1. Mature Sexuality: Sexual History-Taking Association of Reproductive Health Professionals www.arhp.org

2. Expert Medical Advisory Committee Jean Fourcroy, MD, PhD, MPH Kirtly Parker Jones, MD (chair) Louis Kuritzky, MD Sharon Schnare, FNP, CNM, MSN Michael A. Thomas, MD

3. Learning Objectives Understand why assessment of sexual function should be included in the health care of middle-aged and older adults Incorporate assessment of sexual function and risk for STIs into routine health care of mature adults more…

4. Learning Objectives (Continued) Identify factors that may affect sexual function in older men and women Provide appropriate treatment, counseling, or referral to patients experiencing problems with sexuality

5. What Is a Sexual History? “That portion of the medical, surgical, and/or psychiatric conditions or circumstances that might compromise the sexual and reproductive functioning of an individual.” Sickle MA, Rosenstock H. The Female Patient. 1999.

6. Why Take a Sexual History? Sends a message about interest in quality of life Opens the door for patients to discuss issues of concern

7. What Are You Looking For? Risk for genital infections Sexual or reproductive concerns Genital or reproductive disorders Psychosocial concerns Level of sexual education/knowledge Sexual traumas, abuse, or injuries Contraceptive use or needs Sickle MA,Rosenstock H. The Female Patient. 1999.

8. Barriers to Taking a Sexual History Sickle MA,Rosenstock H. The Female Patient. 1999.; McCaffee, K. SIECUS Report. 1998.; Merrill, JM. South Med J. 1990. Younger age of clinician Patients don’t discuss sex unless prompted Providers embarrassed to ask about sex Providers lack adequate training

9. Creating a Positive Atmosphere

10. Who Should Participate? Ideally, only the patient and clinician Chaperone if necessary Family members and friends NOT allowed

11. When is a Chaperone Appropriate? Clinician has no previous knowledge of the patient or rapport established Patient is litigious Patient is in some way impaired Patient acts or speaks in a sexual manner

12. Using an Interpreter Use an interpreter who works for your facility and who has appropriate experience Assess the cultural appropriateness of having interpreters work with clients of the opposite sex Avoid having family members interpret

13. Respect the Patient’s Privacy “Tell me only as much as you need me to know.” “If you do not want specific information noted in your chart, let me know.”

14. Reassuring the Patient “Other patients have shared concerns about sexual activity, such as sexual satisfaction, difficulty achieving erection or orgasm, masturbation, pain or other specific kinds of sexual activity. I would be happy to discuss these or other issues with you. If I can’t answer your question, I’ll find someone who can.”

15. Initiating a Sexual History “Tell me about your sexual activity.” “On a scale of 1-10, how would you rate your sex life? What would you have to change to make it better (a 10)?” “Do you have any concerns about your sexual life that you would like to discuss?”

16. Discussing Sexual Activity “I need to ask you some very personal questions so that I can provide complete care for you. These questions are important to help me examine you better and to determine where I may need to check for infections. If you do not wish to answer a question, tell me. I respect your right not to share information with me.” more…

17. Discussing Sexual Activity (continued) more… “Are you currently sexually active?” “Do you have a sexual partner?” “Do you have sex with men, women, or both?” “Tell me about your sexual activity.” “Do you masturbate or self pleasure?” “Are you sexually satisfied?”

18. Discussing Sexual Activity (continued) “Do you have orgasms?” “Do you have pain with sexual activity?” “Does your partner(s) have pain with sexual activity?” “Is there anything you would change about your sexual activity?” “Do you have any sexual concerns?”

19. Menstrual & Obstetrical History Age of onset of menses Last menstrual period History of unprotected intercourse Length, regularity, and periodicity of menses

20. Pregnancy and the Perimenopause “Do you plan to become pregnant?” “If so, how soon would you like to become pregnant?” “If not, how are you and your partner protecting yourselves from pregnancy?”

21. Assessing STI Risks Evaluate all patients for risks of sexually transmitted infections (STIs), including AIDS. Don’t make assumptions

22. Effects of STIs on Sexual Expression Dyspareunia Prostatitis Chronic pelvic pain Psychological and emotional disturbances Effects of STIs

23. Assessing STI Risk “Have you ever had a sexually transmitted infection?” “What steps or precautions do you take during sexual activity to prevent transmission of diseases?”

24. Assessing STI Risk “How many sexual partners have you had in the past 12 months?” “Have you ever used IV drugs?” “Have you ever had a blood transfusion?” “Have you ever experienced burning when you urinate?”

25. Assessing Prostate Health “Have you had any pain when you defecate or when you ejaculate?” “Have you felt the urge to urinate frequently or had dribbling when you urinate?” “Have you ever had any lower abdominal pain?”

26. Assessing for Hepatitis “Have you had yellowing skin or eyes?” “Have you had upper abdominal pain, light-colored stool, or dark urine?” “Has any friend or family had hepatitis?” “Have you ever been told you had a liver problem/hepatitis?” “Have you been vaccinated for hepatitis?”

27. Assessing Alcohol & Drug Use “How many drinks do you have each day? Beer, wine, or hard liquor?” “Is alcohol or drugs interfering with your life?” “Does your use concern you or your friends and family?” “Have you gotten into trouble because of drug or alcohol use?”

28. Assessing Medication Use “What prescription medications are you currently taking?” “What over-the-counter (non-prescription) medications are you taking?” “Are you taking herbs, vitamins, or supplements?”

29. Assessing Abuse “Have you ever been forced to have sex against your will?” “Did anyone ever touch you, or make you touch them, in a way that made you feel uncomfortable?” “Has anyone ever battered you or hit you?” “Do you live with anyone who verbally abuses you?”

30. Assessing Medical/Surgical Trauma “Have you had any injuries to your genitals or surgeries on your genitals?” “Have you had testicular or prostate cancer?” “Have you ever had surgery on your reproductive organs, such as a hysterectomy?”

31. Making Referrals “Some of my other patients with this experience have found it helpful to discuss this issue with a psychologist/sex therapist. Have you ever thought about doing that?” “Would you be interested in seeing a psychologist/sex therapist?”

32. Making Referrals Reassure the patient Emphasize your ongoing involvement in the patient’s care Follow up with the patient on his/her next visit

33. Appendix

34. Expert Medical Advisory Committee Jean Fourcroy, MD, PhD, MPH Fourcroy Consulting Bethesda, MD Kirtly Parker Jones, MD (chair) Professor, Department of Ob/Gyn University of Utah Health Sciences Center Salt Lake City, UT Louis Kuritzky, MD Clinical Assistant Professor University of Florida Gainesville, FL more…

35. Expert Medical Advisory Committee (Continued) Sharon Myoji Schnare RN, FNP, CNM, MSN, FAANP Clinical Instructor Department of Family and Child Nursing University of Washington Seattle School of Nursing Olalla, WA Michael A. Thomas, MD Director, Center for Reproductive Health University of Cincinnati Cincinnati, OH