Let’s Talk About Sex
But that was about it. “No one talked about issues around intimacy” and interpersonal relationships, or the host of other dynamics from public policies to local cultural forces that can affect sexuality and sexual health, she said. “For sure, nobody talked about same sex partnerships or relationships,” she added, or other forms of diverse human sexual experiences and desires.
Some of this narrowness was a byproduct of the era’s culture, which was generally tight-lipped about anything other than the experiences of heterosexual cis-gendered individuals of reproductive age. Some of it, say nurses who got their degrees around this time, reflected a dominant idea in the field. “You were told that you made the decisions for other people about their health care based on guidelines,” says Wendy Grube PHD CRNP FAAN, Practice Associate Professor of Nursing and Director of the Center for Global Women’s Health. That often meant telling them how to change their individual behaviors based on one-size-fits-all advice rather than working with the complexity of sex and sexuality.
As one might expect, this flattened approach to sexual health just does not work. It historically made many people feel uncomfortable—or even erased—within health care settings, and often unable to get the care or messaging best suited to them, said Grube. This approach also led to some humbling experiences for practitioners of the era. “To this day, I recall an encounter I had as a student nurse-midwife when I was doing a gynecological exam,” said Kimberly Trout PHD CNM APRN, Assistant Professor of Women’s Health. “I asked, ‘Are you sexually active?’ and the woman said yes. I asked, ‘Are you using contraception?’ and she said no. I replied, ‘Are you interested in contraception?’ and she said no. I said, ‘Then I guess that you would like to be pregnant?’ and she said, ‘No, I’m gay.’ It just hadn’t crossed my mind as a possibility, and I felt badly that I’d made that assumption.”
Wendy Grube can relate. When she had a private practice in the Lehigh Valley during the nineties, a woman from a nursing home was brought in with vaginal bleeding. The staff thought she had some kind of malignancy. “I asked her if she knew why she might be bleeding and she said yes. She’d had sex for the first time in 20 years. It made perfect sense, but no one ever asked her if she’d had sex. The concept of post-menopausal women having a sex life, we knew it existed, but it was not discussed or addressed in a clinical setting.” That simply wasn’t part of nursing’s sexual script.
Fortunately, nursing’s approach to sexual health has come a long way since the late seventies, or even the early nineties. Instead of simplistic approaches and biases, Associate Professor of Nursing Bridgette Brawner PHD MDIV APRN said, nurses are “meeting people where they are, in the context of their experiences.” The field today also embraces, as Associate Professor of Nursing Anne Teitelman PHD FNP-BC FAANP FAAN puts it, “the perspective that larger factors play a role in one’s sexuality, and that one’s sexuality plays a role in one’s overall health.” In other words, sexuality must be an essential part of holistic, individualized, and responsive care for everyone.
What does this perspective shift allow? According to Assistant Professor of Nursing Melanie Kornides SCD RN FNP-BC, by drilling down into patients’ unique needs and experiences—especially those in historically marginalized groups—researchers and practitioners can develop more precise and effective messaging and strategies. This is a radical and beneficial transformation. And Penn Nursing has been at the forefront of this shift for well over 40 years.
The Sex-and-Health Connection
Penn’s leadership in the enrichment of sexual health knowledge and services started with Associate Professor Emerita of Nursing Rosalyn Watts EDD FAAN RN, who recalled working in a coronary care unit in the early seventies. One day she looked up at the monitor for one of her patients, “and it was scrambled.” She stepped back into the room to find him masturbating. That experience set her off on a decades-long train of study into how illnesses affected sexuality, and how to best advise patients on how to have safe and satisfying sex lives. It also led her to develop a unique standalone class on human sexuality at Penn Nursing, which she taught from 1974 to 1999. The class, she said, aimed to “get students comfortable with sexuality and recognize that people can be wired differently.”
Among other things, she taught students to take a thorough sex history—for everyone, always—and to factor in elements like relationship problems or a patient’s culture in both taking and responding to that history. Her class also earnestly engaged with the unique experiences of queer individuals and explored the role and development of sexuality throughout the human lifespan, which was fairly revolutionary in the early seventies.
Watts has her doubts about how many students truly internalized those lessons. But she certainly influenced Professor Emerita of Nursing Loretta Jemmott PHD FAAN RN, who took over teaching her class in 1999. Jemmott helped pioneer a community-focused approach to addressing the HIV/AIDS epidemic among Black youths. She explored the attitudes, beliefs, and practices that abetted the spread of the disease among them specifically. With community member insights and input, she developed optimally effective interventions based on their cultural frameworks and contexts to reduce their risk behaviors. Her interventions have been used in every state as well as at least eight nations abroad, with minor tweaks for local context. To this day, she is working on new interventions for new communities—such as a 12-hour educational program tailored for pre-teen and early-teenage males in South African schools that, according to recent analyses, seems highly effective at reducing risky sexual behaviors and forced sex.
During the nineties, Jemmott became a mentor to Antonia Villarruel. Early on in her career, Dean Villarruel set out to understand how beliefs about sex, gender-role norms, and taboos around sexual talk played into sexual behaviors among Latinx youths. Guided by Jemmott’s and Watts’s examples, she developed ¡Cuidate! (“Take Care!”), an abstinence and safer-sex intervention for small groups. Using discussions, interactive games, music, videos, and role-play, all couched within existing Latinx cultural frameworks, the program has proven effective in reducing risk behaviors.
¡Cuidate! was largely a reaction to her realization that Latinx “parents wanted their kids to be safe… They’d say, ‘Yes, I talk to my kids about sex.’ But then you’d ask the kids and they’d say, ‘No, they don’t tell me anything. They tell me to be careful.’ But nobody knows what being careful means.” So she decided to fill some of this information gap for youths. But in recent years, she has turned her eye back on parents, developing ¡Cuídalos!, or “Take care of them.” This web-based educational program aims to help Latinx parents learn how to have more informed and effective conversations about sex, sexuality, and sexual health with their adolescent children.
The Sexual Spectrum
Since the turn of the millennium, this community-informed approach to sexual health and wellness has increasingly become the norm in nursing. And researchers aren’t the only ones moving this norm forward. As society continues to more broadly embrace and explicitly discuss sexual and gender diversity, underserved communities have begun advocating more openly and assertively for better care.
Queer people have been especially keen to get health care providers to recognize diversity within that blanket label, according to Assistant Professor of Nursing Dalmacio Dennis Flores PHD ACRN. “For three or four decades,” he said, “there was an assumption that when you said LGBTQ, it was a monolithic group. Really, much of the focus has been on cis-gender gay males’ sexual health issues.” He noted that this narrow focus is a remnant of often-pathologizing concerns put on gay men and their sex lives in an effort to control HIV/AIDS during the eighties and nineties. But the experiences and needs of trans individuals, of queer cis women, or other queer communities, can be radically different than those of cis gay men.
Likewise, a growing senior population has been calling for more recognition of their sexual lives. “Intelligent, educated, and motivated middle-aged and older women are demanding more care,” including better-informed and specialized sexual care, Grube said. “That’s really changed the face of the whole menopause and post-menopause” field of women’s health care and research.
Community-informed approaches to diverse sexual experiences and contexts have been a hallmark of research at Penn Nursing for decades now. While simultaneously pursuing her doctoral degree, as a nurse practitioner providing primary care to adolescents, for instance, Teitelman found herself wondering why she was seeing an inordinate number of young women coming in to her clinic for repeat STIs and pregnancies. “We did all of our great nursing instruction on how you prevent this, and we had access to birth control,” she said. “So what was missing that this was still happening?”
When she asked young women about factors that could be influencing their sexual behavior, she learned something that seems commonsense now but was largely unconsidered then: Toxic relationship norms or experiences—such as intimate partner violence—can rob young women of a sense of agency over their bodies and sexual behaviors. Recognizing how bad relationships could limit young women’s abilities to act on standard, individual-focused safer-sex advice, not to mention their ability feel comfortable and happy in their intimate lives, Teitelman developed interventions (and continues to do so) to help them learn about relationship dynamics, as well as how to navigate relationships on their own terms.
More recently, Trout interviewed female-identifying sex workers in Kensington, Philadelphia, about their lived experiences and self-expressed health care needs. She and many colleagues had long assumed sex workers just needed more health care services to stay safe and well. But specific services (such as contraception and STI testing) were not on their list of top concerns, Trout said. “The biggest concern was that they wanted to be treated like people, not like drug addicts… to have someone spend time with them and make eye contact and give them time to feel they could reveal themselves.” Rather than navigate provider assumptions and put up with being rushed through visits with a hand-off of messaging and drugs, these women wanted to feel empowered and trusted to ask for what they needed.
Beyond advancing understandings of the sexual health needs and circumstances of various demographics, Penn Nursing faculty members are also committed to innovating new ways of identifying the needs of, engaging with, and serving different populations through interdisciplinary collaborations. “We’ve been working hard on hiring diverse faculty and attracting diverse students,” adds Grube, “and it has really brought incredible richness to sharing information and exploring concepts related to sexual and reproductive health care.”
A number of faculty members, such as Kornides, come from a public health background. She and her colleagues scour large data sources to spot macro sexual health trends and/or identify under-served communities that might be overlooked by more qualitative or clinic-centric approaches. Kornides is currently using insurance claims data to determine who initiates or follows through on HPV vaccinations—and who doesn’t. This information helps her to develop interventions geared towards increasing vaccination uptake and follow-through.
Looking at population level data on HPV vaccinations in the early 2000s, Wendy Grube started to consider the importance of location, beyond broad cultural or economic identities, in pinpointing sexual health needs and approaches. She noticed that Appalachia stood out as having the highest death rates for cervical cancer. Conventional wisdom held that this was just a result of the area being poor and rural, and that the answer was to increase the number of free clinics in the region. But, she notes, after the CDC spent millions on such services, cancer screening rates actually went down. “So I spent four months in the southern coal fields of West Virginia looking at the context of these women’s lives and trying to understand what was going on there.” She discovered a unique mixture of religious, sociological, and structural forces specific to the region, such as the belief, common among fundamentalist Christians, that HPV and cervical cancer are punishments for sin, along with everyone-knows-everyone’s-business attitudes that flaunted medical privacy rules, which contributed to this reality. Grube concluded that region- and/or sociocultural-specific initiatives would be needed to best serve this population.
Bridgette Brawner is also interested in the importance of place to sexual health. She uses computer mapping systems to see how sexual health variables, like the rate of HIV transmission, track “with disadvantage in the built environment: vacant houses, disorderly conduct, things that would be structural indicators of a struggling community.” Her work has revealed how physical environments as much as, or even over, cultural norms and practices can shape people’s sexual lives. A lack of affordable housing, for instance, can push some young women into unequal relationship dynamics with the men they end up living with. High incarceration rates destabilize families and destroy the fiber of communities, over time affecting sex ratios for available sexual partners. This in turn can affect the overlap of sexual relationships and ultimately the prevalence of sexually transmitted infections, making it easier for STIs like HIV to spread in a neighborhood. Even a general sense of neighborhood neglect can seemingly make people more prone to sexual risk behaviors. “It’s not that a broken window causes someone to have chlamydia,” she stressed. “It’s the psychological effects of seeing those windows on a daily basis.”
This focus on the importance of neighborhood factors has pushed Brawner to develop interventions that help people living in certain physical contexts to talk through, and learn to navigate, sex within them. She has also begun advocating for projects like neighborhood greening initiatives or blighted house remediation, along with policies like public housing development and reform, as essential to sexual health and wellness. She argues that keeping neighborhood factors in mind in the clinic puts nurse practitioners in a better place to help patients explore and improve their sexual health. Brawner says that with this environmental awareness, clinicians are able to ask better, more targeted questions to engage with patients. “If I’m in a neighborhood I know is coping with certain specific issues, like the hyper-incarceration of Black men, I might also ask, ‘Has your partner been incarcerated for more than 24 hours?’ and tailor advice based on the answer.”
Meanwhile, Assistant Professor of Nursing Robin Stevens PHD MPH has been exploring how digital neighborhoods, the dense social media networks young people inhabit, might influence their sexual cultures. She turned to this topic after interviewing adolescents in Camden, New Jersey, in 2013 and 2014 and realizing how important social media was to their lives. Her work explores how to use these networks as listening posts to better understand evolving influences on young people’s sexual health. But she is also working with Brawner and others to figure out how to reach people on the digital technologies they use. “If we know that young people in particular are not coming into a provider’s office,” said Brawner, “we can meet them in their Instagram feed” instead.
Teitelman has even started using neural imaging to explore whether differences in people’s brain structures and processing might map to certain sexual behaviors—especially among adolescents whose decision-making centers are especially in flux. “The idea is that if we have a better idea of sexual decision-making in the brain, maybe we can tailor our interventions a little differently or better.”
Staying Flexible and Getting Out There
Recognizing the nearly limitless number of ways one can understand people and their sexual lives and needs, the idea of meeting everyone where they are and serving them efficiently can feel daunting. “It does require a lot of flexibility and constant movement to improve our knowledge and our care,” said Grube. Even with flexibility and adaptation, nurses themselves can only reach so many people, and learn about so many contexts. The interventions they offer, the advice they give, might not be relevant for long as well, as people’s identities, contexts, and needs evolve over time.
This is a big part of why so many Penn Nursing faculty members try to build strong ties with the local community groups and entities they know people visit frequently. “When you start thinking about places like barbershops,” Brawner said, “the population you want to engage is already there—these structures, for some of them, are already built into their lives and are trusted resources.” Nurses can train individuals who are already part of one’s daily life so that one can get contextually appropriate, but also dynamic sexual health information, not to mention be persuaded to visit an STI testing center or engage with some other community resource or expert if and as needed.
Flores’s work focuses less on local institutions and more on empowering parents to fill that role for their gay and bi cis male children. His research has shown that many straight parents want to support their queer children in building safe, happy, and healthy sexual lives. But they feel awkward or at a loss for how to do so. Based on his interviews with gay male youths and their parents, Flores is working on a series of animated videos to help parents have more informed and effective conversations with their queer cis male children about sex, sexual health, and sexuality and make them aware of resources they can draw on as that engagement continues and evolves. Flores hopes one day to have a suite of interventions focusing on each distinct population within the LGBTQIA+ umbrella. He would also like to see clinical nurses help parents start thinking about sexual and gender diversity. “Best case scenario? I’d love for practitioners to be able to say, ‘Oh, just on the off chance that your child may have same-sex sexual attraction or other gender identities, here’s a resource.’”
José Bauermeister PHD MPH, Penn Presidential Professor of Nursing, looks to tech to develop reactive sexual health engagement and information. “A lot of the work I’ve been doing thinks about patterns, typologies, and locations,” he said, “so that when we’re building a website or app or some other virtual tool, the message that you get in some way aligns with” your context and the best practices tailored to it “and increases its persuasiveness and relevance.” Recently, he developed an HIV-prevention messaging tool for young men who have sex with men and find partners on dating apps. He quickly realized that the types of relationships they were looking for could change rapidly on these apps. Each new set of goals or intentions would require unique messaging. This prompted the creation of a web app, myDEx, which would feed them different messaging based on the type of relationship(s) they were exploring at any given moment. The myDEx web app was found to reduce sexual risk behaviors over time and improve young men’s decision-making across several HIV prevention behaviors.
All of this only scratches the surface of the many ways researchers and practitioners at Penn Nursing are trying to improve sexual health care. Bauermeister, for one, is also engaged in interdisciplinary work with faculty at the Penn School of Engineering—specifically experts on friction—seeking to improve the functionality of condoms. This may seem entirely divergent from the rest of the Penn Nursing faculty’s work on sexual health. But it speaks to their core ethos: The drive to embrace the limitless variety of human experiences, desires, and needs, and to provide the best care possible—ideally ongoing, reactive, and highly relevant—for every individual context.