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Despite 20 years of HIV/AIDS, despite blatantly sexual content in prime time television programming, despite adult-content shows like HBO’s "Sex and the City," and despite the easy availability of pornographic pictures and literature on the Internet, American clinicians and their patients still remain squeamish when it comes to discussing sexual activity. At least that’s one conclusion that can be drawn from research suggesting that physicians often fail to screen their patients for STDs or to assess their risk for HIV infection through sexual activity.
Health care providers often lack the training — and, therefore, the comfort level — needed to do a risk assessment and sexual history of patients, says Kathleen Irwin, MD, MPH, chief of the health services research and evaluation branch in the Division of STD Prevention at the Centers for Disease Control and Prevention in Atlanta.
Although men who have sex with men (MSM) often are most at risk for HIV infection, they frequently are not asked about their sexual risk behaviors, says Stephen Goldstone, MD, medical director of GayHealth.com in New York City. "Physicians are uncomfortable with things they don’t know, so they’re reticent to ask," Goldstone says. "For many lesbians or gay men, if you’re unmarried, your physician may assume you’re not having sex."
GayHealth.com, an Internet health information and education web site for the lesbian, gay, bisexual, and transgender community, recently conducted an on-line survey of whether physicians ask gays and lesbians about their sexual practices. The unscientific survey found that 35% of the men and 44% of the women surveyed said their physicians never asked them about sexual practices, and 22% of men and 30% of women said their doctors rarely asked them. The survey included 184 women and 724 men.
"There’s a tremendous reticence among gay and lesbian patients to bring up sexual practices with physicians because of homophobia in the community," Goldstone says. "And those most at risk for HIV infection are MSM who are not self-identified as gay, and they will clearly not talk to their doctors about sexual practices because they don’t want to be outed."
Other barriers to obtaining sexual histories and risk assessments are that providers often have competing priorities and may not have time to add an STD or sexual risk behavior assessment to the routine check-up, Irwin says.
One possible solution to this problem is to have patients fill out a waiting room checklist that includes questions about STDs. An even better alternative might be computer-assisted technologies that some patients will find to be a more private format for disclosing personal information, Irwin adds.
Clinicians also could assign certain staff to obtain sexual histories and to provide counseling when the physician is unavailable. "I think there are also things we could do on a more global level, such as categorizing social change and encouraging more open discussion of sexual issues so patients are more comfortable talking about these issues," Irwin says.
Pediatricians and other clinicians who work with adolescents might be reluctant to ask teen-age patients about sexual risk behaviors in front of their parents, Irwin says. "So there are things we can do like changing patient flow and keeping the parent from the examining room during certain portions of the exam."
GayHealth.com fields hundreds of questions from MSM and others who are too embarrassed to talk with their doctors. "For example, I got a question from a 14-year-old boy about anal sex," Goldstone says. "I felt tremendously privileged to be able to answer his question, because here’s a kid whose parents had no idea what he was typing into his computer, and he couldn’t ask his parents or his doctor about it."
For decades, the CDC and other organizations have recommended that clinicians obtain a sexual risk assessment or sexual history from all patients, and the U.S. Preventive Services Task Force has published a good guide book about what should be included in a risk assessment, Irwin says. To learn more about the HIV screening and counseling guidelines, go to the web site www.ahrq.gov/clinic/uspstf/uspstopics.htm and scroll to "Human Immunodeficiency Virus infection," or go to www.ahrq.gov/ and click on "Prevention Guidelines."
The CDC has provided education about STD screening and sexual history assessments to clinicians. More recently, a Pfizer, Inc. grant to medical schools has provided funding for adding sexual health to the medical curriculum. Mt. Sinai Hospital in New York City, where Goldstone teaches, is one of the Pfizer grant recipients. Now there are new, level-appropriate courses about sexual health, Goldstone says. "For first-year medical students it might be as simple as talking about sexual health and developing a comfort level. As students’ experience and knowledge grow, we’ll broaden the topics," Goldstone says.
Also, a GayHealth.com initiative has brought Goldstone and other health care professionals to college campuses to discuss HIV and sexual practices. "Through discussing sexual practices, risk reduction will come out, and we need to target college students," Goldstone says.
The Public Health Department in Seattle & King County, WA, also has STD and HIV screening guidelines for MSM. Here are some of Seattle & King County’s recommendations, along with recommendations from the U.S. Preventive Services Task Force:
• STDs have a disproportionate impact on women and often have more severe consequences, resulting in pelvic inflammatory disease, ectopic pregnancy, infertility, and an increased risk of cervical cancer. So it’s important to educate women patients about the risks and consequences of silent STD infections, such as chlamydia.
• Men and women under age 25 account for two-thirds of all cases of chlamydia and gonorrhea, and men and women under age 35 account for two-thirds of all newly reported HIV infections. It’s important to provide education and suggest STD and HIV screenings for people in these age groups.
• MSM who have engaged in sexual activity within the past year should be screened for HIV if they haven’t been tested previously and should be subject to a syphilis serology and pharyngeal culture for Neisseria gonorrhoeae.
• MSM who have had receptive anal intercourse in the past year should be given a rectal culture for N. gonorrhoeae and Chlamydia trachomatis.
• MSM patients who need even more frequent screening are those who have had anonymous or multiple partners, those who use crystal methamphetamine or inhaled nitrates, those whose sex partners participate in these activities, and MSM who have symptoms of STD or HIV.
• Clinicians should consider giving all MSM patients immunization against hepatitis A and B and performing type-specific serology for herpes simplex virus infection.
About 40% of MSM are not vaccinated against hepatitis A or B, and both of these are preventable STDs, Goldstone says. "Every gay man or man who has sex with men should have the hepatitis B vaccine," he maintains.