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.
posted by Maurice Bernstein, M.D. @ 4:03:00 PM
13 comments
13 Comments:
I have never been asked anything related to this issue, ever, by any doctor. Seems that most doctors don't want to discuss this.
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.
I think physicians put up barriers without thinking. My physician's office (a multi-practice clinic associated with a non-religious big hospital group) has "Bible Story" books in the exam rooms (the time I looked, the cover showed a Jesus image). I don't know who puts them there, but they send a strong message, and it's not about open-mindedness.
There are also displays associated with Christian seasons.
A single rainbow or other sign that the people there have even thought about diversity? Nope.
(I live in a small city; it's difficult to find a primary care physician. The other choice in my town is associated with a Catholic hospital.)
How relevant is this type of questioning if the patient isn't being treated for an STD where the person's partners need to be informed? What about when the patient is just getting a basic checkup? I can see why the questions are not common.
I could see where these questions might be helpful as part of a sex study where statistical information is being collected, but it seems like almost all doctors don't consider this an important issue.
"How relevant is this type of questioning if the patient isn't being treated for an STD where the person's partners need to be informed? What about when the patient is just getting a basic checkup? I can see why the questions are not common."
Questions concerning sexual activity should be a basic question in all routine examinations; not just for young people. How many "elderly" women wouldn't even think to tell their doctor that sex has become a tad bit painful because the dryness of menopause has caused the vaginal mucosa to thin and dry a little? Maybe, just maybe if the doctor would ask questions about sex during the routine visits, this would give the patient the opportunity to say.... oh yeah, by the way... I've noticed this change when I have intercourse. Who knows, maybe women would be more prone to have a healthy sex life into their "later" years and still enjoy it.
Sometimes if you want to know the answers, you have to ask the questions.
MJ KC, I think, for example, the current described survey of sexual activity in the elderly was published just because the editors of NEJM probably realized that doctors haven't considered that an important issue. Yet, as doctors we know that sexual activity continues on in the elderly, even the debilitated, since we all have heard reports from convalescent hospital nursing staff of sexual incidents occurring by demented but also mentally clear residents and about arrangements that have had to be made to allow elderly sexual partners (spouses or others) to have rooms for privacy.
I feel that physicians must feel that sexual activity is so universal but also in most cases so private activity that unless there is some direct, significant medical reason to investigate sexual practices of a patient or unless the patient makes a request for help taking a sexual history is not necessary or time efficient. I have to admit that I, too, until recent years have been one physician who tended to skip asking about sex during routine physicals. When I was a medical student in the 1950s, I truely don't recall any emphasis on sexual history taking. I think sex, except concern about syphilis or gonorrhea, was not a medically or socially discussable topic. Now most societies, I believe, have made sex, like cancer, more discussable. I think that the presence now of HIV and the other sexually transmitted infections with their drug treatment possibilites along with better medical insight and treatment for depression and other psychiatric conditions including post traumatic stress disorder which may be the consequence of youthful sexual abuse means there is more importance for doctors to consider the sexual history as a routine area of communication with the patient. ..Maurice.
As a woman in her 60's I would be very embarrassed to discuss my sexual activities with doctors in my health center (male or female), because most are 1/3 my age. If I did have a health concern about any part of my body, vaginal dryness, infection or whatever, then of course I would. But a general discussion of how often, what position, if I have orgasms, etc. I can't think of any reason why that information should be entered into my medical records for all to see, thanks to the advent of the new information technology.
The routine basic questions about sex which medical students are encouraged to ask their patients are:
1) When was the last time that you had sexual intercourse? (This is to establish whether the person has had sex with a partner and timeline in case of potential infection.)
2) Do you have sex with men, women or both? (Beyond telling how patients look at themselves in terms of sexual interest, there are health implications associated with the response.)
3) Do you engage in vaginal, anal or oral sex? (Again, health implications.)
4) How many partners have you had in the last 6 months? In your lifetime? (Multiple partners may be acknowledged. Again, health implications.)
5)Are condoms used or protection against infection or pregnancy?
6)Have you ever been tested or had a sexually transmitted disease such as syphilis, gonorrhea, herpes,hepatitis, HIV? Are you specifically concerned about any of these diseases including HIV and AIDS?
7) Do you have any general or specific concerns about your sexual experiences?
Based on the responses, more direct questions are asked if necessary for clarifying issues, risks or symptoms. Emily, there is no need to ask about sexual positions routinely unless the patient complains of specific symptoms such as back pain. Again, in terms of routine questions, asking regarding general concerns about the sexual experience (open-ended question) is more effective than asking first and directly about orgasms or other sexual practices beyond what I listed above.
The patient's personal chart is the appropriate location where the responses to these questions should be documented. Obviously, the persons responsible for the chart in whatever form it is kept should be responsible for its security. ..Maurice.
I think maybe it's because beyond obvious things like treating an STD or telling you how to practice safe sex, if you say you have a sexual problem (pain, etc) doctors don't really know what to do.
Dr. B, just to play devil's advocate......
What if in the course of taking a sexual history of a male patient, it bacame known that he is having sex with minors, small children even.
Is there a legal obligation to report this? If so, is the patient warned in advance? Also, isn't sodomy illegal in some states? What of this issue?
Emily, two good questions. I am not aware of all the legal details. However, I think that reporting a specific patient to authorities based only on the history the patient provides regarding engaging in sex with minors is unwarrented. In issues of child or elder abuse, the physician has the child or the elderly person as a patient and can back up suspicions of abuse by history taken from the suspected victim and/or signs of abuse on physical examination. To act on simply a history without the identification of a specific victim would not be sufficient.
The Tarasoff case would be an example to help answer your question: Here is the story from Wikipedia:
Tarasoff v. Regents of the University of California, 17 Cal. 3d 425, 551 P.2d 334, 131 Cal. Rptr. 14 (Cal. 1976), was a case in which the Supreme Court of California held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient. The original 1974 decision mandated warning the threatened individual, but a 1976 rehearing of the case by the California Supreme Court called for a "duty to protect" the intended victim. The professional may discharge the duty in several ways, including notifying police, warning the intended victim, and/or taking other reasonable steps to protect the threatened individual.
Facts
Prosenjit Poddar was a patient of Dr. Lawrence Moore, a psychologist at UC Berkeley's Cowell Memorial Hospital in 1969. Poddar confided his intent to kill Tatiana Tarasoff, a girl who had bluntly rejected Poddar's obsessive romantic advances. Dr. Moore requested that the campus police detain Poddar, who was shortly thereafter released, as he appeared rational. Dr. Moore's supervisor, Dr. Harvey Powelson, then ordered that Poddar not be subject to further detention.
Neither Tatiana nor her parents received any warning of the threat. Podder then befriended Tatiana's brother, even moving in with him. Several months later, on October 27, 1969, Poddar carried out his desire, killing Tarasoff. Tarasoff's parents then sued Moore and various other employees of the University.
Opinion of the Court
The California Supreme Court found that a mental health professional has a duty not only to a patient, but also to individuals who are specifically being threatened by a patient. This decision has since been adopted by most states in the U.S. and is widely influential in jurisdictions outside the U.S. as well.
In the majority opinion, Justice Mathew O. Tobriner famously stated: "... the confidential character of patient-psychotherapist communications must yield to the extent that disclosure is essential to avert danger to others. The protective privilege ends where the public peril begins."
Justice Clark dissented, stating in his minority opinion that "the very practice of psychiatry depends upon the reputation in the community that the psychiatrist will not tell".
As you see, the potential victim was known. Now if the patient provides me with the names of specific minors with whom the patient had sex, that might be different even though the disclosure was after the fact. The aim would be to protect these specific named minors from further abuse. In any event, I would discuss the issue anonymously with authorities or lawyers to decide what I needed to do. I would also discuss the admission with the patient to remind the patient about the illegality of that behavior but also to see what emotional and sexual factors have lead to this alleged sexual activity in order to provide therapy.
With regard to sodomy: The U.S. Supreme Court ruled 6-3 that sodomy laws are unconstitutional on June 26, 2003.
The majority opinion is based on privacy rights and is written by Kennedy, joined by Breyer, Souter, Ginsburg, and Stephens. O'Connor concurred on equal protection grounds. You can read the opinion here.
Emily, this is the best I can do to answer your quesions. ..Maurice.
Dr. B,
I read your post on what medical students are taught to ask their patients concerning sex. As with anything, modifications can always be warranted. As you said, an open ended question is just the thing to allow an elderly man or woman to express concerns they may or may not be having with their sex life. Even a simple question like, "Is your sex life adequate for you," maybe be all the opening someone needs to expand on the subject.
As far as the woman who would be embarassed to ask her doctor questions about sex life when he is 1/3 her age; I can understand her reluctance, but it is at least his obligation to open the door.
I work in the ER and I'm 51 years old, I've had to explain to more than one 18 year olds things that I thought I'd never talk about to anyone except my husband; but, it is my obligation to educate and most are grateful that I have taken the time to explain things to them.
A couple of comments:
First of all, it is very important to ask older adults about their sexual activity, because of HIV and other STDs. Many older adults who are sexually active are not with partners of long-standing but may be in new relationships. They were not brought up with education regarding safer sex, and therefore are likely to have unprotected sex.
This quote is worth noting:
"One out of three sexually active older adults infected with HIV has unprotected sex, according to a study by Ohio University researchers. A survey of 260 HIV-positive older adults found that of those having sex, most were male, took Viagra and were in a relationship.
AIDs cases among the over-50 crowd reached 90,000 in 2003. According to the Centers for Disease Control and Prevention, they will account for half of all HIV/AIDS cases in the United States by 2015 because medical intervention has extended the lifespan of those infected with HIV. Additionally, drugs such as Viagra have made it possible for older adults to remain sexually active longer.
Past studies have shown that up to 65 percent of older adults ages 60 to 71 have sexual intercourse. Among older adults who are HIV-positive, according to the Ohio University findings, 38 percent are sexually active" (http://news.research.ohiou.edu/news/index.php?item=362)
The other comment is more of a recommendation: There is a lovely movie called "Tonight's the Night" produced by the CBC that is a great way to enlighten health care providers and others who work with older adults about the reality of sexually active older adults (http://www.fanlight.com/catalog/films/226_ttn.php)
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