Doctors Don’t Ask, Women Don’t Tell

Despite ample evidence of its benefits, doctors and patients often are failing to discuss crucial information about sex-related behavior and disease prevention during women’s annual gynecological exams.

That’s the message from a national survey on women’s reproductive health conducted by the Henry J. Kaiser Family Foundation and the Los Angeles Times, with Latina and Essence magazines.

Although the survey found that most women receive a physical exam of the breasts, uterus and ovaries, the majority do not discuss sexual practices, birth control or prevention of sexually transmitted diseases with their doctors--even though sexual behavior can greatly affect a woman’s health.

“It is disheartening to know that so many women are not getting the information that they need,” says Jacquelyn Lendsey, vice president for public policy for Planned Parenthood Federation of America.

The Kaiser/Los Angeles Times poll found that most women do not receive all the tests and counseling that various medical organizations say should take place during an annual gynecological exam. The majority of the unaddressed tests and counseling concerns sexual health.

For example, even though 49% of pregnancies in the United States are unintended, two-thirds of the women of reproductive age (18-44) said they didn’t discuss birth control with their doctor during their most recent gynecological exam. Doctors were more likely to advise women of the benefits of taking calcium to prevent osteoporosis than on using birth control to prevent an unwanted pregnancy.

Seven in 10 women did not discuss whether they were monogamous or sexually active or whether they used condoms.

About the same number were not asked about their sexual history, including the number of partners they’ve had.

And seven in 10 did not discuss sexually transmitted diseases, or STDs, or getting a test to detect such diseases. A similar number said they did not discuss HIV risk or testing with their doctors.

Despite a national campaign to promote the use of emergency contraceptives--a combination of pills that can be taken to prevent pregnancy within 72 hours after unprotected sex--only 8% of the women of reproductive age discussed the method with their doctors.

Women and their doctors must share the blame for allowing so much to go unsaid, according to experts who analyzed the data for The Times.

“We don’t consume health services like we consume other services,” says Alina Salganicoff, director of women’s health policy for the Kaiser Family Foundation. “We are taught to be good patients. A good patient is a compliant patient. And people are taught that the doctor knows the right thing to do.”

Patients often don’t ask which tests are being performed. About four in 10 women who said they were tested for STDs also said they assumed such tests were routine--and that they were never actually told a test was done, the survey found.

And although only 17% reported getting an HIV test at the last routine exam, more than one-third of those women may not have been tested because they did not recall being told HIV tests were being done.

Doctors are not required to get the patient’s permission to run a test for STDs, with one exception: Consent is required for an HIV test. Thus, the only way a woman can know for sure if she has been tested for STDs is to ask.

“I believe patients think, ‘If no one asks me . . . I don’t have to be forthcoming about it,’ ” Salganicoff says.

Doctors, meanwhile, are selective about which patients to counsel on sexual matters. The Kaiser survey found that African American and Latina women were almost twice as likely to receive HIV and STD counseling and testing than were white women. Only 5% of white women discussed emergency contraceptives with their providers, contrasted with 27% of black women and 18% of Latinas.

The Latina and African American women surveyed were somewhat more likely than whites to go to community clinics for their gynecological care; such clinics typically provide extensive STD-related and contraceptives services. Nevertheless, the U.S. Centers for Disease Control advises STD counseling for all women of reproductive age because such infections can have serious consequences, including infertility and ectopic pregnancy. While blacks tend to have higher rates of some STDs, viruses such as herpes and chlamydia are widespread throughout the population, the CDC reports.

The brevity of many women’s visits with their doctors limits discussion of complex or difficult subjects, such as contraception, says Julia Scott, president of the National Black Women’s Health Project. The majority of women said they spent 15 minutes or less with their doctors, according to the survey.

“It’s complicated to find a good marriage between a woman’s life and the type of [contraceptive] method she should be using,” Scott says. “And then to broaden that discussion to include the prevention of disease, that [alone] in and of itself could take up to 45 minutes.”