If you’re going to take proper care of patients, you need to get comfortable with asking them personal questions.
As uncomfortable as it may be, knowing the factors that may be putting people at risk of injury or illness is part of the job of being a medical provider. Are they drinking too much? Do they smoke? Do depressed patients have access to guns? Are they paying attention to diet or getting any exercise? Learning how to ask in a clear, unembarrassed, and non-judgmental way is a necessary skill to giving patients the best care possible.
Perhaps the most personal thing a doctor might ask a patient about is his or her sex life. Those details are among the most intimate of anyone’s life, and it’s tempting to hopscotch over them to avoid seeming crass or nosy. But given that a person’s sex life can have a huge impact on their risk of disease or unintended pregnancy, it does nobody any favors to elide the conversation.
Unfortunately, for far too many gay men, that’s exactly what is happening.
According to the results of a new survey released by the Kaiser Family Foundation, nearly half of gay men report never having discussed their sexual orientation with a medical provider. Conducted this summer, the survey asked 431 gay or bisexual men about HIV, their perception of their own risk for the disease, and how it affected their lives and relationships. The results were illuminating.
Only a third of gay men know that the rate of new HIV diagnoses is rising among men who have sex with men. In fact, as the survey points out, within the past several years gay men are the only demographic within the United States where there has been an increased rate. Despite this, 56 percent of respondents expressed no personal concern about getting infected, which is hard to square with the fact large numbers reported rarely discussing HIV with sexual partners, either casual (50 percent) or long-term (60 percent). There appears to be a disconnect there.
But the number that jumped out at me as a physician was the 47 percent who said that their sexual orientation had never been discussed with a doctor. Unfortunately, I can understand all too easily how that could be.
You’d think that asking a young man if he is gay or straight would be easy for me. After all, I’m an openly gay man myself. In fact, with my most recent birthday, I passed the milestone of having come out of the closet over half my lifetime ago. Often enough, when talking to my patients’ parents about their experience of childrearing, I’ll make reference to my own family and kids and how I’ve coped with the challenges and frustrations of trying to raise children while preserving some small portion of my sanity. During these conversations I will matter-of-factly mention my husband, because it feels nothing but natural for me to do so.
However, when I’m having those one-on-one conversations with my adolescent and young adult patients, wherein I assure them of confidentiality before asking them about things they might be reluctant to disclose, my being gay isn’t really something that comes up. In most cases it’s irrelevant, but for some young gay or bisexual males, it might help put them at ease to know that I’ve felt the same unease talking about it that they might be feeling. Since announcing “Just in case you might be gay and it would help you admit it to me, you should know that I’m gay, too” seems somewhere between stilted and frankly bizarre, it goes unspoken.
Avoiding interactions that will make my patients feel stigmatized is of paramount importance to me. (It’s for related reasons that talking with overweight patients about it can be so difficult.) Numerous survey respondents reported experiencing some kind of stigma, including rejection by a loved one (32 percent), being physically threatened or attacked (26 percent), and being treated unfairly by an employer (15 percent), among other answers. It’s all very well for me, living and working in an area of the country where marriage equality is the law throughout the region, to delude myself that this stigma no longer weighs on my patients. But when one of the suspects charged with the beating of a gay couple in Philadelphia is the daughter of an area police chief, it serves as a reminder to shake off the complacency.
That there is still so much stigma attached to being gay or bisexual is a reality, and no doubt fear of it informs why some patients may be reluctant or unready to disclose it. Fifteen percent of the survey’s respondents reported being treated poorly by a medical provider, so it would be naive of me to assume that mitigating this fear is a priority for every member of my profession. For many patients, if they’re not asked outright, and in an open and respectful way, they’re not going to bring it up themselves.
Given the alarmingly high number of gay and bisexual men who have never discussed their sexuality with their medical providers, it comes as no shock that only 26 percent know about PrEP, a medication that can substantially reduce the risk of infection with HIV. Who has more of a responsibility to discuss this with people than their doctors? Though I had some initial reluctance, I am resolved to offer it to patients who might benefit from it. But that conversation won’t happen if we don’t talk about the sex lives of those patients in the first place.
The only way to get better at asking about sexual orientation is to make a point of doing so. I’ve been happily and openly gay for over half my life and specialize in the treatment of adolescents, effective care of whom admits no squeamishness. If it’s awkward for me to tackle the question head-on, I understand how it could be even more so for others. But by treating questions about being gay or bisexual as too embarrassing to ask, we merely reinforce the idea that they are shameful and allow the stigma to remain.
If you’re going to ask your sexually mature patients if they’re sexually active (and you most certainly should), then the next question should be if they are attracted to members of the opposite sex, same sex, or both. It should be treated as matter-of- factly as any other inquiry, without implying that there’s anything to be ashamed of with any answer. Because there isn’t.