Intuitively, there might seem to be good reasons to try to match the gender of the interviewer to the
gender of the respondent . . . potential respondents were offered the choice of a male or female
interviewer if there appeared to be any hesitation about agreeing to give the interview . . . the
majority had no clear preference . . .
Johnson et al, 19941
The effectiveness of any interviewing technique is, in the last analysis, to be determined by the quality
of the data that are obtained.
Kinsey et al, 19492
When talking about sexual issues with a patient, does it make any difference if the
health professional is a man and the patient is a woman (or vice versa)? What if both
are women or both are men? The answer to the question of whether gender matters
is, “yes.”
A 24-year-old woman medical student joined a 45-year-old psychiatrist/sex therapist
in a consultation regarding erection difficulty in a heterosexual couple. The
medical student stated privately beforehand that she was apprehensive about talking
to patients about sexual issues, since this was not encouraged during her previous
training and she hadn’t done so before.
This visit was the first for the couple. The senior clinician began the interview
by asking both partners about themselves. When the woman partner answered her
part of the question, she was looking at the woman medical student much of the
time. When the details of the couple’s sexual encounters were discussed, this was
even more evident. The medical student completed her Sexual Medicine clinical
experience within the same time as the assessment. The senior clinician continued
to follow the couple in treatment by himself without difficulty for the next three
months.
Gender is probably always an influence when people are talking about
sexual issues. Gender makes a difference because two people of the
same gender talk the same language to each other. There is an immediate
and implicit assumption of communality of development and experience—
probably the principal reason that many women patients seem
to preferentially choose women physicians. When talking to one
another about sexual issues, men are more comfortable talking with
other men (other things being equal such as the absence of homophobia),
since both understand what it means to have an erection and to ejaculate. The
same can be said of women and, for example, the sexual significance of menstrual periods
and breastfeeding.
Does the importance of gender mean that male health professionals
are unable to comprehend the sexual experiences of women and vice
versa? Of course not. One thing it does mean is that when health science
students are beginning to talk with patients about sexual issues, it is
far easier for women students to talk with women patients and for male
students to talk with male patients. As confidence develops, the student
advances into the less familiar territory of the thoughts and experiences
of the other group. Ultimately, patients want help with problems, and, as
important as gender might be to some, competence is the crucial factor.
A 45-year-old woman was referred to a (male) sex-specialist by her (female) family
physician because of lack of sexual activity in her relationship with her husband.
The patient was sexually assaulted five years before by a (male) psychiatrist. She
reported that, despite the referral, her current family physician had difficulty
understanding her problems. The patient said that her family physician told her
that her vagina was “tight as a drum, like that of a 16 year old.” The family physician
was also reported as having said that she, herself, was envious and was sure
that the patient’s husband was quite pleased with the state of his wife’s vagina. In
fact, the patient had not had any sexual experiences with her husband (or anyone
else) for the five years since her sexual assault. Furthermore, the patient felt that her
family doctor was unsympathetic, and she was obviously unhappy over the way her
situation was handled. Unfortunately, she was unable to talk with her family physician
about what she felt to be the latter’s insensitive approach.
In extrapolating from their studies on sexual physiology, Masters and Johnson concluded
that therapist gender was a matter of consequence in the treatment of dysfunctional
couples3 (p. 4). They believed that the presence of a man and a woman was essential
to their research on sexual physiology since “. . . no man will ever fully understand a
woman’s sexual function or dysfunction . . . [and] . . . the exact converse applies to
any woman.” Hence they developed the concept of the “dual-sex therapy team” in sex
therapy in which each partner has a “friend in court” and an “interpreter.”
Gender makes a difference because two people of the same gender talk the same language to each other. There is an immediate and implicit assumption of communality of development and experience.
Ultimately, patients want help with problems, and, as important as gender might be to some, competence is the crucial factor. |
Two considerations balance the logic and
sensitivity of the dual-sex therapy team
approach:
1. The issue of competence is ignored when one thinks only about the primacy of
gender
2. Practicality (insufficient numbers of trained personnel and limited health care
financial resources) usually dictate that treatment be provided by one person
rather than two
When a single therapist versus a dual sex-therapy team approach was examined from a
research perspective, it did not seem to result in any difference in outcome.4 Sixty-five
sexually dysfunctional couples were randomly assigned to treatment by (1) a male or
(2) female professional working alone or (3) a dual-sex cotherapy team. The treatment
results were the same in all three circumstances. Moreover, it made no difference to the
outcome if the therapist who was working alone was a man or woman and the patient
was of the same or opposite sex.
A woman was referred to a “sex clinic” by her family physician because of a diminution
in her feelings of sexual desire. The referral specified that she be seen by a
woman therapist. Although the clinic usually accommodated such requests, it was
not possible to do so in this circumstance. The referring physician was told this
situation and was also told that one of the male therapists could see the patient
within a short time. The referring physician discussed this with the patient and the
referral proceeded. The issue of gender difference and its possible impact on history-
taking and treatment was explicitly raised by the therapist at the beginning of
the first visit and the patient was encouraged to indicate if and when she thought
this might be an impediment to anything taking place in the consulting room.
Furthermore, the therapist told her that if their gender difference proved to be a
problem, he would help her find a woman therapist with whom she might be more
comfortable. By the middle of the first visit, and in response to a question by the
therapist, the patient said that her discomfort in talking with a man about sexual
concerns was much less problematical than she anticipated. The issue of gender did
not arise again in the subsequent six months of care.
Suggested Question to Ask Early in the Interview When Patient and Interviewer are
Opposite Genders: “How do you feel about talking to a man
(woman) about sexual matters?”
The answer to the above question is, “maybe.” However, the real question should be:
are such connections the norm? The answer is unequivocally, “no.” If the answer was
positive, it is logical to expect that sex
therapists (who spend much of their professional
time talking to people about sexual issues) would have to constantly contend
with their own, and their patient’s, sexual feelings toward each another, as well as the
consequences of those feelings. Most professionals working in the area of Sexual Medicine
would declare that these are baseless worries.
Nevertheless, the questions are important, since sexual misconduct concerns are
prevalent in all health professions. When talking about sexual issues with patients, health
professionals exercise a greater degree of caution now than in previous years—a result
of social sensitivity to the problem of sexual abuse by individuals in positions of authority
(e.g., teachers, clergy, and health professionals). When explaining the reasons for
avoiding discussions of “sex” with patients, some health professionals anecdotally include
worries that any inquiry about sexual issues may provoke such an accusation.
It is instructive to consider what science demonstrates about the
issues of talking to patients about sexual issues, sexual feelings in the
health professional toward patients (and vice versa), and professional
sexual misconduct. While not all the questions have answers, information
exists for some. For example, connections between sexual feeling
of the psychologists and sexual misconduct have been examined.5 In
this study, 95% of men and 76% of women report sexual attraction to
a client at some time in their careers, although only 9.4% of men and 2.5% of women
acted on those feelings. The authors conclude that the two phenomena were (mostly)
different—”therapist-client sexual intimacy must be clearly differentiated from the
experience of sexual attraction to clients.” Despite the fact that the attraction to clients
was the norm for men and women psychologists, two thirds of respondents to the
survey felt “guilty, anxious or confused” about having such feelings. Although information
is not yet available concerning other health professionals, there is little reason to
expect different results.
A second study of psychologists by the same group confirmed the finding about
sexual attraction from the previous study.6 The authors also report the following data:
1. Almost 60% of respondents reported feeling sexually aroused in the presence of
a client
2. Over 50% reported hugs, flirting, and statements of sexual attraction from the
client toward the psychologist
3. Client disrobing was “exceptionally rare”
4 . Over one third “reported both male and female client (apparent) sexual arousal
during sessions”
5. Ten percent of therapists had a complaint filed against them
6. This happened to men three times more often than women
7. Therapists who had some sexual involvement with clients were four times more
likely to have had a previous complaint lodged against them (malpractice, ethics
or licensing) than those who did not experience such involvement
Concerns of Canadian physicians regarding the connections between sexual talk,
feelings, and misconduct became complex as a result of the involvement of the Canadian
Medical Protective Association (CMPA; the defense union formed by physicians
against malpractice suits). In the early 1990s, the topic of professional sexual misconduct
received an almost frenzied degree of public and professional attention in Canada.
“therapist-client sexual intimacy must be clearly differentiated from the experience of sexual attraction to clients.”5 |
In the midst of this upheaval the CMPA issued
a bulletin that included the following
definition of patient sexual abuse: (patient sexual abuse can be construed during the
process of) “Requesting details of sexual history or sexual preferences when not clinically
indicated for the type of consultation or presenting problem.”7
The CMPA warning to physicians served only to underline the inhibitions many
already felt when faced with talking about “sex” with their patients. For Canadian professionals
having clinical, teaching, and research responsibilities concerning sexual
problems, the CMPA bulletin was not a welcome statement since it provoked more
questions than it answered:
1. Was there a concern that questions about sexual matters might be misinterpreted
by the patient as a sexual invitation by the physician?
2. Was there a worry that including “sex” in the context of a routine medical consultation
was, ipso facto, an imposition on a patient?
3. Did the definition of sexual abuse represent the attitude of organized medicine
or of malpractice insurance companies (a lawyer wrote the CMPA article)?
4. To what extent was the statement part of a larger social concern about sexual
abuse?
5. Was there a worry that including “sex” in a medical history might uncover or
provoke sexual feelings in the patient toward the physician?
6. (Most importantly), what was the evidence on which the recommendations in
the bulletin concerning sex history-taking were based?
The CMPA bulletin failed to take into account the complexity of professional sexual
misconduct and the fact that the precursors involve much more than talking about sexual
matters. Precursors usually entail problems over “boundaries.” The concept of boundaries
has gained much attention, particularly within the medical disciplines of Psychiatry and
Family Practice. The word boundary refers to the unseen line between health professional
and patient, and the present focus is on what constitutes crossing over that line for both
parties.
A distinction is made between boundary crossings and boundary violations.8 “Boundary
crossings” are not necessarily harmful (e.g., attending the funeral of a patient who
died). A “boundary violation” is a “crossing” that is harmful (e.g., sexual misconduct).
The CMPA might view questions about sexual issues to represent a “crossing” or even
constitute a “violation” unless “. . . clinically indicated for the type of consultation or
presenting problem.”7
Use of the “permission” technique described in Chapters 2 and 3 might substantially
lessen the possibility that questions about sexual matters may be interpreted as a “crossing”
or a “violation.” However, permission is not the equivalent of license. Permission
is given to talk about a subject. It is not assent to a question that has not yet been
asked. The manner in which questions are posed, or the language used, might, for
example, represent a boundary crossing or violation.
When a health professional has a patient who has sexual difficulties, one might legitimately
wonder about the value of disclosing one’s
own sexual thoughts and experiences.
After all, most woman (including women health professionals) have, for example,
had at least an occasional time when intercourse caused vaginal discomfort.
Likewise, most men have, at some time, probably experienced rapid ejaculation in
intercourse. (Neither of these are the same as a sexual dysfunction, which, among
other things, is persistent). Logic indicates that this might be useful information to
have for a patient with a similar problem. It might even allow a patient to be more
optimistic about the result of a treatment program if it was explained that this also
happened to oneself. Intuition provides more guidance to professionals on what to do
or say in this situation than science.
As logical as self-disclosure might seem, the small amount of research on this subject
does not support a great benefit to sharing one’s sexual thoughts and experiences
with a patient. A survey of 63 male psychologists found that sexual experiences were
the least common of the types of disclosure made.9 From a clinical viewpoint, there are
strong opposing opinions to the notion of professional self-disclosure in this area.
First, the crucial question to be answered is: would it help to make the patient better,
which, after all, is the “job” of the health professional (or to use more recent jargon,
the “objective”)? While patients often find it reassuring to know that others have
also experienced sexual problems, the mechanism of self-disclosure by a health professional
is not the best method. Information is often available from, for example, selfhelp
books and the Internet. Patients want something different from a health professional
than what they can easily get elsewhere. Patients want specific help in finding a
solution to their own sexual predicament and are less interested in the personal difficulties
of the health care provider.
Second, it may be difficult to separate discussion of professional self-disclosure on
sexual matters from the issues of professional sexual misconduct and boundaries. Selfdisclosure
may be seen, at least, if not more, as a “boundary crossing.” Health professionals
should be aware that there may be an inclination by “fact finders” (for example,
licensing organizations) to consider the presence of boundary violations (or even
boundary crossings) to be “presumptive evidence of allegations of sexual misconduct.”
8
Self-disclosure, in particular, was one of the issues examined by a Massachusetts
task force that was established for the purpose of developing guidelines on maintenance
of boundaries in psychotherapy.10 While specific to psychotherapists, the ideas
generated are unquestionably serious issues for other health care professionals as well.
The guidelines acknowledge that in some areas, self-disclosure is accepted. One area
is in the treatment of substance abuse. Another is in the selection of a health professional
with the same sexual orientation (gay or lesbian). However, the guidelines also
categorically state that, “It is never appropriate for physicians practicing psychotherapy
. . . to disclose details of their sexual lives.”
Suggested Statement in Response to a Patient Asking About a Health Professional’s
Sexual Experiences: “You came to see me to discover the explanation
for your own troubles and to find help to do something
about them. I don’t believe that talking about my
sexual experiences assists you in doing that.”
In a corollary to the issue of “boundary violation,” some think that “excessive distance”
from a patient (rather than excessive involvement) might constitute another example
of a violation.11 In this view, an act of “omission is at least as dangerous as (one of)
commission.” If one accepts this, avoiding the subject of “sex” in a history might be seen
as an act of omission constituting a “boundary violation.”
“. . . homosexuality . . . [should] . . . not be defined by behavior but by the predominant erotic
attraction to others of the same sex . . . One need not engage in sexual activity to be homosexual,
any more than one need engage in sexual activity to be considered heterosexual.”
Richard Isay, 196912
All of the issues and questions related to the subject of sexual orientation can not possibly
be reviewed in this chapter. The focus in this section is on matters that are problematic
in primary health care. Developmental and frequency aspects of homosexuality
are included in Chapter 5 (see “Puberty and Adolescence—Sexual Orientation”).
The word “homosexual” is often used in the community and among health professionals
to define people who have sexual connections with same-sex partners. However,
some prefer use of the words “gay” and “lesbian” and find the word “homosexual”
uncomfortable and even offensive. One disadvantage to the use of the word “gay” to
describe both groups is that it tends to render individuals apart from gay men as somewhat
invisible.13
A second objection to the word “homosexuality” is that it leaves out the subject of
“heterosexuality” as something that is an equally interesting subject to
study (Tiefer L, personal communication, 1997). (The origins of both
are only beginning to become unraveled).
A third problem with the word “homosexuality” is the emphasis on
the sexual part of the relationship rather than the caring that might
exist between the two people.
The word “homosexuality” implies a meaning that is clear and specific
but in fact the opposite is true. For example, does “homosexuality” refer to sexual behavior
only, without considering what is in a person’s mind? Or could it refer to the exact
opposite, considering only what is in one’s mind without reference to sexual behavior?
Could someone be homosexual but sexually inactive just like a person who is heterosexual
and sexually inactive? If the interviewer is considering mind-issues apart from
behavior, does that include only sexual images such as fantasies, or feelings of love for
a partner as well?
In fact, there are at least three ways to define sexual orientation:
• Behavior
• Fantasy
• Self-identification
A problem with the word homosexuality is the emphasis on the sexual part of the relationship rather than the caring that might exist between two people. |
(See “Sexual Orientation” in Chapter 5 and
Table 5-3 for more discussion on the definition
of “homosexuality” and the variety of meanings of the word).
Interest in the health and happiness of the patient is one of the principal reasons for
knowing about a patient’s sexuality, including their sexual orientation (see “Why Discussion
Should Occur” in Chapter 1; see also Box 1-2). (Before homosexuality was
deleted from the system of psychiatric diagnoses, the principal rationale for asking
about sexual orientation was diagnostic).14
Gay men and lesbians may have an increased vulnerability to some medical and emotional
disorders. Examples of such medical disorders in men15 include the following:
• HIV/AIDS in those who engage in anal intercourse with other men
• Other STDs
• Hepatitis
• Anal cancer
• Urethritis
Examples of a possible increased risk of medical disorders in lesbians include the
following:
• Ovarian cancer as a result of loss of the protective effect of pregnancy16
(although an increasing number of lesbians are choosing to have children)
and the use of oral contraceptives17
• Breast cancer because of increased risk among women who have not
given birth
• Cervical cancer based partly on the “false assumption that lesbians do
not engage in risk behaviors for cervical cancer . . . [when in fact] the
majority of respondents to surveys . . . report a history of heterosexual
activity, often involving multiple partners”18
• STDs (including HIV/AIDS) among bisexual women15
Gay men and lesbians may also have an increased vulnerability to problems affecting
mental health13,15:
• Acceptance
• Ostracism
• Discrimination
• Personal losses
• Stigmatization
• Depression
• Violence (anti-gay and battering)
• Substance abuse
Risk of suicide has been reported as a particular issue among gay adolescents.19 A
population-based study of over 36,000 US junior and senior high school students indicated
that bisexuality/homosexuality was a substantial risk factor for attempted suicide
in male (but not female) adolescents.20 A large proportion (27%) of men with eating
disorders are reported to be primarily gay or bisexual.21 The National Lesbian Health
Care Survey provides more specific information about lesbians and reported on information
gained from 1925 respondents (a 42% response rate).22 The survey found that
30% of respondents used alcohol more than once weekly and 6% used it daily, about
75% “had received counseling at some time, and half had done so for reasons of sadness
and depression.”22
In addition to medical and mental health issues, there is evidence that sexual concerns
among gay men are not identical to those in heterosexual men.23 In one study,
homosexual men cited that the following occurred at least once in their lifetime:
• Painful receptive anal intercourse
• Concerns about the “normality” of their thoughts, feelings, or fantasies
• Harassment for being gay/homosexual/bisexual
(In a comparative group of heterosexual men, premature ejaculation and low sexual
desire were most common).
In the course of asking someone about sexual orientation issues, the health professional
might discover, for example, that the patient has had same-sex sexual experiences in
the past or same-sex sexual fantasies in the present. What does this mean? In some
instances sexual orientation may be a peripheral factor; in others, it may be central.
A 30-year-old woman with her husband of four years was referred by her family
physician to a “sex clinic” with her husband of four years because of her diminished
sexual desire. The couple were initially seen together, but when she was subsequently
seen alone, it became apparent that her sexual interest was far from absent
and that her sexual fantasies included both men and women. Unknown to her
husband, and apart from her relationships with men in her teens and beyond, she
lived with another woman in a romantic and sexual relationship for about three
years in her early 20s. She regarded herself as bisexual and said that her sexual
desire had never been a problem in the past with women or men (including her
husband). She was deeply in love with her husband and concerned about their
present sexual difficulties, which, she thought, more likely involved his erection
problems than her sexual orientation. With an ultimately successful treatment focus
on his situational erectile disorder, the sexual desire issue disappeared.
A 19-year-old student was referred by his family physician because of an inability
to ejaculate. He had not previously disclosed to other health professionals that he
could ejaculate when alone and when with a male partner. His principal sexual
concern was the inability to have the same experience when having intercourse
with a woman. In that circumstance, ejaculation could occur only if he simultaneously
fantasized about having a sexual encounter with a man. He was distressed
about being able to ejaculate only in this way and was concerned that this might
indicate that he was gay. He described his fantasies during masturbation as involving
only men since he began at the age of 13 and added that men were included
when he thought about his most pleasurable sexual experiences with a partner. His
apparent reluctance to accept his homosexuality led him to attempts at intercourse
with four different women, which resulted in an inability to ejaculate without fantasizing
about men on all four occasions.
Suggested Question Directed Toward a Man and Asked in the Context of a Discussion
About a Sexual Dysfunction: “What is your opinion about the connection
between the problem of …….. (e.g., erections) and
your sexual experiences with other men (women)?”
Primary care health professionals learn about the sexual orientation of their patients in
two ways:
• The information is spontaneously revealed
• The patient waits for the health professional to ask specific
questions
Of these two possibilities, survey data indicate that many gay men and
lesbians choose the latter. These surveys leave unclear the answer to
the question of the impact of HIV/AIDS on the extent of disclosure.
Interviews were conducted with 623 gay men in the United Kingdom
who were registered with a general practitioner.24 Forty-four percent
of the men had not revealed their sexual orientation to their family
doctor. This was true as well for 44% of the 77 men who were HIV
positive (in most instances, they were tested in a specialized clinic).
One part of another study of 105 bisexual men assessed the degree
to which male subjects revealed their sexual attraction to other men to
various people in their network.25 Only 23% “fully disclosed” this
information to a “doctor or clinic” and, even more surprisingly, only
53% disclosed this information to a “counselor or psychologist.”
A group of 424 bisexual and lesbian respondents to another survey
indicated that over one third (37.5%) “believed that disclosure of sexual
orientation to their physician would adversely affect their health
care.”26 In addition, over one third of the respondents “said that they
would like to disclose their sexual orientation to the physician providing
their gynecologic care, yet they hesitated to do so.”26 Moreover,
60% indicated that they would be willing to discuss their sexual orientation
if the information was not put in the medical record. In the experience of
Primary care health professionals learn about the sexual orientation of their patients in two ways: • The information is spontaneously revealed • The health professional asks specific questions Of these two possibilities, survey data indicate that many gay men and lesbians choose the latter.
Suggestions for physicians regarding sexual orientation: 1. Offer to not record sexual orientation information in the medical record 2. Allow a friend or partner to be present during the examination 3. Include the friend or partner in treatment discussions 4. Ask questions in a manner that does not presume heterosexuality |
respondents (apart from opinions and desires),
only 41% disclosed their sexual orientation.
The authors of this study concluded with some concrete suggestions for physicians:
1. Offer to not record sexual orientation information in the medical record
2. Allow a friend or partner to be present during the examination
3. Include the friend or partner in treatment discussions
4. Ask questions in a manner that does not presume heterosexuality
Of 622 men and women subscribers to a gay newspaper who responded to a questionnaire
survey, 49% of the respondents explicitly revealed to their primary health
professional that they were homosexual.27 However, an additional 34% said they
would provide this information to their health professional if they “thought it was
important.” This finding suggests that many gay patients may be willing to reveal their
sexual orientation if asked and if the rationale for the question is made clear.
“Homophobia” (defined as “the irrational fear, distrust, and/or hatred of lesbian/gay
people”) seems to be the main deterrent to disclosure of one’s status as gay or lesbian
to health care professionals.13 Some regard an attitude of “Heterosexism” (defined as
a “world-view value system that prizes heterosexuality”) with homophobia. Heterosexism
assumes that heterosexuality is the only appropriate manifestation of love and
sexuality and devalues homosexuality and all that is not heterosexual.13 In one of the
surveys described above, 89% of respondents who rated their primary health professional’s
attitude as very supportive candidly discussed their sexual orientation with
that person, compared to 48% of those who judged their health professional to be
hostile.27 As a result of homophobic attitudes among health professionals, many
lesbians reportedly turned to “complementary health care providers. . . . [and are
therefore] . . . . unlikely to receive any of the standard medical screening
tests. . . . The effects of this alienation. . . . may result in a significant increase in morbidity
and mortality”.28
Given that there is reason to ask about sexual orientation in a health setting and that
the majority of patients do not reveal this information spontaneously, what question(s)
does one ask? How does one determine sexual orientation anyway? By
self-identification? By the fantasies of a person? By the sex of sexual
partners? By some combination of these elements?
Questions that help establish sexual orientation are theoretical and
have a serious practical application as well. For example, in one survey,
78% to 80% of lesbians reported sexual activity with a man in the
previous one to five years. The author concluded from this report that “orientational
identity and sexual behavior are not synonymous and require separate and specific
inquiry”.28 Such information might, for example, be helpful in learning about the origin
of a patient’s STD.
In asking for “identifying information” from a new patient, one usual question relates
to clarification of the person’s living circumstances. If the patient is living with some-
“orientational identity and sexual behavior are not synonymous and require separate and specific inquiry.”28 |
one, the interviewer can simply ask if the
relationship is one that is also romantic
(apart from sharing the cost of the accommodations). If the gender of the other person
has not already been identified (unusual), this question too can easily be asked.
Another approach to clarifying the sexual orientation of a patient is to use the
screening outline provided in Chapter 3. However, one of the problems with this
approach is having to wait until the subject of “sex” arises in the “Review of Systems.”
If one does delay until this point, the specific question(s) asked by a health professional
become influenced by their purpose(s). For example, one reason is to simply clarify the
sexual orientation of a new patient while learning about the person in the first few
visits. Another intention might be to consider an STD in the differential diagnosis of
a patient with a particular medical complaint. A third purpose might be to clarify the
nature of the relationship between a patient who is depressed and a friend who just
died.
The Chapter 3 screening method (with suggested questions) is easily applied to
sexual orientation questions involving a new patient. The four-question model (see
Figure 3-4) entails asking:
1. A preamble/permission question
2. A question that addresses the issue of whether the person is sexually
active
3. Whether the partner(s) was(were) a man, a woman, or both
4. If the patient has any sexual concerns (see Figure 3-4)
A question about the gender of the partner immediately (but implicitly)
tells the patient that the interviewer is not assuming that person
to be heterosexual. “Simply having a nonjudgmental, non homophobic
attitude is not enough. The responsible practitioner needs to convey his
or her nonjudgmental attitude to all patients.”28 On the basis of clinical impression,
questioning the possibility of same-sex sexual experiences by a health professional is
easily accepted by most patients and does not elicit the same response from people as
in a social situation.
Initial use of the undifferentiated word “partner” (rather than spouse, husband, wife,
boyfriend, or girlfriend) also conveys to the patient that the interviewer is not making
any assumption regarding sexual orientation. Furthermore, this approach is beneficial
in talking to heterosexual patients, since it also implicitly dispels any supposition of
particular linkages with sexual activity (such as marriage).
With gay and heterosexual patients, use of the word “partner” conveys an attitude
of acceptance. The health care professional must attend to such issues during an interview,
in the use of patient forms, and in waiting room information pamphlets.
Last, clinicians should be clear about the sexual orientation of the patient before
questions about birth control are asked. To do otherwise risks alienating the patient.
(The comment refers to the order of questions not the relevancy. The health professional
should not assume that questions about birth control are immaterial because
someone is a lesbian. What determines the relevancy is the patient’s behavior).
When a gay or lesbian patient is in a partnership, the health care professional should
inquire about the involvement of the partner in appointments and the extent to which
Questions from a health professional regarding same-sex sexual experiences are easily accepted by most patients and do not elicit the same response from people as in a social situation. |
the partner’s influence is desired in any
future medical emergency involving the patient.
O’Hanlan suggests that couples be encouraged to consider preparing a medical power
of attorney, particularly before elective surgery or obstetric delivery.28
Fearing repercussions, many gay and lesbian patients are unwilling to reveal their
sexual orientation unless this information is not recorded in their medical record. One
suggested possibility under such circumstances is a coded entry in the chart.29
When a heterosexual health professional talks about sexual issues with a patient who
is gay or lesbian, it should not be any different than talking to a heterosexual person,
but it often is. The heterosexual health professional should consider their personal
attitudes and knowledge about homosexuality. Gays and lesbians are often quite tolerant
of professional knowledge-deficits, providing it is acknowledged and does not
extend beyond the “garden variety” lack of information.
A gay male couple in their 40s was referred to a professionally experienced (heterosexual)
sex therapist for assessment of an erectile concern of one partner. One
of the two men was himself a health care professional and explicitly stated on the
first visit that he had “checked out” the therapist before proceeding with the
appointment. (The patient never said what facets of the therapist made him acceptable
but the implication was that it was connected to his professional attitude). The
therapist agreed to continue seeing the couple in treatment but made it understood
that, since the majority of his patients were heterosexual, he would need to be
taught some aspects of the sexual practices of gay men. They were completely at
ease with the professional’s request for more information.
Suggested Statement and Question to a Gay Man or Lesbian in the context of an
HPI: Man or Lesbian in the Context of an HPI: “I know very little about
the activities of gay men (or lesbians) when they are being
sexual with one another. Is it okay if I if I ask you about
them?”
Additional Question if the Answer is, `yes’: “Tell me what you and your
partner usually do together.”
The principal driving force behind the recent large-scale “sex” surveys has been presence
of the HIV/AIDS epidemic together with the absence of reliable information
about community sexual practices (see Table 1-1 in Chapter 1). As a result of these
surveys, more is known concerning gay and lesbian sexual activities. For example, in
the French survey, gay and bisexual men described the following most common sexual
activities during their last intercourse:
• Stroking each other tenderly (96%)
• Reciprocal masturbation (77% to 82%)
• Fellatio—active or passive (72% to 76%)
• Anal penetration—active or passive (28% to 36%)
Anal penetration occurred without a condom in 12% to 15%. Inserting a fist in the
anus was unusual (6%)30 (p. 131). (See also Tables 5-1 and 5-3 in Chapter 5).
PFLAG (Parents, Families and Friends of Lesbians and Gays) is an international organization
that is devoted to support, education, and advocacy. PFLAG circulates a list
of recommended readings (most in paperback) on various sexual orientation issues.
Some readings are directed toward parents, spouses, and children of gays and lesbians;
others focus on particular subjects such as religion and spirituality, history and civil
rights, and HIV/AIDS.
Most large cities in North America have speciality bookstores devoted to gay,
lesbian, and bisexual themes. Health professionals could direct patients to such locations.
Several recent publications seem particularly useful (for patients and for health
professionals):
• Becoming gay: the journey to self-acceptance, Isay R (author): a sensitive and
readable book on self-acceptance and the development of homosexuality
in the individual. It is written from the perspective of a practicing
gay psychoanalyst12
• A natural history of homosexuality, Mondimore FM (author): an informative
review of all aspects of the topic of homosexuality from its history to
recently published research into genetics and the brain31
• The complete guide to safer sex, McIlvenna T (author): in addition to sexual
orientation issues, this material (available in paperback) offers a thorough
review of all aspects of safe sex behavior32
Last, the Internet is a significant resource on gay, lesbian and bisexual issues and
includes a large amount of information (see Appendix IV).33
The gender of the participants in a health care interview that includes sexual issues and
the sexual orientation of the patient are pervasive factors regardless of the setting, be
it medical or mental health. These two issues always must be considered.
Usually, the fact that the health professional is a man or woman does not interfere
with talking about “sex,” regardless of the gender of the patient. However, for some,
the gender of the professional is important (e.g., some women patients have a sense of
satisfaction and safety only when talking with other women). The expectation of comfort
seems mostly related to a communality of life experience.
Some health professionals might be concerned that they or their patient will become
sexually stimulated by a discussion of the topic. Sexual feelings may, in fact, appear,
but when they occur, they are often results of factors that are not necessarily related
to any specific discussion about sexual issues. Whatever the reason for the patient or
professional developing sexual feelings, only infrequently does the other person know,
and less common still is the possibility that either may act on those feelings. “Boundary
violations” that result from sexual feelings, including professional sexual misconduct,
interfere with the entire relationship between health professional and patient. Professional
self-disclosure in relation to sexual issues (other than sexual orientation) may do
the same. At very least, self-disclosure is unconventional, if not unproductive.
In contrast to the gender of the participants in the interview (obvious to all) their
sexual orientation is often hidden. Primary care professionals must have this information
because of its direct relationship to a patient’s health and happiness. Gay men and
lesbians seem particularly vulnerable to some disorders, and importantly the expectation
of a homophobic reception interferes with many undergoing regular screening
procedures.
There are two ways that a health professional discovers the sexual orientation of a
patient:
• The patient spontaneously reveals the information
• Specific questions are asked
Studies show that the former happens in only a minority of situations. An interviewer
might ask about whom the patient lives with and whether the relationship is one that
is also romantic or involves sexual experiences. Somewhat later in the interview, within
a Review of Systems (ROS), the screening outline presented in Chapter 3 suggests a
single straightforward question that asks the patient if their sexual partner is a man or
woman or both. Using the word “partner” and not making assumptions about the gender
of the other person conveys an attitude of acceptance. Questions about birth control
without first clarifying a patient’s sexual orientation risks alienating that person.
Clinicians would also do well to discuss issues related to confidentiality: whether and
how information about sexual orientation should be recorded in the medical record,
and the extent to which a partner is involved in the patient’s medical care.
To better understand their patients, heterosexual health professionals should learn
more about the nature of gay and lesbian relationships, and specifically, about the
sexual practices that their patients experience.
Some of this information is acquired by talk; some is acquired by reading. Patients
should also be encouraged to make use of the self-help literature and information on
the Internet.
1. Johnson AM et al: Sexual attitudes and lifestyles, Oxford, 1994, Blackwell Scientific
Publications.
2. Kinsey AC, Pomeroy WB, Martin CE: Sexual behavior in the human male, Philadelphia and
London, 1949, W.B. Saunders.
3. Masters WH, Johnson VE: Human sexual inadequacy, Boston, 1970, Little, Brown &
Company.
4. LoPiccolo J et al: Effectiveness of single therapists versus cotherapy teams in sex therapy,
J Consult Clin Psychol 53:287-294, 1985.
5. Pope KS, Keith-Speigel P, Tabachnick BG: Sexual attraction to clients: the human
therapist and the (sometimes) inhuman training system, Am Psychol 41:147-158, 1986.
6. Pope KS, Tabachnick BG: Therapists’ anger, hate, fear, and sexual feelings: national
survey of therapist responses, client characteristics, critical events, formal complaints,
and training, Profess Psychol: Res Pract 24:142-152, 1993.
7. Information letter: The Canadian Medical Protective Association 7:2, 1992.
8. Gutheil TG, Gabbard GO: The concept of boundaries in clinical practice: theoretical
and risk-management dimensions, Am J Psychiatry 150:188-196, 1993.
9. Berg-Cross L: Therapist self-disclosure to clients in psychotherapy, Psychother Private Prac
2:57-64, 1984.
10. Hundert EM, Applebaum PS: Boundaries in psychotherapy: model guidelines, Psychiatry:
Interpersonal and Biol Processes 58:345-356, 1995.
11. Lewin RA: The concept of boundaries in clinical practice: theoretical and riskmanagement
dimensions: comment, Am J Psychiatry 151:294, 1994.
12. Isay R: Becoming gay: the journey to self-acceptance, New York, 1996, Pantheon Books.
13. Harrison AE: Primary care of lesbian and gay patients: educating ourselves and our
students, Fam Med 28:10-23, 1996.
14. Marmor J: Epilogue: homosexuality and the issue of mental illness. In Marmor J (editor):
Homosexual behavior: a reappraisal, New York, 1980, Basic Books, Inc.
15. Council on Scientific Affairs, American Medical Association: Health care needs of gay
men and lesbian women in the United States, JAMA 275:1354-1359, 1996.
16. Cramer DW et al. Determinents of ovarian cancer risk. 1. Reproductive experiences and
family history. J Nat Cancer Inst 71:711-716, 1983.
17. Lee NC et al: The reduction in risk of ovarian cancer associated with oral-contraceptive
use, N Eng J Med 316:650-655, 1987.
18. Rankow EJ: Breast and cervical cancer amongst lesbians, Womens Health Issues 5:123-129,
1995.
19. Kournay RFC: Suicide among homosexual adolescents, J Homosexuality 13:111-117, 1987.
20. Remafedi G et al: The relationship between suicide risk and sexual orientation: results of
a population-based study, Am J Public Health 88:57-60, 1998.
21. Carlat et al: Eating disorders in males: a report on 135 patients, Am J Psychiatry
154:1127-1132, 1997.
22. Bradford J, Ryan C, Rothblum ED: National lesbian health care survey: implications for
mental health, J Consult Clin Psychol 62:228-242, 1994.
23. Rosser BRS et al: Sexual difficulties, concerns, and satisfaction in homosexual men: an
empirical study with implications for HIV prevention, J Sex Marital Ther 23:61-73, 1997.
24. Fitzpatrick R et al: Perceptions of general practice among homosexual men, Br J Gen Prac
44:80-82, 1994.
25. Stokes JP, McKirnan DJ, Burzette RG: Sexual behavior, condom use, disclosure of
sexuality, and stability of sexual orientation in bisexual men, J Sex Res 30:202-213, 1993.
26. Smith et al: Health care attitudes and experiences during gynecologic care among
lesbians and bisexuals, Am J Public Health 75:1085-1087, 1985.
27. Dardick L, Grady KE: Openness between gay persons and health professionals, Ann Intern
Med 93:115-119, 1980.
28. O’Hanlan AK: Lesbian health and homophobia: perspectives for the treating
obstetrician/gynecologist, Current Problems in Obstetrics, Gynecology and Fertility 18: 97-133,
1995
29. White J, Levinson W: Primary care of lesbian patients, J Gen Intern Med 8:41-47, 1993.
30. Spira A, Bajos N, and the ACSF group: Sexual behavior and AIDS, Brookfield, 1994, Ashgate
Publishing Company.
31. Mondimore FM: A natural history of homosexuality, Baltimore and London, 1996, The Johns
Hopkins University Press.
32. McIlvenna T (editor): The complete guide to safer sex, Fort Lee, 1992, Barricade Books Inc.
33. Weinrich JD: Strange bedfellows: homosexuality, gay liberation, and the Internet, J Sex
Ed Ther 22:58-66, 1997.