by Fei Cai
Most of us have been there as teenagers.
Wearing a backless johnny, sitting on the way-too-high exam table, and trying not to make too much noise on that weird crinkly tissue paper they always put down for “sanitary” reasons. Your doctor or nurse practitioner stares you in the face and asks the dreaded question: “So… are you sexually active?”
Well, there was that one time I put my hand down that guy’s pants.
What about when I kissed that girl?
It didn’t really go in so does it count?
In your doubt, you say, “…No.”
Hence begins the long road of uncomfortable white lies, or worse, silence on the topic of sexual health in doctors’ offices. Let’s face it: it’s weird to talk about sex with some near-complete stranger, and, well, if the oh-so-knowledgeable doctor doesn’t bring it up, then it must not be a problem right?
Here’s a secret (not really): it’s just as uncomfortable for us healthcare professionals.
Doctors are supposedly trained to talk about sex with our patients in medical school and residency, but the reality of it is a little bleaker. When we first learned how to ask a sexual history, we were given a full page of awkward questions starting with, “Are you sexually active?” (first of all, what does that even mean? The next time a doctor asks me that, I want to answer, “Nah, I just kind of lie there”) to “Do you have problems achieving orgasm?”
We then spent that afternoon going through the list with a standardized patient, who, I have learned, was much more comfortable with these questions than actual patients. Unlike in real life, our standardized patient did not give us the look only adolescents can give when asked, “Do you engage in oral, vaginal, or anal sex?” She seemed perfectly alright disclosing that she had 10 male partners in the last month, and she very confidently stated that she used condoms about 80% of the time.
Even with her, it took each of us approximately 10 minutes to ask all the questions and receive responses. Had there actually been a problem, there would have been much more time spent exploring that issue.
If you take into the account that the average follow-up visit with a doctor is about 15 minutes, and an annual physical is 30-45 minutes, 10 minutes is a big chunk of time to spend on something that the patient doesn’t bring up.
Then, the rest of medical school, we were dispersed to our respective mentor sites where many of us never asked those questions again because it was not something our mentors thought was important. Fortunately, in my third year of medical school, I was paired with a family physician that believed a complete sexual history to be an integral part of every new patient evaluation, and continued to ask pertinent questions about sexual function and health as the years went on.
His questions, even at a new patient annual, took perhaps two minutes. They began with, “What gender do you identify with?” and continued with a few more pointed questions such as, “Who do you engage in sexual activities with?” and “How many sexual partners have you had in the past six months?”
I learned that wording is extremely important. Instead of asking, “Do you have problems with erections or orgasms?” (the question is phrased so that a one word answer is easy), I should ask, “What problems have you had in terms of achieving erections or orgasm?” The second way normalizes the question and the patient has to actively say (and think), “Actually, I don’t have any problems with either.”
Also important was my mentor’s approach to STI testing. When he identified risk factors for heart disease, diabetes, and stroke, we would check lipids and blood sugar. Similarly, if he identified risk factors for STIs, he would say in the same sentence, “Based on your risk factors, I would recommend getting a blood test for your lipids, sugars, and sexually transmitted infections.” This way, STI testing became an “opt out” instead of “opt in.”
His approach is one that addresses a gap we currently have in primary health care. The Journal of Sexual Medicine published an article in 2006 that stated:
Sexual problems have a clear negative impact on both the quality of life and emotional state regardless of age. Learning about specific sexual dysfunctions among men can reveal a variety of as-yet-undiagnosed comorbid pathologic conditions such as: (i) depression and other emotional illnesses; (ii) psychosocial stress; (iii) actual cardiovascular disease as well as related risk factors such as hypertension, diabetes, and/or hyperlipidemia; (iv) hyperprolactinemia; and (v) low serum testosterone. Specific sexual dysfunctions among women can reveal pathologic conditions such as: (i) depression and other adverse imitational and psychosocial conditions; (ii) low serum estrogen or testosterone; and/or (iii) vaginal or pelvic disorders.
Similarly, an article in The Journal of Family Health Care stated, “The rise in sexually transmitted infections (STIs) and the high rate of teenage pregnancies mean that sexual health services need to be increasingly provided in primary care settings by primary care professionals.”
What this all comes down to is that we as physicians care (or should care) about the whole individual, and sexual health is clearly linked with other aspects of wellbeing. Sexual dysfunction can be one of the many signs of declining physical and mental health, and primary care physicians can intervene before these issues become major concerns. Unfortunately, healthcare providers can’t help with what they don’t know.
While physicians and other healthcare providers should make every effort to talk about these issues with their patients, the reality is that this does not always happen, which is why patients themselves should try to bring up the issue of sexual health with their doctors. A complete talk about sexual health should encompass:
1) How you identify
2) Who you are having sex with
3) What sexual practices you engage in
4) Practice of safe sex
5) Satisfaction with your sex life
6) Questions or concerns about your sexual health and function
7) Sexually transmitted infections
With my mentor, because we asked, we had many patients admit to unsatisfactory sex lives. It may have been difficult for them to approach us at first, but once we knew, many of these issues were easy fixes that greatly improved their quality of life. Some postmenopausal women had pain and dryness with intercourse and just needed a prescription for Vagisil. Some men had problems achieving erections and wanted to try Viagra or Cialis. Rarely, we had patients who had more complex sexual dysfunction that we referred to specialists.
What I’m trying to say is that as physicians, we know a heck of a lot about sexual function/dysfunction and health, but we don’t know what or how much to tell you, and that can negatively impact your care. Unfortunately, because of the limited amount of time physicians have per visit, we often orient our care toward patient complaints.
So, the next time you go to your doctor’s office, ask yourself if he or she knows the above facts about you. If not, facilitate a conversation with your doctor. If you are like me and happen to like things in tables, here’s one:
How to Facilitate A Talk About Sex With Your Doctor
|Who you are and your sexual history||“I am a man who has sex with men. I don’t have a history of any sexually transmitted infections.”Other things to include: any pertinent surgeries or medication/herbal remedy/topical remedy use|
|Who you are having sex with and what sexual practices you engage in||“I am currently having sex with three women. We engage in oral and vaginal sex using toys.”|
|What you are doing for protection||“We use condoms 100% of the time.”|
|Satisfaction/Dissatisfaction||“I am currently happy with my sex life” or “I am currently not happy with my sex life because…”|
|Questions or concerns about your sexual health and function/Sexually transmitted infections||“I wanted to ask if you had any thoughts about how I could improve my sexual health.”“Is there anything I can do to be more safe?”“I am having concerns about maintaining my erections.”“My main concern is not getting pregnant right now, though I may want to in the future. What can I do to make sure that I have the most effective form of contraception?”“What sexually transmitted infections do you think I should be screened for?”|
The above table is not by any means a definitive list of questions, but it will at least begin the conversation and hopefully get your doctor to talk to you more about your sexual health. Also, I hope it will make you a little more comfortable when talking to your healthcare provider. So please, don’t brush your questions and concerns about sex under the table because they seem unimportant or embarrassing. Trust me, we want to know.
 Sadovsky R, Nusbaum M. Sexual health inquiry and support is a primary care priority. J Sex Med. 2006 Jan; 3(1):3-11.
 Young F. Moving sexual health into primary care. J Fam Health Care. 2007;17(6):189-90.
Drawings by Marion Foyelle.
Fei Cai is a 3rd year medical student at The Warren Alpert Medical School of Brown University. She is studying to be an Ob/Gyn and is passionate about medical education and research. Her research has been published in Frontiers in Molecular and Cellular Oncology and the Rhode Island Medical Journal.