Talking About Sex

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When it comes to sex, doctors too often have a "don't ask, don't tell" policy. We're a country that's inundated with sex. Yet we have an awfully tough time talking about it like grown-ups.

A Consumer Reports national poll found that 81 percent of adults ages 18 to 75 reported avoiding or delaying sex with their partner in the past year. The most common reasons: tiredness (53 percent), illness (49 percent), and not being in the mood (40 percent). Fifty-six percent of men reported thinking about sex at least once daily versus only 19 percent of the women.

A 2007 study in the New England Journal of Medicine found that about half of men and women ages 57 to 85 had at least one bothersome sexual problem, yet only 38 percent of men and 22 percent of women over 50 discussed sex with their doctor.

Let's face it. Many people are awkward about bringing up the topic of sex with their doctors - or even with their partners (sometimes especially with their partners because of the power sex has in a relationship; sex often doesn't just mean sex). We doctors need to take the lead in making it a normal part of the routine conversation during an office visit. In medical school, we're taught to do a "review of systems" - a head-to-toe checklist to make sure we don't miss an important complaint. But somehow we often skip over the subject of sexuality. And as the New England Journal study found, if I don't bring it up, my patient usually won't.

Doctors need to make patients feel safe discussing the most intimate details of their personal lives. That's sometimes not easy. But I've found that most of my patients greatly appreciate my bringing it up as long as it's in the context of a safe, nonthreatening atmosphere. And if I'm comfortable with the topic and with the vocabulary, they usually follow my lead.

The most common complaint I hear is lack of desire and being out of sync with a partner. Often - with kids running around, schedules to juggle, and fatigue to fight - there's a problem just figuring out the logistics of getting started, after which everything usually goes smoothly. Sometimes there are problems such as erectile dysfunction or inability to achieve orgasm that can be addressed through a combination of treatments that may include medication and therapy.

Sexual dysfunction may be a symptom of depression; it can also be a side-effect of antidepressants or other medications. Patients will sometimes stop their antidepressants on their own because of sexual side-effects such as loss of libido; but if they had just spoken to their physician, the problem may have been greatly helped or even totally solved with a change of medication.

The key is realizing that we're not elementary school students giggling about a forbidden subject. We're adults addressing a crucial element of our health - and communication is the name of the game. Whether it's with a partner, doctor, or trusted friend, communication helps pave the way to a fulfilling and mature sex life.

That brings us to tomorrow's segment of CBS Doc Dot Com. CBS correspondent Richard Schlesinger, renowned sex therapist Miriam Baker, and I take a field trip to a luxury lingerie and intimacy boutique called Kiki De Montparnasse and ask the question, "Why do people often get out of sync sexually, and what can they do about it?"

Here's more input from Mariam Baker in her own words:

People need to be reminded and given permission to see sex as a pleasure in life.It helps our minds to move away from stress, take a break and make a connection to our partners that will soften the difficult moments of daily life. Sex can be an easy way to enhance mood and promote health by stimulating the pleasure centers of our brain and reducing anxiety. Avoidance of sex actually increases stress and anxiety."

And here's more on the subject from William Fisher, Associate Clinical Professor of Psychiatry at Columbia:

Talking about sexual functioning is an important part of the discussion when someone meets with a psychiatrist. Problems with sexual functioning are common symptoms of depression and other psychiatric disorders but they are also a common side effect of antidepressants (as well as many other medications like those for high blood pressure ).

As part of the initial assessment, I try to get a sense of someone's current sexual functioning and whether it's different from their usual baseline. Then as treatment goes on it's important to check in periodically to see whether things are improving. Sexual side effects of antidepressants can be addressed very effectively by changes in the type or dosage of antidepressant or the use of adjunctive medications, but you can't address what you don't know about.

If these side effects aren't discussed and addressed patients may just get frustrated and stop taking their medication without ever exploring alternatives. This leaves the original problem untreated and leaves a patient with a negative feeling about the treatment experience. Since the majority of antidepressants in this country are prescribed by primary care physicians, not psychiatrists, the same rule should apply to any medical checkup. In my experience the physician is often more anxious than the patient about bringing this topic up. Most people are grateful for the chance to talk about it once you make it clear you're open to listening.