Having the talk

Richard Gunderman shares why it’s important for general practitioners to take the additional step with their patients and address the topic of sex.

For most patients, sex and intimacy comprise an important part of life, yet many patients – and even physicians – seem reluctant to broach the topic. To provide good care, it is important for physicians to address sexual concerns, especially when patients are suffering from conditions or undergoing therapies with the potential to have an impact on their sex lives.

For men, foremost among illnesses that impact sexuality is prostate cancer. In developed nations, prostate cancer is the most common non-skin type of cancer, detected in up to 15 percent of men at some point during their lives. Each year in the US, approximately 160,000 new cases are diagnosed, and 27,000 men die of the disease.

Fortunately, prostate cancer is not particularly lethal, ranking third as a cause of male cancer deaths in the US. In fact, when malignant cells are confined to the prostate gland, the five-year survival rate is nearly 100 percent. Favourable prognostic indicators include low-stage, Gleason score and prostate-specific antigen levels at the time of diagnosis.
The burden of prostate cancer extends far beyond lethality, however. Many of the nearly three million US prostate cancer survivors report long-term sequelae of the disease and its treatment, including urinary and bowel dysfunction, non-sexual side effects of hormone treatment and chemotherapy, loss of fertility, and a variety of impairments of sexual performance and experience.

Among the side effects prostate cancer patients may experience are the inability to achieve or maintain an erection, difficulty reaching orgasm, orgasm without discharge of semen, less intense orgasms and pain during sex. Similarly, interest in sex, energy levels for sexual activity, and personal sense of sexual attractiveness may also be impacted.
Caring well for prostate cancer patients means paying attention to the effects of the disease and its treatment on sex life before, during and after therapy. Some patients may be very open and direct in broaching the topic of sexuality. Others, however, are reluctant to do so, despite the fact that they harbour significant concerns. Embarrassment may leave such patients suffering and alone.

General practitioners sometimes assume that colleagues in other medical specialities will address the sexual concerns of prostate cancer patients. For example, they may suppose that urologists, radiation therapists and medical oncologists will each address the sexual complications and side effects associated with the treatments they recommend.
In fact, however, it is not safe to assume that such specialists always address such concerns. Nor should physicians believe that when colleagues do so, they always do an effective job. Additionally, many prostate cancer patients suffer from additional medical problems that impact sex, such as diabetes, and it becomes even more important for general practitioners to attend to the topic of sex.

Unfortunately, many medical schools and residency programs offer little instruction on how to talk with patients about sexual matters. To address this concern, I have started a senior elective course at my medical school called ‘Sexuality for the Clinician’, which aims to better prepare future physicians to address sexual concerns with their patients.

Students in the course learn that, while patients who do not wish to discuss sexual matters should not be compelled to do so, most are grateful when their physician provides an opening for such conversation. It both provides an opportunity to address sexual health and helps to forge a deeper bond of trust between patient and physician.

Physicians need to make clear that such conversations are premised on privacy and confidentiality. The physician may seek the patient’s permission, perhaps by saying, “At this point, I usually ask some questions about sex. Is this OK?” Building trust is important, partly because it enables patients to address other potentially awkward aspects of their health, such as depression and substance abuse.

In working with prostate cancer patients, physicians may initiate the conversation by asking if the patient has any sexual questions or concerns. Another entrée is the patient’s medical condition and medications – specifically, whether the patient has experienced any sexual issues. Sexual history checklists are available, but algorithms should never trump patients’ efforts to share their own story.

Specific topics of inquiry may include the following:
● his level of sexual interest and satisfaction
● the ease with which he becomes aroused
● the overall quality of his relationship(s)
● his mood during the sexual activity and if there’s pain, and
● the effects of illnesses, medications and surgeries

Also physicians may assume that patients are sexually active, but this is often not the case. If not, it is important to know why. On the other hand, if patients are sexually active, it is important to know with whom they are having sex and what kind of sex they are having. Such information can be crucial for assessing the risks of sexually transmitted infections.

Of equal importance is to understand how the patient feels about it. Some people who are not sexually active are not troubled by it, while others find it disturbing. It is also important to recognise the role of the patient’s partner in the situation. In many cases, partners are also experiencing problems – a reminder that sexual difficulties rarely affect only one person.
In addressing sexual concerns, it is important to bear in mind the distinction between sexual activity and intimacy. Some patients who are sexually active find their desire for intimacy unfulfilled, while others who are not having sex nevertheless feel satisfied with the depth of their physical and emotional connection with their partner.

Of course, once prostate cancer patients begin asking questions about their sex lives, physicians need to be prepared to respond. In some cases, the focus will be on medical and surgical options for the treatment of sexual problems, such as the use of PDE5 inhibitors or penile implants to treat erectile dysfunction.

In other cases, the temptation to medicalise sexuality should be resisted, and the primary focus should be on patients’ experiences and relationships. Often what patients need most is not a prescription for medication or a surgical procedure, but counselling to help improve communication with their partner. For some, referral to a sex therapist or counsellor may be helpful.

In addition to addressing particular patient concerns, physicians also need to be good sexual health educators, helping patients better understand what they are experiencing or may expect to experience. For example, patients should understand that, while prostate cancer can affect a person’s sex life, some types of sexual changes are normal features of ageing.

A number of resources are available to help general practitioners develop their knowledge and skill base for addressing sexual health. An example is one that is hosted by the Kinsey Institute. Entitled ‘Sexual Medicine in Primary Care’, it provides an excellent foundation for integrating sexual health into general practice.

By taking care to include sexual health in their care of patients, general practitioners can help to ensure that they receive truly comprehensive care. Such efforts are particularly important in the care of those whose diseases, and their treatment, commonly impact sexuality. Nowhere are such efforts more needed than in the care of prostate cancer patients.

Richard Gunderman
MD PhD chancellor’s professor, Indiana University

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