Reframe the sexual health conversation

Issue: March 2017

ByLisa Larkin, MD, FACP, NCMP, IF

As a trusted resource for women, it is up to health care providers to help change the dialogue by engaging in more meaningful conversations with women about sexual health. During routine visits, the conversation often begins and ends with discussing forms of birth control, if the patient is sexually active. However, patients who have more concerns about the quality of their sex life might be too hesitant to start the conversation.

As a physician specializing in sexual medicine, I frequently see women in my practice who are tentative about discussing sex and intimacy issues they may be dealing with. I like to begin the dialogue by asking them how they feel about the quality of their sex life. This allows me to identify and investigate specific problem areas while providing interventions and solutions that they can incorporate into their lives. I ask questions such as these:

Are you satisfied with your overall sex life?
Do you have any sexual concerns?
Do you have any distress related to your level of sexual desire or interest?
Do you have any distress related to your ability to become or stay sexually aroused?
Do you have any distress related to your ability to experience or reach the desired intensity of an orgasm?
Do you experience discomfort or pain during vaginal penetration?

Common misperceptions

Another way to start the conversation, which I find is a good icebreaker, is to dispel some of the many common misconceptions that women have about their sex life. This is another opportunity to open the dialogue and help women become more comfortable discussing any concerns they have. I have listed some misconceptions and examples on how to address them below:

“Sex only affects the bedroom.” Let the patient know that this is not true; a woman’s sex life affects her overall health.
“Libido/desire is supposed to decline with age.” Mention that every woman is different. If your libido/ desire is causing distress, it is important to let a health care provider know.
“My friends are enjoying and having more sex than I am.” Explain to your patient that this is false because every woman’s desire for sex is different. Having trouble enjoying or desiring sex can make a woman feel alone — as if she’s the only woman with these issues — but many women are experiencing the same things. If a woman is having a hard time enjoying or desiring sex, it’s important to find out why.

PAGE BREAK

Female sexual dysfunction

It is important to have elevated conversations about sexual health with patients because approximately 40% of women will deal with sexual difficulties at some point in their lives. Female sexual dysfunction (FSD) is defined as persistent problems with sexual desire, arousal, orgasm or pain that causes distress or strains her relationship with her partner. The most common type of FSD is when a woman has low sexual desire, also known as hypoactive sexual desire disorder (HSDD) or low libido, that causes distress or a strain on their relationship.

Although periods of diminished sex drive can be normal throughout a woman’s life, nearly 4 million premenopausal women in the United States struggle with HSDD. HSDD is a classified medical condition that is characterized by a deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty. HSDD is not caused by a coexisting medical or psychiatric disorder, medication or other substance or relationship problems. Basically, if a woman is experiencing low desire or low libido and is bothered by her lack of interest in sex, it could be HSDD. An HSDD diagnosis requires a patient history and discussion with a health care professional to rule out certain factors as the source of low sexual desire, such as relationship problems, medications or a medical or psychiatric condition.

Research has found that women with HSDD experience greater health burdens, are more likely to experience negative emotional states and are nearly twice as likely to report fatigue, depression, memory problems, back pain and lower quality of life compared with women without HSDD.

An online Harris Poll surveyed 249 U.S. women, aged 21 to 49 years, who are not experiencing menopause symptoms, who have ever had a sex drive, who currently have a low sex drive that causes them emotional distress and who feel that their low sex drive is not caused by menopause, pregnancy or breast-feeding, health problems, medication, lack of connection/intimacy or relationship challenges. According to the survey results, 82% of these women believe they should see a health care provider, but only 4% of them have actually spoken to a medical professional to address their sexual concern. I find these results concerning and want to reinforce how important it is for us to reframe the initial dialogue with patients about sexual health to extend beyond the simple questions (eg, “Are you sexually active?”) and ask instead about the quality of their sex life and whether they have any concerns.

PAGE BREAK

Practical resources

I understand that there often isn’t much time in one appointment to address sexual concerns when other health issues are present. Unfortunately, this reduces the likelihood that the sexual concern will come up at a future visit. If you determine that your patient is concerned about her sex life, the next best step would be to set up a separate appointment to discuss the issue further, or simply to refer her to a health care provider in the community that specializes in this area.

If you have identified that your patient has a sexual concern but appears hesitant to engage in an in-depth conversation about it yet, you can direct her to FindMySpark.com — a great resource for patients to learn more about FSD. Among other useful tools, the website provides simple steps that a woman can take to start the conversation about her sexual concerns with her health care provider and/or her partner. There are also helpful resources, such as downloadable talking tips, to help women spark a conversation about sex with their health care providers.

Sexual health is an important component of overall health and well-being for many women. Therefore, it is the responsibility of health care providers to encourage open and meaningful dialogue with their patients so that they may continue to have satisfying sex lives.

References:
American Psychiatric Association. Diagnostic criteria for 302.71: hypoactive sexual desire disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.
Biddle AK, et al. Value Health. 2009;doi:10.1111/j.1524-4733.2008.00483.x.
Leiblum SR, et al. Menopause. 2006;13:46-56.
Mayo Clinic. Female sexual dysfunction. Available at: www.mayoclinic.org/diseases-conditions/ female-sexual-dysfunction/basics/definition/ con-20027721. Accessed Feb. 13, 2017.
Shifren JL, et al. Obstet Gynecol. 2008;doi:10.1097/AOG.0b013e3181898cdb.

For more information:
Lisa Larkin, MD, FACP, NCMP, IF, is president of Lisa Larkin, MD, and Associates, a multidisciplinary internal medicine and women’s health practice focusing on sexual health and menopause management. She is also director of Women’s Corporate Health for TriHealth.

Disclosure: Larkin reports one-time advisory work for Valeant Pharmaceuticals.