All reproductive care begins with a sexual history. Traditionally, medical care
practitioners 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 medical care practitioner’s
assumptions about their sexual behavior. Sexually active females were not
provided information because it was assumed they knew everything; those
who were not obviously sexually active were assumed not to need the
information. Patients were sometimes injured by medical care practitioners
who missed diagnosing sexually transmitted diseases because they assumed
the patient was not sexually active.
Medical care practitioners 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. [ACOG
Technical Bulletin 169. Human Immune Deficiency Virus Infections. June
1992.]
This sexual history must be documented as carefully as any other part of the
medical history. The medical care practitioner 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 medical care practitioner’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 medical
care practitioner should treat this information like any other patient- reported
information. As with other changeable behavior, however, the medical care
practitioner has a duty to re-explore the area on future visits. Given the general
unreliability of self-reported information about behavior that the patient may
wish to conceal, the medical care practitioner should continue to consider
pregnancy and venereal diseases when indicated by the patient’s objective
medical condition. This is especially important if the medical care practitioner
is considering prescribing a drug that is a known teratogen.
