Talking%20About%20Sex

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Talking About Sex

• Lecture for of Reproduction and Genetics
• Peter Washer
• Academic Centre for Medical Education
• peter.washer_at_ucl.ac.uk

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Aims and objectives

•  The aim of this lecture is to explore the
  difficulties in talking with patients about sex.
• By the end of this lecture you should be able to
• Identify when doctors might need to discuss sex
  with patients                                     
    
• Summarise some evidence about medical students
  attitudes to sex, communication of sexual matters
  and issues around sexuality
• Discuss some theoretical approaches that might
  help in communication about sex with patients

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When might a doctor have to talk about sex?

• Sexual Health problems
• Common medical / surgical conditions which might
  make having sex difficult
• Psycho-social problems which might affect a
  persons desire to have sex

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How has the medical profession dealt with
sexuality in the past?

• Advent of concept of homosexuality as medical or
  psychological problem in late 19th century
• Any sexual contact between men was illegal in UK
  until 1967
• In 60s early 70s medical treatments to try to
  change sexual orientation were commonly used on
  NHS
• usually behavioural therapy with electric shocks
  or nausea inducing drugs.
• occasionally oestrogen to reduce libido
• psychoanalysis (usually privately)
• (Smith et al 2004, King et al 2004)

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How has the medical profession dealt with
sexuality in the past?

• Homosexuality was included in the Diagnostic and
  Statistical Manual of Mental Disorders until 19??
• (Rose 1994)
• Homosexuality was removed from the International
  Classification of Diseases (ICD 10) in 19??
• (Smith et al 2004)

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How has the medical profession dealt with
sexuality in the past?

• Homosexuality was included in the Diagnostic and
  Statistical Manual of Mental Disorders until 1973
• (Rose 1994)
• Homosexuality was removed from the International
  Classification of Diseases (ICD 10) in 1992
• (Smith et al 2004)

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What are the issues?

• Medical students / Doctors need to reflect on
  their own sexuality and their own attitudes to
  sex and reflect on how this will inform their
  practice
• Specific needs of lesbian and gay patients
• Experience of lesbian and gay doctors

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What are the issues?

• Medical students / Doctors need to reflect on
  their own sexuality and their own attitudes to
  sex and reflect on how this will inform their
  practice
• Specific needs of lesbian and gay patients
• Experience of lesbian and gay doctors

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Reasons for Drs and med. students difficulty in
talking to patients about sex

• Embarrassment and personal unease
• Difference in age / gender
• Concern patient may be offended
• Belief sexual history may be irrelevant
• Assumption it is someone elses task (e.g. GUM
  specialist)
• Lack of skills
• Student may feel inadequately trained
• Lloyd Bor (2003)

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Sexual knowledge and attitudes of medical students

• Those with strong religious beliefs/practices
  (any denomination) most likely to express
  negative attitudes (e.g. towards homosexuality,
  masturbation, unmarried mothers, pre-marital sex
  and abortion) and have the least knowledge about
  sex.
• Negative attitudes associated with never having
  had sex, right wing politics, and lower family
  income.
• McKelvy et al (1999)

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Taking a sexual history

• Medical students most comfortable taking sexual
  history from a heterosexual patient of the same
  gender
•  Older students and those with gay friends more
  comfortable with AIDS patients.
• Students with more knowledge, more appropriate
  attitudes and greater personal sexual experience
  were most likely to have spoken to a patient
  about sex.
• Vollmer et al (1989)

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What are the issues?

• Medical students / Doctors need to reflect on
  their own sexuality and their own attitudes to
  sex and reflect on how this will inform their
  practice
• Specific needs of lesbian and gay patients
• Experience of lesbian and gay doctors

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Dr / patient communication with lesbian gay
patients

• Estimated 3 6 of patients are lesbian or gay
• Significant differences in health care needs
• Compared to straight counterparts, higher rates
  of depression anxiety with associated higher
  rates of suicide alcohol drug abuse smoking
• Many lesbians and gay men avoid routine health
  care
• Reasons perceived insensitivity by health care
  staff, difficulty communicating with Drs,
  assumption they are heterosexual, or that all gay
  people share the same behaviours
•  
• Bonvicini Perlin (2003)

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What are the issues?

• Medical students / Doctors need to reflect on
  their own sexuality and their own attitudes to
  sex and reflect on how this will inform their
  practice
• Specific needs of lesbian and gay patients
• Experience of lesbian and gay doctors

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The experience of lesbian gay doctors

• Training programs were at best indifferent and at
  worst hostile to lesbian gay medical students
• Lesbian gay medical students and doctors faced
  problems with disclosure, career path etc
• Felt they were helped by inclusive curricula,
  anti discrimination policies, which acknowledged
  and supported diversity.
• Risdon et al (2000)

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Context

• It may be easier for a doctor to deal with an
  issue relating to sex or sexuality when the
  context means the subject is expected, e.g. in a
  GUM or contraceptive focused consultation
• It may be more difficult to explore sexual
  matters when talking about relationships e.g. in
  the context of depression or in terms of altered
  body image (e.g. post-surgery)

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Should a sexual history be solicited from all
patients?

• Clearly when a patient complains of a problem of
  a sexual nature
• Some sexual problems are masked by or are a
  result of a related problem
• Difference between asking a patient in the course
  of a medical history if they have any sexual /
  relationship problems and taking a detailed
  sexual history

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Good Practice guidelines for talking about sex

• Where? - appropriate setting, privacy
• Who? Dr. or medical patient might feel
  uncomfortable, may prefer to identify someone
  else with greater experience
• Considerations of personal safety may be
  preferable for more than one person to be present
  if patient is likely to be abusive or violent
• Lloyd Bor (2003)

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The interview

• Introduction handshake, stress confidentiality
• Start with the presenting problem
• Be purposeful and direct
• Remain non-judgemental about lifestyle
• Remain non-judgemental about sexual activities
• Use the opportunity for health promotion
• Refer to appropriate specialists
• Lloyd Bor (2003)

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What further detailed information might you need
to gather?

• Nature of previous sexual activities
• History of pregnancy / miscarriages / abortions /
  contraception
• History of sexually transmitted diseases
• Relevant factors (e.g. travel, drug use)
• History of sexual abuse
• Psychosexual problems (e.g. with erection,
  ejaculation, loss of desire)
• Cultural / religious rules and practices

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Aims and objectives

•  The aim of this lecture is to explore the
  difficulties in talking with patients about sex.
• By the end of this lecture you should be able to
• Identify when doctors might need to discuss sex
  with patients                                     
    
• Summarise some evidence about medical students
  attitudes to sex, communication of sexual matters
  and issues around sexuality
• Discuss some theoretical approaches that might
  help in communication about sex with patients

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References

• Bonvicini Perlin (2003) The same but different
  clinician patient communication with gay and
  lesbian patients Patient Education and
  Counselling 51 115-122
• King, Smith and Bartlett (2004) Treatments of
  homosexuality in Britain since the 1950s the
  experience of professionals BMJ 328 429
• Lloyd M Bor R (2003) Communication Skills for
  Medicine 2nd Ed. Edinburgh, Churchill Livingstone
• McKelvy et al (1999) Sex knowledge and sexual
  attitudes among medical and nursing students
  Australian and New Zealand Journal of Psychiatry
  33 260-6
• Risdon et al (2000) Gay and lesbian physicians in
  training Canadian Medical Association Journal
  162(3) 331-4
• Rose L (1994) Homophobia among doctors BMJ 308
  586-7
• Smith, Bartlett and King (2004) Treatments of
  homosexuality in Britain since the 1950s - the
  experience of patients BMJ 328 427
• Vollmer et al (1989) Improving the preparation of
  preclinical students for taking sexual histories
  Academic Medicine 64 (8) 474-9