Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, March 09, 2007

Getting a Simple Answer

(Edited: Elevated to Marble Dinosaur Egg status)

Poor TBTAM. All she's trying to do is get a straight answer from her patients about whether or not they are sexually active, and everyone wants the question asked differently.

Here's my strategy:

All female patients get asked, "What do you use for birth control?"

Just about every possible answer leads naturally into clarifying questions and answers, providing useful and needed clinical information while generating rapport with a new patient.

One set of answers is simply the method: the pill, the diaphragm, condoms, etc. The natural next question is, "How is that working for you?" or some variant, to determine how satisfied the patient is with whatever method she's using, how effectively she's using it and so on.

Another answer is, "Nothing." Although there are several possibilities, in real life they divide themselves by whether or not the patient continues explaining on her own. Here's how the first set of answers usually plays out:

"Nothing; I've had my tubes tied."
Response: "Cool. Do you also use condoms to protect against STDs?" etc.

"Nothing; my husband's been fixed."
(Vasectcomy. My favorite method. I tell women whose husbands are considering it, "It's great; you won't feel a thing.")

"Nothing; I'm trying to get pregnant."
Response: "How long? Have you ever been pregnant?" etc. (fertility issues)

"Nothing; I'm not in a relationship right now."
Response: "Ok. What do you use when you do have sex?" (also presents the opportunity to find out how she feels about the lack of a relationship.)

Best answer I've ever heard:
*glaring daggers at me*
"I have a 2-year-old. I don't have sex."
(No response; if looks could kill, I would have been dead on the floor.)

Then there's the second group of women who say, "Nothing," and then fall silent. There are several options for the next question, and which way to go is a bit of a judgement call based on the woman's age, demeanor, and just a gut sense on my part. Here's what I usually say:

"Female partners?"

If the patient is a stupid teen (or 20-something) the answer is usually a disgusted, "Eeew! No."
Response: "So how do keep from getting pregnant when you have sex?"
The answer is usually something like, "He pulls out," or, "I don't know," etc.
Note: these patients are usually pregnant.

Lesbians are usually very impressed with me at that point, and answer simply, "Yes." This gives me the opportunity to go on with, "That's nice. Are you in a relationship?" etc. No shock; no surprise; just moving on to find out more about her (which can include, from a GYN standpoint, whether she has ever has sex with a man in the past.) Rather than trumpeting how tolerant and accepting I am, I have demonstrated it by matter-of-factly bringing it up as part of my routine history.

(By the way: males starting about age 14 are asked, "Do you use condoms when you have sex?" thus forcing the explicit answer, "I don't have sex." I call it the "Have you stopped beating your wife yet?" approach.)


At Fri Mar 09, 06:09:00 PM, Blogger MedStudentGod (MSG) said...

Subtle, very subtle.

At Fri Mar 09, 09:18:00 PM, Anonymous Anonymous said...

Why do you need to know their sexual history? That may sound really dumb, but I'd find those kinds of questions very prying if they were asked of me. I might become hostile.

At Fri Mar 09, 09:45:00 PM, Anonymous Anonymous said...

The reasons are myriad - STDs, teratogenic medications, understanding living situation, etc etc.

I would advise avoiding all medical care, then, because a sexual history is part of every history and physical routine taught to every doctor from day 1. Failure to do one (on a full H&P) is probably malpractice.

At Fri Mar 09, 09:47:00 PM, Anonymous Anonymous said...

I should also add that we really could not care less about your sexual history. By the time we've done 20 of them we've heard everything from straight to gay to sex with pandas, let alone 2000. It all elicits a "yeah, whatever".

At Sat Mar 10, 04:57:00 PM, Anonymous Anonymous said...

I cannot recall any of my gynecologists asking those types of questions, except to ask me what type of birth control I use, or if I've ever been pregnant, and are my periods regular. And I believe they simply wanted a simple answer, nothing more.
I've never had a primary care doctor ask any of those questions.

I can see where some patients wouldn't mind your interest in their personel lives, but for myself I'd feel somewhat uncomfortable, especially at a first visit.

On another note, can you give us a more detailed rendition of how you survey a man's sexual history? Especially a man who has multiple partners at the same time, only one of whom is a wife.

At Sat Mar 10, 05:27:00 PM, Anonymous Anonymous said...

Docs don't ask about sex because they're nosey. It's a potentially risky activity - like riding a motorcycle without a helmet, smoking, eating nothing but fast food every day - and they want to address your safety. Wear a helmet, quit smoking, eat better, wear a condom. That's it.

At Sat Mar 10, 08:28:00 PM, Anonymous Anonymous said...

I've never been asked about my sexual history. I have been asked if I have a partner/husband and what kind of birth control I use, but a history? No! Not by the GYN, not by the GP. Not by anyone.

How many pregnancies, yes.

At Sat Mar 10, 10:42:00 PM, Blogger Rebecca said...

I can't believe so many people haven't been asked. I have been and it is just normal. How can they treat me effectively, know what I'm at risk for, and counsel me effectively, without knowing my behaviors??
When I treat, I always start by asking are you sexually active? If no, then I ask, have you been sexually active in the past? If no, I ask them how they plan on protecting themselves if and when they choose to be. If yes, I ask them if they are sexually active with men, women or both. I also ask if they have more than one partner at a time as well and how they protect themselves and their partners.

At Sun Mar 11, 07:43:00 PM, Blogger Dr. J. said...

A sexual history is definetely an important part of many patient interviews. Not only does it inform me about a patients social situation, relationship status, and risk behaviour, it's also a frequently a cause of thinly veiled doctor visits. Men with erectile dysfunction, premature ejaculation, etc. rarely tell the receptionist why they are coming to the doctor (usually the reason for visit reads something like "not feeling well". Women with dysparunia similarly often suss the doctor out before discussing the issue they are really there for.
A non-judgemental, and matter of fact sexual history not only provides important information, it lets the patient know that these things are okay to talk about at the doctors office.
My 2 cents...

At Sun Mar 11, 09:46:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

I find that most patients are not uncomfortable talking about sex if they see that we docs are comfortable with the topic.

Thanks, #1 - this was a great post.

At Sun Mar 11, 10:35:00 PM, Anonymous Anonymous said...

My doc knows I am married (she is also my husband's doc) but still asks me every year at my annual exam how many partners I have. At one point I was having an affair, but instead of telling her the truth, I lied and said just one.

I don't know why I lied. I know she wouldn't have told my husband and I do like and trust her. I guess I just didn't want to answer all the questions that would follow. And yes, I was very responsible about my health during that time.

Maybe you could address how to deal with this subject when both members of a couple see the same family doctor.

At Mon Mar 12, 02:19:00 AM, Blogger View from the Trekant said...

Several of the major classes of drugs we use in cardiology are teratogenic (cause birth defects - like warfarin or ACE Inhibitors) or cause low birth weight babies (beta blockers) or can alter the effectiveness of birth control pills.

We have some (not many) female cardiac patients still of child bearing age.

These are examples of why a doc needs to know a sexual history - not just are you using birth control, but what are your intentions in terms of getting pregnant in the near future.

Echo Doc

At Tue Mar 13, 03:57:00 PM, Anonymous Anonymous said...

A comment from a shy lesbian:

I am always grateful when health care providers seem to be comfortable with the possibility of gayness. I like that you put "female partners" out there because it can be scary to say, particularly with a new doctor if I don't have a read on whether or not s/he's likely to treat me with respect.

I chuckled at "that's nice" (Would you say that to a straight patient about her sexual orientation?! Why is it nice? I mean, I personally agree, but...) but I appreciate that you say that to confirm that you're not homophobic, and I'm sure that your patients appreciate the overt signalling too.

And, as a note to readers who may not know: lesbians are as a group much worse about taking care of our gyn health (pap smears, etc) -- maybe because we don't have to see a gyn regularly for birth control, or maybe because we're not comfortable that we'll be respected at the gyn office, or gosh knows why. So it's a relevant to know that you should inquire a bit more carefully about whether she's taking good care of her gynecological health.

At Tue Mar 13, 09:25:00 PM, Blogger The Hatchling said...

A note to the anon's thats been covered, maybe not explicitly. When we take a "sexual history" its more of a sexual risk assessment. I think the word history gets added because part of an exam is history of present illness, surgical history, past medical history, social history. Perhaps its poor terminology on our part because I feel the sexual history has a completely different use to the physician. Remember its not so much a history as it is a chance to educate, counsel, and manage the risk of the patient.

As for lieing to your doctor, thats always going to happen. I think your relationship with the patient affects truthfulness but the patient needs to know the when they lie, their quality of care is diminished due to the lie. Its our job as (prospective) doctors to a) see through the lies and b) prevent them by developing relationships with our patients. Sometimes you need to be House, but sometimes you need to be Cameron.

BTW watching the 14 year old boy 'trapped' by Dr. D definitely was a good chuckle. The trap was explained and no harm was done, I'm just glad I wasn't the first to laugh. Its methodologies like that Dr. D has polished over the stone and ice ages to apply to the modern world of medicine to STILL get honest answers.

At Sat Apr 04, 11:17:00 PM, Anonymous Anonymous said...

And what of the doctors that always think we're lying if we say...nothing for years?

Now, I know that some women (especially younger women or those harmed) may lie about it. But a middle-aged divorced woman?!

Still, they run pregnancy and STD tests without permission.

At Mon Nov 02, 06:43:00 PM, Blogger RoseHelene said...

Question from a pre-med: How do you handle sexual history for male patients? Do you ask if they've had sex with other men, to check their health risks?

At Sat Dec 26, 10:15:00 PM, Blogger Valerie Bock said...

Just a thought, for the med students out there -- it's amazingly easy to let friendship, etc., bias the way you take a sexual history. When I was pregnant with my second-born, my husband was a resident, hence a colleague to the folks who were working me up. They skipped-over some of the questions, answering them for themselves, aloud, because they knew and liked him.

Which was not a big deal because actually, we've lived a simple life, been faithful to each other, etc., but in theory the baby in utero was also their patient, and none of these people could know were I had been before or during marriage, or where he had. In that I went to college in the late 70's, when it was difficult for gay men to come out and HIV wasn't understood, and there was a LOT of guys having sex with a woman to try to prove they weren't as gay as they feared they were, the failure to ask the uncomfortable questions was Bad Medicine.


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