Sex: Don't Ask, Don't Tell

This past April, Manhattan gynecologist Susan Grant received an out of the ordinary email from an 18-year-old. "There's something wrong with me," wrote the woman, a prospective patient. "I can't orgasm and I think I need to learn how. Can you help me?"

Grant has been practicing obstetrics and gynecology for more than 20 years, but she rarely encounters such frank questions about sexuality. She's not alone. Concerns about sexual pleasure and pain are common, but conversations about them in the exam room are not.

A recent U.S. survey of 1,147 ob/gyns found that just 14 percent routinely ask patients about pleasure. Fewer than 30 percent inquire about sexual orientation, and only 40 percent ask about sexual dysfunction. The study suggests that many MDs are not doing enough to establish an environment where patients feel safe broaching the uncomfortable details of their sex lives.

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When such topics are left unaddressed, serious medical conditions—sexually transmitted diseases, vulvodynia, endometriosis, or worse—can fly under the radar, cautions Vancouver-based gynecologist Trevor Cohen. He recalls one patient whose discussion of painful intercourse helped a colleague diagnose a case of early-stage ovarian cancer. "Not talking to patients about sexual issues is negligent and unethical," Cohen says. "To provide the correct treatment, you have to ask specific questions."

So why do most sexuality questions remain unspoken? Many ob/gyns just don't have the time. Others avoid asking about sexuality, pleasure, and pain "because they fear it would offend patients or be seen as inappropriate," says Stacy Tessler Lindau, the University of Chicago physician who led the survey.

Of course, not all docs hold their tongues. Lindau found that female ob/gyns—who spend more time with their patients in general—are likelier than males to ask about orientation. (Gender differences can increase the perceived awkwardness of a question for a male doctor and a female patient, Cohen observes.) Physicians who focus on gynecology have more time to discuss sexuality than those with an obstetrics practice, which may have them running to the delivery room at all hours.

Including open-ended questions about pleasure and dysfunction on intake forms could help break the silence across practices, notes Grant. Patients, meanwhile, need not wait for a doctor to ask the right questions. Grant suggests scheduling appointments specifically to talk about sexual concerns that aren't covered during routine pap smears or birth control consults, and Cohen emphasizes the importance of being as specific as possible when describing a sexual problem.

Grant's 18-year-old patient had the right idea: If you have worries or questions about sex, don't suffer in silence.

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