1. Asking Patients About Sexual Health and Behavior for Improved Quality in Prevention and Care http://www.nachc.com/SexualHealth.cfm

2. Overview – This PowerPoint presentation has been developed for an all-staff training. This training can also be included in new-employee orientations. Health center leadership should gather all staff together to 1) demonstrate their commitment to taking routine histories of sexual health; 2) present the need and importance of sexual history information; and 3) explain the systems that will be implemented for routine sexual history taking.

3. Why Ask About Sexual Health and Behavior? Learning about the sexual health and behavior of patients is an important part of what health centers do every day: provide high-quality safe accessible, and efficient health care.

4. How Can We Learn about Patients’ Sexual Health and Behavior? Providers, or other members of the clinical care team, should ask all adolescent and adult patients about their sexual health and behavior as part of the routine history. The sexual history for adults generally begins with these three screening questions, with follow-up as appropriate: – 1. Have you been sexually active in the last year? – 2. Have you had sex with women, men, or both? – 3. How many people have you had sex with in the last year?

5. The Sexual History Is Prevention Taking a history of sexual health allows us to find and treat sexually transmitted diseases (STDs) that may otherwise be missed. If left untreated, many STDs: – can lead to more serious illnesses, infertility, and possibly death – can spread to other partners and increase disease in the community. Taking a sexual history also gives us the opportunity to talk with patients about ways they can stay healthy.

6. Taking a Sexual History Helps Us Improve Our Patients’ Overall Health Preventing and treating STDs, HIV, and hepatitis, can help us reduce disease and death among our patients. Identifying and treating sexual problems and low sexual satisfaction can help us improve our patients’ mental health and well-being. When we show our patients that we are interested in and compassionate about their sexual problems, behaviors, and identity, we will see an improvement in our relationship with patients.

7. The Sexual History Helps Us to Be Patient-Centered In a survey of 500 men and women over age 25: – 85% said they were interested in talking to their doctors about sexual issues – 71% thought their doctor would likely dismiss their concerns. 1 The sexual history allows health centers to identify clinical needs early and provide clinically and cost- effective care – essential elements of a patient centered medical home (PCMH). 1 Marwick C. Survey says patients expect little physician help on sex. JAMA. 1999;281:2173-4.

8. Who Is This For? All of our patients! Sexual history information should be taken from all of our patients, regardless of gender, race, ethnicity, socioeconomic status, sexual orientation or gender identity.

9. Who Will Be Involved? All of our staff! All health center staff have a role in making sure that sexual histories are completed in an accurate, appropriate, sensitive, and confidential manner throughout the patient visit.

10. When Are Sexual Histories Taken? The sexual history is taken as part of the general history during the annual prevention visit, or in response to questions or symptoms. It can be taken by the provider or other member of the clinical care team during the visit. Or, much can be filled out by the patient on paper or electronically in advance of the visit, and then reviewed during the visit.

11. Why Now? There are new national plans to reduce HIV infections and hepatitis infections. Taking routine sexual histories are necessary for meeting the goals of these national plans. These plans rely on community health centers because we serve populations with a greater risk of becoming infected with HIV and hepatitis.

12. Who is at Greater Risk? (U.S. Data) African American men and women – 45% of HIV infections – Twice as likely to have hepatitis C compared to rest of US population Hispanic men and women – 22% of HIV infections Asian/Pacific Islander men and women – 1 in 12 are living with hepatitis B

13. Who is at Greater Risk? (U.S. Data) Men who have sex with men (MSM) (gay and bisexual men, and men who have male partners but do not identify as being gay or bisexual) 64% of new HIV infections 37% of HIV+ MSM are African American (48% increase from 2006-9) 15%–25% of all new Hepatitis B virus infections Frequent reports of Hepatitis A outbreaks Transgender women (people born male who feel very strongly that their gender is female, and who express themselves as women) 28% estimated to be HIV infected (57% of African American transgender women)

14. Providing Care To Patients Who Are Gay, Bisexual, Or Transgender The greater risk of hepatitis and HIV in these populations makes it especially critical that a routine sexual history is taken for all patients to help identify those most at risk and then provide appropriate screening and prevention counseling – CDC has specific screening and testing recommendations for MSM, due to their higher risk – The sexual history should be inclusive of all sexual behaviors and be taken without judgment Culturally competent care for gay, bisexual, transgender and lesbian patients will help patients feel safe to disclose full histories to their providers, allowing them to receive clinically effective care. Trainings and resources are available.

15. Asking about Sexual Orientation and Gender Identity In addition to taking a sexual history, asking all patients about their sexual orientation and gender identity is now recommended by the: – Institute of Medicine and – the Joint Commission as a way to improve the care of lesbian, gay, bisexual, and transgender people and overcome a wide range of health disparities, including risk for diseases like HIV and hepatitis.

16. Who Will Be Involved? Examples Of Roles Leadership: Build routine sexual histories into strategic planning process and staff education program; foster a culture of acceptance and respect for all sexual behaviors and identities Medical Staff: Take and document regular histories; peer review of sexual history taking; appropriately communicate medically necessary information with the clinical care team Front Desk and Patient Services: Practice sensitive and confidential collection of forms and communication with patients; master data collection systems Administrative Staff: Revise intake and history forms; develop plan and assign staff person to develop metrics and track data for measuring progress; ensure that outreach materials, brochures, and other materials include images and information that reflect people who are LGBT

17. Who Will Be Involved? Examples Of Roles IT: Develop confidential systems that will include sexual history and sexual orientation and gender identity data in electronic records; train staff in systems Human Resources: Create and implement policies that support non-discrimination and confidentiality around sexual behaviors and identity ; integrate cultural competency training into new employee orientations and annual trainings Finance: Work with medical staff to ensure cost-effective coding and reimbursement for sexual history screenings All: Become familiar with confidentiality requirements, policies protecting patient privacy, and policies regarding discrimination; take trainings that teach about LGBT cultural competency

18. How Will We Know How We’re Doing? Possible Metrics (taken at 0, 6, and 12 months): – Track number of sexual histories taken and documented, and the number of patients screened for HIV, Hepatitis A, B, and C – Compare screening rates to community or state data – Track meaningful use measures, including the number of diagnoses, number in care and treatment, and the number of patients with co- occurring disorders – On patient experience survey, ask how well health center is taking care of patient’s sexual health and how friendly or inviting the health center is toward LGBT patients. By the 12th month, evaluate whether all relevant policies and forms have language that is inclusive of LGBT identities and behaviors.

19. Who Can We Partner With? Organizations that can help with trainings, resources, data and systems: – Schools and school-based programs – Churches – State or County Health Department – AIDS Education and Training Centers – Bureau of Primary Health Care’s National Cooperative Agreements for training and TA – STD and HIV clinics and support groups – Private providers – Academic Health Centers – Community centers and groups that support LGBT people

20. What’s Next? Small group review of the sexual history toolkit Begin implementation Thank you!