16.5 Sexual Health Assessment, Sexual Function & Care After Sexual Assault

Taking a Sexual History That Actually Works

The blueprint asks the midwife to evaluate for concerns related to sex drive and sexual satisfaction, provide counseling for sexual concerns, assess for high-risk sexual behavior, and provide counseling and support following sexual assault. All four begin with a history that patients can answer honestly.

• Ask permission and normalize: "I ask all my patients about sexual health because it affects so much else. Is that okay?"
• Do not assume partner gender, relationship structure, what acts are involved, or which anatomy is used. Ask.
• Use the 5 Ps — partners, practices, protection from STIs, past history of STIs, and pregnancy intention — and add a sixth P for pleasure: "Is sex comfortable and satisfying for you?"
• Ask about pain, desire, arousal, orgasm, and satisfaction separately; patients report only what they are asked about.

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Desire, Arousal and Sexual Function

The older linear model (Masters and Johnson: desire → arousal → orgasm → resolution) describes some encounters but not most. Basson's circular model recognizes responsive desire — beginning from emotional intimacy and sexual neutrality, with desire emerging after arousal rather than before it. This is normal, especially in long-term relationships and postpartum, and telling a patient so is often the entire intervention.

A desire discrepancy between partners is a relationship phenomenon, not a diagnosis.

DSM-5-TR Sexual Dysfunctions

Each requires symptoms for at least 6 months, clinically significant distress, and that the problem is not better explained by severe relationship distress, another condition, or a substance or medication.

Common and Correctable Contributors

• Medications: SSRIs are the single most common pharmacologic cause; options are dose reduction, switching to bupropion or mirtazapine, or adding bupropion. Also consider combined hormonal contraception (raises sex hormone binding globulin), opioids, beta blockers, and antihistamines.
• Hypoestrogenism of lactation or menopause, producing genitourinary syndrome — treat with lubricant, moisturizer, and low-dose vaginal estrogen.
• Pelvic floor hypertonicity, endometriosis, prior perineal trauma, and vulvodynia — refer for pelvic floor physical therapy.
• Body image, fatigue and infant care demands, chronic illness, and history of trauma.

The PLISSIT Framework

Most sexual concerns are handled at the first two levels: Permission (validating the concern), Limited Information (accurate education), Specific Suggestions (lubricant, positions, timing, pelvic floor therapy, medication change), and Intensive Therapy (referral to an AASECT-certified sex therapist).

Two FDA-approved medications exist for hypoactive sexual desire in premenopausal women: flibanserin, taken nightly and carrying hypotension and syncope warnings with alcohol and CYP3A4 inhibitors, and bremelanotide, a subcutaneous as-needed injection whose commonest effect is nausea.

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Assessing High-Risk Sexual Behavior and Offering Prevention

Assess number and concurrency of partners, condom use, transactional sex, injection drug use, a partner's known risk or HIV status, and prior STIs — and respond with prevention rather than judgment.

• PrEP: the CDC recommends that HIV pre-exposure prophylaxis be discussed with all sexually active adolescents and adults, and prescribed to anyone who requests it. Options include daily oral tenofovir-based regimens and long-acting injectable cabotegravir.
• Doxy-PEP: doxycycline 200 mg taken within 72 hours of condomless sex reduces bacterial STIs and is recommended by CDC for men who have sex with men and transgender women with a bacterial STI in the past 12 months. It is not recommended for cisgender women, where trial data did not demonstrate benefit.
• Vaccination: HPV, hepatitis A and B.
• Expedited partner therapy where state law permits, and routine screening per CDC intervals.

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Care After Sexual Assault

The midwife's first job is to make the encounter the opposite of the assault: the patient controls every step.

Immediate Priorities, in Order

1. Safety and medical stabilization. Treat injuries first; assess for strangulation, which carries delayed airway and neurologic risk and is a strong predictor of future homicide.
2. Consent to each component separately — history, examination, evidence collection, photographs, testing, and reporting are all distinct, and the patient may accept any and decline any.
3. Involve a SANE (Sexual Assault Nurse Examiner) or SAFE program when available; they have specific training and better forensic outcomes. Offer a victim advocate and the National Sexual Assault Hotline (800-656-HOPE).
4. Forensic evidence can generally be collected up to 5 days (120 hours) after the assault, with jurisdictional variation. In most states a patient may have an examination and store a kit without reporting to law enforcement.

Prophylaxis and Testing

Trauma-Informed Technique and Follow-Up

Explain every step before doing it, offer a support person, let the patient undress and redress privately, keep the door and your questions predictable, and stop immediately on request. Avoid unnecessary lithotomy positioning and narrate what you are doing.

Arrange follow-up at 1 to 2 weeks and again at 1 to 3 months, repeating STI testing and screening for post-traumatic stress, depression, and substance use. Know your state's mandatory reporting rules, which commonly cover minors and vulnerable adults and sometimes injuries, and tell the patient in advance what you are required to report — before she discloses, not after.

Collecting Sexual Orientation and Gender Identity (SOGI)

The blueprint separately lists "asks about sexual orientation," "asks about gender identity," and "provides care to non-binary individuals." These are data-collection and care-delivery tasks, not optional sensitivities.

• Ask, do not infer. Sexual orientation (who a person is attracted to), sexual behavior (what they do and with whom), and gender identity are three independent variables. A patient may identify as a lesbian and have sex with men; a transgender man may need cervical cancer screening. Screening decisions follow anatomy and behavior, not identity labels.
• Collect SOGI routinely, on intake forms and verbally, with a two-step gender question — current gender identity (including a write-in and a non-binary option) and sex assigned at birth — because the two-step method identifies transgender and non-binary patients far more reliably than a single question.
• Explain why you are asking and how the information will be recorded, and ask what name and pronouns to use in the room, in the chart, and in front of family, which may differ.
• Non-binary patients are not a subset of transgender men or women. Ask what words they use for their own body parts and use those words during the examination; take an organ inventory rather than assuming which organs are present; and confirm before documenting anything that could out them.
• Record name and pronouns in the chart where other clinicians will see them, and correct the record — and yourself — without making the patient manage your discomfort.