Health care providers don’t talk enough to their patients about sex. Sometimes, that’s because they’re uncomfortable talking about the issue or because their appointments are too short. Other times, it’s because providers fear patients don’t want to talk to them about the subject (they’re usually wrong) or because they make assumptions about whether certain patients are sexually active at all.
In the US, the result is that many Americans with sexually transmitted infections (STIs) go undiagnosed and untreated — and that the stigma and shame some people feel about sex persists.
If you’re one of the millions who’s struggling to get the sexual health care you need, it’s worth thinking about how to “manage up” your sexual health care. That is, how to guide your provider toward the conversations you want to have; the testing, exams, or preventive strategies you might need; and the information that will help you make your healthiest decisions going forward.
In an ideal world, offering all patients proactive sexual health care would be a matter of routine for a wide range of health care providers. It shouldn’t be on you to initiate these conversations, but if it is, there are tools to help you get your needs met.
How to talk about STIs and contraception
Many patients feel really awkward bringing up sex with their health care providers. Bruce Furness, a preventive medicine doctor who’s practiced sexual health care in the Washington, DC, area for 22 years, wishes it weren’t that way: “If every primary care provider in this country would ask, at some point in their interactions with their patients, ‘Have you had sex in the last year, and was it pleasurable?’” it would open up so many helpful conversations with patients who simply don’t know where to start, he says.
In the absence of that, you can start by mentioning you’ve read about high rates of sexually transmitted infections and are wondering how to protect yourself. If it applies, you could explain you’re in a new relationship and ask to discuss the best ways to prevent infections and pregnancy. It’s also fine to just say, “I know I’m here for a checkup, but can we talk about my sexual health for a few minutes? I have some questions.”
(These and many of the other conversation suggestions below come from the National Coalition for Sexual Health, which has a whole list of questions to get you started, and from the American Sexual Health Association, which has tips on finding the right health provider. Both organizations have super-rich websites with lots of other info — go click!)
People often seek sexual health care to get evaluated for STIs. Health authorities recommend routine testing for a range of common infections among people who have oral, vaginal, or anal sex, especially when there’s a new sex partner or someone has multiple partners. It also makes sense to get tested if you’re sharing sex toys or having skin-to-skin contact in the genital area with another person. It’s smart to get tested for STIs if you have new symptoms, too; that includes those in the genital area, as well as more general, body-wide symptoms that follow sexual encounters (especially condomless ones) with people who have lots of other sex partners.
There are tons of sex ed and relationship resources for people of all ages. Here are some of the best:
Syphilis transmission, in particular, has risen explosively in the US over the past few years and is broadly underdiagnosed. Ina Park, a doctor at a San Francisco sexual health clinic and author of Strange Bedfellows, a book about the science and history of STIs, recommends that patients getting tested for STIs ask their providers to ensure they’re specifically testing them for that infection.
Your provider may suggest collecting samples during your visit for STI testing, or order tests to be done in a lab. Asking when and how you’ll get your results, as well as what happens if any of the tests turn up positive, can help you anticipate what’s next. You can also discuss which STIs can be treated and what that treatment might look like.
Providers offering sexual health services offer a range of strategies for preventing STIs and pregnancy, including both kinds of condoms and medications or vaccines that can prevent STIs. It might help to specifically ask about “pre-exposure or post-exposure prophylaxis” to learn about strategies for preventing some STIs by taking certain drugs before or after sex.
Don’t hesitate to ask about specific infections you’re particularly worried about. This summer, mpox (formerly known as monkeypox) is on lots of people’s minds, and there’s a vaccine available to protect people at risk. Additionally, the CDC just published new guidelines for using a medication morning-after-style to prevent syphilis in certain people, and you can ask your provider if it might be right for you.
Contraception — including long-acting options like IUDs, daily options like birth control pills, and emergency options like Plan B — is also squarely in the purview of sexual health care. If you’re concerned about unplanned pregnancy, ask your provider what the best options are for you and what side effects you can anticipate. It’s also wise to determine whether contraception is covered by your insurance, something you might need to contact your insurance company about. If the cost of your preferred contraception method is a concern, talk to your provider about how and where to get affordable contraception.
Sexual health care involves a different set of considerations and providers than abortion care. If you need help finding a provider to talk to about abortion, check out I Need An A or Abortion Finder. Aid Access, Plan C, and Mayday Health also offer information on how people in the US can access medication abortion online.
Pleasure, mental health, and relationship issues are also part of sexual health
Pleasure and desire should be part of sex — and if they’re not, health care providers can often help get you on the path to changing that. If sex or masturbation has stopped being (or never has been) pleasurable, you can ask your doctor about what might be the cause. If you’re a woman who’s experiencing pain during sex, you may want to discuss how to use lube, whether you might benefit from pelvic floor physical therapy, or, if you’re menopausal, estrogen cream or pills.
These kinds of conversations might feel weird, but remember — these issues are common, and they’re an important part of your overall health. You can tell your doctor you’re concerned you have a low libido, for example, or that you’re having trouble getting an erection or reaching climax, and ask if there are medications or behavioral strategies you can try. You might also want to ask if and how another illness or its treatment might affect your sex life; this includes men with enlarged prostates, whose treatment can sometimes affect sexual function.
There’s an enormous overlap between mental health and people’s enjoyment of sex.
There’s an enormous overlap between mental health and people’s enjoyment of sex, says Park. “Whether or not [sex] is pleasurable can actually be affected by one’s mental state,” she says. On the flip side, sex can sometimes be the cause of mental health harms: People may use it to fill a need that isn’t being met or may take risks or stay with abusive partners. Park sees many patients in their 30s and 40s who “are now much more aware of how their mental state affects the partners that they choose, and then how it affects their sexual experience.”
You can mention to your provider that you’re concerned your mental health might be impacting your sex life — or vice versa. You can also tell them you’re not always happy with the way your sex partner treats you and ask to chat about that.
Questions about partners are often on people’s minds when they get tested for STIs. Solicit your provider for pointers on how to talk to a partner about testing before having sex for the first time, or how to tell a partner if you test positive for an STI. Providers can also give you advice on what to do if your partner doesn’t want to use a condom.
Many sexual health providers can help you navigate the tricky waters around STIs and concerns about partners who are nonmonogamous. It’s okay to ask your doctor what to do if you or your partner have been nonmonogamous and you’re worried you might have an STI. (It’s also fine to ask whether you should be tested for STIs at all if you’re married and assume your spouse is monogamous!)
Who should I even be going to for my sexual health care?
It would be great if everyone felt comfortable going to their primary care providers for most of their sexual health care needs. However, says Park, people who come to see her for their care are sometimes avoiding their primary care providers due to past experiences of being shamed or judged at their practice. Religious exemption laws have recently made it easier for health care professionals to refuse providing certain kinds of sexual and reproductive health care.
Furness finds that unacceptable. “Every provider should be comfortable talking to any patient about sex,” he says. “We’ve made excuses for far too long.”
He suggests asking your primary care provider if they’re comfortable talking about sex. If not, ask why — it might be less about judgment and more about a lack of knowledge or time. If they bristle or get upset, Furness suggests filing a written complaint. “It’s not about getting them in trouble — it’s about resource allocation and figuring out what they can do both as an individual and as a health care home to make sure this doesn’t happen again,” he says.
“Every provider should be comfortable talking to any patient about sex.”
If you don’t have a primary care provider, or if you don’t want to get your care from them, you can find providers who specialize in sexual health using CDC’s Get Tested website. If price is a concern, clinics run by health departments are often the lowest-cost option.
In their guide on taking charge of your sexual health, The National Coalition for Sexual Health lists qualities to look for in a sexual health care provider: They should speak using words you understand, listen without assumptions or judgment, answer respectfully, ask for and use your pronouns, explain their reasoning for any examinations or testing, support your autonomy, and maintain your confidentiality. (Their front desk staff should also be respectful; tell your provider if they’re not.)
Some issues are truly best addressed by a specialist like an OB-GYN, a urologist, a women’s health nurse practitioner, a mental health professional, or a sex therapist. Talk to whoever ends up providing your first line of sexual health care if you’re concerned you have a less common issue that might require care outside of a general practice setting.
What about online providers and at-home testing?
Many people may find it more appealing to go online to address their sexual health care needs. They have a lot to choose from: There’s a dizzying array of direct-to-consumer home STI testing kits available, plus companies offering telehealth provider-guided care.
Although these options aren’t bad in principle, they’re not right for everyone, and many of them are a lot pricier than their alternatives.
Home testing is best for certain groups of people, says Furness: People who’ve never been tested for STIs or HIV, as a way of getting into the habit; those who live far from a place where they can get STI testing; teens living in urban areas (where the risk that any given sex partner has an STI is higher than in other areas); and sexual or gender minorities who haven’t come out to anyone — including their health care providers. People should only opt for home testing if they don’t have symptoms, says Park. When someone has, say, abnormal vaginal discharge, they should be tested for additional conditions that aren’t included in home tests, including a few that may be more serious.
Several sites make home testing for STIs and HIV available for free, among them I Want The Kit and Take Me Home. Although the tests do not include a telehealth or in-person visit with a provider, they typically ask you to choose a provider you’d follow up with in case of a positive result, and send your results to that provider if you do turn out to have an infection.
These kits can be a reasonable choice, but you do really lose something by not seeing an in-person provider, says Furness: “You’re missing that comprehensive sexual history,” which involves conversations about the kind of sex you have, the anatomical areas that are getting exposed to potential infections, and any behaviors that might create extra risk of STIs, he says. This is where finding the right provider, and knowing how to ask for what you need, especially comes into play.
The better your provider knows you, the more individually they can fine-tune your care. For example, they might recommend not just testing a urine sample, but also swabbing your throat or your butt to look for certain infections. Your provider might recommend more frequent screening if you’re having sex with lots of anonymous partners, sex while drunk or high, or sex in exchange for money. Also lacking from standalone test kits and some online services is guidance on what to do to help your sex partners get treated if you test positive for an STI.
Ultimately, though, the best sexual health care is the kind you actually get. “Some people like to come in in-person and have that interaction and discussion. Some people don’t want to and would rather test in their home,” says Park. “I actually feel like we need to have a lot of options to meet people’s needs.”
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