In this blog for our special series The Problem With Sex, pelvic physiotherapist and comedian Elaine Miller @GussieGrips pulls back the covers and shines a torch on health, research, and asking about your sex life
Adult humans are sexual beings and have the right to information, education and services which help make the most of their intimate relationships. Talking about sex can be difficult enough between partners(1, 2), never mind with your GP – who might be younger than you; or older than you; or knows your partner; or who syringed your ear; or who worships at the same place as you; or is a locum and not the usual friendly face; or who knows you got an STI that time…or…or…
Dr David Haslam has a great talking-about-sex-with-a-patient anecdote :
“Many years ago, I was taking a detailed sexual history from a woman who had been admitted after an overdose. Her sex life was a somewhat unconventional mess and I suspected that one of her sources of difficulty, not to mention frustration, was that her husband had premature ejaculation. So I asked her about it. She clearly didn’t understand any of the terms I was using, so, I asked if it took her husband long to come. “Oh no”, she said. “He just gets the 1a bus from Acocks Green and he’s here in half an hour.”(3)
Discussing sex with our doctor should be routine…
If you take the “sexy” out of sex, it is part of physical adult health, just like sleeping, exercising or eating – all of which can have positive or negative effects on wellbeing. Chronic illness or disabilities can present extra relationship challenges and we know that loneliness, or a person’s inability to express their sexuality can have a negative impact on their life.
So, discussing sex with our doctor should be as routine as discussing our stress levels. Only, it’s absolutely not.
Well, I assume that from the anecdotes I’ve gathered from friends and colleagues about their experiences for the purposes of this blog. Annoyingly, there’s not a handy Cochrane Review about “how to talk about sex with patients” to quote here, because there is very little research on how to talk about sex with patients, never mind research looking at how to talk to patients about sex and chronic illness, disability, or ageing or, if there is, it tends to be hetero-normative, focussed on penetration as if that alone is a measure of satisfaction, and is conducted on people who are cognitively able, can communicate easily and are within a surprisingly narrow age range.
Sharing our sexual issues with our healthcare professional has the potential to reveal just how foolish, ignorant, or depraved we are. Worse still, anything we say about sex has the potential to offend or unsettle those we are in consultation with.
Talking about sex with a partner can be difficult too
Talking about sex even with a partner can leave us vulnerable to embarrassment, rejection, and confusion. Coleman and Ingham (4) found fear of negative reaction to sexual discussion is a communication suppressant. Dana Lear found it’s more acceptable to be silent, or even to talk dirty, than it is to give instructions, share preferences, or reveal secret desires (5).
Mass media further complicates things by showing that sex comes naturally, is spontaneous and your partner will intuitively know what you want – see any film rated 15+ and two impossibly beautiful people will be gasping and arching like a couple of hooked trout before simultaneously orgasming and spooning under their lovely fresh silk sheets. Rarely does realistic clumsy, messy sex on ancient (but really cosy) flannelette sheets feature on the big screen.
Why don’t clinicians ask about sex?
Dr Stacy Tessler Lindau (6) believes that patients are reluctant to bring up sexual difficulties because they worry about being judged or having their fears dismissed. Conversely, clinicians worry that broaching sex could embarrass or offend the patient.
Which doesn’t help the 75% of family practice patients found to have a sexual problem (in a 1998 study on 212 patients, seriously, there isn’t a lot of research into this stuff)(7). That study found that “given adequate training, family physicians may be the ideal providers of assistance for these problems”.
So, how much training do medics get in discussing sexual issues with patients? Not much, 10 of 3000 hours of medical school, and most of that is focussed on the biology and physiology of sexuality (8).
A 2013 study (9) showed that while reproductive physiology, contraception and sexually transmitted infections are covered, many schools devote little or no attention to sexual function, dysfunction and sexual minority groups and concluded that most doctors leave medical school with little idea of how to help patients with sexual problems.
Happily, for this blog, there is a study looking at why clinicians don’t ask about sex (10). This examined a decade of health professionals’ experiences of discussing sexuality with patients and found that HCPs avoid proactive discussion because of fear of “opening up a can of worms”, time constraints, concern about knowledge, lack of training, and fear of causing offence. Themes relating to gender, ethnicity, intellectual ability, sexual preference and age of the service user were particularly marked.
Sex and specific health conditions – can research help?
There’s a small study comparing views and experiences of cardiac patients’ and healthcare providers’ communications about sexual issues. Patients reported that sex was rarely discussed, but, that they would have liked the opportunity. 70% of GPs reported not addressing sex with their patients, whilst 61% of rehabilitation practitioners said that sexual problems were poorly addressed in their service. So, while we have helpful NICE guidelines (11) (based on evidence including Cochrane Reviews) which state that we should be advising and reassuring patients about sexual activity after a heart attack, it seems that is not happening in practice (12).
What about people who aren’t unwell, but, have hip pain or stiffness? Do their clinicians ask whether their hip function affects their sexual ability? Ehm, well, no (13). A systematic review examined 45 years of literature about the effect of total hip arthroplasty on sexual activity. It examined the differences between patient and surgeon perspectives, improvements in sexual ability and differences in outcomes between men and women.
It found that prior to surgery, 76% of patients identified hip arthritis as the primary cause of sexual problems. Post-op, 44% of patients reported improvements in sexual satisfaction. 86% of surgeons rarely or never discuss sexual activity with their patients.
Older people want sex too
Arthritis is going to become a bigger issue for more people because we have an ageing population, but, finding evidence about older people and their sexuality is really challenging.
Both health problems and medications can affect sexual pleasure and performance and it is vital not to make ageist assumptions about people’s sexual expression.
I was schooled on that by a woman in her mid 80s in clinic who presented for help with incontinence associated with a vaginal prolapse. “I ask everyone this question, so, sorry, please, bear with me, if you are sexually active, does this interfere with your ability to have sex?” She peered over her glasses like Jenni Murray’s more forthright mother and said “I’m 86 dear, I’m not dead!”.
Health challenges in older people can present practical ethical issues which may require support from healthcare providers. For instance, what happens if a partner has dementia? It could be unclear whether they have the capacity to consent to sexual relations. Or, if they have the freedom and ability to make that choice, their partner may feel conflicted if they have dual roles of being a carer and a lover.
In residential settings, staff tend to view a resident’s sexual expression as “problem” behaviour (14). A systematic review found a protective care paradigm throughout and that the resident’s perspective was lost (15).
Even gynaecologists are reluctant to ask us about sex
How about gynaecologists? Surely the obvious Activity of Daily Living of the vagina is sex? (if you’re lucky enough), so, bet gynaecologists have talking about intercourse nailed? Again, erm, no. A 2017 study found that only a quarter of clinicians had received training about sexual dysfunction. They tended to agree that “sex is private and discussing it with patients will interfere with our provider-patient relationship”(16).
It is reasonable for women to want to learn about treatment implications on their sexual function. The problem is that most of the research concludes that female sexual responses are “complex” and focusses on “can penetration be achieved?” as if that is the best measure of female sexual satisfaction (if you listen closely now, you can hear lesbians laughing and shaking their heads).
Hearing people’s voices
The glaringly obvious omission in almost all of the research is the voice of the person.
Mik Scarlet is a broadcaster, journalist, actor, musician, and expert in the field of access and inclusion for disabled people. He recently did a comedy set for BBC Ouch in which he talked about his own erectile dysfunction following spinal cord injury and the difficulties of getting help. The video is currently sixth on BBC videos (17).
“The assumption was that you can’t be sexually active without an erection, and I bought into that idea. My GP’s approach was “we’ll fix it” – but I gave all the treatments up. The injections left me like a hat stand (no one can have sex for 8 hours), viagra didn’t do anything apart from burst a blood vessel in my eye and penis pumps give your willy a love bite. No one said to me “you can be happy as you are”.
“It’s a big ask of a GP in an 8 minute appointment, but, it would be great if someone had said “sex is more than what this will take away from you. We can support you with methodologies for having sex in new ways. It won’t be the same sex different, it’s different sex the same.”
“I wanted to do the video because 20 years after ‘coming out as a floppy’ with friends and media I learned that so many people experience it but they won’t tell you, they hide it and are ashamed – so they don’t enjoy sex because how can you have fun if you are ashamed?”
“Why don’t we teach men who are having prostate treatment about techniques they could use before their surgery? We should give them homework, “let’s start trying now!”
“It’s really important to help people be happy with who they are, not miserable wishing for what they used to be”
What can help?
Clinicians almost universally recognise that they need more information, support and training in order to take a good sexual history to enable a patient to be more comfortable about discussing a potentially embarrassing issue. The Sexual Advice Association have advice about how to take a sexual history and information for patients and professionals. (18) Come with questions in your own words, you don’t need to use medical terminology. If even saying the words is too excruciating for words, then print off the “doctor, I have an embarrassing problem” (here are the female and male versions), circle what’s relevant and slide it, wordlessly, across the desk.
Managing an impaired body and a sexual life can involve a lot of work – dealing with issues such as pain, incontinence, fatigue and immobility can often be managed, but patients need skills to be able to disclose they have sexual concerns, preferably at the beginning of the consultation. Top tip for clinicians? Try to avoid being a “knobber”. Dr Myers says “Avoid the “doorknob effect”. When patients get up to leave, they say the number one reason they came for in the first place but didn’t have the courage to say at the beginning.”
Illness and sex are taboos which many people – disabled or not – find hard to talk about. Good care provision should not deny people’s sexual pleasures, desires or practices.
Problems that may seem overwhelmingly big may have simple fixes – so ask! I gave a patient sample packs of vaginal lubricant which is available on prescription. She said “You gave me a miracle treatment that’s changed my sex life.”
Dr Daniel Atkinson, GP who helped put together the Sexual Respect Tool Kit (19) said
“Thinking about discussing sex is more frightening than actually doing it, and the reactions we’re fearful of very rarely occur.”
It’s time we all start talking about it.
References may be found here.
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