Suffering in silence

Mr. R is a 29-year-old man, a cab driver who lives in a village near our clinic but operates out of Chennai. He finished his bachelor’s in mathematics from a private arts and science college in Chengalpet, and after hunting for jobs for several months, decided to drive a taxi for his living. He has been working as a cab driver for 7 years now and has earned a decent amount to build their own home in the village. His mother, younger sister and he live in the house. His sister has just finished her bachelor’s in education from a private college and is preparing for exams to get into the government service. 

Mr. R came to our clinic about 3 years ago. While on a long trip of more than 300 KM on the road, he had developed severe breathlessness, profuse sweating and palpitations and had to stop driving and rest for a few minutes. It frightened him and so as soon as the trip was completed, he came home and the very next day came to our clinic to see me. He looked tired and his face was filled with apprehension and anxiety. “I am worried that I might have a heart attack”, he said. We did a clinical evaluation, an ECG and some blood tests. Everything seemed normal except for a high blood pressure of 180/100 mmHg. We checked his BP after allowing him to calm down and it was still high. So, we started him on medicines for his high blood pressure. 

 

“Mr. R, you must be careful about your diet and must start a physical exercise routine. Cut down on the salt and oil. Start doing some simple exercises like walking, jogging” I gave him all the routine advice that we give a person with high blood pressure. He was only 26 years old, and it warranted a careful evaluation of whether there is anything else wrong in his body including the kidneys, heart, blood vessels, brain or endocrine glands. We sent him to the tertiary care hospital in Chengalpet and got him thoroughly evaluated and everything was normal. So, it was the garden variety of hypertension that usually happens to older people, but it came too early for Mr. R. 

 

He was visiting us regularly for the first 3 months and his blood pressure came under good control. The otherwise serious and worried Mr. R slowly started loosening up and started having cheerful small talk with our staff. After three months, he stopped coming to the clinic. When our community health worker went to follow up on him in the village, his mother said that he got better and so left for Chennai to drive again. For the next six months we never saw Mr. R. 

 

One day he came back out of the blue with a very high blood pressure and return of the same symptoms including breathlessness, palpitations and sweating. “I started feeling normal and better. It was depressing to me to just sit at home not doing anything. It was also very depressing to keep taking pills. So, I stopped the pills and left for Chennai to drive my taxi again” said Mr. R. We counselled him again regarding hypertension, the need to take regular tablets, the need to follow a healthy lifestyle and sent him home. 

 

I thought I understood why Mr. R is not regular on his pills. Diseases like hypertension and diabetes are innocuous and silent for a long time till they start causing complications in the body. So, someone like Mr. R may not have the right motivation to be regular on his medicines. I used to hate mathematics in school. I never understood why I had to study mathematics.  But then the school forced it upon me and said it is necessary for the future. I still vividly remember the horrible times I spent struggling to learn the fundamental principles of mathematics and struggling to scrape through the exams with pass marks. But I am glad that I studied little mathematics even though I hated it. It comes in handy nowadays at work and in real life. Punishing myself with the pain of mathematics gave me some life skills today. But many young patients with conditions like diabetes and hypertension see other patients develop complications despite taking treatment. They see people develop side effects of medicines. They see others struggling with the uncertainty of blood sugar or blood pressure control. They see them losing out on all the small pleasures of life like tasty foods and snacks. I am sure they ask themselves, “Why should I put myself through all this for a treatment that doesn’t guarantee me anything?” I know I can counsel Mr. R and give him all the knowledge and awareness required to understand hypertension. I can scare him with threats of complications like stroke, heart attack and blindness. I can allure him with promises of a long healthy life. But the trade-off between the small pleasures, motivations and indiscretions of youth and the rigorous discipline that managing a chronic disease demand is heavy. We find that even older persons with these chronic diseases barely follow regular medicines or any of the lifestyle modifications that we suggest. So, when Mr. R went home that day, we knew very well that he will default soon and come back with uncontrolled pressures.  

 

I saw Mr. R last Thursday in the clinic. He came to see me after a break of 6 months. His BP was 180/100 mmHg. He was off medicines all this while. This time there was no sweating, breathlessness or palpitations. He is getting married next month and so he came for a ‘checkup’. I told him that he needs to get on regular medicines and a strict lifestyle program to stay healthy. When I prescribed him the tablets, he firmly said, “Please don’t give me those tablets. Give me something else…” and he hesitated. I did not understand the reason for the hesitation. He finally said, “the tablets make me loose interest in sex. I am getting married and I don’t want to be that way…” His face was filled with embarrassment by the time he said this. It is known that drugs working on heart and blood vessels can have the side effect of sexual dysfunction. I asked him, “is that why you have been irregular on your medicines all the time?” He nodded, still unable to establish eye contact from the embarrassment. 

 

I had an open conversation about sexual function and how the anti-hypertension medicines work and why he was having the decreased libido. I explained how the new drug that I am prescribing now will work and why it is unlikely to have the same effect. I asked him to come back if he has that problem again and we can work through it and minimize the side effects. I told him, “This is a well-known side effect and it can be handled easily. It is not permanent and we know how to manage it” and sent him home. 

 

I was thinking about Mr. R on my way back home from the clinic. If only I had asked Mr. R the reason for why he defaulted on his medicines and probed deeply giving him time and a safe non-judgmental space to open and speak to me, he might have probably revealed the sexual dysfunction much earlier. I also realized that while I am comfortable asking about various aspects of their life to understand their physical, mental, social and emotional wellbeing, I have never asked anyone about their sex life. We are taught to elicit sexual history if there is a suspicion of sexually transmitted illnesses, or infertility. In a routine clinical encounter, we ask patients many things including their diet, bowel and bladder habits, smoking, alcohol habits and various behaviors that have an influence on health. But sexual activity is never routinely inquired. Mr. R’s episode helped me realize that if I had only routinely inquired whether he is sexually active and if things were fine, his issue might have come up much earlier. When the health care provider is not comfortable having a conversation about their client’s sexuality, the patient does not realize that it is alright to talk about it. But when the health care provider opens a respectful and non-judgmental conversation about sex, it is normalised, legitimised and a safe space is offered for the client to open up. 

 

We don’t teach our medical students to elicit a respectful and useful sexual history from the patient. As young doctors in the field, we often don’t even know the right words to talk about sex. Which words are too casual? Which words are too difficult to understand? Which words are disrespectful? What are the locally used words? It may be easier for many young doctors to engage in a conversation about sex in English, but in Tamil it becomes even more challenging. Most Tamil words that we know related to sex are either pure literary Tamil words or curse words. I can’t begin to imagine how a gender discordant doctor-patient duo will navigate the issue of sexual history. 

 

I came home and searched scientific journals and found that more than 70% of patients on diabetes or cardiovascular medicines suffer from sexual dysfunction in India. Most of them suffer in silence and it is one of the common causes for medication default. I also found that sexual dysfunction is a very sensitive indicator of early heart problems, because when someone has a heart problem it immediately affects their sexual performance. A person’s sexuality is a core aspect of their life and medical encounters rarely focus on it. I have a good feeling about Mr. R. The ice between us at last broke and we had an open conversation that was important to him. I am quite certain that many other men in my clientele are silently going through similar problems. I must start inquiring routinely into my patients’ sexual history.