How to talk about sexual health issues?
How you approach a discussion in general makes a big difference when it comes to sensitive topics like sex, sexuality, and relationships.
So, before addressing the specifics of discussing sexuality, there are general strategies you can adopt generally to make such conversations flow more smoothly. Some of this section may very well be familiar to you, but it merits some review, if only to serve as a reminder of its importance for sexuality specifically:
- Dialog, not directives;
- Brainstorming, not solution providing
- Commitment elicitation.
Discuss, brainstorm, seek commitment.
Person-centered discussion. Be Askable.
These three principles all emanate from the idea that you are there to help the person define their own problems and find their own solutions. A person-centered approach seeks first to understand, then to walk side by side in seeking solutions, solutions to which, in small and large steps, the young person can commit to action.
PLISSIT and other Models
Another way to think about this is the PLISS part of the PLISSIT model used by some therapists. These steps are:
Permission giving – normalizing feelings
Limited Information – providing information to increase understanding of the diversity that exists, or specifics about an inquiry
Specific Suggestions – Generating ideas and making a plan for actions
(the IT is Intensive Therapy and is beyond the scope of this work and our focus).
Dialogue versus Directives
Engaging in dialogue about sexual health can be difficult. Knowing how to ask questions and how to respond to answers is often just as important as exactly what you ask about.
Remember that your initial goal is to help the person make the unobservable observable by talking about it: what’s troubling them, how do they feel, what’s the problem? To do that well, we cannot put our own words or ideas into the person’s head. Instead we have to ask open-ended questions, listen to the responses, clarify what we hear and move forward.
Open-ended, non-judgmental questions and active listening
You should acknowledge the person’s courage for talking about such difficult topics and emotions. Remind them that they don’t need to be embarrassed or ashamed (“I know this must be difficult to talk about, and I’m so glad you can share this with me”).
Asking open-ended questions, and listening actively, takes time and patience, but it is important. It is often more important to listen without judgment to someone who is willing to open up to you than it is to give advice. You may need to give them a long time to respond – it is common for individuals who are struggling with personal issues to show pauses, sometimes long ones, in their dialogue.
Lyrics and Music.
We often say this interaction is like a song. What we say is the lyrics and how we make them feel is the music. People do not forget the music, while they may forget some of the words.
Silence is hard, but important.
Silence is hard, but is an important part of active listening. The temptation is to fill the silence by talking when a situation is uncomfortable; however, allowing the silence to settle also may spur the other person to clarify their own feelings or to open up further. The other person is likely just as uncomfortable with the silence, and quite likely moreso!
While engaging with someone in a discussion of sexuality or other emotionally charged issues, there are some straightforward principles that you likely already use:
- Give your full attention, and make eye contact.
- Speak only when the other person has finished or when you are asked a question.
- Be non-judgmental by not debating values or morals but allowing the person to clarify their issues.
- Don’t act shocked or disappointed — this creates distance.
- Respect confidentiality, but do not promise it.
A word about confidentiality
We all know that confidentiality is important in gaining someone’s trust. You are probably very careful to respect the confidentiality of those you advise. However, sometimes it will be important to involve others (family and health and mental health providers) to help your client. Depending on the situation, you may need to involve their significant other, friends, or others in the organization. In some cases, you may even be required by law to report what you discuss to a reporting agency.
So, you may need to say to someone “Normally, I keep what people say to me in strict confidence. But in some situations, I have to ask for help from others.”
The concept of maintaining a conversational dialogue may seem self-evident; however, there are some ways that conversations can easily devolve into directives, where you may end up telling the person you are concerned about what you think and what you want them to do. Moreover, it’s not always obvious when this happens.
Maintain Conversational Dialog
One way this can happen is when you try to get confirmation of something you have heard. You may restate the situation, which is an excellent thing to do, but then you may not ask them to actively endorse your restatement—assuming that if the person does not disagree then you must have gotten it right. However, much of the time people are simply not willing to disagree. So, let’s look at an example:
“Seems like you have been struggling about coming out to your friends. This has caused a great deal of anxiety for you but you think you are ready to do that, You haven’t engaged in sex, which is good, and you aren’t depressed, which I’m really glad to here. <Pause> So, what’s your plan for telling your friends?”
What has happened in this conversation? This YDP does not ask the adolescent to confirm the summary and also ‘closed the door’ on the conversation by expressing relief about the sex and depression. Compare that to the following dialog:
“Let me make sure I understand what you have said. You are struggling about coming out to your friends. This has caused a great deal of anxiety for you but you think you are ready to do that.”
“Is that right?”
“Great. Can we talk about each of those a little more? So, what’s your plan for telling your friends?”
The YDP would likely follow up on sex and mental health as well, ending each with a comment that opens the door and that elicits commitment, e.g. “Okay, so I want you to know that it will always be okay for you to come talk to me if you are feeling down or have any other concerns regardless of how personal or embarrassing they may seem to be. I am here to help. Will you do that?”
Brainstorm Solutions and Next Steps
In addition to asking open-ended questions, and being sure you get active confirmation of your understanding, there is a related concept that applies more to working toward solutions and determining next steps.
Remember, person-centered dialog is about helping, not telling. So how do we help someone with a problem? By helping them brainstorm solutions!
Let’s say you were talking to someone about a body issue that might be related to a sexually transmitted infection. You might simply say, “hey, you need to go to the doctor,” but that’s your idea, and not theirs, even if it is a good idea! Instead, wouldn’t it be better if you help the person you are concerned about brainstorm solutions, to get them to better “buy into” and take responsibility for their well-being.
“So, Rick, do you agree that something might be physically amiss?”
“Okay, what’s something you might be able to do about it?”
The conversation then can be lead toward going to a clinic or provider by carefully weighing pros and cons of whatever the adolescent brings up, e.g. “I could just wait and see if it goes away.” “I could put cream on it.” “I could borrow some medication.”
“…I agree that going to a healthcare provider would be a great idea. Are you going to do that? Great. Let’s make a plan. How are you going to go?”
Regardless of whether you are concerned about something as important as deciding report sexual abuse or harassment or simply setting your next discussion, if you can get the adolescent to mention the solution rather than you telling them, then they will be more strongly committed to the action.
The goal with person-centered discussion such as this is help people themselves suggest good practices for being healthier, happier, and safer. Your goal is to help them work toward the things that might be effective, not to solve the problems for them. As in that familiar saying “It is better to teach a person how to fish than to just feed him a fish for today,” we want to help people learn how to help themselves for the long term.
Again, by helping them work out their own next steps, they are far more likely to be committed to those steps than if you simply suggest solutions.
Finally, let’s discuss the issue of getting commitment from the adolescent. One strategy that has been shown time and again to increase participation in different actions is to elicit commitment. This sounds somewhat complicated but is in fact the simple strategy of getting the person you are concerned about to actively and affirmatively endorse whatever next steps you have agreed upon.
“Will you come see me tomorrow, at 12pm?”
“Yes, I will.”
“Will you go to your appointment at the clinic tomorrow?”
“Will you let me know immediately if anyone continues to call you those names?”
Eliciting commitment flows naturally from brainstorming solutions together. If you have guided people to themselves suggest next steps that line up with what you have in mind, whether that is to come in more frequently, to accept a phone call, or even to go with you to a health care provider, then it is a short step for them to re-affirm that they will in fact do those things.
Some key principles to remember are:
- Ask open-ended questions
- Listen actively and empathetically
- Repeat back what is said and get confirmation of your understanding
- Work with the person to generate solutions rather than telling them what to do
- Elicit a commitment to a particular positive action or plan
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