Sexual intimacy is meaningful to people and may function as a buffer against chronic stress, depression, and suicidal ideation [3-6]. Conversely, disruptions in sexual intimacy may be a further source of stress that exacerbate existing difficulties. Veterans, especially women and sexual and gender minority veterans, experience a high rate of disruptions in healthy sexual intimacy. This is due to premilitary trauma, high rates of military-related injuries, multiple and often comorbid chronic illnesses (eg, vascular disease, obesity, depression, posttraumatic stress symptoms, substance use disorders, and tobacco use), and medication side effects that interfere with sexual desire and functioning [5,7-11]. While Veterans are often exposed to risk factors that disrupt sexual health during military service, many of these risk factors contribute to sexual dysfunction in the general population as well. Despite this, sexual health is often overlooked in clinical practice, both in the Veterans Health Administration (VHA) and other health care systems, unless the patient voices concerns [2,12].

Sexual health has recently been acknowledged as an integral part of holistic conceptions of human health. An extensive report from the National Academies of Science, Engineering, and Medicine framed the importance of paradigmatic change in terms of sexually transmitted infection (STI) prevention [13]. They argued that the abstinence and disease-based models of STI prevention have largely failed to control STIs in the United States, and there is evidence that a sexual health framework is more likely to succeed. We extend their argument; shifting toward a sexual health model is important for more than STI prevention. As medical systems embrace whole health (defined as a focus on the multiple components of well-being based on their values, needs, and goals, and not simply the treatment of illnesses, injuries, and disabilities [14,15]) models of care, they will need to include sexual health or risk excluding an important aspect of their patients’ overall health.

Assessing sexual health can give providers important information about a patient’s overall health and well-being; sexual concerns or dysfunction may signal unknown or undiagnosed health conditions. For example, a large meta-analysis demonstrated a correlation between erectile dysfunction in men and increased risk of negative cardiovascular outcomes and all-cause mortality [16]. In addition, sexual health assessment provides an opportunity to discuss treatment side effects such as drug-induced sexual dysfunction, which is common with the use of antihypertensives and antidepressants [17].

Conversely, providers can anticipate sexual health dysfunction when their patients have diagnoses known to impact sexual health or function. For example, sexual health concerns are associated with obesity, diabetes, obstructive sleep apnea in men, and metabolic syndrome in women [18-20]. Discussing this association with patients is one avenue providers can use to introduce the concept of sexual health and potentially motivate patients for behavioral change. In the absence of discussing sexual health, providers may miss the larger patient-centered picture and ignore the interrelationship between sexual health and overall health. For LGBTQ+ patients, this relationship between sexual health and overall health may be especially important.

There is substantial evidence that LGBTQ+ people experience worse physical and mental health outcomes relative to non-LGBTQ+ people [21-26], likely related to sexual and gender minority stress. Minority stress theory predicts that LGBTQ+ people will experience worse mental and physical health outcomes due to chronic stress caused by anti-LGBTQ+ victimization and stigma in society as well as internalization of these biases [25,26]. For LGBTQ+ veterans, this pattern holds [27], especially in relation to sexual health [28], and may be exacerbated by having served in the military under “Don’t Ask, Don’t Tell” [29] and increased exposure to sexual assault and harassment while in service [30-32]. Health care systems implementing policies to normalize the collection of SOGI data in routine clinical practice would help clinicians identify patients at increased risk for poor general and mental health outcomes due to chronic exposure to sexual and gender minority stress.

The VHA has committed to a whole health approach to care where providers partner with veterans to help them achieve their health goals [15]. Although the VHA’s whole health approach covers most aspects of well-being, it stops short of explicitly discussing sexual health. This approach underemphasizes the importance of good sexual functioning and healthy sexual intimacy on patient values or goals. Incorporating sexual health in whole health materials designed to prompt patient-provider communication would signal to providers and patients that these topics can be openly discussed.

A major barrier for VHA in assessing SOGI and sexual health has been the lack of structured data fields for this information within the current electronic health record (EHR) [57]. The VHA’s current EHR has no national sexual health assessment template or note title. This means that, even when providers collect SOGI or sexual health information, these data cannot be readily accessed by other providers. Health care systems’ use of standardized templates or easily identifiable sexual health notes will facilitate providers’ assessment and documentation of patients’ sexual health. When one VHA postdeployment clinic included sexual health in their standard intake, this information was collected and more readily accessible. Researchers examining these intakes found that between 17% to 24% of men assessed in this clinic expressed concerns about their sexual health [58-60].

Whether a barrier to sexual health assessment is poor patient-provider communication or a lack of technological capacity in an EHR system, these barriers will need to be overcome. Fortunately, VHA is moving ahead on several initiatives to reduce these barriers. These initiatives could inform similar implementation efforts in other health care systems.

Several opportunities exist for VHA to improve the sexual health assessment of veterans. Notably, VHA will soon have SOGI data fields within its current EHR. Plans to permit veterans to enter and edit SOGI data themselves through a web portal prior to an initial visit to establish care are currently underway. VHA has also developed a national sexual health note template for providers to facilitate assessment and tracking. In addition, VHA is replacing its current system with a commercial EHR product (Cerner Millennium, Sweden). Cerner Millennium has SOGI fields and three sexual health screening modules that will improve collecting and tracking this information.

The three standardized sexual health assessment forms in VHA’s Cerner Millennium include a brief history screen designed for intake or hospital admission (eg, sexual concerns to discuss with the provider). The second module is a brief sexual health risk screen that focuses on history of and efforts to prevent STIs. The third module is a more detailed sexual health risk assessment that asks about changes in sexual frequency, desire, satisfaction, and function, and evidence of pain or coercion to engage in unwanted sexual activity. Together, these assessments provide structure to make it easier for VHA providers to use best practices when assessing sexual health and, crucially, give room for patient-centered care that goes beyond a focus on risk and dysfunction [47,61,62]. The national sexual health template for the current VHA EHR combines all three assessments from Cerner Millennium. The template will also pull in basic patient data, including gender identity and sexual orientation when these data are available. If not available, the provider is prompted to ask about these identities.

Education programs will follow implementation of the new SOGI fields in the current EHR and the expansion of Cerner Millennium to additional facilities. Two trainings on gender identity—one for current EHR users and one for Cerner Millennium users—have already been released. Separate trainings on sexual orientation and on sexual health (for current EHR users and for Cerner Millennium users) are nearing completion. Training will support all members of primary care teams and patients in recognizing the link between sexual health, general health, and well-being [63-65]. These trainings will also help providers learn how to incorporate and document SOGI and sexual health assessment into their workflows. Educational interventions will include resources for primary care teams to help them conduct sexual health assessments.

Table 1 is an example of a brief sexual health assessment that could be adapted to a “pocket card” format. Providers following this guide would first collect SOGI information, including a 2-step sex assigned at birth (confirming information in the record system) and gender identity assessment. They would then conduct a brief sexual health assessment using the “Five ‘P’” model developed by the Centers for Disease Control and Prevention (CDC) with additional questions incorporating a sixth “P” for pleasure [3,61]. The questions in Table 1 were adapted from a CDC guide, the Cerner Millennium modules being implemented in VHA, and other articles discussing sexual health assessment [62]. Table 2 lists all the questions and responses contained in the Cerner Millennium modules being implemented within VHA. While Table 2 is too large for a “pocket card,” the modules could be broken into separate cards and given to primary care team members assigned to complete those modules. Brief role-plays during preclinic stand-ups could help provider teams become comfortable using these tools.

Teams will be encouraged to assign roles and responsibilities for completing the sexual health intakes and following up on identified concerns. While general recommendations focus on increasing the use of nursing staff [13,66], the VHA’s transition to using Patient Aligned Care Teams in primary care makes it well situated to implement sexual health assessments conducted by several team members, each responsible for completing different components. In addition, as the VHA has also committed to increasing access to whole health coaching, whole health coaches could also play an important role in completing aspects of the sexual health assessment.

In the VHA, a veteran education campaign with brief public service announcements and on-site information will also be needed to inform patients that they will be asked about their SOGI and sexual health and why. When self-report mechanisms are available, veterans will need to be informed about how to use them and how their information will be used and protected. Fact sheets for veterans on why gender identity is asked are already available. Fact sheets for veterans on why sexual orientation and sexual health are assessed are nearing completion. These fact sheets will be available at VHA facilities and on VHA websites. In addition, VHA could leverage its expertise in developing phone apps to create a sexual health education tool targeted toward adult patients. Currently, there is a dearth of apps providing comprehensive information about sexual health [67]; a well-designed app would likely benefit veterans both inside and outside the VHA.

The evidence we reviewed points to the gap in patient-provider communication about sexual health largely due to provider perception. This appears to be driven by providers’ beliefs that patients are not willing to discuss their sexual health when, in fact, they are. While veteran educational interventions are important, provider education is critical for promoting sexual health assessment.