Written by David Gold, Go Global participant (August 2015). David is volunteering with THUHDEG and The Shakeenah Clinic.
In my opinion, one of the most difficult things for a doctor to do is to take a sexual history. This involves asking very personal questions about a patient’s sex life – something that not many people feel comfortable talking about; especially with a stranger that they have only just met!
Whilst working at the clinic, a 40 year old, married, man walked in complaining of chest pain. After a rather long chat using a translator we manage to find out that about a year ago he had a very bad cough and was coughing up blood. He went to the doctor and was prescribed some tablets,the cough went away, however the chest pain persisted. The provisional diagnosis we were thinking was tuberculosis; we were going to refer him to the chest clinic for some tests and a consultation. We find out that 2 weeks ago he had a chest x-ray but he had lost the report, he also had an ultrasound of his liver which found liver nodules.
So to recap we have…
– A 40 year old man
– Bad cough including blood
– Chest pain
– Chest X-ray – nothing to be reviewed
– Liver nodules
So what is this likely to be? Yeh well, whatever you think is the next thing to do, forget it because….
Just as he was getting up to leave he decides to show us his penis – with a hard ulcer on the end of it. As soon as we saw it we knew it could only be one thing; syphilis. Syphilis is a sexually transmitted infection which is easily treated with a single injection of penicillin. But, as soon as we saw it we needed to ask him about his sexual partners. This was going to get interesting…
Using a female translator we carefully asked about his sexual partners. The gist of it is:
– one wife
– one baby (6 weeks old)
– not had sex since the baby was born
All sounding OK, right? Except… syphilis is symptomatic after 4 weeks of infection. So, is our diagnosis incorrect or is the patient lying?
Having the conversation about sex is difficult enough when both of you speak the same language, it’s more difficult when using a translator, and even more so if its a translator is of the opposite sex. So, we decided to ask for a male translator to see if the patient felt more comfortable. Again, the patient said that he has only ever had sex with his wife and they haven’t been intimate since the birth of their baby.
Its important to note, the vast majority of patients with syphilis contract it by having sex with other men. In addition, having both syphilis and TB at the same time is very rare unless you have HIV. Trying to talk about this with a married man without accusing him of being homosexual, in a country where homosexuality is illegal, and where we don’t speak the same language is, for lack of a better word, difficult!
We know that in order to have contracted syphilis he would have needed to have had sex in the last month, we also know that neither his wife nor newborn baby are showing any symptoms. We therefore know that the patient is lying; his story simply doesn’t add up. What do we do?
Rather than accuse him we decide to firstly treat him for the syphilis before he leaves (so he doesn’t spread it) and test him for TB, HIV and hepatitis. We also asks that he brings his wife and newborn in to be examined and tested. There’s not much more to do than that, except to … talk about sex (baby), all the good things and the bad things that may be. Nobody likes giving or taking a sexual history but I will forever grateful in the UK, that I speak the language and attitudes to homosexuality and lifestyles choices are much more legal and accepting.