PROMOTING THE HEALTH OF MEN WHO HAVE SEX WITH MEN WORLDWIDE A training curriculum for providers

Module 6: Taking a Sexual History 2

Learning Objectives Be sensitive when taking comprehensive sexual histories Describe the various steps in the health assessment Assess the health status of sexual partners

Module Overview The importance of confidentiality Barriers to taking sexuality histories and how to overcome them Key communication issues when working with gay men and other MSM Specific questions to ask when taking sexual histories of gay men and other MSM Motivational interviewing Charting sexual history

Introduction Gay men and other MSM are less likely than their non-MMS peers to receive adequate assessment, treatment, and care for their health problems and concerns Health promotion is largely handled at the individual-level, facilitated through meaningful assessments and behavior modification

Confidentiality Confidentiality is critical to all physician-client relationships, including gay and other MSM clients Confidentiality gains special significance for gay men and other MSM Lack of confidentiality may result in harassment, blackmail, imprisonment, or violence Providers should discuss confidentiality and its limits with their clients May alleviate client fears or concerns Fearful clients will be less engaged in counseling 6

Barriers to Taking Sexual Histories Lack of experience or discomfort with asking questions Provider Barriers: Discomfort or inability to respond to issues that arise Homophobia, anti-gay bias, or heterosexism Inability to understand consensual same-sex sexual behavior between adults as a normal expression of sexuality May lead to making false assumptions regarding sexual behavior and level of risk Uncertainty in how to help a client feel comfortable, particularly with regards to discussing same-sex relationships Lack of time 7

Barriers to Taking Sexual Histories Embarrassment or shame Client Barriers: Perception of stigma or judgment from a healthcare provider Lack of awareness regarding sexual health issues Differences between doctor and client Age, gender, skin color, appearance, ethnicity, national origin, language, sexuality, culture, wealth, social class, sexual orientation

Addressing Barriers Develop a plan to respond to information that might surface Train staff to perform a risk assessment Develop a practice policy for when and where sexual risk assessment will be initiated Determine how this will be integrated into the clients’ overall care 2 Identify specific questions that will be asked 9

Asking about Male Same-sex Behavior Same-sex behavior in all male clients Ask About: Same-sex behavior in married men Same-sex behavior across all age groups Opposite-sex behavior in self-identified gay men 5 Steady male partners of self-identified gay men 10

Key Communication Issues Begin by developing rapport with the client Explain the importance of taking a sexual history Never assume that the client is either heterosexual or homosexual Use gender-neutral language when talking about sexual or emotional partners 5 Use the same language as the client when talking about sexual behavior and identity 11

Key Communication Issues Emphasize confidentiality Avoid making assumptions Be nonjudgmental, direct, and specific Begin with open-ended questions Example statement: "As I do with all of my clients, in order to provide you with the best possible care, I am going to ask you several straightforward questions related to your current and past sexual activity. I will also ask questions about alcohol and drug use." 12

Questions, and How to Ask Them Ask about sexual partners “Tell me about your recent sexual partners.” “Have you have sex with men, women, or both?” “How many sexual partners have you had in the past six months?” Ask about sexual practices “Do you have oral sex?” “Do you have anal sex? If yes, Have you been the bottom? The top?” 13

Questions and How to Ask Them Ask about venues where client meets partners “How do you meet your sexual partners?” “Have you had sex abroad recently?” “Have you ever exchanged sex for money, drugs, or anything else?” Ask about experience with condom use and other prevention modalities “Tell me about your experience with condom use.” “Tell me about how you protect yourself from HIV and other STIs.” 14

Summarize responses to questions “I am trying to better understand the situations in which you engage in sex...” “How much alcohol do you usually consume when you are having sex?” “What are other things about your sexual health and sexual practices you would like to discuss today?” Questions and How to Ask Them Ask about known HIV and STI status of your client and their sexual partners “Have you ever been tested for HIV?” “When were you late tested for STIs and what were the results?” Ask about alcohol and drug use “Tell me about your alcohol use.” “What has been your experience with drug use?” 15

Motivational Interviewing A B Motivational interviewing is a person-centered counseling method to help individuals change behavior Four stages: 1. Express empathy 2. Develop discrepancy 3. Roll with resistance 4. Support self-efficacy 16

Charting Sexual History 1 2 Many systems exist with different benefits and risks Some keep all information in one centralized record Some have separate sections for confidential information Clients must have access to their records and understand what was recorded 17

Charting Sexual History Which charting system to use? Consider: Do client history forms include questions regarding sexual history? If not, how will it be documented if a sexual history has been done? How will updated versions be documented? Do client history forms provide for self-identification in categories of gender identity, sexual orientation, marital and family status? Do these forms provide the option for further written explanation? 18

Summary Confidentiality is the cornerstone of provider-client interactions There are a large number of barriers to the taking of a proper history, both from providers and clients The majority of barriers can be overcome by planning ahead as well as becoming educated on clients Ask about same-sex or bisexual behavior in all male clients 19

Summary Avoid making assumptions, be as nonjudgmental, direct, and specific and possible. Taking a sexual history will become more comfortable over time Motivational interviewing is one counseling method that may help clients change problem behaviors. Many charting systems exist, each with benefits and risks to be weighed 20