I’ve asked patients about their pooping habits, the gross rash spreading up their feet, and vaginal discharge, but there was still nothing more awkward than learning how to take a sexual history.
Total tangent: Scrolls through this HuffPo post about politicians looking awkward with babies and your day will be infinitely better.
Asking a patient, “Do you have male or female partners? Or both?” is still challenging. I’ve had more than one male patient bluster to me, “Hey, does it look like I’m not into girls?” or a female patient raise an eyebrow and say, “I”m *only* sexually active with my husband. We’ve been married forty years.”
Here’s my conclusion: It’s okay to not take a full sexual history if you’re not prompted to.
Why would I totally disappoint my Doctoring teachers and tell you that? Let me explain.
First, let’s make it clear: sexual health is an important part of general health. Just like any other part of the social history, a person’s sexual preferences or habits impacts how we think about their risks for certain medical problems. Just as smoking tobacco for X number of years or working as a kindergartner teacher or coal miner puts our patients at risk for different things, sexual state also affects health risks. Understanding all of the (relevant) aspects of our patients’ health equals better care.
Sexual health is personal. Sexual health can be powerful and empowering. But learning about your patient’s sexual health can bring up the ugliness of power, abuse, prejudice, and poor education in your patient’s life. There are vulnerable people who are forced to perform sexual acts they don’t want to, give sex for money, are denied protection from STIs, or who are sexually assaulted. If it is relevant to the reason the patient is presenting to you, the medical provider, it WILL come up. But if you press someone to give you details they are not ready to give you, that can affect your doctor-patient relationship.
For example, one patient I met was insistent that she be referred to an oral surgeon to have her front teeth taken out. I examined her mouth, and it looked fine. I had no idea why she was pushing so hard for it. A couple of minutes later, she confessed that she was a sex worker and she wanted her teeth removed because a friend told her she would be able to give better oral sex and get paid more.
A Puerto Rican gay male couple in the clinic was being seen for an annual physical. Both of them had medical issues, but I got the sense that their biggest problem was anxiety due to their families rejecting them. One of them said his mother told him, “You were a mistake,” and didn’t allow him to set foot in her house. What was worse was that they lived on the same street as their families because they couldn’t afford to move out, and constantly feared that they’d be chased out of the neighborhood.
I met another young gay man, who came from an affluent background and had a father in politics. He was beat up for being gay in his first semester of college, and had to transfer and deal with PTSD and depression afterwards.
He told me that when he was a kid, he hated the pediatrician asking him, “Do you like boys, or do you like girls?” because he didn’t perceive it as a general, neutral question. He perceived as: “I think you look gay, so I’m going to ask you this tricky question and bait you.”
There will always be awkwardness in taking a sexual history. Sometimes that awkwardness can affect the trust you’re trying to establish with your patient. And sometimes, it’s just not relevant–if a patient is gay, and presents with pneumonia, does it matter?
That’s why it’s okay to not take a full sexual history every time. If a patient reports promiscuity, is at risk because of their work, or if you sense abuse, you should take a sexual history. If you do your readings, and are situationally aware, you will be able to sense if a patient’s symptoms might be due to a sexually related infection or practice, and you should get more information.
But above all, be respectful. Be curious, and non-judgmental.
If you’re interested in resources for learning more about sexual health, please see this very short list:
- Go Ask Alice! has great, layperson explanations to common questions
- Publications listed by the LGBT Health Education Center (The Fenway Guide is fantastic!)
- Dartmouth College’s Student Wellness Center website references
- The Center for Sexual Pleasure & Health has a great list