Posts Tagged ‘medical attitudes towards sex and aging’
Doctors, Talk to Us about Our Sex Lives!
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4/3/16: I’m bringing this 2014 post to the top because I’m giving a talk to doctors and other medical professionals tomorrow in Milwaukee. I want these comments from my readers to be easy to find if they read my blog after that — which I hope they will!
About half of all sexually active men and women aged 57-85 in the United States report at least one bothersome sexual problem; one third report at least two. Yet only 38 percent of men and 22 percent of women reported having discussed sex with a physician since the age of 50 years.
Why does this information barrier exist? And what can you, as professionals, do to overcome it with your patients and clients?
These are the questions I posed to the attendees at the beginning of “Talking about Senior Sex:
A Presentation for Medical Professionals, Therapists, and Others Working Professionally with the Older-Age Population,” which I presented at The Smitten Kitten in Minneapolis on June 19, 2014.
I was so jazzed by the responses during that workshop that I wanted to continue the discussion, so I took it to my Naked at Our Age Facebook page (which I invite you to read and “like”).
Our community jumped in eagerly with their comments and experiences. Here are some of those:
- It would suffice if they just asked. I think they are 1) embarrassed, and 2) afraid that a nestful of psychological tangles would emerge, which would take a lot of their time. As a doctor, you would have to believe that relationships, beliefs, and habits contributed to illness, and I think most of them are just looking for a set of symptoms. The mind-body connection is far from their thoughts.
- It may be difficult for physicians to broach topics on sex because of their lack of education on sexual matters – not just with senior sexuality. Often such topics are delegated to nurse specialists or physician assistants. There are also shades of sexuality beyond the range of physiology, endocrinology, anatomy, and other hard sciences that are beyond the scope of topics covered in med school and continuing medical education. We need to take charge and help drag medical providers along with us on this topic.
- Sex over 55 is often challenging if your parts are in perfect working order, but if they are not, then it’s an entirely different ball game. As someone who has lived with a sexual challenge for 20 years (and who is now 67), I found, in the beginning that it was helpful to write a letter to the doctor prior to the appointment – an ice-breaker. Now, however, after such a long-term medical problem, I am really very open with all the doctors I see and they either handle it or they don’t – they can choose!
- We live in a culture that allows only a few sexual subjects to be discussed and those in limited ways. Having lived a lifetime hiding or being ashamed of our sexual natures, it can be a huge challenge to just start talking about “it” when we reach those years. The mechanics of sex may be easier to discuss than unmet needs and innate desires. It is a gift to be sexually sovereign in our culture.
- In my case, no doctor ever broached the subject. I was always the initiator. After 12 years of fertility work, four ectopic pregnancies, numerous spontaneous abortions and nerve damage resulting from a rape, surgeries and malpractice (they refused to remove the infamous Dalkon Shield IUD after the rape and subsequent STD infection), it’s not a stretch to understand why I had a damaged libido. Only with recent help from two amazing physicians, with whom I can discuss anything, have I begun to find help! Finding this and other groups online has also been salvation of yet another kind. Thanks for opening so many doors to those of us who have foundered for so long!
- Actually, it was through conversations with my nurse practitioner that my road to sexual freedom opened up. Also through my wonderful husband’s patience, and Joan’s book, Naked at Our Age. There is a taboo about sex at a certain age, but for us it has just been renewed!
- Particularly as sex and disability is also a taboo subject and many people will have genital dermatoses and that will make it even harder for them to open up to anyone. I am 67 and despite lichen sclerosis, I remain sexually active.
- The doctor needs to be calm, confident and comfortable with the subject. If the doctor is squirmy and clearly uncomfortable, it won’t help the patient to open up. Speaking for myself, if I’m a little squirmy and hesitant, I’d appreciate it if the doctor would give me the time and space to squirm a little and build up my courage. I had that experience with a doctor; he asked what was clearly a scripted question, I hemmed and hawed a little struggling to express an answer. Since the answer wasn’t immediately forthcoming he just jumped right to the next question. I got the distinct feeling he really didn’t want to hear it, so the subject was dropped. On the other hand, a doctor might ask a question and get a very forthright answer they weren’t expecting. They better be ready for that too; no eyes bugging out, no jaw dropping, no flinching. They might need to develop the ‘warm positive regard’ thing that therapists are taught.
- I’m 73, have an older woman doctor trained in Europe who brought the subject up in the course of an annual physical, and was quite matter of fact about it, made me quite comfortable discussing the subject, and referred me to an endo.
- I’m not your target age group but my nurse practitioner at Kaiser simply asked if I was happy with my sex life and, after I affirmed that I was, proceeded to tell me that orgasm was good for my vaginal health (not to mention my psyche) and encouraged me to take charge of my pleasure because it would help make perimenopause easier to take, keep my bladder where it belongs and generally support my wellbeing. Hell yeah -this I knew – but what was even better was that she made it clear that she was there to help. My sexual health was not some secondary aspect. It was a full-fledged piece of my gynecological workup. To which I say – well done!
- I’d like to see it simply become a matter of routine during all regular check ups, or anytime the visit is for more than a sniffle really, as well as anytime mental health/ relationships are discussed. We need to be in the habit of treating the whole person, not just fixing bits and pieces and mending boo-boos.
I hope you’ll continue this important conversation by commenting here. (And if you’d like me to bring this presentation to your organization, please contact me.)
Healing Painful Sex: Interview with Deborah Coady, MD
I was happy to receive a review copy of Healing Painful Sex: A Woman’s Guide to Confronting, Diagnosing, and Treating Sexual Painby Deborah Coady, MD and Nancy Fish, MSW, MPH. This book is entirely devoted to sexual pain in women: the myriad possible causes, how to figure out which one or combination is yours, and what to do about it.
The authors are a power team: Deborah Coady is a gynecologist and a pelvic/vulvar pain specialist. Nancy Fish is a therapist with degrees in social work and public health, and she personally experienced chronic pelvic pain until Dr. Coady helped her resolve it. I asked Dr. Coady if she would answer some questions that women our age often ask me:
Q. Many older women are reluctant to ask their gynecologists about sexual pain because a) they’re embarrassed, b) they think this is part of aging, and c) they fear their doctors will be dismissive. What would you say to these women?
A: These feelings and fears are completely understandable. Unfortunately, the medical profession has until now given too little attention to the sexual concerns of women as we get older. Women often are dismissed or rushed when they bring up their problems. And this is not the fault of the patients: A recent survey of gynecologists by Stacey Lindau, MD of the University of Chicago hints to their discomfort, as well as their lack of experience and formal training in this area of medicine. While 60% responded that they did ask about sexual problems at the first visit, only 14% asked about pleasure with sexual activity. It is often up to women themselves to be pro-active, ask the hard questions, and remember that they are entitled to medical therapy for this medical problem, or referral to an MD who can help.
Q. My readers sometimes report that after a long time without sex (due to lack of a partner or disinterest from a partner), they try to have sex again — and they can’t: It’s too painful. What should a woman do about this?
A: On average, about 5-6 years after their last menses, most women develop thinning of their vulvar and vaginal tissues, often causing pain with sexual touching or intercourse, or with urination after sexual activity, or itching, burning and even surface bleeding after sex. This can occur even in women taking systemic estrogen therapy. As estrogen levels decline both the surface skin and underlying connective tissues thin, shrink, and lose elasticity. Most pain is actually located at the vaginal opening itself, rather than deep inside the vagina as previously thought. The good news is that since these tissues are exquisitely hormonally sensitive, even small doses of estrogen, with or without testosterone or DHEA, applied to the vaginal opening (the vestibule), can reverse these changes within 2-4 weeks, and then even lower doses can be used to maintain the improvement. Some women with severe loss of elasticity will also be helped by a course of pelvic floor manual physical therapy, to help
normalize the connective tissue, and relieve the reflexive muscle spasms that some women develop due to their pain.
Q. I like your questionnaire (107-111) because women often don’t know how to pin down just where and what the pain is that they’re experiencing. I recommend that women scan or photocopy that questionnaire to show their medical professionals. Would it be a good idea to
carry a copy of Healing Painful Sex to the appointment, too, in case the doc hasn’t heard of your book?
A: One of our missions in writing the book is that women would have it as a resource to get their gynecologists informed and up to speed on treating sexual pain. Many patients have done just this, and their MDs have actually been grateful for the introduction to the book.
Q. If a gynecologist says, “You just need lubricant” or – worse! – “Well, at your age, you can expect that,” what should an older woman say to get diagnosis and treatment? I tell women to say, “If you don’t know how to help me, please refer me to someone who does,” but that might
seem more confrontational than you would recommend! What would you advise her to say?
A: I would advise her to say exactly that. We have to advocate for ourselves and we deserve up-to-date treatment for sexual pain. A healthy
sexual life is a basic human right, even defined as so by the World Health Organization!
Q. How can a post-menopausal woman weigh the benefits of HRT vs. the health risks if she’s experiencing vaginal thinning and tearing?
A: There is absolutely no evidence that the small amount of estradiol or estriol available for use at the vaginal opening is absorbed to any degree that would induce breast cancer. The doses are tiny compared to HRT doses that are meant to be systemic, that is, to go to all parts of the body. To help hot flashes the doses need to reach the brain in quantities much much higher than the topical estrogen will ever give. And with the evidence now showing that estrogen alone does not increase the risk of breast cancer anyway, women can be assured that topical therapy, especially if mostly applied to the vaginal opening, is safe. It is also now known that the thicker and more estrogenized the vulvar and vaginal tissues are, the less absorption into the body. So a stable constant regimen is better than going on and off the topicals, with the tissues thinning again in between.
Q. How do we educate our medical professionals to stop being dismissive and take our sexuality seriously, whether we’re 60, 70, or 80?
A: This is a work in progress, but educational outreach through professional societies like NAMS, the International Pelvic Pain Society (IPPS), and the International Society for the Study Of Vulvovaginal Disorders (ISSVD), as well as patient advocacy organizations, especially the National Vulvodynia Association (NVA) is helping. The websites of these societies all list health professionals by area to help patients find a knowledgeable MD. We also need to devote more time to formal education on sexuality and pain in medical schools and residency programs.
As always, I welcome your comments. If you’re experiencing pain with sex, I hope you’ll read both Naked at Our Age and Healing Painful Sex. Then please carry both books with you to show your doctor!
Doctor, Doctor, Talk to Us about Senior Sex
Angry and/or bewildered readers write me or raise their hands at my talks with tales of doctors who can’t or won’t inform them about sex.
Just a few of the many examples seniors have shared with me:
- One woman described how her oncologist bolted from the room when she asked how her cancer treatment would affect her sexuality.
- A man emailed me that he finally got the nerve to tell his doctor that he could no longer have erections. “You have ED,” he was told, and that was that. I was the one to tell him that ED is a symptom, not a diagnosis, and he needed to get tests run to find out what was going on.
- Several women with vaginal pain reported that their doctors offered them no help other than telling them their vaginas were “normal” and they should just use more lubricant. A referral to a vulvar pain specialist or a pelvic floor therapist would have helped these women enjoy sex again.
- Several men told me that they were never told that treatments for their medical conditions would interfere with their erectile difficulty and that other options were available.
A woman at one of my bookstore talks told a roomful of sympathetic listeners that after a hysterectomy at age 70+, she asked her doctor what she should know about resuming sex. He asked, “Do you have a partner?” “No, she replied. “Then you don’t need to worry about that, do you?”
When I retell this story in different parts of the country on my travels, there’s always someone who says, “I know that doctor!”
I always rush to defend doctors, being a doctor’s daughter and a doctor’s sister, and having had my own life saved and quality of life restored by brilliant medical professionals.
But that doesn’t mean that I think doctors and other medical professionals adequately address senior sex — they do not. I know that their medical training barely addresses sexuality at all, and doesn’t deal with senior sex whatsoever. Unless doctors make an effort to educate themselves (and bless ’em, some do!), they just don’t know what to tell us.
I give my readers and audiences tools for talking to their doctors, for example, saying, “If you can’t help me with this, give a referral to someone who can.”
The worst thing we can do is keep silent about our sexual challenges or mumble and give up.
I invite your comments — your stories about doctors who have or have not helped you regarding your sexuality, and especially what you would like doctors to know about what we seniors/boomers/elders need from them in that realm.
For example, Ron posted to my Naked at Our Age Facebook page (which I hope you’ll visit and “like”!), “Docs need to be up on the sexual side effects of medications and we need to be sure to tell docs we don’t want any meds that somehow reduce our libido or capability.”
Your turn!
New England Journal of Medicine: Seniors having sex despite “bothersome problems”
When the news splashed all over the media today that older adults are, indeed, having sex, my first reaction was to laugh and say, “Duhhh!” The idea that senior sex is alive seemed to me as much a news story as the revelation that most people find feet at the end of their legs!
But there was much more to the story. “A Study of Sexuality and Health among Older Adults in the United States,” published today in the New England Journal of Medicine, was a major study of 3005 U.S. adults (1550 women and 1455 men) 57 to 85 years of age which revealed some fascinating facts and a few surprises:
The majority of older adults are sexually active and regard sexuality as an important part of life. The prevalence of sexual activity declines with age, yet a substantial number of men and women engage in vaginal intercourse, oral sex, and masturbation even in the eighth and ninth decades of life.The frequency of sexual activity reported by sexually active older adults (age 57+) is similar to the frequency reported among adults 18 to 59 years of age.The study reported that 78% of men 75 to 85 years of age, as compared with 40% of women in this age group, had a spousal or intimate relationship. Since women live longer, and on average, older men marry younger women, this disparity can be accounted for by the lack of available men for the older single women. The sexually active people in the oldest age group interviewed — 75 to 85 years of age — reported having sex at least two to three times per month, and 23% reported having sex once a week or more.About half of the sexually active men and women reported at least one “bothersome sexual problem,” and almost one third reported having multiple problems. The women’s most prevalent sexual problems were low desire, difficulty with vaginal lubrication, inability to climax, finding sex not pleasurable , and pain, usually during entry. The most prevalent sexual problems for men were erectile difficulty (14% of all men interviewed reported using medication or supplements to improve sexual function), lack of interest in sex, climaxing too quickly, anxiety about performance, and inability to climax. About one quarter of sexually active older adults with a sexual problem reported avoiding sex as a consequence.
Most surprising, given the extent of these problems that prevented sex from being satisfying or pleasurable, was this fact:
Only 38% of men and 22% of women reported having discussed sex with a physician since the age of 50.
The study suggests that the reasons for poor communication include the unwillingness of both patients and physicians to talk about sex and the gender and age differences between patients and their physicians.
Negative societal attitudes about women’s sexuality and sexuality at older ages may also inhibit such discussions.
When I give workshops and talks, both women and men frequently bring up physical problems that affect their sexuality and want me to provide a solution. I always say, “Please get a diagnosis from your doctor.” I emphasize that the problem may be caused by retreating hormones, or by an underlying health condition that you don’t know you have, or a medication, or interactions of medications. You can’t treat a problem until you know what’s causing it.
As the NEJM article states,
Sexual problems may be a warning sign or consequence of a serious underlying illness such as diabetes, an infection, urogenital tract conditions, or cancer. Undiagnosed or untreated sexual problems, or both, can lead to or occur with depression or social withdrawal. Patients may discontinue needed medications because of side effects that affect their sex lives, and medications to treat sexual problems can also have negative health effects, yet physician–patient communication about sexuality is poor.
I invite your comments!