Talking to patients about sexually transmitted infections
Dermatologists discuss interview techniques for taking a sexual history and screening for sexually transmitted infections.
By Emily Margosian, Assistant Editor, January 1, 2023
Historically, dermatologists have played a key role in the diagnosis and treatment of sexually transmitted infections (STIs), many of which have skin involvement. What is presently the American Board of Dermatology was originally established as the American Board of Dermatology and Syphilology in the 1930s — a testament to the specialty’s long-term ties to the management of STIs.
Despite this historical link, present-day dermatologists may not always be comfortable asking patients questions about sexual behavior and STI risk factors. “Just like anything in medicine, practice makes perfect. It’s often the doctor who’s less comfortable talking about sex than patients,” said Kenneth Katz, MD, MSc, MSCE, FAAD, a dermatologist at Kaiser Permanente. “Studies have shown that doctors are more likely to think that their questions are going to offend patients when patients in fact want their doctors to ask if it’s relevant to their care.”
As new data suggest that the incidence of STIs in the U.S. continues to increase and remain high, dermatologists should be prepared to talk to patients about STIs and be comfortable taking a sexual history. “Dermatologists are on the front lines for recognizing the manifestations of some STIs, especially syphilis, genital warts, herpes, and some other rare STIs such as lymphogranuloma venereum, chancroid, and others,” said Erin Amerson, MD, FAAD, medical director of dermatology at Zuckerberg San Francisco General Hospital, and clinical professor of dermatology at University of California-San Francisco. “We must be comfortable asking these questions. The more you do it, the easier it becomes.”
STIs on the rise
Recent CDC data indicate a resurgence of STIs in the last several years. Latest estimates suggest that 20% of the U.S. population — or one in five — had an STI on any given day in 2018, and that STIs acquired that year alone cost the American health care system nearly $16 billion in medical costs.
“Recent STI trends are worrisome, and dermatologists will inevitably see more STIs in our practices than we have for the past 20 years,” said Dr. Amerson. “While we saw a crash in STI prevalence in the U.S. likely due to safer sex practices before the introduction of antiretroviral therapy for HIV infection, that trend has slowly reversed itself since the nadir in the early 2000s, particularly among men who have sex with men.”
“Recent STI trends are worrisome, and dermatologists will inevitably see more STIs in our practices than we have for the past 20 years.”
While not formally considered an STI, the ongoing monkeypox (mpox) outbreak has also underscored dermatologists’ responsibility to be vigilant in screening for emerging infections as the public health landscape evolves. “I think it’s safe to say that sexually transmitted infections are always going to be a major part of dermatology practice, especially as the trends change,” said Brian Ginsberg, MD, FAAD, a New York dermatologist. “For example, we just went through a period where we were seeing cases of monkeypox, which we’ve never really encountered before. It’s important that we become familiar with both new health conditions and new presentations of known conditions.”
CDC data show that the eight most common STIs in the U.S. are chlamydia, gonorrhea, syphilis, trichomoniasis, human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), HIV, and hepatitis B virus (HBV), with chlamydia, gonorrhea, syphilis, and congenital syphilis all increased from 2020 to 2021. “No doubt, some of that is going to land in dermatologists’ offices,” said Dr. Katz. “It behooves us to be aware of those data and be knowledgeable about how to take care of patients who present with those infections, both in terms of the infection itself and by providing preventative health services. History-taking in general helps us take better care of patients by enabling us to know what they might be at risk for.”
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Interview techniques for obtaining a sexual history
Dermatologists versed in taking sexual histories agree on several common themes when interviewing patients. “A few cardinal rules of approaching patients with sensitive questions are to make no implicit or explicit assumptions, prioritize gender neutrality when possible, and be prepared to offer an authentic apology if circumstances require it,” advised Klint Peebles, MD, FAAD, a dermatologist at Kaiser Permanente, and immediate past co-chair of the AAD’s Expert Resource Group (ERG) on Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ)/Sexual and Gender Minority (SGM) Health. “The words we use can make or break a productive therapeutic alliance. Our language can signal inclusiveness and understanding. On the other hand, our words can also signal the opposite.”
When asking questions, it’s important that physicians avoid stereotyping to avoid missing key pieces of information or alienating a patient. “For example, if you were to assume somebody was monogamous, then you’d miss a very vital part of their history. Likewise, if you assume somebody is only having sex with the opposite gender,” explained Dr. Ginsberg. “If a patient sees you as someone who is not open to them sharing that information, they’re not going to volunteer it either.”
According to Dr. Amerson, when taking a sexual history, it’s also important for dermatologists to use non-judgmental language that normalizes the concept of testing or screening. “For example, I might say something like, ‘We are seeing an increase in sexually transmitted infections in our community. As a result, we are asking all our patients about their sexual history. Would it be ok if I ask you some questions?’ Or, ‘We are seeing an uptick in sexually transmitted infections like syphilis in our community, and sometimes I worry about syphilis when I see a rash like the one you have. Would you be open to getting tested?’”
Dr. Katz agrees that it’s important for dermatologists to normalize the history-taking process. “Keep in mind that patients might not know that they have an STI, and they may not be expecting a dermatologist to take a sexual history, unlike maybe a primary care doctor for whom it might be more routine in their experience. I like to preface by saying something like, ‘I ask everyone who has a rash like yours some questions about their sexual history.’ Then I ask for permission, ‘Is that ok?’ I then keep questions relevant to my clinical decision making, and circle back by explaining how their answers affect what we’re going to do moving forward — what testing, what treatment, and what other recommendations I might have for them.”
“If you were to assume somebody was monogamous, then you’d miss a very vital part of their history. Likewise, if you assume somebody is only having sex with the opposite gender.”
Dr. Peebles also recommends keeping questions open-ended and rethinking some of the traditional guidance around sexual history-taking to avoid missing key pieces of information. “The typical way we are taught to begin a sexual history is by asking the question, ‘Do you have sex with men, women, or both?’ While the phrasing of this question appropriately normalizes sexual diversity to some extent, there are several pitfalls. First, the question assumes the patient is sexually active. The question also fails to contextualize the time course regarding current versus past behavior, the distinction of which could be critical depending on the clinical context,” Dr. Peebles explained. “Alternatively, one could ask the following series of questions: ‘Do you have sex?’ and if the answer is yes, then, ‘Are you currently sexually active?’ If the individual is sexually active, remember that sexual behavior is diverse, as are human identities. To be inclusive and to obtain comprehensive information about the individual in front of you, one could further ask, ‘What are the genders and bodies of your sexual partners?’ This acknowledges the spectrum of gender diversity and the critical point that anatomy is not defined by gender identity. When approaching further details of a sexual history, it is important to focus on the information you need to obtain and the precise questions that are required to get there.”
Often, physicians think of a sexual history as something that is limited to discussions regarding STI risks and management, said Dr. Peebles. “However, it is critical that we expand our conversations around sexual behavior beyond the related pathology and to be ‘sex-positive’ in our framework to avoid stigma. We often talk about normalizing these discussions, but ultimately that cannot be accomplished in the absence of an approach rooted in sex-positivity and empowering individuals that all consensual sexual expression is healthy. Conversations focusing on safe sex do not have to be limited to an STI diagnosis, or even prevention. Rather, these discussions can be routinely integrated into our dialogue with patients as we offer them the tools and confidence to live their best lives as authentically as possible.”
While missteps may happen, dermatologists can move forward during an interview by remaining flexible, non-judgmental, and willing to learn from patients. “I think it’s important to not appear surprised by any answers and ask patients about the terminology they use if you don’t understand it,” said Dr. Katz. “It’s going to be impossible to know all the terminology, some of which is non-clinical and a lot of which changes over time. It’s also important to apologize if you feel that you’ve misstepped or said something in a way that was taken wrong by a patient and just move on and recover. If you’re coming from a genuine place by establishing the reasons why you’re asking what you’re asking, I think patients will often forgive a lot and end up appreciating what you’re trying to do.”
The Five P’s approach
The CDC recommends the following starting framework for health care professionals looking to obtain a sexual history from patients:
Are you currently having sex of any kind?”
“What is the gender(s) of your partner(s)?”
“To understand any risks for sexually transmitted infections (STIs), I need to ask more specific questions about the kind of sex you have had recently.”
“What kind of sexual contact do you have, or have you had?”
“Do you have vaginal sex, meaning ‘penis in vagina’ sex?”
“Do you have anal sex, meaning ‘penis in rectum/anus’ sex?”
“Do you have oral sex, meaning ‘mouth on penis/vagina’?”
3. Protection from STIs
“Do you and your partner(s) discuss prevention of STIs and human immunodeficiency virus (HIV)?”
“Do you and your partner(s) discuss getting tested?”
“What protection methods do you use? In what situations do you use condoms?”
4. Past history of STIs
“Have you ever been tested for STIs and HIV?”
“Have you ever been diagnosed with an STI in the past?”
“Have any of your partners had an STI?”
5. Pregnancy intention*
“Do you think you would like to have (more) children in the future?”
“How important is it to you to prevent pregnancy (until then)?”
“Are you or your partner using contraception or practicing any form of birth control?”
“Would you like to talk about ways to prevent pregnancy?”
Improving competency when working with LGBTQ patients
While the basics of discussing STI risk and sexual history-taking apply across all patient populations, dermatologists should keep some additional considerations in mind when collecting information regarding a patient’s sexual orientation and behavior.
“‘I’d say it’s important to keep in mind specifically what you’re asking for. When we think about things like syphilis, it’s sexual behavior, not sexual orientation that is critical to stratifying risk,” explained Dr. Katz. “If it’s a male patient in front of me and I’m suspicious of syphilis, that patient’s sexual orientation is not really that important. That patient’s sexual behavior — and specifically whether that patient’s sex partners include other men — is really what’s important.”
Dr. Ginsberg also recommends dermatologists make it clear that their line of questioning is not out of interest, but because they want to provide medically appropriate care to the patient. “A good way to show that your questions are relevant, is to explain why they’re relevant. For example, if I’m examining somebody’s anus, I might say, ‘It’s possible that what I see here could be sexually transmitted. Do you ever have insertional anal sex?’ By preceding the question with the reason for the question, it gives me more permission to ask.”
When it comes to improving medical and cultural competency in LGBTQ health, seeking additional education can be a critical step. “I think the best way to become more comfortable at doing something is to do it. If you attend lectures on sexual and gender minority health or read CME articles about sexual and gender minority health, that’s often a good way to educate yourself about common terminology that may help you have more comfortable conversations with your patients,” said Dr. Ginsberg.
“I think it’s also important to ask colleagues who might be more comfortable for their tips and maybe even do some role-playing,” recommended Dr. Katz. “It’s important to remember that LGBTQ patients especially, but many patients overall, have had negative experiences in health care settings, especially when related to sexual health. Patients will bring those prior experiences with them, and we should be cognizant of that. We can’t make up for those past transgressions, but we can certainly try to do our best to make sure that they have more positive experiences moving forward.”
New CDC treatment guidelines for sexually transmitted infections
In 2021, the CDC updated their guidelines for treating sexually transmitted infections for the first time since 2015. Read more discussion of the updated treatment guidelines and key takeaways for dermatologists.