Sexual health, though fundamentally important to every human being, is rarely discussed between patients and their healthcare providers. It’s an important conversation and one that requires doctors and patients to venture into less-than-comfortable territory.
Who exactly should treat sexual health issues? Many assume that this should be the territory of a gynecologist for women or a urologist for men.
But because we see our patients more frequently than any other doctors, general internists are on the front line to address sexual health issues.
For instance, during a routine office visit, a 40-year-old mother of three confided to me that she was drinking too much. When I asked why, she said she was depressed because her husband had left her for another woman when her sex drive diminished after the birth of her third child.
If I had followed standard procedure and simply counseled this patient to stop drinking, we would have never addressed the underlying matter: a sexual health problem was destroying her family.
Sexual dysfunction affects more than 40 percent of women and more than 30 percent of men ages 18 to 59, with peak rates among middle-aged and older patients. The conversation about sexual health is a sensitive one for many doctors. They may avoid it, thinking that they are not properly trained, that they have no treatments to offer or that they might offend their patients.
Studies show, however, that patients of all ages want their providers to raise the topic. In fact, two-thirds of patients surveyed said they were concerned about embarrassing their doctors.
In my own experience, some patients will even schedule an appointment for an unrelated complaint, hoping for the opportunity to discuss a sexual health problem: “I never have orgasms” may present as stomach pain or headaches.
Sometimes the questions get answered quickly.
During a routine physical exam, one patient asked, “Is it normal that I never want to have sex?” I asked a few questions and checked her test results to rule out low thyroid and other possible underlying issues. She and her husband were having sex regularly. He was satisfied; she did not feel particularly distressed about her low desire. Our conversation took about three minutes and led to no further action.
Other brief conversations uncover serious medical risks. One 46-year-old male patient stopped taking his diabetes medication because he thought it was causing erectile dysfunction and his partner thought he had lost interest in her. He refused to believe that uncontrolled blood sugar was the actual cause. I wrote him a prescription for sildenafil, hoping that restoring a more satisfying sex life would encourage compliance with his diabetes medication.
So how do we improve the conversation about sexual issues? Doctors needing help with these discussions can find a number of screening tools, including the Female Sexual Function Index (FSFI) and the Decreased Sexual Desire Screener (DSDS).
They can also make statements such as “Anytime you have a question about sexual health, you can bring it up,” or ask open-ended questions such as “Is anything concerning you?” to lower resistance and establish a safe environment in which to talk about sexual health.
By normalizing the subject, integrating sexual history-taking and counseling into our practice and following through with appropriate referrals, we can improve the overall health and well-being of our patients and their loved ones.