History Taking Question
May 24, 2004
I'm a somewhat regular reader of your forum and think that you do an excellent job. A few years ago I was a worried well and this forum really helped me keep things in perspective. I'm currently a first year medical student and today we were discussing how to assess a patient's risk for HIV infection. The doctor speaking to us talked about IV drug use, sexual preference, and sex with prostitutes. I was surprised that they didn't even mention asking about condom usage. So I asked if we should ask about condom usage and they implied that candom usage is irrelevant to risk. I'm not sure if the people who spoke to us today are aware of the anxiety an HIV test can cause. I feel that health care providers should only encourage people to take the test if they have put themselves at risk by having unprotected sex. If they have protected sex it really doesn't matter who they are having sex with. Am I correct to think this?? I know this probably isn't a question that you can answer in the forum, but I was wondering how you would suggest to take a history in order to give advice on whether or not a patient should take an HIV test. Thanks again for the wonderful service that you provide. Like I said 3 years ago I was sure that I had been infected because I had the flu about 4 weeks after I had sex with someone that I didn't know.
Response from Dr. Frascino
Hello First-Year Med.-Stud.,
Congratulations on beginning your medical school education! I'm glad your medical school is addressing HIV disease. Unfortunately, they seem to have a highly incompetent physician doling out some of the information! You are absolutely correct that risk of HIV transmission is linked to unsafe sexual practice. The most effective methods for preventing HIV are those that protect against exposure to HIV. Preventive behaviors must include consistent and correct condom use. I wonder about a physician even using the term sexual "preference." People don't choose to be heterosexual or homosexual. Sexual "orientation" is the more accurate terminology. Next, for a physician to "imply condom use is irrelevant to risk" is shocking. You might want to send a copy of your question and my response to the head of your medical school. The physician spreading such misinformation is in drastic need of a remedial course in HIV/AIDS basics and common sense.
You then ask how to take a medical history in order to give specific advice. The key rule here is to ask questions in a way that is non-judgmental. I'll give you a few examples of mistakes I've seen medical students make recently when taking a sexual medical history. I witnessed a macho medical student ask a well-dressed older single gentleman, "You're not gay, are you?!?" Needless to say, the patient could not answer honestly until I had the medical student leave the room.
Next, at an STD clinic, a patient was being seen for treatment of rectal gonorrhea, penile syphilis, and genital warts. The medical student, following very closely what she was just taught in her medical history-taking class, asks, "Do you practice safe sex?" I had to pull her aside and tell her that was a rather inappropriate question in that particular setting. The guy's here for treatment of anal gonorrhea, penile syphilis, and genital warts. Of course he doesn't "practice safe sex!" It's quite obvious that not only does he "practice" unsafe sex, but in fact he's probably very good at it!
So, what would be the more appropriate thing to say? Well, when asking about sexual orientation, I suggest you merely ask, "Do you have sex with men, women, or both?" -- and then sit back and don't look shocked when they tell you the truth! Oh, and if you are asking the question to a rightwing religious zealot conservative, I've found it helpful to add, "Do you have sex with men, women, farm animals, or all three?"
Regarding the guy with multiple STDs, since unsafe sexual practices are a given, you could say, "Let's talk about some ways to prevent getting conditions like this in the future". You can then discuss safer sexual practices and HIV disease and prevention in a non-judgmental way.
Hope that helps. Stay well.
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