Just ask! Talking to patients about sexual function

Why doctors don’t talk about sex 

A number of practical barriers get in the way of effective dialogue:

Key points 

■Only 14% of Americans aged 40–80 have been asked by their doctor about sexual difficulties within the past three years.

■In one survey, 68% of patients feared that raising concerns about sexual problems would embarrass their physician—71% believed the doctor would dismiss their concern.

■The most important step in starting a dialogue: Simply ask patients about their sexual activity and associated concerns.

■Women are more likely to bring up sexual matters if they have seen the physician before and if the physician seems concerned and comfortable or has a professional demeanor.

■Low sexual desire is the most prevalent female sexual dysfunction and is frequently associated with menopause. Persistent or recurrent low desire that causes personal distress is classified as hypoactive sexual desire disorder.

■If you suspect hormonal imbalance in a patient with hypoactive sexual desire disorder, consider estrogen and/or testosterone therapy.

■Offering brochures or books that address sex and marital problems helps to normalize a patient’s concerns and provide education.

Why patients don’t talk about sex 

Patients are not likely to bring up the subject of their sexuality, and very few women seek help or treatment for sexual concerns. In the American Association of Retired Persons/ Modern Maturity Sexuality Study of 1,384 Americans aged 45 and older, only 14% of women reported ever seeking assistance from a health care professional for problems related to sexual function.6 On the other hand, if a physician takes the lead in discussing sexuality, patients are more likely to report problems. In a study of patients receiving selective serotonin reuptake inhibitors, the incidence of sexual dysfunction was only 14% when based on spontaneous patient reports, compared with 55% when physicians posed direct questions.7

Patients’ reluctance to discuss sex has much to do with the reaction they anticipate from their doctor. In a survey of Americans 25 and older, 68% of men and women said they feared that raising concerns about sexual problems would embarrass their physician— and 71% believed that the doctor would dismiss their concern.8 Women are more likely to bring up sexual concerns if they have seen the physician before and if the physician seems concerned and comfortable or has a professional demeanor.9 Patients thus seem to be looking to their physician for “permission” to bring up sexuality issues.

Getting the conversation started 

Healthcare professionals should approach female sexual dysfunction much like any other disorder: First accurately assess whether or not a problem exists, then treat and/or refer.

Although women are at risk for sexual dysfunction throughout their life span, there are several key periods, including the menopause transition and beyond, that are associated with increased risk.10, 11 Office visits at these times provide an opportunity to screen for sexual concerns (Table 1).

Table 1. Opportunities to screen for sexual dysfunction10

	Prior to surgery	Menopause-related visits	Antenatal visits	Infertility
	Uterine prolapse		Postnatal visits	Chronic illnesses
	Hysterectomy	Prior to discussing hormone therapy
	Oophorectomy		Annual visits	Depression

What is the best way to approach patients about sexuality and related concerns? Simply put, just ask them. Whether or not the patient offers information, physician-initiated questioning conveys concern and comfort and lets the patient know that it is appropriate to discuss these matters in an office setting.

An algorithm for screening sexual dysfunction is available (Figure 1), or the following questions can be used.10, 12, 13

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Figure 1. Screening for sexual dysfunction

Physicians interested in conducting a more in-depth assessment may want to use the algorithm developed by Basson to help establish a diagnosis (Figure 2).10

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Figure 2. Establishing a diagnosis of sexual dysfunction

Menopause, sexual issues, and loss of desire 

Women who are menopausal, whether naturally or surgically, may have specific sexual concerns. Estrogen depletion causes physiologic changes, such as vaginal atrophy and dryness, that affect sexual function. A decrease in testosterone, which may lead to decreased sexual desire in women, occurs with aging and is further pronounced in women who undergo oophorectomy (See also “Women’s sexuality after menopause: What role for androgens?” on page 204 of this issue.)

The following questions will help start a conversation with menopausal patients:

Persistent or recurrent low desire that causes personal distress is classified as hypoactive sexual desire disorder (HSDD). Low sexual desire is the most prevalent female sexual dysfunction and is frequently associated with menopause. The disorder is complex, involving biologic and psychosocial factors, and may overlap with other types of sexual dysfunction.

A careful evaluation of all potential factors is required to diagnose and treat HSDD. The following questions may help assess the impact of low desire:

Complete medical and sexual histories should be taken when making a diagnosis of HSDD:

Most screening tools for sexual dysfunction are lengthy and reserved for clinical research.15 Questionnaires such as the Female Sexual Function Index16 and the Arizona Sexual Experiences Scale for Women17 are available, and additional diagnostic tools for officebased screening are in development.

Treatment options: estrogen and testosterone 

If you suspect hormonal imbalance in a patient with HSDD, consider estrogen and/or testosterone therapy. Systemic or local estrogen therapy can be used to treat problems associated with vaginal dryness but often does not affect a woman’s loss of desire.18 The addition of testosterone to estrogen may increase sexual desire and activity and is welltolerated, but currently there are no FDAapproved testosterone therapies for HSDD.19

Testosterone formulations, such as patches and lotions, are now in development for the treatment of female HSDD.20, 21 Meanwhile, testosterone products developed for men are sometimes used in women.

Remember the psychosocial aspects 

Since many factors contribute to HSDD, psychosocial aspects must be addressed along with any medical interventions. Distinguishing biologic from relationship factors is essential for any physician assessing or treating sexual problems.

Treatments may be very different based on which components of desire are compromised. For example, a woman might have a very strong biologic drive to be sexual, but if she is not happy with her partner and has no motivation to be emotionally intimate, she may not experience any perceived desire. On the other hand, if a woman has lost some of her drive but remains motivated to be close and intimate with her partner, this can compensate for the decreased biologic component of desire. These are important distinctions to make, because physicians can then normalize this reality for their patients who have come to believe that because their initial drive has diminished, they are no longer sexual beings.

In addition to openly discussing sexual health issues, offering brochures or books that address sex and marital problems helps to normalize concerns and provide education.22 Placing brochures in waiting rooms or exam rooms along with a “top 10” list of self-help sexuality books provides easy access for patients and makes their waiting time seem shorter.

Referrals: when and where? 

The decision of when to refer a patient with sexual dysfunction depends on the physician’s level of expertise and the complexity of the patient’s dysfunction. Other considerations include the patient’s own interest in receiving additional evaluation and the presence of sexual dysfunction in the partner.10

If available, a specialist can provide additional evaluation and management (Table 2).10 However, it is important for patients to recognize that treatment is a true collaboration among professionals. You don’t want a patient to feel rejected or conclude that the problem “is all in my head.”

Table 2. Specialists for referral of patients with sexual dysfunctions10

	•Sex therapist •Mental health professional (psychologist, psychiatrist, marriage/relationship counselor) •Neurologist •Gynecologist/urologist specializing in sexual disorders

Psychosocial counseling often is useful even if the primary treatment is a medical intervention. Approaches include couples therapy, communication training, anxiety reduction, cognitive-behavioral interventions, or sex therapy (e.g., sensate focus).23

But is there time? 

The fear that treatment and counseling for sexual function disorders will take too much office time is not well founded, nor is it a valid reason to avoid the responsibility of managing patients’ sexual health. A few brief questions allow the physician to quickly assess the general nature of a sexual concern and determine: