Obtaining a sexual history in MSM
Establishing patient trust is critical in evaluating men who have sex with men.
Clinicians must address the sexual health of their patients. This can be done effectively when the patient's sexual behaviors are discussed openly. We must feel comfortable with talking about sensitive issues, which may include sexual practices, sexual partners, and sexually transmitted infections, including HIV. By familiarizing ourselves with language that we, as health care providers, may not commonly use, we can develop successful patient-provider relationships. Obtaining a sexual history can be uncomfortable for even the most seasoned clinicians. Lack of understanding of gay culture, as well as subcultures, sexual practices, health risks, and terminology, can further hamper communication and promotion of safe sex practices.
Establishing patient trust is critical in evaluating this vulnerable population. Patients may become reticent and unwilling to share sexual practices if they believe that they are being judged or misunderstood. They may feel embarrassed about their sexual concerns and may be ambivalent about broaching the topic. Therefore, we need to choose our words carefully and know the current nomenclature regarding certain practices. Patient education and counseling are some of the cornerstone services that physician assistants (PAs) and nurse practitioners (NPs) can provide to patients. Communication is key in the caregiver-patient dyad.
Men who have sex with men (MSM) represent approximately 4% of the U.S. population. MSM are the most profoundly affected by HIV infection, and among races, African Americans are disproportionately affected. Although MSM represent a minority of the general population, this group accounted for 78% of new HIV infections in 2010. In addition, 52% of all people living with HIV in 2009 were MSM.1 Sexual health is a priority for these men and needs to be routinely addressed. Therefore, to improve the care of these individuals, we must ensure that efficient communication and understanding of language regarding specific sexual behavior is achieved.
As health care providers, we must provide these individuals with information that is useful to protect them from other sexually transmitted infections (STIs) and to prevent them from transmitting disease. One way this can be accomplished is to obtain an accurate sexual history from these men. A thorough sexual history is essential in understanding patient behaviors that will provide the framework for delivering care and education that is specific to their needs. Unfortunately, less than 40% of clinicians obtain sexual histories with patients.2 In addition, a recent study by Barber et al showed that general medicine health care providers do not take a sexual history, and therefore, rarely offer HIV screening.3
Homosexual men may have complicated histories that can include substance abuse and depression. Evidence has shown that gay adolescents (ages 18-24 years) have a greater risk for developing mental health problems, including sexual violence, physical abuse, depression, and suicide.4 This is further affected with the stigma of negative societal views often associated with homosexuality. This stigma may be experienced directly by a patient, or perceived. In other words, the patient may feel that the provider may have preconceived negative ideas or attitudes about homosexuality and/or HIV.5 This perceived stigma may hinder the willingness of the patient to share intimate details of his sex life for fear of being judged or looked at differently. Therefore, clinicians must interview patients with an open-minded, nonjudgmental approach. While obtaining the sexual history, the clinician must also assure confidentiality and privacy. Adequate time without interruptions must be dedicated to gathering a thorough sexual history.
The provider's office should be a welcoming environment. For instance, the waiting room should include a visible statement expressing that equal care is given to all patients regardless of race, ethnicity, and sexual preference. Brochures addressing concerns of the gay community should be available and accessible. Examination rooms can have posters and/or magazines showing same-sex couples, or material provided by HIV/AIDS organizations.