By Cheong Pak Yean & T Thirumoorthy
Human sexuality is a taboo topic across almost all societies and cultures. Sexually transmitted infections, or STIs, are stigmatizing. The patient is unable to discuss his condition socially, in the way a patient with a heart condition can. STIs carry the stench of a socially unacceptable condition that represents a punishment for forbidden sexual adventures.
Fear of discovery is compounded by guilt over the possibility of spreading to others. This is a common, hidden anxiety that patients bring to STI clinics. Patients are known to over-examine their physical body, looking for signs and relating their physical symptoms to a lurking STI.
Haunted by the Past
A young woman was about to marry soon. She consulted the doctor because she had detected small lumps around her introitus, which persisted even though she had vigorously scrubbed the area with Dettol.
She believed these were viral warts transmitted through sexual intercourse with different partners over the years. Hence she feared her future husband may see these lumps, and worse, get infected through her. Examination revealed that the papules she pointed to were discrete keratin papules accentuated by friction and dryness.
Despite reassurance that these were normal skin blemishes and that creams would ameliorate them, she insisted on ablative cautery. In her mind, these were concrete reminders of her past sexual encounters, and she sought medical treatment to expurgate them from her body and her mind.
—-A/Prof Cheong Pak Yean
Discovered
Getting an accurate history is primary. In the drawing, there are three pairs of feet, captioned mènage a trois, which is French for a sexual threesome. The man has painful micturition with purulent urethral discharge but denies any sexual encounter with his wife recently, or with anyone else outside his home.
What he eventually reveals is that he had consensual sex with his domestic helper and her female friend in his home, when his wife was out. Clearly, treating urethritis includes managing biomedical and psychosocial dimensions.
Public health issues are pertinent here. The doctor needs to advise on the epidemiological treatment of the two sexual partners. In this case, one needs to consider the legal aspect as well. As the helper is in the patient’s employment, the question arises of whether the patient has broken any law, even if the intercourse was consensual, and even if the helper has not complained.
——-A/Prof T Thirumoorthy
Cheong Pak Yean is an internal/ family physician and psychotherapist. He is an SMA honorary member, past president of SMA, College & Adjunct Assoc Prof of NUS. His current interest is in medical communication & humanities.
T Thirumoorthy is the Group Chief Medical Officer with a private healthcare group who also teaches at Duke-NUS Medical School. He is a dermatologist and the founder director of the SMA Centre of Ethics and Professionalism.
The commentary and vignette were reproduced with permission from the book “Being Human, Stories from Family Medicine” edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore.
Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.
