The World Health Organization has long proclaimed that sexual health is a fundamental human right, but do physicians realize that?
“Supporting and prioritizing sexual health hasn’t trick-led down to countries like the United States,” explains sexologist Eric Garrison. “Every patient is a sexual being, but a lot of physicians forget that, overlooking how a medical condition is affecting one’s sex life.”
Nowhere is this shortcoming more common than in a practitioner’s failure to address the sexual side effects of prescription and over-the-counter (OTC) drugs, with medical training rarely delving into the subject. “I don’t think this is something I ever heard discussed in medical school,” reflects Dr. Leana Wen, a resident in emergency medicine and a former president of the American Medical Student Association. “We heard about a lot of side effects, like bleeding and low blood pressure, but not sexual ones.”
With the sexual functioning of both men and women impacted by a long list of medications, there’s a lot to be learned—and discussed—by physician and patient alike. Still, physicians-in-training, and their mentors, are failing to disseminate sexuality information, ask sex-related questions, and take a patient’s sexual history. The message they’re sending is that sexual health isn’t a part of overall health.
Not-so-sexy Side Effects
“I’m hearing from both clients and physicians that sexual side effects are not tended to at all,” shares certified sex therapist Lawrence Siegel. “Many physicians just don’t know about them and are the least trained in this area.” The scant research on patient–physician communication and sexual side effects supports that assertion. A 2001 survey conducted by the National Depressive and Manic-Depressive Association found that only 16 percent of patients reported that their physicians mentioned potential sexual problems from using antidepressants.
No matter the condition, in treating anything from allergies to heart disease to bipolar disorder, medications threaten to harm a patient’s sex life and sexual self-concept. Some medications decrease sexual hormone levels, lowering one’s sex drive. Others depress the central nervous system, affecting nerve endings, while still others decrease blood flow to the pelvic region.
The domino effect leads to changes in vaginal lubrication, erectile function, ejaculatory control, sensitivity to stimulation and sensations, or orgasmic response, all of which can impact a patient’s sexual mood, thoughts and feelings. Side effects like changes in weight, skin, body odor or mobility can further negatively impact a patient’s body image or self-image, ultimately affecting sexual libido and the desire for intimacy.
Sex: The Doorknob Issue
With physicians feeling ill-equipped to handle sexuality issues, citing “incapacity” or a “lack of time” as reasons to avoid the topic, many don’t bring up sex until they’ve reached the door. As Siegel can attest, they fear that a dilemma will be too time-consuming and complex to adequately treat in a typical primary care visit. “When I was on an Intrinsa advisory panel for Procter and Gamble, we surveyed physicians about sexual communication with patients and found that the vast majority of physicians really tried to avoid any doorknob issues like sex. They simply don’t have the time to talk and are ill-prepared to do so.”
With emotional inhibitions, like embarrassment, making it even easier to avoid the subject, many practitioners omit a sexual history, claiming that they’re in a hurry, sex is unrelated to the primary presentation, or that they’re worried about seeming per-verted. “No mention of sex” from the patient is another easy excuse, with a 2007 study in the New England Journal of Medicine finding that, while half of men and women ages 57 to 85 reported at least one bothersome sexual problem, only 38 percent of men and 22 percent of women over 50 talked to their doctor about sex.
“Physicians-in-training need to realize that patients are embarrassed about sex, so they won’t ask questions,” stresses Garrison. “Many patients find themselves in a Catch-22, like the guy who is depressed, has gone to the doctor for meds, but now can’t have an erection, get aroused, ejaculate—and he thought he was depressed before! Doctors need to offer patients safety in the third person, being permission-giving with statements like: ‘Many patients are uncomfortable asking about sex, but blank is a common issue.’”
“In my school,” says David Saquet, a third-year at the University of New England College of Osteopathic Medicine (UNECOM), “they give us a class on how to take a proper sexual history. The class represents one week of our ‘how to be a doctor’ class and is very thorough. They teach us to ask about activities—with men, women or both—and if the patient is satisfied.” During simulated patient encounters, students at UNECOM lose points if they don’t do a sexual history when appropriate, like during a complete history and physical or when the complaint could involve sexuality.
The Need for Holistic Sexual Medicine
Given that sexual problems may be multifaceted, involving physiological, psychological, emotional and relational issues, patient concerns need to be explored in-depth. Yet a patient’s sexuality is rarely handled holistically, with physicians-in-training failing to consider anything beyond immediate observations.
Saquet has never heard any of his peers resist learning about a holistic approach to sexual medicine. “For the most part, people I train with agree that sexual health is an integral part of overall health,” he says, “though this sometimes gets bowled over by the huge volume of information required to come up with a good diff at this point in the students’ training.” He points out that this is a “huge” part of the osteopathic philosophy: the person as an integrated unit of body, mind and spirit.
“When considering a patient, I personally put sexuality in all three categories,” Saquet says. “I have taken sexual histories on patients who see me for a 15-minute acute visit for toe pain just because there was nothing in their chart to indicate that it’d ever been done, and it’s essential to be in the patient’s chart at their [primary care physician’s] office.”
Still, issues like whether a sexual problem is caused by the health condition or the treatment, let alone relationship issues, are rarely addressed. Potential drug interactions, including OTC meds, like antihistamines and decongestants, are frequently left unexplored.
“Prescription drugs aren’t the only problem,” Garrison explains. “An OTC that dries up the nose will, for example, dry up the vagina. Women are left wondering if it’s ‘me’ or the medicines. Much could be dealt with via patient–doctor education looking at the big picture.”
While research has found that primary care physicians are well-versed in asking routine questions about patients’ sexual partners and practices, physicians do not often initiate discussions about a patient’s or couple’s intimacy issues or overall sexual health. With traditional medical education inadequately preparing physicians to talk to patients clearly and candidly about their sex lives, many are inexperienced in inquiring about sexual satisfaction.
Though some universities have made concerted efforts to improve sexuality education in medical school, many have not, as resident Dr. Derek Andelloux of Brown University has observed. “I went to Boston University for medical school training, and they were proactive with taking in-depth sexual histories, normalizing behaviors, including extreme behaviors, and asking about sexual satisfaction,” he says. “This wasn’t the case five to 10 years ago, and is quite cutting edge when compared to med schools down South, where issues like sexual side effects of common psychiatric drugs, contraceptives and Viagra aren’t discussed.”
This lack of adequate training on the sexual side effects of medications only complicates the situation, especially since medical students and residents are often unmotivated or too embarrassed to acquire such information, as Garrison asserts. “When a pharm rep comes in and treats everyone to lunch over a drug presentation, that’s all med students learn and recall. Erotophobia and laziness are two major reasons why they’re not asking the rep questions about sexual side effects.”
Siegel, too, sees this type of rote training as an issue. “One thing that continues to be perpetuated in physician training is the memorization of treatments and procedures. This limits a practitioner’s rationale to ‘we do this because this is what we do.’ We need to train physicians to think a little bit more, being open to the possibility that, based on client feedback, they may need to rethink prescriptions.” Yvonne K. Fulbright is a sex educator and author who holds a doctorate in international community health with a focus on sexual health and sex communication. Direct comments about this topic to firstname.lastname@example.org.
How to have the talk
Researchers at the University of Texas at Austin found that educating patients in advance about the sexual side effects of SSRIs decreases the presentation of sexual dysfunction at follow-up visits, demonstrating the value of such discussions. In these talks, during medical training or clinical consultations, practitioners should seek to:
Pose questions about sexual health on patient intake forms.
Some patients are more comfortable writing about their sexual concerns. This also saves time and helps practitioners gather a more detailed sexual history.
Have brochures or posters in the waiting room.
Having materials with sexuality information reassures patients that such conversations are permissible.
Mail educational materials ahead of time.
Patients can be made aware of sexual issues related to medications before their appointments, giving both parties the opportunity to process the information expeditiously during clinical services.
Ask one question during clinical services, like how pleasurable is sex for you at this point in your life?
Such open-ended, single-question inquiries can be highly effective in identifying patient concerns or problems. Even patients who do not open up on their first visit may be willing to follow up during subsequent examinations.
Refer when necessary.
Practitioners need to be willing to refer, sometimes outside of medicine, as Siegel advises: “Doctors have a few minutes to do what they need to do and get out. A number will admit that they don’t have experience or training to do counseling and work with sexuality issues. Those who do refer do an M.D. lateral hand-off with a psychiatrist versus a sex therapist. They don’t know who sex therapists are or what we do, but need to know.”
Participate in sexuality training opportunities.
An evaluation of a sexual history-taking curriculum for second-year medical students, implemented at Northeastern Ohio Universities College of Medicine, showed how workshops, small-group discussions and readings can improve medical students’ performance at taking sexual histories. The evaluation found that 84 percent of students asked at least one sexual history question on the Clinical Skills Assessment. The American Medical Student Association’s Sexual Health Scholars Program has also sought to benefit physicians-in-training, with sex educator Melanie Davis finding that students get over fears and build their comfort levels in activities like role playing. “Practitioners have to act comfortably, projecting that it’s normal to ask about sex. This ability to collect sexuality-related information is critical to overall health, and needs to become part of normal protocol and risk assessment.”