he first time I discussed sex with a patient, I blushed. I felt awkward. But, then I realized my awkwardness is not enough of a reason to miss discussing something so important to a person’s health. 

When we take time to nurture our patients’ physical, mental, and social well-being in relation to sexuality, we witness a series of positive outcomes. By creating open and honest communication channels, we strengthen the provider-patient relationship and increase patient awareness of common sexual health issues.  

Sexual health greatly impacts our overall quality of life. From well-being and healthy relationships to sexually transmitted infections and sexual violence, sexuality is central is to being a human and therefore our health. We must make conversations regarding sexual health an expected part of primary care, especially for underrepresented populations. 

Sexual and gender minority (SGM) populations include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, intersex, non-binary or transgender. SGM patients often have providers who are inexperienced or uncomfortable with their patient’s sexual lives. 

Discussing sexual health history with SGM patients helps us affirm their identities and experiences, promote safer-sex counseling and risk-aversion practices, and offer preconception health guidance. 

Taking an inclusive sexual history  

We can’t assume behavior based on how someone identifies. That is why I use open-ended broad questions when using the “5 P’s” approach to take a sexual health history with my patients. I make sure to leave room for people to answer and ask any clarifying questions of their own. 

I start by telling my patients that because it’s so important, at least once a year I want to check in on your sexual health.  

Partners: Find out what type of sex your patient is having, and what their partners are like before you end up making assumptions about their behavior. I use straightforward questions like these to avoid offense: 

• Tell me about your partner or partners. 

• Do you currently have a main sex partner? Do you have more casual “hook-ups? 

• Does your partner currently have other sex partners? 

Practices: Finding out what types of sexual activity your patient is participating in can guide screenings and determine if PrEP, or pre-exposure prophylaxis to prevent HIV, is indicated. Try to avoid ‘yes or no’ questions. These can come across as judgmental. Try discussion points like: 

• What types of sexual activity do you have? 

• Tell me about the type of sex you’re having (and I’ll ask follow-up questions if they reference something I’m unfamiliar with, “can you tell me more about that?”) 

Protection Against STIs: Screening for HIV and STIs is an essential component of sexual health, for everyone, but especially folks who may be at higher risk, such as some men with male partners, folks with multiple partners, and some transgender women. Remember that we need to learn about behavior to determine risk. Asking open-ended questions can help you identify sites of exposure and other risk factors. Some examples of guiding questions include: 

• How do you protect yourself from HIV and other STIs?  

• Tell me about when you use condoms.

Past History of STIs: For patients who don’t know their partners’ history of HIV or STIs, or may not use condoms consistently, talk about preventative measures. You can advocate for safer sex by asking: 

• Have you ever been diagnosed with HIV or another STI?  

• When were you last tested?  

• Have you had any recent symptoms? 

• Would you consider being tested today? 

Pregnancy: We often blindly assume that our sexual and gender minority patients don’t want to have children, but it’s important to ask all of our patients about their plans for pregnancy or growing their family. Also, these decisions may shift over time, so I recommend checking in with patients every year to keep new information from slipping through the cracks.  

• Do you have plans for pregnancy?  

• If not, what are you doing prevent pregnancy? 

• If so, what questions or concerns do you have? Are you worried about fertility? 

Also, make sure to discuss sexual violence, as SGM populations often experience this at higher rates. I always introduce these questions, not just casually as though as I’m asking about someone’s sleep. I tell patients that screening for violence is something that we don’t always do a great job at in health care, but unfortunately it is something that affects a lot of people so I make sure to ask all my patients about it. I also stay away from the word “abuse,” which can be a loaded term. Instead I say:  

• Are you in a relationship with anyone who physically hurts or threatens you?  

• Have you ever been kicked, slapped, bit, hit, or otherwise physically hurt by anyone?  

• Have you been forced to have sex or participate in sex acts when you didn't want to? 

Getting comfortable asking these questions 

I encourage all leaners to practice these questions and conversations even before you go into a room. To feel more comfortable, I practice using appropriate language out loud beforehand, rehearse open-ended questions, and role-play different scenarios. 

One of the easiest ways to build comfort and trust with SGM patients is to avoid common assumptions. I begin by asking everyone for their preferred name and pronouns, as well as their sexual orientation and gender identity before we talk about their sexual history. I also try to keep myself updated on by learning from my patients. You can also refer to resources like the LGBT National Health Center or the PFLAG organization for more information. 

If you’re unsure or unfamiliar about something, just default back to open-ended questions like: “Can you tell me more about that?” or “Do you mind explaining that a little more?” It shows genuine interest and, since some things have different meanings to different people, and it allows your patients the space to explain something. 

Sexual health impacts our overall wellbeing too much to be ignored. If we don’t communicate the importance of safe practices, effective prevention, and healthy physical relationships, our sexual and gender minority patients will slip through the cracks. 

Let’s normalize these conversations and make these discussions a standard part of patient care.  

Originally published December 2021