Talking sex!

‘Behind every diagnosis is a person and behind every person is a story’

Author: Angela Gregory, Lead for Psychosexual Services at Nottingham University Hospitals Trust (full bio below)

Sex and intimacy is an integral part of being human and it has many health benefits: it’s good for our mood, for feeling loved, showing love and contrary to that well know excuse, it’s a great way to relieve headaches!

Experiencing ill health or being diagnosed with a life-threatening illness is a major life event and can impact negatively on a person’s sexuality, their sexual functioning and their relationship. For some, sex will be the last thing on their minds, for others it will be a way of maintaining a sense of normality. Each person may need different things from those in charge of their care but they should all be offered an early opportunity to discuss the potential sexual side effects or consequences related to their illness, injury or disease, or as a result of their surgery and treatment.

And it is our responsibility to ensure that we have those discussions. Otherwise they will experience what we call ‘the silent scream’, worrying about their problem but too shy or embarrassed to bring it up themselves, waiting in silence for their clinician to initiate a conversation.

So why is sex difficult to talk about?

I’m often asked about how to talk about sex – what to say, when to say it and what language to use. Sorry, there is no magic answer or formula because each clinical speciality has its own potential sexual consequences. The physical and psychological impact will vary as will the impact on people’s relationships.  Some couples will continue to be intimate and sexual while others will not, some partners will be supportive and others not so kind, some will be single, happily so, but others will be actively searching, concerned about what to say to a potential new partner.

So why are sexual function issues not routinely addressed, when clinicians acknowledge that their speciality may impact on their patients’ sexual lives?

The following are some common excuses:

“It will open a can of worms”

How do you know? What evidence is there? Maybe you’ll surprise yourself and find you can handle the worms or you may find the only worms in the can are related to your own anxiety! For some, simply being offered the opportunity to talk and be ‘heard’ will be powerful enough. No one expects you to have all the answers but knowing where further help can be accessed is essential.

Remember – it’s okay to say you don’t know but that you will find out.

“Not enough time”

Lack of time is a reality in many clinical settings but please make time for signposting to reliable websites and online resources. Or you could offer a follow-up appointment when more time is available.

In my opinion, if there’s time to talk about non-sexual symptoms there should be time to address sexual symptoms too. After all, the penis and vagina are only body parts. For example, if a man doesn’t get morning, night-time or sexually induced erections then this is a body part not getting the blood flow needed to stay healthy which impacts on the endothelial function of his manhood.

Remember – managing and treating sexual symptoms is rewarding and may save time in the long run.

“I might embarrass my patient”

Really? How do you know if you don’t ask? If your patient doesn’t want to talk with you about sex then they won’t, but for those who do want that conversation, it will be a lifeline and can prevent more complex sexual problems developing.

Remember – don’t make assumptions based on age or whether someone is in a relationship or not, just talk to them!

“I feel embarrassed”

I think this is the main reason why the subject of sex and sexual symptoms is avoided. However, the more you practise the easier it becomes. Ensure details of websites and leaflets are available in your clinic, talk to your colleagues, ask them how they have approached the subject and what suggestions they make? What have they found helpful? This way you support each other.

Remember – it’s normal to feel anxiety when doing something new but confidence comes with practice. You already have experience talking about difficult issues; sexual symptoms are simply another issue.

“What words do I use?”

Keep it simple; use proper words with a bit of extra explanation, or mime! The index finger on my right hand often doubles up as an erect penis and making a circle with my index finger and thumb with my left hand nicely illustrates the vaginal entrance. Something visual is always helpful to when illustrating a point. And the words to use?  Try penis, vagina, clitoris, labia (outer lips and inner lips) penetration (penis going in your vagina or bottom), sexual intercourse (anal or vaginal), erection (getting hard) masturbation (touching yourself, having sex on your own), breasts, nipples, orgasm, ejaculation (cumming), vaginal discharge, lubrication (getting wet); to name just a few.

When is the right time?

When deciding this, use your experience and common sense. If someone is very distressed they probably won’t hear you but if you are discussing others side effects then sexual functioning should be part of that routine. In some clinical areas sexual concerns are raised post-treatment but it is really important that potential effects are mentioned early on. This allows those who wish to continue to be sexual during and after their treatment a chance to discuss any problems they might have. Make sure there are opportunities for this to happen.

For example:

Your illness, surgery or treatment can cause some sexual symptoms which we normally discuss after your treatment or at a follow-up appointment, if you want to chat about this sooner please just ask me.

By saying this you are giving them permission to bring up the subject with you.

Untreated or unaddressed sexual issues can lead to more complex sexual problems developing and the long-term impact of sexual dysfunction can be devastating. This has the potential to rob men and women of their sexual self-confidence, their femininity/masculinity and the most intimate part of their relationship. Helping to maintain or restore sexual functioning is a quality of life issue. And healthcare professionals have a major role in providing an opportunity for early discussion, offering support and treating sexual symptoms.

Finally…behind every diagnosis is a person and every person’s journey will be different. Allow them a voice and help them have a sexual life that’s important to them.

Top Tips

Hot flushes and night sweats

Separate single duvets on a double bed and a fan in the bedroom.

Problems sleeping?

Get some nice relaxing tunes on your smartphone, radio or CD. This will distract you from feeling anxious or worried and help you fall asleep. Worried about disturbing your other half? Buy a ’sound pillow’ and plug in your device.

Managing anxiety and depression

Download meditations/mindfulness apps from Smiling Mind or Headspace. There is also a really good Aussie website that has lots of info on both anxiety and depression. See Really Useful Websites below.

Erectile dysfunction

Generic Viagra is called Sildenafil (approx. 80p per tablet) and this can be prescribed for any man on an NHS prescription. Our clinic normally prescribes eight tablets at the highest dose. Cialis, Levitra and Spedra are currently only available on an NHS prescription for men who fit Schedule II criteria (i.e. those with MS, diabetes, pelvic surgery or spinal injuries).  However, the long-acting nature of Cialis 20mgs (up to 36hrs) gives men the freedom to be spontaneous and takes the pressure off their partner so if they fit the criteria or can afford to pay for the medication on a private prescription, it is an excellent treatment choice.

Vaginal dryness

This is a very common, distressing and painful symptom of menopause which can be easily treated with vaginal moisturisers such as Hyalofemme. A silicone or oil-based lubricant should also be recommended as this serves a different purpose. Hyalofemme will provide moisture that lasts up to three days and will restore the ability to have spontaneous sex for many women, so that they do not need a lubricant to create a slippery surface on the vaginal walls for a short time (it can last for around 30 minutes). But some women will still want a lubricant, which can ease penetration and enhance sensation as well as avoiding friction. Lubrication also makes penetration easier for men with a less than rigid erection.

Twister for adults

Some people need to change their positon for sexual intercourse due to injury, illness or surgery, and they can ‘practice’ them in comfortable clothing. This makes it fun and means they aren’t trying to stay sexually aroused at the same time as trying something new.

Get fit for sex

We know exercise is good for our general health, to combat fatigue and improve our energy levels but it can also help us get fit for sex. According to Professor Mike Kirby ‘if you can walk on the flat for 20 mins without getting breathless or experiencing chest pain, you are safe for sex’. Sex in the morning when you are awake and relaxed, rather than being tired after a long day, is also a good idea.

Rebuilding relationships

For couples who haven’t been intimate or sexual for some time, suggestions such as sitting together to watch a film or having breakfast in bed together sound simple but can be effective in re-establishing a closer relationship. Showering or bathing together are non-threatening ways of touching each other again. Suggest ‘clear boundaries’ so they know sex is initially off the agenda.  This reduces performance anxiety and improves relaxation and arousal.

This is important for women who are worried about sexual pain or men worried whether they will get an erection, as it allows them to relax and enjoy getting close again without the pressure to perform sexually. Gradually, as their confidence improves, they can take things further.

And some really helpful websites:

  • Breast Cancer care – this charity provides really helpful leaflets and online advice for women – and men. They also offer workshops for women affected by breast cancer.
  • Jo’s Trust charity offering support, help and friendship for women with cervical cancer and cervical abnormalities.
  • Prostate cancer UK – information and support for men with prostate cancer. A phone-line is available for men to speak with a specialist nurse.
  • Cancer research UK – support and information on cancer and treatment.
  • Menopause matters – fantastic website covering all things menopausal, from diet and exercise to vaginal and bladder problems and evaluating risks and benefits associated with HRT.
  • Diabetes – covers all aspects related to living with diabetes including both erectile dysfunction and vaginal dryness.
  • The College of Sexual and Relationship Therapists (COSRT) provides information about what sex therapy involves, helpful suggestions and how to access qualified therapists locally.
  • Mind – mental health charity: “no-one should be left to cope alone”.
  • The Centre for Clinical Interventions is a great Aussie website that addresses anxiety, anxiety-related issues and depression. Really useful handouts for patients (or yourself) can be downloaded.
  • Sexual Advice Association offers advice and information on male and female sexual problems.
  • Relate – lots of useful information about relationship issues with an online facility to get advice from a trained counsellor.
  • The Dirty Normal – general information for women about all things sexual.
  • OMG Yes can teach most women a few things about female arousal – and partners too! But they do charge for it.

About the author: Angela Gregory

ANGELA GREGORYAngela (BA (Hons), PST Dip, CH Dip, COSRT acc.) is the Lead for Psychosexual Therapy at the Chandos Clinic, a sexual dysfunction service for men and women with a wide range of sexual difficulties based at Nottingham University Hospital Trust.

She has worked as a full-time Sexual and Relationship Psychotherapist for the past 15 years and provides in-house training for both medical and nursing staff and regularly lectures at a national level. She is currently the secretary of the British Society of Sexual Medicine.
In 2013 she had work published in the International Journal of Gynaecology on “Sexual Problems in Older Women” and a further two articles were published in 2014, one in the International Journal of Urological Nursing on “The Impact of Trauma on Sexual Functioning” and the other entitled “Tales of the Un-erected” in the Endocrinologist.
In 2015 she was involved in primary research looking at “Women’s experience of using vaginal trainers (dilators) to treat vaginal penetration difficulties diagnosed as vaginismus” published online (link to article).

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