STI testing and how GPs can raise ‘sensitive issues’ with patients
Sexually transmitted infections (STIs) can affect any of our patients, and raising the topic of sex and sexual behaviour can be difficult. Read on to learn how you can get to the sensitive issues without causing offence or embarrassment.
Sexually transmitted infections (STIs) can affect any of our patients - young and old. However raising the topic of sex and sexual behaviour can be difficult. As most STIs are asymptomatic, diagnoses and treatment is largely dependent upon screening. So, how do you get to the sensitive issues without causing offence or embarrassment?
Consider 3 different scenarios:
- The patient presents requesting an STI test
This is straightforward. Most patients in this scenario will expect questions regarding sexual behaviour. Asking ‘Is there is anything you are concerned about?’ is often enough to allow the patient to discuss anything that they feel is relevant. Where information is scant, by explaining ‘I need to ask some personal questions to help guide what tests are best for you’ most patients will give verbal consent for a sexual history.
- The patient presents for an issue regarding a (semi) related topic
Some presentations can easily segue into questions about sexual health - indeed questions involving sexual practice may be a part of investigating a related presentation and arise in routine history taking. Some presentations where STI risk can be addressed are cervical screening, contraception, sexual function or urinary symptoms. Other ‘hooks’ include travel vaccination – ‘Hepatitis A and B can be sexually transmitted - have you considered having a STI test?’.
- The patient presents for something completely unrelated
This is probably the most difficult scenario to ask about sex and introduce STI testing. Some suggestions which may facilitate a discussion include:
- Use a previous STI diagnosis as a ‘flag’; an example would be enquiring how things have been since the treatment for chlamydia, and then suggestion another test
- Identify the patient as being part of a population at-risk of STIs i.e. RACGP Guidelines for Preventive Activities in General Practice recommends annual testing for chlamydia infection in all sexually active people aged 15-29 years (for both sexes). This can be used when suggesting STI testing for a person within this group. Eg. ‘Guidelines advise chlamydia testing for everyone under 30 - would you like one today?’ and ‘In pregnancy STI testing is recommended, would you like one today?’. Describing the recommendation for testing at a ‘population level’ rather than targeting the individual can minimises the stigma someone may feel when the topic of STIs is raised.
- Using props: Desk tools such as the STI/HIV Testing Tool are useful visual prompts to raise the topic of STI testing. Show the patient and ask them if they fall into any of the groups where testing is recommended; and would they like tests today? Using visual aids can normalise testing and minimise the stigma and judgment an individual may experience.
Dos and don’ts
- Don’t assume - ask
- Don’t assume a married man only has sex with women
- Don’t assume all HIV positive men identify as ‘gay’
- Vernacular/slang – if it’s unclear what the patient means - ask
- Beware of negatively phrasing questions
- Eg, asking a man ‘You don’t have sex with men do you?’ may be more likely to get a negative response compared to ‘Do you have sex with men/women or both?’
- Asking a pregnant women- ‘You only have one sex partner right?’ is less likely to get an honest response than ‘When was the last time you had sex with another partner?’
- Beware of judgemental language, e.g.:
- Instead of ‘prostitute’, ask ‘Have you been paid for sex’ or ‘engaged in transactional sex’
- Instead of gay/straight - ask ‘Do you have sex with men/women or both?’
- DO ensure Privacy: see patients individually, without partners, parents, children, friends
- DO assure confidentiality
- DO ask permission and only ask what you need to know
- DO explain why some questions are asked
- Only ask what is pertinent. For most patients an in depth sexual history is not required. Assessing what tests and what sites may be all that is needed. Numbers of sexual partners and so on may be collected at a later consultation should it be necessary.
4 simple ways to make the conversation flow
- Establish rapport
- Use visual resources - Posters; desk top tools and so on can encourage patients to ask for a STI test and also imply that the doctor is open to this discussion
- Give permission - by introducing the topic of sexual health and STI testing, patients will feel more comfortable discussing this in future
- Patients can often detect when a clinician is comfortable with sexual health and this may have an impact in patient discussions
Complete the ThinkGP STI management and contact tracing online learning modules to learn more.
For STI management tools, resources and guidelines visit the NSW STI Programs Unit.
Dr Catrina Ooi
Clinic 16 Sexual Health Clinic - North Sydney Local Health District