UBC Objectives: Women's Health, UBC Objectives: Care of Men, Priority Topic: Gender Specific Issues, & Priority Topic: Sex

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Using their knowledge of normal sexual development and function, fertility and aging processes, manage (including referral as appropriate) patients with disorders of sexual development and function, including erectile dysfunction and ejaculatory disorders
• Using their knowledge of normal sexual development and function, fertility, menopause and aging processes, manage (including referral as appropriate) patients with disorders of sexual development and function
• Evaluate and counsel men around appropriate contraceptive choices
  

Gender Specific Issues

Key Feature 3: When men and women present with stress-related health concerns, assess the possible contribution of role-balancing issues (ex: work-life balance or between partners).
Skill: Patient Centered, Clinical Reasoning
Phase: Hypothesis generation, History

Sex

Key Feature 1a: In patients, specifically pregnant women, adolescents, and perimenopausal women: Inquire about sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).
Skill: Patient Centered, Clinical Reasoning
Phase: History

Key Feature 1b: In patients, specifically pregnant women, adolescents, and perimenopausal women: Counsel the patient on sexuality (ex: normal sexuality, safe sex, contraception, sexual orientation, and sexual dysfunction).
Skill: Patient Centered, Communication
Phase: Treatment

Key Feature 2: Screen high-risk patients (ex: post-myocardial infarction patients, diabetic patients, patients with chronic disease) for sexual dysfunction, and screen other patients when appropriate (ex: during the periodic health examination).
Skill: Selectivity, Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 3: In patients presenting with sexual dysfunction, identify features that suggest organic and non-organic causes.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 4: In patients who have sexual dysfunction with an identified probable cause, manage the dysfunction appropriately.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 5: In patients with identified sexual dysfunction, inquire about partner relationship issues.
Skill: Patient Centered
Phase: History

Sexual problems are common. Despite this fact, for multiple reasons, they are often not talked about. At some level, I get it. It's not necessarily a fantastic conversation starter. But as a family doctor with patients who I will see regularly, I'm hoping I can break through the stigma and address sexual health much as any other component of wellbeing. As in a previous post where I discuss obesity, there is still much stigma regarding certain medical problems. Medical doctors (or at least family doctors in Canada) are moulded to view these issues within a biopsychosocial framework. Knowing the current stigma that exists, and the lengthy process required to break down stigma in society in reality, it really is up to doctors (and especially family doctors) to inquire about these issues that patients may feel too embarrassed to bring up without prompting. This is particularly true during periods of transition in life, when sexual concerns may more frequently arise, as is true with adolescence, pregnancy, and the menopausal transition. It can also be more common in males secondary to aging and underlying disease affecting the physiology of obtaining and maintaining an erection.  These patients with chronic medical conditions can be at increased risk of sexual dysfunction as biological complications of their disease state but also as a consequence of psychiatric issues that can arise secondary to having chronic disease. As a family physician, it is my role to help the patient take care of their illness and promote wellness in all facets of life, and this includes sexual health.

Patients need to be asked about sexual concerns in a safe environment. They need to be asked about safe sex practices and use of contraception and given tools to manage these that fit with their lifestyle. And, where we go less often, they need to be asked about sexual function/wellness. I screen for such concerns by stating that many patients have concerns regarding sexual functioning and sexual orientation, and that because of this I routinely ask about it with patients in my practice. I do this to shape a safe space for discussing issues the patient may feel are sensitive, to help them understand just how normal it is for the physician to talk about. Indeed, because of a lack of common discussion about these issues, some patients find that their "concerns" are really totally a part of the spectrum of normal sexuality. And for those whose concerns are true problems for them, there are effective treatment options that I can offer as a physician, whether they are psychologically based or organic or both.

Once a patient has endorsed having a concern with sex that is indeed dysfunctional, it is my job to elucidate just what really is going on. Often there is more than one contributing factor. Reasons for sexual dysfunction include having a history of genital trauma, medication side effects, vascular insufficiency, neurologic dysfunction, hormonal problems, and psychological or emotional factors (including relationship difficulties). Each etiology creates problems in its own way, and can further lead to problems involving the psyche or other systems, and frequently affecting relationships; obtaining a good clinical assessment helps to create a tailored approach to treatment. Basically my history involves assessing whether any of the known causes may be contributing. In males complaining of erectile dysfunction, the classic question to ask to suss out whether this dysfunction is largely organic in nature is to ask if he still has nocturnal erections or other spontaneous erections. The absence of these does suggest the dysfunction is largely organic. As well, whenever erectile dysfunction is more sudden onset rather than gradually worsening with time, that suggests a non-organic etiology. And it is important to not assume that a male presenting with concerns regarding sex or infertility is having erectile dysfunction; although it is very common, there are other sexual concerns that are managed differently (ex: first-line treatments for ejaculatory disorders, which are considered psychiatric disorders, include SSRIs, topical anaesthetics, +/- psychotherapy). 

• In a women who has associated menopausal symptoms: 
  • If sexual dysfunction is with associated vaginal dryness and dyspareunia, the first line treatment is lubricants and moisturizers, and then vaginal estrogen therapy (or ospemifene, an oral selective estrogen receptor modulator). 
  • If a woman also has hot flashes, consider systemic estrogen or estrogen/progestin therapy.
• In a patient who has symptoms that started after the initiation of a medication, consider changing medications (if the medication was an antidepressant, consider bupropion, which doesn't have negative sexual side effects).
• In a patient who has symptoms associated with psychiatric illness, or any other comorbidity, address the comorbidity. Similarly, address any sources of pain or discomfort.
• For women who have sexual dysfunction experienced as pain after childbirth, consider pelvic floor muscle physiotherapy if the pain is persistent (greater than 3 months postpartum).
• For a primary sexual dysfunction (i.e., not secondary to another suspected etiology), it is important to determine the patients' goals and develop a tailored multimodal strategy that fits the circumstances. This may involve sex or couples' therapy, lifestyle changes, and certain medications such as phosphodiesterase inhibitors, which apparently can even benefit women!