Introduction

Reviews

Let's Talk About Sex

Timothy B. McCall, M.D.

Sexuality can be difficult to talk about, for both doctors and their patients. It's hard for many doctors to ask a patient "Have you had anal intercourse?" or to ask a sexually-active teenager "Do you use condoms?" It may be even more difficult to ask teenagers the follow-up questions to make sure they know how to use them correctly. But these questions are essential, because teenagers who don't use them correctly may end up the parent of an unwanted child or infected with HIV. Unfortunately, many doctors fail to broach the topic of sex.

Researchers at Boston University Medical School found that doctors asked less than one third of new patients if they had any sexual problems or concerns. A sexual history was included in the interview for 43% of men but for only 21% of women. Doctors were less likely to ask older people about sexual problems. Interestingly, the researchers found that the age and sex of the patient did not influence the likelihood of sexual problems. Ninety-eight percent of patients asked about sexual difficulties considered the questions appropriate. The sexual history often improved the doctor's understanding of the patient, and, perhaps most importantly, yielded important medical information 26% of the time and led to changes in treatment or follow-up 16% of the time.

When asking questions about sexuality doctors should be non-judgmental and not jump to conclusions. Doctors frequently assume young lesbians are heterosexual and give them undesired advice about birth control. Similarly, doctors may assume that older patients are no longer sexually active. Faulty assumptions may undermine trust and lead to mistaken diagnosis. If patients feel they are being judged for their behavior, they may be unwilling to talk about it.

Doctors who neglect the sexual history are either reluctant to devote the required time, can’t overcome their inhibitions or assume that sexual functioning is not important to a particular patient. By not asking, the doctor may fail to learn of discord in the patient's marriage or other significant relationship, of sexual abuse or of other problems that could affect the patient's health. Sexual problems can provide clues to diabetes, hormone problems or depression.

Doctors who fail to take a sexual history may not recognize when their patients are suffering a side effect of a prescribed medicine. Several medications for high blood pressure, for example, can cause impotence, difficulty with ejaculation or a loss of interest in sex. Unless the doctor asks, the patient may continue to suffer these side effects when a simple change in medication could solve the problem. Some people don’t realize their problem is a side effect of their medication and falsely attribute their difficulties to old age or a loss of interest in their partner. Others make the connection but rather than mention it to their doctors, simply stop taking their medication, leading to poorly-controlled blood pressure and an increased risk of a heart attack or a stroke.

The bottom line is this: it can be hard for doctors and patients alike to talk about sex but it's vitally important. Not doing so can mean missed diagnoses, lost opportunities to treat and sometimes even death. Maybe it is time to have a little talk with your doctor.

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