How to discuss STDs with patients

Sexually transmitted diseases have reached unprecedented high levels, according to the CDC, with more than two million cases of chlamydia, gonorrhea, and syphilis, the highest number ever, reported in the U.S. in 2016. To make matters worse, not only are physicians not testing for STDs in accordance with CDC guidelines, STD testing rates have declined in the past few years, according to a report recently issued by Quest Diagnostics.

Martin Derrow, MD, an internist in Maitland, Fla., expressed complete agreement with the conclusions of the Quest report. “I'm sure I also fail to consistently and properly screen for STDs, though I try to do so,” he says. “It's an awkward topic for patients and physicians alike. Both groups tend to under estimate the prevalence and risks of acquiring STDs.”

Deborah Ford, MD, a private practice internist in Worcester, Mass., says she was surprised to even hear of the CDC guidance.

“I don’t think a lot of us are aware of the guidelines,” she says.

However, primary care providers have a pivotal role to play in stemming the rising tide of STDs.
The Quest survey explored the perceptions of young women between 15 and 24, an exceptionally high-risk group for contracting STDs and for suffering their long-term effects. The researchers also surveyed the mothers of these young women and their physicians, including primary care doctors, OB/GYNs, and certain other specialists. The investigators compared their findings in the 2017 survey with results from a similar 2015 survey.

In the newest survey, 24 percent of the physicians surveyed said that they are “very uncomfortable discussing STD risk with my female patients.”  Twenty-seven percent stated that they could accurately diagnose STDs in patients “based on their symptoms,” even though STDs often cause none. Furthermore, one in four physicians will disregard screening guidelines with asymptomatic patient even though these patients frequently do have an STD and are at risk for serious future harm, including infertility.

Patients feel uncomfortable discussing STDs with doctors too, and when these conversations do take place, young women often misstate key facts. Overall, 27 percent of respondents admitted to not always reporting their sexual history accurately to their doctor

Special considerations with teenagers

The youngest sexually active female patients, ages 15 to 17, proved to be the most uncomfortable discussing their sexual history and least likely to be candid and truthful about their sex lives. At the same time, clinicians proved to be less likely to ask this group about testing and less likely to test them for STDs. 

Their mothers can be a problem, too. Having a mother nearby through the entire visit can aggravate the tendency these teenagers have to stifle the honesty necessary to set an appropriate screening and, if needed, a treatment, plan, says Damian P. Alagia, III, MD, medical director of woman’s health for Quest Diagnostics. Learn about your own state’s laws about adolescent consent and confidentiality so that you can create private time and space to talk with a young patient, advises Alagia.

These laws vary by state although there are federal guidelines and common law concepts that are valid throughout the U.S., says ED Berlan and T. Bravender, writing in Current Opinion in Pediatrics.  HIPAA also provides guidelines for confidential care to minors.

Confidentiality for minors matters greatly in terms of young people receiving care they need; fear of parents finding out that the teens are having sex emerged as a significant obstacle to teens receiving needed services, according to research done by the Kaiser Family Foundation.  Physicians and other healthcare providers must be aware of how much confidentiality matters, and also of federal policies, common law, and their own state's laws with regard to this important topic, according to Berlan and Bravender.

Keeping the tone matter-of-fact

One way Ford strives to correctly handle STDs among young patients is to make sure they are up to date on all needed screening when they come in for a visit prompted by an illness or injury.

She also does screenings when doing routine pelvic exams. “I explain that we are automatically checking for gonorrhea and chlamydia so they won’t be surprised when they see those tests when they get a copy of their report or access it on the patient portal,” she says. She explains to patients that the tests are routine for their age group and also offers them additional testing for hepatitis C, HIV, and syphilis.

Derrow agrees that adopting a matter-of-fact attitude makes sense. “Probably the best approach is to handle STD screening no differently than vaccines or a pap smear by following a standard protocol and just saying [to patients], ‘It's time for your gonorrhea and chlamydia screen…,’” he says.

Stressing the ‘care’ in healthcare

Everyone in a doctor’s office must help make each patient feel valued, respected, and free from judgment, says Alagia. “It’s a culture of caring that drives these discussions,” he says, adding that all staff members need to treat patients being tested or treated for STDs matter-of-factly because if even one person is judgmental, a patient may withdraw and miss needed care.

If a young woman tells the front desk person that she has come in because of an unusual vaginal discharge, that symptom should not prompt a raised eyebrow or a snippy comment, anymore than an upset stomach would, says Alagia. “Patients who are vulnerable are looking for reassurance,” he says, “in many ways and on many levels.”