Sex is an important part of many patients’ lives. Do we talk about it too rarely in the surgery?
A good sex life may have a major impact on the health and quality of life of each of us (1). Sex has long since moved out of the bedroom and into the social sphere, but there are indications that doctor’s surgeries lag behind. However, there is little information on how often or in what situations Norwegian doctors discuss the issue of sex with their patients.
Sex may seem to be a self-evident topic in the surgery, for example in the context of problems related to the menopause or prostate cancer. This notwithstanding, it may appear that we avoid talking about it, even when the indication is clear. In a study, one in four women who had undergone a total hysterectomy and nearly half of those with a subtotal hysterectomy reported not to have talked about sex with health personnel in connection with the intervention (2). Moreover, even when the topic is breached, it may not necessarily be addressed adequately: in a qualitative study, Norwegian women who had undergone surgery for gynaecological cancer reported a need for more information and guidance about sexual changes (3).
When we fail to discuss sex sufficiently in cases of gynaecological cancer and hysterectomy, what happens in the event of diagnoses where the indication is less clear? American and European guidelines recommend talking about sex with patients after a myocardial infarction (4). However, only 15 % had talked about sex with their doctor in the wake of a myocardial infarction, according to a study from the USA and Spain (5). Most often, the patients themselves had broached the subject. It is even more astounding to see what kind of information the patients had received – the majority were provided with advice that did not accord with the guidelines. A Norwegian study investigated the attitudes of health personnel in the field of rheumatology (6). Almost all (96 %) regarded sex as an important topic to discuss with their patients, but 71 % of them did so only rarely or not at all. Such findings give grounds for concern.
Appropriate information on sex is important not only for patients with somatic illness – a cross-sectional study of 16 to 95-year-olds in Denmark showed that 11 % of both women and men had suffered from at least one frequently recurring sexual problem over the last year (7). The incidence of problems was highest among men older than 60 and women older than 50 years, but the incidence was high even among women younger than 30 years. Many afflictions, such as premature ejaculation and dyspareunia, affected people at a relatively young age. Sex may thus present challenges to people in all age groups.
Does sex need to be a problem before it can be raised as a topic? Most likely, a good sex life has a preventive health effect and may even be associated with lowered mortality. After adjustment for several confounding factors, a British cohort study found that total mortality was reduced by 50 % in men who had sexual intercourse twice weekly when compared to men who had sex more rarely than once per month (8). A good sex life may provide a greater health benefit than many of the other things we spend time on discussing with our patients. So what is needed for us to talk about sex more often?
There are barriers to talking about sex, but these can be overcome. This topic may be taboo, for doctors as well as patients. Like many other taboos, it can be normalised through exposure. We need to dare to talk about sex. Then we have the practical challenges: we may need time to talk about sex once this topic is brought up. Sometimes the consultation will need to be undertaken one-to-one, and for the patient it may be crucial whether the doctor is a man or a woman. Thus, we need to make provision for talking about sex. Moreover, it is difficult – but essential – to possess a broad range of knowledge about various kinds of sexual problems (9). Health personnel will more likely tend to talk with patients about sex if they have training in the field of sexual health (6).
We should not ask all our patients about their sex lives. It is nevertheless a paradox that we talk so little about sex in the doctor’s surgery when sex seems to be omnipresent in society at large. Also for this reason, the important and confidential conversation about sex may make a difference. Therefore, we as doctors need to dare to bring up this subject.