Sharon J. Parish, MD
Associate Professor of Clinical Medicine, Albert Einstein College of Medicine, Director of Psychosocial Training, Montefiore Medical Center, Bronx, NY

Dr PARISH: I'm going to be shifting gears with this presentation and discuss issues of communication. I'm going to be sharing some thoughts with you about how to improve doctor/patient communication in the dialogues around sexual health. I'm going to be asking you to reflect on your own practice and your own experiences through both a few audience response questions and some videos, which I'll be showing you about real interviews between doctors and patients.

Hopefully, you'll have an opportunity to think about how this may apply to you and the work that you do with patients or in the field.

Here we are, challenges in sexual health dialogues, and that's what we're going to be talking about today. First audience response question, "Which do you believe is the most important barrier for your patients regarding discussions about sexual health?"

• Patients believe the physician doesn't have time
• Patients don't want to embarrass the physician
• Patients believe no treatment is available
• Patients feel the MD lacks cultural sensitivity
• Patients perceive a lack of privacy.

I'd like you to select the barrier you feel is most important. I know several may apply—select the most important barrier for your patients.

It looks like the most important one here is patients believe no treatment is available, and also patient's belief about the physician's time. I think these are common barriers, and we all think that our patients feel this way.

What do the data show about patient perceptions of physicians? This study was done about 10 years ago by Marwick and was published in JAMA. The following was found, that although 85% of adults wanted to discuss sexual functioning, 71% in this study felt the physician didn't have time, 68% didn't want to embarrass the physician so they didn't bring it up, and 76% believed that no treatment was available. Again, this was 10 years ago.

They reported non-empathic, judgmental responses, the impression that the MD was unapproachable or uncaring, physician discomfort/embarrassment, concerns about privacy, and a lack of cultural sensitivity.

Let's look at some newer data. These are 2 studies that came out in the past year regarding help-seeking for sexual problems. In one study of mature, sexually active women ages 40 to 80, 43.9% had taken no action regarding seeking help for a sexual problem. Only 16% had spoken to a doctor and close to 80% had sought no help from medical professionals for their problem. So things haven't changed dramatically.

In another study, the PRESIDE study, when we looked at women with sexual problems and distress, they reported the following: 34% had discussed the problem with a health care provider and 41.5% had discussed it with a non-health care provider. Some had sought help from anonymous sources like the web and 14% of those women sought no help at all.

What were some of the determinants in these 2 studies as to why women might initiate a discussion? Women with decreased desire and distress from the PRESIDE study were less likely to initiate a conversation if they didn't have a partner, if they had poor self-assessed health, or moderate embarrassment, whereas they were more likely to bring the conversation up if they used an oral contraceptive or hormone therapy, had more medical conditions, or had a higher distress level.

Regarding embarrassment as a barrier, the patient's own embarrassment in this study was a factor in 12% for them not to bring up the conversation. However, in 68% of the time where they didn't bring up the conversation, they cited anticipation of physician embarrassment as a barrier for their bringing up the conversation about their sexual concerns.

So now the next question: "Which do you believe is the most important barrier for you as a physician regarding sexual health with your patients or as a healthcare provider?" So the response choices are:

• Lack of knowledge or training in communication or sexual health
• You may not recognize that sexual activity is important to your patients
• You have time constraints
• You feel you'll be inadequately reimbursed
• You have a different gender than your patients
• You have personal discomfort about sex and that interferes as a barrier with you bringing up these topics with your patients.

We see the most important barrier is feeling that you don't have an adequate training in either communication skills or sexual medicine itself. So hopefully with some of these programs, we can improve that barrier; and you can feel more comfortable bringing up these issues with your patients. Time constraints and reimbursement run a close second. That's been common in the literature as well.

Let's look at some information about this a little bit further. Some of the physician barriers that have been cited include, like we just talked about, a lack of knowledge and training in sexual medicine, a lack of training in both communication skills and more general as well as sexual health counseling skills, including behavioral treatments, a lack of recognition of sexual activity not being important, the idea that improving quality of life is not the highest priority, especially if the patients have much more pressing health concerns.

There may be a lack of awareness of the comorbid conditions between sexual health problems and medical problems. Therefore, you may not think to bring this up in a patient with certain medical conditions. Or again, physicians commonly, like you did, cite time constraints and lack of reimbursement or lack of knowledge about how to code these issues and therefore be reimbursed in their personal practices.

Other barriers that have been cited include a lack of privacy, cultural and language barriers—not understanding the culture or what might be specific to that culture regarding sexuality, gender. Male physician/female patient seems to be the most common gender concern cited by practitioners.

And then there is personal discomfort about sex, which practitioners certainly sometimes cite as being a barrier. Not knowing what language to use; not feeling comfortable if they're an older patient and they're a younger physician or vice versa; assuming all patients are married, heterosexual, and monogamous and therefore not understanding the array of sexual behaviors, or not supporting those choices.

Here is a study about screening and diagnosis of hypoactive sexual desire. In this study, 53 of 155 University of Virginia internal medicine residents and faculty were asked to respond to a 10-item web-based survey about hypoactive sexual desire disorder. Here are the responses. I will note there were no significant gender differences in these responses.

So you'll see with all 4 of these answers, overwhelmingly close to 90% or more reported these responses. So the respondents had not screened patients with hypoactive sexual desire disorder. They felt little confidence—less than 10% felt confidence in making this diagnosis. Nearly all the physicians had not prescribed a treatment for it, including a medication.

However, nearly all of the respondents felt that this was an important diagnosis and the treatment was important to patients. But they just didn't really know what to do.

Let's do the last question here. “Which do you believe is the best method for screening for sexual problems?” The choices are

• "Do you have a problem during sex?"
• "Many women your age report problems during sex. How about you?"
• Ask a patient if they have any questions in an annual PAP smear or similar visit
• Wait for the patient to initiate the conversation
• Use a self-report screening instrument like the samples you were shown in the earlier presentations

We see the responses here. People seem to like the second response most. That's one we'll endorse in just a little while: "Many women your age report problems during sex. How about you?" Others favor self-reporting screening instrument or even maybe a direct question, "Do you have a problem during sex?"

Regarding sexual history-taking in older adults, let's look a little bit at the information around screening. The National Sex and Health Study of Older Patients, was a sex health and social life survey of older patients. Twenty-two percent of the women reported ever having discussed sex with a physician since age 50. In a study published around the same time, in women in a primary care setting who were over the age of 70, less than 4% reported initiating a discussion with a physician, and 7% stated the physician had brought the idea of sexual activity up in the past year. However, one-third felt the physician should inquire and should be the one to initiate the conversation.

In the study that I showed you earlier that was published this year regarding mature women who were sexually active, 15% of those women had been asked by a health care provider about sex, but approximately half or more believed the healthcare provider should be the one that should ask routinely.

In another study, the PRESIDE study that we've been discussing, women who sought help from a health care provider reported the following responses. These younger women reported they initiated the discussion 78% of the time, but only 6% had scheduled a specific visit for the problem. Younger women in this study were more likely to initiate a conversation, and interestingly ObGyns were more likely than other health care providers to have been the ones that initiated the conversation with a patient—except for older women, where primary care physicians, in this case, were more likely than any other type of physician to initiate a conversation.

Regarding sexual history-taking and detection, I want to make a point on this slide that only one-third of physicians routinely take any kind of sexual history. This could include contraception or STD assessment in primary care settings. In this particular study where clinic physicians were trained to screen, their detection rates went up to detecting a problem in 50% of the patients. Over 90% of the patients in this study felt this was important to their doctor's knowledge of their medical and sexual concerns.

Screening sexual histories improved detection and addressing sexual problems satisfies patients, certainly as demonstrated in this study.

Now we're going to transition to watching some interviews. I would like to give you some orientation to the videos you're going to be seeing. These videos are in-office videotapes of both primary care physicians and obstetric/gynecology practicing physicians who agreed to be videotaped and audiotaped discussing sexual health with their patients.

In this study, the physicians were asked simply to discuss sexual desire with their patients. Patients were screened, and those who did screen positive on the decreased sexual desire screener were videotaped. The doctors did not know which patients screened positive, so they talked about it with all their patients. They had no idea which patients might answer positively.

We're going to watch this first video. I want you to pay attention while you watch and maybe jot a few notes down. See what you think about how this doctor did with screening. Let's focus on the screening.

Reflect for a moment on how you felt the doctor did with screening this patient for low sexual desire.

Here is his opinion. So let me just say something before we play this. With each of these interviews, we have post-visit interviews where both the doctor and the patient were interviewed about how they felt the interview went. This is the doctor's point of view.

Let's see how the patient felt.

While the physician did screen the patient, it doesn't seem that he got the full story. What were some of the things that maybe would have helped him get a little bit more information about the whole story with this patient in terms of what she felt? Like many of you suggested, screening with an open-ended, ubiquity-style question is recommended as one of the best strategies. "Many women with diabetes have sexual problems. How about you?" This seems to have a higher yield than a direct question like this physician asked, "Well, how is your sexual desire?"

Continuing with inquiry about specific questions may help reveal a little bit more information about the nature of the problem. "Are you having problems with desire or interest in sex? Are you having any problems with lubrication or dryness? Are you having any problems with orgasm or coming?" Then the positive response, like this patient gave us, could be followed up with an open-ended question, "Tell me more about it." He concluded with a close-ended statement, "Well, it must be the kids." Then she agreed and wasn't invited to go forward.

Let's look a little bit more at principles of sexual history-taking. Like I've already demonstrated with some of the data, women prefer their primary care clinician or health care providers to be the one to initiate the topic. Simple, direct language seems to be helpful. Compassionate honesty and normalizing statements, sometimes adding a ubiquity component, can be very helpful. Declaring and demonstrating the lack of embarrassment and the willingness to listen can improve disclosure.

So let's turn to another video. Here with this video, in addition to screening, I'd like you to look at how the physician gets the narrative about the patient’s situation and concerns about her sexual response. We are focusing on the narrative here, the story that the patient has, the back story. So let's watch.

Let's look and see how the physician felt about the content of the interview, how he felt about what he learned about the nature and the details of the patient's problem.

The physician felt that once the patient said, "I'm not having sex," pursuing further about why she had chosen that, how she felt about sexual activity was really not indicated. It was a “conversation stopper.” So let's see what the patient tells us about her sexual function. Let's get a little more detail that was revealed to the interviewer in the post-visit interview.

Everything came from one sexual experience with one guy. There was pain, sadness, and anger. This didn't come out in the interview. So one question we want to ask ourselves, "Is it important to learn more about how patients feel about what's happened to them with the diagnosis of an STD or negative sexual experience and its impact on them and their well being?"

I think these are things we need to all reflect on regarding learning more about our patients' experiences in the interface between medical complications, medical problems, and sexuality.

So let's go back to open-ended questions. Many of you early on in your training learned about those. Let’s see how they may be important for understanding more about the sexual problems of our patients. So open-ended questions require narrative elaboration, not yes, no, or short responses. Directed, open-ended questions can focus the topic but don't prescribe the form of a response. They can open the door to content, understanding, and feelings.

On average, if you look at doctors' behavior, doctors ask about one question per minute, and in studies that evaluate this, over 90% are close-ended, including this study. Close to 100% of the questions that the doctors asked were closed-ended.

Open-ended dialogue can be efficient. In one study that looked at impairment in migraine, in 90 seconds impairment was revealed as long as an appropriate open-ended question was asked. Syndromal symptoms were effectively revealed.

In eliciting the patient's story around sexual problems, we can listen for critical elements in the patient's speech and ask a directed open-ended question to follow the thread. I'll give you an example of another patient. "I just don't want to have sex with Peter," she says "the way I used to. It's got me so down and he's so. . . it's just no good now."

If you were going to ask an open-ended question, "Tell me about it," which way you would you go? As you can see from the next slide, there are a lot of possible options. "I just don't want to have sex with Peter." You could go with, "Tell me about not wanting." This might reveal information about low desire or even coercion. You could go with, "The way you used to? Is this about frequency, technique, enthusiasm, desire?"

You could pursue, "Tell me about feeling down." Does the patient have low desire because she's depressed? Or is she distressed about her low desire? You could ask, "Tell me about being no good now.” Is there a change in arousal or orgasm? Is it another phase of the sexual response cycle? Is there a change in the relationship? Is he no good now?

You could ask, "He's so— you were saying— well what is it about Peter? Is he understanding? Is he angry? Is he different? Is Peter the problem?" And lastly, we could say, "Tell me about it. Tell me about Peter." Is the problem situational or generalized? Is it relationship issues between the two?

So when you look at the slide, you may feel overwhelmed and say, "No wonder there are so many barriers." Or you may see it as a gold mine of opportunity to use open-ended questions to pursue the nature of the problem and understand the impact on the patient.

So lastly, I'm going to make a couple of points about continuing the narrative and the role of functional assessment, and then I'll conclude. In eliciting the narrative, continuers and emotionally supportive statements can help the patient reveal more about the nature of the sexual problem. "That sounds distressing, upsetting, frightening," etc. "Go on. Tell me more," and waiting and letting the patient reveal the story.

You can restate with clarification to confirm understanding. So if the patient said it's uncomfortable, you might respond with the following. "Do you mean you had discomfort or pain when he was touching you or when he tried to penetrate? Please explain."

I think in the interest of time we'll skip the next two slides. They further demonstrate the role of open-ended questions in revealing emotional content. I'll end with this slide.

So, on average, physicians are strong on symptom assessments and poor on the following: functional impairment, associated emotions, and the psychosocial context of the situation. They are also poor on the patient's understanding and explanatory models of symptoms. And based on the limited data we have about sexual health interviewing, physicians talking to patients both in the ObGyn setting and the primary care setting, and maybe other settings as well, seem to have similar challenges. This is not easy to do, especially given the time constraints.

But I believe based on some of the techniques that work in other disciplines, that primary care providers, ObGyns and other health care providers can increase their use of open-ended questions, focus-directed open-ended questions, emotion-seeking questions and other strategies to assess distress and functional impairment, to improve adherence to the treatment plan and patient satisfaction. With that I'll conclude my presentation.