Sex Ed: Beyond the ClassroomWhy Doctors Are Bad at Sex EdBy failing to promote healthy sex lives, physicians fail their patients December 5, 2018February 6, 2019 - by Lauren VogelLauren Vogel Updated 12:09, Feb. 6, 2019 | Published 15:43, Dec. 5, 2018 Natalie Vineberg / The Walrus Auden Steane is more intimate with the health care system than most twenty-three-year-olds are. After being diagnosed with an inflammatory bowel disease five years ago, she has undergone thirteen surgeries. One of these procedures, a failed operation to repair an abnormal passage or fistula between her rectum and vagina, led to the permanent diversion of her bowels to an external bag. Steane’s doctors explained to her how this would affect her daily life, from diet to bathing. But in all the hours of consultations and weeks in hospital, they never discussed how it might impact her sex life. “It just seemed odd to me that they weren’t covering that upon my discharge or bringing it up ever,” Steane says. Her boyfriend often stayed the night when she was in hospital. “They knew that he was a part of my life,” she says. But even in the lead up to her fistula repair, “at no point was I given any information.” After so many medical crises, Steane says she felt embarrassed to raise the topic of sex with her care team. She worried that her doctors might judge her for being concerned about “something that might be considered so insignificant” compared with her other medical issues. Still, Steane had questions. In May, after her most recent operation, she worked up the nerve to ask her mother how long she should wait to have sex again, and her mother asked the surgeon. The answer—a couple of months—was a much longer wait than Steane had expected. The surgeon didn’t explain further about the risks, she says, “so I didn’t really ask.” In other health matters, Steane is persistent. It took months of repeated visits to the emergency department complaining of severe nausea, pain, and bloody diarrhea before doctors first hospitalized and diagnosed her with ulcerative colitis. (She has since been diagnosed with Behcet’s disease, a rare disorder that leads to the inflammation of blood vessels.) But talking about sex is a challenge unto itself—and not just for patients. Simply put, many doctors are bad at talking about sex. “It silences so many people about their sexual life,” says Lucia O’Sullivan, a professor of psychology at the University of New Brunswick who studies intimate relationships and behaviour. Doctors’ awkwardness, insensitivity, or ignorance about sexual issues can leave their patients feeling “invisible or sidelined,” she says. Some are so fearful of saying something that might offend their patients that they avoid the topic entirely. But doctors can’t rely on patients to start the conversation, O’Sullivan says. In some cases, “they won’t even know necessarily that there is a problem.” Yet problems abound. Rates of sexually transmitted infections, or STIs, rose steadily between 2005 and 2015. Issues with sexual function, from vaginal pain and trouble orgasming to erectile dysfunction and premature ejaculation, are also relatively common. One study estimated that up to a quarter of Canadian men experience premature ejaculation, and 90 percent of those had not discussed the problem with their doctor. Most of those who did seek treatment were not satisfied with the results. Sexual health tends to fly under the radar because doctors share the same deep cultural discomfort about sex as their patients, O’Sullivan says. Many Canadians grow up with conflicting messages about sex as “this shameful thing” that’s only legitimate if you’re in reproductive mode, and doctors are no exception, she adds. This taboo has contributed to a narrow focus in medicine on the negative consequences of sex over promoting healthy sex lives. When patients seek help for a problem like vaginal tearing from a lack of arousal, O’Sullivan explains, doctors will often hand them lubricants without asking if they’re having sex they don’t want or whether they were aroused at all. Studies show that sexual satisfaction and healthy relationships are linked to better physical and mental health. A study of teenage girls in Indiana, for instance, found that over the span of ten years, positive sexual experiences in romantic relationships were linked to lower use of nicotine and other substances; less thrill-seeking, delinquent, or criminal behaviour; lower self-reported depression; higher self-esteem; and better social integration. By failing to promote healthy sex lives in addition to treating dysfunction and disease, doctors may be ignoring a determining factor of patients’ overall wellbeing. Research published in Canada and the United States reveals large gaps in the sexual-health counselling doctors provide, particularly for people they might assume aren’t sexually active. Physicians don’t spend much time discussing sex with teens, or with seniors, even when some of their patients wish they would. The needs of gay, lesbian, bisexual, and trans people are often overlooked, as are those of people with disabilities. When sex does come up, the conversation is usually brief and focused narrowly on pregnancy and infections. Natasha Johnson, a professor of pediatrics at McMaster University and an adolescent specialist, is working on a document to guide members of the Canadian Paediatric Society on how to have meaningful conversations with teens about sex. For some young people, she says, a doctor’s visit “may be their only opportunity to talk about their sexual health in a confidential and comprehensive way.” Canadian teens and their parents rank doctors among their most valued sources of sexual-health information. Yet doctors aren’t initiating conversations about sex as often as they should. According to a presentation at the Pediatric Academic Societies meeting in Toronto earlier this year, 45 percent of teens surveyed in Minnesota said their primary care providers didn’t routinely ask about sex, and only 13 percent of the teens had been offered STI screening. Another study, conducted in North Carolina, found that doctors brought up sex in two-thirds of visits with teens, but those conversations lasted just thirty-six seconds on average. Race appears to play a role in these discussions; doctors were 60 percent more likely to discuss sex with black teens, and a sex talk was nearly 90 percent less likely to occur if the physician was Asian. No teen raised the topic themselves. When doctors remind patients that their conversations are confidential, patients are more likely to discuss sexual health—but, according to the study, confidentiality was discussed in only a third of the conversations. Time and privacy are essential when talking about sex, says Johnson. “You cannot do this in thirty-six seconds.” And the conversation should go beyond just contraception and infections, she adds. “Gender identity, attraction, consent, all of those things need to be incorporated into the expectations that a competent physician should be able to address.” This is especially true for transgender patients. A 2009/10 study of trans Ontarians found that half of those who had family doctors were uncomfortable discussing trans-health issues, while a third reported unmet health needs. “Screenings that are sex specific can be extra uncomfortable, and providers can be extra uncomfortable providing them,” says Ayden Scheim, one of the investigators for the study, called the Trans Pulse Project. In interviews with trans men, some reported that doctors didn’t want to examine their genitals or provide them screening for STIs, Scheim says. Others reported that doctors wanted to perform seemingly unnecessary or unwanted genital exams. Many trans people avoid care that requires talking about their bodies or having their bodies examined, Scheim says. Some are poorly prepared by their providers for the sexual changes that can occur with transition. And, up to a decade ago, doctors routinely asked trans patients intrusive questions about their sex lives to decide whether they qualified for hormone treatment or surgery. “Things like what they think about when they masturbate are totally irrelevant and really unsafe,” says Scheim. “It leaves people not wanting to open that conversation with a health care provider, even though those kinds of dynamics are much less common now.” These barriers put trans people at higher risk of undiagnosed and untreated STIs. The Trans Pulse Project found that 46 percent of trans Ontarians have never been tested for HIV. Meanwhile, American studies show that trans women with HIV get diagnosed later and in more advanced stages of the disease. Scheim says that some doctors assume this means that all trans women have high risk for HIV. In fact, the study found that about half of trans women “aren’t sexually active and many are sexually active with other women,” lowering their risk. Focusing too much on HIV when talking to these women “really shuts down conversation,” he says. Doctors’ assumptions also lead to gaps in sexual-health care for seniors. Most seniors are sexually active and say sex is important to their quality of life, but a national survey of Americans aged sixty-five to eighty found that only 17 percent had discussed their sexual health with a care provider in the past two years. Sixty percent of the time sex did come up, the seniors initiated the conversation. “It’s not as though this is a population for which the issue is irrelevant,” says Erica Solway, associate director of the survey. Rates of STIs increased significantly among adults over forty-five in the United States, Canada, and the United Kingdom from 2000 to 2009, a trend that could be linked to seniors leading more active lifestyles and the use of sexual-performance drugs. Nearly one in five men in the American survey reported taking medication or supplements “in the past two years” to improve their sexual function. This becomes a problem if doctors prescribe other medications without knowing their patients are taking performance enhancers, Solway says. “It’s possible that there could be a negative interaction.” Unless doctors start the conversation about sexual health, patients might not know how or when to bring it up. Better sex ed for medical trainees and doctors may help close some of these gaps in care, says Eli Coleman, director of the program in human sexuality and academic chair in sexual health at the University of Minnesota Medical School. He co-authored an international report that found current medical education on sexuality was not adequate to prepare students for practice and varied widely by school. According to a 2003 study, most medical schools in Canada and the United States spend just three to ten hours on sexuality across four years of training, and to Coleman, that figure seems to be decreasing. “This is a global issue,” he says. “I’m not sure that I can point to some place in the world that’s necessarily doing so much better, and there are obviously places that are doing it far worse.” Medical students tend to come from more conservative backgrounds, and those who receive abstinence-focused education often lack even basic understanding of sexual-health issues, Coleman says. That’s starting to change as more liberal students are pursuing medicine, but this division in class politics can also polarize discussions about sex and gender. Without the right training, Coleman says, “physicians will simply not go where they don’t feel comfortable.” Sexual education is often relegated to adjunct professors. The Mayo Clinic’s medical school has contracted Coleman to teach a portion of the course that deals with attitudes and values toward sex. “There wasn’t faculty who felt that they could do it themselves.” Coleman and others have called on the International Society for Sexual Medicine, a global organization of health professionals, researchers, and educators in the field of human sexuality, to develop training resources. So far that hasn’t happened, he says. “I think that they recognize the need, but there are a lot of needs, and that one has not risen to the top.” Pierre-Paul Tellier, a family physician and medical educator at McGill University, says he has three hours specifically allocated to teaching students what and how to ask about a patient’s sexual history, and he covers topics such as domestic violence, sexual assault, and human trafficking. “I don’t think many other people do a lot more.” Tellier says this time crunch continues once trainees enter practice, where family doctors are expected to spend just ten to fifteen minutes with patients. Electronic medical records may not include prompts about sexual health, and doctors usually aren’t compensated for extra counselling. Tellier says he sometimes sees patients whose family doctors won’t do pelvic exams for STI screening or pap smears. “They send them away.” Gender dynamics “have definitely been an obstacle, at least in the past,” says Alex McKay, executive director of the Sex Information and Education Council of Canada. Conversations about sex are most likely to happen when both doctor and patient are female. For all their locker-room talk, in McKay’s experience, men are more uncomfortable discussing sexual issues. However, McKay disagrees that doctors have the required training to be sex educators. Some form of sexual-health assessment should be worked into annual checkups, he says, but requiring much more may “put the cart before the horse,” given doctors’ limited time and expertise in this area. According to Wendy Norman, a professor in the department of family medicine at the University of British Columbia, “the onus is on the school system to support the delivery of high-quality, well-rounded information that addresses the appropriate, wide ranges of sexual-health questions.” Doctors should be able to respond to patient questions when they come up or know where to refer them for answers, Norman says. But anything more would require changes to preventive-care guidelines. Such changes, she says, depend on proving that more proactive sexual-health counselling would improve patient outcomes enough to reduce overall health costs. However, Tellier argues that even a short conversation can go a long way. “If you avoid the topic, then it means you’re not interested. It means if they have problems, they’re not going to engage with you.” There is also no guarantee that patients are getting good information elsewhere, especially if they’re young. “It’s not being so well done in schools, and often the parents are not knowledgeable,” Tellier says. Johnson hopes the emergence of adolescent health as a medical subspecialty will lead to more research on teen sexual and reproductive health. “There’s a paucity of Canadian data, there’s no doubt about it,” she says. Putting together a recent presentation on LGBTQ youth, Johnson had to rely on US statistics. There has been some progress to close these knowledge gaps. Scheim says an upcoming national survey of trans Canadians will include questions about their reproductive-health care. New generations of medical trainees are also challenging some of the discomfort around these issues, he says. These grassroots efforts have led to the introduction of “trans 101” training sessions in medical schools. “A lot of the change that is happening in the medical curriculum is happening because the students are agitating for it.” For patients like Steane, it matters that doctors recognize their own blind spots. She was touched when her surgeon let her know she was undertaking a study on doctor-patient conversations about sex. “Seeing that side of doctors, where they’re caring about something outside their specialty, does make me kind of feel like, oh wow, they’re looking at me like I’m a person,” says Steane. It also suggests that patients may be pushing for change behind the scenes, she says. “For doctors to know that it’s something they’re not good at talking about, it must have come from somewhere.” Lauren VogelLauren Vogel (@ellevogel) is an award-winning health journalist based in Toronto.