"A lesson taught with humor is a lesson retained," Westheimer said, recalling an old Jewish saying. She does not tell jokes during therapy, she said, but she has found that introducing "a little laughter here and there helps people to be more at ease with what is an unusually difficult subject."

Indeed, the topic at hand was a serious one. Sponsored by the APA Office of HIV Psychiatry and the APA Commission on AIDS, the workshop explored the difficulty of taking a full and accurate sexual history with psychiatric patients.

"Certainly in our psychiatric practices," said Marshal Forstein, M.D., chair of the Commission on AIDS, "we are constantly working with people who have sexual issues." But he added that psychiatrists are never taught how to deal with these issues effectively. "As a psychiatrist, you spend many, many hours studying schizophrenia, which affects about 1 percent of the population, but you get almost no training in human sexuality, which affects 100 percent of the population."

This lack of knowledge, skill, and experience, in exploring a patient’s sexual history can lead to many problems, Forstein said. Foremost among them is the spread of sexually transmitted diseases, in particular HIV.

"We have many tough questions facing us with this subject in the mental health arena," Forstein continued, not only in how to integrate a sexual history into intake evaluations for new patients, but how to introduce the subject to patients who are already in treatment.

"I believe that sex is a very private matter, and should remain so. When a new patient comes into my office," Westheimer told the group attending the "talk show" format, "I will ask them very, very specific questions about their sexual history, but that is in the privacy of my office. But I have also learned to talk about every aspect of sexuality in more open situations without ever asking a personal question." With her characteristic style, Westheimer joked that during the annual meeting workshop, all of the attendees should have felt very comfortable asking questions, because as a group of psychiatrists, each could start a question with "A patient of mine. . . ."

A sexual history should include a thorough review of the patient’s activities with all of his or her partners, Westheimer emphasized, and should be geared toward educating the patient about risk and decreasing that risk.

"You in the mental health arena are very important people," she continued, "because by being comfortable in asking the right questions, you may be the first person to get the patient to talk about his or her sexuality. And the ability to talk about it and your asking about it provides you, as psychiatrists, the unimaginably important opportunity to educate about it."

The most important aspect of obtaining an accurate and complete history from a patient lies in the way in which the questions are asked, Westheimer believes. "Ask questions with the utmost of respect for the patients’ religious, cultural, and societal differences. Understand that what is ‘normal’ to one may not be normal at all to another."

It was in June 1981 that the first published report of five young gay men from the Los Angeles area were confirmed to have what would later be called AIDS. Now, 20 years later, both Forstein and Westheimer emphasized that the need to educate the public on the risk of sexually transmitted diseases, and especially HIV, continues to be apparent in current statistics: 40,000 new HIV infections per day in the U.S., 1 of every 12 gay men in the U.S. is currently HIV positive, and women now account for nearly 50 percent of all new HIV diagnoses.

"What upsets me," Westheimer said, "is that people are getting back into indiscriminate sex because they believe that HIV is not a serious concern any more."

Forstein agreed. "If we don’t talk about it and educate about it, people are going to continue to die," he said.

Dr. Ruth Westheimer’s Web site is found at www.drruth.com. More information on HIV is available from the APA Office of HIV Psychiatry at www.psych.org/aids. ▪