Editor’s note: A recent post on The Doctor’s Tablet concerning the communication gulf between patient and doctor about sexual activity generated a lot of interest. Why is it so difficult for doctors and patients to discuss the topic openly?
Here, we explore how medical education plays a key role is setting the stage for these important conversations.
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Sex.
It’s a three-letter word that carries a potent emotional charge: excitement, mystique and desire on one side; discomfort, inadequacy and even stigma on the other.
Physicians and other clinicians know that sexuality and sexual well-being are important topics for many patients—often, more patients than we care to acknowledge. There are many factors that hinder physicians from routinely asking patients about sexual issues and concerns.
Too often, physicians are inhibited by lack of knowledge or familiarity with a broad range of sexual practices. They might be embarrassed or feel discomfort about broaching a discussion of such practices or presume that their patients are uncomfortable speaking about them. Other “excuses” abound: a patient is “too old,” “too young,” “too religious,” “married, with children”—or reflects some other characteristic that provides an excuse to “not go there.”
Clinical time constraints and the opinion that questions about sex are not relevant to the reason for the visit are often cited as reasons for avoiding this important topic; these considerations are sometimes valid, but their importance is overstated. While it’s true that face time between a primary care physician and a patient averages about 10 minutes, we need to find time to discuss sexual issues as a matter of course.
In a broader context, our culture often treats sexuality as a commodity, even as we remain ambivalent about the significance we assign to it in education, science and medicine. I believe this ambivalence gets played out at medical schools across the country, where studies have shown that sexuality occupies a tiny place in the overall curricula. According to a 2003 study in the International Journal of Impotence Research, just over half of the responding U.S. and Canadian medical schools reported that the total number of curricular hours dedicated to sexual topics averaged between 5 and 10.
At Einstein, we are at the high end of the norm. We devote about 10 hours to the topic. We try to provide basic content and address clinical applicability by providing opportunities for interview practice.
In the Intro to Clinical Medicine course, we not only cover a broad range of sexual topics, we encourage first-year students to practice eliciting sexual histories from patients they interview at their assigned clinical sites. This not only provides experience with real patients in clinical settings, but allows students to confront their own discomfort and test assumptions they may have about patient attitudes and sexual practices.
In the second-year Human Reproductive Systems course, we organize a half-day symposium on sexuality, fondly referred to as “Sex Day.” This session focuses on talks about the physiology of male and female sexual response, detailed information about taking a sexual history, sexual dysfunction, sex therapy and the sexual healthcare needs of LGBT patients. During this session, students complete a confidential questionnaire that surveys their beliefs, attitudes and personal experiences. Composite classwide responses are shared, and each student has the opportunity to compare his or her own private responses to those of his or her classmates in an exercise that highlights prevalence rates for attitudes and behaviors.
In the clerkship year, during the Family Medicine rotation, we offer a one-hour didactic unit called “Advocacy for Vulnerable Populations: Optimizing LGBT Health.” During case-based discussions, we review clinical best practices for LGBT patients, including sexuality-related issues, and explore the healthcare disparities that affect this group of patients.
These curricular offerings are meant to provide a solid foundation in knowledge, skills and attitudes about sexual health, to decrease embarrassment and discomfort among our students and to encourage further skill development on this important topic so that patients can receive knowledgeable, competent and supportive care.
Frank, open communication is essential when talking about sex. Communication in healthcare is increasingly a partnership. Traditionally it has been the doctor’s role to educate patients. While this is still the norm in many instances, in our current social-media-stoked “information age,” the sharing of knowledge and decision-making is more of a back-and-forth process between doctors and patients than ever before.
Here are some tips to help both parties approach the topic of sex with increased comfort and confidence.
Tips for Doctors in Talking about Sex with Patients
1) Remember that patients often want to talk about sexual issues, but wait and watch for signs that their doctors are open to such a discussion. It is your responsibility to take the lead.
2) Take the initiative by routinely including questions about sexuality in your patient encounters. You might consider amending your Review of Systems to include a section on sexuality.
3) Communicate in plain, everyday language. Avoid the use of jargon.
4) Exhibit a nonjudgmental attitude through your responses and questions.
5) Never phrase a question so that a negative answer is the easiest response. Instead of “Have you ever . . . ,” try “When was the last time . . .” or “How often . . . .”
6) Be prepared for some embarrassment or awkwardness, but don’t allow it to be a deterrent.
7) Be forthcoming about potential sexual side effects related to medications or treatments.
8) Reward and encourage patient initiative by saying “I’m glad you brought up this important issue.”
9) Keep the door open for further discussion. Say “Let’s talk about this more next time,” or “This is an essential topic to revisit in the future; let’s agree to bring it up again.”
10) Practice, practice, practice having these discussions with most of your patients until sexuality becomes a routine topic.
Tips for Patients in Talking about Sex with Doctors
1) Think about your sexual questions or concerns in advance. Be as clear, concise and specific as possible. Try writing down your questions.
2) Be in charge of your sexual health. Consider your doctor your personal expert to enhance your knowledge gained elsewhere.
3) Be as honest and forthright about your sexual practices as possible. It is in your best interest for your doctor to have accurate information.
4) Phrase your questions or comments using words that are comfortable for you. Don’t worry if they sound nonmedical.
5) Don’t be too embarrassed to ask follow-up questions or seek clarification.
6) Come out to your general practitioner if you’re LGBT. Important healthcare issues and decisions may change if your doctor has this vital information.
7) You may need to take the initiative in starting this conversation. Let your doctor know what you’d like to talk about.
8) Try not to leave your questions about sex until the end of a visit. There may not be enough time, or the subject may be put off until later.
9) Doctors need positive reinforcement too. Express your appreciation for their openness and thoughtful counsel.
