Guidance: Adopting a Patient-Centered Approach to Sexual Health

Guidance: Adopting a Patient-Centered Approach to Sexual Health

Lead authors: Shauna H. Gunaratne, MD, MPH, Columbia University Irving Medical Center, New York; Mary Beth Hansen, MA, Johns Hopkins University Clinical Guidelines Program
Writing group: Joseph P. McGowan, MD, FACP, FIDSA; Steven M. Fine, MD, PhD; Rona Vail, MD; Samuel T. Merrick, MD; Asa Radix, MD, MPH, PhD; Charles J. Gonzalez, MD; Christopher J. Hoffmann, MD, MPH
Committee: Medical Care Criteria Committee
Date published: April 29, 2022

Purpose of This Guidance

This Committee encourages clinicians to adopt a patient-centered approach to sexual health care to improve the health and well-being of people in New York State (NYS) who receive HIV prevention and care services and prevention and care services related to other sexually transmitted infections (STIs).

In a February 2020 Dear Colleague letter, the Director of the New York State Department of Health (NYSDOH) AIDS Institute (AI) noted that the prevailing disease-based approach to sexual health care is outdated and agreed with the American Sexual Health Association definition of sexual health: “the ability to embrace and enjoy our sexuality throughout our lives.” The letter explained that a sexual health framework:

“. . . includes ensuring that all people in NYS are empowered to exercise and achieve control over their sexual health and can access sexual health services that promote wellness in a manner that is respectful of their needs. This framework acknowledges sexuality as a life-long endeavor for people of all identities. It recognizes the importance of sexual pleasure, satisfaction, and intimacy to overall health and well-being.”

Adopting a patient-centered sexual health framework when implementing Clinical Guidelines Program recommendations and guidance for clinical care of people with HIV and other STIs can improve patients’ overall health and well-being, reduce stigma, empower patients, and increase their uptake of sexual health–related resources. The patient-centered, HIV status–neutral approach to sexual health encouraged here promotes disease prevention and harm reduction and recognizes that there is much more to sexual health than disease prevention and treatment.  

An individual’s sexual health may be related to their gender identity, sexual orientation, sexual practices, reproductive health and rights, safety, knowledge of harm reduction, disease prevention and treatment, and overall health. The multifaceted patient-centered sexual health framework illustrated in the figure below relies on open discussion of sexual identity, expression, experiences, preferences, and care planning and delivery. Sexual health is an important component of overall health that care providers should address as part of routine health visits.

Multifaceted Patient-Centered Sexual Health Care

Resources for Care Providers, below, provides links to a wide variety of informational sources that address the many facets of sexual health care.

Inclusive setting: All patients are entitled to a safe, welcoming, and affirming healthcare experience regardless of their sexual identity, expression, orientation, or experience. In an inclusive setting, care providers approach discussions of sexual health and history in an open and nonjudgmental manner and:

  • Meet patients’ sexual health care needs regardless of gender, gender expression, sexual orientation, and sexual experience
  • Recognize and respect that a patient’s gender identity, gender expression, sexual orientation, and sexual experience may not align with the care provider’s interpretation and understanding of each, may be fluid, and are defined by individual patients
  • Focus on issues relevant to a patient’s care and does not rely on patients to satisfy others’ personal curiosity or to ensure that care providers or staff are comfortable with a patient’s gender identity, gender expression, and sexual experiences
  • Avoid using stigmatizing language, such as “safe sex” or “high-risk sex,” when referring to patients’ experiences and maintain knowledge of up-to-date, accepted terminology
  • Take an HIV status–neutral approach to discussions of sexual health
  • Address structural, racial, socioeconomic, and cultural barriers to sexual health and health care

Empowerment: Care providers and staff refrain from making any assumptions based on a patient’s age, physical appearance, or gender expression and:

  • Ask patients to identify their preferred pronouns and then ensure use of these pronouns when addressing patients
  • Support patients in identifying their sexual identity, orientation, experience, and needs
  • Engage patients in shared decision-making for care planning
  • Support patients in setting the pace in discussions of sexual experience with their care providers and sexual partners
  • Support and encourage patients’ self-efficacy
  • Provide information that can help reduce stigma and fear, such as information about U=U (undetectable = untransmittable) for patients with HIV
  • Advocate for patients’ sexual rights, including the right to make sexual health–related decisions

Wellness: Recognizing that sexual health depends on more than just disease prevention or treatment and taking a comprehensive approach to sexual health care, care providers: 

  • Ask about patients’ comfort with sex or pain during sex and assist patients in overcoming challenges, including those posed by age-related physiologic changes, chronic disease, disability, or dysfunction
  • Recognize that the concerns of patients ≥50 years old may differ from those of younger patients
  • Recognize that patients’ sexual health concerns may change as they age and avoid assumptions based on a patient’s age
  • Screen for erectile dysfunction in patients who may be at risk
  • Educate patients about the possible sexual health effects of chronic conditions
  • Provide information and support for patients to achieve intimacy and sexual satisfaction

Harm reduction: To identify and meet patients’ needs for harm reduction counseling and education, care providers:

  • Encourage patients to disclose experiences that may be harmful, including activities that may lead to acquisition of STIs, such as condomless sex, drug use, and sex with multiple or anonymous partners
  • Ask patients if they engage in transactional sex and link to services as needed
  • Ask open-ended questions about any experience with sexual violence, intimate partner violence, or other types of abuse and link patients to services as needed
  • Educate patients about harm reduction and help them identify and implement manageable options
  • Ensure that patients who do not have HIV know about pre- and post-exposure prophylaxis and about how to access both

Reproductive health: Recognizing that reproductive health and services are central to sexual health for many patients, care providers:

  • Provide information about contraceptive choices for all genders
  • Link patients to gynecologic and obstetric care, abortion services, and other services as needed
  • Educate patients with HIV who wish to conceive with a serodifferent partner about U=U

Information and resources: Sexual health–related information and resources are readily available in multiple languages and formats to meet diverse needs, including those of patients who:

  • Identify as lesbian, gay, bisexual, transgender, questioning, queer, intersex, asexual, pansexual, or gender fluid (LGBTQIA+)
  • Are ≥50 years old
  • Live with chronic disease or disability
  • Engage in transactional sex or sex work
  • Use substances
  • Have experienced trauma
  • Require housing, social services, or other specialized services
  • Have low or no literacy or health literacy
  • Have limited or no computer or internet access
  • Require or prefer receiving information via audio or video

Figure 1: Components of a Patient-Centered Approach to Sexual Health Care

Download Figure PDF

Resources for Care Providers

NYSDOH: 

American Academy of HIV Medicine: Sexual Health in HIV and Aging Clinical Recommendations

American Association of Sexuality Educators, Counselors, and Therapists (AASECT): https://www.aasect.org/

American Sexual Health Association (ASHA):

Better Health Channel: Sex and Chronic Illness

Canadian Public Health Association: Discussing Sexual Health, Substance Use and STBBIs (sexually transmitted and blood-borne infections)

Centers for Disease Control and Prevention (CDC):

Gay & Lesbian Medical Association: Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients

HIV.gov: Standing Up to Stigma

International Society of Sexual Medicine (ISSM): https://www.issm.info/

National Association of County & City Health Officials: Including People With Disabilities in Reproductive Health Programs and Services

National Coalition for Sexual Health:

National Institute on Aging: Sexuality and Intimacy in Older Adults

National LGBTQIA+ Health Education Center:

New York City Health: Sexual and Reproductive Justice

Positive Women’s Network: Harm Reduction Factsheet

Reproductive Health Access Project: Focus on Abortion, Contraception, Miscarriage

Reproductive Health National Training Center: Patient Experience Improvement Toolkit

Sexual Medicine Society of North America (SMSNA): https://www.smsna.org

The Well Project: Undetectable Equals Untransmittable: Building Hope and Ending HIV Stigma

Joint United Nations Programme on HIV/AIDS: Transactional Sex and HIV Risk: From Analysis to Action