Can we talk? Four tips to discussing STIs with patients

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Rates of sexually transmitted infections (STIs) in the United States are at epidemic levels. The number of diagnosed cases of syphilis, gonorrhea, and chlamydia has climbed for four consecutive years, with nearly 2.3 million cases in 2017 alone – the highest number ever reported nationwide. Alarmingly, these statistics probably understate STI prevalence in the United States. 

Many patients harbor infection without manifesting symptoms. Untreated, they may pass disease unknowingly to others or experience adverse health outcomes, such as loss of fertility. For these reasons, the CDC recommends annual lab testing for gonorrhea and chlamydia for all females 18-24 years of age and for women 25-65 years based on risk.

Lab testing is readily available and medical guidelines are clear, so why does STI prevalence continue to rise? While many factors are to blame, gaps in patient-physician communications - about sexual health, risk, and screening - is a major cause. 

According to results of a survey commissioned by Quest Diagnostics, 51 percent of females 15-24 years of age don’t want to bring up sex or STIs with their clinician, and 27 percent admit they don’t always tell the truth about sexual behavior. In addition, about one-quarter of primary care physicians agreed with the statement, “I am very uncomfortable discussing STI risk with my female patients.”

Communication gaps with physicians impact both young and older, men and women. Frank conversations between young people and healthcare providers about STIs is imperative, considering the CDC estimates young people aged 15–24 years acquire half of all new STIs, and that one in four sexually active adolescent females has an STI.

In separate research, we found similar communication gaps involving providers and women 25-65 years of age. Ob-Gyns, primary care physicians, and nurse practitioners expressed concerns about collecting adequate patient histories, citing discomfort discussing risk factors and concerns about offending patients (especially those who are married or older). A majority of these providers also said they use the phrase “at risk” when discussing STIs with these patients rather than the guideline-based phrase “high risk”, which may be perceived as threatening or accusatory.

Over the years as a practicing Ob-Gyn, and based on what I’ve learned through the Quest research, I’ve collected a few tips that may help facilitate frank, honest, and productive conversations with male and female patients, regardless of age:

Start with “just the facts” to lessen discomfort. Conversations can be initiated in the same conversational tone of voice that might be used to talk about non-threatening subjects, like nutrition guidance. I begin with, “As I say to all my patients…” and then share the facts: there is a high prevalence of gonorrhea and chlamydia in the United States; many STIs are asymptomatic; and STIs can have negative outcomes. These messages are judgement-free, and do not require a reference to sexual activity, which helps to transition the conversation into screening.

Stress medical guidelines to avoid “screening stigma.” Some patients may feel that when doctors order screening, they are being targeted – or even judged – because of sexual behavior. But the CDC provides very clear guidance for chlamydia and gonorrhea screening. As conversations about screening and risk proceed, practitioners can reference other STDs, including syphilis and HIV and emerging STIs such as M. genitalium infection, to determine additional screening needs.

Make it about “we” rather than “you.” Short of sexual abstinence, there is no way that any individual can be 100 percent sure that they are not at risk, so I focus on larger public health risk (“we all are at risk”) versus my patient’s individual behaviors (“you are at risk”). 

Instruct all clinical staff to follow your lead. Many patients see nurse practitioners and physician assistants for annual visits. Coordinating on office goals, messaging, and expectations will ensure that all patients are assessed sensitively and consistently. And given that the Quest research revealed that only four in 10 healthcare providers are aware of STI-related ICD-10 codes [most frequently STD Screening (Z11.3) and Contact with/Exposure to STIs (Z20.2)],it may also help to review coding to ensure that follow-up visits are productive as well.

No one wants to talk about STIs, and that’s part of the problem. Frank, direct conversations may be uncomfortable, but they are critical to safeguarding patient and public health.

Damian P. (“Pat”) Alagia, MD, is an Ob-Gyn and senior medical director of women’s health for Quest Diagnostics, the leading provider of diagnostic information services, including for women’s health and infectious diseases such as STIs.