Asking all the questions…

‘The things she said seemed to have very little relation to the last thing she had said a minute before. She was the sort of person, Tommy thought, who might know a great deal more than she chose to reveal.’
Agatha Christie, By the Pricking of My Thumbs

I love, love, when I read something that gets under my skin; that gets my brain whirring and I just can’t stop thinking about it. Today’s catalyst was an article about how doctors should pay more attention to the needs of kinky patients and *BOOM* I am reconsidering my entire practise…

Having said that I previously wanted to keep being a doctor a secret, I now find myself talking about it here all the time but there are so many interesting areas where medicine and kink, or even just medicine and sex, clash that I can’t keep quiet!

OK, qualifications first – I am a medical registrar working in the UK for the NHS at a country, district general hospital. I have worked in bigger London hospitals but never as a GP, never in family planning or sexual health, never in obstetrics or gynaecology, never in infectious diseases, and never in surgery. I have worked in A+E but I am now the doctor who you see when the emergency doctors think you’re too sick to go home. Most of my patients are elderly, most of my patients have chronic diseases; and I think I could count on two hands the number of sexual histories I have taken and these have always been when it has been directly relevant to the presentation. But the concerns and questions that this article flooded into my mind are not really connected to sexual health specifically. My experience of these services, particularly in London, is incredible – the staff are helpful and non-judgemental; they have walk-in clinics and postal testing services, and they offer support and treatment as needed to everyone. My interest is in other areas of medicine, particularly hospital medicine.

Reading in the article about the numerous times that doctors have misunderstood patients or not been able to meet their needs, it made me think of the number of times that I could have asked about sexual health and I didn’t. I specialise in lung diseases and see a lot of breathless people. I have literally never asked how this impacts their sex lives or advised them on how to enjoy sex despite difficulties breathing. I have started so many patients on blood thinners to reduce their risk of stroke and never even thought to ask if they undertake impact play when the combination could cause terrible bruises. It would certainly have on effect on their agreeing to start treatment, and compliance later, if they couldn’t be spanked hard anymore, and I’ve never asked. There is so much emphasis on holistic care and I talk about nutrition and exercise in my clinics, but never sex. I am ashamed to say that it just never quite feels appropriate.

Some of this is definitely my issue as I don’t talk about sex well except in this blog and with partners, it was one of the reasons that I started blogging, but it is also a more systemic problem – doctors don’t often ask about sex and so patients notice when we do. They don’t see it as a routine question, it must mean something. I know this because I’ve been questioned on it! Asking my patients about their bladder and bowel habits, for example, is seen as OK and part of my routine patter, but I have twice been asked why I needed to know when I mentioned sexual partners. I could easily justify it – I don’t ask unless I had a specific concern after all – but it serves as a reminder that this type of question is still seen as intrusive. Too personal.

Should that be the case? Should we be asking everyone to normalise the subject? If questions about sex were as routine as questions about weight, would that encourage people to disclose? Is it worth shocking some to help others?

Oh, the more I think about this, the more confused I become! The article suggests asking a vague, catch-all open question when taking a sexual history that gives people the option to disclose if they wish: “What would you like me to know about your sexuality so I can take the best possible care of you?” I love this, and will certainly be stealing it, but it doesn’t answer my question on who needs a sexual history! As medicine is moving towards a more holistic approach, should I ask everyone? I always do a rapid fire health screen at the end of my history, asking patients about weight loss, breathlessness, pain, blood loss, recent illnesses etc whatever their original problem to pick up any aspects that they may not feel are relevant but could have huge implications on my understanding of their health in general. So should I add that question routinely?

Sadly, it always seems to come back to normality and expectation. Sex is still a private affair for too many people and they won’t and don’t understand why I am asking. It’s where sex differs from so much else in our lives – if you attend A+E with a cough, being asked about recreational drug use would perhaps not be a surprise but questions on sexual preference do elicit raised eyebrows even if justified. Patients, in the large part, are just as uncomfortable talking about sex as doctors are with asking. They may be happy talking about the intimate details of their bowel habits in front of anyone but not their sex lives. I will never forget a man who took me to one side after I had clerked his wife to tell me that she had being having an orgasm at the moment of her collapse – she was too embarrassed to mention it, he didn’t want to further embarrass his wife by bringing it up in front of her but didn’t want me to think she had just collapsed while washing up. And he was right – to put it clinically again, knowing the exact level of exertion at the time of collapse made a significant change in the direction of my investigations!

And there are so many ways that doctors have to change so I hope that this doesn’t come across as an excuse for the awful experiences people may have had coming to doctors with their sexual health problems, or when their sexuality crossed into regular health issues. There is no excuse for judgemental or dismissive behaviour, no excuse for not even trying to understand or to direct you to someone who can help. We may not be taught much in that area, but we are taught to listen and empathise and learn from our patients. It’s just that we are lightyears behind.

Our teaching on sexual health if you don’t chose that speciality is too clinical and we aren’t given the right language to talk to patients comfortably. I have to check Urban Dictionary regularly as the descriptive language we use is changing so rapidly and I don’t want to misunderstand or be misunderstood. The relief that I felt only a few weeks ago when I realised that I could refer to the plastic packaging that my patient had been using as a butt plug as simply a ‘toy’ shamed me, but I would otherwise have stumbled through euphemisms before probably calling it an implement and confusing everyone!

Doctors attitudes also have a way to go. Unfortunately, there are still traces of the boy’s club and a macabre and infantile sense of humour pervades the profession. Everyone has a story about something weird pulled out of a patient’s arse and they are shared with collective glee. When a shift is spent pulling others back from the brink of death, sexual injuries are light relief and we giggle like children. It’s no wonder the same lies about slipping and falling onto objects keep recurring, and it’s no wonder everyone is reluctant to disclose the truth!

So what should I do? Should I be giving everyone the opportunity to disclose aspects of their sexuality regardless of why they’re seeing me as their doctor? Should I be asking everyone how their chronic disease impacts on their sex lives in my clinic reviews? Would it normalise the issue or risk further stigmatising people by asking questions that perhaps don’t always need to be asked? Would you even be happy telling people your sexual preferences or kinks without knowing how it will be documented and later received by other doctors?

Gosh, it’s complicated. All I know is that as a profession, we really do have a lot of work to do and a lot of changes to make…

Wicked Wednesday... a place to be wickedly sexy or sexily wicked

0 thoughts on “Asking all the questions…

  1. I understand that comic relief can be essential, but I think treating patients’ sexual injuries as a joke serves to reinforce among doctors the idea that sex is shameful and embarrassing. That doesn’t seem wise. It also strikes me as a failure of empathy – setting the patients apart as others to be laughed at.

    Avoiding talking about things that are awkward isn’t going to make those things less awkward. On the other hand, raising them awkwardly isn’t going to help either. There’s a long way to go in the profession, but perhaps as a first step you could preface the sex questions by saying “I have some routine questions to ask you about your sexual history. It’s perfectly fine if you don’t feel comfortable answering any of those questions. Just let me know and I’ll move on.” Or something like that. And then actually be comfortable asking the questions and make it feel utterly routine, like the bladder and bowel questions.

    I had a checkup years ago and the doctor (female) asked if I was sexually active. I said yes. She asked me what if I was using contraception and what I was using. I wasn’t there for contraception so I don’t know why she asked, but I told her – condoms. I was in a long-term relationship, and she told me that condoms were a bad option for frequent sex, so I told her that I was having sex very infrequently. She asked why – I think she was expecting me to say that I found it painful – and when I told her I didn’t like it very much, she got all flustered. Suddenly I had given her info that she didn’t want.

    Since I wasn’t asking about contraception, her telling me that my choice was a poor one struck me as judgmental and unwelcome – she was trying to fix a problem that didn’t exist. If she was trying to figure out whether there was a medical reason for my having sex infrequently, she should have asked the question in a way that would elicit that kind of answer. Instead she asked an open question and didn’t like the answer.

    But the problem isn’t just in medicine. It’s the whole culture.

  2. A really thoughtful post – and I definitely appreciated your take on this. The only times I’ve been asked, in a medical context, about kink, is when I went into the A&E with heart problems and happened to be covered in bruises. Then it was more a matter of me being /very/ clear that they were achieved consensually, and then having to reiterate it when my partner was not in the room and they asked again. Woo.

    xx Dee

  3. Isn’t it incredible that we are all still horribly victorian when it comes to sex in the UK! When you dig deeper though into victorian sexuality it was all there in it’s kinky fullness just underground and in the darkness, where it still seems to remain in certain circles.

    It is a tricky situation for you in your professional role trying to find the balance between needing the full relevant information and how to obtain that information with sensitivity and respect.

    The time when we can discuss sex and sexuality with openess and freedom will be a good day!

    Velvet x

  4. What a fascinating response to this week’s prompt! Thank you for this! I agree, it does seem as if 90{f9264c1b08ec794f1cf6cd6d13ef8a87ec0de6a492dab0f81db5d3b37fb3799c} of of the human race is in some form of dark ages when it comes to sexual culture. Why is it so hard to talk about? Complicated, indeed! Nonetheless, knowing there are doctors like you in the world gives me hope.

  5. I thought of you when I tweeted the link, I’m so glad you’ve written this. It’s a really difficult subject, where do you draw the line? What is too personal and irrelevant?

    Having said that I have been in several situations where sex, surgical procedures and medication have indeed crossed paths and I didn’t get the answers to the questions I needed or my concerns weren’t taken seriously.

    It’s lovely to know there are medical professionals, such as yourself, out there who want to change that and want to make a difference.

  6. Really enjoyed reading your thoughtful post. I believe it’s handled just as awkwardly here in the US. Don’t recall ever being asked any questions by docs about my sexual activity, other than when I asked my gyno about birth control options – and I was the one asking the questions.

  7. Like others have said: a very thoughtful post. I have never been asked about my sexual preferences by any of my doctors. Frankly, I would appreciate if they do ask me, because I prefer to be treated with them having ALL the knowledge about ME than them not knowing at all. I think the question “What would you like me to know about your sexuality so I can take the best possible care of you?” is a very good place to start. I hope that one day talking about sex and our sexual preferences will be as common as talking about our bowels.

    Great post, thanks for linking it to Wicked Wednesday.

    Rebel xox

  8. I like the open ended question you bolded.

    I have had a psychiatrist not understand why I was upset when I told him I needed to change my meds because my sex drive was being murdered. But I was stable, right? It took a lot of self-advocacy to get him to understand that it was important and to consent to change my meds.

    When I was pregnant with Ms. 7, I had to disclose to my ob that I was kinky and that when I had bruises it wasn’t from an abusive partner, but a consenting sexual relationship.

    I have chronic pain issues. I have multiple disk hernations, including one operation. There is a possibility for fusion. I have a persistently swollen piriformis (despite so many anti-inflammatory injections and botox injection). I have a hyper senstivie sciatic nerve, which can make even walking painful at times. My doctors don’t ask, and as I currently live in hyper conservative Singapore, it can be difficult to find resources to help me address my sexuality in a way that respects my physical limitations.

    i wish a doctor would bring it up and help me manage my conditions in a way that didn’t limit my sex life.

  9. I still think there is a huge assumption among the general population, including Dr’s. that older people do not have sex or at not interested in having sex and so when someone in their 50+ presents with any sort of problem as ‘the contraception’ (for women) is never asked, there is no opener for any dialogue about this subject to take place. When you are younger you tend to get asked that question (again talking about women here) and it can give a opening into further discussion around the topic, once you are older, not a chance.

    I think the open ended question you mention at the beginning is a great idea and one I would love to see adopted across the medical profession


  10. I’ve found a psych nurse who is responsive to sex questions that I see about every three months. I take multiple meds for drug resistant depression and am going through menopause at the same time. :/

    Since I am married to a woman, there are doctors who I’ve seen before that are jerks because of it. I changed doctors twice because of that. We usually quiz our kink friends as to who they see, so if anyone has a kink friendly doctor, we know ahead of time.

  11. If I’m sick enough to have to go to the emergency room or see my primary physician, the last thing I’m worried about is my sex life. Relieve from my pain, suffering , and symptoms are my main concern. Relax, you’re doing just fine in your doctoring.

    respectfully stan

  12. I have serious issues of trust with disclosing details of my sexual activity to Drs. I am still furious that after a trip to a sexual health clinic, the nurse marked my medical records that I have FGM because I have a piercing. Now I see that pop up in the corner of the screen everytime I visit the GP. Even if I was asked, I would be unlikely to disclose anything that they will record with such negative judgement and harmful interpretations.

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