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All reproductive care begins with a sexual history. Traditionally physicians avoided discussing sexual practices with their patients, due partly to mutual embarrassment and, more recently, a fear of seeming judgmental. This reticence has contributed to the epidemic spread of sexually transmitted diseases, including HIV. It has also encouraged the perpetuation of the stereotyping of patients, especially women, by the physician's assumptions about their sexual behavior. Sexually active females were denied information because it was assumed they knew everything; those who were not were assumed not to need the information. Patients were sometimes injured by physicians who missed diagnosing sexually transmitted diseases because they assumed the patient was not sexually active.

Physicians can ignore patient sexuality no longer. They must ask patients about high-risk behavior and counsel them in the risks of such behavior:

Counseling and testing are recommended in any medical setting in which women at risk are encountered, including private practices and clinics offering services for gynecologic and prenatal care, family planning, and diagnosis and treatment of sexually transmitted diseases. Voluntary and confidential HIV antibody testing, with appropriate counseling and consent, should be offered to all women and encouraged for those who are at risk for acquiring the disease.

The risk factors for acquiring HIV infection apply to a woman or to her sexual partner and include the following:

Illicit drug abuse (especially intravenous drug use)

Current or previous multiple sexual partners or prostitution

Transfusion of blood or blood products before adequate screening began in the United States (between 1978-1985)

Bisexual activity

Origin in countries where the incidence of HIV is high

Symptoms of HIV-related illnesses

History of or current sexually transmitted diseases

In addition, testing is recommended in the presence of tuberculosis or any illness for which a positive test result might affect the recommended diagnostic evaluation, treatment, or follow up.[165]

This sexual history must be documented as carefully as any other part of the medical history. The physician should ask every patient the same basic questions. Even if a woman is self-identified as homosexual, she should be counseled to ensure that she understands the options for contraception and reproductive health. These matters may not be of immediate concern to her, yet many male and female homosexuals do enter into heterosexual relationships to conceive children or as a variant on their usual sexual activity. It is also important to ask self-identifed heterosexuals about homosexual activity. This is especially important for prisoners who may engage in homosexual activities in prison but self-identify as heterosexuals and have only heterosexual relationships outside prison.

The physician's duty to ask about a patient's sexual activity must be balanced against the patient's right of privacy. If a patient denies sexual activity and there is no objective evidence to the contrary, the physician should treat this information like any other patient-reported information. As with other changeable behavior, however, the physician has a duty to reexplore the area on future visits. Given the general unreliability of self-reported information about behavior that the patient may wish to conceal, the physician should continue to consider pregnancy and venereal diseases when indicated by the patient's objective medical condition. This is especially important if the physician is considering prescribing a drug that is a known teratogen.

[165]ACOG: Technical Bulletin 169, Human Immune Deficiency Virus Infections. (June 1992).

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