How to talk to your patients about sex

The doctor's office is the logical—and sometimes the only—place where people can seek help with their most intimate problems.

By Gail Garfinkel Weiss
Senior Editor

You can talk about your patients' stool and urine, and you have no difficulty mentioning genitalia if the subject is, say, vaginitis or testicular cancer. But if you're like most physicians, you don't ask about patients' sexual functioning. Yet sexual dysfunction isn't rare, says Larry Maguire, an internist who runs a sexual wellness program in Lexington, KY. "We see it all the time."

Research bears Maguire out. A national study reported in JAMA in 1999 showed that 43 percent of women and 31 percent of men age 19 to 59 have had sexual difficulties. The main problem in women was low sexual desire (22 percent); in men, it was premature ejaculation (21 percent).

Nonetheless, physicians and patients both seem to have a tacit "don't ask, don't tell" policy when it comes to discussions about sex. A 1999 poll indicated that 68 percent of respondents were reluctant to mention sexual dysfunction to their doctor for fear of embarrassing the physician. And in the Global Study of Sexual Attitudes and Behaviors released by Pfizer last February, only 12 percent of Americans reported being asked about sexual difficulties during a medical checkup.

"The reluctance to speak about sexual concerns begins in childhood, when we're told, 'One doesn't talk about sex,' " says ob/gyn Gloria Bachmann, associate dean for women's health at Robert Wood Johnson Medical School in New Brunswick, NJ. "We all bring our cultural, religious, and family beliefs to the table."

What should you ask—and when?

"Doctors' medical training and high standard of confidentiality make them a natural choice for sex counselors," says psychiatrist Domeena Renshaw, director of the sexual dysfunction clinic at Loyola University in Chicago. But you have to be willing to serve in that capacity. You can put yourself in the role, Renshaw says, by asking three simple questions:

• Are you sexually active?
• Are you having any sexual problems?
• Are there any questions about sex you would like to ask me?

Elizabeth A. Pector, an FP in Naperville, IL, asks during a physical if a patient is currently involved in a relationship. If the answer is Yes, Pector asks about sexual function and contraceptive methods, and also about urinary tract difficulties and gynecologic problems. She then goes on to neurologic, psychiatric, musculoskeletal, and other topics. "This makes inquiries about sexual function a routine part of a medical exam," she says.

That makes sense, because these aren't just quality-of-life issues, says Richard Kogan, a psychiatrist and sex therapist in New York City. "Medical interventions are among the key causes of sexual problems. Many antidepressants and antihypertensives, for example, diminish libido and interfere with orgasm. At the same time, sexual dysfunction might be a symptom of a physical problem, such as diabetes, atherosclerosis, or hormone deficiency."

Rebecca S. Kightlinger, a gynecologist in Erie, PA, agrees. "You have to ask whether medication is causing sexual problems, because a lot of patients aren't going to volunteer that information. You can't be afraid that questions about sexual function are going to open a can of worms. That can needs to be opened."

Opinions differ on whether you should ask sex-related questions directly or include them in the medical history form. Bachmann prefers the verbal approach, because she thinks patients might be reluctant to put intimate details in writing. "Suppose you're examining Mrs. Jones, who's married to a colleague. It's unlikely that she'll write, 'My husband is impotent and I have vaginismus' on a history form."

Still, if you review the medical history form with the patient, even a written question that requires only a Yes or No answer—such as "Do you have any sexual problems"—can lead to a nice discussion, says Larry Maguire. "And if it's asked yearly, the question loses its taboo aura."

Kightlinger recommends a combination approach, tailored to your patient population. If your patients are at high risk for STDs, for instance, then your intake questionnaire might include some of the following:

• Do you use contraception?
• Number of current sexual partners
• Number of sexual partners in the past
• Do you notice any genital warts?
• Do you notice any discharge?

"I deal mostly with people over 40," Kightlinger says. "Their issues tend to be low libido and painful intercourse, so I ask about that during the physical. Any sexually related topic will be less jarring if you approach it casually, rather than portentously announcing, 'Now we're going to talk about sex.' "

Overcoming embarrassment: the patient's and yours

"I think the main reason internists, GPs, and family doctors have trouble discussing sexual issues with patients is that it's never been a part of our formal training. Even now, there are few med school courses and not much CME on addressing sexual dysfunction in a primary care setting," says internist Larry Maguire.

Another reason doctors are tempted to duck the issue is that there's no "one size fits all" treatment for any sexual problem. "A physician can't say, 'I treat all my patients with anorgasmia this way,' " notes Gloria Bachmann. "It's not like treating vaginitis with an antiyeast preparation."

Educational opportunities are out there, though. There are a handful of sexual dysfunction clinics you can train at and there's information available on the Internet, including an AMA curriculum on talking with patients about sex and sexuality (see "What to ask").

Elizabeth Pector learned how to treat sexual dysfunction at Domeena Renshaw's Loyola clinic and from professionals associated with Masters and Johnson. Among the lessons she's learned:

• If the doctor isn't embarrassed to talk about sex, the patients won't be.
• Misinformation and bad counseling are worse than any harm that could come from taking a sexual history.
• You don't have to use the patient's terms and language, but you do need to be sure that the patient understands the terms you choose. It's important to avoid loaded words such as "frigid," "impotent," and "unfaithful."
• You don't need to be able to treat what you uncover in history-taking. Especially in primary care, the focus is on providing education about normal function, discovering problems, and referring to specialists when appropriate.

Referral is sometimes difficult, however, if the patient is a woman. "A lot of urologists are ready and willing to treat male sexual dysfunction," says family physician Birgit Houston of Nashua, NH, "but not many gynecologists are comfortable dealing with these problems, even severe dyspareunia. In part, this is because there are far fewer treatments for female sexual dysfunction than for male, and those that exist haven't been as well studied."

So in many cases, you may be your patient's best bet for getting any help.

When counseling patients, "be respectful of the value patients place on sexuality," says Pector. "One woman I saw recently would rather live with drowsiness and nausea from an antidepressant than the sexual dysfunction caused by an alternative medicine. On the other hand, a different patient is willing to tolerate a loss of libido in exchange for freedom from painful migraines."

Will asking about sex get you in trouble?

Sex is such a highly charged topic that many doctors duck the subject because they fear their motives will be misinterpreted.

"I try to monitor the nonverbal cues my female patients give me when we discuss the issues of sex, arousal, and intercourse, being especially mindful of the color of their cheeks," says Gregory Hood, an internist in Lexington, KY.

Birgit Houston thinks that a female doctor/male patient combination can be a plus when the topic is sexuality, especially if the doctor doesn't express any overt embarrassment. "I've discussed sexual dysfunction enough to understand the impact it has on males," she says, "and they don't have to get into any male/male competition issues with me. I'm pretty shock-proof, so that helps a lot."

Denver internist Judy Paley agrees that female physicians are on safe ground when they broach the subject of sex with male patients. "I figure if they've opted for a lady physician they must be comfortable having such conversations with me," she says.

Things are dicier when the doctor is male and the patient is female—especially if they're both relatively young. If you're concerned about how such a discussion might be construed, you can bring in a nurse before introducing the topic of sex—or you can have the nurse make some general inquiries when she's checking weight and blood pressure. If problems exist, you can address them during the exam.

"Generally speaking," Hood says, "I think that most patients who introduce the topic of sexuality or acknowledge it as an issue do so with the perspective of wanting to improve, just like any other condition. If we approach it thoughtfully and professionally, we seldom get into trouble."

Ask your older patients—especially your older patients

"A survey we did here showed that the most reluctance to talk about sex was among the very young and the very old—and they're the cohorts that need the most education," says Robert Wood Johnson's Gloria Bachmann. "With adolescents, you're basically providing information and dispelling myths. A typical ice-breaking question would be, 'Is there anything I can tell you about puberty?' Aging brings a wide range of medical, surgical, and menopausal issues."

Where will you find the time for all this? "Any problem that's uncovered during a checkup—whether it's a blood pressure of 200/120 or premature ejaculation, must be dealt with," Bachmann says. "Usually, however, sexual dysfunction doesn't represent a crisis. So if you have a very full schedule, you'll still be doing right by your patient if you identify the problem and then handle it during a subsequent visit."

"The key is attitude," Richard Kogan adds. "If the primary care doctor is supportive, nonjudgmental, and empathic, the patient will realize that he or she has permission to talk about sex—if not now, in the future.

"Patients really care about their sexuality, and if physicians show they're interested it will forge a deeper bond."

What to ask

The following questions will give you good start constructing a sexual history form. They are included in the AMA's workshop curriculum to train physicians to talk with patients about sex and sexuality. To view the entire curriculum—as well as a list of Web sites on the subject—go to www.ama-assn.org/mem-data/joint/sex001.htm .

In order to give you the best care, I need to ask you about all of the behaviors that affect your health:

• Are you sexually active?
• Have you ever had a sexually transmitted disease?
• Was it treated?
• Are you currently involved with more than one partner?
• Have you ever had more than one partner?
• What methods do you use to prevent pregnancy?
• What methods do you use to prevent transmission of disease?
• What type of sexual practices do you engage in?
• When you engage in sexual activity, is it with men, women, or both?
• How old were you when you became sexually active?
• Have you ever been tested for HIV?
• Do you want to be tested for HIV?
• Do you have any questions or concerns about sexual activity or sexual functioning?

Gail Weiss. How to talk to your patients about sex.

Medical Economics

2002;20:40.