Transcript: Discussing Sexual Health With Your Patients - An Interview With A Sexual Health Educator

​Liz Rohr:
A lot of people are like, "What questions do I ask? I am uncomfortable. I'm going to make the person uncomfortable." And so that people tend to avoid it, right? But I think what you're saying about that permission-based, making everything really permission-based is so crucial.

Well, hey there, it's Liz Rohr from Real World NP, and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

Thank you so much for being here. Will you introduce yourself, just background about where you work, or anything you want to share with us?

Genesis:
Great. So my name's Genesis. I'm a college nurse practitioner, and I work at a college. I was a nurse for a few years before I jumped on the nurse practitioner wagon, and so I've been doing this for a couple years, still a bit of a fresh graduate, but we see people from all ages as young as 16 to as old as, I want to say, late seventies and anything from ortho to reproductive health to well woman and small sprains and ankles, concussions, things like that.

Liz Rohr:
That's so cool. So it sounds like you're not just seeing undergraduates, you're seeing the whole university basically.

Genesis:
Yeah.

Liz Rohr:
Cool, cool. That's awesome. So you're seeing faculty members? Do you see family members of faculty?

Genesis:
No. So we keep it strictly to students and then we will see staff for first aid, vaccines, things like that, preventative short bits, but mostly it's students.

Liz Rohr:
Cool.

Genesis:
And we do have students who are returning or are just taking classes just for hobby or international students which those are pretty fun.

Liz Rohr:
That's awesome. That's really cool. That's awesome, and I actually have a lot of questions about college health, but we are going to primarily focus on sexual health because that's such a big topic and something you're very passionate about too.

So I think to start, we chatted before this recording, let's start by talking about getting a sexual health history because I know that that is such a pain point for so many both new and experienced providers because it can just be, I don't know, I think people just feel really overwhelmed with it, but anyway, what are your thoughts about obtaining a sexual health history? What is your kind of approach, your advice, your recommendations?

Genesis:
For sure. I think that, you and I talked about this, but it's something that should be addressed, the CDC recommends and other sites recommend, at least annually, and so it is a very uncomfortable topic for some people, just as much for the patient as much as the provider. And I think that before you even start getting into this topic, you do need to do a check in with yourself and see what things are you comfortable with? What responses are you comfortable with? What things might trigger you? And check your own biases and assumptions that you've made about a certain age group or a certain gender so that you know what you're coming in with, and you can educate yourself to be better prepared to serve your patient.

I like to start off with five P's, which is something that the CDC created. Now it's up to six P's. And so it's just a good approach, very methodical about how to start asking these questions in a way that's nonjudgmental, that's very factual, but also open ended. So things as far as pregnancy intention, protection, the six P's that were just integrated, talk about pride and any problems that the person might have as well as pleasure, right? And so those are the three pieces that I think were lacking in the five P's because we don't address, have you come out to your family? Are they supportive of your identity? Are they supportive of your orientation? As well as, do you have pain when you have intercourse?

And so those things were missing, and I think that initially these five P's were more targeted to our young population, and so we do have our baby boomers, we have older adults that, whether we want to see it or not, they're having intercourse or maybe they want to, but they're too shy to ask about how can I make it more pleasure for myself? And there are tools that we have. We can make referrals, we can talk to them, there's tons of things that we can do for them, but we can't do any of that unless we address it initially and we open that door to that conversation.

Liz Rohr:
Totally. So I don't want to put you on the spot to name all of the P's, but I'm thinking about, especially with students or newer grads who are like, "I don't even know what the P's are."

Genesis:
Yeah.

Liz Rohr:
Could you give us it a little overview of the P's? Or how you use the P's, even if you don't, you don't have to rattle them off. I'm not quizzing you, but what is your approach with that? What are the P's?

Genesis:
So I initially start off with asking, are you sexually active? Do you have sex? Right? Because then that leads you on a different road. If the person's not having sex, are you planning to? Have you ever? Right? If the person is sexually active, then what kind of sex do you practice? With what partners do you practice? And some people like to phrase it, what part of your body goes in who's part of the body? And the whole bit of that, and I'll finish with the P's, but protection, pregnancy intention, that also goes along with it, and there's a fifth one that I can't think of. I have it written down.

Liz Rohr:
I feel like there's always one that escapes in those little acronyms. You're like, "What is that last one?"

Genesis:
Yeah.

Liz Rohr:
So we'll link to the resources, the CDC resources, down below, but yeah, go ahead. What were you going to say about that?

Genesis:
And so that just helps to establish a little bit of framework so that when a person is asking for testing or a person is having some complaints that you wouldn't have thought, "Oh, maybe it's sexually related," you have that information for testing. If they're having rectal sex or having oral sex or whatever sex that they're having, then you can provide the correct testing for it because you're not going to be testing a urine sample when maybe you should have gotten a pharyngeal swab. And so in the end, this is what it's about. It's about giving the best care that you can with the information that you have.

Liz Rohr:
Yeah.

Genesis:
I do want to add in that before you start in that conversation, letting your patient know, "This is something that I ask all my patients. It's not just for you, but we do want to go over your sexual health. And so some of the questions that I ask are very private and I hope that you feel comfortable enough to talk to me about this today. If not, we can always talk about it at some other time." And so then you kind of leave that door a little open, and you make it okay for them to say, "You know what? I'm not interested, or I don't want to talk about it, or I don't feel comfortable." And that's okay. And then you just maybe address it in the future again.

Liz Rohr:
Absolutely. Yeah. I think that when I think about my own experience, because I'm also included in this journey of trying to step into this provider role, is I think a lot of people are like, "What questions do I ask? I am uncomfortable. I'm going to make the person uncomfortable.' And so that people tend to avoid it, right? But I think what you're saying about that permission based, making everything really permission based is so crucial. I actually have an episode I'll link to below. It reminds me of this topic is trauma-informed care where you're kind of like there's such a power dynamic already with you being the provider and them being the patient that we have to be really mindful of that permission. First of all, can we talk about this? This is something that you'd like to talk about. And they get to say no whenever, and they get to decline to answer whatever they want to.

But then I think the other thing, I love how flat you are when you talk about it, right? Because so many people have this really uncomfortable response of, "Oh, who are your partners?" Which is what you were saying. We have to think before we even get into the room. We have to kind of practice this. Even if we're just practicing pretend in our minds or whatever, but you have to get through what is going to come up for me in this visit? What do I have an issue with? And until we can get to that place of the way that you're saying things in this very matter of fact way, this flat, very matter of fact way, we have to think about those pieces.

But I think just sharing from my own personal experience, I'd love to hear what your thoughts are, but it feels like people are waiting for us to ask these things. The people who come in with the, there's somebody I follow online. I think it was, I think it's Dr. Millhouse, he's a urologist physician who was talking about, I'm an expert in the urologist mumble because patients come in and they're like, "I need help with this." Because they don't want to talk about it. But then the people who don't come in with that also want to talk about it. And so I guess my personal experience, and I'd love to hear yours, is when you bring this up with people, most of the time it's like 99% of the time it's a yes. I'm always asking permission. I'm always very delicate about it, very sensitive, but people want to talk about it, and they just want to be candid. What are your thoughts about that?

Genesis:
Definitely. I think that a lot of people appreciate just the fact that you're asking for permission, and that's that whole patient center approach is that shared decision-making model, asking for permission, using verbiage that they can understand, no medical jargons, respecting their privacy, and also just going in line with what are they comfortable with as well as going at their own pace.

Liz Rohr:
Yeah.

Genesis:
I mean there's tons of things that you can do in order to make it a lot more comfortable for them, and so again, just going back to that five P's, it lines it up in a way that's very professional.

Liz Rohr:
Yeah.

Genesis:
I think that sometimes we get caught up in this extreme curiosity to understand someone through other lenses, and we kind of take it a little advantage. That is a possibility. And so just lining yourself up and you can create a template if you want. Lining yourself up and asking these questions in this order keeps you very professional. They know that you're not out to get other information that you don't need necessarily. Right? Because sometimes we do get information that's too much, it's over the top, we didn't necessarily need it to make a diagnosis or to order certain tests.

Liz Rohr:
Yeah. Yeah. And I think when you talk about parts, I can imagine myself, my former self and my students being like, "There's no way I'm going to ask that." And the moral of the story is, the reality is that people want to talk about this and the more we can practice being matter of fact about it, it can be uncomfortable, I think, the first times that people are doing it, but once you get in into the hang of things, it really is the most supportive because I think it really ties into this kind of next question that we kind of summation type of question. We got multiple questions from the audience, but the question about STI testing.

Genesis:
Yes.

Liz Rohr:
So basically the scenario is people will come in, and I get this all the time, "Test me for everything." And you're like, "Okay. Awesome. And that's fantastic. I am really excited." And my experience is that there's a lot more questions that we need to ask, especially if they come in leading with, "Test me for everything." And so what are your thoughts about STI testing and your experiences with that? How to facilitate if somebody comes in to see you with that kind of chief complaint, what is your approach with those those patients?

Genesis:
What I initially tell them is, "I'm more than happy to order whatever tests you may need, but let's talk about what concerns you might have."

Liz Rohr:
Yep.

Genesis:
Right. What concerns do you have? Are you having any symptoms at this time? Did you have a recent encounter? What are you worried about?

Liz Rohr:
Totally.

Genesis:
And so if they're concerned about syphilis, let's say, and they intercourse a week ago, too soon to test, right? Things of that matter and so it just helps to zoom in on the tests that are actually needed whenever you ask these questions. And then also it just provides education to your patient when you go through a timeline. Chlamydia, gonorrhea, syphilis, HIV, this is when we can run these tests. "I can give you lab slips, you can come back in four months and have this done. I think that would be a better idea."

But also taking that opportunity to talk about protection. How do we keep you safe? It looks like this time you were really worried that something might have happened. How do we give you the tools that you need so that next time this happens again, you're not so anxious about this experience?

Liz Rohr:
Yeah.

Genesis:
I think every opportunity that, however small, whatever you say to your patient, however small it is, it's still an opportunity that you can take to educate them or prepare them for next time and to keep them safe because essentially these questions that we ask, yes, it allows us for better testing and diagnoses and treatment, but also it's to keep them safe, keep their bodies safe, keep them from being in dangerous situations, give them the tools necessary to make better choices.

Liz Rohr:
Yeah. Yeah. And I think it ties, so I love that approach of, I think, just thinking of through a couple of examples, like patients coming in, "I want to be tested for everything." "Okay, check, check, check, check, check. Here is your order lab slip." For people who feel really uncomfortable talking about sexual health, I imagine people will be tempted to do something like that, but to your point, we have to gather more information about symptoms, exposure, timeline of exposure, and sites of exposure. I think that when, someone I know did this DNP project about extra genital sites for STI testing specifically, I think, for gonorrhea and chlamydia, and there's just, I don't know what the data shows right now, but I think it's a lot of missed cases. So if we're talking about pharyngeal exposure, rectal exposure, et cetera, we want to think about that is so tied into that sexual health history, and so we have to be comfortable talking about that and letting this be a longer visit than just check, check, check, check, check.

Genesis:
Yeah. Yeah. Super important. Good point that you brought up is that three site testing, and you wouldn't get that information unless you brought up this history taking.

Liz Rohr:
Yeah.

Genesis:
What kind of sex are you practicing? With who are you practicing? And just going back to those basic questions is going to better prepare you to order the right tests and not waste time on unnecessary tests that might not be relevant to them, but also catch certain results that you might have missed had you not asked those questions or had your patient not be comfortable disclosing that information. That's a big piece is making them comfortable, checking your face, your expression, and not being... when they respond in a certain way.

Liz Rohr:
Totally.

Genesis:
It's just going to take you a lot further than-

Liz Rohr:
Definitely.

Genesis:
Than doing the opposite.

Liz Rohr:
Definitely. And I think I want to normalize, too, that I try very hard to be approachable and not threatening and patient-centered and trauma-informed, all the things. I'm very passionate about this, and people will still disclose much later than the first visit. Doesn't matter. Some people disclose on the first visit, and I'm like, "Wow, I've never told anybody that before." I'm like, "Oh my gosh, that's wonderful. I'm so glad. Let's help, blah, blah, blah." But most people don't. And I want to normalize that that's a normal experience, and it's nothing necessarily to do with you, but we do want to be mindful of our biases, our face, what we're bringing in terms of our own stuff because, and you and I talked about this, we come to our practices as full humans with our own perspectives, beliefs, choices, and also we do need to take care of people where they're at. Yeah. Do you have any thoughts about, I don't know. I don't know. Any words of wisdom I guess about that especially for a newer clinician who's kind of feeling uncomfortable with all of this?

Genesis:
The more you talk about it, the more comfortable you're going to be. Right? Practice makes perfect.

Liz Rohr:
Yeah.

Genesis:
Almost.

Liz Rohr:
Yeah. Right.

Genesis:
But being comfortable in your body also helps.

Liz Rohr:
Yeah.

Genesis:
There's tons of trainings out there, there's tons of books, there's tons of videos I mean right now with Instagram and YouTube and all those things, there's tons of resources. They have trainings for people who want to become health educators. I have been doing this since I was 18, not nurse practitioner, clearly, but talking about reproductive health, and so I'm very comfortable with it.

Liz Rohr:
Yeah.

Genesis:
So I think just repetition and reading and educating yourself and doing role play is going to be helpful. Just practice, practice, practice because the more you say penis, right, the more comfortable you're going to be. I mean I remember we had an instructor in nursing school who said, "When you get home, say this word and check yourself and make sure you're not flushing." Right? And for me I was fine, but it is outside of taking a history, if you're working in med surg or wherever you're working and you're placing a condom cath, right, you're going to have to say these things. And so just being comfortable with it again so that your discomfort doesn't pass on to your patient and then that gets affected.

Liz Rohr:
Totally. And I do have a strong flush response with anything. Anything. My face just turns red all the time. I have makeup on, so it's less red right now. But yeah, I think it's a good thing to practice. And I think that's just, it's so humbling being a new provider, whether you're a physician associate, nurse practitioner, physician, too. Honestly, it's so humbling that it's more, my perspective is opinion obviously. It's more important than we take care of our patients and put our egos aside and feel a little bit silly or embarrassed or feel like I'm not an expert at this. That's been my perspective of coping with that whole transition to practice is just got to eat that humble pie and take good care of our patients and practice, and it's going to get easier, and you can't go from nothing to an expert. It's going to be messy.

Genesis:
And that's a great point that you bring is you can always tell it to your patient, "Hey, I'm trying something new with my patients, and I'm still working on the way that I present it, but I just wanted to ask you a couple questions and feel free to answer or just skip." And just coming up with that initially I think is a good idea too on saying like, "Hey, I haven't done this before, or I've done this once or twice. I'm going to try and do the best that I can but heads up." And so that also just takes that power relationship, brings it down to an even playing field and then reminds your patient that, "Okay, this person's another human being, they're trying to help me. They're not over here coming from a different standpoint of trying to tell me what to do or looking at me under a magnifying glass."

Liz Rohr:
Totally. And I think it's really hard, especially as newer providers, of just, it's really hard to accept that you're allowed to have your own humanity and because it's like, "Oh well they're going to think I'm an idiot or they're not going to want to go to me anymore." And honestly I think there's just a transition of time where that doesn't change, that humanity piece doesn't change that whole time. You just get more comfortable with it. Right? Because I appreciate sharing my humanity with my patients in an appropriate way like that. And I think patients really do respond to that. And if they don't, then it's fine. They can see somebody else. But you get to be a human too. And I do love what you said, it really kind of evens the dynamic. It doesn't have to be, "I'm in charge here." We get to be full people.

Genesis:
Yeah.

Liz Rohr:
I have a question. I want to go back to what you said about, what did you say? Your sexual practices and your sexual partners? Is that what you said? How do have you have conversations? I think one of the pitfalls of sexual health does, one more thing to add before you answer is, I think one of the pitfalls is people come in and they're like, "Are you sexually active?" And there's an assumption about genders. There's assumption of you have one gender partner, one monogamous, one partner at a time. There's this paradigm, there's this cultural paradigm of this is how this works.

So how do you talk about that with people? How do you advise newer clinicians or again, even experienced clinicians, of how do you go into those conversations and elicit that information? So for example, if you have one person who is a cis male patient, and he has multiple sexual partners per week, and that's just his thing, and that's just an ongoing thing. And then you have another person who has a polyamorous relationship with multiple partners and multiple genders. Do you know what I mean? There's different, how do you go into a patient visit with one person in front of you and elicit that? What would you give us an example?

Genesis:
I think it starts off with a registration and asking about their gender identity and then from then on asking about their, or their orientation, I'm sorry. And then taking that information and framing your questions, but asking that initial question, "Are you sexually active? Yes. No." "Yes." "Okay. What kind of sex are you having?" And if they look at you confused, then you ask, "What part of your body goes into who's part of the body? Or what do you find enjoyable?" You can always frame it differently. And then going on to, "Do you have sex with men, women, or both?" It's going to be forever changing as far as the terminology that we use. And we kind of just have to roll with it.

Liz Rohr:
Also asking what are the genders? And also asking what are the genders of their partners? Because we can have people with multiple gender identities.

Genesis:
Exactly.

Liz Rohr:
Yeah.

Genesis:
Yeah. And you're going to have, you may have someone queer who's active with people who identify as men one week and then women the next week or in between the following, and you just don't know where they're at, and so I think what also helps is saying, "I'm asking these questions because it's going to better equip me to be able to order certain tests or take care of you in a better way. And so I know that they're uncomfortable, but if you could just answer as honestly as you can, it would help me and you the most." And framing it that way too. I've done that in the past where I ask these questions and then I thank them. I said, "I really appreciate how honest you were with me. I know it's a very sensitive subject, but it's really going to help me order the right test because if you had not mentioned this then I wouldn't have ordered this." So it's acknowledging the fact that this is uncomfortable and then also thanking them.

Liz Rohr:
And then letting them know at any time that they can not, which if they choose not to disclose information to us, we may miss things, but also they get to have that choice of like, "Okay, I'm done. I'm good." Because it can be very, it's just very sensitive for some people.

Genesis:
Yeah. And it could be that you wrapping your, that part of that visit with that.

Liz Rohr:
Yeah.

Genesis:
Might be like, "Oh wait, I forgot to tell you."

Liz Rohr:
Yep, yep.

Genesis:
Right. And so that's a good opportunity too. "Oh great. Fantastic. I can go ahead and order this test then."

Liz Rohr:
Totally.

Genesis:
Or, "Let's talk about that more."

Liz Rohr:
Totally.

Genesis:
But just framing your questions and as neutral as you can without assumptions and giving options when they're looking at you kind of blankly because a lot of younger people, a lot of older people are going to use different terms or they're not familiar with the terms that we're familiar with.

Liz Rohr:
Yeah. And I think when we give examples for patients, when we give options, it's kind of making it clear what we're specifically asking. But then also it creates a little bit more safety because it's like I've said these words and you can use these words or you can use whatever words. And if they come back with a different set of words, we use the words that they use and we just try our best. And some people, like you said, some people use different words for different body parts, for different practices, all that stuff, and we just try to be humble, and we try to leave it in an open place of just asking people to share. But I love that.

We have a couple other questions I wanted to touch on from the audience. So one of the questions was about, so we talked about the sexual health history, we talked a bit about STI testing. We didn't get into super specifics of the STI testing, and I think that's kind of on purpose like you and I talked about because these episodes stay up for a while, and it's really important to look at the most current guidelines, but I think the moral of the story with the STI testing is really it's tied to sexual health history and practices and three site testing, making sure that we're not just, oh, we're doing extra genital testing, we're doing all the sites of exposure, and we're keeping in mind what those timelines are and that's a lot of learning that we have to do, but as we approach each one, how soon can we test for HIV? How soon can we test for syphilis? How soon can we test for X, Y, and Z, right?

Genesis:
Yeah.

Liz Rohr:
But anything else you wanted to add about that, either the sexual health history or STI testing?

Genesis:
With STI testing, I know that, so there are a lot of people that are concerned about costs, right?

Liz Rohr:
Right. Oh, that's a good point. Yeah. Go ahead.

Genesis:
And so we talked about this, and I think that depending on where you work, whether it's a federally qualified center or it's a private practice, the information or the programs that you're exposed to are going to be different in different settings. And your state might have tons of other programs that you're not aware of because that's not the population that you deal with. You deal with patients who are insured, and so if you have someone who has insurance but once privacy or isn't able to afford their share of cost, don't be afraid to look around or ask other people if they know of other programs because the cost or the privacy piece is preventing someone from getting tested. We don't want to do that. You want to be able to offer as many services as you can, being conscious of the cost as well, but there are programs that offer sliding scale or maybe you can prioritize which one's most important.

Again, we can always do future orders, we like to call those, where you don't do it that day, but because you want to keep that relationship with your patient, you want to let them know that, "I heard you, I do want to help you. I'm going to do the best that I can. Here's a lapse for you to come back in four months when you would be better suited to have this test." Or, "Here you can go ahead and do this today." I mean, another part is you can collect a urine sample and send it out that same day rather than sending them to a lab and perhaps I'm having it done in two weeks or two months or maybe losing a lab slip and then they don't come back until a few months later to see you again and saying, "I lost my lab slip." Those sort of things we can do for our patients right then and there, and that would just bring those results a lot quicker, and you'd get sooner results for them and give them a peace of mind sooner rather than later.

What else about STIs? So as far as the five P's go, you have partners, practices, past history of STIs, protection, and pregnancy intention. And then the sixth part that was added on is on pleasure, problems, and pride. So as far as partners, we talked about that. Practices, we've touched base on that. Past history of STIs. Has this person in the past been diagnosed with syphilis? Right? That's important information that you want to know because if you order a test, and it comes back positive, then at least, "Okay, they had an infection in the past, I don't need to freak out and call them wanting to give them penicillin injections." Protection. Again, just another important point to talk about with them. What are you currently using to protect yourself.

And pregnancy. How far from now would they like to start a family? Whether it's a male or a female, whether they're cis or non-binary, whatever they identify with, it's an important conversation to have because they may or may not want to start a family. You don't know that unless you ask. And so how do you keep them healthy enough to get there? How do you place them on birth control if that's what they want to do in order to respect and guide that family planning that they're trying to reach?

Liz Rohr:
I love the question of, "Do you intend?" What is it? Oh, I just lost it. But it's something about do you want to, I phrase it as, "Do you have any plans of having a family? Would you like to have a family? And how far from now would you like to do that?" Because if you start with the answer of no, then that really leads you on two different paths. Yes or no is two different paths of counseling.

Genesis:
Yeah. And that's where the closed ended and open ended questions come from, right? You're always going to get a lot more information from open-ended questions than the closed ended ones. But asking them, "Do you want to have a family in the future? Is that something that you're thinking about? If so, how far from now would you like that to happen? What goals do you have that you want to accomplish before that happens and how can I help you get there?"

The sixth P that was added on is on pleasure. And that's where you touch on, "Is it enjoyable for you? Do you have pain? Do you suffer from other problems that I might be able to help you with?" You talk about pride, and we touched on this, but, "Do you have support from your family? Have you disclosed your identity to them?" Right? That's another piece that's important to talk about because a person may be in a relationship with person of the same gender and their family has no idea about it. And so is that something that they want to talk to their family about in the future? Do they need to role play? Should we refer them to therapy so that they can get some help on that, some coping skills, or is that causing so much anxiety for them or depression that they're doing self harm? There's so many things that can be uncovered through these questions. And then the last one is problems, which we talked about already, but difficulties when you're having intercourse.

Liz Rohr:
Yeah. And that really leads into one of the other questions. We had a lot of questions, but one of the things we wanted to talk about was about libido, sexual drive and sexual desire. How do you talk about that with your patients?

Genesis:
It's definitely a whole body approach.

Liz Rohr:
Yeah.

Genesis:
Because you're thinking of this, any other illness or any other chief complaint. You're going to ask questions, get a good HPI, you always talk about the HPIs, go through a physical or examine whatever the part of the body that they have complaints about, but also take into account their psychological state and also their relationship factors because it's such a dynamic area that you don't know what's causing what, or maybe this thing is causing this and therefore that's being caused by this. For example, if someone's having a low libido, then is this due to maybe cancer or maybe their partner or maybe stress, or maybe it's that they don't have an arousal or they're not reaching their climax. There's all these things, and so the more information you get, the more you can comb through.

If they're on a medication because they're depressed, that might be a cause. And so is this something that can be switched to a different medication that doesn't have that side effect? Or does this person, are they past that stage in their life where they were feeling this way? Can they be taken off it? There's a lot of avenues that you can take.
If it's more physical, there's tons of creams and pills and rings that can be given to women to help with those things. And with men, is it an issue of testosterone? And so just going through that whole body approach and systematically knocking things out and seeing where is this coming from? Not jumping straight into medication, but therapy, role playing. Can they talk to their partner about their concerns or is that something that they're not comfortable with as well as not being comfortable in their own body? Because body image is a big one. If they're not comfortable in their skin, that's going to affect their drive, that's going to affect the comfort that they have in bed.

Liz Rohr:
Totally, Totally. Yeah. No, I really love that. And I think another thing that's tied to it, well, first of all, the whole body approach, absolutely. I think it's of one of those other things of if you're not comfortable, and I think this applies not just to sexual health, but other chief complaints in primary care of, if you're not that comfortable with something, you're kind of apt to jump to the solution before you get into the problem, so it's like, "Okay, we'll send some medicine, we'll send some tests." But if we can take a step back and think about that bigger picture of what else could be going on, what else could be contributing, that can definitely help our patients, and I think it's also really tied into pain too.

There's a psychological component, there's a physical component, there's problem related, they're having physical pain, pelvic pain, for example. I just want to yell from the rooftops about pelvic floor physical therapy is a real thing that people don't really know about, and it can be extremely helpful for patients with pelvic pain. And I have an episode about that, I'll link to you below here. But yeah, it's really is such a whole body approach, and it's not just jumping to those test their solutions.

I wanted to also, one of the questions that came up was, I think it's in the Medicare annual physical exam, and there's a requirement to talk about sexual health. Like you and I have talked about already, this is something we should be talking about anyway, at least once a year at physical, at a patient's physical or just in general, but there was a concern that somebody wrote in about just how to have conversations with patients. They were just feeling uncomfortable having a partner there and how to have those conversations. And you and I talked about, before we started recording, talking about sexual health with older adults. I don't know. Where should we jump in with that? What are your thoughts about that? What do you want to share?

Genesis:
We'll start with a mini stat. My favorite, not so much. So we talked about this already, but 50 to 80% of males and females are having intercourse, right, over the age of 60.

Liz Rohr:
Yep.

Genesis:
So it just gives a perspective when you think about, "Oh, this older person who's 70 isn't possibly having intercourse."

Liz Rohr:
Yeah.

Genesis:
No, most likely they probably are.

Liz Rohr:
Yeah. What biases are you coming in with and what is older even mean, right?

Genesis:
We had a hard time define that, right? Is it 65? Is it 60? What is that? We have a lot of, our population's aging, and that number's growing, and they were 50 not that long ago, so what makes us think that this is no longer something that they desire? But you know what? These Medicare wellness visits, again, asking in the most dignifying way and letting them know this is part of their wellness check, Medicare is requesting, and it's a question that you need to ask, and they're more than welcome to decline. But just asking in a way, "Do you have intercourse?" Right? I find that when you're just very direct and very factual and very professional, people are more willing to open up rather than you're like, "Oh, I have a question to ask you and I don't want to." When you're not so sure of yourself, then they're like, "Oh, okay, maybe." And then they weirded out.

Liz Rohr:
Can I trust this person?

How are they going to respond when I say something? They're going to be like, "Ugh." Like that, no, for sure.

Genesis:
But asking that, and then again going into, "Is there something in your sex life that you struggle with that you want to talk to me about? Is it enjoyable to you or do you have concerns about or discomforts that you want to talk about?" Because a lot of these conditions that older aging adults have can be lessened or improved with certain therapies, whether it's psychological or medicinal or it's physical therapy, things of that nature. And so just having that conversation and again, checking your own biases at the door and letting them know that you're going to be asking them a very private question.

Liz Rohr:
Totally.

Genesis:
And going through that, right? Again, what can I do as a provider to help you have a more enjoyable sex life?

Liz Rohr:
Yeah.

Genesis:
The other part that I want to talk about, it's not so much related to older adults in general, but just asking these questions really empowers our patients to get to know their body, what they like and what they don't like, and so when you do that, they're more able and prepared to keep themselves safe, get tested, keep their partners safe, have more care for their body, be more picky with who they interact. I don't know how that's going to be received by people, but it just, asking these questions and allowing them to take better care of themselves is going to just put them in a much better situation had you not had these questions, had you not tested them, had you not asked them these things. Right? I don't know.

Liz Rohr:
Yeah. And I think I wanted to add, I went to this really great continuing education about, I think it was STI testing and treatment, and I can't remember what this equation is, so I should have looked this up beforehand, but it just occurred to me while we were talking about there's an equation of number of cases of STIs and then you have something about the behavior and then treatment behavior. I can't remember what the variable is. Do you know what that equation? I don't know.

Genesis:
I have not seen that.

Liz Rohr:
It's an epidemiological kind of equation. And basically the moral of the story is that for the number of cases in a population, you cannot intervene on behavior. Factually from epidemiological research, you can't, and I'll try to see if I can find this and put it in the resources, but basically I think that sometimes when we talk about sexual health related things, it brings up a lot of people's personal feelings about it, and truly what our job is in primary care and taking care of patients as providers is to keep them safe, is to assess for wellness, for illness, to test and treat and support them in that, right?

That is our job, bottom line, and the truth of sexually transmitted infections, at least in this epidemiological way, is that you cannot intervene on behavior. It doesn't pan out. We can have conversations, and like you said, when we talk to people, they can absolutely have different choices that they make potentially of keeping themselves safe. And also when we talk about population level, the bottom line is we just have to test and treat patients and without judgment, without our own personal feelings, whatever they are, that is the thing that's ultimately going to achieve our aims in global healthcare is keeping people well, is test and treat, test and treat, test and treat.

And hopefully we have those conversations as well. But just on a numbers basis, it's a big topic, but I really appreciate how you're bringing all of these things in a very matter of fact way, and I really do agree with the directness of, "Are you having sex?" Right? That's just the question. And they're like, "Okay.? I mean people might still not know what that means, but at the same time, I think about language too, of everyone comes with different languages. Not everybody speaks English, not everybody is from the US, it's talking about international students. So how can you be as direct and matter of fact and clear in your communication so that we're all on the same page?

So wrapping up, one question, we kind of touched on this earlier about billing or about expenses of testing, and then there was another question about billing and coding, and we don't necessarily have specifics about billing and coding, in this moment, but I can pull in some stuff about that, but I wanted to talk with you about your experience with resources. And I know that you practice in California. So what do you have to share for people about those kind of cost prohibitive pieces or resources to access when it comes to sexual health?

Genesis:
So in California, we are very lucky to have a program called Family Pact. And so that program is more geared towards family planning and reproductive health, and so depending on the person's income, their family size, they could even have insurance, but if privacy's an issue or the cost is a barrier to access, they can be eligible for this program, and so it's limited in the services that it covers, but it helps a ton because it covers STI testing, STI treatment, well woman exams, if UTIs or vaginal infections coincidentally happen at the same visit when you're filling the birth control, then that visit's covered along with the treatment, which is wonderful.

But there are laboratories that will do sliding scale as well if the person has a limited income. And so those are questions that you would ask your laboratory, your office manager, and I spoke with Liz about this, but just seeking out resources, asking your office manager, "Is there a program that we might be eligible for that we could bring in?" Or talking to your labs, you'd be surprised how many labs just want to work with other people because they want to get paid. And so if you just say, "Is there a packet that we can purchase or is there a discount that you can give us if our patients paid the same day?"

There's also tons of laboratories that are privately owned that are offering test kits for STIs that they'll mail to your home, and you'll collect samples, send it back out, and then you get your results through the app, so there's a lot of innovation going on around that. As far as other resources, you have Planned Parenthood, you have all these local clinics that a person could go to if you're not able to meet their needs there, if it's too expensive for them, so that's another thought.

Liz Rohr:
Totally. Yeah. And especially for, I'm thinking about NP students especially, I didn't know this until I was out in the real world, but federally qualified health centers typically have some sort of grant funding. It depends on the clinic, but either it's funded either through patient visits and the typical route, or they also have grant funding that supports things and some of the grants can be related to sexual health. Or you could talk to your supervisors about, "How do we go about doing that?" And sometimes you have a grant writer, sometimes that's just whoever's on staff who's passionate about getting grants.
And then there's 403B pharmacies too.

Genesis:
Yeah.

Liz Rohr:
That's more on medications versus on testing, but if patients qualify for the federally qualified health center, they can get discounted pharmacies through this 403B pharmacy that might be associated with it.

But yeah, I think that's the way that I've primarily found out about our family planning or sexual health resources that are available. We had a sexual health educator for a while at my clinic. I can't remember. We had some other type of funding, but that would be, I would agree with you, I think that's the first place that I would start is office manager or your supervisor, and then hopefully they can start to direct you, especially if you're not at a federally qualified health center. What state based resources do you have to potentially utilize when it comes to that funding specifically for sexual health related expenses or testing or education?

Genesis:
Yeah.

Liz Rohr:
Definitely. Well thank you so much for being here. This is super fun. I really appreciate you giving your time to us. Any other kind of parting pearls of practice or pieces you want to share?

Genesis:
I mean, I think it's just get started and do it.

Liz Rohr:
Yeah.

Genesis:
Because these are missed opportunities when we're not comfortable with it and we're like, "We'll ask next time," or, "I'll have so and so do it. I'll refer them to this person. They'll ask them." You're banking on that, but if you just get started, ask these questions, you most likely already have somewhat of a relationship with your patient, and they might just be waiting for you to ask them because maybe they are having a discomfort or a problem with their intimate life, and so you can be the person to help them and just broach that subject by asking that first question, "Are you having sex?"

Liz Rohr:
Yeah, absolutely. Thank you so much.

Genesis:
Yeah.

Liz Rohr:
I really appreciate it.