« A Funny Thing Happened on the Way to the Nurses' Station | Main | Feeling Like a Fraud »
Let's Talk About Sex
There are homosexual men who don’t have anal sex, plenty of heterosexual women who do, and many combinations in between. To simply ask men if they are homosexual seemed to miss a lot of other possible factors. It got me thinking about how many physicians take very good histories and ask open-ended questions, yet sometimes miss relevant details related to their patients’ sex lives. I know that I’ve experienced this as a patient, and I’ve seen other doctors and students make this mistake.
A patient’s sex life is obviously quite relevant to both their physical and mental health. In order to properly address all of a patient’s concerns, it’s important to know relevant details such as their sexual activity, preferences, safe or unsafe practices, and level of functioning. It could be relevant to their transmission of STDs, medication side effects, emotional issues, and many other aspects of their health.
I think that the problem of physicians not delving deeply enough into a patient’s sex life is probably related to embarrassment, a lack of time, and a general ignorance with respect to the varieties of sexual experiences. I know that so far in my medical education, I’ve received only one very brief lecture about human sexuality, and I’d hazard a guess that many medical curriculums are similarly lacking information in this area.
Many people, physicians included, make a lot of assumptions about other people’s sex lives without being truly informed. For example, a doctor might ask a patient if they are heterosexual or homosexual, without providing for all the other options that exist. There is also a strong age bias that older people don’t have sex. However, there are many older people who would quickly dispel this myth. If a physician fails to ask an older person about their sex life, they could be missing out on many important clues to their level of health and potential problems.
The doctor-patient relationship is very intimate. Physicians have to ask patients about some of their most private details. Without this level of intimacy, the relationship breaks down, and patients can receive less than optimal care. I’m not saying that it’s completely one sided. There are plenty of patients who are less than honest with their doctors. But I think it’s important that as physicians, we do everything we can to put our patients at ease and to help them feel comfortable sharing intimate details with us. And in order to do this, we can’t forget to appreciate all the varieties of human experience, including sexual. We should try to be more mindful of individual differences, ask more open-ended questions, and we should not be afraid to talk about sex.
October 2, 2007 in Kendra Campbell | Permalink
Comments
Something one of my physical diagnosis professors said that's stuck with me is to make sure the patient (and yourself) knows that what's important for the physician to know about the patient in regards to their sexual history is THE PRACTICE, NOT THE PREFERENCE. It's not important clinically (yes, perhaps if you're doing an epidemiological study) whether the patient is homosexual or heterosexual; knowing such things at the outset starts your mind going down certain avenues of diagnosis that might not be correct.
Posted by: | Oct 2, 2007 4:43:38 PM
My experience in medicine has always been that they will almost certainly never teach you that everyone dies, and that everyone interacts with other people in a myriad of ways.
Modern allopathic medicine is more about the disease than the patient. It's up to us on the OJT part to make it all fit. Those are the benefits of having the beancounters control the schools and hospitals.
Posted by: Jared | Oct 3, 2007 5:09:36 AM
People over 70 do NOT have sex. *covering ears* "Lalalalala"
Posted by: Ew | Oct 3, 2007 8:12:49 AM
Ew, that is indicative of the problem.
Posted by: Jared | Oct 3, 2007 9:16:27 AM
Hey Kendra, nice topic. I'm studying in South Africa (get out the atlas if necessary haha) and I'm busy doing a 3-week intro to women's health. Last week we had a sexologist come speak to us about sexuality for 2 hours. It was initially weird, uncomfortable even, but we quickly realised that there was no escape.
This is true when speaking to our patients - it's something we will all have to do, and just like everything else, it gets easier with practice. I've added sexual history taking to my general examination.
Oh, and I agree with the first responder - it's the sexual practice, not the preference, that counts.
Posted by: Ryan | Oct 3, 2007 12:19:47 PM
Just wanted to say I miss you. And that it is comforting that someone as open minded as yourself is going into medicine. Come to Hopkins. =]
Posted by: Nate | Oct 3, 2007 4:49:35 PM
The way that I usually start a sexual history, after explaining to the patient that I'm about to ask questions that may seem personal but they are medically important, is by asking
-Are you sexual active?
-How recently? How frequently?
-With men, women or both?
-Do you do/use anything to prevent pregnancy?
-Do you do/use anything to prevent STD's?
I figure those questions are pretty neutral and get to what's important.
Posted by: Dev Thakur | Oct 3, 2007 6:00:21 PM
well reading all above all that i can say is the scenario is far different in indian subcontinent.forget homosexuality, here even asking a patient asking about his or her heterosexual life is also a problem. asking about hetrosexual relationship can be done with least difficulty only in gyne & obs department . neither our teachers advice us to ask, nor they ask, nor we ask of matters related to homosexual relationships to our patients. In this part of world your patient may take it as a direct insult from you & many a times they are too shy of replying to this type of questions. I remember my 3rd year gyne obs posting in opd. A female patient [age-around 20] came in our opd with history of amenhorea [primary type]. We were told to take her history in detail. We were 5 or 6 medical students attempting to take history & out of us 2 or 3 were girls & they were actually taking the history. What happened was we saw books & ruled out almost all causes of amenorrhoea, but we couldn’t reach the diagnosis. So while reviewing the history I found we have not asked a single question about her external genitals. So I told my friends to ask them about the genital openings. so my female colegues tried to extract the answer asking a huge number of indirect questions but they couldn’t ask a direct question like if she had a patent external genital opening or not. unfortunately our patient couldn’t get our indirect questions. So lastly we waited for our teacher to evaluate & which lastly revealed that her vaginal opening is absent. So think when a female cant ask another female about her patients genitals history think how difficult is asking about homosexuality in our part of world. During my whole of the mbbs period not single time a teacher made mention of the word homosexuality in case of history taking. Not only this if you consider about the country india where homosexuality is treated as a criminal activity even if you ask your patient about homosexuality he might not say the truth because they are scared of being puted behind the bar.
Thanks.
dr_sumantasaha@hotmail.com
Posted by: Sumanta Saha | Oct 4, 2007 4:55:19 AM
hi kendra has raised a pertinent q..i am also a student from india. as a follow up ot the prev comment i would like to add tht the issue is as big as we seem to make it..like in the example given above if there had been only one student interacting n been more straightforward in the qs i m sure there would have been more answers ..i have myself found many patients to be shy yes but when asked in the right way they are eager enough to share any problems because it is an issue which is not widely discussed in homes n if made comfortable patients do want to come out n discus their sexual issues ..in my opinion it is our duty to be extremely thorough irespective of any constraints and sensitivity tact n yet boldness to ask details n give the apropriate advice works for all situation
Posted by: prerna | Oct 4, 2007 11:36:55 AM
This is the sex exam on history in the ER:
Are you sexually active?
Last time, how many life partners?
With men, women, or both?
Pregnancy: how many times, how many abortions, how many living kids?
STD's: past and present. Any discharges, dysuria, frequency?
Always, ALWAYS, get a urine HCG in the ER, always do a rectal and pelvic.
It wasn't a short-sighted piece of advice from the guy. He was probably helping folks break the ice who have trouble asking people about their sex lives, especially variants of cultural norms. No matter what you think about it, you gotta ask, so do the best for your patients and keep it short, simple, and ALWAYS do the appropriate physical exam and labwork.
Posted by: Anony-mouse | Oct 9, 2007 2:18:35 PM
May I make one observation about the otherwise excellent regular sexual history questions? I have been told by faculty and preceptors alike that some people do not know the "definition," if you will, of "sexually active." I don't know if it was a joke or not but someone even said that a woman diagnosed with pregnancy later admitted that she thought "sexually active" meant she was the one doing all the moving! :) But seriously, there's a lot to consider besides what many people think is sex (ie penile/vaginal penetration). I spent some time with an ob/gyn who phrased the question as (and I hope I remember this correctly): "What kind of sex are you having, if any?" That, he told me, opened up the arena to oral, vaginal, anal, or none, as well as hetero-, bi-, or homosexual. So I'm more likely to phrase the question that way, too. Makes sense.
Kendra, you are one of my favorite bloggers. I love how candid and sensitive you seem to be! :)
Posted by: Amy | Oct 9, 2007 4:53:57 PM
The first poster ought to consider that knowing whether a patient is homosexual or heterosexual need not make the diagnostician jump to conclusions. Rather, it can be an important fact in development of a differential diagnosis.
Posted by: | Oct 9, 2007 5:26:51 PM
"medical curriculums"
My Dear:
It looks like you have never studied any Latin.
Any shame(!!!), when using that uneducated expression with your cultured patients???
Posted by: medik | Oct 9, 2007 8:15:38 PM
I had a similar experience when a professor was talking about particular rectal issues and said something to the effect of "homosexual men are at a higher risk than heterosexual men," to which I replied that it must be a genetic illness or be in linkage disequilibrium. My questionable wit was lost on him based on his blank stare so I clarified by saying that it wasn't being homosexual that put someone at a higher risk, but their sexual practice, and like the original poster, made a few comments about not all gay men have anal sex, of those that do, not all are the receptive partner, and of course, there are many heterosexual couples (both men and women) who practice some form of anal sex/stimulation, who would be overlooked using his parochial view/interpretation.
My point wasn't to pick nits, but to point out what I felt was a strong lack of clue in his interpretation and how it did a disservice to the patient, but also kept the clinician from seeing the real connection (ie it's not being gay that puts you at risk, but being a receptive partner in anal sex). I think much of this has to do with embarassment or a lack of clue on the clinician's part (for example, there are some subcultures that fall far outside the societal "normality band" that I have to struggle to wrap my mind around to understand its implications and impacts on the patients health), but it's important, as an advocate of your patient, that you provide a safe and comfortable (as possible) environment for your patient and sometimes that means admitting your ignorance to your patient and expressing a real desire to understand her/his condition vis-a-vis their lifestyle, IMHO.
Posted by: TEMSGunner | Oct 10, 2007 10:36:58 AM
When I was 15, my doctor asked me if I was sexually active, and I said no. Then, he said, "So, what do you think about when you think about starting to have sex?" I thought, "I don't know...silk sheets? a little wine with dinner?" I said nothing. He stared me down and then finally said, "Condoms?" I finally understood what he wanted and listed several forms of contraception. He looked relieved and ended the discussion pronto.
Posted by: Anonymous | Oct 10, 2007 12:56:00 PM
We touched on the subject of taking a sexual history today in a physical diagnosis class. The lecturing doc told us, "Most of my patients are up front about their sexual orientation. But then again, I don't care how they identify, I'm interested in their behaviors."
I study naturopathic medicine in Seattle. People are pretty open with their sexuality here, compared to southern California, where I did my undergrad. I've learned that people can identify as heterosexual and have sex with members of their same gender (and gender does not always equal sex).
A better question might be, "Do you have sexual contact with guys, gals or both?" Otherwise we may be making assumptions that aren't true.
Posted by: colourblind | Oct 10, 2007 5:14:11 PM
Talking about sex may be that some kind of serious and private thing especially amongst conservative people. Yes, indeed, it is good to ask about it for additional information purposes but giving an open-ended questions must have its limitations because we must take considerations from it especially of their sexuality. And also, I agree that if we want an information something about sex medically, it's the practice nothing else.
Posted by: BabOy_Ok2 | Oct 11, 2007 6:23:21 AM
I am from India, and i am working with marginalized population, who would be dispropotionately affected due to HIV/AIDS if they get it, (sadly everybody can!), I have a few questions for everybody, which will help me search a little more if at all, and they may sound naive, but here it goes,
Are there any documented cases of homosexuality in women who have had sex only with other women and have been diagnosed to have HIV, If yes then what was the kind of sex that they mostly practiced? If it was Oral then was it associated with ulcerations in the oral cavity or any break in the skin (as in STDs)? (that last part of the question also applying to any cases of homosexual men)
The reason I need to know the answers to these questions is because, I have faced them myself and they are also intriguing to me since I usually suggest them to be as safe as possible!!
It would be kind of anyone to reply or send a link regarding the same.
And as you can see my work involves asking these questions one needs to very discrete and open and more importantly non-judgemental not only with regards to the answers you recieve but also the reaction and your body language, which should be assertive and encouraging!
Posted by: Major_flaw | Oct 11, 2007 11:17:59 AM
please,can anyone tell me the diagnostic values of knowing that the patient is homosexual ?
i think it has little values that can be avoided till i suspect certain conditions.
thanks for topic
Posted by: galoum | Oct 14, 2007 9:57:04 AM
i'm 24years old,but i have not sexual practices,it'normal?
Posted by: nini | Oct 14, 2007 2:58:09 PM
Hi! great topic, I am from Peru, here as part of the general examination we ask about our patient´s sexual backround:
-age at First Sexual Intercourse?
-are you sexual active? How recently? How frequently?with men, women or both?
-do you have sexual intercorse with prositutes? when was the last time? how often do yo do it? with how many? when you do it, do you use a condom?
-how many life partners?
-do you use some contraceptive method?
-have you ever had a STD?
Always is worth asking!
Posted by: Rocío | Oct 14, 2007 3:45:00 PM
hi kendra
its a great topic,but its not applicative in Iran,my country.you know kendra ,here ,asking patient any question about sex assumpting he/she is heterosexual is very very difficult,much less i as an extern ask "have you ever had sex with a homosexed?"religious rules neither let me ask such questions nor the patient express the truth.(although science and reason let us).
Posted by: k | Oct 17, 2007 7:55:59 PM
Hi......
I am from jaipur-INDIA doing P G in AYURVEDA this is good topic & im getting so much knowledge, Day by day awareness about sexual life is increases in my country & peoples are openly discuss the sexual problems with their physicians.
Posted by: Dr.mukund | Oct 19, 2007 11:54:22 PM
