Don’t ask, don’t tell: Silence in the medical encounter when sexual problems, ageing, and health conditions meet

Dr Sharron Hinchliff is Reader in Psychology and Health at the Health Sciences School, University of Sheffield. Dr Kirstin Mitchell is Professor of Social Science and Public Health at the University of Glasgow and an Investigator on the Natsal study. Their latest research, co-authored with Dr Ruth Lewis, Professor Kaye Mitchell, and Jessica Datta, entitled ‘Pathways to help-seeking for sexual difficulties in older adults: qualitative findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)’ was published in Age and Ageing. @DrSharronH @KMitchinGlasgow @DrRuthLewis @NatsalStudy

If sex was important to you and you had a sexual problem, would you seek help? Would you know where to go? Evidence shows that high numbers of women and men aged 50+ have a sexual problem caused by a health condition or the medications taken to manage it, but that they do not always seek help. Some are okay as they are, while others are not, yet they often delay their help-seeking. Those who experience distress about a sexual problem are more likely to seek help but the journey is not straightforward. And the response of the health practitioner is pivotal to patient satisfaction and resolution of the problem.

Although sex and intimacy are important to many romantic relationships, they can be one of the most difficult topics to talk about. This difficulty is exacerbated / compounded when a sexual problem is involved. Research tells us that sexual problems can have an adverse effect on psychological wellbeing. They are associated with greater depressive symptoms and lower relationship satisfaction. Indeed, sexual and intimate relationships are a key component of quality of life for adults aged 50+, with reported benefits for mental and physical health.

Diabetes, high blood pressure and cancer are just a handful of conditions that can interfere with our sexual lives; there are many more. The physical and psychological effects of some health conditions and their medications include a reduction or elimination of sexual desire, the prevention or delay of orgasm, or difficulties with physical function such as erection maintenance and vaginal atrophy. Many of the medicines prescribed for these long-term conditions require patients to take them every day. And if the patient is older, they are more sensitive to drug effects including their side-effects.

In our study published in Age and Ageing, we interviewed 23 women and men aged 58-75 about a health condition, medication, or disability which they believed had affected their sex life in the last year. The data were collected as part of the Third British National Survey of Sexual Attitudes and Lifestyles (natsal 3).

We found that only a small number of participants had sought professional help for their sexual difficulty. Some had not sought help because they were embarrassed, and others simply felt that they were ‘too old’ to find a solution. When participants had sought help, this was chiefly because of the importance of sex within the relationship and the impact of the sexual difficulty on sexual pleasure.

We also found that seeking help was not a straightforward or linear process. For example, participants did not necessarily seek help when they first noticed their sexual difficulty. There was a delay in help-seeking while they made lifestyle changes to see if that would make a difference, or they waited to see if the problem got better on its own. Many did their own research, mainly online, to identify the cause and potential cure.

The decision-making process involved weighing up the importance of sex within the relationship alongside the potential risks of taking a medicine that could interact with those already taken for chronic health conditions. This is an important point: people are living for longer, and models of projected disease burden have identified that multi-morbidity will grow significantly over the next 20 years in the UK. Additionally, we are yet to see the long-term effects of COVID-19 on physical and mental health from the disease itself and from lockdown measures; all of which could have an impact on our sexual wellbeing.

Overall, the participants in our study had not been asked about sexual issues by doctors even though all had a health condition known to interfere with sexual wellbeing. For those who had sought help and asked the questions, an approachable doctor facilitated the process. However, when a doctor was unhelpful, for example, and was perceived to not take the sexual problem seriously, the implications for the patient’s sex life could be severe. It often heralded an unwanted end to sex.

We know from other research that older patients want doctors to ask them about sexual wellbeing whereas doctors want patients to raise the topic themselves. Consequently, there is unmet patient need when the practitioner does not ask and the patient does not tell. One way to overcome this impasse is to give patients and practitioners permission to raise the topic, for example by providing patients with a pre-consultation card which lists a range of topics they might like to talk about, including sexual issues, during the consultation. As practitioners we have a duty of care, and to not consider sexual wellbeing in the conditions we treat and the drugs we prescribe can be considered a breach of older adults’ sexual rights. We hope that the help-seeking pathway map that we have developed from our study will help practitioners to manage this process.

Read the Age and Ageing paper Pathways to help-seeking for sexual difficulties in older adults: qualitative findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)