Taking a Sexual History with LBGT Patients


Alfred Kinsey posed taking a sexual history
[Photo: Bill Dellanback/Kinsey Institute]

Goal

The resident will be able to perform a sexual history that is sensitive to the issues that affect LGBT patients.

Objectives

By reviewing this module, the resident will learn:

Pre-Test

  1. Taking a sexual history is no different when interviewing LGBT patients as compared to heterosexual patients.
    True False
  2. As lesbians in long term relationships commonly experience "bed death," it is important to ask about this early in the interview.
    True False
  3. The psychiatrist must observe confidentiality guidelines regarding GLBT youth, even when parents insist upon knowing all information.
    True False

Creating a Welcoming and Safe Atmosphere

Taking a sexual history is an important part of the evaluation of every patient. Patients often will not bring up sexual problems unless the clinician raises the issue in a way that is conducive to open and comfortable disclosure. For good practices on taking a general sexual history, refer to the Association of Reproductive Health Professionals, TheBody.com, or Tomlinson (1998).

This unit will focus on specific techniques useful for taking a sexual history in LGBT patients.

In general, creating a safe environment for taking a sexual history is similar in LGBT and heterosexual patients. In all such situations, the therapist strives to be open minded, nonjudgmental, patient, tactful, respectful and provides assurances that privacy and confidentiality will be maintained. It is useful, however, to keep in mind that many LGBT individuals may approach a clinical interview with greater anxiety and guardedness than their heterosexual counterparts. Their anxieties may stem from past experiences with clinicians who were critically judgmental or they may anticipate a critical or judgmental response by projecting their own "internalized homophobia" or "transphobia." These patients may need additional time and encouragement to reveal the true nature of their concerns. Conversely, a therapist who is comfortable taking an in-depth sexual history expects that they themselves may feel more vulnerable as very sensitive and private matters are discussed.

As with any patient, the clinician's non-judgmental attitude will help elicit honest and relevant information. Such an attitude is conveyed to the patient both verbally and non-verbally through body posture and room set up. A relaxed stance and not conducting an interview from behind a desk can be beneficial. Techniques such as open-ended questions, verbal mirroring of the patient's own language, use of non-judgmental language, attention to heterosexist assumptions and avoidance of stereotyping can all lead to greater success in obtaining a more accurate sexual history. If a patient acts offended or becomes anxious in response to a question or certain word, rather than avoiding the topic, the clinician could explore the reaction, rephrase the question or ask the patient what terminology would feel more comfortable. The patient may be having many anxiety-provoking thoughts at once, and the topic at hand may not necessarily be the cause of the observed reaction. Clinicians need to be aware that they may have uncomfortable feelings when hearing about sexual practices with which they are unfamiliar, e.g., fetishes, paraphilias or public sex.

Confidentiality

Confidentiality is the cornerstone of all physician-patient relationships and assurances of confidentiality are crucial when taking a sexual history. Maintaining confidentiality is done by assuring the patient that any information provided will not be shared with others unless the patient gives their express consent. Patients may have unfounded or illogical concerns that their partner (or parents, or another provider) may learn the content of the conversation, and specific assurance that this will not happen can be very helpful to develop further trust in the process. In cases where complete confidentiality cannot be assured, the clinician should clarify the limits of confidentiality from the outset and respect the patient's decision as to how much sexual history s/he is willing to reveal.

Special caution and attention to confidentiality needs to be taken when working with children, adolescents and young adults who may not have shared their concerns about sexual orientation or gender identity with their parents. Children and adolescents are particularly unlikely to share their intimate feelings with clinicians unless their wishes and sensitivities are recognized.

Other situations where special caution needs to be taken include cases where revealing information may affect the outcome of a legal case such as child custody, divorce or guardianship of an elderly dependent.

Use of Inclusive Language

When taking a sexual history, the clinician's task is aided by using inclusive terms and language. Inclusive language should not make assumptions about a patient's sexual identity or sexual behavior, particularly in situations where patients do not volunteer such information. One way to do this is to have intake forms and questionnaires available that do not make heterosexist assumptions.

Some examples of questions that assume heterosexuality are:
  • "Are you married or single?"
  • Asking a female patient: "Do you have a boyfriend?"
  • Asking a male patient: "When did you first become interested in girls?"

Some examples of inclusive questions are:

  • "Are you dating anybody?"
  • "Are you currently in an intimate relationship?"
  • "What's your level of commitment to your partner?"

Such inclusive language also conveys to the LGBT patient that the interviewer is potentially open to hearing about his or her sexual identity, practices, and relationships. Having intake questionnaires that have options such as "Single, Married, Widowed, or Partnered" will increase the patient’s level of comfort that the office is open to all kinds of relationships. The accuracy and completeness of the information elicited will reflect the patient's level of comfort with the process.

Evaluating Sexual Risk

A sexual history should explore the patient's knowledge of both high risk and safer sex behaviors. The following are important to keep in mind:

  1. Antihomosexual attitudes and stigma can contribute to a patient's lack of information about what constitutes risky sexual behavior and may contribute to a patient's inability or unwillingness to use safer sex practices. For example, internalized homophobia has been found to be associated with increased problematic substance use and riskier sexual practices (Meyer 2003).
  2. Depression, anxiety, psychosis, mental retardation and other psychiatric disorders can contribute to inconsistent use or even complete neglect of safer sex precautions.
  3. A patient may lack or have inaccurate knowledge about HIV and other sexually transmitted diseases. Providing a patient with up-to-date information about STDs can be a useful part of taking a sexual history.
  4. In general, giving advice or telling patients what they should or should not do may not lead to behavioral change.   Exploring the motivations behind patient choices, the accuracy of their information, and their capacity for self-care can help patients think through risk-benefit scenarios.

Identifying the Patient's Concerns

When taking a sexual history, it is important to assess its relevance to the patient's presenting complaint (i.e.,an LGBT patient being seen for congestive heart failure) or whether some aspect of the patient's sexual activity or identity represents a source of concern to the patient and therefore warrants clinical attention. In both situations, the information gathered may be critical to the development of a reasonable treatment plan. It also serves to inform the patient that the clinician is willing to “go the extra step” and gently insist on sexual matters that the patient is keeping private.

However, the patient's major focus of concern should always be uppermost in the therapist's mind and guide how the interview proceeds and how much detail is required in the sexual history.

Common Assumptions NOT to Make in Taking a Sexual History

Clinical Vignette

A child psychiatrist is asked to consult with a 15 year old adolescent boy after the parents discover he had been going to gay pornographic websites. Although the adolescent is displaying no overt behavioral problems, is doing well in school and has many friends, his parents are concerned that he might be involved in sexual activity that might put his health and welfare at risk.

The first meeting is with the parents and adolescent together. The parents are told from the outset, and in the adolescent's presence, that the psychiatrist is not ethically allowed to reveal to them any confidential information regarding the adolescent's sexual behavior. In addition, the psychiatrist tells the family that any of his communications with the parents will be shared with the adolescent. The parents accept the ethical limitations on what can be revealed to them but wish the child to undergo treatment at least for educational purposes.

In their first individual session, the adolescent starts out sullen and resentful. The psychiatrist begins by asking general questions about his family, his friends, his schoolwork, his hobbies and athletic interests. The psychiatrist raises the issue of sexuality, asking, "Want to talk about your sex life?" The boy responds that he would rather not. Switching gears, the psychiatrist says, "We don't have to talk about it if you don't want to. But is there a reason why you'd prefer not to?" The adolescent again demurs in his response and becomes sullen.

The psychiatrist says "That's OK," choosing not to pursue a sexual history during this early phase of treatment. However, he reminds the adolescent about the assurances of confidentiality he previously offered in front of the parents. He lets the patient know that they can return to the subject later on if and when the patient feels more comfortable in the clinical setting.

Other suggested topics that can be explored to get to know the adolescent better are Home, Education, Activities, Education, Suicide (-al thoughts), Sex (HEADSS), as suggested in the adolescent medicine literature. Many adolescents use social media outlets such as Facebook and Twitter to communicate with friends. Although these may provide a source of community for the adolescent, they can also be the context in which bullying happens unbeknownst to parents, and therefore should be explored as well.

Clinical Vignette

A 55 year old woman presents to her primary care physician complaining of painful blisters on her right thigh. Based on the distribution of the skin lesions and a childhood history of chicken pox, the physician makes a diagnosis of shingles.

The patient has been seeing her physician for two years and from the outset presented herself as a lesbian woman living with her domestic partner of three years. The physician does not, however, inquire further about her sexual history and no further medical work-up is considered for possible causes of shingles. When directly asked, the patient says she has no history of drug abuse.

Several months later, the patient is hospitalized with an acute change in mental status, primarily characterized by confusion and disorientation. A neurological workup reveals nonspecific cortical atrophy. The patient is too disoriented to provide much of a coherent history. Her partner, however, is available to answer the hospital physician's questions about the patient's past history. The patient had been involved with a man for several years in a relationship that ended two years before the patient became involved with her current partner. The partner never met the ex-boyfriend but recalls hearing from the patient that he had a "drug problem," although she had no specific details about his drug use.

The patient was tested for HIV and found to be seropositive.

For many patients who present with a sexual complaint, taking a thorough, respectful and timely sexual history can be the first step to exploring their concerns. Very often, patients need clinicians to help them understand what is considered normative and healthy behavior, and to also help them explore the differences between their experiences and their expectations. The more different their expectations and experiences are, the more likely they are to have concerns about their sexual performance and knowledge.

Post-Test

  1. An open and accepting atmosphere can help the clinician successfully elicit a patient's sexual history. This atmosphere can be best created by:
    1. asking specific and exact questions
    2. placing a clean desk between the doctor and patient
    3. asking if a patient is married, single or gay
    4. using gender neutral language, such as "partner"
  2. In exploring safer sex practices, it is helpful to
    1. insist that the patient always use condoms or dental dams
    2. provide information and offer support for the patient expressing fears or ignorance regarding safer sex
    3. evaluate the possible interaction of depression, anxiety and substance abuse in using safer sex guidelines
    4. insist that patients practice abstinence
  3. Most gay men are extremely promiscuous, so they should receive safe sex education regularly.
    True False
  4. Gender ambiguity is an emergent situation, and it is important for healthy development for a child to be unambiguously male or female.
    True False
  5. Domestic abuse can occur in any relationship, but in gay and lesbian relationships it may feel more shameful to report than it is for heterosexual victims of abuse.
    True False

References

Meyer IH. 2003. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull 129(5):674-97.

Tomlinson J. 1998. ABC of sexual health. Taking a sexual History. Brit Med J. 317: 1573-76.