Taking a Sexual History: Words Matter (Part 1)
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introduction[00:00] Introduction
Dr. Meena Ramchandani
Hello everyone. My name is Meena Ramchandani. I’m an infectious disease physician at the University of Washington in Seattle. This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs.
For this episode, we welcome two wonderful people that I'm very excited to speak with today. Barbara Wilgus is a Program Administrator for the STD/HIV Prevention Training Center at Johns Hopkins and is a member of the senior staff in the Division of Infectious Diseases at Johns Hopkins University School of Medicine. She’s a certified women's health nurse practitioner who specializes in reproductive health, STIs, and HIV.
Bambi Galore is an assistant training coordinator for the Prevention Training Center at Johns Hopkins and works closely with the LGBTQ and kink communities. They help to train providers on the importance of language. It is a distinct pleasure to have both of you on this episode. Welcome, and thank you for being with us today. Since we know each other well, I'm going to refer to you as Barbara and Bambi if that's okay.
Barbara Wilgus
That is perfectly wonderful.
why-is-it-important[01:15] Why is It Important?
Dr. Meena Ramchandani
So, let's first start by talking about the sexual history. Why is taking a sexual history important?
Barbara Wilgus
So, taking a sexual history is important for a wide variety of reasons. Number one being that a person's sexual health is one of the important parts of their overall health, and that kind of gets overlooked even though it is really a key part of all of our health. So not just related to how likely you are to have an STI or HIV, but a whole breadth of issues, not the least of which is that everyone should have a pleasurable and wonderful life as a sexual being and whatever that means for them. And the only way that a provider is going to know what is going on with someone's sexual health is, really the keystone, is taking a sexual history just like other parts of one's medical history.
And unfortunately, providers are still... I mean, younger providers are probably improving, but most providers are still not taking a sexual history. When we do our class, either online or in-person training, every time we do a survey at the very beginning that says, "A show of hands or show of Zoom poll, how many of you have had a routine visit in the past year?" Usually, and it's providers, so generally, a majority of people, like 80, 90%, have had some sort of routine exam. And the next poll we do is, "How many of you at your routine visit were asked any kind of sexual history?" And I actually even say “any kind of,” I set the bar real low, and every time, it has never failed yet, like 30% have been asked. And that's with the bar being, like, next to the ground, so low.
Dr. Meena Ramchandani
Why do you think that is? Do you have any insight into why so few providers are asking a sexual history, especially since it's a very important part of patient care?
Bambi Galore
If I may, I think one of the reasons is, is that there is a disconnect in the interconnectedness of the human body almost, that it gets set aside as this thing that you do versus a thing that impacts all these other aspects of your life and what's going on in other aspects of your life can impact your sexual health as well. And because sex is seen as something you do versus something that's a part of you, they don't feel that they need to ask the questions about it, not realizing that they could be missing a connection that could help them with something else going on medically.
Barbara Wilgus
And this is Barbara again. I also think along those lines of what Bambi said, providers in general or people in general actually, sexuality has been stigmatized, and I don't know if tabooized is a word, but I'm going to make it a word so tabooized for so long that it feels for both the patient and the provider, like something that is an uncomfortable thing to bring up, like the whispered secret in the room rather than just a thing, another part of your health. And so yeah, it is now getting more focus in medical and in health care provider curriculums, but for a long time, again, even the subject in schooling is kind of just swept over to the side. So, it's really a systemic issue that sexual health is just kind of set aside for the most part; it's something else instead of something fundamental.
Dr. Meena Ramchandani
That's really helpful. It sounds like a lot of providers are not asking sexual histories, not comfortable with sexual histories, and it's a really important part of patient care. We were just talking about how the 2022 STI Surveillance Report was just released and alarming concerns around syphilis, congenital syphilis epidemics in this country, and the highest number of cases that have been reported actually since 1950. And so what it signals to us is this urgent need for providers in all aspects of health care, no matter what background or specialty they might be, to have a really key understanding of how to take a good sexual history and not make assumptions about their patient who's sitting in front of them.
Bambi Galore
Absolutely. It's almost like clinicians forget that people sometimes dress up to go to the doctors, that they dress up when they come into the clinic. And so they just assume, based on an outward appearance, that they know what's going on in someone's life and you're not going to know unless you ask questions.
sexual-history-5ps[06:12] Sexual History 5Ps
Dr. Meena Ramchandani
The CDC has a guide to taking a sexual history, which can be really helpful for providers who want to learn more. Can you guys describe the 5Ps of a sexual history?
Barbara Wilgus
Yeah, and actually, I do want to give a shout-out to CDC’s A Guide to Taking a Sexual History because for the 2021 STI Treatment Guidelines update, they also completely renovated that space of taking a sexual history, and it's much more patient-centered and strengths-based, and there's a lot of role-playing, so you can kind of think to yourself, if this person walked in, you could practice what kind of questions you might ask or things like that. So, but to the 5Ps that's been a longstanding conceptual framework that is very helpful for providers. The 5Ps are partners, practices, protection from STIs, past history of STIs, and pregnancy intention. And, of course, we in the sexual health field love our Ps. So, we have always more Ps. Pleasure, problems, pride, and pronouns. Yeah, I mean, we can go on and on. But with the 5Ps, that is actually kind of getting at things that you would want to know in sexual history taking that would help you understand what someone's likelihood is of having an infection or needing to be tested for sexually transmitted infections and at what frequency and from what places on the body.
Dr. Meena Ramchandani
It's really helpful to have some sort of algorithm to take that sexual history because I think it helps to reduce some of that stigma. In talking to a patient, you can say, "I ask these questions of everyone. This is a part of my patient care. These are questions that we want to ask to be able to help you in terms of what I need to do to take care of you in a full way.” Bambi, any additional thoughts on this?
Bambi Galore
I would just say that it's one of those things to your point, that when you set up the parameters of what's about to be discussed, that's really going to help the conversation move because it's going to set the client up to know what's going to be talked about and get themselves mentally and emotionally prepared to talk about the subject matter. But it also opens up the air of like, "Hey, we're going to cover some stuff that may feel uncomfortable for you, may feel uncomfortable for me. Just laying it out there, this is part of your health, and that's why we're asking these questions. Now let's go through it, and if we stumble through it, we stumble through it together." And I don't know anyone who prefers to have someone just push through versus someone who's willing to be open about their own humanity.
Dr. Meena Ramchandani
That's a great way of putting it to make a patient to feel comfortable in that situation when you're going to be asking very intimate questions and things that they don't necessarily talk about with other people.
how-to-ask-questions[09:20] How to Ask Questions
Dr. Meena Ramchandani
I'm curious to hear more, your thoughts, in terms of providing examples of what are good ways to ask about partners, for example, or practices. Is there good questions to ask that providers can learn from your experience?
Barbara Wilgus
Sure. So, you need to ask very specific and sensitive questions. I think, first off, getting consent is a wonderful thing in all parts of sexual health. So, first permission, another P, getting consent for this information by introducing and saying, "I need to ask some questions about sexual activity or sexual history." Partners and practices, sometimes there is a lot of focus on how many partners, how many partners, which kind of leaves out the issue or the thought of quality of sexual relationship. So, there's a whole lot of difference between three people who are in a consensual relationship of some algorithm where everyone is aware of everyone else, everyone is tested, everyone is a closed loop, and there's communication between all partners than three people who one person is having sex with two people and doesn't know even who they are or isn't telling them about the other or things like that that happen in life. And so, there's a difference between just straight-up numbers and actually the quality of relationship or a situationship or a sexual contact.
So, in general, in practices, what I always say when I'm doing a training is you definitely want to know what parts a person is using on their body to have sexual contact to another person and what parts on their body are they having sexual contact with. And, in general, knowing how someone is using their parts. So, if someone's performing oral sex, what are they performing it on? And you may have to use the words that the people you see use because lingo is ever changing. I am 53 years young, and back in my day, back in the 80s or 90s or sometime back in there, Gen X people would hear of oral/anal contact or analingus being called tossing the salad, which still mystifies me because I don't understand what one has to do with the other. The terms today are very different, and I don't know if we can use salty language. But just ask your patient, what's the term for... How do you describe oral/anal contact? And see what they tell you because it's always changing. Bambi has a good way of describing how to ask people about practices.
Bambi Galore
Yeah. Well, I wanted to say to the point that you were making earlier, so much has been put on quantity. How many people, how many things when really, it's quality. The quality versus the quantity is really what's going to matter. So if someone's going to be deemed with that horrible label, in my opinion, of “high risk” because I think there's just a lot of baggage that comes with that term. But to Barb's point, there is a lot of change in language, and you can ask someone what they're doing, and they may say something like, "Oh, I do the fruity loop." I don't know what that is. That's something I just made up. But if someone comes to you asking, "Well, what does that mean to you?" Someone may say, "Well, I do scat play." Well, “What does that mean to you?” because that could mean a whole mess of things figuratively and literally, but it really depends on the person. So finding out, “What does that mean to you?” opens up the door for them to then explain without being an educator as to what activities they're engaging in. Because that's one thing that often if people are in marginalized sexual communities, one of the apprehensions they have is they feel that when they come in, they're having to be an educator, that they're not just being able to be there as a patient. They're being there as a teacher. So, to that point, you don't want to fake it until you make it when it comes to what activities they're doing. But asking “What does that mean to you” allows more communication around the activity to be expressed without it being like, “What is that? What do you mean?”
Dr. Meena Ramchandani
That's really helpful. That's a great overview. So, keeping really an open mind, asking patients what they mean, allowing patients to talk a little bit more about their sexual practices.
Barbara Wilgus
And in general, asking about partners too, you want to know, again, who they're having sex with and what organs are being had sex with. I have a joke because there are lots of, but it's a serious joke, but there are lots of— what is it when you use initials? Acronyms. So, like MSM meaning men who have sex with men, or whatever. And when you look statistically, it's really if YHSWP is actually the thing that you want to know about, if you want to know someone's likelihood of an STI, because if You Have Sex With Penis, there's always a higher risk than if you are not having sex with a penis in whatever orifice or whatever manner. So, in general, whether or not someone has a penis doesn't tell you anything about their gender.
Also, just when I'm asking about partners, I just kind of start with, like, “Who are you having sex with?” And sometimes people are like, "John Doe." I'm like, "No, no, not specifically with a name. Just in general, like “Who do you have sex with when you have sex? Do you have sex with men? Do you have sex with women? Are any of your partners trans?" When I ask you about men or women, that's also not getting at whether or not a partner is trans. So, actually, it would be better to say, "Are you having sex with cis women, cis men, trans women, trans men, nonbinary? What's going on? Who do you have sex with in general?" And just whatever they say.
Another really simple umbrella ask that I loved that a trainee once had said in doing a kind of mock sexual history taking. And my mock patient was so thrilled also with the question that they actually almost broke character and started telling him, but he said, "I need to ask some questions about sexual activity. Now, when I say sexual activity, that can mean a whole lot of things to a whole lot of different people, sexual activity. So, what does that mean to you? What does sexual activity mean to you?" And, because there are lots of people who don't think that oral sex is sex and don't think that anal sex is sex. And so really somebody saying, "I'm not having sex," they could completely be having oral or anal sex, sexual contact.
a-brave-space[17:09] A Brave Space
Dr. Meena Ramchandani
These questions can be very sensitive for patients. How would a provider create a safe space, that comfortable space for talking about these intimate questions that might be uncomfortable for patients?
Bambi Galore
I would push towards setting up for a brave space. A safe space can often feel tumultuous because people have been in places that have been labeled safe spaces, and then information got out, or someone took something and twisted it. So, even that term itself has become almost like a point of contention for some people. Whereas when you ask someone to come into a brave space, you're asking them to be vulnerable. You're saying, "I know that what we're about to talk about it's going to be hard, and I'm asking you to be brave in this space and share with me."
So, giving the explanations for why you're asking the questions can help set up to get honest and open answers. But again, I work with marginalized sexual communities. A lot of people in those communities get asked inappropriate questions by inappropriate people at inappropriate times. So even though the questions are being asked in an appropriate way by an appropriate person, it can still cause them to react from those past experiences. So, setting up the groundwork of, "Hey, we're going to talk about this," back to that, like, you can have one conversation. "This is going to be uncomfortable. This may go over some things that you don't share often. I'm asking this to be a brave space where you share this with me so that I can give you the best care possible."
Barbara Wilgus
I think also setting up a space before even the patient gets to you. So, the second somebody walks in the door of a clinic, there can be an air of either this is not a place where I want to talk to anybody about my sexual health, or this is a great place for me to talk about my sexual health. So right even before the person sees the provider, if the front desk staff seems judgy that can shut somebody down long before they get to the provider. So I always tell people to kind of survey your clinic area and just think about what things might be helpful or not helpful as far as letting somebody know that this is a place where my sexual health is important.
Pamphlets in the waiting room. I love… well, we'll talk about resources. I'm going to assume we're talking about resources towards the end. But pamphlets about relationship negotiation and things like that, advocating for yourself, self-esteem building things, on top of the usual suspects of reasons to get extragenital testing or things like that, you know. Those are all things that can be around information in the waiting area. But then, in general, even the registration forms can make a difference. And certainly, the first face you see, being an open and welcoming face, even if it's not the face of your provider, is very helpful too.
Bambi Galore
And to that, if you have those forms, especially ones that ask for pronouns or ask for names that you… chosen names, actually using that information because, unfortunately, sometimes that trust can be broken before even entering to the room because when you are someone who is in the trans or nonbinary community, and you're like, "Wow, here's a place where it wants to know what I identify." You assume if you're filling out a form, it's because they're going to use that and then they don't, you've already broken the trust in the system.
Dr. Meena Ramchandani
I really like the idea of setting up a brave space and then also thinking about the clinic as a whole. And that patient becomes your patient as soon as they enter that door. And so, creating this brave space all around can really make a patient feel comfortable in terms of thinking about their sexual history in all aspects of their care.
in-time-limited-settings[21:08] In Time-Limited Settings
Dr. Meena Ramchandani
Sometimes, a practice or a clinic can be quite busy, especially if you're in urgent care, the ER, a clinic where there's just a high number of patients being seen and medical needs to attend to. Do you have some concrete advice for providers to fit in a sexual history into those patient visits? Any questions that you'd prioritize to be efficient? Especially when time is limited?
Barbara Wilgus
And I'll especially say with emergency rooms and urgent care that is a key place where people come for a wide variety of concerns. And, if someone comes into the emergency room because they've been run over by a bus or they just broke their arm in two, okay, I can give a pass to not taking a sexual history then. But, if somebody comes in with a fever, could it be COVID? Sure, it could be COVID. Could it be acute HIV? Sure, it could be acute HIV. You're not going to know unless you take a sexual history. Or, is that weird rash contact dermatitis or is that weird rash syphilis, secondary syphilis? So, in the absence of actually understanding more about the whole patient, that's where it really becomes important. But yes, you have to ask a whole lot of things.
So, I would say if there was one kind of overall question, at least to start the conversation would be again, getting consent saying, "I need to ask a few questions about sexual activity, which can mean a lot of things. Are you sexually active?" And they could say yes or no. That's a close-ended question, which isn't great. But then follow it up with, again, "What does that mean to you, being sexually active or not?" And then people will answer. Whatever the open-ended question, people will answer however they answer. It could be, "Well, I'm not sexually active because I’m not… nothing is going in my vagina." And then, hopefully, the provider would understand that maybe they should ask a few more questions, like, “Is something going in somewhere else?” Or things like that. If there's only one question or a very limited amount of time, which I do understand in an emergency room setting, there is a limited amount of time, but at least getting the door open and then figuring out whether the sexual history needs to be involved in that current visit.
Bambi Galore
I will say that I once had to go to the emergency room, and I was asked the question, "Is there anything about your sexual experience that we should be aware of? Is there anything about your sexual history that we should be aware of?" Because I was coming due to something that was of a sexual-ish nature. We don't need go into that story, but it was one of those things where it did give me an, "Oh, actually, let me inform you of these bruises because they were consensual; they were from this thing, but I could understand where in a different light with different information, it could set off alarm bells." So, asking, even just like, "Is there anything I should know?" will sometimes elicit a response if you truly have only one question. If you can only ask one thing, "Tell me one thing. Is there one thing I need to know?" Just putting it out there will sometimes be enough to elicit the information that you need to move forward.
providers-most-common-questions[24:24] Providers Most Common Questions
Dr. Meena Ramchandani
Within your trainings or even outside of your trainings, what is the most common question you get from providers about taking a sexual history, and how do you usually answer this question?
Barbara Wilgus
Other than how do I do it? In general, by the time people come to taking a sexual history course, they're not being forced to. They actually really do want to improve. And so, in general, I find that people tend to want to be sure of their language when they're asking about practices or want to be sure that they're asking things the right way. We have a section in our talk on gender-inclusive language, which is of benefit for trans patients or not, but trans patients may or may not want to talk about their parts in biologic terms. Cis patients may not want to talk about their parts in biologic terms. Sometimes people just don't want to talk about their vagina or penis or whatever part in any kind of term that's biologic.
So, sometimes, just kind of the art of medicine is also a little bit talking to your patient and finding out what words work best for them to describe their body. And so there's a lot of walkthrough and practice in how would I best say this? And we can give as much feedback in my limited experience or even Bambi's limited experience, and that might work or that might not, depending.
Dr. Meena Ramchandani
Can you tell me a little bit more? Can you give some examples of the right way potentially to ask these types of questions, things that we haven't already covered?
Bambi Galore
Well, I was going to say it's not so much that I find with the people who come to our trainings necessarily what questions because they are like, "I can go to the CDC, I can get a list of questions. I can find out." I see a lot of people having their aha moments around realizing their own unconscious biases and their own fear over, "Well, if I'm working with communities that do things that don't align with my own moral or ethics, how can I serve them in a way that benefits them without, like, in some way encroaching on my own beliefs?” And explaining the difference between morals and values and understanding that you can see someone for the value that they have in their lives. And it doesn't mean that you have to be like, "I'm A-okay with everything you're doing." But you can still give them the care that they need, and for a lot of them, it's getting over that, "Oh, that's why that matters. This is why it matters that we use proper pronouns with the person. This is why it matters that I ask them these questions about these activities that I might find morally reprehensible, but it doesn't matter what my morals are. It's about making sure that they get the best health care that they can."
resources[27:24] Resources
Dr. Meena Ramchandani
If providers wanted to learn more about taking a sexual history, what are some good resources you'd recommend?
Barbara Wilgus
Well, I always recommend the Prevention Training Center trainings, including ours, but online resources, I love the National Coalition for Sexual Health. They have a toolkit for health care providers, but also, they have patient-facing materials too. They're one that has the pamphlet on advocating for yourself in a relationship, like ways to make sure you're getting what you want out of your sexual relationship, and/or five tips to sexual health or things like that. And they also have a good extragenital... like understanding what extragenital testing is and why I should be getting it if I need it. So, National Coalition for Sexual Health, I really like their resources. The CDC, again, they updated… they kind of did a whole floor-to-ceiling renovation of their sexual history taking section in the [2021] STI Treatment Guidelines. And I really like it now because it has really good sections on goal setting. It has a focus on goal setting for what do you want your ideal sex life to be because we all want our ideal sex life, whatever that may be, and whomever it may be with. So, it has a better way of addressing that or thinking about that as a provider. And then the American Sexual Health Association, ASHA. Their website also is a good resource, really again, more for patient-forward materials as well.
Dr. Meena Ramchandani
That's really fantastic. Thank you. Bambi, anything to add?
Bambi Galore
No. Barb is the resource queen, so if there's information to be found, Barb knows where to find it, so, she's who I turned to.
Dr. Meena Ramchandani
Thank you. That was awesome.
Barbara Wilgus
I have to say, I did a talk recently about really just what is sexual health, like a whole stem to nuts. It had everything from screening guidelines to taking a sexual history to whatever. But just in setting up my slides, I like to sort of reframe myself periodically. So, I just started by just doing a Google search of “What is sexual health?” And it was amazing because there's this awesome ongoing Wikipedia article on sexual health that has the entirety of WHO’s position statement, which back in 2006 was a radical statement. And it's still a radical statement that people should just have a joyful and wonderful sex life that they want to have without being persecuted for it. And all kinds of different resources. One of which I'm going to give a shout-out to, not in our region. I'm going to give a shout-out to the Minnesota Department of Health. They have whole characteristics of a sexually healthy person on their website. And it is just talking about advocating for yourself, to get regular screenings if you need to, to talk to your partners about your relationship and your sex life. And it's just amazing and very holistic, like talks about the spirituality of a sexually healthy person. So I'm like, shout-out Minnesota.
Dr. Meena Ramchandani
Yeah, that's awesome. I'll have to check that out. Wow.
Dr. Meena Ramchandani
Thank you, Barbara and Bambi, for joining us today. It’s been an absolute pleasure to speak with you on these important topics. For our audience, please tune in to our next episode where we welcome back Barbara and Bambi to continue our discussion on words matter.
credits[31:13] Credits
This podcast is brought to you by the National STD Curriculum, the University of Washington STD Prevention Training Center, and is funded by the Centers for Disease Control and Prevention. Transcripts and references for this podcast series can be found on our website, the National STD Curriculum at www.std.uw.edu. Thank you and have a wonderful day.