Sexuality: its not just sex

Sexuality is much more than just having sexual intercourse. General wellbeing, psychological wellbeing, relationship satisfaction and prevention of deterioration of diseases are all important considerations to have in mind when discussing matters of a sexual nature with patients. The magnitude of the degree of sexual problems remains hotly disputed, although the numbers appear to be age related. Over 50% of men over 40 years of age are affected with erectile dysfunction, with incidence approaching 70% by 70 years of age. ¹ Up to 53.8% of women may have a minimum of one sexual problem lasting at least one month over a two-year period in the UK. ²

It is widely accepted that erectile dysfunction is a sentinel marker and predictor of coronary heart disease and metabolic syndrome, especially in aging men. ³ Erectile dysfunction and heart disease have both common and shared risk factors; these have been described as diabetes mellitus, hypertension, dyslipidaemia and smoking cigarettes.^4-6 Conditions which affect women in a similar way may also present as sexual problems, although the problems themselves may present through different portals and with differing degrees of bothersomeness or distress. ⁷ There are already numerous good reviews in the literature for men with sexual problems but increasing attention is now being given to women's sexual problems. ⁸ As the profession is increasingly aware of the need to screen for endocrinological disorders, diabetes mellitus and other treatable medical conditions in men, we must now ensure we apply a similar process and ensure equity for women.

This series of articles brings together a number of themes which may affect sexual wellbeing. For many individuals, sexual activity is not always a positive or gainful experience, and a key area where increasing clinical involvement is sought is dealt with by Cybulska in her article on sexual assault (JRSM 2007;100:321-324). The series will continue with five further articles, covering user perceptions of what sexual health may be; better education, access to contraception and (where necessary) termination of pregnancy services; a review of sexually transmitted infections, complemented by the review of 25 years of HIV management of HIV; and a review article on the assessment and management of sexual problems focusing on women.

In 2004, Gott et al. ⁹ undertook in-depth, semi-structured interviews of 22 GPs and 35 practice nurses. The barriers to frank communication described by the interviewees included ‘opening up a can of worms’ that would have to have been followed through; fear of patients believing that the clinicians may be sexualizing the consultation; middle age and older patients who may be more easily offended and sensitive to such issues; patients from ethnic minorities who may not openly discuss such issues; religious beliefs; fear of possible prejudice towards non-heterosexual patients; and a general uncertainty regarding which terms to use.

Similar issues of poor training and fear of raising the subject have been described by Rele and Wylie ¹⁰ and Humphrey and Nazareth. ¹¹ The latter noted personal embarrassment, inadequate skills and knowledge and a fear that ‘a flood gate’ might be opened as key issues.

Clearly, more than just addressing lack of awareness and knowledge is necessary to secure the confidence of the physician to broach and manage the topics within the specialty. For many clinicians and patients, the scope contained within this series can act only as a taster for future collaborative thinking and working. I hope it serves to initiate new ways of thinking and interest in sexuality and sexual health.

Competing interests None declared.