How Should I Discuss Sex With Patients?

Sarah Averill, MD

Disclosures

September 03, 2010

Question:

Asking about and discussing sexual health and sexual problems with patients often isn't emphasized in medical education. How can I learn to feel comfortable with this responsibility?

Response from Sarah Averill, MD
Resident, St. Joseph's Hospital, Syracuse, New York

"So, uh... things aren't working down there," he said, looking straight at me. I was a third-year medical student on a Family Medicine rotation, suddenly taking a sexual history on a man nearly twice my age. "Wow, I can't believe he's telling me this," I thought. Then, I took a deep breath and started asking him about it: "When did this start?" It wasn't hard to ask questions that I'd asked a thousand times already.

As a premed student, I overheard an upper-class medical student talking with a group of his peers about how he wanted to be a doctor who helped his patients with all aspects of their lives, including their sexuality. I liked what he was saying, but inside I cringed and thought, "Oh God, can't I just let someone else deal with the sex stuff?" If you should happen to have the same reaction, rest assured, you are not alone. Despite years of training in dealing with complex and difficult medical conditions, many physicians still have difficulty talking to patients about their sexual health. Patients have come to expect that they won't get much help in that area from their doctors.[1]

Yet sexual health and sexuality are areas of life that have myriad implications from reproduction to infectious disease to mental health. Sexual dysfunction can also be a clue to significant underlying medical problems, such as heart disease or hormone deficiencies.[2] The potential implications for all areas of patient health reinforce the fact that it's worth getting comfortable taking a sexual history and addressing patients' concerns about sex and sexuality.[1] As a medical student you may find that this is not emphasized in your training and you may need to be proactive in learning these skills.

I was fortunate as a medical student to learn to take a sexual history and the related components of the physical exam by a group of diverse volunteers, including gay and straight, young and old, and men and women of various racial backgrounds. They taught me to approach these issues in as straightforward a way as possible and offered many useful suggestions. I also learned from reading books by people with disabilities, such as Mean Little Deaf Queer and Waist-High in the World, that you can't assume anything. Nancy Mairs, author of the latter memoir, is a writer who suffers from multiple sclerosis. She writes that not one of her doctors ever asked her about her sex life, despite having a very robust one. She writes beautifully and will challenge you as she did her own physicians to consider the sex lives of patients with physical disabilities.[3]

I don't mean to imply that asking sensitive questions is ever easy, but it does get easier with practice, like all parts of the physical exam and history-taking.

So, how do you learn how to take a sexual history as a medical student? You must practice asking questions and you must practice tolerating the discomfort you might feel about asking these questions, or listening to the answers. You may not be required to ask about sexual health as part of your social history, but it's a good idea to get in the habit of asking basic questions, such as "Are you sexually active? With men, women, or both?" The more you practice, the more comfortable you will become in the future.

According to Gloria Bachmann, MD, Chief of the OB/GYN Service at the Robert Wood Johnson Medical School, if you have only limited time, the best 2 questions to ask as part of a minimal "review of systems" are: 1) "Are you sexually active?" and 2) "Are you having any sexual difficulty such as pain or lack of sexual desire?"[4]

As a medical student you can also try asking questions in class. I once asked if Viagra works for women. After years of spam in my email inbox, I couldn't resist the temptation of asking the physician who was teaching us about erectile dysfunction in men, including treatment options, if Viagra had a role in treating female sexual disorders. The question generated stunning silence. I wasn't the only one who wanted to hear his expert opinion that in select situations these drugs can help.

Ask the physician you are working with how she or he approached getting comfortable asking difficult questions. Ask the patients that you get to work with in medical school which qualities in a physician help them feel comfortable talking about sexual health and which ones make them uncomfortable. Medical school is a laboratory and the patients you get to work with during school are a good source of information. They will teach you more than you can imagine, but first you have to ask.

Seek out role models. If you can't find anyone at your school to work with, seek models elsewhere. Sue Johanson, a Canadian sex educator, is someone whose straight talk and nonjudgmental approach is worth emulating. The content of her website is explicit but relevant and may be helpful.[5]

Reflect on your own biases and behaviors. Observe what makes you uncomfortable and try not to avoid that feeling. What makes you uncomfortable can be a signal to you of where you have room to grow. Approach your education as a social experiment. Remember that what in another context might be considered prurient curiosity is actually critical to your patients' health. Physicians have an obligation to be aware of what their patients may be doing in order to give thoughtful advice.

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