“How is your sex life going? Are you and your partners on the same page about what’s pleasurable?”
If you’ve never fielded questions like those from a doctor, you’re not alone. According to a review of 33 studies in the journal Patient Education and Counseling, most patients say they’d feel comfortable discussing their sexual health in the exam room — but only if their providers initiated the conversation. Yet most doctors aren’t taking the lead. Many health experts see this as a missed opportunity.
“Sexual health doesn’t exist apart from physical and mental health,” says Aleta Baldwin, associate professor of public health at California State University, Sacramento, who was not involved with the review. “Issues with sexual health can be causes or symptoms of other health issues. If these conversations don’t happen, these issues can go unresolved.”
The National Coalition for Sexual Health agrees. The organization, which seeks to improve Americans’ sexual health, is developing an updated approach to incorporating questions that address sexual satisfaction, functioning and concerns, and support for a patient’s gender identity and sexual orientation into routine patient visits, and plans to release its tool in the fall.
“If doctors take a comprehensive and inclusive sexual health history, they can better understand their patient’s level of risk, determine whether they need to recommend screenings or vaccinations, and offer appropriate counseling and education about contraceptives, STI treatment and sexual pleasure and functioning,” says NCSH codirector Jennifer Rogers. “But it’s not only disease avoidance that matters; sexual wellness, including sexual pleasure, is also a key element of good sexual health.”
Barriers to sex talks
Individual healthcare providers aren’t completely to blame for not asking about sexual health. For one thing, it’s not typically part of the curriculum in medical school. “Sexual health might sometimes be addressed insofar as it’s related to STIs or pregnancy. But it’s not given its own domain,” Baldwin says. “So providers don’t have the education they need or may feel they need.”
Additionally, many clinics and other healthcare facilities don’t offer any guidance to employees. In the review, some providers said that if they received adequate training from their administrators on how to discuss these issues with patients, they wouldn’t mind bringing them up, says coauthor Ledric Sherman, assistant professor of health and kinesiology at Texas A&M University. Since they don’t get that kind of sensitivity training, they’re uncomfortable initiating conversations.
And that assumes doctors always have the chance to talk about sexual health during visits. “Given the demands on their time — when they can’t fit everything into one appointment and have to make a decision about what not to address — a topic like sexual health may go unaddressed, especially if the provider is uncomfortable with the topic,” Baldwin says. We also tend to see healthcare providers as the authority in the doctor-patient relationship, she adds. Their lack of knowledge about sexual health or gender can challenge that sense of authority, further disincentivizing the conversation.
Lastly, doctors are exposed to the same cultural messages we all are. “Just because they have medical degrees doesn’t mean they have all our cultural stigmas and taboos about sex trained out of them,” Baldwin says. “In general, my work with providers has only ever shown me they want to do a good job. They want to do right by patients, but there are a lot of barriers to doing that.”
Sexual health is health
Getting rid of sex-talk barriers matters to patients’ health cand care. This goes beyond the fact that undetected and untreated sexually transmitted infections such as HPV and chlamydia can lead to serious health issues, including cancer, infertility and ectopic pregnancy. It’s also about the interconnection between our various aspects of health. “Sexual health is an essential element of one’s overall health and well-being. Being sexually healthy means being able to enjoy a healthier body, a satisfying sexual life, positive relationships and peace of mind,” Rogers says.
Sexual health conversations can also foster a stronger provider-patient relationship. “Bringing up these issues helps solidify trust,” says Dr. Jesse Ehrenfeld, the previous chair of the board of trustees for the American Medical Association. “When a patient understands that we have their best interest at heart, it strengthens that bond. The patient understands we hold confidentiality as a key part of our relationship.” That can lead to the patient being more open overall, which in turn promotes better care.
Sexual health conversations are particularly important for LGBTQ+ people. As a whole, this community has had negative interactions with the medical system, Baldwin says. “They’ve likely already faced discrimination within healthcare, so the care that providers take with the questions they ask and the things they say is especially important for transgender and gender nonbinary patients,” she explains.
If providers don’t ask questions or initiate conversations about sexual health, LGBTQ+ patients may feel othered. In turn, they may feel like “their sexual health is too different, too difficult, too challenging or beyond [the provider’s] capacity to address,” Baldwin explains. And any discrimination or negative interactions can lead to delaying or forgoing healthcare.
At the same time, some LGBTQ+ patients are not aware of the unique aspects of their care, Ehrenfeld adds, such as different STD screenings, vaccinations, safe sex education and counseling, and sexual functioning and satisfaction. Even if the patient comes in for a sprained ankle, “when a patient is open, it allows the physician to provide comprehensive care that supports mind, body and spirit,” Ehrenfeld says. “They can also refer the patient to specialists or wellness providers who are competent in the care of LGBTQ+ people.” But patients will only share this information if they feel comfortable with their providers, who need to ask for it in an affirmative and welcoming way.
Let’s talk about sex
At this point, the onus may still be on patients to find providers who actively initiate and then engage in nonjudgmental conversations about sexual health during appointments. If your doctor doesn’t, it may be a sign to see someone else, especially if you feel at all uncomfortable or judged. For LGBTQ+ people, consider resources from OutCare, GLMA, GLBT and the Human Rights Campaign to find LGBTQ+-friendly providers and information on your healthcare rights.
And when you’re asked about anything related to sex or sexual health — whether that’s on an intake form or during an interaction with any member of your healthcare team — do your best to answer honestly for the sake of your care.
“Sexual activity is a natural part of life and can bring pleasure, joy and both physical and emotional intimacy,” Rogers says. “Everyone has a right to good sexual health that involves respect, dignity and safety.”