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Why We Need To Talk About Sex
Anne Koplin, MD
Pelvic Health Collaborative CME
March 9th, 2016
Why We Need To Talk About Sex
● Anne Koplin, MS, MD
○ Medical Director Dean Foundation
○ Tel Aviv University
● Ayla Green, MD
○ University of Queensland, Australia
Authors have no financial disclosures
About Me
● Training
● Dean trials
● Loveandmedicine.com
Objectives
Upon Completion of this lecture participants will:
1. Understand the importance of sexual health to overall
physical and psychological well being.
2. Feel more comfortable talking about identifying and
discussing sexual health concerns with patients.
Definition
Sexual Health- “…a state of physical, emotional, mental and social well-being in
relation to sexuality; it is not merely the absence of disease, dysfunction or
infirmity. Sexual health requires a positive and respectful approach to sexuality
and sexual relationships, as well as the possibility of having pleasurable and safe
sexual experiences, free of coercion, discrimination and violence. For sexual
health to be attained and maintained, the sexual rights of all persons must be
respected, protected and fulfilled.” (WHO, 2006a)
Sexual Response
Cycles
Males and Females
Sexual Desire
Sexual desire is a fascinating interplay of biological,
psychological and cultural factors. A healthy sex life in a
loving relationship is a key component to happiness, general
health, and well-being. While we know one’s libido ebbs and
flows, a prolonged lack of sexual desire should not be
ignored. HSDD patients are missing out on the important
benefits of sex: for pleasure, exercise, stress relief, pain
reduction, and special intimacy with their partner.
Benefits of Sex (the short list)
● Improvement in body image and mood- feeling
desired
● Improved intimacy with partner
● Form of exercise- 4 calories/min for men, 3 for women
● Pain relief- back, leg, menstrual cramps, migraines
● Boosts libido- ‘kindling’ effect, lubrication increases
Benefits of Sex Continued
● Improved immunity- inc IgA with sex 1-2x week
● Improves sleep- prolactin and oxytocin release
● Heart health- at least 2x week lowers risk of heart disease
by 45%
● Decreases age related atrophy- by increasing lubrication
and blood flow
● Improved bladder control- strengthens pelvic floor
muscles, doing Kegels during sex
● May reduce prostate cancer risk
American Journal of Sexuality
Education 3/2014
Study of 500 adults
• 85% would talk to their doctor about a sex problem
• 71% felt their physician would dismiss their concerns
• 68% felt their physician would be uncomfortable talking about sex
• 9% were asked about their sexual health during routine visits
What we don’t talk about
when we don’t talk about
sex
Comprehensive National Survey of U.S. Ob/Gyns
● ⅔ ask about sexual activity
● Only 40% assess for sexual problems or
dysfunction
● 29% ask about level of sexual satisfaction
● 28% confirm sexual orientation
What we don’t talk about when we
don’t talk about sex
● Female Ob/Gyn more willing than males
● Gynecology appointments more than prenatal
● Younger docs more than over 60 year old
docs
What we don’t talk about when we
don’t talk about sex
• HIGH prevalence of sexual function concerns
• ⅓ of young and middle-age women and ½ of
older women experience some type of sexual
problem such as low desire, pain during
intercourse or lack of pleasure
Average length of time for conversations between
physicians and adolescents about sex = 36
seconds
Why Sex Questions are
Not Asked
1. Not sure what to do with the
answers…Pandora’s Box
2. Fear of offending the patient
3. Generational obstacles
4. Fear of sexual misconduct
5. Considered another doctor’s
problem
6. Unfamiliar with certain sexual
practices
7. Not considered a priority
How to Broach the Subject
● A reflection of your relationship with your patient in
general. Assurances of confidentiality and trust.
● Think of it as part of the review of systems. It has to
be seen as a medical question. Include the question
as a quality of life measure. ‘How is your current
sexual relationship?”
● Be specific, not vague. “Are you having sexual
concerns? “ will give you nothing. What are your fears
about sexual activity (after heart attack, after
procedure)? Open-ended questions!
How to Broach the Subject
● NORMALIZE- ‘many women/men, after this
procedure experience lack of interest, fear of
not having an erection, fear of leakage during
sex...’ etc.
How to Broach the Subject
● Don’t worry that you will not know how to address
their concerns. It is highly likely you will not know the
answer. You haven’t been trained!
● It is not necessary to do a full assessment, and there
is no time. That is when you give a referral. A referral
network is essential!
77 year old married male, enrolled in an
Alzheimer’s genetic marker study for healthy
seniors. Both were widowed and met later in life
on Facebook. Married 12 years, each have their
own set of children. Meeting with partner, no
complaints. No changes in cognition in the past
6 months. Meeting with subject, his only
complaint is the lack of intimacy with his wife.
She was diagnosed with breast cancer 2 years
ago. Underwent mastectomy, radiation and is
currently on Tamoxifen. No sexual interest
since the cancer.
Case Study
What is going on here?
How can we help?
Case Study
❖ Body image issues
❖ Depression
❖ Anxiety
❖ Hormonal side effects of
treatment
❖ HSDD
❖ Normal effects of aging
Treatable?
Case Study
● Alternatives to intercourse
(cunnilingus revisited), sensate
focus
● Promote communication
● Education and insight into
causes
● Referral
Possible Treatments
Disincentives to Sex in Married
Women
• Fatigue
• Boring Sex
• Negative Body Image
• Familiarity breeds discontent
HSDD (Hypoactive
Sexual Desire Disorder)
Definition
● The persistent or recurrent deficiency or
absence of sexual fantasies, sexual
thoughts or desire for sexual activity
● Causes marked distress or interpersonal
difficulty
● Cannot be explained by other factors such
as psychiatric or medical illness or
medications
● May be lifelong or acquired
● May be generalized or limited
HSDD
● Most common- Both men and
women
● One medication approved -
flibanserin (nyt)
○ Bremelanotide in testing
● >20 treatments for male sexual
dysfunctions
● Ramifications
○ Relationship
○ Vulvovaginal atrophy
References
1. WHO (2006a). Defining sexual health: Report of a technical consultation on sexual health, 28–31 January
2002. Geneva, World Health Organization.
2. Marwick C. Survey Says Patients Expect Little Physician Help on Sex. JAMA. 1999;281(23):2173-2174.
3. Sobecki JN, Curlin FA, Rasinski KA, Lindau ST. 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. 2012;9(5):1743-6109. DOI:
10.1111/j.
4. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A Study of Sexuality
and Health among Older Adults in the United States. N Engl J Med 2007; 357:762-774. DOI:
10.1056/NEJMoa067423. DOI: 10.1056/NEJMoa067423.
5. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A study of sexuality
and health among older adults in the United States. N Engl J Med. 2007;357(8):762-774.
6. Montalto NJ. Implementing the Guidelines for Adolescent Preventive Services. Am Fam Physician. 1998
May 1;57(9):2181-2188.
7. Nelson R. How to Talk to Your Patients About Sex. Medscape. Oct 15, 2015.
8. Sims KE, Meana M. Why Did Passion Wane? A Qualitative Study of Married Women's Attributions for
Declines in Sexual Desire. J of Sex and Marital Therapy. 2010; 36(4)360-380. DOI:
10.1080/0092623X.2010.498727.
9. Warnock JJ. Female hypoactive sexual desire disorder: epidemiology, diagnosis and treatment. CNS
Drugs. 2002;16(11):745-53.
10. Leiblum S, Bachmann G, Kemmann E, Colburn D, Swartzman L. Vaginal Atrophy in the Postmenopausal
Woman-The Importance of Sexual Activity and Hormones. JAMA. 1983;249(16):2195-2198.
doi:10.1001/jama.1983.03330400041022.
11. Davis SR, Braunstein GD. Efficacy and safety of testosterone in the management of hypoactive sexual
desire disorder in postmenopausal women. J Sex Med 2012; 12;9:1134–1148.
Questions

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Why We Need to Discuss Sexual Health

  • 1. Why We Need To Talk About Sex Anne Koplin, MD Pelvic Health Collaborative CME March 9th, 2016
  • 2. Why We Need To Talk About Sex ● Anne Koplin, MS, MD ○ Medical Director Dean Foundation ○ Tel Aviv University ● Ayla Green, MD ○ University of Queensland, Australia Authors have no financial disclosures
  • 3. About Me ● Training ● Dean trials ● Loveandmedicine.com
  • 4. Objectives Upon Completion of this lecture participants will: 1. Understand the importance of sexual health to overall physical and psychological well being. 2. Feel more comfortable talking about identifying and discussing sexual health concerns with patients.
  • 5.
  • 6. Definition Sexual Health- “…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” (WHO, 2006a)
  • 8.
  • 9. Sexual Desire Sexual desire is a fascinating interplay of biological, psychological and cultural factors. A healthy sex life in a loving relationship is a key component to happiness, general health, and well-being. While we know one’s libido ebbs and flows, a prolonged lack of sexual desire should not be ignored. HSDD patients are missing out on the important benefits of sex: for pleasure, exercise, stress relief, pain reduction, and special intimacy with their partner.
  • 10. Benefits of Sex (the short list) ● Improvement in body image and mood- feeling desired ● Improved intimacy with partner ● Form of exercise- 4 calories/min for men, 3 for women ● Pain relief- back, leg, menstrual cramps, migraines ● Boosts libido- ‘kindling’ effect, lubrication increases
  • 11. Benefits of Sex Continued ● Improved immunity- inc IgA with sex 1-2x week ● Improves sleep- prolactin and oxytocin release ● Heart health- at least 2x week lowers risk of heart disease by 45% ● Decreases age related atrophy- by increasing lubrication and blood flow ● Improved bladder control- strengthens pelvic floor muscles, doing Kegels during sex ● May reduce prostate cancer risk
  • 12. American Journal of Sexuality Education 3/2014 Study of 500 adults • 85% would talk to their doctor about a sex problem • 71% felt their physician would dismiss their concerns • 68% felt their physician would be uncomfortable talking about sex • 9% were asked about their sexual health during routine visits
  • 13.
  • 14. What we don’t talk about when we don’t talk about sex Comprehensive National Survey of U.S. Ob/Gyns ● ⅔ ask about sexual activity ● Only 40% assess for sexual problems or dysfunction ● 29% ask about level of sexual satisfaction ● 28% confirm sexual orientation
  • 15. What we don’t talk about when we don’t talk about sex ● Female Ob/Gyn more willing than males ● Gynecology appointments more than prenatal ● Younger docs more than over 60 year old docs
  • 16. What we don’t talk about when we don’t talk about sex • HIGH prevalence of sexual function concerns • ⅓ of young and middle-age women and ½ of older women experience some type of sexual problem such as low desire, pain during intercourse or lack of pleasure
  • 17. Average length of time for conversations between physicians and adolescents about sex = 36 seconds
  • 18. Why Sex Questions are Not Asked 1. Not sure what to do with the answers…Pandora’s Box 2. Fear of offending the patient 3. Generational obstacles 4. Fear of sexual misconduct 5. Considered another doctor’s problem 6. Unfamiliar with certain sexual practices 7. Not considered a priority
  • 19. How to Broach the Subject ● A reflection of your relationship with your patient in general. Assurances of confidentiality and trust. ● Think of it as part of the review of systems. It has to be seen as a medical question. Include the question as a quality of life measure. ‘How is your current sexual relationship?” ● Be specific, not vague. “Are you having sexual concerns? “ will give you nothing. What are your fears about sexual activity (after heart attack, after procedure)? Open-ended questions!
  • 20. How to Broach the Subject ● NORMALIZE- ‘many women/men, after this procedure experience lack of interest, fear of not having an erection, fear of leakage during sex...’ etc.
  • 21. How to Broach the Subject ● Don’t worry that you will not know how to address their concerns. It is highly likely you will not know the answer. You haven’t been trained! ● It is not necessary to do a full assessment, and there is no time. That is when you give a referral. A referral network is essential!
  • 22.
  • 23. 77 year old married male, enrolled in an Alzheimer’s genetic marker study for healthy seniors. Both were widowed and met later in life on Facebook. Married 12 years, each have their own set of children. Meeting with partner, no complaints. No changes in cognition in the past 6 months. Meeting with subject, his only complaint is the lack of intimacy with his wife. She was diagnosed with breast cancer 2 years ago. Underwent mastectomy, radiation and is currently on Tamoxifen. No sexual interest since the cancer. Case Study
  • 24. What is going on here? How can we help? Case Study
  • 25. ❖ Body image issues ❖ Depression ❖ Anxiety ❖ Hormonal side effects of treatment ❖ HSDD ❖ Normal effects of aging Treatable? Case Study
  • 26. ● Alternatives to intercourse (cunnilingus revisited), sensate focus ● Promote communication ● Education and insight into causes ● Referral Possible Treatments
  • 27. Disincentives to Sex in Married Women • Fatigue • Boring Sex • Negative Body Image • Familiarity breeds discontent
  • 28. HSDD (Hypoactive Sexual Desire Disorder) Definition ● The persistent or recurrent deficiency or absence of sexual fantasies, sexual thoughts or desire for sexual activity ● Causes marked distress or interpersonal difficulty ● Cannot be explained by other factors such as psychiatric or medical illness or medications ● May be lifelong or acquired ● May be generalized or limited
  • 29. HSDD ● Most common- Both men and women ● One medication approved - flibanserin (nyt) ○ Bremelanotide in testing ● >20 treatments for male sexual dysfunctions ● Ramifications ○ Relationship ○ Vulvovaginal atrophy
  • 30.
  • 31. References 1. WHO (2006a). Defining sexual health: Report of a technical consultation on sexual health, 28–31 January 2002. Geneva, World Health Organization. 2. Marwick C. Survey Says Patients Expect Little Physician Help on Sex. JAMA. 1999;281(23):2173-2174. 3. Sobecki JN, Curlin FA, Rasinski KA, Lindau ST. 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. 2012;9(5):1743-6109. DOI: 10.1111/j. 4. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A Study of Sexuality and Health among Older Adults in the United States. N Engl J Med 2007; 357:762-774. DOI: 10.1056/NEJMoa067423. DOI: 10.1056/NEJMoa067423. 5. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357(8):762-774. 6. Montalto NJ. Implementing the Guidelines for Adolescent Preventive Services. Am Fam Physician. 1998 May 1;57(9):2181-2188. 7. Nelson R. How to Talk to Your Patients About Sex. Medscape. Oct 15, 2015. 8. Sims KE, Meana M. Why Did Passion Wane? A Qualitative Study of Married Women's Attributions for Declines in Sexual Desire. J of Sex and Marital Therapy. 2010; 36(4)360-380. DOI: 10.1080/0092623X.2010.498727. 9. Warnock JJ. Female hypoactive sexual desire disorder: epidemiology, diagnosis and treatment. CNS Drugs. 2002;16(11):745-53. 10. Leiblum S, Bachmann G, Kemmann E, Colburn D, Swartzman L. Vaginal Atrophy in the Postmenopausal Woman-The Importance of Sexual Activity and Hormones. JAMA. 1983;249(16):2195-2198. doi:10.1001/jama.1983.03330400041022. 11. Davis SR, Braunstein GD. Efficacy and safety of testosterone in the management of hypoactive sexual desire disorder in postmenopausal women. J Sex Med 2012; 12;9:1134–1148.