Integrating Sexual Health in Clinical Care
Sexual health concerns will frequently surface first in conversation with primary care providers.
Sexual health affects patients' quality of life in almost every domain: safe, consensual, pleasurable sex stabilizes relationships and is a fulfilling, integral part of life for many. Yet only 12% of nurses reported that they address sexuality with a majority of their clients.1
Healthcare education lacks the fundamentals required to properly address sexual health, leaving providers poorly prepared to support patients when sensitive conversations arise. Most medical programs dedicate 3 to 10 hours to sexual health content, the majority of which is focused on reproduction and disorders of anatomy, rather than the practice of integrating sex into everyday clinical conversations. Even skilled healthcare practitioners may lack the tools to effectively incorporate this core element of integrated medicine, although successful intervention models like PLISSIT have been available for decades.
The PLISSIT model offers a succinct method for introducing sex into a clinical conversation, narrowing the scope of a patient's concern and offering effective counseling and treatment. (Its name derives from the 4 levels of intervention that comprise the model: permission, limited information, specific suggestions, and intensive therapy.) Healthcare professionals from all medical specialties can apply the PLISSIT model, orienting it to their patient-limited information.
The PLISSIT model is composed of 4 steps:
- The provider creates the space for a patient to bring up sexual health concerns, usually through open-ended questions such as “Is there anything about your sexual health you would like to discuss?”
- Once the patient has identified a concern, the provider can offer targeted information, including potential causes of the symptoms.
- A differential diagnosis is offered, with specific suggestions for how to begin addressing the problem. The provider can let the patient know that this is just the first attempt at addressing their issue, and that there are other treatment options if this suggestion does not solve their problem.
- If necessary, a referral can be made to a sexual health specialist, such as a sex therapist, pelvic floor specialist, or sex educator, to provide more comprehensive support and guidance.
Primary Care Benefits
The most crucial application of PLISSIT for primary care providers is in triaging and routing patients with complex sexual health issues to appropriate specialists. Sexual health concerns will frequently surface first in conversation with primary care providers, not specialists.
A qualitative study by Brooks and colleagues found that patients with vestibulodynia had seen up to 15 physicians before receiving a diagnosis, delaying treatment by an average of 24 months.2 Primary care providers can encourage earlier intervention by questioning all patients about common sexual health concerns, such as vulvodynia (localized vaginal pain) and dyspareunia (painful intercourse).
The most crucial application of PLISSIT for behavioral health providers is to differentiate between psychological and physical causes of pain, dysfunction, or difficulty. Behavioral health providers have a unique opportunity to delve deeper into the etiology of a patient's concerns by uncovering sources of stress, shame, guilt, or fear attached to their sexuality or sexual behaviors.
For instance, a woman referred to therapy for depression may note that, because of her mental health issues, she does not feel pleasure during masturbation or sex. A provider can use the PLISSIT model to determine whether her sexual difficulties stem from her depression, or whether they have a physiological cause, such as lichen sclerosus or pelvic floor damage. If the latter, referral to a sexual health specialist is warranted.
Oncology and Other Chronic Disease Specialties
The most crucial application of PLISSIT for chronic disease specialists is to identify potential adverse effects of treatments and offer strategies for preventing sexual morbidity. Providers should be able to offer time markers for returning to sexual activity after invasive procedures and suggest interventions such as dilation or topical estrogen to counteract sexual adverse effects.
Despite these crucial care needs, a recent survey of gynecologic cancer patients found that 62% reported never having a physician-initiated conversation about the sexual effects of cancer or treatment. Moreover, those who had not discussed sexual health with their provider were significantly more likely to report complex sexual morbidity.3 Early use of PLISSIT can prepare patients for the expected sexual effects and begin the process to restore sexual function.
Minority populations, such as LGBTQ people, sex workers, and non-monogamous individuals, have their own unique sexual health considerations that well-informed providers should include in discussion. The PLISSIT model is optimal when providers reflect on their own biases and seek to provide safe spaces for all populations, using additional resources like conferences, books, and webinars that focus on various communities. According to Michael Giordano, a licensed clinical social worker in Washington, DC, “we are in a society that has stigmatized LGBT people, pathologized kinky and [polyamorous] folks, and patronized sex workers.” Healthcare providers need to “check their own beliefs in advance and continue doing so as they work with sexual minorities.”
For practicing clinicians, incorporating sexual health into patient care is as simple as starting a conversation, asking guiding questions, and ensuring the patient feels comfortable and safe. According to Nancy Niemczyk, CNM, PhD, Nurse-Midwifery Program Director at the University of Pittsburgh School of Nursing, in Pennsylvania, taking the initiative to begin those conversations is well worth it. “About 2 or 3 years into clinical midwifery practice, I realized I needed to get more comfortable talking to people about sex, so I made a conscious decision that for an entire month I would bring up sex with every single client I saw. That got me over the barriers!”
- Matocha L, Waterhouse J. Current nursing practice related to sexuality. Res Nurs Health. 1993; 16:371-378.
- Feldhaus-Dahir M. The causes and prevalence of vestibulodynia: a vulvar pain disorder. Urologic Nurs. 2011; 31(1):51-54.
- Hill EK, Sandbo S, Abramsohn E, Makelarski J, et al. Assessing gynecologic and breast cancer survivors' sexual health care needs. Cancer. 2011;117:2643-2651. doi:10.1002/cncr.25832