What should primary care physicians do about sexually transmitted infections?

Despite advances in medication that have reduced occurrences of sexually transmitted infections (STIs) like HIV, other STIs are increasing. The CDC recently reported that chlamydia, gonorrhea, and syphilis reached an all-time high of 2.3 million in 2017 and emergency departments saw a 39 percent rise in STIs.

While the causes of this increase are multi-factorial, some experts say that one of the most influential factors is that primary care physicians are not routinizing sexual health discussions as part of general health screenings.

Veronica Whitehead, M.Ed, director of programs at the North Texas Alliance to Reduce Unintended Pregnancy in Teens (NTARUPT), based in Dallas says, “We have found that physicians don’t talk about sexually transmitted infections until there is an infection.”

There may be a variety of reasons why physicians are not comfortable discussing sexual health, ranging from personal discomfort to the frequency with which they see their patients.

“If the physician isn’t comfortable with talking about sex, they probably are not emphasizing it in talking with the patients,” says Michael Horberg, MD, FACP, FIDSA and executive director of research, community benefit and Medicaid for the Mid-Atlantic Permanente Medical Group in Washington, D.C.

Victoria Mobley, MD, MPH, North Carolina Department of Health and Human Services, HIV/STD medical director and adjunct assistant professor in epidemiology at UNC Gillings School of Global Public Health suggests another cause of the rise in STIs may be that physicians stick too closely to traditional screenings-urine, vagina, cervix, and urethra.

“We know that sexual experiences are much broader than that,” Mobley says, “People have oral sex, people have anal sex, including a good portion of heterosexuals.”

She points out that a urine-only screening will miss more than 50 percent of infections in individuals who have exposures in other sites.
“We have to be culturally competent in how we’re asking the questions about exposure and where we’re screening based on those answers,” Mobley explains.

There may come a time when more people can take advantage of newly available home STI testing kits, which can be taken in a private setting and then shared with a doctor via mail or a follow-up appointment, But for now, the best method is to go to a physician. These kits are still relatively new and do not screen for all STIs.

Mobley says the opioid epidemic, which is linked to risky sexual practices, including the exchange of sex for drugs or other goods or services, may also be contributing to the rise in STIs. “In some places in the country, they’ve seen quite a significant increase in STIs associated with drug use, particularly meth use.”

Opening the conversation

The key to better screening, Mobley says, is making it routine to stave off some of the discomfort of this personal dialogue.

“Every primary care provider should have a sexual health history as a part of every visit,” Mobley says. “If you do it for every patient, whether it’s a 22-year-old sexually active young man or a 54-year-old sexually active married woman, you ask the same questions, so they come to expect it.”

For physicians who aren’t comfortable discussing sexual health right away, Ada Stewart, MD, a family practice physician with the Eau Claire Cooperative Health Center in Columbia, S.C., recommends making it part of written questions for the patient to fill out before the visit.

Once a year, Stewart asks her patients to answer written questions about sensitive issues such as smoking, alcohol, drug use, and sexual issues. “Make it simple and as easy as possible so that you’re not overwhelmed and your patients don’t feel you’re rushing them through a visit.”

Most important, she says, is developing a relationship of trust so the patients feel that they can talk about these issues. “It’s all about making patients feel comfortable with you and the care you’re going to provide them.”

Horberg says that a sexual health screening need not be convoluted or invasive. He suggests beginning with two very simple questions, which are recommended by the CDC-supported Health Care Action Group, “Have you been sexually active in the past year?” And “Have you been sexually active with men, women, or both?”

Asking the second question in particular can help determine which testing is needed. The CDC report found that the rise of syphilis was especially high in populations where men have sex primarily with men.  While no single population should be named as the culprit, Horberg emphasizes, it is important to note that as sexual relations with types and numbers of partners increase, so potentially do STIs.

“We also know there are a lot of people who have sex with multiple sexual partners, both same sex and heterosexual sex, so if one population has an increase, it’s eventually going to spread to the other population,” Horberg says.

Horberg acknowledges that medical schools don’t do a good job of teaching physicians to be comfortable discussing sexual health.
“We forget sometimes that physicians come in with all of their anxieties,” Horberg says. “We try to leave them all at the patient’s door but sometimes it is hard to do. And it takes practice. Good sexual history like any other part of exam, it’s an art, something you have to practice,” Horberg says.

He says that physicians should initially work from a script to reduce anxiety and standardize the process, which may make these conversations more natural over time. He also hopes that EHRs will eventually integrate sexual health screenings in a way that makes it easier for both physician and patient.

Some resources for scripts include the AAFP’s article on “The Proactive Sexual Health History,” the National Coalition for Sexual Health’s guide, “Sexual Health and Your Patients: A Provider’s Guide,” and a guide by the American Sexual Health Association, “Sexual Health: Resources for Healthcare Providers.”

Educate patients

Robert Segal, MD, a Manhattan-based cardiologist and founder of LabFinder, which offers home testing kits for a variety of medical issues, including some STIs, says it’s just as much a part of the physician’s role to educate patients as to screen them, as well as ask them more than routine questions, such as number of partners, and use of protection.

“No matter our patient demographic, if they’re sexually active, we should be educating them not only on the importance of using protection, but on the fact that some STIs don’t always exhibit symptoms and the only way to know if you’re carrying a disease or infection is to get tested,” Segal says.

This will be most effective, Segal says, when this is done with the intent to reduce a patient’s anxiety. “[Physicians] need to have an open and non-judgmental demeanor when inquiring about a person’s sexual history,” Segal says.

Horberg also points out that patients need to know about the long-term effects of untreated STIs, which can lead to a variety of very significant health problems.

“Even though many STIs are asymptomatic, the long-term effects of untreated STIs are legion,” Horberg says.

While most physicians have a ways to go at becoming more comprehensive in helping patients prevent and treat STIs, the patient also has to play a role. Horberg says, “It’s important to mention that STI prevention is still also based on safer sex practices and rekindle those conversations.”

The teen trend

Another likely cause of rising STIs is a vulnerable population: adolescents.

“Young people feel indestructible. STIs are just not on their minds,” Mobley says.

Physicians who see teens, whether pediatricians or family practice doctors, may not all be screening their patients for sexual activity or STIs for reasons that could range from personal discomfort to parents interfering.

According to a 2015 article in JAMA Pediatrics, teens report low discussion rates around sexual issues during regular health visits and a reluctance to bring these issues up on their own.  One-third of all teen participants reported having regular health visits in which their physicians did not mention sexual issues at all.

Mobley says this lack of discussion is especially concerning for teens, particularly girls. “A lot of these infections can be asymptomatic and if you don’t catch it in these young women, the consequences long term can be so severe.”

Whitehead says that both physicians and parents need to work together to make sure these conversations, and when necessary, screenings, are taking place.

She recommends that physicians start the conversation from a health perspective and make clear, “We’re not assuming anything about your child. We’re just sharing information.”

Adolescents are hungry for this information, she says, because much of what they are getting non-medical sources, such as their peers or the internet, is incorrect. When her organization brings in a nurse practitioner to schools to discuss sexual health issues, she says: “The students just absorb it. The nurse practitioner will talk about anything from how STIs are transmitted to pap smears and breast exams. The students really appreciate that dialogue.”

When it comes to discussing sexual health, she says: “Everybody is nervous. We have to put ourselves out there as the adults whether as a sex educator or as a physician.”