Health care providers can play a key role in supporting their patients – both in having healthy and positive sexual lives and in taking care of their sexual and reproductive health. Part of this work means considering sexual health care as integral (rather than marginal) to health care in general. It also means recognizing the diverse experiences of sexuality and gender, based on disability, sexual orientation, gender identity and expression, class, race, religion, ethnicity, and along other lines, and by taking these experiences into account when we provide health care.
How can we proactively and routinely address sexual health with patients?
Increasing the frequency of when we discuss sexual health with patients or clients can substantially improve sexual health care. It can lead to earlier identification of issues they face, supportive interventions and crucial information sharing. It also means more opportunities for preventive care, such as immunization, STIs and other important tests, and counseling on safer sex.
Health care providers who are open to addressing sexual and reproductive health regularly can develop greater competence in dealing with issues as they come up. One important way to get the information we need to support our patients is to discuss sexual health history or develop a routine way to include open ended questions meant to encourage people to bring up their sexual or reproductive health concerns.
Things to keep in mind
Generally speaking, questions about sexual health should be asked routinely, in a matter-of-fact, yet sensitive manner
If you believe someone may feel uncomfortable discussing their sexual history, an explanation or linking your questions to the person’s medical history may be helpful. Note that asking, “What sexual concerns do you have?” implies that many people have sexual concerns and that it is common to discuss them with one’s health care provider!
You might say “Sexual health is important to overall health so I always ask patients about it. If it’s okay with you, I’ll ask you a few questions about sexual matters now.” Or “Many people with depression notice a change in their sexual function. Have you noticed any change?”
Communicate clearly, openly and make the conversation interactive
In discussing sexual behaviours, make sure you are clear and that your patient understands you, including when you use medical terminology.
How to make your practice inclusive
Sometimes being inclusive (or not) can be as simple as an intake form. Here are some questions an inclusive in-take form might include. Source: National LGBT Health Education Center
Preferred name (if different from the one on official documentation): _________________________
Preferred gender pronouns:
Do you think of yourself as:
Female-to-Male (FTM)/Transgender Male/Trans Man
Male-to-Female (MTF)/Transgender Female/Trans Woman
Genderqueer, neither exclusively male nor female
Additional gender category/(or Other), please specify:_____________________
What sex were you assigned at birth on your original birth certificate? (Check one)
Ambiguous/intersex : __________________________
Decline to Answer
Do you think of yourself as:
Straight or heterosexual
Lesbian, gay, or homosexual
Something else, please specify: ____________________________
How we conduct conversations with patients can signal what we are open to discuss (or not) or narrow the scope of answers we get. Here are some tips to help you develop your ‘script’ for a sexual history intake or to help you review your forms to make sure you are not missing crucial information.
Non-heterosexual sexualities are erased or invisible in health care settings: Whether we are talking about intake forms, medical training, medical texts, health resources, pamphlets, or health care providers, often, heterosexuality is assumed.
Tip: Do scan your work setting, office space, the forms you use, your practice habits and the trainings you pursue, to assess how to make sure you offer the best possible care for people of various sexual orientations, whether you knowingly have patients who identify as LGBQ or not. Chances are, you do.
Evaluate your assumptions, including the ones about who you believe you are seeing in your practice, seek out information on risk factors associated with LGBQ patients, work towards building your knowledge of relevant LGBQ health care and basic human sexuality (maybe by enrolling in continuing education courses on human sexuality), modify medical intake forms and interview practices (including how you take a patient’s sexual history), review staff training and office procedures, and become familiar with available tools and resources (including pamphlets and written material to offer your patients).
Health care providers, even well-meaning ones, make assumptions about their patients, the relationships they are in, and the services they need. Heterosexism exists when heterosexuality is expected and assumed (unless and until people state otherwise).
Tip: Ask open ended questions about your patients’ partnerships and take cues from them about how they refer to their partners/families/romantic relationships. Same goes for what kind of services they may need.
Better wait to hear if the person mentions their wife or husband before defaulting to those terms. In the meantime, you can ask open ended questions like “are you partnered or are you sexually active?” or stick to more neutral terms like “partner.” If your patient mentions a partner, you can ask if the partnership is monogamous or not, opening up the conversation if the person has multiple partners. Same goes for assuming what forms or tests or screening may be necessary, only based on an assumption of heterosexuality.
Health care providers sometimes assume that a patient’s sexual orientation and sexual behaviours can be identified by the way that they look or the information that they’ve provided on an intake form.
Tip: Ask questions like “Are you sexually active? If so, with men, women, or both?” or, alternatively, “if you were sexually active, would you be with men, women, or both?” Asking for this information in clinical settings is a critical step that can improve patient-provider interactions because sexual practices, like other health behaviours can affect physical and emotional well-being. Asking these questions also signals that you are open to talking about health concerns that may be unique to your patient’s sexual orientation.
There are important health reasons to ask about sexual orientation. Although there are no LGBQ-specific diseases, clinicians must also be informed about LGBQ health because of numerous health disparities that affect members of this population: for example, higher rates of avoidance of routine health care, which can mean being less likely to get preventive services for cancer (like vaginal or anal pap tests) or may impact the choice of a treatment plan; or specific risk factors for certain STBBIs; or how having to navigate homophobia, transphobia, etc. takes a toll on people’s health and well-being and/or can also impact what kind of resources they have available to them.
Of course, how the question is brought up matters! The people we care for can certainly mirror our discomfort. When you ask them about their sexuality – and you are embarrassed – that awkwardness can be transferred to the person you are talking to. The best way to bring up a question or issue touching on sexual or reproductive health with anyone is to ask your question in as plain terms as possible. Ask and answer questions as you would if you were discussing an allergy or a stomachache with your patient.
Health care providers sometimes conflate sexual orientation and sexual behaviours. Sexual expression/behaviours may not always align with self-perceived sexual orientation and this can mean missed opportunities for screening, for tests, for diagnoses, and can generally hold back the therapeutic relationship.
Tip: To have a complete understanding of a person’s identity and behaviour, a health care provider needs to explicitly ask for both. It is important to avoid assuming certain behaviours and/or needs based on sexual orientation alone.
This means being thorough when taking a sexual history and not skipping questions or tailoring our questions to what we think is relevant based on how we “assessed” someone.
In general, creating a safe environment for taking a sexual history is similar in LGBQ and heterosexual patients. Same goes for trans or gender diverse people. Strive to be open minded, nonjudgmental, patient, tactful, respectful and assure people that their privacy and confidentiality will be maintained. Keep in mind that many LGBTQ people may approach a clinical interview with greater anxiety and caution and some information may not be shared until trust is established.
For example, do not assume a woman who identifies as a lesbian never has or had penile/vaginal or anal sex, or that a man married to a woman never has sex with other men, or that someone does not need to be screened for HPV, to be counselled on birth control options, to get tested regularly for STBBIs (including HIV) or to be given information on safer sex options.
LGBTQ-positive programs, clinics or providers may be difficult to access, particularly for individuals living in rural or remote areas or requiring specific services or treatments. In the same vein, health care providers and clinics known specifically for their positive work within LGBTQ communities are in high demand, which can lead to long wait-times or the disappearance of services when someone retires or moves.
Tip: LGBTQ people are represented in every demographic group: they are old, young, from communities of color, women, disabled, refugees, working class, people of faith, homeless, incarcerated, head of families, pregnant, etc. They may need mental health services, heart surgery, abortions, STI tests, prenatal care, cancer treatment, etc. They live in urban centers but also in smaller towns, rural areas, or reserves. It is important that health care providers do not assume that LGBQ communities can only be found in urban centers, or only seek services in specific clinics. Both preventative and therapeutic health services should be prepared to address the specific needs of LGBTQ people and communities, as well as being generally welcoming of diversity so people can share important information about themselves with their health care provider.
For example, this can involve actively supporting the creation and implementation of LGBTQ programming/services in your area. It can also mean not having to rely solely on specialized health care centres or health care providers. Having to do so can impact access to care, especially if they move, if wait lists are long, or if the provider moves or retires. It also includes making sure that we assess our practice and educate ourselves to become competent health care providers for LGBTQ patients.
When engaging with health care providers, LGBTQ people often feel required to act as educators, correcting misinformation and providing appropriate resources. This can be incredibly difficult to do when sitting on an exam table.
Tip: Patients shouldn’t have to do all the work when they come to you for help. Not all health care providers can become experts in LGBTQ health, but it is important to take the time to learn how to offer affirmative care to all patients and learn how to address population specific issues.
LGBTQ health adds up to about five hours of clinical training in Canadian medical schools. Without formal instruction, it is important for providers to turn to national guidelines and resources that are offered by organizations dedicated to offering affirmative and culturally-competent care to LGBTQ patients.
If you feel like you are lacking the right information or training to tackle a specific issue, be respectfully upfront about it and see how you can explore the topic or research options with your patient without putting an extra burden on them. Make them your partner in your quest for the best possible options and care with the understanding that you can seek out the basic education/language/issue on your own.
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