Advancing Sexual Health Histories in Dermatology: A Modernized Comprehensive Approach for Diverse Populations
According to the CDC’s 2022 STI Surveillance Report, sexually transmitted infections (STIs) have seen a 1.9% increase in diagnoses over the past five years, underscoring a persistent public health challenge.1 STIs disproportionally affect LGBTQ+ individuals, predominantly men who have sex with men, as well as racial minority or Hispanic ethnicity groups.1Although this discrepancy is thought to be initially attributed to sexual behaviors, the increased incidence of STIs in these populations are complex and multifaceted. For instance, in some minority communities, such as among Black individuals, there is evidence of less frequent oral and anal sex than Hispanics and White yet a significantly higher prevalence of STIs.2 This may instead highlight disparities in quality of sexual health care received, resulting in higher prevalence of STIs among these communities and their sexual networks. As demonstrated in studies of adolescents and adults, there is a deficit in education on the common types of STIs, symptoms, and potential complications.3Dermatologists may frequently encounter STIs with cutaneous findings in diseases such as mpox, syphilis, disseminated gonococcal infection, herpes and HPV.4,5Furthermore, it is vital to the practice of dermatology, historically linked to venereology (the study of STIs), to feel comfortable in collecting a sexual health history to properly diagnose and manage these STIs as well as counseling patient education of their awareness.
Establishing a Comfort Level
To initiate the process of gathering a sexual health history, dermatologists should feel confident and comfortable in doing so. However, this can present a challenge due to the limited exposure to sexual and gender minority content during undergraduate medical education, as well as within many dermatological residency curricula.6–8 Nonetheless, to begin doing so, introductory statements should normalize taking a sexual health history among all patients and ensure confidentiality. Furthermore, to assess the need of completing a comprehensive sexual health history, questions regarding (1) sexual activity within the last year, (2) genders of partners, and (3) number of partners within the past year are screening questions to begin with per the National LGBTQ Health Education Center.9
Current dermatological clinical guidelines recommend utilizing the Center for Disease Control and Prevention’s 5 P’s approach: Partners, Practices, Protection from STIs, Past history of STIs, Pregnancy plans.6 This technique enables dermatologists to collect a generalized sexual health history via trauma-informed care approach. Per Fenway Health, an additional few questions may help understand sensitivity to language regarding preferred language for body parts.10 For example, utilizing non-gendered language like “chest” and “bleeding” in place of “breasts” and “period or menstruation.”
Diversity of Identities
Ultimately, it is valuable to acknowledge the heterogeneity of sexual identities and diverse sexual partnerships and practices to better understand likelihood of STI risks. As sexual gender and identity have begun to be viewed on a spectrum, it is important to ask questions concerning sexual orientation since the risks for STIs based on sexual behavior may not always be equivalent depending on identity. For example, STI risks were increased among heterosexual and bisexual women who reported same-sex interactions but decreased among gay “lesbian” identifying women with same-sex sexual histories.11 Furthermore, considering factors such as sexual and romantic relationships may help to understand STI risks as well. In a study assessing sexual health history and practices between monogamous and consensually non-monogamous (CNM) sexual partners, those in monogamous relationships did not report lower rates of STIs than CNM individuals.12 Despite increased number of sexual partners in CNM individuals, monogamous individuals were less likely to report STI testing, possible leading to underreporting, and one in four reported sexual infidelity, increasing risk of exposures.12
Furthermore, utilizing clinical examination findings to gather an individualized social history may effectively complement sexual health history-taking. As depicted in Figure 1, finding donut-shaped pseudo-pustules on exam may clue dermatologists into mpox that can be further elucidated by asking questions about recent travel, attendance of large gatherings (e.g. pride events), participation in sex on-site venues (e.g. sex parties, saunas), and chem-sex (i.e. sex associated with drugs like mephedrone and crystal methamphetamine) as outlined in a 2022 human mpox case series.13,14 For indiscriminate rashes that may be concerning for secondary syphilis, several case reports illustrate the value of considering age of first sexual contact and occupational status, e.g. sex worker, to consider lifetime risks of STI exposure.15,16Lastly, for example, if assessing condyloma acuminata on the anal cavity of men who have sex with men, this may prompt dermatologists to inquire about positional preferences for penetrative anal sex. This may serve as an opportunity to educate patients on risks for anal cancer and transmission of HIV, both increased in those on the receptive side of anal sex.17
Importance of the Dermatologist
Overall, as STIs are on the rise, it is important for dermatologists to consider taking thorough sexual health histories to be able to fully capture their patients’ circumstances when assessing dermatoses. Creating an individualized sexual health history, as outlined in Table 1, builds upon the CDC’s 5 P’s approach by prompting permission and probing conversational and sexual preferences. Ultimately, it is upmost importance for dermatologists to create dialogue that precludes assumptions, utilizes nonjudgmental language, and prioritizes open ended questions to provide culturally competent care to everyone, especially sexual minorities, as outlined by the Office of Disease Prevention and Health Promotion.18
“When diagnosing an STI, explain it to the patient directly, including their long-term risks, risks for current and future sexual partners, and that there is the chance to have picked up more than one,” said Dr. Kieron Seymour Leslie, UCSF Department of Dermatology Faculty and HIV dermatology and Kaposi Sarcoma expert, in an interview. “It is important to provide open dialogue to educate patients on the need for screening for additional infections and future screening either with their primary care provider or an STI clinic and protection, such as vaccinations for HPV, mpox, HepB, if sexually active. If you’re [a patient] having sex, you do not absolutely know if the other individual is having sex with others and thus, assume you are at risk of STI acquisition and therefore, take preventive precautions like pre-exposure prophylaxis.”
The authors report no relevant financial disclosures.
2. Pflieger JC, et al. Racial/Ethnic Differences in Patterns of Sexual Risk Behavior and Rates of Sexually Transmitted Infections Among Female Young Adults. American Journal of Public Health. 2013; 103(5);903–909. Doi:10.2105/AJPH.2012.301005
4. Brown TJ, et al. An Overview of Sexually Transmitted Diseases: Part I. Journal of the American Academy of Dermatology, 1999;41(4):511–529. Doi:10.1016/S0190-9622(99)80045-0
6. Yeung H, et al. Dermatologic care for lesbian, gay, bisexual, and transgender persons: Epidemiology, screening, and disease prevention. Journal of the American Academy of Dermatology. 2019;80(3):591–602. Doi:10.1016/j.jaad.2018.02.045
7. Obedin-Maliver, J, et al. Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education. JAMA. 2011;306(9):971–977. Doi:10.1001/jama.2011.1255
8. Jia, J. L., Nord, K. M., Sarin, K. Y., Linos, E., & Bailey, E. E. (2020). Sexual and Gender Minority Curricula Within US Dermatology Residency Programs. JAMA Dermatology. 2020;156(5):593–594. Doi:10.1001/jamadermatol.2020.0113
10. Thompson, J. (n.d.). Taking a Sexual History with Sexual and Gender Minority Individuals.
11. Everett, B. G. (2013). Sexual orientation disparities in sexually transmitted infections: Examining the intersection between sexual identity and sexual behavior. Archives of Sexual Behavior. 2013;42(2):225–236. Doi:10.1007/s10508-012-9902-1
12. Lehmiller, J. J. (2015). A Comparison of Sexual Health History and Practices Among Monogamous and Consensually Nonmonogamous Sexual Partners. The Journal of Sexual Medicine 2015;12(10):2022–2028. Doi:10.1111/jsm.12987
14. Thornhill J, et al. The New England Journal of Medicine. 2022; 387(8):679–691. Doi:10.1056/NEJMoa2207323
16. You C, et al. Solitary Interdigital Condyloma Latum in a Female Adolescent: A Case Report of an Unusual Form of Secondary Syphilis. 2023; 15, 793–797. Doi:10.2147/IJWH.S408853
17. Quinn R, et al. Human Papillomavirus Infection in Men Who Have Sex with Men in Lima, Peru. AIDS Research and Human Retroviruses. 2012. 28(12), 1734–1738. Doi:10.1089/aid.2011.0307
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