This site is intended for health professionals only

Let's talk about sex: tackling embarrassing issues

Elizabeth Cort
RGN RMN DN MSc
Research Nurse
E:psychosexualnursing@btopenworld.com

Sexual adjustment is an important component of overall wellbeing and mental health and a building block of self-esteem and self-image.(1)
Although the prevalence of sexual dysfunction in general practice patients is likely to be high, it is also recognised that patients are often not questioned directly, and therefore many sexual problems may go undetected.(2) Skilled practitioners who can respond to the sexuality inherent in everyday practice are likely to contribute to the effective management of a range of sensitive ­healthcare challenges.(3)
Nurses have a professional responsibility to create an environment in which patients feel enabled to express their sexual and relationship concerns. Any illness can impact on core feelings of self and relatedness to others and can diminish sexual and relationship functioning. Some common conditions that can cause sexual dysfunction include:

  • Hypertension.
  • Ischaemic vascular disease.
  • Diabetes.
  • Depression.
  • Schizophrenia.
  • Conditions that limit movement (eg, arthritis).
  • Enduring pain of any type.
  • Fatigue.
  • Any condition or disorder that affects self-esteem, body image or interferes with normal function.

Changes in sexual function can occur as a biological consequence of disease, in relation to illness experience, or as a direct or indirect consequence of treatment. Such changes can cause considerable anxiety and/or distress. Primary care patients may also present with specific sexual problems or difficulties (see Table 1). Some of these problems will be dealt with in the primary care setting, while others will require referral to specialist agencies.

[[NIP13_table1_79]]

The nurse-patient consultation is a dynamic interactive process that forms the basis of the therapeutic relationship. The interaction is influenced by the characteristics of both patient and clinician. Although we may aim towards a nonjudgemental stance, in reality the way the patient is approached in relation to sexual issues is likely to reflect to some degree the attitude and values of the clinician. Nursing practice in relation to sexuality can and must be tailored to each patient's needs.(4) It is helpful for the nurse to develop insights and awareness of their own attitudes and views around ­sexuality issues, as this can help reduce the likelihood of imposing one's own values on the patient. Lewis and Bor found that the strongly held attitudes of nurses were one of the greatest obstacles to an increased openness in discussion of sexuality.(5)
Many nurses are concerned about broaching sexual matters with patients. Although some nurses may feel skilled and confident to address sexuality-related matters, traditionally this has been an area that has been less than adequately dealt with and one that raises discomfort.(6-8) It is important for each nurse to reflect on their practice to identify any possible barriers that may hinder the way they approach discussing sexuality with patients. Box 1 lists some barriers commonly cited in the literature. Working together in the multiprofessional team is beneficial, as is sharing concerns and uncertainties. In some instances a patient may need to be seen by a health professional of a particular gender, personal quality or specific expertise. The dynamics of each situation should be considered, and the patient and nurse should feel comfortable with the level of disclosure and safe to explore the topic (or bring the topic to closure - to be dealt with at an alternative time).

[[NIP13_box1_80]]

Assessment is accomplished by interviewing the patient and employing sensitive observation. This stage of care is important as it precedes and determines subsequent therapeutic interaction, intervention and prevention. In general, if the nurse is able to deal with sexual matters in a relaxed, professional manner then the patient will also feel comfortable to discuss their concerns. It is helpful for the nurse to include sexual questions as an integral part of the whole assessment as this signals to the patient that sexuality is a legitimate area of concern that can be addressed within a consultation. As a broad rule of thumb, sexual information should be gathered with the same routine sensitivity as any other personal heath information.
As in any consultation, it is helpful to consider the layout of the consulting room and the seating arrangements. Privacy should be ensured as many patients may have concerns about confidentiality. Communication is a key factor. The nurse should be diligent in attending not only to what the patient says or presents, but also to all aspects of their verbal and nonverbal communication. The psychosexual model of understanding suggests that patients may present unconscious tensions as physical symptoms or somatic worries.(9) Patients may use physical complaints as a "ticket of entry" into the medical consultation, believing they shouldn't waste the nurse's time with emotional worries. It is important to really listen to the patient - to what is said and to what is unsaid. Sexual worries may be disclosed in the course of a consultation or nursing intervention for a separate problem. Courtenay (1976; cited in Skrine(9)) found that only 18% of patients with sexual disorders had presented the problem directly.
Sexuality issues need to be understood from a bio-psychosocial perspective that regards each individual within their social system and in relation to the range of factors that determine how problems develop and are maintained.(10,11) Basic questions about how illness has impacted on and continues to affect sexual and relationship function can be included in the assessment and formulation process for all patients. By routinely opening a discussion about sexuality, the nurse is communicating several things. Not only are they offering to share information; they are also recognising that the illness may have affected the patient's life in this way.(12) Asking the patient about their personal, social history and background helps the nurse to build up an image of the patient and their life. It is important to consider personality factors affecting sexual adjustment and the premorbid level of personal and sexual function. Extensive sexual history taking may be neither required nor appropriate but all patients should have at least an opportunity to discuss such matters. Open questions that encourage the patient to tell their story in their own words are often most useful, and these can be followed as necessary with more direct questions.(13) The thought of asking sexual questions can at first seem daunting; however, with repeated practice the nurse becomes less sensitive and more comfortable with the process. Questions should be legitimate, relevant to healthcare and in line with each patient's level of comfort.
Guides to history taking are available.(13,14) Box 2 outlines some components of a psychosocial history. The primary care team may find it useful to develop an assessment proforma that could be used as a general guide. A generic assessment format that integrates the psychosocial and sexual history could be used with all patients, while practice staff with specific roles are likely to apply a detailed assessment to their specialist areas such as contraception and sexual and reproductive health.

[[NIP13_box2_82]]

What happens if a patient discloses a sexual problem?
In some instances health professionals avoid asking sexual questions because of their uncertainty about how to actually deal with the problem. Risen suggests that clinicians rationalise not talking to patients about sexuality matters by saying that the patient did not raise the issue.(13) The onus to actively report problems should not always be placed on the patient.
A model that features frequently in the nursing literature in relation to sexual history taking is the P-LI-SS-IT model devised by Annon, an American psychosexual therapist.(15) This cognitive-behavioural programme involves four graded levels of assessment and intervention - permission, limited information, specific suggestions and intensive therapy.
The levels are distinct and yet form an interconnected process. Waterhouse suggests that most nurses are able to intervene at level one and two, while further knowledge and skills are required for level three and specialist training for level four.(16) White presents a detailed discussion about applying this model in contemporary nursing practice and in particular highlights the importance of seeing sexuality-related nursing practice in the context of the individual and the influence of the managerial and organisational culture.(17) Each nurse should work within the limit of her competence and knowledge.

Level one - permission
Permission involves the nurse raising the topic of sexuality as a legitimate dimension of healthcare. In the first instance, listening sensitively is the key skill required and the nurse enables the patient to share their anxieties and talk through concerns. In addition, the nurse provides reassurance and validation of the patient's experience. This in itself is usually experienced as therapeutic, as often people have felt unable to disclose sexual concerns and fears even to their closest friend or partner.
The nurse is then in a position to negotiate the next level of intervention. Having initiated the relationship with the patient it is often helpful for the health professional to continue the assessment. Further gathering of information can help to guide the patient down the appropriate therapy channel.
When a specific problem is identified it is important to gather information as to the exact nature of the ­problem (see Table 2). What is the problem? When, where and how did it start? What was the patient's sexual life like before the problem? This is important - a gradual onset, especially after previously satisfactory sexual activity and with a good concurrent relationship, may point to an important physical cause.(11) Having identified sexual concerns it can be useful to consider any predisposing, precipitating and maintaining factors.(18)

[[NIP13_table2_84]]

If the patient is in a relationship, it can be very useful to see the couple together to inform the assessment, as sexual problems are best evaluated in terms of the relationships in which they are manifest. Relationships can be classified as stable or unstable and satisfactory or unsatisfactory, and most relationship problems can be thought of as including difficulties with communication, conflict and commitment.(11) It is useful to think of the relationship in relation to the lifecycle and what else is happening to the couple in their life.
It is important to remember that assessment is a process that may need to be carried out over time. It can be helpful for the nurse to utilise the professional support from her colleagues - for example, in clinical supervision and multiprofessional case meetings.

Level two - limited information
This involves giving the patient information relevant to the problem area and/or guiding them to appropriate resource materials. This could include sexual health education or information about sexual side-effects of illness or medication. Practice nurses need to be aware of the range of sexual side-effects from commonly prescribed drugs such as antihypertensives, antidepressants or b-blockers.

Level three - specific suggestions
At this level direct attempts are made to help the patient change behaviour to reach a specific goal or address a specific problem.(1) This level of intervention is likely to require a more detailed assessment and full sexual history. For example, a woman with arthritis is experiencing pain and discomfort during sex with her partner - it could be useful to consider use of analgesia, look at communication between the couple, explore the usual ways the couple approach sexual intimacy and consider alternative behaviours or positions.

Level four - intensive therapy
This level of more structured therapeutic support is likely to be provided by a trained psychosexual or relationship therapist. Depending on the nature of the problem, the therapy may follow a particular model - for example, medical, psychodynamic or cognitive behavioural. In ­primary care it may be that certain nurses or other health professionals are based in the GP practice. Alternatively, a list of therapists can be obtained from the British Association of Sexual and Relationship Therapy (BASRT - see Resources ­section).

In practice
Level one is a crucial stage in the process in terms of addressing the patient's concerns. Often the most important thing is to be willing to listen, communicate interest, understanding and respect, and not to label or judge the patient.(1) Each nurse should ensure that their work is fully supervised.
Some nurses may welcome a more specialised role, although all should know what backup services are available and should have an established referral system.(19)
Nurses can have a pivotal role in helping patients to express their concerns and should feel confident to include sexuality routinely as an integral part of patient care. Nurses' professional response to sexuality should be proactive, considered and planned rather than reactive to overt distress.(3) When sexual care is not acknowledged as part of every healthcare practitioners' concern and responsibility, then the principle of holistic care is lost and there is potential for patients' needs to remain unmet.(20) Nurses may vary in their skill levels of sexuality-related practice; however, the RCN points out that their duty is to work at their level of competence using evidence-based practice.(21) Nurses are often very skilled in developing a rapport with patients, providing reassurance and enabling patients to express their feelings - they may need encouragement to extend these skills into the realm of patient sexuality. In addition, practice nurses need to be actively involved to ensure that improved, relevant sexuality and sexual health training and quality support services become more easily accessible.

[[nip13_box1_83]]

References

  1. Chapman J, Sughrue J. A model for sexual assessment and intervention. Health Care Women Int 1987;8:87-99.
  2. Read S, King M, Watson J. Sexual dysfunction in primary medical care: prevalence, characteristics and ­detection by the general practitioner.J Public Health Med 1997;19:387-91.
  3. Heath H, White I. The challenge of sexuality in health care. Oxford: Blackwell Science; 2002.
  4. Caruso-Herman D. Concerns for the dying patient and family. Semin Oncol Nurs 1989;5(2):120-3.
  5. Lewis S, Bor R. Nurses' knowledge of and attitudes towards sexuality and the relationship of these with nursing practice. J Adv Nurs 1994;20:251-9.
  6. Webb C. Sexuality nursing and health. Chichester: J Wiley & Sons; 1985.
  7. Webb C. Living sexuality: issues for nursing and health. London:Scutari Press; 1994.
  8. D'Ardenne P, McCann E. The sexual and relationship needs of people with psychosis; a neglected topic [Editorial]. Sexual Marital Ther 1997;12(4).
  9. Skrine RL. Sexual problems in primary care: psychosexual medicine skills and training. Sexual Marital Ther 1989;4(1):47-58.
  10. Cohen MAA, Alfonso CA. A comprehensive approach to sexual history-taking using the biopsychosocial model. Int J Mental Health 1997;26:3-14.
  11. Watson JP, Davies T. Psychosexual problems. In: Davies T, Craig T, editors. ABC of mental health. London: BMJ Books; 1998.
  12. Clifford D. Psychosexual awareness in everyday nursing. Nurs Standard 1998;12(39):42-5.
  13. Risen CB. A guide to taking a sexual history. Psychiatr Clin North Am 1995;18(1):39-53.
  14. Spence S. Psychosexual therapy:a cognitive-behavioural approach. London: Chapman and Hall; 1991.
  15. Annon J. The PLISSIT model: a proposed conceptual framework for the behavioural treatment of sexual ­problems. J Sex Educ Ther 1976;2:1-15.
  16. Waterhouse J. Nursing ­practice related to sexuality: a review and recommendations. NT research 1996;1(6):412-8.
  17. White I. Facilitating sexual ­expression: challenges for contemporary practice in the challenge of sexuality in health care. Oxford: Blackwell Science; 2002. ch. 16.
  18. Hawton K. Sex therapy: a practical guide. Oxford: Oxford University Press; 1985.
  19. Van Ooijen E, Charnock A. What is sexuality? Nurs Times 1995;91(17):26-7.
  20. Clifford D, Rutter M, Selby J. Caring for sexuality. In: Wells D, editor. Health and illness. Edinburgh:Churchill Livingstone; 2000.
  21. RCN. Sexuality and sexual health in nursing practice. London: RCN; 2000.

Resources
The British Association of Sexual and Relationship Therapy (BASRT) Contact this group for a list of clinics in your area
T:020 8543 2707
W:www.basmt.org.uk
Family Planning Association ­Reproductive and sexual health services
To find out where your local service is based visit the Family Planning Association's main website
W:www.fpa.org.uk
Relate Relationship and psychosexual counselling. Website contains information about available services in your area, online advice and helpful links
W:www.relate.org.uk
Association for the Sexual and Personal Relationships of People with a Disability (SPOD)
286 Camden Road
London N7 0BJ
T:020 7607 8851
F:020 7700 0236
E:info@spod-uk.org 
W:www.spod-uk.org
The Association of Psychosexual Nursing 
PO Box 2762
London W1A 5HQ
W:www.psychosexualnursing.org.uk
The RCN has produced a discussion and guidance ­document that aims to equip nurses to deal with these issues in a professional, sensible, legal and practical way (ref 21). Readers are recommended to read this useful guide to practice. The document urges nurses to liaise with managers with regard to sexual health policies and highlights the legal and conduct issues relating to sexuality-related nursing practice