‘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…