1. T AKING A S EXUAL H ISTORY LGBTQ H EALTH C URRICULUM 8/29/15 Carrie Link, MD Smiley’s Family Medicine

2. O BJECTIVES – Y OU WILL BE A BLE TO … 1. Understand why & when to take a sexual history 2. Identify appropriate questions to ask patients 3. Identify barriers & how to deal with them

3. W HY ? Primary prevention Unplanned pregnancies >50% Safer sex - Hep B, HPV Prevention or treatment of sexual dysfunction 52% male 63% female Nusbaum, Hamilton. The Proactive Sexual Health History American Family Physician: 2002, 66,1705-1712.

4. W HY ?

5. DTC A DVERTISING

6. W HY ? Patient-centered 72% of women 6 73% want provider to bring it up Sexual functioning = longevity 7 Sexual & gender minorities ignored – huge opportunity Education Enhancing trust

7. W HY TALK ABOUT SEX ? Indicators of systemic disease DM CAD Medication side effects Community Health Childbirth, family support

8. W HY N OT ? Embarrassment No training Time Believe sexual history, sexual or gender identity is not relevant to health Making assumptions about sexual practices “I know she is married.” “He’s 65, he probably doesn’t have sex anymore.”

9. W HEN ? Take a sexual history if indicated by: 1. Symptoms 2. Medical illnesses DMReproductive CAArthritis DementiaGU surgeriesAnxiety DepressionCardiovascular disease 3. Prescriptions HormonesAntihypertensives Opiates Steroids Antiepileptics Anticholinergic SedativesAntidepressants 4. Routine wellness care

10. W HERE ? Take initiative Ask permission Use patient’s words, model as needed Respect privacy Don’t assume (partner, gender, MSM) Start with the medical In the ER?In the clinic.

11. S EXUAL H X 1. Contraception 2. STI’s 3. Sexual function Medical Health status PmHx & Meds Gender assigned at birth EtOH/tob/drug use Psychosocial Relationship/family status Partners Body types of partner Body parts of patient Abuse history

12. T HE B ASICS Sexually active? With what types of bodies? Men, women or both implies gender binary. Trans? What kind of sex? Contraception Do you want to have a child/become a parent? STI’s What are you doing to protect yourself from STI’s? Immunized to Hepatitis B/HPV?

13. M AKE N O A SSUMPTIONS http://www.lgbthealtheducation.org/training/learning-modules/

14. R EMEMBER - A CTIVE L ISTENING !!

15. S EXUAL F UNCTION ? Open ended questions Do you have any sexual concerns? How satisfied are you with your (your partner’s) sexual functioning? Is there anything about your sexual activity that you would like to change?

16. B ASIC S CREENING FOR S EXUAL F UNCTION Legitimize Importance Handbook on Female Sexual Health and Wellness, Assoc of Reprod Health Professionals Handbook, Kingsberg, S et al, 2011. “It is part of my routine to ask about sexual health as part of the well-woman visit. Do you have any concerns?” “Some studies show that as women age, they may have less desire for sex or decreased lubrication, which makes intercourse uncomfortable. Have you noticed any changes?” “It is part of my routine to ask about sexual health as part of the well-woman visit. Do you have any concerns?” “Some studies show that as women age, they may have less desire for sex or decreased lubrication, which makes intercourse uncomfortable. Have you noticed any changes?”

17. O PEN E NDED  DIRECT Getting aroused or turned on? Maintaining erections (if you want them?) Early ejaculation? Pressure from partners? Pain with sex? Lack of interest in sex? Having an orgasm? Do you think any of your medical conditions or medications are causing problems?

18. H OW ? Clumsy Conversations Tell me more about that Assume everyone does everything Avoid inviting a negative answer Instead of asking “Do you masturbate?” ask “Are you able to orgasm when you masturbate?”

19. B ARRIERS Combat with: Practice! Lifelong learning Develop a routine ask EVERYONE! Do the medical ?s first Awareness of implicit biases Multiple visits

20. O BJECTIVES – N OW Y OU C AN … 1. Describe why & when to take a sexual history 2. Identify appropriate questions to ask patients 3. Identify barriers & how to deal with them

21. A NY Q UESTIONS ?

22. R EFERENCES 1. Minnesota Department of Health STD Surveillance Statistics 2010 http://www.health.state.mn.us/divs/idepc/dtopics/stds/stats/stdsur vrpts.html http://www.health.state.mn.us/divs/idepc/dtopics/stds/stats/stdsur vrpts.html 2. Minnesota Department of Health HIV/AIDS Surveillance 2010 http://www.health.state.mn.us/divs/idepc/diseases/hiv/hivstatistics.html http://www.health.state.mn.us/divs/idepc/diseases/hiv/hivstatistics.html 3. National Cancer Institute CML Statistics SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2008/. http://seer.cancer.gov/csr/1975_2008/ 4. Nusbaum, Hamilton. The Proactive Sexual Health History American Family Physician: 2002, 66,1705-1712. 5. Association of Reproductive Health Professionals Handbook on Female Sexual Health and Wellness 6. Association of Reproductive Health Professionals Curricula Organizer for Reproductive Health Education (CORE). www.ahrp.org/corewww.ahrp.org/core 7. Robinson, Bean. Talking about Sex with your Patients presentation, December 2, 2010. 8. Fenway Institute, Training modules on GLBT sexual health