Introduction to Taking a Sex History (PowerPoint)

Document Sample
Introduction to Taking a Sex History (PowerPoint) Powered By Docstoc
					   An Introduction to
 Taking a Sexual History
and Client-Centered Risk-
  Reduction Counseling
            Linda Creegan, FNP
   California STD/HIV Prevention Training
                   Center
            STD Clinical Series
    STDs in the New Millennium:
       Scope of the Problem
   STDs are among the most common infectious
    diseases in the U.S. today
     Chlamydia   is the most common reportable
      disease
     About 1 in 5 adults has HSV-2; HPV is even more
      common in some populations
   STDs increase transmission risk for HIV by 2-
    5 fold
   Current syphilis outbreaks in many urban
    centers including Honolulu, SF, LA , NY,
    Chicago
A Sexual History is an essential part
     of many provider/patient
          interactions….
 Allows individualization of STD/HIV
  diagnosis and screening
 Guides counseling through risk
  assessment
 Allows patient to express concerns
  and ask questions
 Enables appropriate referrals
     …However, it is often given
                          short shrift.
   Fewer than half of physicians report taking a
    sexual history from their patients
       40% of MDs screened teen patients for sexual activity
       15-40% asked questions of adult patients about # and
        gender of partners, and condom use
   Kaiser Family Foundation patient survey,
    1997
       39% were asked about sexual history
       12% were asked about STDs
       83% felt STDs should be discussed at a first-time Ob/Gyn
        visit
Millstein et al, Jour. Adol. Med., Oct, 1996 Haley et al, AJPH, June 1999
                     Why is this?
   Structural barriers (time/reimbursement concerns)
   Patient barriers (privacy/confidentiality concerns)
   Provider barriers
     Low     priority given to STD prevention
           Acute versus preventive role perception
           Low priority given to sexual health issues
           Devaluation of behavioral interventions
     Provider     discomfort discussing sexual issues
           Concern for patient privacy
     Unfamiliarity     with content or language
           Perceived complexity of the sexual history
           Inadequate training
     Primary Factors in Taking a
           Sexual History
   Ensure privacy and confidentiality
   Establish rapport
   Accurately define the problem(s)
   Determine the level of HIV risk
   Ensure successful patient management
     Diagnosis  and treat symptomatic disease
     Detect asymptomatic disease
     Prevent serious sequelae, (i.e.infertility in women)
     Promote behavior changes to prevent future
      infections
       Who is most at-risk for an
                STD?
            Risk Factors and Markers
   Young age (15-35)          Sexual practices or
   Higher prevalence in        behaviors
                                 multiple partners
    urban areas
                                 new partner
   Disproportionately
                                 casual partners
    affect those of lower        improper or
    economic status               inconsistent condom
   Exposure to an STD            use
                                 earlier age at first
   History of certain            sexual activity
    STDs
      Who is most at-risk for an
               STD?
            Presenting Symptoms
   Discharge (vaginal,      Itching
    urethral, rectal)        Pain
   Vaginal odor             Swelling
   Dysuria (frequency,      Change in bowel
    urgency)                  habits
   Skin lesion(genital      Vaginal or rectal
    or extragenital)          bleeding
   Rash                     Sexual dysfunction
Remember: Many STDs give no symptoms.
         Introducing the Sexual
                History
   Acknowledge personal nature of the subject
    matter
   Emphasize confidentiality
   Stress health issues related to sexual
    behaviors
   Be able to explain how the information will
    help you care for the patient
      “I’m going to ask some questions about you sexual history.
       I know this is very personal information, but it involves
      important health issues and everything we discuss is
      confidential”
      Sexual History - Content
   Chief complaint              Past and current sexual
   General health history        practices
                                     Gender of partners
   Allergies
                                     Number of partners
   Recent medication                Most recent sexual
   Past STDs                         exposure

   Women: brief Gyn             New sex partners
    history                      Patterns of condom use
   HIV risk factors (IVDU,      Partner’s condition
    partner’s status)            Substance abuse
   HIV testing history          Domestic violence
                                  issues
    Summary: The Five “P’s”

   Past STDs
   Pregnancy history and plans
   Partners
   (Sexual) Practices
   Prevention of STDs/HIV
 Communication Skills to
Facilitate the Sexual History
   Use open-ended questions rather than
    leading or “yes/no” questions
     Who,  what, when, where?
     “Tell me about…”
     Cone Style of interviewing

   Encourage patients to talk, when needed
     Permission-giving:“Say it in your own words”
     Give range of behavior and ask for patient’s
      experience
   Active listening cues to urge patient on
     Eye   contact, nodding, “Yes, go ahead”
    General Considerations for
     Taking a Sexual History
   Make no assumptions
    Ask all patient about gender and number of
     partners
    Ask about specific sexual practices
       Vaginal, anal and oral sex


   Be clear
    Avoid   medical jargon
    Restate    and expand
    Clarify   stories when necessary
     General Considerations for
      Taking a Sexual History
   Be tactful and respectful
    Use an unrelated translator whenever
     possible
    Use accepting, permission-giving language
     and cues
   Be non-judgmental
    Recognize   patient anxiety
    Recognize our own biases
    Avoid value-laden language (“You
     should..”, “Why didn’t you..” “I think you..”)
             Primary Prevention
     Integrating Risk-Reduction Counseling into
             Routine Patient Encounters

   A client-centered approach is most effective
   Similar messages will help patients prevent
    HIV, STD, and unintended pregnancy
   Emphasize remaining uninfected, by
    changing behaviors to decrease risk for
    acquisition and/or transmission of STD/HIV
     Client-Centered Counseling:
              Definition
        Counseling conducted in an interactive
         manner through the use of open-ended
         questions and active listening, which
         focuses on developing prevention
         objectives and strategies with the client
         rather than simply providing information.

CDC HIV Prevention Case Management Guidelines, 1997
         Factors that Affect
         Behavior Change
   Knowledge                Actual
   Perceived risk            consequences
   Perceived                Access
    consequences             Intentions
   Attitudes (beliefs)      Perceived social
   Skills                    norms
   Self -efficacy           Policy
     Counseling vs. Education
   Dialog                    One-way
   Individualized            Levels of detail but
   Takes feelings and         not tailored to an
    beliefs into account       individual

   Helps client              Sticks to the facts
    understand                Helps client
    themselves better          understand a
   Short and focused          subject better
                              Short and focused
     Project Respect - A Relevant Model
        for STD/HIV Clinical Settings
   Large, randomized, multi-center study funded by
    CDC, completed in 1997
          Evaluated efficacy of STD/HIV prevention counseling in
           changing risky sex behaviors and preventing new STDs
          Almost 6000 patients attending large publicly-funded
           STD clinics (SF, LB, Denver, Baltimore, Newark)
          Patients received client-centered counseling by
           trained (non-clinical) staff
          Outcome measures:GC,CT,Syphilis, HIV
   Findings: two short counseling sessions (20
    minutes each) successfully increased condom
    use and prevented new STDsKamb et al, JAMA Oct.7,1998
    General Principles for Client-
       Centered Counseling
   Approach each patient as an individual
   Focus first on issues and realities that the
    patient identifies
   Use open-ended questions and active
    listening skills to establish a dialog
   Maintain a neutral, non-judgmental attitude
   Offer options, not directive
   Onus of action and responsibility remains with
    the patient
     Three Steps in a Client-
            Centered
     Risk Reduction Session
   Focus on personal risk assessment
     Identify   patient’s personal perception of risk
   Identify safer goal behaviors
             patient’s level of readiness for change
     Identify
     Assess barriers to behavior change efforts

   Develop a personalized action plan
     Negotiate small, realistic risk-reduction steps
     Refer to specialized services, if needed
            Assess Client Risk
Begin dialogue with patient to determine
     number,  gender of partners
     sexual practices (anal, oral, vaginal sex)
     patterns of condom use
     prior STD testing history, and diagnoses

   Identify factors affecting patient risk
     current/past  history of unprotected sex
     intentions for becoming pregnant
     history of domestic violence
     history of injection drug use
      Sample Risk Assessment
            Questions
   What are you doing in your life that might be
    putting you at risk for STD/HIV?
   What are the riskiest things that you are doing?
   What are the situations in which you are most
    likely to be putting yourself at risk for HIV or
    STD?
   What is your experience with shooting up
    drugs?
   When was the last time that you put yourself at
    risk for STD/HIV? What was happening then?
   When do you have sex without a condom?
   How do drugs or alcohol influence your STD or
    HIV risk behaviors?
    Assess Personal Perception
             of Risk
   Identify factors affecting patient’s personal
    perception of risk (knowledge, attitudes,
    beliefs)
    Note: if perception of risk is not accurate, counselor
     assists patient in recognizing risk
   Consider patient’s level of readiness for
    change:*
       Pre-contemplation
       Contemplation
       Preparation
       Action
       Maintenance
       Safer Goal Behavior
            Questions
   How would you like to change that?
   What would you like to do differently?
   What might be better for you to do?
 Client Centered Counseling

Risk Behavior      Safer Goal Behavior
Unprotected        Consistent condom
vaginal sex with   use with this partner
new partner
Possible Goal Behaviors for
   STD Risk Reduction
   Reducing # of sexual partners
   Increase in condom use with main/non-
    main partners
   Partner testing
   Monogamy
   Abstinence
   Consideration of any of the above
 Client Centered Counseling

Risk Behavior           Safer Goal Behavior



                Factors that
   Barriers     influence         Benefits
                behavior
Identify Barriers/Sources of
    Support for Change
   Personal perception of risk
   Self efficacy related to negotiating safer
    sex
   Power and control dynamics in
    relationships
   Cultural issues
   Access to care
   Significant others
Client Centered Counseling
  Risk Behavior                   Safer Sex Goal



 Barriers        Factors that          Benefits
                 influence behavior


            Personalized Action Plan
            1.
            2.
            3.
Negotiate Realistic, Simple Risk
 Reduction Steps with Patient

Risk reduction plan must be patient-driven,
  based on pt. history, readiness, & ability
  to adopt safer behaviors

Health care providers should:
  support   efforts previously attempted by
   patient
  offer options, not directives
  remain non-judgmental
    Personalized Action Plan
          Questions
   How will you go about that?
   What will you need to do first/next?
   When will be a good time to try/begin
    this?
   What is one thing you could do to
    begin?
   Who can you talk to about this for
    support?
    Refer to Specialized Services,
              If Needed

   Alcohol or drug treatment programs
   Partner/domestic violence services
   Partner counseling and referral services
   Couples counseling
   Benefits counseling to obtain access to
    services
        Taking Personal Stock
   Helping clients change behavior may
    begin with changing some of our own
    Recognize   our biases and keep them in
     check
    Talk less, listen more
    Encourage step-wise, incremental, realistic
     changes
    Avoid “should/shouldn’t”,”I think you…..”
     “You need to…..”
    Be willing to give it a try!