Why do you want the blue pill?

"Imagine two people having sex," said our doctoring instructor last week during a lecture about taking sexual histories.

When most people envision two individuals making love, they tend to think of young, attractive, beautiful people, she said. She made a valid point; it is unlikely that you think about disabled or obese individuals or older people having sex because we are conditioned by society to think about sex with a limited perspective. Such a perspective has to be challenged when taking a sexual history since your are working with diverse patients of all ages, sizes and walks of life.

In order to take an adequate sexual history, you have to be non-judgemental and avoid making any assumptions. From a medical standpoint, we have to rely on our patients to divulge all the pertinent details about their sexual lives (and without asking, it will be difficult to elicit information about sexual behavior). It is just one of those topics you do not talk about, unless you are Carrie Bradshaw and a columnist for Sex and City.

The line of questioning is unique and intended to cover a wide-range of topics pertaining to sexual health, including sexual function, sexually transmitted infections, barrier and contraception use, frequency, desire, behaviors, positions, partner interactions and relations, patient concerns, etc. The list goes on (as directed by the patient and the interview flow) and there is no way to contain the scope of the questions that go into a sexual history within a list.

Outside of a clinical environment, it gets a bit awkward to discuss such topics (or ask such questions) without getting others to raise their eye brows at you. Despite being in a clinical role, it still difficult to ask such questions for the first time.

Today, I had an opportunity to complete my first full sexual history during our Foundations of Patient Care session. My patient was James (he was a standardized patient, an actor who plays out a patient's role). Going into this interview, I was anxious, nervous, and uncertain about what to expect. I wondered if I could ask questions like "can you maintain an erection?" or "how often do you masturbate?" or "do you get an erection in the morning?" And when I met James, I knew it was going to be a challenge.

In an non-medical setting, asking such questions would be awkward and bizarre. But for the purposes of a medical interview, these questions can be essential when assessing a differential diagnosis that pins erectile dysfunction on the top of the list.

I opened my interview with open-ended question.

"James, what brings you into our clinic today," I said. The moment he responded, I knew this interview was going to get interesting; he had come in to get Viagra at the recommendation of his girlfriend due to difficulty during "love making."

So, then began the barrage of questions designed to understand why James would want the blue pill. I had lots of questions swimming in my mind- I wanted to ask how many partners he had, how frequent he had sex, if he used protection, if he had sex with men, women (or both)...but the first question that came out of my mouth was "What do you know about Viagra?"

It is interesting, the moment the words came out- I knew there was no turning back. We were about to begin a discussion of erections, sexual behaviors, and everything in between. For a moment, I wondered- am I prepared to be the recipient of all this information? And as we talked, I realized it's just another interview and there was no need to hesitate when asking the questions and processing the information.

In all seriousness, a sexual history is nothing more than asking different questions with the same goal- collecting data to help understand the patient's chief complaint.

James, a fifty year-old man, nervously responded to each of my questions, giving me specific details about how he can achieve an erection but struggles to maintain an erection during intercourse. Along with the sexual history, we were able to get a comprehensive medical history, information that is extremely valuable that helps us understand where James is coming from medically-speaking, including his past medical history (PMH) and history of present illness (HPI).

Balancing the patient history (and all its components) with the full sexual history can be challenging. There are so many questions to ask, and it's easy to get side-tracked and lose focus of the patients chief complaint. But as long as you can come full circle, you can effectively elicit both histories to help see the intersections.

At the end of the interview, James was able to step out of his patient role and give me feedback. He felt comfortable during the interview and was impressed with how I handled the interview (wow, really? I guess I hide my nerves really well).

I'd like to say the interview went smoothly (better than I thought it would go). There are definitely areas of improvement that will require practice and more interviewing. At least now, I know I can complete a sexual history and ask all those questions I never thought I would ever ask for someone seeking that small blue pill.