sexual life…. It’s also important to remember
that it is okay to be uncomfortable about asking
people about sex. You can actually use that to
your advantage by just asking your client to tell
you exactly what he/she means &
acknowledging that you don’t necessarily have
all the answers.“
Clinician Clip #3
The one pearl to remember when taking a
sexual history is just to ask in the most openended non-judgmental way that you possibly
can & patients will give you usually the
information that you need. Don’t box them into
a corner. Just be open-ended & don’t be afraid
to ask something. If you are worried how they
will take it, you can always explain that I am
asking you this because I am worried about
this.”
Clinician Clip #4
“With all my experiences in my clinical practices
the more I do it the easier it sort of feels, or the
more natural it feels. I think it has to do with
self-consciousness to ask someone if they have
had multiple sexual partners or have had varied
sexual experiences… you have to say it a few
times to feel like you can actually say it and not
blush or feel to nervous about it”
Clinician Clip #5
“Talking with patients about their sexual lives
gives us a chance to dispel all sorts of
misconceptions that people have. It gives us a
chance to teach people how to reduce their risk
for bad outcomes, like unwanted pregnancy and
STDs. But what’s really unique about this kind of
discussion in medicine is that it’s really all about
pleasure. What an incredible thing to be able to
help patients increase the amount of pleasure
they have in their lives!”