Promoting Positive Sexual Health

“Doc, I’m having the best sex of my life. I’m 67 and I just tried anal sex and I love it!” This was not the response I expected while inquiring about my primary care patient’s new boyfriend, especially not during my first morning encounter, but it was a welcome surprise. My patient followed with a question: “Can you go back and forth, like from hole to hole?” referring to both anal and vaginal penetration during the same sexual encounter. At the tender age of 67, my patient was in the prime of her life, exploring and enjoying her sexuality, and had questions for me about sexual health.

Sexual health has been defined by the World Health Organization as a “state of physical, emotional, mental, and social well-being in relation to sexuality.”¹ Sexuality, in turn, is defined by the American College of Obstetricians and Gynecologists as “a broad range of expressions of intimacy and is fundamental to self-identification, with strong cultural, biologic, and psychologic components.”² Bottom line, sex matters and is an essential element to our patients’ overall health and, therefore, conversations about sex cannot be ignored or undervalued. Unfortunately, the majority of our patients believe their doctors will dismiss concerns about sex.³

SEX MATTERS

As health care providers, we are charged with discussing our patients’ social histories, which include pressing issues such as smoking, alcohol, and drug use. Let’s be honest, time is precious. Fifteen-minute visits do not give providers enough time to have detailed conversations with patients about sex amid the myriad bureaucratic and business-minded pressures. When we do ultimately ask our patients about sex, rather than focusing on it as a way to connect and find intimacy, pleasure, or joy, we instead focus on sex as a mechanism for disease acquisition. This perspective has been shaped and sustained by the discovery of sexually transmitted infections, such as gonorrhea and syphilis, and the HIV/AIDS epidemic, which together cast sex and sexuality as shameful and, hence, vilified. In response, health care providers simplified conversations about sexual health to one message: “Use a condom. Every time. Or you’ll suffer.”

We need to change this narrative. The National Coalition of Sexual Health has outlined key points to ensure productive conversations with patients about sex.⁴ Important elements include avoiding assumptions based on patient age, appearance, or marital status. Yes, older adults have sex, as my patient proudly demonstrates, and many adults enjoy sex throughout their life, irrespective of gender. Also, unless told explicitly, medical providers should not assume a patient’s gender identity, sexual orientation, or sexual practices. Just because a person appears masculine does not automatically designate him or he as their pronouns nor their partners as straight or cisgender. To facilitate conversation, the guide outlines questions that should be asked at least once or annually to all patients. For example, “What is your gender identity?” and “What questions do you have about your body, sex, or both?”⁴ The American College of Obstetricians and Gynecologists also suggests questions that may be asked after general information is gathered, such as, “Are you satisfied with the frequency of sexual activity,” “Do you have orgasms,” and “Does your vagina lubricate enough?”² We can then follow up or clarify unfamiliar vocabulary used by patients. This conduct allows us to promote comprehensive and affirming sexual health care that is ultimately “sex positive” regardless of our patient’s gender or sexuality.

BE SEX POSITIVE

What does it mean to be “sex positive,” and how can we as health care providers better engage with our patients about sex? First, being sex positive includes accepting a great diversity of sexual activities. It is founded in the philosophy that consensual expressions of sexuality are healthy and strips away the belief that some types of sex are more acceptable than others.⁵ Second, being sex positive affirms an individuals’ right to enjoy the kind of sex they are having without feeling judged. And lastly, it demands comprehensive education, particularly on sexual practices, pregnancy and family building, and sexually transmitted infections (STIs). There are many resources available to providers that can help us become sex positive, including scripts, toolkits, and guidelines.

SEXUALLY TRAMSITTED INFECTIONS

We cannot discuss sexual health without acknowledging the overwhelming public health impact of STIs, “the hidden epidemic.” In 2017, the Centers for Disease Control and Prevention reported increases in infections with Chlamydia trachomatis, Neisseria gonorrheae, and primary and secondary syphilis. It is important to remember that a significant proportion of those who contract STIs will not have symptoms, and thus if not screened appropriately will remain undiagnosed and continue transmitting infections. Furthermore, patients undiagnosed or untreated for STIs may develop long-term sequelae, with the potential for significant morbidity (e.g., pelvic inflammatory disease, infertility, and disseminated gonorrhea). Therefore, patients need to be educated about risk-reducing practices regularly and screened routinely according to the Centers for Disease Control and Prevention guidelines.

As providers, we also cannot forget about stigma directed toward individuals diagnosed with STIs, as it poses a substantial threat to the care we aim to deliver. Shame of acquiring an STI keeps patients from getting tested or being honest with their medical providers about their sexual behaviors. With the advent of effective HIV-prevention strategies such as pre-exposure prophylaxis and treatment as prevention, people are more comfortable having sex without condoms and thus are at greater risk for STI acquisition.⁶

OPPORTUNITY IN THE SEXUAL HISTORY

Rather than approaching the sexual history as an opportunity to give all or nothing advice about condoms or abstinence, we can use it to encourage healthy expressions of sexuality and provide culturally affirming advice. It also offers an opportunity to improve the sexual health information we deliver to our patients and enhance services, services that are more convenient, welcoming, and readily accessible to patients. For example, (1) expanding sexual health access, like the eight New York City Department of Health Sexual Health Clinics, located in four of the five boroughs, offering low- or no-cost services for STI testing; (2) calling for the development of screening protocols that incorporate effective point-of-care and at-home testing options that may limit clinic visits⁷; and (3) establishing patient-centered and nonstigmatizing STI testing and treatment that is fast and efficient and automates the notification process, as in the London’s Dean Street Express testing model. Such innovative initiatives may be applied to areas most afflicted by HIV and other STIs, taking into account racial, ethnic, and religious diversity.

We have powerful biomedical tools to end the HIV epidemic and reduce the spread of STIs. One essential tool is becoming providers who embody the philosophy of being sex positive and gender and sexuality affirming. Changing the conversation on sexual health moves us from stigma to action and exemplifies our commitment to realistic patient safety and experience, built on trust and openness. Hearing my 67-year-old patient talk about sex reminded me of its importance to overall health, as well as the diversity of sexual practices being explored by patients irrespective of gender and age.

“You’re the only doctor I’ve ever talked to like this. To be honest, I don’t usually talk about this stuff.” I believe validating my patient’s questions about sex allowed me to engage with her on activities that bring her joy and connection, and strengthened an already enduring therapeutic relationship. If medical providers are comfortable talking about sex, patients will be too, and an opportunity to engage and connect with patients is gained.