Doctor/Patient Communication About Sexuality Issues

Patient sexuality issues can be difficult and daunting for a doctor to explore, but accurate diagnosis and effective treatment hinge on good communication between doctor and patient, as well as between the patient and her sexual partner. Given the increasing emphasis on sexuality in our society, the continuing sexual activity of midlife and older women and their partners, the aging of Americans, and the growing awareness of sexual disorders, the chances are good that most doctors will encounter patients who inquire about their sexuality.

Many doctors say they don't broach sexuality issues because they lack training and skills to deal with human sexuality concerns, feel personal discomfort with the subject, fear offending the patient, have no treatments to offer, or believe that sexual interest and activity naturally decline with age. ^(1,2) They also may avoid the topic because of concerns about time constraints, ⁽²⁾ although initial general assessments need not take an inordinate amount of time. Follow-up appointments or referrals can be made to perform more complete assessments. Sometimes, a brief discussion about sexual issues can reveal that education is needed more than treatment. For instance, many patients may not know about the ways in which aging can affect their and their partner's sexual function.

Many patients are unaware that it is appropriate to discuss sexual issues with their doctors or are concerned about embarrassing those doctors. According to Marwick, 68 percent of patients surveyed cited fear of embarrassing a doctor as a reason for not broaching sexuality issues.³ In the same survey, 71 percent of the respondents believed their doctors would simply dismiss their sexual concerns. And in a survey conducted by the American Association of Retired Persons of 1,384 Americans aged 45 or older, only 14 percent of women had ever visited a doctor for problems related to sexual function.⁴ In a Web-based survey of 3,807 women, 40 percent of women said they did not seek help from a doctor for sexual function problems they experienced, but 54 percent said they wanted to see a doctor. ⁽¹⁾ Those who did seek help did not rank the attitude or services provided by their doctors highly.

In contrast, a recent survey revealed that only 14 percent of Americans age 40 or older have been asked by their doctors over the past 3 years whether they're having sexual difficulties.⁽⁵⁾

Because of the many interpersonal variables that come into play in creating sexual problems, it is important for the doctor to approach a sexual disorder as a couple's problem rather than just one female partner's problem. Doctors also should be open and non-judgmental about the types of sexual activities patients are engaging in (including masturbation and same-sex partnerships) and should not make assumptions that all patients are involved in heterosexual relationships. Finally, they should be aware that midlife patients may not all be in long-standing relationships.

Table 8 lists skills that all doctors can develop to communicate with patients about sexuality issues.

TABLE 8. Communicating with Patients About Sexuality

• Be a sympathetic listener
• Reassure the patient
• Educate the patient
• Address sexual problems as a couples issue
• Provide literature
• Schedule a follow-up visit to focus on sexuality issues
• Make a referral as necessary

Concomitant medical and psychological approaches to sexual problems are often warranted. In fact, Sheryl Kingsberg, PhD, a clinical psychologist specializing in sexuality at Case Western Reserve University, suggests that if a doctor ignores psychosocial issues related to sexual disorders, medical interventions can be sabotaged and destined to fail.⁽⁶⁾

As a doctor, you may not feel comfortable or prepared to offer extensive counseling to patients with sexual problems. Partnering with a psychologist, psychiatrist, sex therapist, or other professionals with expertise in this area who offers couples therapy, sex therapy, training in communication techniques, anxiety reduction, or cognitive-behavior approaches is often beneficial to the patient so that both medical and psychological etiologies are managed.⁽²⁾

The Impact of Male Sexual Functioning on Midlife Women

For many midlife women, sexual activity is dependent on the health of their male partner. The Duke Longitudinal Study of men and women aged 46 to 71 found that sexual activity for women often declined as they aged because of the death or illness of a male spouse (36 percent and 20 percent, respectively) or because the spouse was unable to perform (18 percent).7-9

In the National Health and Social Life Survey, 31 percent of men between the ages of 18 and 59 years suffer from a sexual dysfunction, most notably erectile dysfunction (ED), premature ejaculation, and lack of desire for sex (which is often related to performance issues).10 A more recent international survey of 27,500 men and women 40 to 80 years of age found that 14 percent of male respondents suffer from early ejaculation, and 10 percent suffer from ED.¹¹ ED tends to increase with age and become more severe: The Massachusetts Male Aging Study found that 40 percent of men age 40 suffer from some degree of ED, a figure that jumps to 70 percent by age 70.¹²

According to Whipple, some women feel that ED is their fault, suggesting they are no longer attractive to their partner or that he is having an affair. Some welcome the cessation of sexual activity and feel that it is better to avoid sexual encounters that can't be taken to completion of sexual intercourse so as not to embarrass their partner.^13,14 Others may find that sex becomes mechanical and boring, or focused on maintaining or prolonging a man's erection, rather than on mutual pleasure.¹⁴

The advent of phosphodiesterase type 5 (PDE-5) inhibitor treatment of ED has changed sex in America for midlife couples. Many couples that were not engaging in sexual activities are now attempting to have intercourse and encountering female sexual problems caused by the previous cessation of intercourse and the effects of aging on the vagina. Common complaints of midlife women resuming sexual intercourse after abstinence due to their partner's ED include vaginal dryness, dyspareunia, vaginismus, urinary tract infections, and lack of desire.

Three oral PDE-5 inhibitors are currently available.^15,16 The three represent the current standard of care for ED and have different durations of action.^15,16 As a group, the PDE-5 inhibitors have similar efficacy rates^15,16 - although 30 to 40 percent of men with ED are resistant to the drugs.¹⁷ According to Sheryl Kingsberg, the 36-hour duration of tadalafil may offer some psychological advantages to couples.¹⁴ For men, it decreases the pressure to perform immediately after pill-taking and allows for more sexual spontaneity. For women, it decreases the perception of "sex on demand."

Sharing this type of information with couples can be the first step to putting them back on the path to a mutually satisfying sex life. These women and their partners need education and counseling about the changes their bodies have undergone since they last were having sexual intercourse on a regular basis, and possibly psychological counseling and other medical treatment as well.¹⁴

References:

1. 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.
2. Kingsberg S. Just ask! Talking to patients about sexual function. Sexuality, Reproduction & Menopause 2004;2(4):199-203.
3. Marwick C. Survey says patients expect little physician help on sex. JAMA 1999;281:2173-2174.
4. American Association of Retired Persons. AARP/Modern Maturity Sexuality Study. Washington, DC: AARP; 1999.
5. The Pfizer Global Study of Sexual Attitudes and Behaviors. Available at www.pfizerglobalstudy.com. Accessed 3/21/05.
6. Kingsberg SA. Optimizing the management of erectile dysfunction: enhancing patient communication. Slide presentation, 2004.
7. Pfeiffer E, Verwoerdt A, Davis GC. Sexual behavior in middle life. Am J Psychiatry 1972;128:1262-1267.
8. Pfeiffer E, Davis GC. Determinants of sexual behavior in middle and old age. J Am Geriatr Soc 1972;20:151-158.
9. Avis NE. Sexual function and aging in men and women: community and population-based studies. J Gend Specif Med 2000;37(2):37-41.
10. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537-544.
11. Nicolosi A, Laumann EO, Glasser DB, et al. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology 2004;64:991-997.
12. Feldman HA, Goldstein I, Hatzichritous DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61.
13. Whipple B. The role of the female partner in assessment and treatment of ED. Slide presentation, 2004.
14. Kingsberg SA. Optimizing the management of erectile dysfunction: enhancing patient communication. Slide presentation, 2004.
15. Gresser U, Gleiter H. Erectile dysfunction: comparison of efficacy and side effects of the PDE-5 inhibitors sildenafil, vardenafil, and tadalafil. Review of the literature. Eur J Med Res 2002;7:435-446.
16. Briganti A, Salonia A, Gallina A, et al. Emerging oral drugs for erectile dysfunction. Expert Opin Emerg Drugs 2004;9:179-189.
17. de Tejada IS. Therapeutic strategies for optimizing PDE-5 inhibitor therapy in patients with erectile dysfunction considered difficult or challenging to treat. Int J Impot Res 2004;suppl 1:S40-S42.