What is Sexual Health?
Sexual Health: Communicate, Inquire, and PromotePrint This Post
Healthy People 2020 identify Reproduction and Sexual Health as a leading health indicator. Leading health indicators, or high priority health issues, list objectives to improve the health of the US population. Providers and healthcare organizations are encouraged to implement these objectives in their practice in order to meet these health care goals for the nation.  Sexual health is a broad category that includes a patient’s physical and emotional well-being. If sexual health is threatened it has far reaching consequences for the patient including infectious disease, cancer, child mortality, mental health issues, financial instability, and health disparities. Primary prevention is an essential strategy employed by health care providers to help patients obtain optimal sexual health. [1-2] Thus, education on safe sex practice is one means of primary care prevention leading to sexual health.
What is Sexual Health?
Sexual health is a state of physical, emotional, mental, and social wellbeing in relation to sexuality, not simply the absence of disease. It is multidimensional. Striving for optimal sexual health entails prevention of sexually transmitted infections (STIs), unintended pregnancy and abortion, infertility, and cancers resulting from STIs. It requires understanding of social, cultural, and economic factors that place patients at risk. [2-3]
Seventy-three percent of patients surveyed by The Women’s Sexual Health Foundation prefer the healthcare provider to bring up the topic of sexual health.  A poll of U.S. healthcare providers also found that 74% of providers rely on their patients to initiate a discussion about sexual health.  And yet only 35% of primary care providers report taking a sexual history.  Reasons given for this limited approach to care include embarrassment, feelings of unpreparedness in dealing with sexual health issues, lack of commitment to primary prevention, and time constraints.  These findings suggest needed provider leadership and communication in the discussion of safe sex practice, primary prevention, and sexual health.
This discussion begins with a brief sexual health history, which prompts conversation on safe sex practice. Primary prevention is avoidance/prevention of disease and injury, including mental health illness. When the sexual health history identifies plans for sexual activity and/or a need for STI screening, the commitment to primary prevention needs to include discussion of safe sex practice.
Three basic questions to initiate inquiry about the need to discuss safe sex practices include: Are you currently sexually active? Have you ever been? Are you planning to be sexually active? The answer to these three questions will determine the need for education regarding safe sex practices, STI screening, and pregnancy. Guidelines for sexual history taking include sexual activity, partner status, sexual risk factors, sexual function, contraception, and sexual orientation.  Using the five “P”s is a helpful guide to explore in detail the patient’s sexual history :
- Partners (note the gender and number of partners)
- Practices (to determine anatomical site of STI screening needed)
- Protection from STIs (what preventive methods are used)
- Past history of STIs (including partner history and treatment)
- Prevention of pregnancy (question if attempting pregnancy or need for birth control)
The Sexual Health Crisis
Every year U.S. healthcare providers diagnose 19 million new cases of STIs, a problem that has become a significant healthcare challenge in the United Sates.  STIs account for $17 billion a year in healthcare costs, a figure that does not include the indirect emotional and long-term cost to the individual diagnosed.  Moreover, the pathogen Neisseria gonorrhoeae continues to develop resistance to the drugs traditionally used to treat it. To date, N. gonorrhoeae is considered resistant to sulfonilamides, penicillin, tetracycline, and ciprofloxacin. Dual therapy with IM ceftriaxone and either azithromycin or doxycycline is recommended by the CDC to treat all uncomplicated gonococcal infections in adults and adolescents.  Adding to this problem is the ability of HIV to reproduce despite treatment that was previously effective with antiretroviral medications. 
Populations that are most at risk for STIs and their sequelae include young people ages 15-24 (half of all new diagnoses are made in this age range), women, infants, minorities, men who have sex with men (MSM), and individuals in correctional facilities.  Though less than 50% of persons who should receive STI screening actually are screened, improvements have been made in secondary prevention in all populations.  The spread of STI is greater with intercourse, but infection also occurs with skin-to-skin contact, oral and digital sex, and with the use of sex toys. Recognition of these facts stresses the importance of inquiring about all sexual practices including women who have sex with women (WSW) and MSM. [6,9]
What Is Safe Sex?
Providers have an opportunity with each patient visit to educate patients on safe sex practices. Safe sex should not be considered common knowledge among patients. Key patient education points are as follows:
- Know what is considered sexual behavior and what behaviors put patients at risk for STI.
- Encourage patients to know their partner and the partner’s sexual history, including the number of past sexual partners. A higher number of sexual partners put one at higher risk for contracting an STI.
- Stress the proper use of condoms for vaginal and/or anal intercourse with every act of intercourse, before any genital contact.
- Discuss use of female condoms and how to use them.
- Discuss the use of oral dams to prevent oral transmission of disease.
- Discuss care of sex toys to reduce transmission from cross contamination of body fluids.
- Discuss lubricant products that are safe to use with rubber latex condoms.
- Discuss that STI prevention can include the decision to abstain from sexual intercourse.
- Review safe sexual activities such as body massage, dry kissing, cuddling, and hand-holding. [2,10]
Effective provider-patient communication is the basis for establishing a trusting relationship.  Patient disclosure of sexual health issues is more likely with a positive and interactive communication style, giving the patient a sense of caring. Taking a sexual health history should be preventive in approach and non-judgmental in response to patient disclosure of sexual orientation, sexual behaviors, and number of sexual partners. To accomplish this, create an environment that promotes communication with demonstrated understanding. Use open-ended questions to encourage in-depth answers lending to further discussion. Establish rapport with introductions, and/or pleasant neutral observations such as the weather, inquiring about a book they may be reading, etcetera. This eases the transition to conversation about sexual health history and the review of systems.
The pace of each patient visit is recognizable once rapport is established between the patient and provider. Some visits are fairly straight forward and patients are readily expressive and quick in understanding. Other visits need a slower pace to allow the patient to feel more at ease and trusting. Providers need to be cognizant of and perceptive to the patient’s verbal and nonverbal communication in order to allow full patient disclosure of questions and answers. The sexual history is then is gradually approached and finally focused upon.
- Assist the patient to feel comfortable by talking openly about sexual health.
- Educate the patient in plain language to augment patient understanding.
- Sit at eye level with your patient.
- Use visual models to illustrate how to use condoms, dams, and teach anatomy. Use of pictures or illustrations can help eliminate concern regarding literacy.
- Ask for the patient to repeat back in their own words the instructions given to them in order to verify understanding of safe sex practices. [11-14]
Clinic Settings for Teens
Teens are a sub-population that requires special attention, and the goal is to develop a youth friendly environment. The ideal teen setting encourages teen visits, personal disclosure, and acceptance of education given. Cultivate a clinic setting that fosters access to care, promotes trust by confidentiality, normalizes history taking, supports screening, and gives an expectation that education will be given readily and questions encouraged. Examples of teen friendly office settings include:
- Teen friendly magazines and posters
- Office hours after school or walk in hours
- Posted confidentiality policy that is readily visible to all patients
- Consistent care that normalizes screening, treatment, and discussion of partner notification of positive STI results
- Resources for low cost or free screening for STI, pregnancy, and birth control
- Education that is sensitive to age, sexual orientation, and literacy
Providers must also remember that not all teens are truly aware of what sexual activity actually is and may be at risk for abuse or sexual activity against their understanding. A clear description of what entails sexual activity is an important education piece that gives the patient safety by knowledge. Describing what places the patient at risk for STIs and pregnancy is critical information in early teen clinic visits. 
Relationship Violence and Sexual Health
All patients, regardless of age or gender, are at risk for sexual assault and relationship violence. Domestic violence knows no bounds as it affects all races, pays no respect to level of education, and crosses all socioeconomic classes. According to the American Academy of Family Physicians, domestic abuse affects one in three American families cared for by family doctors, and accounts for $67 billion in healthcare costs annually.  Moreover, an estimated 39,000 office and ER visits a year are thought to be related to domestic abuse. Yet only an average of 13.5% of providers screen for it.  The biggest barrier to abuse screening is provider unpreparedness on how to respond once an abuse victim has been identified. 
How do you Screen for Domestic Abuse?
Asking, “Do you feel safe in your relationships at home, school, and work?” is a non-threatening opening to more detailed questions such as, “Have you ever been hurt in a sexual way or forced to have sex when you didn’t want to?” Asking every patient about relationship safety at the time of the sexual history will encourage consistent inquiry. This is information every provider must ask to thoroughly complete the physical and emotional health assessment of their patients.
Clinical complaints often seen in patients who are possible victims of relationship violence include:
- Chronic complaint of headache, pelvic pain, fatigue, recurrent vaginitis
- Sleep problems
- Anxiety (shortness of breath, dizziness, chest pain)
- Injury not consistent with history
- Psychiatric complaints- substance abuse, depression, suicidal ideation
Patient behaviors include:
- Moody and withdrawn
- School problems
- Frequent canceled appointment
- Delay of injury care
- Fear of relationship breakup or fear of partner
Partner behaviors include:
- Possessiveness, jealous of others including friends and family
- Uses alcohol and other drugs
- Sabotages birth control method/use
- Refuses to leave exam room during health exam of partner
How Does the Provider Respond?
Healthcare providers need to be aware of their role once partner violence is identified:
- Access safety for the patient
- Give key message that victim is not at fault, they are not alone, no excuse for violence, support is available
- Report depending on state law and mandates of patient age
- Document with continued reassurance of confidentiality 
There may be a time when a patient discloses to the provider that they are indeed in an abusive relationship, but does not want anything to be done. Provided there is no legal obligation to report abuse, such as in the case of a minor or vulnerable adult, it is the role of the provider to offer non-judgmental support and provide resources as noted previously.  In addition, it is of upmost importance to objectively document any findings. Detailed descriptions of physical findings are paramount and the use of quotation marks in the review of systems (ROS) helps prevent the interjection of provider bias in the medical record.
Abuse screening adds an extra fifteen seconds to each patient visit when done routinely.  A safe place is created when a provider inquires about domestic abuse, and that is what helps break the cycle of violence. [16-17] Lastly, providers need to know their resources (social work, community safe houses, support groups), as this will make screening more comfortable for them as they are better able to respond when an abuse victim is identified.
Health care providers have the opportunity to improve the sexual health of their patients at every visit, which lends to the long-term success of their over-all health, economic status and mental well-being. This starts with a commitment to primary prevention, incorporating a basic sexual history as part of a review of systems, and a consistent emphasis of safe sex practices with each sexually active (or planning to be sexually active) patient. Communication skills using empathy, partnership, and respect legitimize and support the patient in understanding, self-care, and violence prevention. In taking these basic steps, meeting the objectives of HealthyPeople-2020 will be within reach.
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Question 1: A 15 y.o. female is in clinic on a late summer day. The appointment states reason of visit- Birth Control. She is a new patient to your practice and the clinic. Your schedule is heavy and the other exam rooms are full. What is the best practice choice considering the patient and clinic schedule:
a) Enter and greet the patient with a smile, sit at eye level with the patient to establish rapport. “I see you are new to the clinic. Tell me a little about yourself, (give her time to answer, and feel comfortable). Now, what can I do for you today”?
b) Due to time constraints, enter the room, sit and start immediately entering information into EMR. “ I see you are here for birth control. Is this a refill request or are you just wanting to initiate birth control?” While documenting a brief history on EMR, briefly look up from the laptop while typing at the same time.
c) Have your nurse get all the information from the patient including form of birth control desired. Have the nurse obtain the patient history and VS. Pt really wants to start on oral birth control – no contraindication by history taken by staff nurse. Simply walk in and give her a prescription for birth control and state that your nurse will tell her everything she needs to know. Tell her to call if she has questions.
Correct answer: a
Rationale: Establishing rapport and trust is critical first step of providing care for the 15 y.o. patient.
Question 2: 26 yr old Caucasian female presents to your office for her annual well-woman exam. The ROS is negative for abnormal findings, but when you begin your physical exam you note multiple areas of ecchymosis at various stages of healing across her abdomen. At first the patient states she fell down the stairs, but upon further investigation she reports, “My boyfriend will sometimes hit me, but it’s only when I mess up, he loves me. Please don’t say anything to anyone.” Your next best course of action is:
a) Provide support, offer resources, and file a report with the local police department
b) Provide support, offer resources, and document findings in the medical record
c) Notify social work and do not allow her to leave
d) Respect her wishes and omit finding from the medical record
Correct answer: b
Rationale: In this case the provider has no legal obligation to report the abuse (she is not a minor nor a vulnerable adult), and in fact doing so may damage patient-provider trust as well as place the patient at increased risk for violence at home. It is the provider role to create a safe and trustworthy environment, offer resources, and document findings objectively and meticulously in the medical record. If at a future time, legal documentation is needed, the charting will be retrievable and reliable.
Diane Muckenhirn MSN, FNP-BC, WHNP-BC
Sarah Priem BSN, RN
Published on January 15, 2013
Diane Muckenhirn has been an NP in women’s health since 1983 and is employed with Hutchinson Health in Hutchinson, MN. She is Adjunct Faculty at St Cloud State University, St Cloud, MN and is a preceptor for Nurse Practitioner students in clinical rotation. Past Chair and member of Rural Health Advisory Committee for the State of Minnesota.
Sarah Priem graduated from Minnesota State University, Mankato in 2008 with a Bachelors of Science in Nursing and spent her career as an RN working in acute care. It is in this setting of managing disease after its onset and progression that she developed a passion for preventative medicine and primary care. In 2010 she began her graduate work at Concordia University Wisconsin, Mequon, WI and will graduate in May of 2013 with her certification as a Family Nurse Practitioner.
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