Tips for Talking to Your Patients About Sex

Have you ever asked a patient, “How’s your sex life?”

If your answer is “No,” you’re not alone.

The Centers for Disease Control and Prevention (CDC) finds healthcare providers don’t talk about sex with their patients for a variety of reasons:

• They feel uncomfortable discussing sex and sexuality with patients;
• They believe discussing sex will take a lot of time;
• They believe their patients are uncomfortable discussing sex;
• They’re worried about cultural differences or saying the “wrong thing”; and
• They don’t think older (age 60+) patients are having sex.¹

An article titled, “‘Opening a Can of Worms’: GP and Practice Nurse Barriers to Talking about Sexual Health in Primary Care,”² seems indicative of the situation.

Patients, meanwhile, don’t seem to be bringing up the topic, either: “Talking to the doctor about sexual health” yields a mere 100 results in PubMed.

It makes sense that any illness or disability will have an impact upon sexual health. After all, in the circle of the holistic self, sexual health has the same importance as psychological health, social health, physical health and spiritual health. Asking about sexual health concerns in the field of rheumatology, where so many patients are living with chronic pain, joint complications and other debilitating physical symptoms, is crucial. Patients may find it hard to feel intimate when they feel, or think they look, different or project their partner perceives them differently.

I believe healthcare providers have a responsibility to help patients gain a better understanding of how health complications can affect sex and intimacy, as well as offer support and suggestions. Making ourselves open to talking about sex and trying to answer questions can help our patients regain intimate relationships. Such conversations help strengthen and improve the relationship between provider and patient.

You needn’t be a sex-pert 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 you’re ready to listen.

Sexual Health Issues

Following are examples of sexual health encounters from my experience and that of physical therapist Katie Gilin, DPT:

Patient 1: Edger, age 56, with ankylosing spondylitis (AS), confided he had been experiencing impotence. I explained that, because the spinal nerves innervate the penis and help with its functioning, anything affecting the spinal nerves, like AS, can cause problems related to impotence.

We discussed the use of sildenafil, the importance of taking the medication exactly as prescribed and the need for manual stimulation to prime the body to achieve the desired result.

He really wanted to surprise his wife with his new ability to get a sustained erection, until I stressed that she, too, needed to be prepared for intercourse.

Patient 2: Tina, age 35, with Sjögren’s syndrome (SS), told me she hadn’t been intimate with her husband for the past two years, because she is no longer able to have orgasms and intercourse is very uncomfortable for her.

We talked about clitoral neuropathy and vaginal dryness, which can be associated with SS, and that additional lubrication and stimulation would be essential for her sexual enjoyment. We also talked about her joint pain, and how her husband no longer wanted to touch her for fear of hurting her.

On Tina’s next visit, her husband came with her. He said, “I wanted to meet the woman who gave me back my wife.” He said Tina’s fatigue and joint pain were improved and that having her back to her old self made him feel better too. He added, “We’re taking things slowly, but we hug, kiss and hold hands a lot, and I’m not afraid to touch her anymore.”

Patient 3: Lynda, age 31, with Ehlers-Danlos syndrome, was experiencing stress urinary incontinence, bladder prolapse (cystocele) and urinary frequency with incomplete emptying. She had undergone a surgical hysterectomy five years before, which she believed had worsened her prolapse and urinary symptoms. She also described pelvic pain with any vaginal penetration. After 10 visits for pelvic floor physical therapy, she was able to demonstrate improvements in all of her symptoms; she also reported improved intimacy with her husband, including enjoying intercourse without any pain.

Patient 4: DeeDee, age 61, came to see me for a routine checkup for her AS, which had progressed to the point that she was using a wheelchair or walker due to pain and mobility options. She explained that she was having difficulty opening her legs open wide enough to have sex with her wife. This complication was due to the fusion of DeeDee’s sacroiliac joints.

I contacted a osteopathic medicine (DO) resident I had worked with before. After two months of intensive orthopedic manual physical therapy (PT), DeeDee had regained enough mobility to allow for more satisfying intimacy.

At her next visit, I asked DeeDee how she was doing. “As soon as I stopped the home PT exercises and took a break from seeing the DO, my hips started to stiffen up again, and intimacy became difficult again,” she confessed.

I replied, “Then you’ll just have to keep yourself mobile in order to maintain your sex life.” Compliance to therapy is as important to sexual health as it is in other treatment areas.

Initiate the Discussion

As you can see, many hidden issues fall into the category of sexual health that may be unspoken and, consequently, remain unaddressed. By initiating the conversation, you may be able to add the role of detective to your credentials. Bringing up the subject is easier than you may think.

To open the conversation with male patients, you can ask such questions as: How are things between you and your spouse/partner? Are you and your spouse/partner still intimate? Has your rheumatic condition affected your sexual functioning?

Opening a dialog with female patients can be as simple as asking when they last saw their gynecologist, asking about birth control or asking about vaginal dryness when discussing sicca symptoms.

My husband, Chris, a nurse practitioner, offers his patients the chance to talk about their sexual health concerns by asking them: Do you feel comfortable talking to me about sexual health issues?

Sexual Health: Top 10 Tips

Based on my 21 years as a rheumatology nurse and unofficial sexual health expert, here are 10 suggestions to help you address a patient’s sexual health concerns.

1. Bring up the topic of sexual health with patients, their spouses and partners. Talking about sexual issues isn’t the easiest thing in the world, but people are more likely to ask questions and ask for help in the privacy of the exam room. Just because a patient doesn’t bring up the subject doesn’t mean they’re not thinking about it. You can help normalize the discussion of intimacy and sexual health by including sexual health questions in each visit. That way, you’ll be able to respond quickly to patients’ questions and help with any problems.

An individual’s attachment history, sexual history, relationship history and trauma history can be uncovered over time.

A sexual health history can include the following questions:

• Are you currently sexually active?
• Are you currently sexually active with more than one partner?
• What kinds of protection do you and your partner(s) use during sexual activity?
• How has your illness or disease affected your sexual activity?
• How have your medications affected your sexual activity?
• Have you ever had a sexually transmitted disease or knowingly been exposed to a sexually transmitted disease?
• Have you ever had, or do you now have, any discharge, rash or sores in your genital area?
• Are there any sexual issues you would like to talk about?³

Asking about birth control choice(s) is also important. Certain medications are linked to health risks. Medications used for rheumatic diseases can also be contraindicated in individuals with human immuno­deficiency virus (HIV) or hepatitis C. Reactive arthritis can be activated by certain sexually transmitted infections (STIs), such as gonorrhea and chlamydia.

2. Become aware of common sexual health concerns among patients. Patients may be thinking about:

• A lack of desire/desire discrepancy between partners;
• Difficulty with arousal—lack of wetness; how to get in the mood; difficulty getting/maintaining erections; taking a long time to ejaculate/reach orgasm;
• Genito-pelvic pain and penetration disorders—dyspareunia due to atrophy; vaginismus (overtight vaginal muscle); overactive pelvic floor (can cause muscle spasm); vestibulodynia;
• Lack of pleasure from sex—primary or secondary anorgasmia vs. situational anorgasmia;
• Their physical appearance and how they appear to their partner and to others;
• Their feelings about sex and how their partner feels about sex;
• The kind of sex life they have or think they should have; and
• The frequency of sex in their relationship and whether it’s right for their partner.⁴

3. Understand sexual orientation and gender identity terms. Sexual orientation encompasses a wide range of sexual and/or romantic attractions (or lack thereof). Some people may be heterosexual, while others are lesbian, gay, bisexual, transgender, queer or other (LGBTQ+).

Gender identity is simply someone’s gender, which is based on how they feel and not on physical characteristics. How they share their gender with the outside world, through how they dress and act, contributes to their gender expression. Research conducted in recent years has led to a better understanding of gender. For example, the use of “they’ has become more common as a pronoun for an individual.

Those who don’t identify as cisgender (i.e., the gender assigned at birth) or who use different pronouns in their identity will understand if you misstate their gender pronouns. The best way to react to a correction is to apologize, correct yourself and move on.⁵

Adding a question to the patient intake form about what pronoun they prefer is one way to ensure you are addressing your patient the way they want to be addressed.

4. Provide patient education.

• Be prepared with recommended reading, websites, organizations and sexual health experts;
• Suggest website searches for “sexual health and …” rather than “sex and …”;
• Explain the importance of self-care and stress management;
• Talk about the importance of physical touch in maintaining intimacy and strengthening the bond between individuals;
• Suggest that understanding one’s own body through self-touch can improve one’s sex life;
• Encourage partners to share any concerns about sex and intimacy during the office visit and offer evidence-based suggestions they can try at home;
• Nobody wants to be seen as dumb about sex, so be respectful when providing information: “Perhaps you already know …”; and
• Remind patients that orgasm can be a successful pain relief strategy.

5. Have the “safe sex” talk. Perhaps nothing is as imperative as talking to sexually active patients about safe sex. This discussion will enable your patients to prepare for sexual contact ahead of time.

The American Sexual Health Association’s sexual health toolkit is an excellent resource to give to patients. It discusses the importance of knowing one’s personal boundaries, and offers pro and con lists for latex condoms, internal (i.e., pouch) condoms, lubricants and barrier methods used during oral sex, and has a section on sex toys.⁶

6. Don’t be afraid to refer out. Many different healthcare clinicians are trained to address sexual rehabilitation and other sexual health-related issues.

• Nurses assist with the overall medical management of a disability and can help patients understand instructions given by the occupational therapist, the physical therapist, the physician or another clinician;
• Sexual health nurse-clinicians educate clients and their partners on changes to sexual function as a result of chronic illness or disability, and are qualified to make specific suggestions to enhance sexual functioning and fertility;
• Sexual medicine physicians or physiatrists assist with maximizing sexual physiology and reducing the medical issues that often interfere with sexual interest and activities; other physicians (e.g., urologist, gynecologist, neurologist) may also have valuable expertise;
• Physical therapists, also called physiotherapists, address clients’ physical function by helping with range of motion, pelvic muscle strength and other movement-related issues;
• Occupational therapists help clients manage and perform their daily activities and can address sexuality issues, such as how to adapt sexual devices to meet the abilities of clients (e.g., adding switches, making hands-free options);
• Recreation therapists help clients explore meaningful recreation and leisure choices; involvement in recreation activities of mutual interest is often key to meeting potential partners;
• Social workers educate and counsel partners and families on sexual and fertility concerns;
• Psychologists explore with clients, in depth, the many different emotional components of sexuality, such as self-esteem, assertiveness and positive self-talk; they also can address trauma that has affected a client’s sexuality; and
• Peer counselors, such as persons with disabilities themselves, can provide critical sources of information on what their bodies experience in different situations.⁷

7. Recognize the role grief plays in the context of a chronic illness diagnosis. Being diagnosed with a chronic illness that has no cure can, and often does, create a sense of loss. People grieve losses in different ways, but by discussing Elizabeth Kübler-Ross’ stages of grief with your patients, you’ll help educate them on the emotions they may be experiencing due to a loss or change in health.⁸

Some strategies:

• Acknowledge that a chronic illness diagnosis can cause extreme stress within a relationship, as well as worsen existing stress. For example, the healthy partner may respond to the diagnosis by pretending nothing is wrong, by trying to fix the ill partner with medical advice or unproven treatments, or by denying the disease exists. These are all attempts to regain normalcy within the relationship. Once these responses are recognized, more appropriate responses can
  be discussed;
• Encourage patients and partners to allow for feelings of loss, anger and depression so they can recover and rebuild their lives and their intimate relationships;
• Encourage patients to draw on resiliencies that already exist from a lifetime of coping; and
• Counsel patients to find appreciation for those who stood by them in their time of need and who continue to stand by them in life—not just in times of illness.

8. Follow up at each visit. Problems with intimacy may occur at any time during the disease course. You may be able to improve a situation the patient has given up on.

9. Think of other ways to engage with and relate to patients.

• On the way to and from the exam room, try to walk alongside the individual or couple—not behind or in front;
• Check your assumptions at the exam room door. We all have differing views on heterosexuality, monogamy, celibacy in single women and the importance of sex;
• Address anxieties first. For example, you can say: “Many people experience this …”;
• Don’t underestimate the importance of education, including terminology, anatomy and specific facts about sex and the body;
• Conducting a physical exam can reveal potential complications for sex and intimacy;
• Complete a psychosocial history slowly, over several meetings; and
• Include grief work over what’s been lost.⁴

10. Believe in the importance and value of what you’re doing. For a subject that’s so relevant to our patients’ lives, health and well-being, sexual health is one of the least discussed areas of health. Intuitively, we may know there’s a need for intimacy among partners, yet it can be hard to know what to say and when to say it. It can also be hard to be a good listener, and it can be hard, sometimes, to know how to receive what we hear.

Each patient is an individual, and each individual has a personal and particular relationship to the world at large. As healthcare providers, we can help each person best by making them feel they can talk to us without fear of judgment, misunderstanding or rejection.

Iris Zink, RN, ANP, RN-BC, has been a rheumatology nurse practitioner for 21 years. She founded and runs Lansing Rheumatology, the first early arthritis intervention clinic in Michigan, to provide access to care for individuals who are under- or uninsured. In December 2020, Ms. Zink and Jenny Thorn Palter published their book, Sex—Interrupted: Igniting Intimacy While Living with Illness or Disability.

Acknowledgment

The author thanks Jenny Thorn Palter, former editor of Lupus Now magazine, published by the Lupus Foundation of America, for her invaluable assistance on the development of this article.

References

1. Safer sexual behavior. Centers for Disease Control and Prevention (CDC).
2. Gott M, Galena E, Hinchliff S, Elford H. ‘Opening a can of worms’: GP and practice nurse barriers to talking about sexual health in primary care. Fam Pract. 2004 Oct;21(5):528–536.
3. Pelon S, Huang L. Sexual health promotion in long term care (lecture). 14th Annual Art & Science of Aging Conference—Revisiting Relationships: Intimate, Intergenerational, and More. 2019 Feb 22. Grand Rapids, Mich.
4. Braford J, McKenzie N. Menopause, manopause, and redefining sexuality (lecture). 14th Annual Art & Science of Aging Conference—Revisiting Relationships: Intimate, Intergenerational, and More. 2019 Feb 22. Grand Rapids, Mich.
5. Schultz GK. Appendix B: Sexual orientation terminology; and Appendix C: Gender identity. In: Zink I, Palter JT. Sex—Interrupted. Austin, Texas: Atmosphere Press; 2020:122–134.
6. American Sexual Health Association (ASHA). Your Safer Sex Toolbox.
7. MacHattie E, Napthtali K, Elliott S. PleasureABLE: Sexual device manual for persons with disabilities. Self-published: 2009.
8. Kübler-Ross E. On Death and Dying. Philadelphia, Pa: Routledge Press, imprint of Taylor & Francis Group; 1973.