1. 1 Talking About Sex Lecture for of Reproduction and Genetics Peter Washer Academic Centre for Medical Education peter.washer@ucl.ac.uk

2. 2 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

3. 3 When might a doctor have to talk about sex? 1.Sexual Health problems 2.Common medical / surgical conditions which might make having sex difficult 3.Psycho-social problems which might affect a person’s desire to have sex

4. 4 How has the medical profession dealt with sexuality in the past? Advent of concept of homosexuality as medical or psychological problem in late 19 th 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)

5. 5 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)

6. 6 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)

7. 7 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

8. 8 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

9. 9 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 else’s task (e.g. GUM specialist) Lack of skills Student may feel inadequately trained Lloyd & Bor (2003)

10. 10 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)

11. 11 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)

12. 12 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

13. 13 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 Dr’s, assumption they are heterosexual, or that all gay people share the same behaviours Bonvicini & Perlin (2003)

14. 14 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

15. 15 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)

16. 16 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)

17. 17 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

18. 18 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)

19. 19 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)

20. 20 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

21. 21 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

22. 22 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