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The Hole is not the Whole … Especially when it comes to screening for STIs.

Updated: Jul 24, 2019

By April Autry

I have so many patients who I see who come into my office requesting STI and/or HIV screening. This is great! And I love this type of visit. Not only because of its generally relative ease, but also because of the implicit relational aspect of it. We can’t be properly tested for STIs unless someone has had a good conversation with us about the details of our sex lives.

And those details really do matter! From the gender of our partners, the anatomy of our partners, contraception risk and intent, need for and use of barriers, toys, lubes, and of course type of sex is had – what holes are we giving, and/or receiving sex into – it’s all so relevant!

Why?? Well, in the news just this week (from the New England Journal of Medicine #veryrealnews) it was shown that if women are not tested for gonorrhea and chlamydia in their rectums (and they are having anal sex), nearly 20% of sexually transmitted infections could be missed. That’s a huge number! And I don’t know about you, but I have NEVER had my gyn provider ask me if I was having anal intercourse. Or even inquire about oral sex… This study looked at more than 3,000 women in a one year period who had volunteered that they had had anal sex in the last three months and again, 1 in 5 infections were missed! And this was among women who OFFERED information on their sex lives! Think of all the ones who didn’t share.... and oral sex wasn’t even looked at.

I totally get it – it can be super weird to talk about our very personal sexy time with a relative stranger … and I think we’d ALL rather just pee in a cup and call it a day, when it comes to getting tested for STIs, but is being honest and direct or having the discomfort of a swab in our rectum or throat, worth having an undiagnosed STI? Or living in a false reality where we are or the incorrectly reassured that we, or our partner, are STI negative?


The best way I was ever questioned about my sexual happenings was by a provider who simply asked “Can you tell me about your sex life?” I loved this! And have since incorporated it into my own practice. It makes a conversation that can be uncomfortable for patients (and unfortunately for providers as well!), more natural and empowering to the patient to choose how, and what, they want to share. Perhaps they are married but have an open relationship, or maybe only have receptive (bottom) anal intercourse with their boyfriend, or maybe her and her girlfriend generally have oral sex, but occasionally will play with a toy.

I will never forget a young man I saw once while working on a mobile unit that offered free sexual and reproductive health. He was about 18 years old, cis male and gay. He had a boyfriend of a few months and only had receptive anal intercourse with him, no condoms. After I was able to elicit this information I explained I would need to swab his rectum. He was surprised saying he had always just been asked to pee in a cup. I discussed the reasoning and the risk, he agreed, and he tested positive for rectal Chlamydia. He had had no symptoms and it was an easy win, and easy cure, but without me asking, and him being honest, it was an infection that could have been ignored for ages and increased his susceptibility to other STIs or HIV.


So, our take away message - if your provider isn’t asking good questions about your sex life, or making assumptions in how they screen you, it may be time to either challenge them to practice good, evidence based medicine, OR to look for someone who works hard to better know you, so as to better care for you.


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