As a primary care physician, a significant part of my job is helping patients better understand and deal with the public health issues that affect our society—whether it’s the dangers of smoking tobacco or the importance of getting a flu shot or the need to get tested for STIs.
But there is one health issue in particular that is impacting so many and yet talked about by so few: consent. Talking about the nuances of consent can be complicated and uncomfortable. The subject has long been dismissed as a “mood ruiner” among sexual partners—and as a result, many choose to ignore these conversations altogether, creating a silence around something that desperately needs to be discussed and unpacked.
Since I know that many of my patients are not having these conversations with their friends, family, or even partners, I make it part of my regular practice to bring up the subject of consent with my patients. I talk to my patients about other necessities when practicing safe sex, such as birth control and STI-prevention, so I’m in a unique position to be able to also discuss consent with them. Even a simple question like, “How do you give and receive consent with your partner?”, can make a huge difference when it comes to starting a conversation and, ultimately, creating a safer, more comfortable environment for sex.
When it comes down to it, consent is all about respect for another person’s bodily autonomy: when you want to touch another person or have sex with them, you should ask first (verbally) and continue to give and receive consent in this way throughout a sexual encounter. That doesn’t necessarily mean running through a monotone checklist of “can I…,” but it does mean paying attention to the physical and verbal cues of the person you’re with, while maintaining clear and open communication. Consent also doesn’t have to be sexual. Getting and receiving consent extends to situations such as borrowing your friend’s shirt or using your coworker’s phone. We wouldn’t do either of those things without asking, so of course an act as intimate as sex deserves the same consideration.
It also means being sure that the person is able to give consent. A few important factors to consider: is your sexual partner above the age of consent in your particular state? Are you certain that they are not under the influence of mind-altering substances, and they are in no way being coerced or pressured into saying yes?
The unfortunate reality is that a lack of consent can often be difficult to prove, which is one reason an estimated 80 percent of sexual assault and rape cases go unpreported and around 995 of 1000 perpetrators of rape will avoid prison. This lack of action through the justice system is one reason why it is critical to address the underlying cultural and societal issues as swifty and resoundingly as possible.
This is why I talk to all of my patients (and anyone else who will listen, really) about the importance of both giving and receiving enthusiastic consent with all partners. In my work as a primary care physician, I have spoken to many patients about their experiences with sexual assault and consent. It’s a subject I believe all PCPs should broach with their patients if they have the training and resources to do so, since it directly impacts the physical, emotional, and psychological health of the people in our society.
The taboo and shame surrounding non-consensual experiences coupled with the physical and mental trauma many survivors experience can cause severe health problems for years to come. Health issues like depression, anxiety, PTSD, and long-term physical challenges are far from uncommon in survivors and can cause irreparable damage, both mentally and physically.
But, as it currently stands, only eight states require consent or sexual assault to be mentioned as part of public school sex education curriculum. These are typically as pieces of a larger discussion on healthy relationships, which doesn’t always help young people make the necessary associations between safe sexual activity and consent.
So, why should I—a family medicine physician—be the one bringing this up? The number one reason for me is that it ensures that someone does. Too often, other leadership figures for young people, like their parents or their schools, either don’t know how to bring up consent or simply don’t feel comfortable. Unless someone else—like a primary care provider—takes on the subject, sometimes it never gets broached at all.
When talking to patients, I do my best to normalize discussions about sexual activity by asking about things like the body parts they use for sex (vagina, anus, penis, mouth, etc.). In these discussions, I ask patients open-ended questions about how they would describe their communication with their partners, or any tension they feel in those relationships. I also ask them how they typically give and receive consent. Patients are often surprised by these questions. They may expect to be screened for STIs or asked about pregnancy, but they don’t usually associate consent with their overall health.
But the reality is that consent is a hugely important component of a patient’s sexual and overall health. Talking about consent can help me identify other conversations that I should be having with that patient and may lead to a bigger discussion about past experiences, mental and physical health, and sexual practices.
The reality of consent is that it’s not always as cut and dry as “yes” or “no,” which can make it difficult for people to speak up when a non-consensual encounter has occurred. In the past, I’ve had patients open to me about situations such as partners taking off the condom during sex without asking, leading to thoughtful discussions about bodily autonomy that they may not be having otherwise.
In my professional opinion, consent is a public health issue. I believe that viewing the prevention of sexual assault and rape through the lens of public health will help protect the overall mental and physical well-being of our society. But what exactly does treating consent as a public health issue look like—and why does that matter?
First, this would mean funding studies about attitudes toward consent and the long-term impact of non-consensual encounters by qualified researchers, helping advance policy that would advocate for explicit consent in sexual encounters as well as creating and promoting educational materials to introduce the subject to children in school.
Recognizing consent as a public health issue would also shape evidence-based guidelines for clinicians, allowing us to treat it as we would any other widespread health problem—by making it common practice to talk about consent with our patients in the context of their overall health, and by giving our patients a safe place to discuss non-consensual experiences. Smoking tobacco is a good example of a public health issue that both the medical world and general society have made strides towards improving. Many of us can remember watching anti-smoking ads on TV, or being shown an image of a blackened lung in a health class. When we go to the doctor, we’re always asked whether or not we smoke tobacco. It’s not a perfect comparison, but it shows the positive impact a multifaceted approach can have on public health issues.
As with any public health crisis, laws won’t be passed overnight and changes to education requirements can take years to go into effect—though we have and will continue to see strides made in these areas. Importantly, individuals also have the opportunity to take action now in small, deliberate ways. Perhaps the most critical thing that an individual can do to address consent is to discuss it in whichever ways we can with those around us—our sexual partners, our friends, and even our children.
While starting with the youngest members of society may sound difficult, parents and schools should introduce the concept of consent in elementary school, in the right way. While some might argue that doing so would expose children to sexual content too young, the truth is that consent can easily be introduced and reinforced in non-sexual contexts from a very early age. Familiarizing children with the idea of bodily autonomy—that no one has the right to touch them without their approval—can go a long way toward applying the concept of consent to their own bodies and those of their peers as they mature. For example, the District of Columbia’s requirements space out this subject over the course of an entire public school education. In the third grade, schools teach the importance of respect for other bodies. In fourth grade, students learn why talking about sexuality can be helpful. And in sixth grade, the curriculum includes a discussion on the repercussions of unhealthy or violent relationships.
When I look at how society has evolved in the last few years, it is clear that progress has been made. We are far more aware of what consent is and why it is important, but this education very often comes too infrequently and too late. Too many of us have long been uncomfortable discussing healthy and consensual sexual activity, but it is critical that we do so in order to set an example for future generations. One way to do this is to start talking about consent with people you trust. And in the meantime, I’m going to continue talking to my patients about the subject to ensure that they have at least one safe space—and a trusted confidant—to share.
Natasha Bhuyan, M.D., is a family medicine physician with One Medical.