At a time when sexually transmitted infections (STIs) are on the rise, all providers need to develop skills in sexual health screening. New research shows these skills are lacking among many physicians, and there are other barriers to screening patients for STI risk factors.1
Sexual health screening in primary care settings often is lacking because providers have limited time at each encounter. It also is a low priority based on resources and reimbursement.
Another factor is that clinicians may not know how to obtain the information they need to assess a patient’s risk for STIs if the patient declines to freely talk about or bring up the subject. Some providers use soft skills to revisit the topic.
The authors of a new study found that clinicians who identified as women were more likely described as using soft skills to navigate hesitation or discomfort from patients during sexual history screening.1
Qualitative results showed that male physicians would describe asking the question about sexual history, and if the patient expressed disinterest, then the physician would move on, says Kelly W. Gagnon, PhD, MPH, lead study author and a post-doctoral fellow in the division of infectious disease at the University of Alabama at Birmingham School of Medicine.
“Female providers would use soft skills, where they would look for opportunities to ask the questions again — unless the patient [said], ‘Don’t ask me,’” Gagnon explains. “The gender of the patient didn’t matter.”
For example, one female physician told investigators that it was a little awkward for patients to mention their sexual history, so it was easier if she was the one who initiated the conversation. “But then there’s some who are a little bit hesitant about it. So, I’ll just kind of read into the patient and I go from there,” the physician said. “Depending on how the conversation is going, then I’ll probe a little bit more … I just try to tell them upfront whatever we discuss is between us.”1
Male physicians were more likely to report that if a patient expressed concern, they would drop the subject. “If the patient would not outwardly decline but be uncomfortable, the women physicians would move on to a different topic and try to reinitiate it,” Gagnon explains. “It was important for them to initiate [the conversation] because patients wouldn’t bring it up unless it was for erectile dysfunction.” Female physicians would intentionally return to sexual health questions after reading the patient’s body language and finding an opening to mention it again, she adds.
Gagnon and colleagues also found that providers were less likely to believe sexual health screening was needed if the patient was older. They harbored the false assumption that older adults were not having sex or that if they were in long-term partnerships, they were monogamous.
Culture and religion were listed as barriers to clinicians initiating sexual health screening. Patients from certain cultures and religions were believed to hold stringent standards on sexual practices — and so they were believed to be at less risk of STIs.
The people most likely to receive sexual health screening were younger and were gay and lesbian patients and cisgender women.
By focusing on certain groups, providers miss opportunities to identify risk factors for STIs. At the minimum, primary care providers and reproductive health physicians could ask patients these basic sexual health screening questions:
- Have you been sexually active in the last 12 months?
- If so, then with men, women, or both?
- Did you use protection during your last sexual encounter?
Asking even these brief questions is not a mandated reporting measure for Federally Qualified Health Centers (FQHCs), so when providers are faced with the tasks they must cover in a 10- to 15-minute patient visit, sexual history is low on their priority list.
“We haven’t reached standardization of sexual history for a variety of reasons, and discomfort is definitely one of them,” Gagnon adds.
Standardized screening questions may not be a panacea, either. For instance, a recent study revealed that when FQHCs assessed the effectiveness and accuracy of the two-item Patient Health Questionnaire for depression screening and generalized anxiety disorder screening from 2019 to 2021, the scores showed a low likelihood of depression or anxiety. This contrasted with published literature on screening outcomes, suggesting it may be more challenging than a few questions to screen patients for problems.2
“Researchers looked at whether doing those quality metrics with patients all the time was associated with decreased validity of the screeners, and that’s what they found,” Gagnon says. “Patients are not reporting accurately anymore because they’re reporting them so frequently.”
Many FQHC patients return every three months to see a clinician for medical management. If they are screened for anxiety, depression, and a half-dozen other measures at the same time, they may stop answering these as accurately.
Another reason why the short screening questions may not be as helpful is that it takes a comprehensive sexual health screening and history to understand each patient’s behaviors and risks, and comprehensive screenings are mostly not performed, Gagnon says.
Another tactic to screen patients efficiently and effectively for sexual history and behavior may be to provide questions on the patient portal, along with other medical questions. Patients could answer these on their phones. Or, patients could be asked to keep diaries of their behavior, although that method can be burdensome.
“We really need that comprehensive sexual history,” Gagnon says. “It’s good to have a conversation and not just have patients fill that out ahead of time.”
FQHCs and other reproductive care providers could offer patients a visit with a nurse who has been trained in sexual health to answer any of their questions. Nurses could provide comprehensive sexual health screening, and it could be scheduled separately from the patient’s general medical visit, Gagnon suggests.
Although many providers feel discomfort with sexual health screening, some also express interest in receiving additional training on soft skills.
“They want to know how to discuss it with patients and how to navigate that situation,” Gagnon says. “Research shows that patients generally want to talk about sexual health, but they don’t know how to bring it up.”
The reason some providers may hesitate to perform sexual health screening is because they may worry about offending their patients.
“It feels like a minefield to clinicians, especially if they have 10 to 15 minutes for the visit, and it’s a risk they might not be willing to take,” Gagnon explains.
REFERENCES
- Gagnon KW, Coulter RWS, Egan JE, et al. Patient and clinician sociodemographics and sexual history screening at a multisite federally qualified health center: A mixed methods study. Ann Fam Med 2023;21:395-402.
- Simon J, Panzer J, Wright KM, et al. Reduced accuracy of intake screening questionnaires tied to quality metrics. Ann Fam Med 2023;21:444-447.
At a time when STIs are on the rise, all providers need to develop skills in sexual health screening. New research shows these skills are lacking among many physicians, and there are other barriers to screening patients for STI risk factors.
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