Doctors need help collecting sexual histories (Medical Post)

FP: Doctors need help collecting sexual histories

Few resources exist to help doctors deal with discomfort

Medical Post By Matthew Sylvain

ORLANDO, FLA. – Discussing sex with patients is daunting for physicians, yet medical schools generally do little to prepare future doctors for the realities of collecting information on sexual history, says a professor at the University of California at San Francisco.

Dr. Laura Hill-Sakurai, who interviewed physicians while preparing a teaching video on the subject for use in medical schools, found "there was very little (available) research looking at what physicians find challenging in taking sexual histories."

During a presentation at NAPCRG, Dr. Hill-Sakurai, an assistant professor of family and community medicine, discussed issues that commonly emerge when physicians query patients about their sexual health. She said physicians were daunted by the sheer diversity of sexual behaviours and complexities of attitudes their patients exhibited.

Many issues stem from a patient-doctor clash of values, a doctor's possibly inaccurate assumptions regarding a patient's sexual choices, and differences about patient-doctor boundaries.

For some patients, simply collecting sexual history "represented a transgression of the patient's own values," Dr. Hill-Sakurai said, citing physician responses to the study.

"Another area that came up repeatedly (was that of) people who were having attractions or relationships of the same gender in their communities (but) could not accept the label of being gay or lesbian. And so this would both interfere with them giving information to clinicians, and would interfere with their overall health, because it was felt to be very stigmatizing for them," he said.

"We want to avoid value clashes, but of course we (doctors) make assumptions. And we make inaccurate assumptions. Both we make them about patients and they make them about us," Dr. Hill-Sakurai said.

And despite the apparent shield of clinical detachment, many respondents revealed they sometimes weren't comfortable with some topics broached in the process of gathering the history. A common indicator of this discomfort was the "I know it's okay, but" attitude, she continued. "This is clinicians saying they were okay with something intellectually, but still being emotionally a little uncomfortable with it. . . . Bisexuality or 'open relationships' were (such) issues," she said.

Some physicians were concerned that encouraging frankness in their discussions with patients may be misunderstood as the pushing of liberal values, she added. According to Dr. Hill-Sakurai, one pediatrician who participated in the survey said: "By trying to be so open-minded, I worry sometimes that I come across (like): 'Oh, you are not having sex and you are already 15?' "

Male patients may respond negatively to standard, gender-neutral language, such as to the question "Do you have sex with men, women or both?" a phrasing physicians are encouraged to use in the U.S. The query can have particularly strong repercussions, "especially (with) adolescent males from underserved communities," she warned.

An open-ended question about whether a teenage boy is sexually active with members of the same sex could easily tap into underlying homophobia, and cause the patient to lose trust in the doctor, she said.

Some patients misinterpret the sexual discussion as a romantic advance, and overreact by being offended or attempting to pursue a relationship, Dr. Hill-Sakurai said.

Language itself can be a challenge. For example, patient slang for sexual activities may be incomprehensible to the clinician, and clinical language may be bewildering to the patient. "A classic one is men talking of something being wrong with my 'nature.' That means erectile dysfunction," she said.

The study was based on semi-structured interviews of 22 physicians and one nurse practitioner in the San Francisco area. The sample was collected via "snowballing," the practice of seeking interview volunteers by networking, and was slightly skewed toward women psychiatrists. Six specialties were included.

Dr. Hill-Sakurai added the practice of showing pornographic material in some medical schools, in a bid to desensitize students, often backfires as it immediately triggers strong reactions in the viewer. She relayed an anecdote from early in her project in which a student emphasized the point by saying: "If you want to prepare me to be ready to be challenged by (collecting) sexual history, show me videos of doctors taking sexual history. Don't show me pictures of people having sex."