Venturing Beyond the Binary Sexual Health Interview

Steffie Goodman, PhD, CNM


Am J Public Health. 2018;108(8):965 

" The limits of my language mean the limits of my world."
—Ludwig Wittgenstein, 1921

Going beyond binary thinking changes the brain, akin to finding yourself in the dark; your eyes slowly adjust, and the brain accommodates. The change in the brain allows you to move forward. We do this every day, yet we prefer binary thinking. It lends clarity and comfort to an ever-changing world.

Binary thinkers consider and prefer two mutually exclusive possibilities, such as black or white, right or wrong, and male or female. Nonbinary thinkers are aware of the nondistinct areas in between. Some nonbinary thinkers are aware that nothing is a true straight line with two endpoints and a middle. Sexuality and gender issues are a perfect example of multidimensional, nonbinary experiences.

The goal of this article is to use words to extend the "limits of ourworld" through rewriting the sexual health interview. The rewritten sexual health interview simply asks "what went where." In addition, categories of sexual orientation and gender identities are all-inclusive and self-descriptive, allowing for answers that are beyond heterosexual or lesbian, gay, bisexual, transgender, questioning, intersex, and asexual. Asking questions in this manner will ultimately change everything about the data we collect and the terms we use.

The Centers for Disease Control and Prevention advocates for a sexual health interview that uses the five P's: partners, practices, protection, past history, and pregnancy prevention. Protection, past history, and pregnancy prevention are straightforward questions. The trouble with the five P's is related to how we ask questions about partners and practices. A sixth P, assessment for preexposure prophylaxis, is another potential component of the sexual health interview.

The current sexual health interview collects information about the sexual health of primarily heterosexual, homosexual, and transgender people by asking mainly binary questions and assuming binary answers; for example, "Do you have sex with men, women, or both?" "Have you had any female partners in the past, ever?" "Number of female partners in the past 3 months?" "Number of NEW female partners in the past 3 months?" "Total lifetime number of female partners?" (Questions are repeated with the word "female" replaced with "male.")

These types of questions are problematic. They leave us with insufficient data, because they do not adequately address or describe sexual behaviors that have implications for public health and epidemiological research. They undermine gender self-description and simplify the scope of sexual orientation. They use and promote binary thinking and the assumption that all men have penises and all women have vaginas—which does not serve any patients, including the majority who live in the binary world. They present us with a missed opportunity to endorse all-inclusive acceptance and obtain complete data. Therefore, it is preferable to assess which parts go where instead of who is having sexual contact with whom if we want to better monitor sexual behavior and health outcomes irrespective of identity and sexual orientation.

We use these questions in our clinic: "How many people have you had sex with in the last 2 months, year, lifetime?" "Since my last STI [sexually transmitted infection] screen, my genitals [or my mouth, or my anus] have had contact with someone else's [relevant options] mouth, vagina, penis, anus, foreign object." Furthermore, we find that people self-describe beyond lesbian, gay, bisexual, transgender, questioning, intersex, and asexual and use words such as agender, androgyne, demigender, gender fluid, gender nonconforming, demisexual, polysexual, or pansexual. Allowing for self-description shows the profound need to change the sexual health interview.

Rewriting the sexual health interview provides an all-inclusive safe space for patients. It helps promote acceptance and respect and acknowledges the presence of nonbinary thought and experience. It encourages the use of words to expand our thinking, to extend the "limits of our world," and to embrace the diverse world in which we live.