Talking With Patients About Sexuality and Sexual Health

(Created March 2010)

It can be difficult for health care providers and patients to begin the discussion about sexuality and sexual health, but patients want to talk to you about their sexual concerns—and they want you to raise the subject first.^1,2

• A survey of 391 women conducted by The Women’s Sexual Health Foundation found that 72 percent of respondents would be comfortable talking to their clinician about sexual problems, but 73 percent preferred that the health care provider bring up the topic.¹
• An online survey of 3,807 healthy volunteers reported that 40 percent of women who participated did not talk to a clinician about a sexual problem, but over half of them wanted to.²
• A consumer poll of 1,209 US women found that 70 percent of respondents had experienced a sexual health issue (e.g., lack of desire or arousal, inability to orgasm, pain during intercourse, vaginal dryness, or excessive desire for sexual activity) and 22 percent were very or extremely concerned about it—yet only 18 percent had consulted a health care provider about their problem.³
• The National Health and Social Life Survey of 1,749 women ages 18-59 found that 43% of respondents had a sexual issue; only 10%-20% had seen a clinician about it.⁴

In addition, a poll of 304 US health care providers commissioned in 2009 by the Association of Reproductive Health Professionals (ARHP) and HealthyWomen found that:

• Sexuality is the least commonly discussed health topic with female patients for half of providers.
• Providers discuss sexual health issues with less than half (39%) of their female patients.
• Female providers are somewhat more likely than male providers to discuss sexuality with their patients (45% versus 34%, respectively).
• Most providers (74%) rely on their patients to initiate a discussion about sexual health.

Why are providers apprehensive to initiate the discussion about sexual health issues with patients? The lack of training and skills to deal with these concerns is cited as a reason. The personal embarrassment or discomfort of talking about sex is another. Many providers underestimate the prevalence of sexual dysfunction in their patient population or the impact that sexual complaints have on their patients’ global health and wellness, and some are concerned about offending patients. The lack of effective and safe treatment options has also been a factor and others feel that sexuality is too complex of an issue to tackle in limited time allotted for a routine visit.^2,6,7

Whatever the reason for the lack of communication, these provider and consumer surveys highlight a major gap between what patients need and want regarding their sexual health and what front-line clinicians are offering them.

Basic Behavioral Counseling for Female Sexual Health Issues

Talking about sexual health issues with patients should not be intimidating for providers—nor does it mean opening up the conversation to a slew of concerns that will disrupt the office schedule.

Experts in the field recommend several effective ways to broach the topic of sexuality during visits. You might open with a normalizing statement such as “It is part of my routine to ask about sexual health as part of the well-woman visit. Do you have any concerns?” and include sexual health questions as part of a review of systems. Or you might question the patient’s reproductive stage of life, saying “Some studies show that as women age, they may have less desire for sex or decreased lubrication, which makes intercourse uncomfortable. Have you noticed any changes?”⁶

Basic screening for sexual function should begin with two key questions:

1. Are you currently involved in a sexual relationship?
2. Are your sexual partners men, women, or both?⁶

From there, you would continue with the history-taking process. One effective model that follows the “stepwise approach” is based on the PLISSIT (permission, limited information, specific suggestions, and intensive therapy) Model of Intervention for Sexual Problems developed by psychologist Jack Anon, and helps to streamline this process.⁸

1. Ask open-ended questions to give the patient permission to talk about her sexual concerns and reassure her that her feelings are normal and acceptable. Validate and legitimize the patient’s complaint. Open-ended questions are preferred to “yes/no” questions, and may even help to constrain the interview time by focusing the history-taking on key areas of concern. Open-ended questions can also be used when a patient presents with a specific sexual health problem.^6,9

Below are some commonly used examples that are effective in clinical practice.

Open-Ended “Icebreakers” to Start the Discussion

• Tell me about any sexual concern/problem/issue you would like to discuss.
• How does the problem affect your life and relationship(s)?
• How does the concern present?
• What is the most distressing part of this problem?
• Tell me about your last sexual experience.
• How have you tried to manage the problem so far?
• Do you have a medical condition that affects your quality of life, including your sexual health?
• What are your goals for your sexual health?
• Tell me about the conversations you have had with your partner so far about this problem.^6,9,14

2. Provide limited information. Address whatever topics you can in the limited time you have available and perhaps encourage the patient to make a follow-up appointment to focus solely on her sexual health concerns. It is important to educate the patient about anatomy, physiology, sexual response, and sexual changes that may occur with age, use of certain medications (such as antidepressants), and under the influence of medical conditions (such as depression). (See ARHP’s CORE program [keywords “sex and sexuality”] and other Sexual Health Fundamentals fact sheets to get yourself up to speed on these topics.) Dispel myths about the sexual concern and offer handouts and resource lists on the subject. Potential sources of handouts include:

• American Association of Sexuality Educators Counselors and Therapists (www.aasect.org)
• ARHP Sex and Sexuality Reproductive Health Topic Area (www.arhp.org/Topics/Sex-and-Sexuality)
• International Society for the Study of Women’s Sexual Health (www.isswsh.org)
• North American Menopause Society (www.menopause.org)
• Sex and a Healthier You website (www.sexandahealthieryou.org)

3. Offer specific suggestions and solutions to treat the complaint. You may offer specific suggestions and solutions to begin to try to treat the complaint. First, manage co-morbid conditions that alter sexual function and consider assessment of medications that may impact sexual function.^6,12

Next, provide specific suggestions related to the patient’s sexual health goals. For instance, if the patient is interested in having a more active sex life, you might encourage her to learn more about her sexual response and sexual wellness (e.g., that women in long-term relationships often may not feel spontaneous desire but may experience desire if their partner stimulates them or that women often require direct clitoral and/or breast stimulation to have an orgasm; vaginal penetration alone is not sufficient for most women). See the box on “Educational and Erotic Resources” for excellent sources of information to recommend to patients.^11,12

If she’d like to make sex more of a priority in her life, you might suggest she:

• Get a lock for the bedroom door if privacy or interruption is a concern and making it a sexual sanctuary.¹³
• Schedule regular date nights (at home after the kids have gone to bed if she can’t afford a babysitter or out at a restaurant if she can).¹³
• Learn time and stress management skills to create a space in her life for sex.¹²
• Improve her exercise and diet habits and stopping smoking so she feels well enough for sex.¹²
• Address sexual boredom (change the sexual routine, spend time as a couple on a regular basis, treat one another with respect and interest, and look to sex education books and videos for new techniques).¹²
• Explore sexuality via masturbation and use of accessories, sexual enhancers, self stimulators, and sex toys.¹²

4. Beyond providing basic information and suggestions, most primary care providers will want to refer a patient, possibly for intensive therapy, to qualified specialists including sex therapists, couples counselors, cognitive-behavioral therapists, physical therapists, medical or surgical subspecialists (gynecologist, psychiatrist, endocrinologist, urologist, urogynecologist) for further expert intervention.

Providers should refer any patient with a sexual issue that exceeds their comfort level or expertise. They should also refer patients who are victims of intimate partner and domestic violence to the National Domestic Violence Hotline at 1-800-799-SAFE (7233) or www.ndvh.org and local shelters, authorities, and domestic violence specialists, and recommend patient support groups for sexual abuse survivors.

For more information on this topic, refer to the other Sexual Health Fundamentals fact sheets, The Top 10 Things You Need to Know about Female Sexuality and Sex Therapy for Non-Sex Therapists.

References

1. The Women’s Sexual Health Foundation. Sexual Health Discussion Survey. Available at www.twshf.org/survey.html. Accessed 12/14/09.
2. Berman L, Berman J, Felder S, et al. Seeking help for sexual function complaints: What gynecologists need to know about the female patient’s experience. Fertil Steril. 2003;79:572-576.
3. Association of Reproductive Health Professionals and the National Women’s Health Resource Center (now HealthyWomen). National survey shows 70% of women have experienced a sexual health issue. Available at /Publications-and-Resources/Studies-and-Surveys/SHY-Survey. Accessed 11/9/09.
4. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA. 1999;281:537-544.
5. Association of Reproductive Health Professionals and the National Women’s Health Resource Center (now HealthyWomen). Women’s Sexual Health: Provider Survey. 2009. Available at /Publications-and-Resources/Studies-and-Surveys/SHY-Survey. Accessed 11/9/09.
6. Kingsberg SA. Taking a sexual history. Obstet Gynecol Clin N Am. 2006;33:535-547.
7. Gott M, Galena E, Hinchliff S, et al. “Opening a can of worms”: GP and practice nurse barriers to talking about sexual health in primary care. Family Practice. 2004;21:528-536.
8. Leiblum SR, ed. Principles and Practice of Sex Therapy. Fourth Edition. New York, NY: Guilford Press. 2007.
9. Andrews WC. Approaches to taking a sexual history. J Womens Health Gend Based Med. 2000;9 Suppl 1:S21-S24.
10. Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States Women. Obstet Gynecol. 2008;112:970-978.
11. Basson R, Leiblum S, Brotto L, et al. Definitions of women’s sexual dysfunction reconsidered: Advocating expansion and revision. J Psychosom Obstet Gynecol. 2003;24:221-229.
12. Krychman ML. 100 Questions & Answers About Women’s Sexual Wellness and Vitality. Sudbury, MA: Jones and Bartlett Publishers. 2010.
13. Berman J, Berman L, Bumiller E. For Women Only: A Revolutionary Guide to Reclaiming Your Sex Life. 2 nd ed. NY, NY: Holt. 2005.
14. Association of Reproductive Health Professionals (ARHP). Sexual Health Fundamentals for Patient Care Initiative: Report of a US Consensus Process. Available at www.sexualhealthfundamentals.org. Accessed 3/2/10.

Sexual Health Fundamentals is a publication of the Association of Reproductive Health Professionals (ARHP) for health care professionals, educators, and researchers working in the field of reproductive health. This fact sheet is part of the Sexual Health Fundamentals for Patient Care Initiative, which was guided by principles established by a consensus committee of renowned experts in female sexuality, led by cochairs Michael Krychman, MD, and Susan Kellogg Spadt, CRNP, PhD. The goals of this initiative are to assist “frontline” members of the reproductive health care team with expert, evidence-based guidance on sexual function, health, and wellness, and to provide freely available needs assessment tools for professional societies to customize for their specific constituencies. Sexual Health Fundamentals are available at www.arhp.org