Date of Degree
Doctor of Public Health (DPH)
Community Health and Social Sciences
Betty Wolder Levin
Family Medicine | Health Communication | Public Health | Women's Health
patient-provider communication, sexual health, history taking, primary care, gynecology
Background: In the United States (US), women face a number of serious issues concerning sexual health. Current surveillance data indicates that overall rates of bacterial sexually transmitted infections (STIs) are increasing rapidly. While rates of new diagnoses have decreased, the risks of acquiring HIV are still relatively high for some females, specifically Black/African-American women. In New York City (NYC), where this dissertation research was conducted, similar HIV/STI rates exist among females of reproductive age (aged 15-44). Among women in the US, there are also high estimated rates of other sexual health problems, such as sexual anxiety, sexual dysfunction, and intimate partner violence (IPV). For those reasons, current clinical practice guidelines (CPGs) from international and national entities take a broad and integrated approach to sexual healthcare, and include sexual history taking guidance for healthcare providers regarding assessing a patient’s risk for and/or presence of HIV/STIs and other sexual health issues.
Previous studies have shown that the frequency of sexual history taking and documentation of sexual histories vary widely during medical exams. Based on that prior research, there appears to be a disconnect between published recommendations and real-world implementation of CPGs around sexual history taking during medical encounters, similar to what has been shown with recommendations for other health issues. To help determine what gaps exist, previous studies have examined the barriers and facilitators to sexual history taking through surveys, focus groups and interviews with either providers or, more rarely, patients. However, few researchers have attempted to explore both patient and provider lived experiences and perspectives of sexual history taking within the same study. Therefore, due to an increased emphasis on integrating family planning and sexual and reproductive health care in primary care settings, this pilot study was developed to examine sexual history taking and sexual health discussions during gynecological care encounters from the perspectives of family medicine providers and their patients.
Specifically, this dissertation research examined: 1) how female patients (of reproductive age) and family medicine providers navigate sexual history taking during gynecological care; 2) barriers and facilitators to sexual history taking and sexual health discussions from the perspectives of female patients and their providers; and, 3) their suggestions for improvements to the sexual history taking process and subsequent discussions. Additionally, in order to better understand how sexual health issues are talked about during medical encounters, this study explored how female patients and their providers define and think about (frame) sexual health and behaviors. Finally, specific factors (intrapersonal, interpersonal, institutional, and structural) were identified as influencing their framing of sexual health and experience of gynecological care.
Methods: Family medicine providers and female patients were recruited at two clinics in an academic family medical setting in NYC to participate in individual, in-depth interviews. Eligible providers (physicians and nurse practitioners) must have provided regular gynecological care. Eligible patients were aged 18-44 years, identified as female, reported sexual activity in their lifetime, were not currently pregnant, and had a recent medical visit involving a pelvic exam. Interviews were conducted after screening and obtaining written consent. Similar, though separate, interview guides were developed for patients and providers with open-ended questions to capture a number of domains, including: expectations for and overall perceptions of a recent medical visit; framing of sexual health and behavior; perceptions of, acceptability of, and navigating sexual history taking; knowledge schema around sexual health; and suggestions for improvements. Interviews were recorded, transcribed, and thematically analyzed for similarities and differences between patients and providers.
Results: 18 patient and 9 provider interviews were conducted; all participants identified as female. In their interviews, patients and providers described numerous ways in which they navigate sexual history taking during medical encounters. Most of these findings were similar to what has been reported previously; however, there were a few findings which have been rarely mentioned or not previously reported in the literature.
First, for most patient interviewees, sexual health was described as protection (e.g. condoms, testing, birth control, etc.) from HIV, STIs and pregnancy, as well as an individual’s risk of acquiring STIs and/or becoming pregnant, which was coded as a risk-based/protection framing. Provider interviewees appeared to mirror this protective view of sexual health when talking about discussions with their patients. Conversely, providers revealed a broader, holistic framing of sexual health when asked what sexual health meant to them personally during their interviews. Only a few patients also framed sexual health and behavior using this broader definition.
Second, when examining how they navigate sexual history taking and sexual health discussions, overall, the perspectives of patients and providers were similar, with many thematic parallels. However, one area of difference was that patients often described a profound responsibility to be honest and open during conversations with providers about sexual health. In contrast, while providers mentioned appreciating honesty during these discussions, they questioned the utility of some patients’ openness. They found that receiving copious amounts of personal information was often not useful for risk assessment or diagnosis, which was particularly problematic during time-limited medical encounters. This revealed a tension between honesty and openness on behalf of the patient and a perception of oversharing on behalf of the provider during sexual history taking.
Third, when describing barriers and facilitators to sexual history taking and sexual health discussions, most of thematic findings were similar among patients and providers. The interviewees primarily discussed the onus for reducing barriers to be on the providers, as opposed to the patients. One variation, however, was that some provider interviewees described patients and providers as using different definitions for types of sexual behavior. Some patients mentioned disengagement on behalf of providers as a major barrier to patient-provider communication during sexual health discussions. Regarding facilitators, providers often stressed the importance of creating an open, receptive environment when discussing sensitive topics, such as a patient’s sexual history. Most patients described a positive and respectful provider approach and demeanor as facilitating patient-provider communication during sexual health discussions.
Fourth, there were several suggestions from patient and provider interviewees on how to improve sexual health discussions and the implementation of CPGs. Namely, patients described numerous ways in which providers and clinic sites could offer additional resources, support and education around sexual health, including printed informational materials, educational workshops, and visual aids. Provider interviewees discussed their desire for clinically-relevant and suitable sexual history taking questions to aid them in gathering the information needed to assess, diagnose and treat patients to the best of their ability.
Lastly, the patient and provider responses led to the identification of various interpersonal, institutional, and structural factors that influence sexual history taking and sexual health discussions. For patients, the most important interpersonal factors were the influence of family members and others in their personal social networks upon their conceptualization of sex and sexuality, their perceptions of judgement, shame and stigma, as well as their perceptions of provider compassion and empathy. For providers, the most salient factor was their perceptions regarding the importance of patient honesty and openness. Several institutional factors were mentioned, including: 1) social desirability around number of sexual partners, and 2) encounter length. Regarding structural factors, patient and provider interviewees mentioned their desire for increased/improved education, resources and training which they believed would positively influence sexual history taking and sexual health discussions.
Discussion: This pilot study presented a distinct opportunity to learn about female patient and family medicine provider experiences, perspectives and needs during gynecological care. Furthermore, this study helped identify gaps in the implementation of CPGs around sexual history taking during medical encounters. Providers reiterated their specific goals (risk assessment, provision of contraception and identification of certain sexual health issues) during these time-limited encounters, which are narrower in scope than current CPGs that approach sexual healthcare in a holistic way. Interviewees also described the need for additional education and training materials to improve patient knowledge and understanding about sexual health and to help providers navigate these oftentimes difficult discussions. The results from this study can be used to make modifications to history giving/taking guidance to incorporate these real-world experiences, perspectives and needs, with the goal of improving patient-provider communication, as well as increasing the frequency of sexual history taking and documentation, and improving sexual health outcomes.
Chastain, Ashley M., "Patient and Provider Perspectives on Sexual History Taking During Gynecological Care: A Pilot Study in an Academic Family Medical Setting in New York City" (2019). CUNY Academic Works.