How to Talk to Your Patients About Sex

Roxanne Nelson, BSN, RN

When Patients Need to Talk About Sex

It seems that everyone is talking about sex these days, except where it may really matter most—inside the doctor's office.

Even though sex is an integral part of life, studies show that all too often doctors aren't having "the talk" with their patients. Instead, the topic is frequently glossed over or pushed by the wayside, even though it means missing an important component of the patient's overall state of health.

"The majority of patients, including seniors, would like their physicians to bring up the topic of sexuality, especially related to aging and chronic illness," says Leslie R. Schover, PhD, a professor in the Department of Behavioral Science at The University of Texas MD Anderson Cancer Center in Houston.

She notes that even though healthcare providers, including physicians and nurses, typically agree that it's a good thing to discuss sex with patients, it frequently doesn't come to pass. "Repeated surveys suggest that each professional group regards this topic as 'not my job,' and unfortunately, it's rare for patients to find someone who does regard it as their job," Dr Schover says.

Still Regarded as a Major Taboo

Although the World Health Organization has declared that sexual health is an important and integral aspect of human development and maturation throughout life,^[1] shortfalls in doctor/patient communication about sexual matters appear to be the status quo. Take a look at some of these statistics:

• Only about 15% of patients reported getting counseling for sexual activity after an acute myocardial attack, and among US patients, most stated that they initiated the conversation.^[2] These were younger patients (median age, 48 years), with the majority reporting that they were sexually active before their heart attack.

• In a study looking to identify and quantify the barriers that physicians encounter in discussing sexually transmitted infections with their patients, less than one half of primary care doctors (44.3%) provided some form of counseling (eg, asking about sexual history, information about safe sex,) on a regular basis.^[3]

• Among a sample of more than 3000 adults aged 57 years and older, only 38% of men and 22% of women reported having discussed sexual issues with a physician after age 50 years.^[4]

• A study among very long-term survivors of vaginal and cervical cancer showed that 62% had never discussed the effect of genital tract cancer on sexuality—even though three quarters of the women surveyed believed that doctors should talk about sex.^[5]

• Less than two thirds of doctors and teenage patients talk about sex, sexuality, or dating during annual visits, and when these topics were mentioned, conversations lasted an average of 36 seconds.^[6] None of the teenage patients initiated the talk, and only 4% of them had prolonged conversations with their doctors.

All of this raises the question: Why is the "sex talk" not happening?

Barriers to Communication on Both Sides

Doctors and their patients share more or less equal blame when it comes to talking about sex. Patients may be reluctant to ask questions, feel uncomfortable about discussing sex, balk at being the one to initiate the conversation, or feel that their physician may be dismissive.^[3] Physicians cite a lack of time, fear of intrusion or embarrassing the patient, cultural differences, presence of a third party in the exam room, and general discomfort with the subject.^[4] Inadequate training of physicians in sexual health is probably a contributing factor, too, and doctors have also reported feeling uncomfortable when discussing sexuality with patients of the opposite sex.

"The research suggests that many clinicians feel it's appropriate to discuss sexual issues with their patients, but time constraints and a lack of training on how to manage sexual problems are important barriers," says Andrea Bradford, PhD, an assistant professor in the Department of Gynecologic Oncology and Reproductive Medicine at the University of Texas MD Anderson Cancer Center in Houston. "Many physicians are understandably reluctant to bring up a problem that they don't know how to treat."

She adds that although some physicians are personally uncomfortable with questions about sexuality, "I think most are open to the discussion if the circumstances are conducive to it."

But it really shouldn't be all that difficult to create circumstances that are conducive, because sexual health is still "health," even though it continues to be somewhat taboo to discuss. Sexual health is complex and diverse and applies to patients of all ages, whether they're sexually active or not, according to Virginia Sadock, MD, a clinical professor of psychiatry and director of the Human Sexuality Training Program at New York University Langone Medical Center.

"This is something that as a physician you have to address, and it's an important part of peoples' lives, even if we don't talk about it over dinner," says Dr Sadock, who estimates that at any given time, about 30%-40% of people are dissatisfied sexually.

One way for a primary care doctor to address sexuality is to think of it as part of the review of systems. "Just as you review the head, the lungs, the heart, and so on, you review the sexual system," she advises. "As a physician, you have to see it as a medical question, and as part of the medical review of symptoms."

Heart disease, cancer, diabetes, or other chronic diseases can affect sexual function. Medications can also cause sexual side effects. How is it possible to fit all of this into the discussion?

Obviously, if a patient has just undergone surgery or has a serious illness, there are other topics that will need to be addressed first, says Dr Sadock. But at some point, she adds, sexuality needs to be touched upon, and it can be brought up very simply and in line with other questions.

"Doctors need to think of it in terms of not being this titillating subject, which will cause embarrassment, but instead as a health issue," Dr Sadock points out. "They just need to be able to hear the questions patients may ask or be able to ask the appropriate questions, but they don't necessarily need to treat the problem themselves."

First Steps: Keep It Simple and Clinical

There's no one specific method or algorithm for initiating the "sex talk" and moving through it. But several experts weighed in on how to break the ice, and where to go with the conversation.

For some patients dealing with a chronic disease, such as diabetes, or those who have recently been treated for cancer or a heart attack, there's a high likelihood of sexual problems. New York City sex therapist Stephen Snyder, MD, associate clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai, emphasizes that you should be as specific as possible in your questions.

"If you just ask if they're having any sexual concerns, you're not going to get many positive answers," he says. "Ask specifically about things that you know how to treat."

For example, after a heart attack, he suggests the following:

"Instead of asking about 'sexual problems,' ask a man whether he is having erectile dysfunction. Ask whether he's having any fears about resuming sexual activity. That's especially pertinent to patients who have had a heart attack, who might be afraid that sexual activity is dangerous. Being specific can make the questions less intrusive."

The same goes for a female patient, he says. "After a heart attack, you can ask, 'Have you started having sex again? Any fears about having sex?' If so, give reassurance."

During a woman's regular office checkup, you should ask whether she's having any pain with intercourse; if so, you might want to refer her to a gynecologist. Making the question as specific and as clinical as possible can help even the most squeamish doctor be more comfortable dipping their toe into the sexual waters.

But Dr Snyder is realistic about what can and can't be covered in the short time allotted to an office visit.

"Most primary care doctors aren't going to have much time to get into the psychological issues that are often involved in sexual matters," he says. "Instead, keep it simple, and focus on things you can do something about. For instance, loss of sexual interest due to marital conflict is going to be outside the scope of practice of most primary care physicians. But simple interventions—such as prescribing a phosphodiesterase-5 inhibitor for someone with erectile dysfunction, making changes to a patient's medication regimen, or referral to a specialist—can be quite valuable."

Start With Vanilla Questions

First and foremost, Dr Schover emphasizes, "it's not necessary to do an extensive assessment or to try to provide treatment beyond your own expertise. That is what referrals are for."

An easy way of breaking the ice, she suggests, is to put sexual questions into the context of asking about other aspects of quality of life, such as stress, fatigue, ability to accomplish tasks of daily living, relationships, and social support.

"You can also preface a question," she says, "with a simple statement like, 'One aspect of your quality of life is your sex life. How are you doing with sexual function?'"

Dr Schover notes that it helps to begin with the more "vanilla" questions, such as "How is your current sexual relationship?" or "How often have you had some sexual activity in the past several months?"

She points out that one half of all US women older than 50 years do not have a sexual partner.

Doctors should also be aware of the patient's sexual orientation. "I ask all my patients whether their sexual attraction is usually to men, women, or both," she says. "If you assume that a gay or lesbian patient is heterosexual, it's a major source of alienation."

It's also important to "normalize," Dr Schover says. An example would be when trying to assess whether a man with erectile dysfunction should be referred for specialty urology or sex therapy services. "In that case," she says, "you might ask something like, 'Many men with erection problems try to see whether they can get an erection by touching themselves, or looking at sexy videos on the Internet. Have you tried getting an erection when you aren't with a partner?'"

Both Dr Snyder and Dr Schover agree that it's essential to have a referral network set up. This makes it that much simpler to direct the patient to the appropriate specialist, whether it's a urologist, gynecologist, mental health professional, or a sex therapist.

Rid Yourself of Old Assumptions

Patients at both ends of the age spectrum may be getting the least amount of attention when it comes to talking about sex with their doctor. Mainstream American culture ignores or negatively interprets the sexuality of the very young and the very old—not to mention people with health problems or disabilities, says Dr Bradford. "Physicians are no less vulnerable than anyone else to these attitudes."

Doctors have in fact reported and perceived the greatest discomfort when taking sexual histories of patients of the opposite gender, as well as very young persons (under 18 years of age) and adults older than 65 years.^[7]

For instance, although frequent among older adults, sexual problems aren't often discussed with physicians. "We do still have a taboo in this country—probably the last taboo, seeing older adults or the elderly as being sexual," says Dr Sadock.

There's often an assumption that the elderly don't engage in sex or aren't interested in it, but sexuality doesn't necessarily change just because one gets older. Although it's true that physiologic problems can interfere with sexual function as people age, one large survey found that among respondents 75-85 years old, 54% of sexually active persons reported having sex at least two to three times per month, and 23% reported having sex once a week or more.^[5]

"We have two very different groups of older adults," says Dr Sadock. "We have the elderly and the 'well-derly.' And even if they can't function all that well, they're still thinking about sex."

Some older patients are reluctant or embarrassed to discuss sexual matters with their doctor, and as we mentioned earlier, the doctor's attitude also has a strong impact on their level of comfort in having this kind of conversation.

"You just have to remember that you're a doctor, even if the patient is old enough to be your grandfather," Dr Sadock emphasizes. "If you're a younger doctor, this is where the taboo about sex and the elderly comes in. But this is a patient, and this is part of their lives and part of their health."

At the other end of the spectrum, there's no doubt that teens are talking about sex—just not with you, if you happen to be their doctor. Both the American Medical Association^[8] and American Academy of Pediatrics^[9] recommend that doctors carve out some time during health maintenance visits with early and middle adolescents to discuss sexuality and counsel teens about sexual behavior and risk reduction.

However, some data show that this isn't as easy as it may sound. Many physicians report not being comfortable discussing sex and sexuality with teens, and adolescents tend not to think of their doctor as the best person to discuss sex with.^[10]

Discussions of Sex Are Woefully Brief

In a recent study that recorded conversations between physicians and adolescents during annual health maintenance visits, the authors found that doctors spent about 36 seconds talking about sex, during a visit that averaged 22 minutes.^[8] And about one third of adolescent patient/doctor interactions included no mention of the topic.

There was reluctance on both sides. None of the teens brought it up and, when asked a question, were generally tight-lipped and not very forthcoming. But there are "millions of reasons" why these discussions aren't happening, explains the study's lead author, Stewart C. Alexander, PhD, an associate professor in the Department of Consumer Science at Purdue University in West Lafayette, Indiana.

"This is a wellness exam, and there's a lot of ground to cover," he says. "Clinicians have 10 or 20 minutes, so it becomes a decision of 'what can I accomplish in this time frame.'"

"Sometimes doctors see siblings together," he adds, "so there may be more than one kid in the room. And Mom may be there, so that changes the picture considerably."

Much of the time, questions regarding sexuality become part of a checklist to go through, he says, rather than serve as the basis for initiating a real discussion.

"But it's not just about body development; it's also about orientation and identity, how do you talk to your partner, and so on," Dr Alexander says. "We found that that was missing from a lot of these conversations."

Another issue is confidentiality. If the teen is unable to speak with the doctor alone, he or she will be less likely to disclose sexual details or answer honestly. "You need to kick the parent out, and if there's another kid in the room, kick him or her out as well," says Dr Alexander. "And then the doctor needs to explain why we're having this discussion: 'I'm not your parent, and I'm here to help you with your health decisions. But to do that, I need to know what you're doing, or thinking of doing, so I can help you.'"

Dr Bradford notes that the physician can also be an important resource for parents who wish to discuss sexuality with their children but aren't sure how. To help you hone your skills and get further guidance, she recommends consulting the website of the Sexuality Information and Education Council of the United States (www.siecus.org).

Is More Training the Answer?

Part of the communication problem stems from a lack of training in sexual medicine. About a decade ago, a comprehensive study of 101 medical schools in the United States found that more than one half (54%) provided only 3-10 hours of instruction in sexual health.^[11] Most of the schools also did not provide clinical training programs in sexual health or continuing medical education. This scant training appears to be reflected in a 2010 survey of medical students, in which 53% of 1206 respondents stated that they felt they hadn't received sufficient training in medical school to address sexual concerns clinically.^[12]

"It's good to have guidelines, but training is needed on how to actually do it," says Dr Alexander. "Having specific training in medical school or continuing education is really the only way to become comfortable talking about it."

A recent summit on medical school education in sexual health has called for national standards for sexual health education to be put in place in every medical school in the United States and Canada.^[11] Some schools have already stepped up to the plate. The Robert Wood Johnson Medical School in New Jersey, for example, requires medical students and physician assistants to complete a mandatory, week-long, multidisciplinary course in human sexuality during their second year of medical school.^[12] No student is permitted to graduate without it.

In the school's pilot program, 22 of 46 medical residents (48%) said that they were uncomfortable discussing sexual issues and wouldn't feel comfortable in addressing the topic with their patients. After the workshop, however, more than one half reported that the workshop had greatly helped them in developing comfort and skill in sexual history-taking.

But to help doctors learn how to communicate in difficult situations, they not only need to practice these skills but also receive feedback on how well they're doing, says Dr Alexander. "It's more labor-intensive and time-consuming, but it's the only way to improve those skills." His group is already working with oncologists in other clinical areas, where they record them and then provide constructive feedback.

"And now we're hoping to do this with sex," he says. "We've applied for a grant and are now just waiting to get started."

Conclusion

Despite the knowledge and communication gaps, there are a couple of things that physicians can do right away to help their patients with sexual issues. "The first is to educate themselves on how to ask the right questions and implement them in their practice," says Dr Bradford.

For starters, the Kinsey Institute's website hosts a free textbook titled Sexual Medicine in Primary Care, which is a great entry point for any healthcare provider interested in learning more about this topic

Second, because many treatments for sexual problems involve psychosocial or behavioral management, Dr Bradford recommends that physicians might want to consider partnering with psychologists or other behavioral health clinicians.

"It's worthwhile to cultivate relationships with mental health providers in the community to help achieve better health outcomes," she says.

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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this article: Roxanne Nelson. How to Talk to Your Patients About Sex. Medscape. Oct 15, 2015.