Doctors, psychologists and other healthcare professionals, both in mental and physical health, are used to talking about difficult subjects. Bowel movements, terminal diagnoses, suicide and self-harm, tricky topics are a standard part of the job. Yet somehow when it comes to sex, many struggle to find the words or avoid the topic all together.
Sex, whether defined by sexual acts, more generally as intimacy or in many other ways, is an important human need. It contributes highly to individuals’ quality of life. On Maslow’s famous Hierarchy of Needs it comes only after physiological and safety needs in terms of importance. I think I can go as far as to say that changes or difficulties relating to sex are common to the majority both physical and mental health problems, whether they relate directly to the symptoms (e.g. impact of pain and limb weakness on sex positions, hypersexuality in mania) or are secondary to medication used to treat the problem or further consequences (such as impact of taking on a sick/carer role, self-consciousness relating to skin conditions). Anti-depressants are very widely prescribed, yet often information on the (common) sexual side-effects is left to be read in the small print. I’m reminded of a quote from Ben Goldacre on SSRIs,
“ I’m trying to phrase this as neutrally as possible, I really enjoy the sensation of orgasm. It’s important to me, and everything I experience in the world tells me that this sensation is important to other people too. Wars have been fought, essentially, for the sensation of orgasm.”
Stroke for example, is a condition where sexual dysfunction has been well documented. Yet in research speaking to rehab staff, they rarely brought the topic up with clients and on the occasion when it was brought up, staff often felt embarrassed and uninformed (McLaughlin & Cregan, 2005). Reasons given for staff not approaching the topic also included fear of upsetting clients and there has been other research suggesting that (often unconscious) stereotypes relating to sex, relationships, illness and disability, play a role in this silence. Although sex problems have been particularly highlighted in stroke, there is evidence that these staff attitudes and difficulties exist in a variety of settings and in relation to many other conditions. Whilst working in a clinic for Chronic Fatigue, I approached staff about the possibility of including sex and relationships as a topic to include in a psycho-education group, and was met with quite a dismissive response. It was too sensitive, and time was needed for other important areas. However, a friend with the condition informed me that on a service-user forum, the sections relating to questions and advice about sex were by far the most used. Service-users often have to go and seek out their own information because professionals fail to provide it.
Feeling inexperienced and unskilled with regards to approaching sexual matters with clients is common amongst staff and training on such matters is often not provided. Other than a brief presentation in a team meeting, I’ve never had any job-based training in working with sexual matters. However, a quick Google search of the condition+sex or searching the research literature is likely to generate a summary of the common difficulties experienced. Although knowledge of sex-related interventions and medical details will obviously require some in-depth training, talking about sex isn’t necessarily something that requires a particular qualification or expertise. Staff may need to pro-active in informing themselves and also flagging up the training-need at work, where it might be provided by a specialist practitioner. I think that a bit of empathy and the general knowledge about sex and relationships that you have just from personal experience should be sufficient to open a dialogue. Thinking that the topic is ‘someone else’s job’ can often lead to the topic being left by everyone.
I’m not sure where the idea that talking about sex upsets people comes from. Admittedly there probably are some individuals who for personal reasons (perhaps cultural or some past experiences), find it difficult to talk about sex. Probably for some of the same reason staff find the topic difficult. Like I’ve already mentioned, healthcare professionals often tackle topics that can upset people; diagnosis, discussion of death or past history etc. Is this really any different? Just because a topic might make a client experience some distress, isn’t always a good enough reason to avoid it all together. Sometimes becoming upset might be an important part of a client coming to terms with a particular problem, and it may not have any more serious consequences.
Embarrassment about talking about sex doesn’t just seem to be a UK-based phenomena, but it does seem to be something very cultural. Beginning in childhood, there’s often a lack of frank and open discussion of sex, perpetuating into adulthood. Our society is probably more sexually open now than it ever has been, but taboos, shame and stigma still live on. This isn’t something that’s going to change very quickly, but professionals do have a role in giving the message that sex IS something that can be talked about and that enjoying a sex life (in whatever way individuals choose to define this) is part of healthy and very normal life and sexual problems are of importance and will be treated as significant.
Flawed and inappropriate stereotypes and attitudes, which staff may be unaware that they even hold, may also impact on how they treat service-users and sexuality. Common views include:
- Older people don’t have sex
- People with disabilities (including learning disabilities) don’t have sex
- It isn’t necessary to bring up the topic of sex with individuals who are single/not married or in ‘typical’ relationships
- Sex will not be important to someone recovering from illness/in rehabilitation, they will have more pressing concerns
- Other benefits of a medication out-way the sexual side-effects, so there is no need to mention these when helping an individual decide on their treatment
- Thinking of sex purely in terms of penetrative vaginal sex, and not considering other forms of sexual activity and intimacy
- When a couple take on patient/carer roles, they won’t carry on having sex
- And so on…
Again, staff may need to take some responsibility for informing themselves about sex and diversity, but it can be aware of what you don’t know yourself, so training will also play a big role here.
Healthcare staff often have high workloads so the time they get to spend with individual clients can be limited. However, given the high levels of sexual difficulties in both mental and physical health conditions and the detrimental impact of these on quality of life, there isn’t very much excuse to not bring up the topic. In the absence of professional training, staff will need to be pro-active in their own learning and informing colleagues. The main challenge is facing a long-standing cultural taboo about talking about sex, but as service-users are becoming more likely to request information on sex-related areas, the health service needs to get up to speed to meeting their needs. It might mean sitting with discomfort and awkwardness, but like learning to give bad news and carry out a risk assessment, it’s likely to get easier in time and as staff we can play an important part in promoting sex-positive and inclusive messages to the public.