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.