Talking About Sexual Issues:
Gender And Sexual Orientation

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


Gender: Issues And Questions

When Talking About Sexual Issues, do Health Professional and Patient Genders Matter?

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



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



Ultimately, patients want help with problems,

and, as important as gender might

be to some, competence is the crucial


Two considerations balance the logic and sensitivity of the dual-sex therapy team


1. The issue of competence is ignored when one thinks only about the primacy of


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?”


Does Talking About Sexual Issues Evoke Sexual Feelings in the Patient Toward
the Health Professional, and is There a Connection Between Talk, Feelings, and
Professional Sexual Misconduct?

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


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


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.


Does Disclosure of the Health Professional’s Sexual Experiences Help the Patient?

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.”


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.”


Sexual Orientation: Issues And Questions

“. . . 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


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).


Why is it Necessary for a Health Care Professional to Know the Sexual Orientation of a Patient?

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


• 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).


What is the Relevance of Past Homosexual Behavior to a Current Sexual Dysfunction?

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)?”


Disclosure of Sexual Orientation to Health Professionals

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


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


• The health professional asks specific


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


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


What Questions Does One Ask?

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


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


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



What Does the Heterosexual Health Professional Know About Homosexuality and the Sexual Practices of Gay Men and Lesbians?

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


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).


What Information Can a Health Professional Provide to Patients about Sexual Orientation and Sex-related Issues?

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


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


There are two ways that a health professional discovers the sexual orientation of a


• 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.



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