Chapter 116: Sexual health

Sexual health is the ability to embrace and enjoy our sexuality throughout our lives. Our sexuality is a fundamental human experience that encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction.¹

Family doctors are often asked to provide advice and help for sexual concerns and are continually challenged to detect such problems presenting in some other guise. Since we deal with so much illness and prescribe so many drugs, we must be aware of the possible implications of their various effects on sexual health.

SEXUAL DYSFUNCTION²

Several studies have demonstrated that sexual concerns and problems are common, with a prevalence ranging from 20–40%. Difficult problems are summarised in TABLE 116.1. There is also evidence that health professionals do not discuss sexual concerns in consultations as often as patients would like.

Sexual dysfunction can be the bodily expression of many sorts of distress and requires consideration of biological, psychological, sociocultural and relationship factors. The unique place of general practice and the family doctor provides ideal opportunities to address the sexual concerns of patients as the family doctor often has considerable insight into the family dynamics and first-hand perspective of the individuals involved.

OPPORTUNISTIC SEXUALITY EDUCATION

The family doctor has many opportunities to provide education in sexuality throughout the lifelong care of the patient and it is wise to have a strategy that matter of factly incorporates enquiries and information about sexual health.

Examples include:

• antenatal and postnatal care

• contraceptive requests

• parents concerned about their children’s sex play

• serious illness—medical and surgical

• adolescent problems

• menopause problems

PRESENTATION OF SEXUAL CONCERNS

Although some patients may present directly with a complaint of sexual dysfunction, many will be less direct and use some other pretext or complaint as a ‘ticket of entry’ for their sexual concerns (see TABLE 116.2). Despite a seemingly terse approach the issue must be recognised and treated with considerable importance. This may mean scheduling an appropriate time to discuss the concerns.

THE EFFECT OF ILLNESS ON SEXUAL FUNCTION

Doctors seldom enquire about the impact of an illness on the sexual function of patients and their partners (see TABLE 116.3). It is most appropriate to enquire about these issues with patients, e.g. the postmyocardial infarction patient, the postprostatectomy patient, the patient taking antihypertensives or other drugs (see TABLE 116.4), and the post-mastectomy or posthysterectomy patient. Diabetes deserves special attention as more than 60% of diabetic men have reported erectile difficulties.⁴

TAKING A SEXUAL HISTORY

It is important to create a safe environment for patients to talk about their sexual behaviour and sexuality. Consider explaining why you are asking for this information and request permission to proceed. Avoid being too formal or too familiar but aim to display a wise, matter-of-fact, empathic, commonsense rapport. CHAPTER 117 covers the sexual history required when assessing for sexually transmitted infections (STIs).

Be aware that many patients will have an undisclosed history of sexual abuse.

Probing questions for a suspected sexual problem

• How are things going in your sex life?

• Do you have any difficulties with your relationship or sex life?

• Are you satisfied with the frequency and quality of your sexual experience?

• Do you have any pain or discomfort during intercourse?

• Have you had any difficulties with erections (men)?

Sexual and relationship history

A general medical history should be taken including surgical history, medication use, recreational drug and alcohol use, and smoking.

Consider the following when exploring a sexual symptom:

• What sex education did you have as a child at home or at school?

• What were your parents’ attitudes to sex?

• Have you experienced any upsetting or traumatic sexual experiences?

• Are you experiencing stress in any area of your life—relationship, work or home-life?

• Are you able to talk to your partner about sex?

• How was your coming-out experience (patients in same-sex relationships)?

Examination

The routine medical examination should include the basics such as urinalysis, BP measurement, genital examination and neurological where indicated.

Investigations

No particular routine tests are recommended. Tests for male erectile dysfunction (impotence) are outlined later in this chapter. Tests that may help exclude significant causes of low libido are those for diabetes, liver dysfunction, thyroid dysfunction and endocrine dysfunction. Endocrine dysfunction tests include prolactin, free testosterone, FSH, LH and oestradiol estimations. Other investigations may include pelvic ultrasonography, colposcopy or laparoscopy.

The acceptance of many sexual myths that have prevailed in our society may affect a couple’s sexual relationship. Sexualised images in the media and pornography are a common cause of unrealistic expectations in the bedroom. These expectations can exacerbate the problem, causing disappointment and a feelings of inadequacy.

Sexual myths that could be explored include:

• men need sex, women need love

• men need more sex than women

• men must be the instigators

• sex = intercourse

• a hard erection is essential for good sex

• sufficient sexual thoughts should always make the penis erect

• both partners should achieve an orgasm every time and simultaneously

• women should be able to achieve orgasm through penetrative intercourse

• men should be ready and able to last all night

• as a person gets older there is a loss of interest in sex

The family doctor can learn to be an effective sex counsellor. Sex counselling can be emotionally demanding and, while good interviewing skills, interest, support and basic advice are important, additional skills are needed to be an effective counsellor.

Principles for basic sexual counselling:

• give the patient permission to talk openly about sexual matters

• allow for a relaxed exchange of information

• dispel sexual myths and correct misunderstandings

• explore the patient’s anxiety and any impact on their relationship

• de-emphasise the modern-day obsession with performance and orgasm and emphasise the value of alternative forms of sexual expression (e.g. caressing, kissing, and manual and oral stimulation)

• reassure the patient that he or she is normal (where appropriate)

Inappropriate doctor behaviour is presented in TABLE 116.5.

Sexual problems can be grossly underestimated. Human beings generally have a basic craving for intimacy, touching, stroking and loving sex. Apparently harmonious relationships can lack this type of intimacy, which may lead to various psychosomatic manifestations.

Ideally the family doctor should undertake a course in sexual counselling to promote confidence in the counselling process. Patients can be taught basic methods (where appropriate) such as sensate focus, squeeze or stop–start techniques for premature ejaculation, self-exploration using Kegel pelvic floor exercises, fantasy conditioning with books or videos, use of sex toys and behaviour modification. Complex or serious problems, especially those involving compulsive sexual behaviour, demand specialist referral.

The PLISSIT counselling model developed by Annon⁵ can be used to build the skills needed to deal with sexual problems, especially if there is a psychological element.³

The mnemonic PLISSIT stands for:

• P = Permission giving

• LI = Limited Information

• SS = Specific Suggestion

• IT = Intensive Therapy

‘Permission giving’ allows patients to talk about sex, ask questions, feel guilty and so on. Their problems are shared with a reflective listening confidant.

Most medically trained people can probably provide the limited information required about sexual physiology and behavioural patterns. ‘Specific suggestion’ provides ideas for self-help and may include key reference books and relevant videos. With a little support and permission, the patient can take simple action to remedy or improve a problem.

Intensive therapy, whether psychiatric or emotional, calls for deeper involvement and can be a dangerous area for the inexperienced. Referral to an appropriate practitioner is usually advisable.

An explanation of the analogous roles of the penis and clitoris (proposed by Cohen and Cohen) is a very useful strategy for educating patients and helping them to understand the relationship of intercourse and penile and clitoris stimulation with orgasm. The simple model (see FIG. 116.1) can be shown to patients to explain, for example, why some women are unable to achieve orgasm by intercourse alone, especially using the conventional missionary position.³ It can readily be explained that clitoral stimulation in women is analogous to penile stimulation in men.

Female orgasmic difficulties

It is necessary to determine whether the woman has been anorgasmic or can experience orgasms from other activities such as masturbation, or manual or oral stimulation, even though she is non-orgasmic during intercourse. One-third of women may never experience orgasm, but enjoy their sexual relationships despite this.²

A common concern of women is the inability to regularly achieve orgasm through vaginal intercourse, believing there may be a physical cause. It is important to reassure that this is normal, as the majority of women are able to achieve orgasm through clitoral stimulation rather than intercourse.

The use of the Cohen model (see FIG. 116.1) is very helpful in emphasising the importance of clitoral stimulation.

Therapy includes:

• sensate focus exercises⁶

• advice on the most appropriate positions for intercourse

• permission to use:

  • – books, videos

  • – self-stimulation

  • – vibrators

Dyspareunia

Painful intercourse is a source of considerable distress both physically and psychologically for the sufferer and also for her partner. It may be one of the ‘hidden agenda’ presentations with a vague complaint such as ‘I am uncomfortable down below’. Tact and sensitivity is very important in management.

In particular it is helpful to keep in mind vulval vestibular syndrome, which has subtle physical signs (see CHAPTER 107). Important causes are listed in TABLE 116.6. A common problem encountered is the presence of painful scar tissue following an episiotomy, especially after the first vaginal delivery. Women who experience deep pain with intercourse need a gynaecological referral to assess for pelvic pathology.

Management of dyspareunia involves treating the organic cause and giving appropriate advice about the use of lubricants, including topical oestrogen where indicated. While this may be enough in simpler cases, it does not address the often accompanied fear of penetration,^2,7 which can continue even after the cause of dyspareunia is addressed.

Vaginismus²

Vaginismus is the involuntary contraction of muscles around the introitus (outer third of vagina) in response to and preventing the possibility of penetration. It can be classified as primary or secondary. In primary vaginismus, tampons will probably never have been inserted. It is often related to provoked vestibulodynia (vestibular hypersensitivity—see CHAPTER 107).

A fear of penetration can be the underlying cause and may be associated with fears of internal damage, pregnancy, learned negative attitudes to sex and past sexual trauma. It is not an uncommon cause of unconsummated marriage. The problem may respond to sensitive exploration of fears and education of the anatomy and physiology. Encourage use of lubricant and a comfortable sexual position that the woman can control, usually superior.

Consider referral to specially trained physiotherapists for pelvic floor relaxation and use of vaginal trainers. Vaginal trainers can be inserted at increasing sizes for desensitisation, allowing for progressive vaginal dilation. Expert counselling is necessary if fears remain a barrier to recovery.

Lack of libido²

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) defines lack of libido in women as sexual interest/arousal disorder (FSAD), and in men as male hypoactive sexual desire disorder (MSHDD).⁸ Lack of libido is usually due to a combination of factors including relationship issues, illness, medications, drug and alcohol use, hormonal changes, stress and fatigue. Other sexual difficulties that are treated medically (e.g. erectile dysfunction) may later present with reduced libido, indicating that the underlying relationship factors have not been addressed.

Individuals or couples may benefit from basic sexual counselling from their GP, while others may request input from a sex therapist. If lack of libido is secondary to menopause, a trial of hormonal replacement therapy (HRT) may be useful. Tibolone is an HRT that has been shown to have benefit in managing loss of libido in some women.⁹ Conclusive evidence in support of other drug therapies is lacking.¹⁰

Erectile dysfunction

Erectile dysfunction (impotence) is the inability to achieve or maintain an erection of sufficient quality for satisfactory intercourse.

Erectile dysfunction is a common problem. In an Australian study, the overall prevalence of erectile dysfunction was 61% (25% sometimes, 19% usually and 17% had complete erectile dysfunction). More than 20% of healthy men aged 60–65 years with no risk factors had moderate or complete erectile dysfunction.⁴

Traditionally, the aetiology of erectile dysfunction is classified into organic, psychogenic or mixed. In reality, however, anxiety and depression commonly accompany erectile dysfunction, irrespective of the original aetiology. Consequently, nearly all organic erectile dysfunction will eventually become ‘mixed’.¹¹

• psychogenic: related to stress, interpersonal or intrapsychic factors (e.g. depression, marital disharmony, performance anxiety)

• neurogenic: disorders affecting the parasympathetic sacral spinal cord (e.g. multiple sclerosis); it usually develops gradually

• vascular

• diabetes

• hypertension

• chronic kidney disease

• urological problems (e.g. Peyronie disorder, pelvic trauma and surgery)

• hormone disorder

  • – androgen deficiency (e.g. testicular disease)

  • – hypothyroidism

  • – hyperprolactinaemia (rare) → impotence and loss of libido due to secondary testosterone deficiency

• drug-induced:

  • – alcohol

  • – cocaine, cannabis

  • – nicotine (four times the risk by age 50)

  • – antihypertensive agents

  • – finesteride

• ageing

• unknown

The nature of the onset of erectile dysfunction is very important and this includes the nature of the relationship. Of particular importance is a drug history, including alcohol, nicotine, recreational drugs and pharmaceutical agents, particularly antihypertensives (beta blockers and thiazide diuretics), hypolipidaemic agents, antiandrogens (prostate cancer treatment), antidepressants, antipsychotics and H₂-receptor antagonists. Ask about nocturnal and early morning erections.

Genitourinary, cardiovascular and neurological examinations are appropriate, although may not reveal the diagnosis. A focused examination should include a rectal examination and examination of the vascular and neurological status of the lower limbs and the genitalia, especially the testicles and penis. Check the cremasteric and bulbocavernosus reflexes.

First-line blood tests:

• morning testosterone

• TSH

• prolactin

• luteinising hormone

• fasting blood glucose

Other blood tests to consider:

• LFTs, especially GGT (alcohol effect)

• kidney function tests

• lipid studies

When the aetiology is unclear, specialist testing includes a penile duplex doppler ultrasound using an intracavernosal vasoactive agent.

Management

Address modifiable risk factors, including medications (if feasible), psychosocial issues and lifestyle (see NEAT, CHAPTER 7). Management should comprise appropriate patient education. The partner should be included in the discussions and general management process with an emphasis on bolstering the couple’s self-image, which may have been affected by feelings of rejection or avoidance.

Psychogenic disorders

These involve psychotherapy and sex behavioural modification as outlined earlier in this chapter under Basic sexual counselling. Referral to a consultant may be appropriate.

Oral medication

PDE-5 inhibitors: the phosphodiesterase type 5 (PDE-5) inhibitors are the first-line oral medication (see TABLE 116.7). They are about 70% effective but not very effective for neurogenic ED. They do not initiate an erection but enhance whatever erection the man is capable of having. Sexual stimulation is necessary. They are contraindicated if the patient has unstable angina, recent stroke or myocardial infarction. Use with nitrates should be avoided and a nitrate should never be taken within 24 hours of use. The interaction with nitrates can result in a severe and potentially fatal hypotensive response. PDE-5 inhibitors have the potential for side effects, especially headache. Treatment is not considered a failure until a full dose has been trialled 7–8 times.¹²

Intrapenile injection

Intracavernosal vasodilator injections are second-line therapy and should be supervised by an experienced practitioner.

Alprostadil intracavernosal injections:

• self-administered after supervised teaching (use a penile model if available)

• start with a lower dose, 2.5–5 mcg

• spontaneous erection in 5-20 minutes

• if prolonged erection >2 hours take 120 mg pseudoephedrine orally and have a hot shower—repeat at 4 hours if necessary (provided not hypertensive)

Vacuum constriction

Vacuum constriction devices (VEDs) may have a place in management, where pharmacological therapies have failed or are inappropriate. VEDs are often poorly tolerated in the long term due to side effects such as pain, inability to ejaculate, bruising, ‘hinging’ and paraesthesia.¹¹

Surgery

• malleable penile prosthesis

• inflatable penile prosthesis (see FIG. 116.2)

Premature ejaculation

Premature ejaculation is defined as ‘ejaculation that occurs sooner than desired’ or, more precisely, as ‘persistent or recurrent ejaculation, before, on or shortly after penetration and associated with significant personal distress’. In most cases, this occurs within 1 minute of vaginal penetration. It may not be clearly described by the patient so a careful history is necessary to define the problem. Ensure that the person is not suffering from erectile dysfunction. Both patient and partner may complain about the problem.

There are many approaches to treatment but they are aimed either at prolonged ejaculatory control or at satisfactory sexual activity without preoccupation with ejaculation.

Non-pharmacological treatment includes psychosexual therapy and/or behaviour therapy (including ‘stop-start’ techniques).

Pharmacological treatment

SSRIs have also been reported as effective—using dapoxetine 30 mg, sertraline 50 mg or paroxetine 20 mg, all about 3 hours before intercourse.¹⁰ Some men may prefer to take SSRIs daily for managing premature ejaculation. Local anaesthetic has been suggested to reduce penile sensation, however this tends to be counterproductive as it reduces sexual pleasure.²

For some individuals, gender identity and sexual orientation are fixed and clear, while for others it may be more fluid. It is also worth noting that identity, attraction and behaviour are not necessarily congruent. It is incumbent on the general practitioner to have a good understanding of the diversity of sex, sexuality and gender and the specific needs of the LGBTIQ (lesbian, gay, bisexual, transgender, intersex and queer) community.

Studies have found that the medical experiences of individuals identifying as LGBTIQ are ‘generally poor’. Contributing factors include assumed heterosexuality, health professional discomfort, poor knowledge of LGBTIQ issues and appropriate referral networks and resources.

Definitions and facts

Lesbian: A woman who experiences an attraction to other women.

Gay: A man who experiences attraction to men. Men who have sex with men (MSM) do not always identify as gay. It can also be used as an umbrella term to describe both lesbians and gay men and perhaps bisexual people of both sexes.

Bisexual: A person who experiences attraction to their own as well as the opposite gender.

Transgender: A person whose gender identity and/or gender expression differs to their birth sex. Sexual orientation varies and is not dependent on gender identity.

Intersex: People who are born with genetic, hormonal or physical sex characteristics that are not typically ‘male’ or ‘female’. Causes include congenital adrenal hyperplasia and androgen insensitivity syndrome. Intersex individuals can have a broad range of gender identities and sexual orientations.

Queer: A political statement as well as a sexual orientation which advocates non-binary thinking and seeing both sexual orientation and gender identity as potentially fluid.

A recent Australian sample found that 14.7% of women are same-sex attracted, 13.5% engage in same-sex behaviour, 1.2% identify as lesbian and 2.2% are bisexual; and 6.8% of men are same-sex attracted, 6.0% engage in same-sex behaviour, 1.6% are gay and 0.9% bisexual.¹⁴

It is estimated that up to 8% of Australians are gender diverse and individuals who are intersex constitute 1.7% of births in Australia.

Gender dysphoria¹⁵

Gender dysphoria is the distress or discomfort that may occur when a person’s biological sex and gender identity do not align. Individuals who identify as transgender are vulnerable and have higher rates of discrimination, depression and suicidality compared with the general population.

Some patients may be happy to live in their desired gender role, but many will want to physically transition with the use of hormones, with or without surgery. Specialist referral and a multidisciplinary approach is required for those considering physical transition. Given gender identity develops in the first four years of life, young children may also require referral.

Concerns of penis size

In general practice it is not uncommon to counsel men and adolescent males for anxiety about the size of their penis. It is a manifestation of abnormal body image perception and related to the myth that a man’s sexual performance depends on the size of his penis. The patient may present with minor (often trivial) non-sexual complaints as a ‘ticket of entry’ into the consulting room.

The average adult penis measurements are summarised in TABLE 116.8.^16,17

Psychological factors

It should be explained that virility and performance are not related to the size of the penis.¹⁷ Orgasm in the female does not depend on deep vaginal penetration. Penile size was found to have little relationship to a partner’s satisfaction from sexual intercourse. The vagina, which is 10 cm (4 inches) long in the unstretched state, tends to accommodate itself to the size of the penis.

There is undoubted evidence that sexuality, and its expression, remains important to both men and women as they age.¹⁹ While there is a decline in sexual activity with age, many older men and women remain sexually active through their later years.

Studies also show that maintaining sexual activity is generally more important to men than women. Dyspareunia due to vaginal atrophy may be a contributing factor, for which additional lubrication, topical oestrogen or systemic hormone therapy can be of benefit.

Older people have the same needs as younger people—namely, the need for closeness, intimacy and body contact. Intercourse in the elderly may be difficult or not possible, so it may be appropriate to advise ‘outercourse’ which is an extension of foreplay and which provides loving body contact and intimacy. Other suggestions include planning of sexual activity, taking analgesia prior to sexual activity, alternative activities to ensure physical comfort and use of specific aids.

Jean Hailes Foundation <www.jeanhailes.org.au>