Advancing Sexual Health Histories in Dermatology: A Modernized Comprehensive Approach for Diverse Populations

Rash of secondary syphilis on trunk and limbs | Image credit: DermNet

According to the CDC's 2022 STI Surveillance Report, sexually transmitted infections (STIs) have seen a 1.9% increase in diagnoses over the past 5 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.¹ Although this discrepancy is thought to be initially attributed to sexual behaviors, the increased incidence of STIs in these populations is 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 a 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.³ Dermatologists may frequently encounter STIs with cutaneous findings in diseases such as mpox, syphilis, disseminated gonococcal infection, herpes, and HPV.^4,5 Furthermore, 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.

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 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 using the Centers for Disease Control and Prevention’s 5 P’s approach: Partners, Practices, Protection from STIs, Past history of STIs, and 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, using non-gendered language like “chest” and “bleeding” in place of “breasts” and “period or menstruation.”

Ultimately, it is valuable to acknowledge the heterogeneity of sexual identities and diverse sexual partnerships and practices to better understand the 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 because 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, possibly leading to underreporting, and 1 in 4 reported sexual infidelity, increasing risk of exposures.¹²

Figure. Infographic on utilizing clinical exam findings to direct sexual health history taking and differential diagnoses with Mpox used as an example

Furthermore, using clinical examination findings to gather an individualized social history may effectively complement sexual health history-taking. As depicted in the Figure, finding donut-shaped pseudo-pustules on an 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.^15,16 Lastly, assessing condyloma acuminata on the anal cavity of men who have sex with men 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

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 the Table, 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, uses 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

Upon asking the expert opinion of Kieron Seymour Leslie, MBBS, a UCSF Department of Dermatology faculty and HIV dermatology and Kaposi Sarcoma expert, these are the following comments he had to say: “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. 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.”

Mitchell Hanson is a third-year MD/MPH candidate at the Medical College of Georgia with interests in public health, sexual and gender minority topics, and dermatology.

References

1. National Overview of STIs, 2022. January 30, 2024. Accessed September 23, 2024. https://www.cdc.gov/std/statistics/2022/overview.htm

2. Pflieger JC, Cook EC, Niccolai LM, Connell CM. Racial/ethnic differences in patterns of sexual risk behavior and rates of sexually transmitted infections among female young adults. Am J Public Health. 2013;103(5):903-909. doi:10.2105/AJPH.2012.301005

3. Jefferson IS, Robinson SK, Tung-Hahn E, et al. Assessing and improving the knowledge of sexually transmitted infections among high school adolescents. Dermatol Res Pract. 2021;2021:6696316. Published 2021 Apr 9. doi:10.1155/2021/6696316

4. Brown TJ, Yen-Moore A, Tyring SK. An overview of sexually transmitted diseases. Part I. J Am Acad Dermatol. 1999;41(4):511-532.

5. Mpox: Caring for skin. Accessed May 10, 2024. https://www.aad.org/member/clinical-quality/clinical-care/mpox/treatment

6. Yeung H, Luk KM, Chen SC, Ginsberg BA, Katz KA. Dermatologic care for lesbian, gay, bisexual, and transgender persons: Epidemiology, screening, and disease prevention. J Am Acad Dermatol. 2019;80(3):591-602. doi:10.1016/j.jaad.2018.02.045

7. Obedin-Maliver J, Goldsmith ES, Stewart L, 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 JL, Nord KM, Sarin KY, Linos E, Bailey EE. Sexual and Gender Minority Curricula Within US Dermatology Residency Programs. JAMA Dermatol. 2020;156(5):593-594. doi:10.1001/jamadermatol.2020.0113

9. Taking Routine Histories of Sexual Health: A System-Wide Approach for Health Centers. (2015). LGBTQIA+ Health Education Center. Accessed September 23, 2024. www.lgbtqiahealtheducation.org/publication/taking-routine-histories-of-sexual-health-a-system-wide-approach-for-health-centers/download/.

10. Thompson J. . Taking a Sexual History with Sexual and Gender Minority Individuals. March 2020. Accessed September 23, 2024. https://www.lgbtqiahealtheducation.org/wp-content/uploads/2020/03/6.-Taking-an-Affirming-Sexual-History.min_.pdf

11. Everett BG Sexual orientation disparities in sexually transmitted infections: Examining the intersection between sexual identity and sexual behavior. Arch Sex Behav. 2013;42(2):225-236. doi:10.1007/s10508-012-9902-1

12. Lehmiller JJ A comparison of sexual health history and practices among monogamous and consensually nonmonogamous sexual partners. J Sex Med. 2015;12(10):2022-2028. doi:10.1111/jsm.12987

13. Prasad S, Galvan Casas C, Strahan AG, et al. A dermatologic assessment of 101 mpox (monkeypox) cases from 13 countries during the 2022 outbreak: Skin lesion morphology, clinical course, and scarring. J Am Acad Dermatol. 2023;88(5):1066-1073. doi:10.1016/j.jaad.2022.12.035

14. Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022. N Engl J Med. 2022;387(8):679-691. doi:10.1056/NEJMoa2207323

15. Crouch EM, Stein MTO, Geringer MR, Weiss A, Stalons M, Geringer JL. Don't Overlook Syphilis: An Atypical Rash in a Woman With Neurologic, Ocular, and Otic Involvement. Mil Med. Published online March 25, 2024. doi:10.1093/milmed/usae084

16. You C, Wang K, Liao M, et al. Solitary interdigital condyloma latum in a female adolescent: a case report of an unusual form of secondary syphilis. Int J Womens Health. 2023;15:793-797. Published 2023 May 18. doi:10.2147/IJWH.S408853

17. Quinn R, Salvatierra J, Solari V, Calderon M, Ton TG, Zunt JR. Human papillomavirus infection in men who have sex with men in Lima, Peru. AIDS Res Hum Retroviruses. 2012;28(12):1734-1738. doi:10.1089/AID.2011.0307

18. 2024 Phase 1 HP2030 Microsite Survey. Healthy People 2030. Accessed May 12, 2024. https://survey.alchemer.com/s3/7793088/2024-Phase-1-HP2030-Microsite-Survey