13.6: We Asked! Answers to Some Questions from Jamie Weinstein, MD, Family Physician

As a family doctor, I see folks of all ages. I focus on people in the whole context of their lives and relationships, not just as a collection of illnesses. I have spent a lot of time talking/thinking/reading and educating myself on adolescent medicine, gender affirming care and human sexuality. I have a privileged perspective to be able to learn from my patients over the past 20 years.

What are common sexual health concerns that patients bring to you?

Many people come for contraception counseling or concerns about STIs or genital symptoms or pain. I also see a lot of women, between the ages of 20-40, who are raising kids, working and trying to partner. They report feeling overwhelmed, often not in a great place with their body, and sex becomes a point of tension or conflict. Typically, they are experiencing more lack of interest than lack of enjoyment, but sometimes, they do experience a combination of both.  Many women have super supportive partners and just need reassurance and support to navigate this new phase of their relationships. I don't have time/permission in my practice to really delve into women’s sexual history like a therapist might.  I would also wonder if some of them may not have had a lot of great sex before and this phase of life is not always super conducive to figuring it out. If you have only ever really had male orgasm driven sex, and now you have 30 other competing demands that your partner may or may not be stepping up for, it's not surprising that sex might not feel like your priority.

A lot of women want me to ‘check their hormones” which is not really a thing. Like so many things, people really just want me to find a ‘medical reason’ which there rarely is… I usually try to do what I can to reassure and rule out, and then I want everyone to read Come As You Are  by Emily Nagoski, or subscribe to OMGYES.

I see peri and post-menopausal women often for a combination of lack of interest/enjoyment Which may be due to decreased lubrication and also sometimes compounded by male partner with erectile challenges. In many cases they just need validation and support to adjust to what is their ‘new normal,’ but there are also medical interventions that can help.

I also see men of many ages who are struggling with ED and interested in medication. I try to talk about social/emotional/cultural factors, but often I just give them the prescription. I recommend they listen to the episodes on Viagra and ED especially #3 :  death sex and money

Occasionally I see younger men with premature ejaculation. SSRIs (antidepressant medications) can help, as a side effect of them is delayed ejaculation.

I also see people who have been sexually assaulted, or had nonconsensual sex or sexual experiences they are regretting. I also see patients with a history of trauma, who struggle with body image issues, and sometimes eating disorders.

I also have seen a fair number of mostly older adults in my practice who are really hung up about ‘intercourse’ aka penis and vagina sex, patients who seem to be really unable to regroup and recover from not being able to have penis and vagina sex in the way they used to. It speaks to how male orgasm ‘centric’ we are as a culture about what defines “good sex.” I think many folks could benefit from exploring the idea of sex as a journey, rather than a transactional destination. The lack of eye contact, blushing and obvious discomfort when I suggest to people there are other ways to have intimacy and pleasure or ask them to consider that millions of folks have amazing sex that doesn't involve a penis and a vagina speaks volumes. I wish sex therapy was more widely available for everyone!

More and more in my work, I really try to think about what is the purpose of my questions, especially as it relates to sex and gender. For example, when I was in training, I was taught that the most appropriate way to take a nonjudgmental sexual history was:

“Do you have sex with men or women or both?” Now I realize that question is ridiculous...

What do I actually need to know? 

For a person with a uterus, I usually want to know if they are having any type of sex that could lead to a pregnancy. For everyone, I want to know if they are at risk of sexually transmitted infections and this is much more about behaviors than the gender of their partners. If someone wants to talk about issues related to the gender of their partner or feelings about sexuality, I am more than happy to but it's not actually relevant a lot of the time. For someone who thinks she is good at this, I have had a surprising number of encounters where I asked a woman about contraception in a mindless hetero-centric way that forced her to have to tell me she has female partners. That did not feel like good care. I am always refining and trying out different ways of asking questions that feel open and respectful of different identities, that also get me the info I need to know.

Even when folks have actual questions about their bodies, especially genitals and if it relates to sex, they are often hesitant to talk about it. They are coming to me for a problem and concern and sometimes they can barely form the words or ask the questions, and then get really squirrelly when I try to get even the most basic supporting info to try to help them.  Yes, if you come to me with concerns about your penis, I am actually going to have to ask you questions about your penis.

I also think sometimes for things related to sex I don't actually need to know all the details. In some cases making folks talk about it when that's not what they are looking for may actually be a barrier.

For example, we have transitioned to offering 3 site testing for gonorrhea and chlamydia (urine, throat and rectum) because of data suggesting you miss a lot of infections if you just did urine tests in specific populations (see STI chapter for more info). It didn't take long to realize that lots of folks use different parts of their body for sex, and now most of us offer all 3 tests to everyone as part of the STI screen, along with blood tests. Folks just go to the bathroom in the lab - pee and do the self-swabs and turn them in. This is one area when I have been thinking a lot about universal education/patient autonomy. Is asking folks to tell us their individual behaviors or experiences always the best tool for patient health? Do I actually have to ask folks to tell me about their sexual practices if they don't want to? Or can I just educate them about the fact that many folks use lots of parts of their bodies for sex and you can get STIs in your throat or rectum and let them know that they can choose to do those tests if it's relevant for them. I don't have the ability to do a randomized trial on this, but anecdotally, it seems like the majority of my patients who want STI screening do all three tests. Is that because they automatically do whatever tests the lab gives them and they don't really need it? Is that because they realize they are at risk and are glad for the screening? Maybe it’s a combination of both. And would they be less likely to do it if I asked them specifically, “do you have oral or anal sex?,” and made them talk about it to get the test done?

How do you help patients feel comfortable coming to you with their concerns?

When I first started learning to be a doctor, I realized right away that I was never going to entirely fit in the “doctor box.” I'm a little spazzy and casual. I like to dress differently. At some point I realized that could be a strength for me. When I worked more with teens (my previous job), it was a really great way to get kids to let me in a bit. I think one of the biggest things about being a good primary care provider is being observant, and then trying to mirror/match your patients, not to be fake, but rather, to help them be more comfortable. It's also interesting to note that I think many doctors focus way too much on what they are telling their patients, rather than making sure that their patients feel listened to.

Then the other part is being able and willing to talk comfortably with folks about personal things. Also signaling to people in verbal and nonverbal ways that you are a safe nonjudgmental person and their concern is something you are willing and able to help with.  I had to actually practice saying certain things to not blush. It's kind of stereotypical and seems obvious, but actually saying “some of my patients say/do/feel...”  can work as a signal and a way of getting the conversation where you think it might want/need to go.

What do you think doctors can do to improve the sexual health of their patients? How do you define sexual health?

I think sexual health is part of overall personal health and well-being and it means different things to different people. I don't want to impose my ideas on other people, but sometimes I do interrupt/interrogate if I think their ideas are unsafe or not serving them well. I think a lot of the reasons folks struggle is more about social and cultural norms, so how much I can impact that in the exam room really depends.

I want folks to know they CAN talk to me about questions. There are a lot of competing demands in a primary care visits, and questions about sex and sexuality are not likely going to be brought up unless the patient initiates. Consider how weird/hostile Americans can be about discussions of sex and sexuality, and add in power/gender/age discrepancies between doctor and patient. I am always happy to answer questions about most anything. I am interested in sexuality, so I weave it in more than most other doctors I suspect. We got zero training in anything resembling sex positivity. I'm guessing it's slightly more now maybe, and doctors are just people so they may also just generally be uncomfortable talking about sex outside of the purely medical aspects.

There is no one right way to be or look or feel in regards to sex and sexuality. I support my patients to feel good about themselves and their bodies in whatever way works for them. I think many folks are in a challenging place navigating current ideas about sex positivity/sexual freedom and their own feelings and boundaries. I highly recommend this interview, and this one for starters.

For little kids, I think sexual health starts with using correct names for body parts, encouraging parents to support their children’s body autonomy (often very challenging when you are literally in charge of their body functions), and giving kids information about reproduction and bodies and sex in developmentally appropriate ways.  Sex ed in schools is generally lame - in my experience it barely gives even the most basic info kids need. I wish we had a system for everyone to get basic developmentally appropriate education about their bodies and sex that included safety (STI, consent, social media/body shaming/porn literacy, etc.), understood sex/gender/identity/expression, AND talked about pleasure.

Acknowledging this is gendered and stereotyped I'll say this-- For young assigned female at birth people, I want them to learn about their own bodies and feel okay prioritizing their own pleasure, not just their partners. I want young people, especially anyone who was or is a woman, to have sexual agency AND know that it's always more important to be safe than polite. For young cisgender/heterosexual men, I want them to also learn about how other bodies experience pleasure, and disrupt some very common cultural misconceptions in porn. I want some men generally to think about their privilege and what they think they deserve from women. Everyone might benefit from thinking more about how their bodies feel during sex, and less about how they look. I want everyone to feel comfortable with the idea that it's okay to want and expect emotional intimacy before and in addition to physical intimacy. Or even to be able to distinguish that those might be different things. I want folks to feel safe and empowered to try things out, ask for what they want and also to be able to say “no thank you” without feeling like they are being sex-negative. I'm not sure sexual freedom today is actually that liberatory.

For adults, especially those struggling with changes in their bodies, I think about what someone said in the Death Sex and Money Podcast, about being lucky enough to live in an aging body. A lot of my job is helping folks come to terms with where they are now. This is part of the reason I think a lot about child development and supporting teens and young adults. So many things in adulthood, including sexual health, might feel better if we weren’t trying to reeducate and heal a lot of damage from when we were young.

Sexual Desire and Functioning

Many people end up consulting with a medical professional when they feel their sexual desire or ability to perform has changed in a way they are unhappy with. Causes for this vary, but sometimes it may be related to common medications people take.  There are many medications that have been shown to affect sexual desire and functioning including:

• Antidepressants and antipsychotics
• Blood pressure meds
• Incontinence meds
• Birth control pills
• Antihistamines
• Anticonvulsants
• Steroids
• Sedatives

Sometimes people take “drug holidays” or plan sexual activity around times when the effect of the medication is at its lowest, in order to manage this. Be sure to speak with a healthcare professional before changing or skipping medication.