SEXUAL HEALTH FUNDAMENTALS

Talking With Patients About Sexuality and Sexual Health

It can be difficult for health care providers and patients to
begin the discussion about sexuality and sexual health, but
patients want to talk to you about their sexual concerns
and they want you to raise the subject first.1,2
A survey of 391 women conducted by The Womens
Sexual Health Foundation found that 72 percent of
respondents would be comfortable talking to their
clinician about sexual problems, but 73 percent preferred
that the health care provider bring up the topic.1

others feel that sexuality is too complex of an issue to

tackle in limited time allotted for a routine visit.2,6,7
Whatever the reason for the lack of communication, these
provider and consumer surveys highlight a major gap
between what patients need and want regarding their sexual
health and what front-line clinicians are offering them.

Basic Behavioral Counseling for Female Sexual

Health Issues

An online survey of 3,807 healthy volunteers reported

that 40 percent of women who participated did not talk
to a clinician about a sexual problem, but over half of
them wanted to.2

Talking about sexual health issues with patients should not

be intimidating for providersnor does it mean opening up
the conversation to a slew of concerns that will disrupt the
office schedule.

A consumer poll of 1,209 US women found that 70

percent of respondents had experienced a sexual health
issue (e.g., lack of desire or arousal, inability to orgasm,
pain during intercourse, vaginal dryness, or excessive
desire for sexual activity) and 22 percent were very or
extremely concerned about ityet only 18 percent had
consulted a health care provider about their problem.3
The National Health and Social Life Survey of 1,749
women ages 18-59 found that 43% of respondents had a
sexual issue; only 10%-20% had seen a clinician about it.4

Experts in the field recommend several effective ways to

broach the topic of sexuality during visits. You might open
with a normalizing statement such as It is part of my routine
to ask about sexual health as part of the well-woman visit.
Do you have any concerns? and include sexual health
questions as part of a review of systems. Or you might
question the patients reproductive stage of life, saying Some
studies show that as women age, they may have less desire
for sex or decreased lubrication, which makes intercourse
uncomfortable. Have you noticed any changes?6

In addition, a poll of 304 US health care providers

commissioned in 2009 by the Association of Reproductive
Health Professionals (ARHP) and HealthyWomen found that:

Basic screening for sexual function should begin with two

key questions:
1. Are you currently involved in a sexual relationship?

Sexuality is the least commonly discussed health topic

with female patients for half of providers.

2. Are your sexual partners men, women, or both?6

Providers discuss sexual health issues with less than half

(39%) of their female patients.
Female providers are somewhat more likely than male
providers to discuss sexuality with their patients (45%
versus 34%, respectively).
Most providers (74%) rely on their patients to initiate a
discussion about sexual health.5
Why are providers apprehensive to initiate the discussion
about sexual health issues with patients? The lack of
training and skills to deal with these concerns is cited as
a reason. The personal embarrassment or discomfort of
talking about sex is another. Many providers underestimate
the prevalence of sexual dysfunction in their patient
population or the impact that sexual complaints have on
their patients global health and wellness, and some are
concerned about offending patients. The lack of effective
and safe treatment options has also been a factor and

From there, you would continue with the history-taking

process. One effective model that follows the stepwise
approach is based on the PLISSIT (permission, limited
information, specific suggestions, and intensive therapy)
Model of Intervention for Sexual Problems developed by
psychologist Jack Anon, and helps to streamline this process.8
1. Ask open-ended questions to give the patient
permission to talk about her sexual concerns and
reassure her that her feelings are normal and acceptable.
Validate and legitimize the patients complaint. Openended questions are preferred to yes/no questions, and
may even help to constrain the interview time by focusing
the history-taking on key areas of concern. Open-ended
questions can also be used when a patient presents with a
specific sexual health problem.6,9
Below are some commonly used examples that are
effective in clinical practice.

Open-Ended Icebreakers to Start the Discussion

1. Tell me about any sexual concern/problem/issue you
would like to discuss.
2. How does the problem affect your life and
relationship(s)?
3. How does the concern present?
4. What is the most distressing part of this problem?
5. Tell me about your last sexual experience.
6. How have you tried to manage the problem so far?
7. Do you have a medical condition that affects your
quality of life, including your sexual health?
8. What are your goals for your sexual health?
9. Tell me about the conversations you have had with your
partner so far about this problem.6,9,14
2. Provide limited information. Address whatever
topics you can in the limited time you have available
and perhaps encourage the patient to make a follow-up
appointment to focus solely on her sexual health concerns.
It is important to educate the patient about anatomy,
physiology, sexual response, and sexual changes that
may occur with age, use of certain medications (such
as antidepressants), and under the influence of medical
conditions (such as depression). (See ARHPs CORE
program [www.arhp.org/core; keywords sex and
sexuality] and other Sexual Health Fundamentals fact
sheets [www.arhp.org/factsheets] to get yourself up to
speed on these topics.) Dispel myths about the sexual
concern and offer handouts and resource lists on the
subject. Potential sources of handouts include:
American Association of Sexuality Educators
Counselors and Therapists (www.aasect.org)
ARHP Sex and Sexuality Reproductive Health Topic
Area (www.arhp.org/Topics/Sex-and-Sexuality)
International Society for the Study of Womens
Sexual Health (www.isswsh.org)
North American Menopause Society
(www.menopause.org)
Sex and a Healthier You website
(www.sexandahealthieryou.org)
3. Offer specific suggestions and solutions to treat
the complaint. You may offer specific suggestions and
solutions to begin to try to treat the complaint. First,
manage co-morbid conditions that alter sexual function
and consider assessment of medications that may impact
sexual function.6,12
Next, provide specific suggestions related to the patients
sexual health goals. For instance, if the patient is interested
in having a more active sex life, you might encourage
her to learn more about her sexual response and sexual
wellness (e.g., that women in long-term relationships often
may not feel spontaneous desire but may experience
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Sexual Health Screeners

A variety of screening instruments have been developed to help clinicians quickly recognize female sexual problems and whether they are causing women distress. There are several validated screening tools that
focus on hypoactive sexual desire disorder (HSDD),
which is the most common sexual complaint of women
of all ages.4,10
Although not all screeners will be relevant to your
practicethey vary in their usefulness depending upon
your clinical specialty and the patient population you
serveseveral have been validated in clinical trials.
Below is a list of a few of these tools.
Decreased Sexual Desire Screener (DSDS)
Clayton AH, Goldfischer ER, Goldstein I, et al.
Validation of the decreased sexual desire screener
(DSDS): a brief diagnostic instrument targeted for
generalized acquired female hypoactive sexual desire
disorder (HSDD). J Sex Med. 2009 Mar;6(3):730-8.
Consists of 5 questions; self-administered.
Female Sexual Function Index (FSFI)
Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): A multidimensional self-report
instrument for the assessment of female sexual function. J Sex Marital Ther. 2000; 26(2):191-208.
Consists of 19 questions to assess key dimensions of
sexual function in women; self-administered.
Sexual Interest and Desire InventoryFemale (SIDIF)
Clayton AH, Segraves RT, Leiblum S, et al. Reliability
and validity of the Sexual Interest and Desire InventoryFemale (SIDIF), a scale designed to measure
severity of female hypoactive sexual desire disorder. J
Sex Marital Ther. 2006; 32(2):115-35.
Consists of 13 items to assess the severity of HSDD;
clinician-administered; more advanced screener.
Brief Hypoactive Sexual Desire Disorder Screener
Leiblum S, Symonds T, Moore J, et al. A methodology
study to develop and validate a screener for hypoactive sexual desire disorder in postmenopausal women.
J Sex Med. 2006; 3(3):455-64.
Consists of 4 questions; self-administered; targeted to
postmenopausal women.
Brief Profile of Female Sexual Function (BPFSF)
Rust J, Derogatis L, Rodenberg C, et al. Development
and validation of a new screening tool for hypoactive sexual desire disorder: The Brief Profile of Female
Sexual Function (BPFSF). Gynecol Endocrinol. 2007;
23(11):638-44.
Consists of 7 questions; self-administered; targeted to
postmenopausal women.

Educational and Erotic Resources*

Sex Education Books
100 Questions & Answers about Womens Sexual
Wellness and Vitality by Michael L. Krychman, MD
Becoming Orgasmic: A Sexual and Personal Growth
Program for Women by Julia Heiman, PhD, Joseph
LoPiccolo, PhD, and David Palladini
For Yourself: The Fulfillment of Female Sexuality by
Lonnie Barbach, PhD
Getting the Sex You Want: A Womans Guide to
Becoming Proud, Passionate, and Pleased in Bed by
Sandra Leiblum, PhD
The G Spot: And Other Discoveries about Human
Sexuality by Alice Khan Ladas, EdD, Beverly
Whipple, PhD, and John D. Perry, PhD
The Joy of Sex by Alex Comfort, PhD, DSc
Passionate Marriage: Keeping Love and Intimacy
Alive in Committed Relationships by David Schnarch,
PhD
She Comes First: The Thinking Mans Guide to
Pleasuring a Woman by Ian Kerner, PhD
Instructional Videos
The Better Sex Video Series from the Sinclair Institute,
featuring real couples with advice from sex therapists;
available at www.bettersex.com.
Volume 1: Advanced Sexual Techniques & Positions
Volume 2: Adult Sex Education about 22 Sex
Secrets, Tips & Turn-ons
Volume 3: Adult Sex Education about Erotic Sex
Play & Beyond
Erotic Reading
Bedtime Stories for Lovers by Joan Elizabeth Lloyd
The Erotic Edge: 22 Erotic Stories for Couples edited
by Lonnie Barbach
Herotica: A Collection of Womens Erotic Fiction
edited by Susie Bright
The Mammoth Book of Best New Erotica series
edited by Maxim Jakubowski
Sexual Accessories, Vibrators, and Sex Toys
Eves Garden, www.evesgarden.com/shop, 800848-3837
Good Vibrations, www.goodvibes.com, 800-2898423

desire if their partner stimulates them or that women often

require direct clitoral and/or breast stimulation to have
an orgasm; vaginal penetration alone is not sufficient
for most women). See the box on Educational and
Erotic Resources for excellent sources of information to
recommend to patients.11,12
If shed like to make sex more of a priority in her life, you
might suggest she:
Get a lock for the bedroom door if privacy or interruption
is a concern and make it a sexual sanctuary.13
Schedule regular date nights (at home after the kids
have gone to bed if she cant afford a babysitter or out
at a restaurant if she can).13
Learn time and stress management skills to create a
space in her life for sex.12
Improve her exercise and diet habits and stopping
smoking so she feels well enough for sex.12
Address sexual boredom (change the sexual routine,
spend time as a couple on a regular basis, treat one
another with respect and interest, and look to sex
education books and videos for new techniques).12
Explore sexuality via masturbation and use of accessories,
sexual enhancers, self stimulators, and sex toys.12
4. Beyond providing basic information and suggestions,
most primary care providers will want to refer a patient,
possibly for intensive therapy, to qualified specialists
including sex therapists, couples counselors, cognitivebehavioral therapists, physical therapists, medical
or surgical subspecialists (gynecologist, psychiatrist,
endocrinologist, urologist, urogynecologist) for further
expert intervention.
Providers should refer any patient with a sexual issue
that exceeds their comfort level or expertise. They should
also refer patients who are victims of intimate partner
and domestic violence to the National Domestic Violence
Hotline at 1800799SAFE(7233) or www.ndvh.org and
local shelters, authorities, and domestic violence specialists,
and recommend patient support groups for sexual abuse
survivors (e.g., Sex and Love Addicts Anonymous
[www.slaafsw.org]).
For more information on this topic, refer to the other
Sexual Health Fundamentals fact sheets, The Top 10 Things
You Need to Know about Female Sexuality [www.arhp.
org/SHFTop10] and Sex Therapy for Non-Sex Therapists
[www.arhp.org/SHFTherapy].

* Recommended by sexual medicine experts Susan

Kellogg-Spadt, CRNP, PhD and Michael Krychman, MD.

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1.

The Womens Sexual Health Foundation. Sexual Health Discussion Survey.

Available at www.twshf.org/survey.html. Accessed 12/14/09.

2.

Berman L, Berman J, Felder S, et al. Seeking help for sexual function complaints:
What gynecologists need to know about the female patients experience. Fertil
Steril. 2003;79:572-576.

3.

Association of Reproductive Health Professionals and the National Womens

Health Resource Center (now HealthyWomen). National survey shows 70% of
women have experienced a sexual health issue. Available at
www.arhp.org/Publications-and-Resources/Studies-and-Surveys/SHY-Survey.
Accessed 11/9/09.

4.

Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States:
Prevalence and predictors. JAMA. 1999;281:537-544.

5.

Association of Reproductive Health Professionals and the National Womens

Health Resource Center (now HealthyWomen). Womens Sexual Health: Provider
Survey. 2009. Available at www.arhp.org/Publications-and-Resources/Studiesand-Surveys/SHY-Survey. Accessed 11/9/09.

6.

Kingsberg SA. Taking a sexual history. Obstet Gynecol Clin N Am. 2006;
33:535-547.

7.

Gott M, Galena E, Hinchliff S, et al. Opening a can of worms: GP and practice

nurse barriers to talking about sexual health in primary care. Family Practice.
2004;21:528-536.

8.

Leiblum SR, ed. Principles and Practice of Sex Therapy. Fourth Edition. New York,
NY: Guilford Press. 2007.

9.

Andrews WC. Approaches to taking a sexual history. J Womens Health Gend

Based Med. 2000;9 Suppl 1:S21-S24.

10. Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United
States Women. Obstet Gynecol. 2008;112:970-978.
11. Basson R, Leiblum S, Brotto L, et al. Definitions of womens sexual dysfunction
reconsidered: Advocating expansion and revision. J Psychosom Obstet Gynecol.
2003;24:221-229.
12. Krychman ML. 100 Questions & Answers About Womens Sexual Wellness and
Vitality. Sudbury, MA: Jones and Bartlett Publishers. 2010.
13. Berman J, Berman L, Bumiller E. For Women Only: A Revolutionary Guide to
Reclaiming Your Sex Life. 2nd ed. NY, NY: Holt. 2005.
14. Association of Reproductive Health Professionals (ARHP). Sexual Health
Fundamentals for Patient Care Initiative: Report of a US Consensus Process.
Available at www.sexualhealthfundamentals.org. Accessed 3/2/10.

Sexual Health Fundamentals is a publication of the

Association of Reproductive Health Professionals
(ARHP) for health care professionals, educators,
and researchers working in the field of reproductive
health. This fact sheet is part of the Sexual Health
Fundamentals for Patient Care Initiative [www.
sexualhealthfundamentals.org], which was guided
by principles established by a consensus committee
of renowned experts in female sexuality, led by cochairs Michael Krychman, MD, and Susan Kellogg
Spadt, CRNP, PhD. The goals of this initiative are to
assist frontline members of the reproductive health
care team with expert, evidence-based guidance
on sexual function, health, and wellness, and to
provide freely available needs assessment tools for
professional societies to customize for their specific
constituencies. Sexual Health Fundamentals are
available at www.arhp.org/factsheets.

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