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The “vortex of silence” around sexual health and wellbeing

For health professionals 19 Oct 2021
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For some clinicians, talking about sexual health – particularly with older women – can be an awkward topic that they often avoid. Here, we get some expert insight and unpack the barriers to these important discussions and how to overcome them.

Health professionals have a key role to play in the sexual health and wellbeing of their older women patients but research suggests that it’s common for them to avoid the topic altogether during consultations.

A 2018 study found that most GPs believe it is appropriate to discuss the issue of sexual health with their older patients (aged 60+ years) but did not routinely do so.

“There’s a vortex of silence around this whole area of sexual health,” explains Dr Sue Malta, a researcher at the University of Melbourne and one of the authors of the 2018 study.

However, given the increasing rates of STIs (sexually transmissible infections), including gonorrhoea, chlamydia and syphilis, in older women, it may now be time for health professionals to carefully consider their position and bring sexual health discussions to the fore – no matter the age of the presenting patient.

The conversation roadblocks

According to the study co-authored by Dr Malta, time constraints were cited as a major barrier to raising the topic of sexual health. However, this involved multiple factors including the complexity of presenting complaints associated with later life.

The study also found that practice nurses commonly raised the topic of sexual health with older patients during health assessments, stating that the topic arose in the context of talking about cervical screening tests or healthcare plans, even though sexual health was not a formal part of these discussions.

Another of the common barriers to GPs initiating sexual health discussions with older patients according to the study, was age and gender discordance between GP and patient.

When dealing with older patients, a younger doctor may feel embarrassed to raise the topic or assume – like so many others in the community – that older women are not sexually active.

It’s not all about “deficits and dysfunction”

Dr Malta believes it is important for health professionals to abandon the notion that older patients are not having sex – they are, and they continue to, well into older age.

“What is surprising is the lack of knowledge in the medical profession or the lack of recognition that sex in ageing is not all about deficits or dysfunction,” she explains. “It clearly is not.

“They need to imagine how it would feel to be an older person and to be judged as being too old to have sex,” she says.

Dr Malta believes that questions about sexual health should be routinely included in the annual health checks that most older people undergo.

In bed together

Make no assumptions

Dr Deborah Bateson, medical director of Family Planning NSW, says that when it comes to talking about sexual health with any person, the key thing is never to assume.

Not having assumptions ensures [an awareness] that anyone of any age can catch an STI."

Dr Deborah Bateson, medical director of Family Planning NSW

She believes that consultations for menopausal symptoms or cervical screening tests present ideal opportunities for having broader discussions around sexual health and wellbeing. “We need to start normalising these conversations so that it trips off a doctor’s tongue to ask questions about sexual history and health.”

Dr Bateson encourages health professionals to get comfortable talking about the topic, “We know that any sort of discomfort on our part will be picked up by a patient.”

Creating the right environment

Professor Susan Davis, a leading international researcher in women’s health and menopausal medicine, says it is important for clinicians to create an environment where women feel comfortable about discussing their sexual health. While some may be reluctant or embarrassed to raise the topic, research has indicated that women do want to discuss their sexual health and concerns.

40% of women in their 50s and 60s, and 10% of women in their 70s, have personal distress related to their sexual function. It is something they need to be able to talk to their doctors about."

Prof Susan Davis, leading international researcher

The difficulties around these conversations were addressed in the International Menopause Society White Paper which suggested that screening for women’s sexual concerns was often short-changed during the clinical encounter.

This was due to several factors that included absent or inadequate physician/practitioner training in sexual medicine, the belief that such menopausal changes were a normal and inevitable part of ageing, and time constraints.

Vaginal dryness that causes pain and discomfort during sex, for example, is a common symptom experienced by menopausal and postmenopausal women, and doctors are ideally placed to help. Sadly, there are many women, says Prof Davis, who accept this symptom as part and parcel of menopause and are not aware they can use vaginal oestrogen to effectively treat it. Moreover, this is not a symptom that might spontaneously resolve like hot flushes. Women who have vaginal dryness and irritation, which is over 50% of women, need long-term treatment.

The White Paper provides clinicians with a framework for approaching the discussion on sexual wellbeing after menopause, clinically identifying women with sexual dysfunction, and managing sexual difficulties in postmenopausal women with the available biopsychosocial therapies.

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Download the White Paper
Click here

Conversation starters

To initiate conversations on sexual health with older women, Dr Bateson suggests opening the discussion with: ‘I talk to all my patients about their sexual lives, so I hope you don’t mind if I ask…’

Prof Davis agrees that it’s important to find an opening sentence that feels comfortable for you. “You might consider: ‘Many women experience sexual concerns and difficulties. Is there anything about your sexual wellbeing that you would like to discuss?’

“Alternatively, when you are doing a menopause check, it should be part of the conversation,” explains Prof Davis. “Throw it in with the hot flushes. If it’s part of the shopping list, it’s part of the assessment.”

“If she is sexually active and has no concerns, I’d be asking if she has a regular partner and, if she has not a regular partner and is sexually active, if she has thought about the possibility of an STI.”

Sexual healthcare for all

Sexual health is a critical element in the care of a woman’s holistic health and wellbeing. The impact of poor sexual health can be devastating, affecting a patient’s emotional, social, and physical wellbeing. A timely intervention by a doctor could help. And it all begins with a series of questions about sexual health.

We are asking these questions for good reasons, and we should ask them of everyone."

Dr Deborah Bateson, medical director of Family Planning NSW

To read more on how GPs can take the lead in initiating conversations about sex and sexual difficulties, read this this article from RACGP: