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Talking with Patients about Sex Curriculum Introduction Talking with Patients about Sex Curriculum Jennifer Potter MD.

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Presentation on theme: "Talking with Patients about Sex Curriculum Introduction Talking with Patients about Sex Curriculum Jennifer Potter MD."— Presentation transcript:

1 Talking with Patients about Sex Curriculum Introduction Talking with Patients about Sex Curriculum Jennifer Potter MD

2 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

3 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? Part 1: Introduction Part 2: Taking a Sexual History Part 3: Providing Risk Reduction Counseling Part 4: Assessing and Addressing Satisfaction

4 Multiple Sources of Information Clinician voices… Patient voices… Peer-reviewed literature…

5 Lets Talk about Sex

6 Sex Is Normal

7 Sex is Healthy

8 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. Sex is Important to Patients

9 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

10 It’s Not a Perfect World… Unintended pregnancy Sexually transmitted diseases (STDs) Sexual assault / abuse Sexual difficulties / dysfunction Cultural taboos

11 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

12 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

13 Consider the Impact of Culture

14 Common Cultural Taboos 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

15 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’

16 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

17 Clinician-Patient Relationship: Also Impacted by Culture

18 Consider Conception / Pregnancy

19 Misconceptions You Can’t Get Pregnant If… 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

20 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.

21 Consider Sexually Transmitted Diseases STD’s: If I can’t see it, I don’t have one, right?

22 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

23 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)

24 Consider Abuse and Assault

25 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

26 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

27 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.

28 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

29 Last but not Least… Consider Sexual Satisfaction

30 Misconceptions of Sexual Function & Satisfaction 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

31 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..

32 We Can Make a Difference By Talking about Sex

33 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

34 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

35 Unfortunately… We Don’t Do a Very Good Job “I don’t take a sexual history, as often as I should”

36 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

37 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.

38 It’s Important that We are the Ones to Raise the Topic

39 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”

40 Patient Clip “I really wish they had asked…Its really hard for a patient to bring it up…afraid of being dismissed…”

41 Don’t Ask Don’t Care What We Want to Avoid…

42 Why don’t we ask?

43 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.”

44 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”

45 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.”

46 Embarrassment

47 We Don’t Ask Because Of… 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

48 Lack of Sexuality Education

49 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.

50 How can we do a better job?

51 Clinician Clip #1 Quote: (1) Examine our biases (2) Listen to our patients (3) Be willing to practice

52 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.“

53 Clinician Clip #3 The one pearl to remember when taking a sexual history is just to ask in the most open- ended 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.”

54 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”

55 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!”


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