Sexual Secrets in Primary Healthcare
Five Key Issues for Medical Attention
Everyone has sexual secrets, and "secrets" are – by definition – what I don’t want you to know about me. So why should the healthcare practitioner care? And why should sexual health assessment – as well as counseling for safer sexual practices -- be made a routine procedure in every primary care relationship?
If we define sexuality – or sensuality -- as the experience of bodily pleasure (including the pursuit of "pleasurable pain"), then we can immediately appreciate that, whereas medical science views the body as a system of structures and functions having instrumental purposes, the patient experiences that same body as the personal locus of his or her sexuality, and experiences sensuality as fundamental to his or her positioning within the social and natural worlds.
Moreover, the especially wonderful sensuality of our genitals is, for each one of us, complexly embedded in networks of meaning: moral precepts, value judgments, attitudinal conflicts, prohibitions and taboos. Only rarely are our genital pleasures the health-enhancing source of healing and happiness that they are meant to be.
My sexual secrets may be precisely what I do not want you to know about me, but they are also likely to be what a competent and compassionate healthcare practitioner should indeed know, if my physical and emotional welfare is to be properly safeguarded.
The first sexual secret is always something like: The sexuality of my body is far more important to me than I usually admit, and I am more unhappy, conflicted and communicatively closed about my sexual feelings and behaviors than I want to discuss (with my healthcare practitioners or with my partners)! A major variation of this first secret is as follows: Because sexuality is difficult, in pursuing my sexual pleasures, I do not always honor myself, or my partners, by safeguarding my physical and emotional health even while celebrating the enjoyable dimensions of life. From this secret comes a medical mission. Healthcare practitioners have to care about the patient’s sexual secrets because:
Sexuality is both the prime source of our patients' stress and distress, including their anxieties, depressions, emotional conflicts, as well as so many other mind-body illnesses, and has the potential in every patient’s life to be the prime force of physical and emotional healing and happiness.
Over 22% of the U.S. population is currently infected with a sexually transmitted disease; all of these diseases are damaging, some are incurable, and at least one is deadly.
Sexual difficulties and disorders are prevalent at every stage of the life cycle, and impact profoundly on physical and emotional health.
Sexual practices that are physically risky are far more common than most healthcare practitioners realize.
Sexual practices that are socially or legally risky, and psychologically stressful are far more common than most healthcare practitioners realize.
In this context, our medical mission has to include routinely talking with our patients about their sexual lives in a manner that is nonjudgmental, open to the diversity of human sexual practices, and that affirms each patient’s right to enjoy sexuality as a source of healing and happiness (rather than a secretive mode of suffering).
In short, as healthcare professionals, we need to be proactive in helping patients discuss their sexual lives in a way that empowers them to make healthier personal choices. Rarely are the routines of "Sexual Health Assessment" and counseling for "Safer Sexual Practices" comfortable for most of us as healthcare practitioners. This is why, in the Wayne State University M.D. program, we encourage students to learn and practice these routines from the first day of class, and why learning materials for more advanced practitioners still need to be made available.
The second sexual secret is: I do not consistently practice my sexual pleasures with partners in ways that reduce the risks of disease transmission. Currently in the United States, too many of the public believe that HIV/AIDS is irrelevant to them, or that the crisis has passed. Too many of the public are entirely unaware of the prevalence of diseases other than HIV. And most of the public is insufficiently informed about the specific methods of sexual sharing that are risk-reductive. Today’s high rates of sexual disease transmission, in which over 1 in 5 of the U.S. population are currently infected and viral infections such as herpes and HPV are escalating uncontrollably, constitute a mandate for every healthcare professional: All sectors of the population, with the possible exception of young children, need to know how sexual diseases spread, and how sexuality can be enjoyed minimizing these risks of transmission. This then is the mandate of primary care intervention.
We know clinical education that merely delivers an injunction to be abstinent or to use condoms falls short of adequacy, not only because abstinence education has been shown to have little impact except on those who are already abstinent, but also because the majority of the population know far too little about the details of effective condom use. At the Midwest Institute of Sexology, we recommend that caretakers initiate regular conversations that include:
What sexual fluids are most likely to convey which diseases (ejaculate, pre-ejaculate, vaginal secretions, and blood for HIV, as well as saliva and fecal matter for a range of other viral and bacterial entities).
How sexual diseases are most often received into the body via mucosal tissue (especially anal and vaginal for HIV, and oral for a range of other viral and bacterial entities), or more rarely via skin abrasions (including gum lesions for HIV).
What bodily fluids are relatively safe (urine, sweat, tears), and what methods of sexual sharing are relatively risk-free (hugging, massage, mutual masturbation).
How "Safer Sexual Practices" can dramatically reduce the risks of disease transmission by barrier protection and chemoprophylaxis.
How these practices can be discussed with partners and potential partners, in ways that honor both oneself and the other individual, and that therefore enhance rather than detract from the pleasure of sexual experiences.
Preparation for sexual encounters needs to be emphasized. Men should be encouraged to find a brand of condom that works well for them (specific condoms are manufactured for the latex sensitive, for the uncircumcised, for the outsize and the undersize). Before they are in the heat of a sexual situation, men should find and practice with the brand of condom that suits them best: checking expiration dates, avoiding air bubbles, being careful of sharp fingernails or jewelry, ensuring a comfortable, secure fit during penile movement, etc. Heterosexual women should be supported in trying the so-called female condom (brand name Reality). The importance and the various methods of barrier protection for cunnilingus and fellatio needs to be taught to all post-pubescent (and some pre-pubescent) individuals, as does the selection and liberal use of water-soluble lubricants for almost all sexual activities.
Despite the medical necessity of detailed discussion of sexual practices and risk-reductive procedures, as healthcare practitioners few of us find these conversations easy. We find ourselves invoking several types of excuse to avoid this responsibility. None of these has validity. "The patient doesn’t want my involvement with sexual issues" is an excuse that is belied by studies showing that over 90% of the public believes that medical professionals should lead the way in promoting sexual health. Another common mistake is that "The patient doesn’t need this discussion because he or she is…" Is what? "Too young…" – we know from CDC data that about 50% of 15 year olds have experienced genital intercourse. "Too old…" – yet sexually transmitted diseases are an increasing problem in the geriatric population. "Too religious…" – research on the sexual behaviors of the clergy trenchantly invalidates this notion. "Too married…" – whatever we might wish to believe, scientific investigations indicate that somewhere between 25% and 85% of contemporary American marriages are in fact sexually non-exclusive.
This brings us to the third sexual secret: My sexuality does not fit society’s mainstream ideal … I may feel comfortable that I am "normal" but I anticipate you may be judgmental. Paradoxically, this sort of concern applies to the majority of our population, all of whom belong to "minority" groupings. It applies to young adolescents who expect general condemnation from the adult world for their sexiness; to elderly patients who expect younger healthcare practitioners to view them as "past it"; to gay, lesbian, bisexual, and transgender individuals who are accustomed to prejudicial treatment by "straight" professionals (and who may even avoid medical care because of the expectation of such prejudice; and to every adult whose sexual behaviors do not conform to the "ideal model" that was propounded by our parents, from the pulpit, or in the average "sex ed" classroom. The lesson for the healthcare practitioner is clear: We should set aside our presumptions, and communicate accordingly with our patients.
The fourth sexual secret is similar: My sexuality includes activities that are condemned by society … and I fear disclosing them to you. Professionals who may not themselves have participated in "non-normative" sexual activities are often surprised how common such practices are among their patients. Multiple partnerships, for example threesomes, consensual "swinging" or partying, may be beyond the personal experience of many healthcare practitioners but are certainly not uncommon in the general population. "Sadomasochism" -- a term that encompasses a very wide range of patient behaviors, from "mild" bondage or fantasy play to "heavier" activities which may include consensually inflicted pain – is also far more frequent than is often supposed. Fetishism, meaning the use of non-human objects for sexual pleasure, is commonplace. Voyeuristic and exhibitionistic activities are similarly prevalent. Sex for economic gain is all around us. However, the frequency of non-consensual behaviors including abuse and assault is often known more to the compassionate, inquiring healthcare practitioner than it is acknowledged by the general public.
Medically, the crucial response to this awesome variety and variation in human sexual experience is fivefold:
Help the patient to talk comfortably about his or her sexual behaviors.
Assess what physical risks the patient may be taking, and offer appropriate physical intervention as well as education.
Evaluate with the patient what psychological stresses may be involved and intervene accordingly.
Discuss with the patient what social or legal risks may be implied by certain behaviors, and intervene accordingly with education (and by indicating clearly to the patient the circumstances under which you would feel obliged to inform a third party, such as protective services.
Get to know a competent and compassionate clinical and educational sexologist from whom support may be sought whenever necessary. To find such a practitioner in your locality, contact the American Association of Sex Educators, Counselors, and Therapists, which is the reputable certifying organization in this field. Their web site is www.aasect.org.
The fifth sexual secret is: I want to be happy sexually and I fear that medical conditions as well as aging processes will deprive my life of this pleasure. Too often we assume that "Sexual Health Assessment" and counseling for "Safer Sexual Practices" are only relevant to the primary care setting. Secondary and tertiary care medicine, however, need also to be responsive to these concerns. Too often, patients with major illnesses have been treated as if sexuality should be the first dimension of their life to be relinquished, rather than the last.
A quick glance around us indicates that we live in a sexually schismatic society: at once both “hypersexified” and sexually fearful. Sexiness is everywhere on the surface of our culture, yet often our patients are deeply worried about their entitlement to sexual pleasures. In this context, the wise healthcare practitioner will affirm proactively every patient’s right to sexual health, healing, and happiness.
Tips for Condom use
When dryness is a problem
Intimacy and XXX
Sex before and after Childbirth