Starting The Conversation

Patients want to talk to you about their sexual concerns—and they want you to raise the subject first. So how do you start the conversation?

The PLISSIT model can be a helpful tool for discussing sexual health or concerns with patients. The model provides the following guidance:

• Ask open-ended questions during routine history to give the patient permission to talk about her sexual concerns and reassure her that her feelings are normal and acceptable (see figure)

  PLISSIT MODEL Permission Limited Information Specific Suggestions Intensive Therapy

  
  Example: “Many women with menopause have sexual concerns. Do you?”
• Follow-up questions: “What do you mean by that?” “Tell me more.”
• Provide limited information
  • Education about female pelvic anatomy, the sexual response cycle, or the neurobiologic etiology of sexual problems
  • Discuss changes in sexual function throughout the lifecycle
  • Explain that sexual interest or desire may not be the first stage in response, and women may not experience orgasm 100% of the time
• Address the most important topics that you can in the limited time you have available; do not feel pressured to cover it all in one visit
• Encourage a follow-up appointment to focus solely on sexual health concerns
• Offer specific suggestions and solutions to treat the problem
  Examples: Use lubricant, over-the-counter moisturizers, or topical estrogen for dryness/dyspareunia; plan date nights and make sexual behavior a priority; improve diet, exercise, and sleep patterns to help overall mood
• Beyond providing basic information and suggestions, many primary care providers will want to refer a patient, possibly for intensive therapy, to qualified sexuality specialists (see box).

When conducting an interview, the PEARLS model can provide a useful structure to elicit empathy and open communication:

• Partnership: acknowledges that the health care professional and the patient are in this together
• Empathy: expresses understanding to the patient
• Apology: acknowledge that the health care professional is sorry the patient had to wait, that a laboratory test had to be repeated, etc.
• Respect/Reflect/Reinforce: acknowledge the patient’s suffering, difficulties, etc.
• Legitimize: acknowledge that many patients are angry, frustrated, depressed, etc.
• Support: acknowledge that the health care professional will not abandon the patient

The following basic clinical competencies can help any women’s health care practice integrate conversations about sexual concerns into routine patient visits:

• Initiate a frank concise conversation about sexual health in an appropriate health care environment
• Complete an appropriate sexual health history, appropriate to the concern
• Bring closure to a current appointment and segue to a subsequent appointment if needed
• When appropriate, recommend and refer to a qualified specialist best suited to address the patient’s sexual concern

Psychosocial Issues

Sexual function does not exist in a vacuum—it is influenced by relationships, fatigue, stress, and other sociocultural factors in a woman’s life. The following issues are important to assess to provide the appropriate context for your clinical evaluation:

• Sexuality and desire can be deeply affected by the health, stability, and status of the woman’s relationship
• There is an important difference between sexual drive (primarily the biological component of desire) and sexual motivation (primarily the intrapsychic and interpersonal components)
• Current and past abuse can impact sexual health; ask about a history of sexual abuse in routine health care examinations with clear, direct questions (e.g., “Has anyone, including your partner or a family member, ever forced you to do something sexually that you did not want to do?”)
• Cultural and religious backgrounds can influence sexual health; therefore, without judgement, ask about the patient’s values, beliefs, and desires regarding sexuality and sexual activity within her relationship(s)
• A partner’s sexual dysfunction can affect your patient’s sexual health and satisfaction; be sure to ask about the health and well-being of the patient’s partner(s) as well