BACKGROUND: Sexual health concerns, risk-taking behaviors, and experiences of violence are common among outpatients but are rarely addressed during healthcare consultations. Patients seldom raise these issues themselves, and healthcare professionals (HCPs) often lack the knowledge and confidence to initiate discussions. The SEXual health Identification Tool (SEXIT) was developed to facilitate identification of sexual health concerns, risk-taking behaviors, and experiences of violence. This is the first study to evaluate the use of the SEXIT Adult questionnaire (18+) in a diverse Swedish outpatient population. The study examined the questionnaire's ability to identify individuals' needs of further discussion and explored whether responses indicating need for follow-up differed by age, gender identity, sexual orientation, or clinics sexual health specialization.

METHODS: Consecutive data collection was conducted using the paper-based SEXIT Adult questionnaire at 10 publicly funded outpatient clinics in Sweden during a three-month period in 2023-2024. The sample comprised 438 patients. Data were collected by 61 HCPs, including physicians, midwives, nurses, psychologists, and social workers. Analyses included descriptive statistics and parametric tests. Differences in the mean number of responses indicating need for follow-up were examined using one-way ANOVA (age, gender identity) and independent t-tests (sexual orientation, clinic specialization).

RESULTS: More than 90% of participants provided at least two responses indicating follow-up. Nearly half (49.1%) reported ongoing sexual problems, and 58.0% reported experiences of sexual violence. Furthermore, 4.4% reported having crossed another person's sexual boundaries. Patients attending clinics specializing in sexual health reported significantly more responses indicating need for follow-up than those attending non-specialized clinics. Individuals aged 30-54 years reported more such responses than both younger and older age groups. Sexually diverse participants reported more concerns than heterosexual participants.

CONCLUSIONS: SEXIT Adult identified a substantial and likely unmet need for discussions about sexual health, risk-taking behaviors, and experiences of violence in outpatient care. The findings highlight the importance of routinely addressing these issues in clinical encounters and underscore the need for knowledgeable, inclusive, and tailored care, particularly for gender and sexually diverse populations.

Earlier research has found that sex could be used as a means of self-injury with functions comparable to other self-injurious behaviors such as cutting or burning the skin. A suggested definition for sex as self-injury (SASI) is "a pattern of seeking sexual situations involving psychological or physical harm to themselves." The research concerning SASI is sparse and the behavior is still in need of further understanding. The aim of this study was to investigate the prevalence of SASI among visitors to youth clinics in Sweden and the associations with sexual risk-taking, drug and alcohol consumption, and experience of violence. The study was based on data collected through the SEXual health Identification Tool (SEXIT) at youth clinics in multiple Swedish cities. A total of 813 participants were included in the study (Median = 19 years, SD 2.52 years, 734 identified as women, 78 as men, and 1 as other). Overall, 12.30% of the participants reported experience of SASI. SASI was most strongly associated with experience of sexual harassment or assault (OR 6.22), ever being diagnosed with a sexually transmitted infection (OR 3.07), drug use (OR 3.02), and experience of physical and/or psychological violence (OR 2.78). In conclusion, SASI is occurring among youth clinic visitors and is associated with factors that endanger young people's physical and psychological well-being. Healthcare professionals need to have knowledge of SASI to offer proper help and support.

Sexual health concerns, experiences of violence, and risk-taking behaviors significantly impact various aspects of life, leading to adverse health outcomes. Unfortunately, few patients disclose these problems to healthcare providers (HCPs) due to shame and fear. While HCPs recognize the importance of addressing sexual and reproductive health related issues, time constraints, lack of knowledge, and fear of embarrassing patients often hinder thorough investigation. SEXIT (SEXual health Identification Tool) was developed to facilitate and initiate conversations about sexual health, experiences of violence, and risk-taking behaviors between youths aged 13–24 and HCPs. However, no comparable methods exist for adults. This study aimed to explore which questions professionals believe HCPs should ask adult patients. Using a Delphi methodology, 19 academic and/or clinical experts participated in two online questionnaire rounds and a web meeting. The panel identified 25 highly relevant questions covering diverse areas (e.g., sexual and gender identity, sexual satisfaction, experiences of violence, and substance use). These questions may empower adult patients to disclose sexual health concerns, enabling HCPs to comprehensively address these issues during medical history assessments. The identified questions have been incorporated into the development of the SEXIT Adult questionnaire.

Objectives: Few patients voluntarily disclose problems with sexual health, experiences of violence, and risk-taking behaviors to their health care providers. Despite health care providers being aware of the importance of these topics, few regularly address these areas in outpatient settings. This is often due to a lack of knowledge about sexual health among providers and a fear of embarrassing patients by asking questions that might be perceived as private or intrusive.To address these challenges, the SEXual health Identification Tool (SEXIT) was developed. Initially designed to identify sexual ill health, experiences of violence, and risk-taking behaviors among youth through a structured questionnaire and follow-up conversation, SEXIT has proven effective in these demographics. However, there is an absence of comparable methods tailored for adult populations.

Methods: This study aimed to identify the specific questions that health care providers should ask concerning sexual health, experiences of violence, and risk-taking behaviors in adult outpatient settings. Utilizing a modified Delphi methodology, a panel of 19 experts from clinical and academic fields was recruited.

Results: In the end, 25 questions were identified as highly relevant. These questions cover topics including sexual and gender identity, sexual satisfaction, experiences of violence, and substance use.The findings from this study provide a deeper understanding of the pertinent questions that should be integrated into medical history taking to address sexual health, experiences of violence, and risk-taking behaviors. By incorporating these questions, health care providers can bridge the knowledge gaps commonly experienced in the Sexual and Reproductive Health and Rights (SRHR) field. Moreover, this approach can remove the barriers that patients face when attempting to discuss these sensitive issues.

Conclusions: The questions identified have been included in the development of the first version of the SEXIT Adult questionnaire. This tool, along with the accompanying guidance for health care providers, is currently undergoing clinical evaluation. The implementation of SEXIT Adult holds promise for enhancing the identification and management of sexual health issues, experiences of violence, and risk-taking behaviors in adult outpatient settings, ultimately contributing to improved patient well-being.

Conflicts of Interest: There are no potential conflicts of interests.

Sexual ill health among young people, in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence, is a global public health concern. To that end, the SEXual health Identification Tool (SEXIT) was developed. The purpose of this study was to explore the visitors' experiences of a youth clinic visit when SEXIT was used. A purposively selected sample of 20 participants (16-24 years of age) was recruited from three Swedish youth clinics using SEXIT. Participants were interviewed individually in March and April 2016, and data were analysed using inductive qualitative content analysis. The analysis resulted in four main categories describing the participants' experiences of using SEXIT: "Issues of concern" includes descriptions of the items in SEXIT as important; "Enabling disclosure" describes how SEXIT serves as an invitation to talk and facilitates disclosure of negative experiences; "Road to change" captures experiences of the conversation with the healthcare professional; and "Managing power imbalance" describes experiences regarding the response and attitudes of the healthcare professional as well as the participants' fears of being judged. The categories are connected by the overarching theme "Ask me, listen to me, treat me well and I shall tell". This study contributes knowledge on young people's experiences of a tool-supported dialogue on sexual health and risk-taking initiated by the healthcare professional. Structured questions in a written format, as a basis for dialogue, are appreciated and experienced as a functioning way of addressing sexual ill health and risk-taking at Swedish youth clinics.

Background

In 2016 SEXIT, an evidence-informed the toolkit, was developed and pilot-implemented at three Swedish youth clinics. Swedish youth clinics are highly accessible and focused primarily on concerns related to sexual and reproductive health and mental health among young persons aged 13-25 years.  The SEXual health Identification Tool (SEXIT) was developed to facilitate identification of young people exposed to, or at risk of, sexual ill health in terms of sexually transmitted infections, unintended pregnancy, transactional sex, or sexual violence. The tool includes three components; (1) staff training, (2) a questionnaire for visitors, and (3) a written guide for staff to support the dialogue and risk assessment. Previous results demonstrated promising results; a high response rate from visitors (86%), few missing answers, and youth clinic visitors reporting factors associated with sexual ill health. Interviews demonstrated that youth clinic visitors appreciated structured questions in a written format as a basis for dialogue and found SEXIT appropriate for addressing sensitive topics. 

Objectives

To explore the youth clinic staff’s experiences of using SEXIT systematically with all visitors, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics.

Method

Four focus group discussions with youth clinic staff who participated in the pilot implementation. The clinics had used SEXIT systematically with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups.

Results

Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. Youth clinic staff experienced that SEXIT advanced their knowledge and the midwifes experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced on how SEXIT best should be applied. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours. Further, the staff were concerned about the continued care of vulnerable, and hard-to-reach youth clinic visitors that sometimes do not attend the scheduled revisits.

Conclusions 

Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible.

Background: Young people are disproportionally burdened by sexual ill health. The SEXual health Identification Tool (SEXIT) was developed for use at youth clinics, to facilitate identification of visitors exposed to or at risk of sexual ill health. The aim of this study was to explore experiences of using SEXIT among youth clinic staff who participated in a pilot implementation, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics. Methods: Four focus group discussions were conducted with youth clinic staff from three clinics. The clinics had used SEXIT systematically in consultations with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups. Results: Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. The medical staff experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours. Conclusions: Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible.

Objectives: We aimed to develop and pilot-implement an evidence-informed toolkit (SEXual health Identification Tool; SEXIT) for identifying young people exposed to or at risk of sexual ill health, at Swedish youth clinics, and to investigate SEXIT's potential to identify young people in need of special care and monitoring. Methods: The SEXIT toolkit was developed, validated and pilot-implemented at three Swedish youth clinics. Pre-implementation staff readiness was assessed and youth clinic visitors' responses to SEXIT were analysed. Results: All staff perceived a need for screening for sexual risk-taking and exposure. The response rate from 268 youth clinic visitors (aged 15-24 years) was 86%. Half of the visitors had one or no variable associated with sexual ill health, a third had two or three, and 15% reported between four and seven variables. The most common variables were alcohol use, three or more sexual partners in the past year and previous chlamydia. Visitors rated SEXIT as important and not uncomfortable or difficult to answer. Conclusions: The SEXIT toolkit was found to be feasible and highly acceptable in a clinical setting. The use of SEXIT may facilitate important questions on sexual risk-taking and sexual ill health to be raised with youth clinic visitors.