Doctor Doesn't Ask, Patient Doesn't Tell: Sexual Activity in the Elderly

Although the value and need for taking a sexual history from a patient, even for a routine complete history and physical is emphasized to the first year medical student, it is clear from the article "A Study of Sexuality and Health among Older Adults in the United States" by Lindau and others in the current August 23 2007 issue of the New England Journal of Medicine and the editorial "Sex and Aging" in the same issue (no free reprints available) that doctors are not asking and elderly patients are not telling their doctors about sexual activity and issues they may have. In the survey study of 1550 women and 1455 men ages 57-85, only 38% of the men and 22% of the women reported having discussed sex with a physician since the age of 50 years. The study showed that the prevalence of sexual activity declined with age (73% ages 57-64, 53% 65-74, 26% 75-85) with women aignificantly less likely than men at all ages in this study to report sexual activity. It is clear, if you are able to read the study, that sexual activity is not gone just by being old. All the forms of sexual activity are carried out by the elderly. The person's health has an influence on whether sexual interest and activity can continue. The article by Lindau concludes: "Many elderly adults are sexually active. Sexual problems are frequent among older adults, but these problems are infrequently discussed with physicians. Physician knowledge about sexuality at older ages should improve patient education and counseling, as well as the ability to clinically identify a highly prevalent spectrum of health-related and potentially treatable sexual problems."

I think that physician knowledge of sex in the elderly is generally poor. I think that physicians may be reticent to talk to the elderly about sex for some of the same reasons our first year medical students give: "The elderly patients are like my grandma and grandpa and I wouldn't dare talk about their sex with them." Further, physicians, though aware of the effects of illness and medications on sex, are probably unaware of the extent of sexual activity present in the elderly. That is why, just as the elderly talking to their doctor about their symptoms and treatments is important so is it important for the elderly to communicate their their own personal concerns regarding sex and sexual activity and the quality of that activity associated with how they feel and their illnesses.

Studies such as the one noted above should be publicized to both physicians and patients for the knowledge and benefit of both groups. Actually, that is why I thought this was an important thread to begin now. ..Maurice.

ADDENDUM 8-25-2007: I found the initial commentary by MJ KC stimulated a response by me which after writing it seemed appropriate to include on this Home page. ..Maurice.

At Saturday, August 25, 2007 7:32:00 PM, MJ_KC said...
I have never been asked anything related to this issue, ever, by any doctor. Seems that most doctors don't want to discuss this.
At Saturday, August 25, 2007 10:00:00 PM, Maurice Bernstein, M.D. said...
MJ KC, isn't that interesting? It seems that you are not the only one. Obviously, there is a resistance for sex to be brought up by the patient unless there is some symptoms of specific concern.But what is the resistance for a physician not to try routinely to obtain a sexual history as part of the patient's general history? I mentioned in my posting something about age difference and transference. Other factors could be gender and cultural differences.All of these factors may represent social taboos which need to be overcome. Beyond general social taboos, there is something which might be interprete by the physician as a "professional taboo." This would be concern by the physician that asking about and delving into the sexual life of a patient may be considered by the patient or others as voyeuristic, intrusive or seductive, all of which are professional "no-nos." They are really not that if the approach of the physician is consistent with good basic interviewing principles in an appropriate setting, approached in a professional manner and a professional vocabulary ( but with appropriate use of the patient's own terms or expressions to facilitate communication.) All of this is carried out after establishing general rapport and trust with the patient.Obviously, the initiation of the discussion of sex should be in the context of the patient's concerns or symptoms and appropriate to the clinical situation. Asking about sex when the patient comes to the office for a simple cold is inappropriate. Asking about sex as part of a initial complete history or annual exam or related to specific symptoms or side effects of medications is appropriate.One of the most important conditions which physicians need to bear in mind regarding asking about sex as with other personal questions deals with the need to emphasize confidentiality of what is discussed.Finally, other barriers which may present to the physician regarding talking to the patient about sex and sexual activity is what the physician might consider "acceptable" vs "deviant" behavior. These attitudes might affect whether and how the doctor communicates with the patient regarding sex. Perhaps related to this or not, a barrier may have to do with the personal sexual difficulties of the physician. After all, physicians are human beings with their own sexual history and it may be difficult to ask questions and interpret the answers of the patient objectively.This commentary was all about my thoughts of why despite learning about the taking of a sexual history in medical school some physicians just don't do it in practice. The other issue is, if the doctor doesn't ask, why is it that the patient doesn't tell?What factors would my visitors see as affecting why the patient doesn't tell and what could the physician do to mitigate that resistance?.. Maurice.

Physician's Right to Choose and Duty Not to Neglect

The responsibilities of a physician include not to abandon his or her patient. A patient can abandon their physician as desired but the physician cannot abandon the patient. Abandoning a patient means halting the attention and care of a patient without referral and establishment to another source of care. Physicians do have the right not to accept a patient who comes to a physician when no life or death emergency exists. Physicians also have the right to terminate a doctor-patient relationship for a number of ethical reasons including problems with personality issues, inability to follow patient requests either based on moral reasons or standards of medical practice and perhaps some others including a beginning non-professional interest between the two parties. Reasons to terminate the relationship that are not ethical might include inability of the patient to fully pay for the services rendered. Another would be to terminate care simply because the patient failed to respond to treatment and that the physician might not want an unsuccessful result to be part of his or her medical record which might discourage further aquisition of patients.

There is a whole history regarding the right of physicians to choose patients and the duty not to neglect as written in the American Medical Association's Code of Medical Ethics. The story of the Code and its revisions is presented by Faith Lagay in the September 2001 issue of Virtual Mentor. Read the article.

It would be interesting to read my visitors experiences regarding termination of relationships with their physicians or about physicians who refused to start a relationship with a visitor. Remember, no names please! ..Maurice.

Donation By Cardiac Death: When Is the Patient Dead?

An organ procurement practice, in order to obtain more organs for the needy patients, has involved obtaining organs by permission from patients who are alive but have decided to end life-supportive treatment but also want to donate their organs after death. The procurement of organs, in keeping with the ethical "dead donor rule" cannot begin until the patient is pronounced dead. The process is called DCD (donation by cardiac death) and the procedure is to terminate life support (ventilators, blood pressure support, etc.) and wait until the patient's heart stops but if the heart does not spontaneously stop within an hour or so, the patient is no longer a candidate for donation (because of deterioration of organs beyond an hour) and is given comfort care until the patient dies. If the heart has stopped within the hour, then the patient's physician must wait for usually 5 minutes before pronouncing the patient dead.

Here is the issue with DCD: Is the patient really dead after 5 minutes with no heart beating (and associated no breathing)? It has been fairly well established that the heart will not resume beating on its own and without physician resusitation after about 5 minutes. So therefore if no mechanical/electrical resusitation is attempted by the physician, could the physician honestly and with confidence pronounce the patient dead? When the patient is pronounced dead by the attending physician, the procurement surgeons are then given permission to begin removing organs. But at that point is that patient really dead? At 5 minutes, the brain is working to some degree even if the patient is unconscious. And if the physician at 5 minutes actually attempted to restart the heart and it started beating, how would that be consistent with a dead patient?
Moreover, suppose the heart had stopped beating in the donor patient and was removed and eventually transplanted into the recipient patient and then began to beat and function in the recipient's chest, would that mean that, in essence, when the still heart was removed from the donor patient, that patient was actually alive and not dead?

These are all questions which continue providing consternation to doctors, lawyers and ethicists.
What is death, when does it really happen and when can an essential organ, like the heart, be removed from a patient for transplant without the fear that that very act of removal is in essence killing the patient? These are not just philosophical and medical or legal questions that can only be answered by ethicists, physicians or lawyers. There has to be a societal consensus of everyone like my visitors for "donation by cardiac death" to be an acceptable way of fairly, ethically and legally obtaining those very much needed organs for the sick. This process for obtaining organs must be publicly in the open and not in any way made secret.

Please write me your answers to these questions. I will describe without identification your responses to a bioethics listserv so that physicians and ethicists and lawyers there learn what the public thinks. ..Maurice.

Illegal Immigrant to a U.S. Citizen Physician: What Can We Learn by this Story?

From the August 9 2007 Perspective column of the New England Journal of Medicine:

"You will spend the rest of your life working in the fields," my cousin told me when I arrived in the United States in the mid-1980s. This fate indeed appeared likely: a 19-year-old illegal migrant farm worker, I had no English language skills and no dependable means of support.

Click on the above link and read the whole story (free full text) of Alfredo Quiñones-Hinojosa, M.D. and how he made the journey from migrant farm worker to neurosurgeon and professor at Johns Hopkins School of Medicine.

What does this migration of an illegal immigrant to a U.S. citizen physician and scientist tell us about issues of illegal immigration but also the potential of living and developing in the United States? Do you find anything unethical or of concern or caution in this uplifting story? ..Maurice.

Power of a Fetus vs the Autonomy of the Mother and the Carder Court Reversal Decision

You are a woman and you are pregnant. You are at term, in labor, and you have been fully informed by your doctor who insists that you deliver by C-section otherwise the baby might not survive. You have previously told your doctor that you never want a C-section operation and you are sure that you can deliver vaginally as you did with your other child. Your doctor is upset with your refusal for surgery.. the doctor is angry that you will not listen to medical advice. Guess what? The doctor and the hospital are contacting the court for an emergency order by a judge to perform a C-section against your wishes. The fetus is, at this moment, more important than your autonomous decision.

You are a pregnant woman with cancer and needs chemotherapy. Your fetus is viable but the doctors don't want to treat you for your cancer until they protect the fetus by removing it from the womb otherwise the chemotherapy will poison it. You are fully informed about the benefits of chemotherapy and the potential risks to the fetus and yourself. They get a court order to perform a C-section against your decision to treat your cancer now and not be concerned at present with the fetus.


You are a pregnant woman and have been voluntarily snorting cocaine. You have heard that there is some controversy that cocaine may be harmful for the fetus but, nevertheless, you consciously decided that you wanted to continue the drug. You are arrested, convicted of harming your fetus by the cocaine and you are now in prison.

If you think these stories are all made up, you are wrong. This is what has been happening in the United States. It appears that legislatures and the federal government put more power in the unborn denying the born pregnant woman the autonomy regarding the control of her body, such autonomy being granted to every adult woman or man. The unborn, through court order, can lead to personally unwanted and perhaps unneeded operations or other procedures carried out on the woman's body. Even a born infant or other born child of the mother would not be granted such power. So why the unborn fetus?

Read the Angela Carder story of a young lady whose drive for her own survival from cancer caused her and her fetus to become the fatal victims of a court decision. Read about the entire subject of "The Rights of Unborn Children and the Value of Pregnant Women" in the Hastings Center Report. And finally, read the advice of the American College of Obstetrics and Gynecology regarding autonomy of pregnant women in view of the D.C. Court of Appeals reversal of the initial court decision regarding Carder but after both the mother and fetus had died.

Although the word has not fully gotten around to all the doctors, lawyers and legislatures and federal government, the courts are not the ones to be ordering surgery and other procedures on women who are pregnant against the woman's autonomous decision in order to attempt to preserve the life of a fetus. In fact, no one, even doctors may do so either. ..Maurice.

Specieism: Treatment of My Kitten vs My Child

Should we treat our kitten different than our young child? How much protection do we owe the animals we own? And if they need to be protected against pain or death, why do we need to do that? Is it for our own comfort and peace of mind? Do our animals know the consequences of what we are deciding for them? Should non-human species of animals who are believed to be able to think be treated the same or differently than humans? If cattle can think, why do we kill them for food? If dogs think, why, in some cultures, they are killed for food? Is it fair for humans to behave in a different manner depending on what species of animals are being considered and acted upon? This is all bioethics and currently on a bioethics listserv these questions are being considered. One of the ethicists on the listserv wrote the following questions today which I am reproducing here. Maybe some visitor can provide an answer to one or more of my questions or those of the ethicist. ..Maurice.

Is it true that specieism is on a par morally with racism?

Singer thinks that there’s nothing wrong with human animals having sexual relations with non-human animals, e.g., the great apes. Is that true?

Is it true that we are as much responsible for evils we could have prevented as those we cause?

Non-human animals display specie preference (and sex preference). If specieism and sexism are inherently objectionable, shouldn’t we breed that out of them, if possible? If not, why not?

A non-human prey animal’s loss when killed by a non-human animal predator is the same as his loss when imposed by a human animal hunter. Why is predation by non-human animals Ok, but predation by human animal predators not-Ok?

If one objects to wearing the skins of animal martyrs on principle, mustn’t one object to accepting medical treatments developed at the cost of animal martyrs for the same reason?

And mustn’t one similarly object to accepting insurance coverage specifically targeted to offset the costs of products and services developed at the expense of animal martyrs?

Isn’t it perverse to favor further expansion of insurance coverage that fuels an industry based on the idea that non-human animals shall bear the initial costs of product development?

Commercialization of Healthcare

Js md brought up an issue that has been noted on previous threads here but I haven't presented it as a specific thread--the commercialization of healthcare in the United States. I would like to present this subject now. Obviously, this is a major issue in the upcoming presidential debates because how healthcare is to be provided for everyone in the U.S. should be a concern for all of us. I look forward to read responses from my visitors to js md's comment. ..Maurice.

The commercialization of health care is harmful to everyone, especially patients. I'm not a big fan of Michael Moore either. He gives a one sided biased view to make a point, but his anecdotes are all valid.We have an insurance based system which is not rational to begin with. You shouldn't insure expenses which absolutely everyone will face sometime in their lives; it cries out for a different mechanism. The insurance companies provide no health care; they just shuffle paper and soak up profits. The CEO of I believe United Healthcare retired with the better part of a billion dollar bonus! What a colossal misuse of health care dollars. We are I believe the only Western country in the world which doesn't have a national health care system and doesn't regulate the price of pharmaceuticals. We only regulate doctor's fees.I could go on, but I'll quit now.

The Sexually Seductive Patient: How Should Doctors React?

On my other threads on patient modesty and why doctors are hated, there is much concern and worry about sexually seductive doctors. Such concerns are warrented even though I am sure most doctors will treat patients professionally and keep to the professional and legal boundaries of behavior. However, physicians have their own concerns. One of their concerns is the behavior that the patient will bring into the office. There are the angry, disruptive and frankly belligerant patients. Medical students are taught to expect such patients and to react by trying to understand what is motivating these patients to these behaviors since such understanding may provide a therapeutic approach rather than the physician simply reflecting anger back to the patient. One of the more subtle and difficult patient behaviors for physicians to deal with is the sexually seductive patient. Such a patient, often a female relating to a male physician enters with the expression of obvious greater attention and interest with respect to the physician's personality and appearance than true concern about her own symptoms. Her actions may be sexually provocative. The patient may expose her body to the physician during the interview or exam to an extent which is clinically unnecessary. Female physicians are not free of seductive male patients.

Psychologists explain these patients' behavior as expressions of transference--where psychologic unmet needs are attempted to be met by engaging physicians who seem to resemble and reflect critical persons in the patients' emotional life. Of concern is the issue of counter-transference--where the physician may respond to this situation in a manner to support the physician's unmet needs based on the physician's emotional life. This can lead to physicians responding to the seductive patient in a manner beyond the professional boundaries of sexual attention.

How should physicians react to the seductive patient? Should they consider the patient has a psychologic or psychiatric problem in addition to their other disease and seek out evaluation, patient education and treatment for this disorder? Or should the doctor go ballistic and spell out the established rules of further behavior? Medical schools find that the need to educate students regarding how to deal with the seductive patient an important topic. I would like to read the views of my visitors on the subject of the seductive patient and what they think would be the very best approach to deal with the issue if it arises. One point I don't want to read from my visitors is that there is no such person as a sexually seductive patient or that the way patients behave is simply a reflection of the doctor's unprofessional behavior at the onset of the relationship. You have to be in medical practice yourself to see that this conclusion applied to all is not true! ..Maurice.

Pro-Life and Favoring the Death Penalty: An Ethical Conflict?

Here is an apparent ethical conflicting view that I have heard. How can a person be "pro-life" and still be in favor of the death penalty? Is the answer simply that "pro-life" means in favor of the life an innocent embryo or fetus and not necessarily for the maintaining of all life, including criminals who are to be executed nor the killing of enemy soldiers or innocent civilians during times of war? If being "pro-life" means something more than protecting the fetus, is that being clearly expressed to society? Or if not, should those who claim to be "pro-life" define their objectives. Or have they and I have missed it. Physicians are involved in this distinction as they are personally and professionally challenged by various people including patients and authorities with issues such abortion, contraception, invitro fertilization, termination of life-supportive measures, participating in death penalty activities and in war and torture. Those of my visitors who consider themselves "pro-life" can you define the extent to which you support the preservation of life. Should the preservation of life only be extended to the embryo and fetus, to the ill or patients in the persistent vegetative state? Is the death penalty, war and torture another matter? ..Maurice.

What is a "Good" Patient?

Anonymous has written in a previous thread regarding patients ideas regarding teaching ethics to medical students an interesting comment about what patients are looking for in their medical care and how they should or should not respond. Anonymous wrote:

"I read somewhere that patients try to prevent three things inherent in the healthcare system: depersonalization, loss of control and lack of knowledge. I would consider it normal and healthy for a patient to try to prevent these things from happening to them. But the behaviours they use to prevent this go against how a "good" patient is supposed to behave."

I thought it might be worthwhile to set up a new thread on a subject I haven't tackled before. On this blog, I have covered about what make up an ideal doctor but I have never covered the issue of what is a "good" patient, either from the view of patients or from the view of the healthcare provider. So here is the chance to make your opinions known. How do you think a "good" patient should behave? ..Maurice.