How To Talk About Sexual Health with Your Healthcare Provider
In my late forties, I worried about what would happen to my sex life as I approached menopause. I had purchased a few books but was never motivated enough to read them. When I asked my gynecologist, she gave me an unhelpful and dismissive, “It is different for everyone” answer. After that, I sought out an “expert,” a women’s health nurse practitioner and national spokesperson on the sexual health of aging women. I asked her, “What am I to expect about sex after menopause? What is going to happen to my body and sex life?”
“Sex after menopause?” she reflected back to me. “Most of my patients are happy to be done with sex!” Knowing that I was a fellow nurse practitioner, she didn’t pull her punches. “I saw a 68-year-old woman this morning whose vagina had narrowed so much that it would hardly admit one finger during the exam. That is what happens to the body.” [1] I cowered. Had she just told me that I was an outlier because I hoped to have sex after menopause and that my vagina was going to shrivel up? It took me months to recover from that conversation! A few years later, during an appointment for a routine pap smear, no one even bothered to ask if I was sexually active.
What should we expect from our medical providers regarding sexual healthcare? How can we best get our sexual health issues addressed?
If you are disappointed that your provider does not routinely, if ever, consider your sexual health, you are not alone. Research shows that most people wish that their healthcare providers would address subjects related to sexual health.[2], [3] Both men and women frequently have issues that they want to discuss.[4],[5] Yet most providers ask little, if anything, about their patients’ sexual health.[6],[7] Of the women I interviewed, only one in eight had ever talked to a healthcare provider about sex. Those who had reported that they, not their providers, usually initiated the conversation. Unfortunately, healthcare providers have historically received insufficient training on taking a sexual history or talking about sexual issues with their patients.[8],[9],[10]
In order to facilitate a better conversation about sexual health with your healthcare provider, please consider the following tips. Remember, you may be the one who has to introduce the topic.
1. Plan. Well before your visit, consider the details of what you want to address and write them down. If you are having pain with intercourse, for example, is the symptom new? Does it occur every time? Does it last for the entirety of penetration? What have you tried? A symptom diary, kept over weeks or even months, can help you to document and understand such factors as quality, duration, alleviating and aggravating factors.
2. Record. Write down your questions. Be specific. Are you asking for information, advice and guidance, medical solutions, a sympathetic ear? You might ask, “What causes pain with intercourse? Is it normal? Is it common? What can I try? What do you recommend that I read?”
3. Be up front. At the beginning of the appointment, state your agenda. For example, “I am here for a Pap smear, and I also have questions to discuss. I’d like to talk with you about the pain that I have during sex. When would be a good time to talk about that?” Or, “I am here for a Pap smear and birth control. I also have questions about orgasms.” Yup, just put it on the table. Look your provider in the face as you speak. You don’t want to miss their reaction. Do they sigh, blush or stare at the floor? Or, do they say, “Thanks for bringing that up. Let’s talk about it before your exam.”
4. Bring notes. If you anticipate difficulty asking, carry a note with the exact wording of your issue(s). And tell your provider the nature of answer you want. You might want reassurance, instruction, information, resources (books, websites, other providers), or a prescription? You might say, “I am having trouble with my sex drive. I rarely feel the desire to have sex, and it takes a really long time for me to get turned on. I am wondering about any medical issues that could be contributing to this.”
5. Temper your expectations. Don’t expect a quick fix. The complicated nature of sexuality- with its mental, emotional and physical components- means that sexual issues may require multifaceted solutions. Look for direction and a path forward, not a solution. Otherwise, you may be disappointed.
6. Evaluate your provider. Does your provider show curiosity and ask questions about the issue you raise? Do they ask, “What have you tried? What helps? What are your fears? How is this affecting your relationship? Or, do they give a quick answer (like, “It is different for everyone”) and move on?
7. Evaluate yourself. How do you feel after the appointment? Do you feel heard and empowered? Hopeful for progress? Or, embarrassed and ashamed for trying? Discouraged or judged?
8. Seek different care if your issues are not being addressed. You may need to find another provider or other resources. Check out some of the resources on this blog and search the Web for answers. If you live in a large enough community to have numerous choices, ask around for a health care provider who may be more sex-positive, someone able to converse about all consensual sex as a normal, healthy part of life. Consider seeing a sex therapist in addition to a medical provider. Try searching for a provider affiliated with one of the following organizations.
a. International Society for the Study of Women’s Sexual Health
c. Society of Adolescent Medicine
d. Gay and Lesbian Medical Association
e. The North American Menopause Society
g. American Association of Sexuality Educators, Counselors and Therapists. Consider calling the office of a sex therapist and asking for a recommendation for a healthcare provider in the community.
I have thought a lot about the visits I had with my healthcare providers leading up to menopause. I recognize now that, perhaps subconsciously, I had been looking for a guarantee that my sex life would survive menopause, which was clearly an unreasonable ask of my healthcare provider. I should have asked specific questions and taken responsibility for my fears by actually reading the books I had purchased. That being said, however, my provider would have done well to probe further when I raised the issue and, at the very least, asked if I was having sex. In the end, I found a different provider.
[1] Don’t freak out like I did. Vaginas just need regular attention and blood flow. Masturbation and sex help a lot, as well as topical or systemic hormones.
[2] Margaret, R. H., Nusbaum, M. R. H., Singh, A. R., & Pyles, A. A. (2004) Sexual Healthcare Needs of Women Aged 65 and Older. Journal of the American Geriatrics Society, 52(1), 117–122. DOI: 10.1111/j.1532-5415.2004.52020.x
[3] Zhang, X., Sherman, L., Foster, M. (2020). Patients’ and Providers’ Perspectives on Sexual Health Conversations in the United States: A scoping review. Patient Education and Counseling. 103, 2205-2213. https://doi.org/10.1016/j.pec.2020.06.019
[4] Berman, L., Berman, J., Felder, S., Pollets, D., Chhabra, S., Miles, M., & Powell, J. A. (2003). Seeking Help for Sexual Function Complaints: What gynecologists need to know about the female patient's experience. Fertil Steril. 79, 572-578. DOI: 10.1016/s0015-0282(02)04695-2
[5] Shifren. J. L., Monz, B. U., Russo, P. A., Segreti, A., & Johannes, C. B. (2008). Sexual Problems and Distress in United States Women: Prevalence and correlates. Obstet Gynecol. 112, 970-978. DOI: 10.1097/AOG.0b013e3181898cdb
[6] Thirty-seven percent of obstetricians and gynecologists disclosed that they do not ask their patients about sexual activity, and 60% fail to ask about any sexual-related problems or issues. Most shocking, 25% admitted that they convey disapproval to their patients regarding some of their sexual practices. Sobeki, J. N., Curlin, F. A., Rasinski, K. A., & Lindau, S. T. (2012). What We Don’t Talk About When We Don’t Talk About Sex: Results of a national survey of U.S. obstetrician/gynecologists. J Sex Med, 9(5), 1285–1294. DOI: 10.1111/j.1743-6109.2012.02702.x
[7] Only 22% of urogynecologists asked about sexual activity. Pauls, R. N., Kleeman, S. D., Segal, J. L., Silva, W. A., Goldenhar, L. M., & Karram, M. M. (2005). Practice Patterns of Physician Members of the American Urogynecologic Society Regarding Female Sexual Dysfunction: Results of a national survey.” International Urogynecology Journal and Pelvic Floor Dysfunction, 16(6), 460–467. DOI: 10.1007/s00192-005-1286-5
[8] Solursh, D. S., Ernst, J. B., Lewis, R. W., Prisant, L. M., Mills, T. M., Solursh, L. P., Jarvis, R. G., & Salazar, W. H. (2003). The Human Sexuality Education of Physicians in North American Medical Schools. International Journal of Impotency Research, 15(5), S41-S45. DOI: 10.1038/sj.ijir.3901071
[9] Coleman, E. (2012). Editor's Note: A Crisis in Medical School Education in Sexual Health, International Journal of Sexual Health, 24(4), 237-238, DOI: 10.1080/19317611.2012.743362
[10] Simmonds, K., Cappiello, J., & Hoyt, A. (2019). Sexual and Reproductive Health Content in Nurse Practitioner Transition to Practice Training Programs. Contraception X, 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286177/