Let’s talk about sex(ual) history

Looking back in disbelief at my early years as a GP, I wonder how it was ever possible to have a 10-minute consultation for a first contraceptive pill prescription.  Yet in the UK GP consultations were booked at 10 minutes intervals.

Perhaps my speed reflected my own experience of being prescribed the pill in the 1970s.  I was a naïve pre-clinical medical student bursting with medical facts but no patient contacts, who had rarely consulted with any doctor.  I booked into the university health centre and turned up on the day, anxious and somewhat embarrassed. ‘I want to go on the pill’ I answered to the doctor’s opening question.  He said they only did contraception at one time in the week, and I would have to make another appointment.  At that appointment I was even more anxious, but I remember it was quick and medical.   Short history, blood pressure, weight, last period – not pregnant, prescription, some instructions, come back in 6 months.  

In some ways that consultation was ok for me (except for being weighed – but that’s another story).  I didn’t want to talk about sex but only to make sure I wouldn’t get pregnant.  I didn’t feel judged – just one in a line of other students being processed. 

I was brought up as a Catholic by a staunchly religious mother, who still believed that the story of Adam and Eve, and original sin, was literally true.    And, of course, marriage was instituted for the purpose of having children, therefore between a man and a woman, and pre-marital sex was a sin.   

I became a teenager in 1970 during ‘the permissive society’ though I knew little about this at the time.  Supposedly there was greater tolerance of behaviours by a younger generation that had been frowned upon before the swinging 60s.  These included sex, sexuality and drug use, as well as more widely available contraception and abortion in the UK.  The ramifications meant that all schools were supposed to provide some form of sex education though parents could choose for their children not to attend.  At my Catholic primary school, we had a series of biology lessons in the final year, when I was 10.  The last of these, from which several classmates opted out, focussed on human reproduction including menstruation and sexual intercourse.  Sex was for conceiving babies within a marriage.  We heard nothing about sexual pleasure, or sexual diseases.   We were told that it was sinful to artificially avoid pregnancy but having intercourse at a safe time in the ovulation cycle was allowed.  What wasn’t clear to me was why a couple would want to have sex.  The lesson was very matter of fact, but something seemed to be missing for it all to make sense.  I remember asking my mum why a man want to take off his pyjamas to have sex if there was no plan to have a baby.  She was vague in her answer – along the lines of it was a nice thing to do.  Very mysterious.  

It is difficult now to remember how naïve I was.  I assumed that my all-female secondary school classmates were also similarly callow, but we did not talk about sex only about the possibility of boyfriends.  But I was one of those girls that did keep a diary and I still have them.  Up until 1971 they are mostly about school, food, my weight, and sport.  I recorded my first kiss while on a holiday in a caravan park. A ‘boy asked me out’. His name was Pete and I suppose he was about the same age (14).  We went into the local town together (obviously my parents had no worries about my virtue or being out and about with an unknown boy in an unfamiliar place).  We spent the evening at the fairground. He kissed me and I wrote ‘embarrassed’.  I had no idea what to do as I was taken by surprise.  The next day ‘most miserable – didn’t meet Pete again – crying – want to kiss him again’.  

As teenagers we had to navigate this world of hormones and boys without much help.  Except, one of the nuns advised us at some point that if we ever were on a boy’s lap, we should make sure there was a telephone directory to sit on, and if we were ever concerned about a boy’s intentions we should jump and down shouting ‘I am a Catholic’.  Wearing shiny patent leather shoes was also to be avoided as boys might be able to see our knickers reflected in their surface.  The message was that physical contact with boys was bad, sinful even and that we were all at risk.  But while I understood that girls could be forced to have sex, that wouldn’t be by the sorts of boys I was likely to meet at the church disco. 

In 1972 David Bowie appeared on the BBC (https://www.youtube.com/watch?v=oOKWF3IHu0I) singing Starman.  The rumour was he was bisexual.  I had no idea what this meant. Of all the knowledge I gained at grammar school, I wasn’t prepared for living in the real world. Rather than be frightened of unwanted sexual advances, the real concern was getting pregnant.  At school we learned nothing about contraception – we knew of it from books as we also knew of the shame of an unplanned pregnancy. 

So, I should have had some empathy for those teenagers who came to see me to ask for the pill.  But medical school was not a great foundation for learning how to explore psychosocial and sexual concerns sensitively. When we finally began to talk to patients, I was 21 on the pill but with little life experience.  As part of the detailed medical history we had ‘to take’ with each patient, I was expected to ask a much older woman about her gynaecological history (periods, pregnancies, abortions) which may seem to her (and me) to have very little relevance to, for example, her discharging left ear.  But even worse were questions about sex and sexual dysfunction especially if the patient was a mature man.  I pretty much ignored all those. 

Years later, when discussing communication skills with medical students, male students admitted they usually skipped the period questions – ‘it would be like asking my mum’ – and the sex ones unless the presenting complaint was potentially directed related to obstetrics, gynaecology or urology.  And yet, many medical students of any gender would have been sexually active.  These young people were astonished that the prevalence of sexually transmitted infections (STIs) was increasing in the over 50 age group. Working with simulated patients helped them to frame questions but it was still challenging with real patients.

The problem is that many health professions learn to medicalise human behaviour.  We frequently look for ill-health rather than good health.  Moreover, students have diverse perspectives on sex because of their education, culture, religion and life experience.  As educators we expect them to ask the most intimate questions of patients they have never met before, which can be traumatic for the patient and the learner. 

My contraceptive consultations got longer over time, first with that emphasis on ill-health (questions about abnormal periods, sexually transmitted infections, pain…) and then thinking more about the sexual health perspective, including making no assumptions about gender, sexuality or behaviour without asking in a non-judgemental manner.  

There is much more information about sex available these days.  But there is frequent misinformation.  There is easy access to pornography, yet there is still ignorance about the types of contraception available, safe sex practices, and the female orgasm.  

How many people are put off interacting with a health professional because of the way that first consultation about contraception and sexual health is conducted?  Such consultations are an opportunity for discussion on many facets of sexual health – if the health professional has time and the skills to do this. 

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