Vignette 2: Asking about Sexual Activity in a Preventive Services Visit

This vignette deals with a preventive services visit and screening questions about sexual health. Kevin is a 16 year old boy who has come to an outpatient clinic for a physical exam. He has some concerns about sexual health as well as previously unreported sexual activity. An adolescent may be reluctant to disclose sexual information for fear that the information will not be kept confidential, and may experience discomfort with the topic. The provider may also feel somewhat uncomfortable asking these questions, which can increase the patient’s anxiety. It is reassuring for the patient if the provider is relaxed and comfortable and tells the patient that this is a routine part of the preventive services visit.

In this vignette:

  • The provider introduces the topic of discussion.
  • When the provider asks if the patient is interested in females, males, or both, the patient answers that he is interested in girls. The provider looks uncomfortable and this may inhibit the patient’s ability to answer honestly.
  • The provider asks if the patient is “sexually active”. Many adolescent boys find this question confusing, as they are often unsure what activities they are being asked about. This patient asks for clarification, but many boys do not.
  • The provider clarifies sexual activity in a way that seems to be satisfactory to the patient. He expresses concern about confidentiality, even though she has already discussed it with him. She reassures him that this information will be kept confidential.
  • The provider has asked about sexual preference but now asks about sexual activity with both genders. She understands that although the boy may have expressed a preference for females, he may have had sexual activity with males as well. Although the provider is uncomfortable, as is the patient, the provider acknowledges that this can be awkward to talk about and assures the patient that these are routine questions.
  • The provider asks more specific questions about sexual activity. She uses terms the boy is uncomfortable with, so he uses his own term, substituting “regular” for “vaginal”.
  • The provider asks again about sex with a male. The patient answers but is clearly uncomfortable. Even though this is difficult for the patient, the provider has put him enough at ease that he is willing to answer the question.
  • The provider asks about condom use. When the patient indicates that he only uses condoms some of the time, the provider becomes stern about using them all the time. He then becomes non–verbal and the tenuous connection suffers. She then “lectures” him on condom use. This may be a necessary part of patient education, but the provider’s tone of voice and timing of this advice is critical to the boy’s comfort level. She doesn’t ask about barriers to use and what strategies work for him.
  • When the provider asks about testing or treatment for infections, the boy discloses his concern that he may have an infection. The provider responds in a comfortable and confident way. She assures the patient that he was right to raise this concern and that she can help him with it.

The positive elements of this interview are:

  • The provider introduces the questions about sexual activity in a comfortable manner, saying they are going to talk about relationships.
  • When the patient expresses confusion about sexual activity, the provider clarifies for him.
  • The provider reassures the patient about confidentiality.
  • The provider asks appropriate questions, even though both she and the patient are uncomfortable. She acknowledges the awkwardness of the questions and normalizes by stating that she asks all her patients these questions.
  • The provider educates the patient about condom use.
  • The provider asks the right questions to help the patient disclose that he is concerned about having an infection.

The negative elements of the interview are:

  • The provider is clearly uncomfortable, as demonstrated by her body language.
  • The provider asks too soon about sex with both genders. She could have eased into this by saying “Some of my patients have had sexual contact with men, women, or both, and although some of these questions may seem uncomfortable, the answers help me know whether you could have an infection or have a question I haven’t answered.”
  • The provider asks if the patient is sexually active – a confusing term for adolescent boys.
  • The provider is confrontational about condom use, alienating the patient. The provider could encourage the patient to discuss any difficulties he has had with condom use.
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