JANUARY 2020

ACHA Guidelines

Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings

ccording to The World Health Organization’s Using this document: Readers are encouraged to utilize (WHO) working definition, “sexual health” is: each of the resources and citations provided for more information on a particular issue, choosing which ones A… a state of physical, emotional, mental and may work best for their health center and in what manner. social well-being in relation to sexuality; it is not The goal of these recommendations is for them to be merely the absence of disease, dysfunction or infirmity. utilized by a wide variety of institutions, and the Sexual Sexual health requires a positive and respectful Health Promotion and Clinical Care Coalition is always approach to sexuality and sexual relationships, as well available to ACHA members for consultation. as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and Structure of the recommendations: Certain best violence. For sexual health to be attained and practices and recommendations will be more clearly maintained, the sexual rights of all persons must be relevant for either clinicians or health promotion respected, protected and fulfilled. professionals due to the nature of their roles, though it is of utmost importance to understand that improving sexual The American College Health Association (ACHA) has health is also a shared responsibility that requires close recently released a number of position statements and collaboration among clinical and non-clinical staff. As guidelines regarding sexual health issues, on topics such as such, this document is organized into three sections: expedited partner (EPT),1 pre-exposure prophylaxis shared responsibility, health promotion and clinical care. (PrEP) for HIV prevention,2 trans-inclusivity,3 sensitive exams4 and trauma-informed sexual violence prevention.5-6 A note about language: We will use “queer” as an Links to current guidelines, resources, and evidence are umbrella term to describe students whose sexual provided throughout this document, which are intended to orientation is not heterosexual/straight, and “trans” as an serve as a resource for a broad range of sexual health topics umbrella term to describe students who are not cisgender. in college health. However, it is not exhaustive. The intent of this paper is to consolidate this information Shared Responsibility with guidelines and best practices presented by other national organizations to assist colleges and universities in Incorporate Pleasure and Intimacy into the provision of sexual health services both in health Sexual Health Efforts promotion and clinical care—specifically through the Sexual health should not only be discussed in relation to lenses of public health and medicine. sexually transmitted (STIs)/human Acknowledging WHO’s working definition of sexual immunodeficiency (HIV) and unintended , health, which emphasizes the need for a holistic approach, but also how it can promote pleasure and intimacy. The we recognize the importance of mental health primary reason many people engage in sexual activity is to practitioners’ roles in supporting sexual health. This is experience pleasure. To ignore this fact not only prevents especially relevant for college health settings as campuses us from meeting students where they are and strive to meet their students’ increasing mental health acknowledging the realities of many of their sexual needs—which can and does include topics such as sexual experiences, but also reproduces (and reinforces) stigma dysfunction, healthy communication, dealing with a and shame around their bodies and sexuality. As such, it is difficult diagnosis or managing intimate relationships. recommended that questions about sexual functioning and With that said, the current version of this document does satisfaction are included during routine sexual histories. not include comprehensive guidance for clinical mental It is also worth acknowledging that a student’s personal health professionals such as counselors and therapists. views—including faith-based—will affect their decision This is both a limitation of this paper and recommendation to engage or not engage in sexual activity, and that those for a future paper. decisions should be validated and respected. Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 2

Here are a few practical examples of how to incorporate Considerations for Trans and Non-binary Students pleasure and intimacy: College health practitioners should seek professional • Discuss fit and feel of external ; if condoms development opportunities to increase their competencies fit properly and feel good, then students will be much in caring for transgender and gender-nonconforming more likely to use them individuals. Further, several professional organizations • Explain how using external condoms with IUDs, for endorse gender-affirming hormone therapy and pre- and example, can enhance the sexual experience by post-gender affirming surgical care as being within lowering anxiety about STIs/HIV and unintended primary care provider’s scope of practice.7-9 While gender- pregnancy affirming care is not exclusively related to sexual health, • Emphasize to students with new STI/HIV diagnoses sexual health clinicians often have enhanced training in that they still have the right to healthy and queer and trans health and provide these important pleasurable sexual experiences services. As such, we advocate for the provision of these services in CHCs. More Information: Implementation Resources: • Sexual Pleasure, American Sexual Health Association • Gender Dysphoria/Gender Incongruence Guidelines and Resources, Endocrine Society • Publications, International Society for the Study of Women's Sexual Health • Safer Sex for Trans Bodies, Human Rights Campaign • Herbenick, Fu, Arter, Sanders, Dodge. (2018). Foundation and Whitman-Walker Health Women’s experiences with genital touching, sexual • UCSF Center of Excellence for Transgender Health pleasure, and orgasm: Results from a US probability • Trans-Inclusive College Health Programs, ACHA sample of women ages 18 to 94. J Sex Marital Ther • World Professional Association for Transgender Feb 17; 44(2): 201-212. Health (WPATH) • Herbenick, Bowling, Fu et al. (2017). Sexual diversity in the United States: Results from a Collect Sexual Orientation and Gender Identity (SOGI) nationally representative probability sample of adult Data women and men. PloS ONE 12(7):e0181198. Queer and trans communities experience unique health Create a Welcoming Clinic Environment and disparities and are invisible until they are specifically Provide Inclusive Resources and Services counted in electronic health records (EHR) and other public health systems (i.e., needs assessments, program Services start when patients enter your college health evaluations, infectious disease reports). As such, CHCs center (CHC). Care should be taken to use gender-neutral should collect and document these demographic data in terms interpersonally and on forms. Posters, brochures and order to: other materials should have sex-positive messages with • Provide tailored campus and community resources same- and different-gender couples, as well as people of different ethnicities, gender expressions and physical • Measure healthcare utilization among queer and trans abilities. Spaces should be sensitive to trauma experiences students through using calming designs and providing students • Identify at-risk student populations when reporting with as much control over their experience as possible. infectious disease data Implementation Resources: • Adequately conduct quality improvement activities and patient satisfaction surveys • Healthcare Equality Index, Human Rights Campaign • Provide a more holistic approach to care • 10 Ways to Make Your Health Center More Welcoming for Diverse Students, ACHA Ideally, explicit fields in the EHR should capture the patient’s: • Statement on Cultural Competency, ACHA • • Creating an Inclusive Environment for LGBT Sexual orientation Patients, LGBT Health Education Center • Gender identity • Sex assigned at birth

• Pronouns • Name that they would like to be called (i.e., lived name or chosen name). Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 3

The collection of gender identity should be a two-step behaviors do not always correlate with sexual identities, so process, where the patient is first asked their gender identity, simply taking a sexual history and asking about partners is followed by their sex assigned at birth; this is to not an accurate way to determine a patient’s sexual immediately validate a student’s gender identity before orientation or gender identity. determining their medical needs. Additionally, sexual Figure 1. Gathering Sexual Orientation and Gender Identity (SOGI) Data Adapted from the 2017 Recommendations from the University of California LGBTQIA+ Directors' Council

Lived Name What name would you like to be called?

Pronouns What are your pronouns?

Gender Identity What best describes your gender identity? ● Woman ● Man ● Transgender ● Trans Woman ● Trans Man ● Non-Binary ● ● Intersex Woman ● Intersex Man ● Genderqueer ● Gender Non-Conforming ● Questioning ● Two Spirit ● Agender ● Other (Please specify) ● Decline

Assigned Sex at Birth What sex were you assigned at birth? ● Female ● Male ● Intersex ● Non-Binary ● X

Sexual Orientation What best describes your sexual orientation? ● Lesbian ● Gay ● Straight ● Bisexual ● Pansexual ● Queer ● Questioning ● Asexual ● Two Spirit ● Same Gender Loving ● Other (Please specify) ● Decline Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 4

See Figure 1 for a recommended way to ask these Students of marginalized identities are particularly questions on pre-visit questionnaires. It is worth noting vulnerable given the impacts of historical trauma and that the use of “preferred name” or “preferred pronouns” minority stress, which further highlights the importance should generally be avoided, as these are not of addressing health equity in our work. For example, “preferences” and such language is invalidating to trans trans and non-binary students who have a and persons. As language is always changing, it is important to cisgender women with a history of trauma may allow students to self-identify by leaving an open-answer experience particular emotional and/or physical option. discomfort during pelvic examinations. Initiating the visit by establishing rapport and obtaining a history It is important to let students know that the information while the patient is clothed, allowing the presence of a provided will remain confidential in accordance with the support person and using sufficient lubrication with law, and that they do not have to answer any questions smaller-size speculums may ease some of the stress and they do not want to answer. Student confidentiality is anxiety around the exam. Best practices before discussed in greater detail later in the document. conducting a medical exam include always asking how Implementation Resource: they refer to their anatomy and informing the patient that • Ready, Set, Go: Guidelines and Tips for Collecting they are in control and are able to stop the process at any Patient Data on Sexual Orientation and Gender time. Identity, National LGBT Health Education Center ACHA recommends utilizing a clinical chaperone for both clinician and student protection when the breast, Staff Training in Collecting SOGI Data genital or rectal areas are involved in any medical CHCs should develop policies and procedures that examination or procedure.4 While mandatory policies are address how to ask these questions, document patient supported to mitigate risk, it is recommended that CHCs responses and interact with patients accordingly. The implement clinical chaperones through an opt-out policy patient’s response can not only determine which that enhances patient autonomy.4 resources and referrals are most appropriate and relevant Further, providing trauma-informed sexuality education to the patient, but also the language used during their prioritizes creating a culture of consent and letting the visit and the care they receive. Assuring the patient that audience members know what to expect so that they can their responses are confidential is of utmost importance, be given the choice whether or not to engage with the as many college students have privacy concerns not only material. Consider emphasizing during the establishment around the services they receive, but also around their of group agreements that audience members are able to SOGI data. Patients may have disclosed their sexual leave for any reason at any time so that they know they orientation and gender identity to their healthcare are in control. It is also important to be mindful that each providers but not to their parents, for example, so they audience member may describe their bodies in different need to know that their information will be protected. ways, and to validate each person’s right to call their Implementation Resource: body parts whatever they want. For example, some • Resources for Collecting Sexual Orientation and transmasculine folks may use “front hole” or “genital Gender Identity Data, National LGBT Health opening” instead of “.” Similarly, transfeminine Education Center folks may use “strapless” instead of “penis.” This brief listing of examples is not exhaustive by any means but is Use a Trauma-Informed Approach to Sexual included to provide visible respect for and validation of Health Promotion and Clinical Care how people, especially trans and non-binary students, may refer to their anatomy. Many of our students come to campus with various experiences of trauma that they are struggling to deal On an organizational level, it is recommended that with every day—and many of these experiences have CHCs conduct an organizational assessment of trauma- occurred since becoming college students. Sexual health informed practice and consider incorporating being professionals in the higher education setting must have a trauma-informed into strategic planning processes, fundamental understanding of how trauma impacts our building design and policies/procedures. Appropriate students’ daily lives, especially since our sexual health training of all staff should follow any assessment. See efforts can have a high potential for re-traumatization. the United States Department of Education’s National Center for Safe and Supportive Learning Environments’ resources below for a comprehensive implementation guide. Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 5

Implementation Resources: For example, think about the following questions: • Safe Place: Trauma-Sensitive Practice for Health • Does your CHC have a procedure for linking Centers Serving Higher Education Students, US students newly-diagnosed with HIV to Department of Education comprehensive medical and mental health care? • Trauma and Trauma-Informed Approaches, How are they referred to Partner Services/Disease Substance Abuse and Mental Health Administration Intervention Specialists? • Trauma-Informed Care Project • Do you know how to refer a trans student to gender-affirming care? • Best Practices for Sensitive Exams, ACHA • What is your CHC’s referral procedure when a • Addressing Sexual and Relationship Violence: A student discloses sexual and relationship violence? Trauma-Informed Approach, ACHA How is this reported to your Title IX office (if required), and how is the student referred to a Address Confidentiality Concerns mental health professional or academic CHCs should have policies that support confidentiality, accommodations? as privacy concerns are well-documented barriers to • Does your CHC maintain a list of campus and accessing sexual health services. Changes in coverage community sexuality professionals? that allow young adults to remain on their parents’ or • How does your CHC’s clinical staff know when to guardians’ health insurance policies until age 26 put refer to specialists for complicated STI diagnoses? students at risk of having an unintended breach of confidentiality when explanations of benefits (EOB) that Implementation Resource: include tests ordered and prescribed are sent • Recommendations for Providing Quality Sexually 10 to the primary policyholder instead of the patient. Transmitted Diseases Clinical Services, 2020 Some strategies that can support confidentiality include: Evaluate Your Efforts • Providing STI/HIV screening at low or no cost so that students can pay out-of-pocket and avoid As with any discipline or area of health, evaluation is billing their insurance plan essential. Understanding current best practices with a • Educating students on state confidentiality laws and mechanism for ongoing evaluation of the adherence to navigating insurance those best practices is important for maintaining quality health promotion and healthcare delivery. • Listing any charges on student accounts generically (e.g., “Student Health Center Fee” instead of “Birth Evidence-based/informed practices come in a variety of Control Visit”) forms, and may include: • Encouraging students to have different passwords • Reviewing the literature for their online health portal and other university • Conducting quality improvement studies accounts, and not to share them with anyone • Adhering to national guidelines and benchmarks Implementation Resources: • Focus groups with students and other stakeholders • Position Paper: Confidentiality protections for • Surveys adolescents and young adults in the health care billing and insurance claims process. Journal of Quality improvement or evaluation projects could Adolescent Health. 2016; 58(2016):374–377. include: • Guttmacher Institute (2019). Protecting • Adherence to STI/HIV guidelines Confidentiality for individuals insured as • Frequency of capturing demographic data dependents. (accessed November 19, 2019). • Identifying individuals concerned with body integrity, sexual safety, sexual response and Make Referrals as Appropriate pleasure, gender, sexual orientation, emotional A holistic approach to sexual health requires attachment and reproduction.11 understanding the limits of one’s knowledge and role in Evaluation should be conducted using a health equity an effort to ensure each student receives appropriate lens and include consideration of utilization rates for care. Maintaining up-to-date linkage procedures and lists sexual health services by different populations. of referrals—beyond the campus setting—is of utmost importance. Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 6

In considering health equity, one must understand how level. While providing comprehensive, evidence- the Social Determinants of Health12 affect sexual health. informed sexuality education directly to students may be Social determinants of health reflect the social and a function of college health promotion, the greatest physical environments (such as neighborhood, school, impact is achieved through a data-driven, public health religious community and workplace) in which the approach that emphasizes primary prevention. Health student lived prior to entering college.13 promotion should “focus on the processes that aim to expand protective factors and campus strengths, and Once in a college setting, one may think that social reduce personal, campus, community and environmental determinants and place are more equalized, but the health and well-being risk factors.”14 students’ upbringing and experiences they have before college as well as continued experiences with family and As such, efforts must be focused on enhancing the many others both inside and outside of the collegiate environments in which students live, work and play -- by environment will still have an impact on their attitudes, working to ensure that the healthier choice is always the knowledge and behaviors around health, health easiest choice for them to make in every setting. screenings and accessing health services. Sexual health professionals on college campuses and If discrepancies exist between service utilization and the universities can use the Standards of Practice in Health certain populations served in terms of sexual orientation, Promotion in Higher Education to support and guide gender, gender identity, race or ethnicity, then an their work. It suggests several strategies, including but examination of possible causes and subsequent action not limited to socioecological-based practice, evidence- should rectify these discrepancies. informed practice and collaboration. Here are some examples of sexual health interventions at each level of One important tool for measuring success is ACHA’s the socioecological model: National College Health Assessment (NCHA), which asks several questions intended to measure sexual health • Individual Level: on a population level. Results of the NCHA can be used . Providing skills-building activities that teach in combination with ACHA’s Healthy Campus Initiative students how to properly use safer sex to see population-level changes and progress (or lack of products and engage in effective sexual progress) toward reaching established public health communication goals among college students. • Interpersonal Level: In addition to quantitative measures such as the NCHA . Recruiting, training and managing a team of and clinic utilization data, it is important to gather student peer educators who engage in outreach qualitative data from students through focus groups or to provide sexuality education across campus student interviews. These data can be especially useful in . Role-modeling consent and effective evaluating health communication campaigns or communication in daily life conducting needs assessments among various sub- • Organizational Level: populations within the campus community. . Implementing mandated training for all CHC staff Implementation Resources: around best practices in queer and trans care • Social Determinants of Health, Office of Disease . Developing a sexual health clinic to increase Prevention and Health Promotion access to STI/HIV screening • ACHA National College Health Assessment . Working with clinical staff to implement • ACHA Healthy Campus STI/HIV testing reminders in the EHR • • Practical Use of Program Evaluation Among STD Community Level: Programs, CDC . Working with stakeholders to improve the safety and walkability of campus and enhance the • ACHA Sexual Health Services Survey design of social spaces to prevent sexual violence . Conducting an environmental scan to create a Health Promotion campus and community map of sexual health resources Use the Socioecological Model to Improve . Collaborating with campus and community Sexual Health partners to install a vending machine that Sexual health promotion professionals are trained to dispenses and safer improve sexual health and well-being on a population sex products (where laws allow) Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 7

. Developing campus-wide sexual health for accurate and inclusive sexual health information. The campaigns ease in which social media and online search engines • Societal (Public Policy) Level: produce health information on demand are more enticing than potentially experiencing the embarrassment of . Advocating for policies that enhance sexual health and improve sexual health equity asking a parent or calling the CHC. There are many social media platforms from which to choose (e.g., . Advocating for and/or implementing a Facebook, Snapchat, Instagram, Twitter), and each one mandatory human sexuality course for all would require a unique strategy to build an engaged incoming students student audience. The needs of each campus community will be unique, Evidence for the use of social media in promoting sexual and collaboration with campus and community partners health is increasing, particularly for promoting STI/HIV is vital to success. 16-17 testing and use. As sexual health can be a Implementation Resources: stigmatizing topic, it must be noted that students may be • Standards of Practice in Health Promotion in less likely to engage with sexuality-related content -- Higher Education, ACHA especially when their peers may see their social media activity.15 However, this does not mean that students will • Okanagan Charter: An International Charter for not review and use the information or privately share Health Promoting Colleges and Universities with their friends. • United States National Prevention Strategy Ensuring that social media content and messaging is • Health, Safety and Well-Being Initiatives of “engaging, has a positive tone, is not too clinical, is NASPA focused on building social norms and delivered by trusted 18 Implement an Inclusive, Evidence-Based organizations” has also been found to be important. Testing content for acceptability with students and Availability Program for Safer Sex Products developing a social media strategy that considers their Condom distribution/availability programs have been unique needs will always be most effective. You may also proven to increase condom use, prevent STIs/HIV and consider incentivizing student engagement with your save money.15 social media to grow your student audience. For example, you may offer some free swag when a student “follows” Many programs focus on providing external condoms, your account or shares your content. but not all students engage in sexual activity that involves a penis or insertive sex toy. As such, it is While time-intensive, it is also important to regularly important for a variety of safer sex products to be made analyze social media metrics (i.e., engagement, reach, widely available to students at no cost. Such safer sex impressions, shares) to measure what is working and not products include dental dams, internal condoms, nitrile working in terms of reaching students and keeping them gloves, non-latex options, water-based lubrication and engaged. If your CHC has a marketing and silicone-based lubrication. communication team, it is highly recommended that you consult with them in order to adhere to your institution’s The Centers for Disease Control and Prevention (CDC) communication guidelines and best practices. has many resources available for implementing a condom availability program as a structural-level Implementation Resource: intervention that creates a more health-promoting • Digital Tools from HIV.gov environment. Implementation Resources: Clinical Care • Condom Distribution, CDC Effective Interventions • Condom Distribution as a Structural Level Be Proactive about Sexual Health with All Intervention, CDC Patients and Take an Inclusive, Comprehensive Routine Sexual History • Condom Availability Programs, County Health Rankings and Roadmaps Clinicians should have conversations about sexual health with students, as appropriate, during preventive visits for Leverage Social Media all genders—not just during problem-focused sexual health visits. Clinicians might set the stage by letting Social media use is common among college students, patients know that the questions are asked of all patients and it is important that our systems meet students’ needs Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 8

because of their importance to overall health. If a student • Makadon H, Mayer K, Potter J & Golhammer H reports that they are not sexually active, then that (2015). The Fenway guide to lesbian, gay, bisexual, decision should be validated. and transgender health 2nd edition. Philadelphia: American College of Physicians. These discussions provide important opportunities for risk-reduction counseling, identification of anatomical • Deutsch MB, Green J, Keatley J, et al. Electronic sites for STI and HIV screening (discussed in greater medical records and the transgender patient: detail later in this document), promotion of healthy and recommendations from the World Professional satisfying sexual functioning as well as diagnosis and Association for Transgender Health EMR Working treatment of sexuality-related conditions.19 Group. J Am Med Inform Assoc. 2013;20(4):700– 703. doi:10.1136/amiajnl-2012-001472 Using an “8 Ps” approach when taking a sexual history allows for a comprehensive and inclusive springboard Assess Patients’ Reproductive Goals for discussion.20 Some college students do want to become pregnant and The “8 Ps” approach includes questions about: not all are sexually active. Refrain from making 1. Preferences assumptions by using a more inclusive approach to 2. Partners consider a patient’s reproductive goals, with attention to their potential to become pregnant. 3. Practices 4. Protection from STIs/HIV Students desiring pregnancy or not using reliable forms of contraception or who are otherwise capable of 5. Past history of STIs pregnancy (i.e., transmasculine students having penis- 6. Pregnancy vagina sex) should be counseled to take a supplement 7. Pleasure containing 0.4-0.8 mg of folic acid daily for the 22 8. Partner violence (discussed in greater detail later prevention of neural tube defects. in this document) Implementation Resource: The sexual history is ideally conducted by asking open- • Committee Opinion 762: Pre-Pregnancy ended questions with a nonjudgmental tone and Counseling, American College of Obstetricians and demeanor. If the sexual history is taken during an Gynecologists (ACOG) appointment that includes an examination, the history should be obtained prior to having a patient remove any Assess for Trauma and Violence clothing. Given the prevalence of trauma, it is important to For trans and non-binary patients, it is recommended universally screen for trauma and trauma symptoms,6 that providers “maintain an organ inventory to guide despite national guidelines using gendered language in screening and management of certain specific their recommendations. People with marginalized complaints.”21 identities experience higher rates of violence (and trauma, more broadly), and this must be taken into Implementation Resources: consideration to provide the best care. • Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services, 2020 According to the US Preventive Services Task Force (USPSTF), screening for intimate partner violence (IPV) • Sexual History: Talking Sex with Gender Non- using an instrument should be done for.23 Conforming and Trans Patients, Fenway Institute • all women of reproductive age • A Guide to Taking a Sexual History, CDC • other vulnerable patients without recognized signs • Addressing HIV and Sexually Transmitted and symptoms of abuse Infections Among LGBTQ People: A Primer for Health Centers, LGBT Health Education Center The following screening instruments accurately detect • Taking Routine Histories of Sexual Health: A IPV in the past year among adult women: System-Wide Approach for Health Centers, LGBT • Humiliation, Afraid, Rape, Kick (HARK) Health Education Center • Hurt, Insult, Threaten, Scream (HITS); Extended– TransForming Health: Taking a Sexual History Hurt, Insult, Threaten, Scream (E-HITS) • Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST) Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 9

Screening should be done in private and may be done on Screening an annual basis. Those with positive screens should be For patients with a uterus, screening for cervical cancer provided ongoing support or referred to appropriate (via ) is recommended starting at age 21 agencies. regardless of sexual activity.32-33 Implementation Resource: Insufficient evidence exists to recommend for or against • US Preventive Services Task Force. Screening for performing pelvic examinations as screening in Intimate Partner Violence, Elder Abuse, and Abuse asymptomatic persons for early detection/treatment of of Vulnerable Adults: US Preventive Services Task gynecologic conditions not related to screening for Force Final Recommendation Statement. cervical cancer.34 The decision to perform a pelvic exam JAMA.2018;320(16):1678–1687. should be based on medical history or symptoms and be a shared decision between patient and provider.35 Orient Clinical Care Toward Prevention Regardless of their sexual partner(s)’ body parts, While there is limited evidence to support performing individuals with a uterus are at risk for STIs/HIV and pelvic exams and comprehensive physical exams on cervical cancer and should follow guidelines addressed asymptomatic young adults, annual “wellness” visits, above. Shared insertive sex toys and previous partner(s)’ geared toward prevention, can provide an opportunity to body parts may affect the degree of risk, but do not screen for unhealthy or harmful behaviors and provide change the recommendations. education regarding health and function of the human In the interest of providing trauma-informed care while body, and counseling regarding healthy lifestyle and risk 24 acknowledging transmasculine students and students reduction —such as substance misuse or depression. who have never had penetrative vaginal sex, it is recommended to provide patients an option to use a smaller-sized speculum if there is physical or All patients age 45 years and younger should be asked if psychological sensitivity. they have been vaccinated against human papillomavirus (HPV), with a strong recommendation from the provider Implementation Resources: to start or complete the series for those not fully • Screening Guidelines, American Society of vaccinated.25-29 Provision of the vaccine during the clinic Colposcopy and Cervical Pathology (ASCCP) visit may increase uptake with use of a reminder system • Screening Recommendation, USPSTF in EHR to help ensure patients return to complete the • Practice Advisory: Cervical Cancer Screening, ACOG series. against virus (HAV) should be STI and HIV Screening encouraged for any patients who are men who have sex Implement Routine, Opt-Out HIV Screening with men (MSM), who have not previously been vaccinated.30 Implementing this best practice will look different for Routine vaccination for virus (HBV) should each CHC, depending on staff resources and workflows. be provided for those not previously vaccinated, those at The CDC recommends that everyone ages 13-64 be risk for HBV (i.e., sexual exposure) or those tested for HIV as part of routine medical care at least requesting protection from HBV without a specific risk once in their lifetime, and more frequently depending on factor.31 the patient’s risk.36 As such, it is recommended that HIV Implementation Resources: testing be included as part of routine medical care—and any STI screening—preferably through an “opt-out” • HPV Vaccine Schedule and Dosing, CDC option where all patients are informed that they will be • HPV Vaccine Recommendations, CDC Advisory tested for HIV unless they decline.37-38 Committee on Immunization Practices (ACIP) CHCs may also consider implementing rapid point-of- • Viral Hepatitis and Men Who Have Sex with Men, care (POC) HIV testing to improve the chances of CDC students receiving their test results.39 Fourth-generation • Hepatitis A Vaccine Recommendations, ACIP POC HIV tests, which can detect p24 antigens in • Hepatitis B Vaccine Recommendations, ACIP addition to antibodies, are able to detect HIV infection earlier than previous testing generations; this is an especially important factor to consider in ensuring all students living with HIV can begin treatment as early as Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 10

possible to stay healthy through an undetectable viral Screen for STIs at All Appropriate Anatomical Sites Site- load and prevent transmission to their sexual partners. specific screening for STIs should follow recommendations published by the CDC and USPSTF, Implementation Resources: regardless of sexual orientation or gender identity.40-41 • HIV Screening in Clinical Settings, CDC For most sexually active students, screening should • Hurt CB, Nelson JAE, Hightow-Weidman LB, et al. occur at least annually for and with Selecting an HIV test: A narrative review for more frequent intervals (i.e., every 3-6 months) based on clinicians and researchers. Sexually Transmitted risk. Screening for HIV should be done at least once in a Diseases 2017; 44:739–746. lifetime, with repeat screenings based on risk.36,42 • HIV Screening, Standard Care (campaign), CDC Chlamydia and gonorrhea live in mucous membranes, • HIV Screening, Standard Care: A Guide for and as such, all mucous membrane sites that have had Primary Care Providers, CDC contact with another person’s mucous membranes • Ending the Epidemic should be screened. It is imperative that clinicians know how patients are using their bodies for sexual

encounters. See Table 1 for STI/HIV Screening Offer Concurrent Screening for STIs and HIV Recommendations Overview, per guidance from the CDC40 and USPSTF.41-43 Sexual activity can facilitate transmission of HIV, in Referring to a previous recommendation in this addition to STIs such as chlamydia and gonorrhea. As document about taking a sexual history and maintaining such, HIV should be included as part of any STI an organ inventory for trans and non-binary patients, it is screening, preferably through an “opt-out” option.37-38 important to acknowledge that the current national Likewise, STI screening should be offered when an HIV screening guidelines and recommendations use binary, test is requested. All sexually active persons should be gendered language (i.e., “men” and “women”). offered an HIV test. Screenings should always be performed based on the actual organs that patients have. For example, a patient may be a woman and have a penis or may be non-binary and have a cervix.

Table 1. STI/HIV Screening Recommendations Overview

Women Men Men who have sex with men (MSM)

Chlamydia Yearly < 25 y.o. and * Consider yearly in high prevalence At least yearly at all sites of contact 25 with risk factors settings (urogenital tract/urine, ) •Retest ~ 3 months after treatment

Gonorrhea Yearly < 25 y.o. and * Consider yearly in high prevalence At least yearly at all sites of contact 25 with risk factors settings (urogenital tract/urine, rectum, pharynx) •Retest ~ 3 months after treatment •Every 3 m (increased risk)

Syphilis *At high risk for infection *At high risk for infection At least yearly •Every 3-6 m (increased risk)

Trichomonas * In high-prevalence settings or at *Consider in high prevalence settings *Consider in high prevalence settings high risk for infection (HIV infection)

HIV All women aged 13-64 years (opt- All men aged 13-64 (opt-out) At least annually if HIV status out) unknown or negative or patient or All women seeking STI screen or partner(s) have had > 1 partner since treatment last test Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 11

Allow Patients to Self-Swab When Possible Implementation Resources: Research studies indicate that self-collected vaginal • ACHA Guidelines: HIV Pre-Exposure swabs are patient-preferred and just as reliable as Prophylaxis. clinician collection for chlamydia and gonorrhea • HIV Nexus Clinician Resources, PrEP, CDC 40 testing. Therefore, self-collection is reasonable at all • USPSTF Final Recommendation Statement: HIV sites, including oral and rectal samples, for self- Pre-exposure Prophylaxis motivated patients as indicated. Keep in mind that your CHC’s laboratory may need to conduct a validation Offer Post-Exposure Prophylaxis (PEP) as study before conducting any self-collection. Appropriate Implement EPT Where Legal PEP can reduce someone’s chances of getting HIV if they may have been exposed to HIV -- such as when a EPT is the clinical practice of prescribing and student has experienced a sexual assault or was dispensing medications to the sexual partner(s) of exposed to HIV during sexual activity (e.g., the patients diagnosed with STIs such as chlamydia and condom broke). Clinic visits to access PEP may also be gonorrhea without them needing to see a healthcare an opportunity to promote PrEP, especially if the provider. Although EPT does not replace other student is in a sexual relationship with someone who is strategies for management of partners, the CDC living with HIV. recommends that it be available to clinicians as an option for partner treatment.44 This has been affirmed Implementation Resources: by ACHA as an effective means of preventing • Updated Guidelines for Antiretroviral reinfection1. CHCs are encouraged to research the legal Postexposure Prophylaxis after Sexual, Injection status of EPT in their state. Be advised that gonorrhea Drug Use, or Other Non-occupational Exposure to treatment currently requires combination therapy (an HIV (2016), CDC injection as well as an oral ) due to antibiotic • Non-Occupational Post-Exposure Prophylaxis resistance. (nPEP) Toolkit, AIDS Education and Training Implementation Resources: Center • ACHA Position Statements Moving Forward • Expedited Partner Therapy, CDC • EPT Gonorrhea Guidance, CDC Sexual health is a wide-reaching topic that intersects with multiple dimensions of health and wellness. The • Legal Status of Expedited Partner Therapy, CDC young adults we serve are at a crucial developmental • State Policies: Partner Treatment for STIs, stage where they are not only learning about Guttmacher Institute themselves and their bodies, but also trying to navigate the healthcare system and develop healthy intimate Offer Pre-Exposure Prophylaxis (PrEP) as relationships in a rapidly-changing social and political Appropriate landscape. In addition to safer sex prevention strategies, ACHA As such, college health practitioners are in a unique endorses the wide availability of HIV PrEP in CHCs2. position to meet their need for holistic resources and Clinicians should be proactive about talking about care that consider their experiences and prioritize PrEP with students and help to dispel myths about who health equity. The sexual health field is always is a candidate. Any visit for sexual health services evolving as new evidence emerges, and it is important provides an opportunity to share information about to seek out professional development opportunities PrEP and make a significant impact on the health of whenever possible to remain innovative and competent young adults. for the students we serve. Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 12 References 1. ACHA Executive Committee (2018). ACHA position statement on expedited partner therapy. https://www.acha.org/ACHA/About/Position_Statements.aspx 2. ACHA (2019). ACHA guidelines: HIV Pre-exposure prophylaxis. https://www.acha.org/documents/resources/guidelines/ACHA_HIV_PrEP_Guidelines_Jan2019.pdf 3. ACHA (2015). ACHA guidelines: Trans-inclusive college health programs. https://www.acha.org/documents/Resources/Guidelines/Trans-Inclusive_College_Health_Programs.pdf 4. ACHA (2019). ACHA guidelines. Best practices for sensitive exams. https://www.acha.org/documents/resources/guidelines/ACHA_Best_Practices_for_Sensitive_Exams_October2 019.pdf 5. ACHA Executive Committee (2016). Sexual violence positions statement. https://www.acha.org/ACHA/About/Position_Statements.aspx 6. ACHA (2017). ACHA guidelines. Addressing Sexual and Relationship Violence: A Trauma-Informed Approach. https://www.acha.org/documents/resources/Addressing_Sexual_and_Relationship_Violence_A_Trauma_Infor med_Approach.pdf 7. Nurse Practitioners in Women’s Health (2017). Position Statement : Healthcare for transgender and gender non-conforming individuals. https://www.npwh.org/lms/filebrowser/file?fileName=Transgender%20Care%20PS%20final.pdf 8. Klein, David A, Scott Paradise and Emily T Goodwin. 2018. “Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know.” American Family Physician. 98:11 (645-653). 9. Jason Rafferty, Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence and Section on Lesbian, Gay, Bisexual and Transgender Health and Wellness. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. 2018. Pediatrics. 142:4. 10. Kendra M. Cuffe, Melissa A. Habel, Alexandra E. Coor, Oscar Beltran & Jami S. Leichliter (2019) University efforts to address confidentiality issues for STI services, Journal of American College Health, 67:7, 717-726. 11. https://www.who.int/reproductivehealth/topics/sexual_health/issues/en/ 12. Marmot, Michael & Allen, Jessica. (2014). Social Determinants of Health Equity. American journal of public health. 104 Suppl 4. S517-9. 10.2105/AJPH.2014.302200. 13. Centers for Disease Control & Prevention (CDC). Social Determinants of Health: Know What Affects Health. https://www.cdc.gov/socialdeterminants/. Accessed December 1, 2019. 14. ACHA. 2019. Standards of Practice in Health Promotion in Higher Education. https://www.acha.org/documents/resources/guidelines/ACHA_Standards_of_Practice_for_Health_Promotion_ in_Higher_Education_October2019.pdf 15. Condom Distribution as a Structural Level Intervention. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/programresources/guidance/condoms/index.html. Updated October 31, 2019. Accessed November 19, 2019. 16. Stevens, Robin & Gilliard-Matthews, Stacia & Dunaev, Jamie & Todhunter-Reid, Abigail & Brawner, Bridgette & Stewart, Jennifer. (2017). Social Media Use and Sexual Risk Reduction Behavior Among Minority : Seeking Information. Nursing Research. 66. 368-377. 10.1097/NNR.0000000000000237. 17. Gabarron, Elia & Wynn, Rolf. (2016). Use of social media for sexual health promotion: A scoping review. Global Health Action. 9. 10.3402/gha.v9.32193. 18. Kesten, J.M., Dias, K., Burns, F. et al. Acceptability and potential impact of delivering sexual health promotion information through social media and dating apps to MSM in England: a qualitative study. BMC Public Health 19, 1236 (2019) doi:10.1186/s12889-019-7558-7 19. National LGBT Health Education Center (2015). Taking routine histories of sexual health: A system-wide approach for health centers. https://www.lgbthealtheducation.org/wp-content/uploads/COM-827-sexual- history_toolkit_2015.pdf. Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 13

20. Cavanaugh, Timothy. LGBT Health Education Center. https://fenwayhealth.org/wp-content/uploads/Taking-a- Sexual-Health-History-Cavanaugh-1.pdf 21. UCSF Transgender Care and Treatment Guidelines. 2016. Physical Transgender Patients and the Physical Examination. https://transcare.ucsf.edu/guidelines/physical-examination. Accessed December 1, 2019. 22. US Preventive Services Task Force. Folic Acid Supplementation for the Prevention of Neural Tube Defects: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(2):183–189. doi:10.1001/jama.2016.19438. Retrieved August 12, 2019. https://jamanetwork.com/journals/jama/fullarticle/2596300 23. US Preventive Services Task Force. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: US Preventive Services Task Force Final Recommendation Statement. JAMA.2018;320(16):1678–1687. doi:10.1001/jama.2018.14741. Retrieved August 13, 2019. 24. Well-woman visit. ACOG Committee Opinion No. 755. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e181–86. https://www.acog.org/Clinical-Guidance-and-Publications/Committee- Opinions/Committee-on-Gynecologic-Practice/Well-Woman-Visit 25. American Cancer Society National HPV Vaccination Roundtable (2018). Cancer prevention through HPV vaccination: An action guide for physicians, physician assistants, and nurse practitioners. cancer.org/health- care-professionals/national-hpv-vaccination-roundtable.html. Accessed May 23,2019. 26. American College of Obstetricians and Gynecologists (ACOG). Human Papillomavirus Vaccination. Committee Opinion No. 704. Obstet Gynecol 2017;129:e17-38. Available at: https://journals.lww.com/greenjournal/fulltext/2017/06000/Committee_Opinion_No__704___Human_Papillo mavirus.52.aspx. Retrieved August 12, 2019. 27. American College of Obstetricians and Gynecologists (ACOG). (2019) Practice Advisory: FDA approval of 9- valent HPV vaccine for use in women and men age 27-45. https://www.acog.org/Clinical-Guidance-and- Publications/Practice-Advisories/FDA-Approval-of-9-valent-HPV-Vaccine-for-Use-in-Women-and-Men-Age- 27-45. Retrieved August 12, 2019 28. Centers for Disease Control and Prevention (2017). HPV vaccine information for clinicians. https://www.cdc.gov/hpv/hcp/clinician-factsheet.html. Accessed May 23, 2019. 29. Nurse Practitioners in Women’s Health (2017). Position Statement: Human Papillomavirus Vaccination. https://www.npwh.org/lms/filebrowser/file?fileName=NPWH%20Nov%202017%20Position%20Statement- 2.pdf. Accessed May 23, 2019. 30. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm 31. Schillie S, Vellozzi C, Reingold A, et al. Prevention of Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(No. RR-1):1–31. DOI: http://dx.doi.org/10.15585/mmwr.rr6701a1 32. American College of Obstetricians and Gynecologists (ACOG). Cervical cancer screening and prevention. ACOG Practice Bulletin Number 168. & Gynecology 2016; 128(4):e111-e130. DOI: 10.1097/AOG.0000000000001708 33. Massad LS, Einstein MH, Huh WK, et al. 2012 ASCCP Consensus Guidelines Conference. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2013;17(Suppl 1):S1–27. 34. US Preventive Services Task Force. Screening for Gynecologic Conditions With : US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(9):947–953. doi:10.1001/jama.2017.0807. Retrieved August 12, 2019. 35. American College of Obstetricians and Gynecologists. Committee Opinion No. 754. The utility of and indications for routine pelvic examination. Obstetrics & Gynecology 2018; 132:e174-80. Retrieved August 12, 2019. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on- Gynecologic-Practice/The-Utility-of-and-Indications-for-Routine-Pelvic-Examination 36. Screening in Clinical Settings. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/clinicians/screening/clinical-settings.html. Updated October 21, 2019. Accessed November 19, 2019. Best Practices for Sexual Health Promotion and Clinical Care in College Health Settings / page 14

37. Centers for Disease Control and Prevention. 2006. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006; 55(1-17). Accessed from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. 38. Centers for Disease Control and Prevention. 2015. STD Treatment Guidelines: HIV Detection, Counseling and Referral. https://www.cdc.gov/std/tg2015/hiv.htm. Accessed November 19, 2019. 39. Hurt CB, Nelson JAE, Hightow-Weidman LB, et al. Selecting an HIV test: A narrative review for clinicians and researchers. Sexually Transmitted Diseases 2017; 44:739–746. 40. Centers for Disease Control & Prevention (CDC). 2015 Sexually Transmitted Diseases Treatment Guidelines. Atlanta: U.S. Department of Health and Human Services; 2015. Accessible at: https://www.cdc.gov/std/tg2015/clinical.htm 41. LeFevre M.; US Preventive Services Task Force (2014). Clinical Guideline: Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161:902- 910. doi:10.7326/M14-1981 https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chlamydia-and- gonorrhea-screening 42. Moyer V; US Preventive Services Task Force (2013). Clinical Guidance: Screening for HIV: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:51-60 https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human- immunodeficiency-virus-hiv-infection-screening 43. US Preventive Services Task Force (USPSTF). Screening for Infection in Nonpregnant Adults and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(21):2321– 2327. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/syphilis- infection-in-nonpregnant-adults-and-adolescents 44. Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006

Developed by the ACHA Sexual Health Promotion and Clinical Care Coalition

8455 Colesville Road, Suite 740 | Silver Spring, MD 20910 | (410) 859-1500 | www.acha.org