Think back to the last time you had a checkup with a doctor. He or she might have asked you about how often you exercise, how well you sleep and whether you drink or smoke. But does your doctor ask you about sex?
Asking patients about sexual matters is universally recognized as an important part of collecting a patient’s medical history. But many physicians don’t take sexual histories from their patients.
And medical schools often don’t offer students a lot of instruction on how to talk about sexual matters with patients, even though it is a critical aspect of personal health and well-being.
To be human is to be sexual, and whether healthy or sick, sex plays an important role in the lives of many patients. This is why I teach a senior elective on the subject at the nation’s largest medical school, Indiana University. Some of the course’s students helped with the research for this article.
Patients want to talk to their doctors about sexual matters
Health care conversations about sex can be difficult for both patients and doctors. According to a 2012 survey, even among obstetricians and gynecologists, physicians for whom addressing sexual issues would seem to be most routine, fewer than two-thirds routinely ask about sexual activity and only 40 percent inquire about sexual problems. Just 29 percent query patients about sexual satisfaction.
According to one survey, 99 percent of patients presenting for routine gynecologic care had at least one sexual concern, the most common being lack of interest (87 percent), difficulty with orgasm (83 percent), painful intercourse (72 percent) and unmet sexual needs (67 percent).
Other studies have shown that between 16 and 43 percent of women and 9 and 29 percent of men report distressing sexual problems, if asked.
Of course, some patients may not wish to discuss these matters, but there is evidence that the majority of patients would prefer to have an opportunity to discuss their sexual concerns with a health professional.
One international study of over 27,000 male and female patients showed that more than half had at least one sexual problem or concern, but only 19 percent had sought medical care and only 9 percent had been asked about sexual health in the last three years.
Uncomfortable questions are often the important ones to ask
While taking sexual histories is crucial to identifying sexual problems and concerns, it can also be helpful in establishing a more open and trusting relationship between patients and doctors.
For many patients, discovering that they can talk with their doctor about sex means that they can broach virtually any topic, which can be helpful in recognizing other difficult concerns, such as domestic violence and substance abuse.
Naturally, taking a sexual history is premised on privacy and confidentiality. Most experts recommend that doctors request permission to address the topic. For example, a doctor might say, “At this point, I usually ask some questions about your sexual life. Will this be okay?”
Sexual history checklists are available, but it is important not to let data acquisition interfere with patients’ efforts to share their stories.
When it comes to taking a sexual history, the first question is generally the most important. One option is to ask the patient if he or she is sexually active. However, such a question is easily misinterpreted, eliciting responses such as, “No, I just kind of lie there.”
Another approach is to ask if the patient has any sexual questions or concerns. Still another is to mention the patient’s medications and medical conditions, and ask if the patient has experienced any sexual issues with them.
A good sexual history covers many of the same topics for both female and male patients. In both sexes, it is important to ask about sexual interest, arousal, satisfaction, quality of relationship, mood, pain, and the effects of illnesses, medications and surgeries.
Medications are especially important, in part because studies show that seven in 10 Americans take at least one prescription drug, and hundreds of drugs, including many for blood pressure and depression, have sexual side effects.
Some doctors tend to assume that their patients are sexually active, but this is often not the case. Broadly speaking, it is important to know why a patient is not sexually active, or if they are, with whom they are having sex and what kind of sex they are having. For one thing, such information can be crucial in addressing concerns around birth control and sexually transmitted infections. It also provides a foundation for addressing other aspects of the patient’s health.
It is important to know not just what the patient is doing but how the patient feels about it. For example, some people who are not sexually active are not troubled about it. It is also important to know how partners are reacting to any problems patients are experiencing, as well as to inquire if partners are experiencing sexual problems. In most cases, sexual difficulties adversely affect two people.
Medical students need sex ed, too
One challenge for physicians in addressing sex is the paucity of attention paid to sexuality in most medical school curricula. While a 2013 study showed that essentially every medical school covers topics such as reproductive physiology, contraception and sexually transmitted infections, many schools devote little or no attention to such topics as sexual function and dysfunction and sexual minority groups. Most doctors leave medical school with little idea of how to help patients with sexual problems.
The same 2013 study found that, in many cases, medical students themselves have recognized the problem and taken steps to enhance the quality of sex education at their schools.
In an effort to ensure that fellow learners have an opportunity to learn more about the underaddressed aspects of sexuality, students at some schools have created their own extracurricular programs, some with names such as “Sex Week.”
Only by elevating the importance of sexual matters in the education of physicians and other health professionals can we ensure that this important domain of health receives the attention it deserves, reducing the number of patients who are suffering in unnecessary ignorance, misinformation and embarrassment.
Azmina Alibhai, Daniel Driver and W. Aaron Marshall assisted with research for this article.