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Sex Matters

Effective Communication: Overcoming the Embarrassment

Lisa Martinez, RN, JD

Even in todayÍs permissive atmosphere, sexuality remains a source of embarrassment for many patients. Overcoming this barrier is essential to appropriate care, however, and there are many approaches that the physician can use to promote comfort and confidence.

Female sexual dysfunction (FSD) affects a significant number of women,1 with difficulties ranging from lack of sexual desire, arousal, or orgasm to dyspareunia. In the context of primary care, the physician should be aware that FSD may occur secondary to medical conditions (eg, diabetes, cardiovascular disease, breast/gynecologic cancer, pelvic surgery), and/or the use of particular medications (antidepressants, antihypertensives).2,3

Although practitioners may hesitate to discuss sexual health concerns due to lack of educa-tion or time, or perceived lack of treatment modalities, women expect physicians to initiate such discussion.4,5 However, according to an ongoing survey by the Women’s Sexual Health Foundation, less than 8% of women are routinely queried about sexual health difficulties during an annual office visit.5

Even in the absence of available treatment, the physician who raises these issues can validate the patientÍs concerns, providing reassurance and often relieving a sense of isolation. Indeed, validation can be very therapeutic for this patient population. Therefore, practitioners should take a proactive approach to addressing FSD and ensuring that sexuality is included in all routine assessments.

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SETTING THE STAGE

Patients should routinely be asked about their sexual health. To “set the stage” for this discussion, practitioners can communicate with their patients in many ways. Indirect communication is least intrusive, and is an effective prelude to direct questions. For example, by placing educational brochures in the waiting and examination rooms, the physician implicitly indicates that sexual issues are important; placing brochures in the examination room ensures that women who are too embarrassed to pick up this information in the waiting room can do so in privacy. In addition, having a few books on women’s sexual health available and visible in the office further reinforces the physician’s receptivity.

Another minimally intrusive technique is to list a question or two on the history sheet that the patient completes on her annual visit. Questions may include:

• Are you having any concerns about your sexual health?
• Would you like to discuss sexual health concerns?
• Are you having problems with vaginal pain or dryness, arousal, desire, or orgasm?

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DIRECT COMMUNICATION

With regard to direct communication, the PLISSIT and BETTER models can easily be incorporated into routine practice to improve communication and assist the practi-tioner in gradually introducing the topic of sexual health.6,7

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PLISSIT

• Permission. Give the patient permission to discuss sexual concerns.
• Limited Information. Provide information based on the discussion with the patient and her questions.
• Specific Suggestions. This encompasses specific recommendations, such as lubricants, positions, exercises, or other techniques that address the patientÍs individual needs.
• Intensive Therapy. This applies to referral to a counselor or sex therapist for the patient or the couple as appropriate.8

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BETTER

• Bring up the topic of sexual health.
• Explain that for many, sexuality is an important quality-of-life issue, and that you are open to discussing these issues.
• Tell the patient that there are resources, and that you or your staff will assist her in finding them.
• Time the discussion to the patientÍs preference.
• Educate the patient regarding sexual side effects of treatments or medical conditions.
• Record the assessment, treatment, and outcome in the patientÍs files.9

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MEDICAL ISSUES

If the patient has a medical condition that could affect her sexual health—eg, diabetes, multiple sclerosis, depression—she should be informed that sometimes women with these conditions may have trouble with arousal or desire, so a sexual assessment will be a routine part of her care. Thus, even if the patient is not having problems at that time, the physician both provides her with information and creates an open atmosphere for future discussions of sexuality.

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PROFESSIONAL BOUNDARIES

It is never appropriate for physicians to confide in a patient about their own sexual relationships or problems. The patient may perceive such comments as crossing professional boundaries. Professional distance and decorum must be maintained. For most women, sexual issues are very personal, and the visit should be confined to the patientÍs concerns. Rather than personalizing explanations, the physician should use a third-person approach—eg, ñMany women experience vaginal dryness after a hysterectomy, and there are several over-the-counter preparations that may be helpful.î Such an approach can also help to validate the patientÍs concerns.

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TERMINOLOGY

Patients often use slang terminology to describe sexual problems, and this is a wonderful opportunity to educate them on the correct terminology and anatomy. Many women confuse the vulva or labia with the vagina, so anatomical drawings can be used to explain genital features. This is especially important when instructing women on the use of topical medications that require correct application for efficacy. However, medical terminology should be used on a level that the patient understands; if she feels embarrassed about her lack of knowledge, she may become inhibited about voicing further concerns.

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SOCIAL AND CULTURAL ISSUES

Any woman can have a problem with any aspect of her sexual functioning—regardless of age, marital status, or sexual orientation. All patients should be asked whether they have partners. In addition, even if the patient does not have a partner, she may still have sexual concerns. Likewise, sexual health should not be dismissed in the elderly.10 In essence, the physician should never assume that a patient does not need a sexual assessment.

The physician should avoid cultural, religious, and ethnic judgments concerning the patientÍs complaints. It is also important to be aware of how the physicianÍs personal, cultural, and religious background may affect his or her ability to assess and treat a given patient. For example, masturbation is sinful according to some religions and certain cultures forbid reading erotica, so the patient may reject such recommendations.

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OFFICE STAFF

The physician should make sure that the office staff is comfortable with the topic of patientsÍ sexual health. For example, the receptionistÍs voice or body language should not convey discomfort when a patient asks to schedule an appointment to evaluate painful intercourse. The office environment should be friendly and welcoming, encouraging patients to feel secure. However, only staff members trained in sexual health should assess, educate, and treat the patient.

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CONCLUSION

Female sexual dysfunction is common, but all too often it is neither recognized nor treated. The comfort level of the physician, patient, and office staff plays a major role in promoting an appropriate and positive discussion of these issues. The physician can create the requisite atmosphere by ensuring that communication about sexual health is incorporated into standard practice routines.

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Lisa Martinez, RN, JD, is executive director, the WomenÍs Sexual Health Foundation, Cincinnati, Ohio; and bylaws cochair, American Association of Sexuality Educators, Counselors, and Therapists.

References

1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6):537-544.
2. Salonia A, Lanzi R, Scavini M, et al. Sexual function and endocrine profile in fertile women with type 1 diabetes. Diabetes Care. 2006;29(2):312-316.
3. Phillips NA. Female sexual dys- function: evaluation and treatment. Am Fam Physician. 2000;62(1):127-136, 141-142.
4. Press Y, Menahem S, Shvartzman P. Sexual dysfunction—what is the primary physicians role? [in Hebrew]. Harefuah. 2003;142(10):662-65, 719.
5. The WomenÍs Sexual Health Foundation. The WomenÍs Sexual Health Foundation survey: discussing sexual health with women [abstract]. Available at: http://www.twshf.org/whats_ new_november2006.html. Accessed September 1, 2006.
6. Katz A. Sexuality and hysterectomy: finding the right words: responding to patientsÍ concerns about the potential effects of surgery. Am J Nurs. 2005;105(12):65-68.
7. McInnes RA. Chronic illness and sexuality. Med J Aust. 2003;179(5): 263-266.
8. Annon JS. The PLISSIT Model: a proposed conceptual scheme for behavioral treatment of sexual problems. J Sex Educ Ther. 1976;2:1-15.
9. Mick J, Hughes M, Cohen MZ. Using the BETTER Model to assess sexuality. Clin J Oncol Nurs. 2004;8(1):84-86.
10. Sexuality in middle and later life (fact sheet). Sexuality Information and Education Council Web site. Available at: http://www.siecus.org/pubs/fact/fact0018.html. Accessed November 1, 2006.

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