Bet You and Your Doctor Don't Talk About Sex: A Conversation Starter for HIV-Positive Men and Women

Are we right? We thought so. Even though sex is an integral part of life, communication about the details with your doctor can be very difficult -- for both you and your doctor. In fact, studies show that a lot of doctors are embarrassed to talk about sex or may avoid the topic out of concern about offending you, their patient. Following are some tips and advice to help change this. You can be part of the plan to make good communication about sex between patients and doctors the norm rather than a rarity.

The Importance of Having "The Talk"

It's not a secret that unprotected sex can harm people's health. But until now, the emphasis has been on partners of people who are HIV+, not HIV+ people themselves. We believe the focus should be on you as well as on your sex partners. There have been alarming headlines recently (February 2005) about a new strain of HIV that resists almost all anti-HIV drugs and quickly progresses to AIDS. We do not know the full implications of this case report, yet the announcement may serve as an impetus for you or your doctor to bring up the subject of risky sexual practices in order to help protect your health and well-being.

Yes, unprotected sexual intercourse can increase the risk of you spreading HIV to your partners, but these risky behaviors can also put you at risk for acquiring and/or passing on resistant HIV strains. Unprotected sex also increases the risk of getting a sexually transmitted disease (STD). STDs are very common among sexually active adults. An STD can seriously harm the immune system of a person living with HIV. And, they can cause bothersome, often painful symptoms. They can also disrupt relationships by forcing people to temporarily give up sex during the treatment period.

Safer sex practices, such as using a condom for every act of intercourse and abstaining from semen-exchanging activities, remain the best way of preventing HIV from passing to your partners, reducing STD infections, and avoiding resistant HIV strains. Of course, the decision for safer sex is yours, but we encourage you to explore options with your doctor to protect your health and that of your sex partners.

Getting Past the Barriers

Regardless of how competent and helpful your doctor may be, talking about sex, especially specific risky sexual behaviors, can be difficult. Your doctor may resist talking about the topic because he may worry about ruining the mutual trust the two of you have built. Your doctor may also worry about adding to the stigma that HIV-positive patients sometimes feel. If your doctor is of different sexual orientation than you, he may worry about not understanding your sexual life. Plus, there are many other priorities to be completed during your medical appointment. Reviewing your lab results and discussing your treatment options may leave little time for an adequate and helpful discussion about your sex life. As the HIV epidemic and treatments have evolved, doctors still struggle to make medical visits as productive and helpful as possible for their patients without leaving anything out. Give him the benefit of the doubt and start the conversation yourself.

Tips to Get the Conversation Going

As a patient, you can take a personal and active role in solving your health problems. Since doctors can be one of the best sources of support and information, we offer some strategies to support you in this process.

• Before going to your doctor's appointment, take some time to think about health issues that you want to discuss with your doctor. Having a clear agenda will help you and your doctor make the most of your visit. This can include questions about your sexual practices.
• Write down your questions before you actually meet with your doctor. This will help you to remember issues that concern you. Sometimes at the doctor's office, a lot of things are going on at the same time that may make you feel anxious or nervous, and you might forget your questions. Having them in writing can help you to stay on top of your health care.
• Before your doctor breaks into his routine, help set the agenda for your appointment. You might start the conversation by saying, "I have some concerns about my sex life. Could we take some time today to discuss them?" Your initiative can guide your doctor to prioritize your sexual concerns.
• If your doctor dances around the topic of sex, you can reframe the discussion and steer the conversation to one that meets your needs. You can say, "How can I stay healthy and have sex?" You can ask for suggestions on how to disclose your HIV status to partners and/or ways to negotiate safer sex with your partner(s).
• Let your doctor know that you also do not want to pass HIV on to others or risk getting re-infected yourself. Let him know you understand that new drug-resistant HIV strains can greatly harm you and others.
• Remember to encourage your doctor in talking about sex. You might say, "I am glad we are talking about sex. I appreciate your suggestions."
• Share your life's realities with your doctor. This may mean opening up to him about the behavior and attitudes of people around you that make it tough to stay safe. Naming your obstacles will help your doctor better support you in staying healthy.
• Your doctor may overlook your successes. If you've cut back on your drinking, drug use, or the number of sexual partners, share that information with your doctor. Knowing how you are making a change will help your doctor think of ways to support you further.
• If you hear your doctor repeat the same advice time after time, consider it proof of his caring about you. Such words of concern can make a big difference.
• We encourage you to do your own research online or in the library to learn more about what sexual practices are considered safe and unsafe, and what you can do to protect yourself and others. After the research, you may have further questions to discuss with your doctor. Taking charge of information and news sources can ensure that you obtain the best care possible.
• Keep the door open for further discussions. Ask your doctor if he would be willing to take more time to discuss safer sex with you at your next appointment or whether he could refer you to another member of the health care team who can help you develop a safer sex plan.

For Further Information

We also wish to offer worksheets that could help you to make the most of your doctor's appointment. These worksheets are tailored to your readiness for change. If you are ready to start practicing safer sex with your current and/or new partners, you can download the Worksheet for Practicing Safer Sex. If you are considering practicing safer sex but need more information, you can download the Worksheet for Thinking About Safer Sex.

A good relationship relies on good communication. In the past, it has been the responsibility of doctors to educate their patients. We think that these days, your doctor can learn a thing or two from you. Good luck!

Barbara Gerbert, Ph.D., Dale Danley, M.P.H., Dung Huynh, B.A., Daniel Ciccarone, M.D., M.P.H., Paul Gilbert, M.S.P.H. and David Bangsberg, M.D. are with the University of California San Francisco. Kathleen Clanon, M.D. is with the Alameda County Medical Center. Anas Hana, M.D. and Michael Allerton, M.S. are with The Permanente Medical Group, Kaiser Permanente.

Funding support from the National Institute on Drug Abuse (R01 DA 15016).