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)
| 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
|
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.
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 professional 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:
sildenafil
(Viagra®),
vardenafil (Levitra®), and
tadalafil (Cialis®).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 rates15,16—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 |
More Taking A Sexual History
References:
- 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.
- Kingsberg S. Just ask! Talking to patients about sexual function.
Sexuality, Reproduction & Menopause 2004;2(4):199-203.
- Marwick C. Survey says patients expect little physician help on sex. JAMA
1999;281:2173-2174.
- American Association of Retired Persons. AARP/Modern Maturity
Sexuality Study. Washington, DC: AARP; 1999.
- The Pfizer Global Study of Sexual Attitudes and Behaviors. Available
at www.pfizerglobalstudy.com. Accessed 3/21/05.
- Kingsberg SA. Optimizing the management of erectile dysfunction:
enhancing patient communication. Slide presentation, 2004.
- Pfeiffer E, Verwoerdt A, Davis GC. Sexual behavior in middle life.
Am J Psychiatry 1972;128:1262-1267.
- Pfeiffer E, Davis GC. Determinants of sexual behavior
in middle and old age. J Am Geriatr Soc 1972;20:151-158.
- Avis NE. Sexual function and aging in men and women: community and
population-based studies. J Gend Specif Med 2000;37(2):37-41.
- Laumann EO, Paik A, Rosen RC. Sexual
dysfunction in the United States: prevalence and predictors. JAMA
1999;281:537-544.
- 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.
- 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.
- Whipple B. The role of the female partner in assessment and
treatment of ED. Slide presentation, 2004.
- Kingsberg SA. Optimizing the management of erectile dysfunction:
enhancing patient communication. Slide presentation, 2004.
- 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.
- Briganti A, Salonia A, Gallina A, et al. Emerging oral
drugs for erectile dysfunction. Expert Opin Emerg Drugs 2004;9:179-189.
- 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.
Last reviewed 10/05
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