Let’s talk about sex — with our patients

I recently read a book by Dr. Barbara Natterson-Horowitz a UCLA cardiologist who also happens to be a consultant for the Los Angeles Zoo. In her book Zoobiquity, Dr. Natterson-Horowitz demystified the story of HIV (Human Immunodeficiency Virus) transmission from monkeys in West and Central Africa to humans. Most physicians today, including me, have a limited knowledge of zoonosis (the science surrounding bugs that can be from animals to humans) and can be totally unaware of the extent to which we share pathogens with our animal neighbors.

After reading about rabbit syphilis, Chlamydia in koalas in Australia which almost threatened to totally wipe out these small cuddly marsupials and trichomoniasis in T. rex, I could say nothing but agree that SIV (Simian Immunodeficiency Virus) from the chimpanzees to humans was not that fantastic a tale after all. If trichomonas has moved through the different species from as far back as the time of the dinosaurs to now infect both pigs and cats, what stops SIV from expanding its real estate empire to include humans? We, after all, are the most dominant species on earth. As such, we are a very attractive real estate acquisition for any bug.

Today, HIV is a worldwide pandemic affecting almost every community in the world. But it is believed that prior to its journey to the western world, the virus had affected various communities in West and Central Africa for several decades. HIV-1 the commonest HIV subtype in the western world is believed to have entered the United States by way of Haiti. This is based on molecular genetics which shows close to 99 percent similarities between the gene sequences of viruses from Haitian patients compared to U.S. patients. In the early days of the epidemic, HIV was associated with the four H’s: homosexuals, hemophiliacs, heroin addicts and Haitians. Unfortunately, on account of the stigma associated with HIV, my Haitian colleagues did not look too pleased when I mentioned this on a recent visit to Haiti as a visiting faculty.

More than 30 years after I read the Newsweek headline on AIDS in 1986 which featured Rock Hudson’s declaration that he was gay and had AIDS, the stigma persists. In this era of good, life-sustaining treatment, though, the terror and fear that made most people treat individuals known to be HIV positive like lepers has abated. The stigma still continues and in many cases makes efforts at prevention very difficult. This is a stigma that I can understand based on how society addresses sexuality.

Sexuality is humanity’s biggest double standard; while most of us are sexually active, getting a sexually transmitted disease is considered a social taboo. Somewhere between our birth and early adulthood we somehow conveniently forgot that if sex really was so nasty, we would be extinct as a race.

To adequately address this issue, all providers — especially those involved in primary care — must make it their business to know about the sex lives of their patients. From my experience, most patients do not mind talking about sex with their doctors and appreciate when providers bring this up. Such conversations, if done well, will open doors to preventing STDs (Sexually Transmitted Diseases) and HIV by ensuring we screen our patients appropriately for STDs. One has no way of knowing to take a GC/Chlamydia swab from the throat or the rectum if one does not know the sexual practices of our patients. We just take the easy route of just getting a urine test when young John does not even remember the last time he used his penis for sex.

This brings to mind the issue of HIV prevention with Truvada — PrEP (pre-exposure prophylaxis) — that can reduce HIV transmission by close to 90% with appropriate, most primary care doctors fail to use it in appropriate patients. One important reason for this low utilization is because the sex conversation rarely ever happens to any meaningful extent. We cannot allow stigma and societal taboos around sexuality to get in the way of our patients’ health. If we think that HIV and other sexually transmitted diseases are dirty diseases then we are all dirty anyway. So let us get out there and serve our patients well to ensure they at least have the chance of good, healthy sex lives.

Leonard A. Sowah is an internal medicine physician.

Image credit: Shutterstock.com

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