M Vendlinski, G Simons, J Yen, S Larsen
Background: It is widely recommended that sexuality be discussed during health-care assessments and treatment. Health-care providers often do not raise the topic of sexuality, even though patients typically welcome these conversations.
Purpose: The current study examines whether veterans report having discussions about sexuality with their psychotherapists.
Material and methods: Seventy-two veterans receiving individual psychotherapy at a US Veterans Affairs medical centre completed anonymous surveys. Surveys queried whether patient sexuality was discussed in psychotherapy, how the topic was broached, opinions on the relevance of sexuality in psychotherapy, and concerns associated with disclosing sexual information.
Results: The majority (76%) of veterans reported their psychotherapists were aware of their sexual orientation. It was much more common for veterans to broach the topic (51%) than for psychotherapists to ask (4%), even though the majority of veterans either believed psychotherapists should ask (44%) or were neutral on the topic (25%). Many veterans (43%) viewed their sexuality as relevant to their mental health problems, and most veterans (82%) reported that concerns over what would be entered into the medical record did not keep them from discussing their sexuality.
Conclusion: Psychotherapists often leave it to their patients to broach the topic of sexuality even though patients typically welcome the discussion or feel neutral. Since many veterans see their sexuality as relevant to their mental health problems, psychotherapists could play an important role in addressing problems of sexuality if they regularly raised the topic in psychotherapy.
Key words: veterans, sexuality, psychotherapy, LGBT, sexual orientation
Discussions of sexuality and sexual orientation are recommended in the provision of comprehensive, culturally competent care,1 and a recent policy within the US Veterans Affairs health-care system now mandates asking all patients about sexual orientation and sexual behaviour as indicated.2 Initial studies find that civilians seeking medical treatment welcome discussions with their medical providers regarding sexuality.3 Inconsistent with patient preferences, however, most health-care providers do not initiate discussions of sexuality with their patients.4 Embarrassment and inadequate training are common barriers for medical providers,5 and providers tend to vastly overestimate the possibility of giving offence by asking about sexual orientation and gender identity.6 While this phenomenon has been documented in the private sector with civilian patients, less is known about the attitudes of veterans towards discussing sexuality or sexual orientation with health-care providers in the Veterans Affairs health-care system, though that is starting to change.7
It is especially important to assess sexual practices and sexual orientation in the veteran population. Active duty women engage at elevated rates in high-risk sexual behaviours such as inconsistent condom use, multiple concurrent partners, and unintended sexual behaviour under the influence of alcohol or drugs.8 Compared to nonveterans, female veterans report higher rates of lifetime sexual activity, younger age at first intercourse, greater number of both male and female sexual partners, and higher rates of sexually transmitted infections.9 For male veterans returning from Iraq and Afghanistan, a significant proportion experienced sexual dysfunction.10 Male combat veterans diagnosed with post-traumatic stress disorder (PTSD) experience significantly higher rates of sexual dysfunction compared to veterans without PTSD.11
Much of the extant research on discussions of sexuality between health-care providers and patients has focused on interactions with physical health-care providers (e.g. physicians and nurses). Less is known about these discussions between psychotherapists and their patients. Discussions of sexuality in mental health treatment are particularly relevant as sexual dysfunction is more prevalent in those with common mental disorders including PTSD,11 major depressive disorder12 and substance use disorders.13 Further, those seeking psychotherapy are often prescribed psychotropic medications that carry sexual side effects.14 Given the increased risk for sexual dysfunction in psychiatric populations and appreciation for the value of holistic and culturally competent health care, there is growing sentiment that care providers should broach the topic of sexuality with their patients.1,15 Psychotherapists may be able to help address sexual dysfunction through direct intervention or referral, and it may be easier for some veterans to address such issues with a psychotherapist (with whom they have more time and regular contact than a primary care provider). Additionally, discussions of sexuality and sexual health address a more fundamental need for assessing general health risks, as well as attending to the functioning of relationships which can provide potent buffers against psychological stress.
Given the relevance of sexuality and sexual orientation to veteran mental health and to health more broadly, as well as the dearth of information about whether and how these topics are discussed in this population, we undertook a survey of veterans receiving mental health care to better understand whether and how such topics are discussed.
Materials and methods
We conducted an anonymous survey at a Veterans Affairs hospital in a large US city. Data were collected within three separate mental health clinics (psychiatry, female mental health, and psychotherapy—both general and PTSD). Blank surveys with cover sheets (asking veterans to complete surveys only if they received individual psychotherapy) were placed in the waiting rooms, and veterans completed them at will. Participants could deposit the completed survey into a locked box in the waiting room or use a reply-paid envelope to send in the survey by post. The study was approved by the organisation’s Institutional Review Board, and de-identified data were collected from March to June 2013.
In total, 72 surveys were returned. The sample was 51% female, 45% male, and 1% transgender identified (3% missing data). Most respondents (57%) were aged between 46 and 65 years, ranging from 18 to over 76 years. In terms of sexual orientation, 82% of respondents identified as heterosexual, 13% as homosexual, 4% as bisexual and 1% as pansexual.
Demographics. We assessed demographics (age, gender, sexual orientation). To encourage frank responding, we did not collect identifying information.
Discussions of sex life and sexual orientation, barriers and comfort. A measure was designed for this study, which assessed nine factors: whether the individual psychotherapist knows patient sexual orientation; how psychotherapists learned about it; how long into treatment before psychotherapists learned about it; whether veterans purposely withheld information about their lifestyle to hide their sexual orientation; whether sex life or sexual orientation is considered relevant to mental health or therapy; what would increase comfort with these discussions; psychotherapist response to hearing about sex life or sexual orientation; concerns about these discussions being recorded in the medical record; and desire for additional mental health services related to sexuality and sexual orientation.
In this sample of veterans, most (76%) reported that their psychotherapists were aware of their sexual orientation, while 22% were unsure.1 Only 4% of veterans reported that their psychotherapists had asked them explicitly (51% brought it up with the therapist themselves). Forty-four per cent agreed that psychotherapists should ask their patient about sexual practices and sexual orientation (17% disagreed, 25% were not sure, and 7% indicated ‘other’). Anecdotally, participants mentioned in open-ended responses that they would appreciate if psychotherapists would raise these issues or initiate discussions. Many (43%) believed their sex life or sexual orientation was relevant to their mental health problems or therapy (e.g. erectile dysfunction, depression, anxiety, substance abuse, relationship problems, reduced sex drive), and the same number (43%) did not (11% were not sure). Many (43%) reported that after discussing their sex life or sexual orientation with their psychotherapist, they were ‘more comfortable now’ and only 4% endorsed that they were ‘less comfortable now’. Most (82%) veterans reported that concerns about what would be entered into their medical record did not keep them from discussing their sex life or sexual orientation with their psychotherapist.
Though exploratory given the small sample size, we also examined whether lesbian, gay, bisexual and transgender (LGBT) and heterosexual populations differed in their responses to relevant questions. Interestingly, many responses were very similar (e.g. 46% of LGBT and 44% of heterosexual respondents agreed that providers should ask about these topics; 46% of LGBT and 42% of heterosexual respondents agreed that sex life or sexual orientation was relevant to care). Both LGBT (54%) and heterosexual (41%) respondents were more comfortable after discussing these issues. However, some responses differed: LGBT veterans were more likely than heterosexual veterans (15% vs. 2%) to indicate that they withheld personal information so as not to disclose their sexual orientation; and LGBT veterans were more likely to indicate that they wanted more services related to sex or sexual orientation (61% vs. 32%), though both populations wanted more of these services.
Overall, most veterans’ psychotherapists were aware of their sexual orientation, but rarely because psychotherapists had asked about it. Most of the sample agreed that psychotherapists should ask about these issues or were neutral on the topic, and nearly half believed sex life or sexual orientation were relevant to therapy. Results were largely similar in the LGBT subgroup, and both groups indicated a desire for more services related to sex or sexual orientation.
Limitations of this sample primarily involve the small sample size and self-report nature of the data (e.g. memories of discussions may not be accurate). This was not necessarily a representative sample and, indeed, it included a higher than average proportion of female and LGBT veterans. Nevertheless, given that this is a new population for this study question, our results provide relevant information.
The findings indicated that most veterans either want to discuss sexuality and sexual orientation with their psychotherapists or were neutral on the subject. Veterans recognise these topics as valuable and relevant to their mental health treatment. In fact, the majority of veterans in both LGBT and heterosexual groups felt more comfortable in therapy after discussing their sexuality with their psychotherapist. Our results suggest indirectly that even psychotherapists are often uncomfortable asking about sex life or sexual orientation. Therefore, psychotherapists are encouraged to seek training when appropriate, and initiate these discussions with veterans as part of providing comprehensive, culturally competent health care.
As psychotherapists broach the topic of sexual practices, they can play an important role in guiding veterans to the providers that can best meet their needs. Given that sensitive topics are often discussed in psychotherapy, therapists are well placed to broach this topic and to serve as a bridge between veterans and relevant providers in other disciplines. For instance, psychotherapists can help identify veterans who would benefit from referral to a prescriber for erectile dysfunction medication, or to a couples therapist. Psychotherapists could also encourage discussion of the sexual side effects of medications between patients and prescribers. Additionally, further training could position psychotherapists to assess for sexual history and risk identification around HIV, blood-borne viruses or sexually transmitted infections. Even if veterans do not wish to disclose information related to sexuality when first asked, asking about this topic opens the door for future discussion. Asking can send the message that sexuality is an important aspect of behavioural health, and that providers are ready to help if and when the veteran would like. Along with Veteran Affairs’ new mandate to ask all patients about sexual orientation and health, a training course has been created on how to do so for veteran- or civilian-oriented providers.16
Our findings, taken together with civilian empirical literature and general calls to include sexuality in comprehensive care, should encourage psychotherapists to ask veterans about their sexuality and sexual orientation, thereby opening the door to better overall care.