I was seeing a continuity patient with chronic back pain after a traumatic accident left her partially paralyzed. Although she regained most of her muscle control, she still lived with daily baseline pain interspersed with periods of excruciating pain. I asked her how it was affecting her quality of life, and she tearfully shared with me that her pain meant she was no longer able to engage in intimacy with her husband.

I expressed my sympathy and thanked her for being open and honest. We then talked about how discussing intimacy and sex in the exam room can not only be uncomfortable for physicians and patients alike, but that it can also be taboo.

 

Sexual health and quality of life 

 

My encounter with this woman opened my eyes (and my mind) to the importance of integrating sexual health into the exam room. 

 

Sexual health should not only be considered from a disease prevention and management standpoint, but also in how it relates to quality of life.

I believe physicians have a responsibility to help their patients gain a better understanding of how medical complications can affect sex and intimacy.

When patients feel and look different, whether they have an illness or disability, they find it challenging to be intimate, and their quality of life suffers.

 

Why do we struggle to talk about sex?

 

For many physicians, sexual health is only a topic of conversation in regards to sexual dysfunction or a potential STI. We wait for our patients to bring up the issue first, instead of having an open dialogue about sex and intimacy. Many of us learned in medical school and residency to inquire about STIs, pregnancy prevention, and sexual dysfunction, but we rarely talk about pleasure and intimacy with our patients. The amount of hours dedicated to sexual education in medical school and residency is embarrassingly low. 

Many of us were not appropriately trained to address sex in the exam room unless we took elective rotations in an STI clinic or an HIV infectious disease rotation. Sexual history is often not our priority, and we may not only feel uncomfortable talking about this, but we may not have the resources to adequately address these concerns. While we are well-versed in medical history, surgical history, and family history, discussions about lifestyle usually only include inquiries about tobacco, drug, and alcohol use, skipping over the equally important sexual history. 

We might think, “I don’t have time to take a sexual history,” or “My patient is too young or too old to be having sex,” or “I don’t want to offend her by asking those questions.” But when we wait for our patients to bring up the issue first, it often goes unaddressed. 

 

Putting our patients at ease

 

Many of our patients want to talk about sex, but they typically want their physicians to bring it up first. So, how can we address the elephant in the room while making our patients (and ourselves) feel at ease?

We must make talking about sex routine and do it in a way that is open-minded, compassionate, and empowering to our patients.

We must ensure privacy and confidentiality by saying things like, “Anything you share with me stays in this room and this room only.” We can tell them that we have these conversations with every patient, so it doesn’t make them feel like we are singling them out. We can seek out training in sexual health and learn about the resources that are available to patients who are struggling with sexual health issues.

We should not only talk about the “5 Ps” (that is, partners, practices, protection from STIs, past history of STIs, and pregnancy), but we also must ask about pleasure from a quality of life standpoint. 

 

Empowering our patients

 

Instead of saying, “I am going to ask you a few questions about your sexual history,” allow the patient to lead the conversation by asking, “Is it OK if I ask you questions about your sexual health now?” This gives them the power. 

You can then ask, “Is there anything about your sexual health that you would like to share with me today that I can help you with?” Instead of short, blunt, awkward questions, we can ask permission and follow up with open-ended questions that will hopefully foster safe and effective communication between you and your patient. 

 

• When the conversation begins, we can ask questions from a disease management standpoint, such as “Is anything bothering you, such as discharge or burning while you pee?” and “Do you feel safe in your relationship?” 

• Before we ask questions related to family planning, make sure you are being sensitive to your patient’s sexual orientation. If your female patient’s partner is female, it can be foolish and tone deaf to ask about birth control. 

• Avoid using gendered terms such as “girlfriend” or “husband,” and use neutral words such as partner—your patient may not be monogamous, cisgender, or heterosexual. At the start of the conversation, ask how they identify their sexual orientation and whether or not they are monogamous. 

• You can also ask if they are satisfied with their sexual health and if they are having sex in the way they want to have it, with people they want to have it with. 

You do not have to be an “expert” on sex to talk about sexual health with your patients—they don’t expect you to have all the answers. It’s far more important you show that you’re compassionate, that you want to engage, and you are ready to listen.