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Let's Talk About Sex

Posted By Kenny Phelps and Tina Schermer Sellers, Tuesday, November 13, 2012
Talking about sex...It is difficult to avoid the multiple sexualized images in American culture. From Janet Jackson’s Superbowl peepshow to the popularity of the Sex and the City episodes to television programs of young girls being dressed up like 21 year old beauty queens, the messages of sex are inescapable in recent years.

While the quantity of sexual images and information has increased in our society, the quality of this information is severely lacking. Myths and misnomers about contraception and human anatomy are two examples of how we have a lot of information, but also a lot of misinformation. Additionally, the medicalization of sex has led to conceptualizations of the sexual response cycle separate from the inherent relational and systemic dynamics involved.
US Surgeon General David Satcher
"Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health" .
  --U.S. Surgeon General

Certainly, we must conceptualize sexual health as a biopsychosocial phenomenon. For the past several decades, there has been increasing recognition in medicine of the importance of sexual health and sexual health education in supporting both physical and emotional health(Foley, Wittmann, & Balon, 2010). In 2001, the surgeon general made this statement about the importance of sexuality as a contributor of overall quality of life: "Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health” (Satcher, 2001). Thus, is seems only natural that sexual health should be a part of the dialogue between patients and providers, but is it?

While professionals might recognize the importance of sexual health in the life of their patients, this is not equating to an increase in sexual education or patient assessment, treatment or referral. Sexuality is routinely overlooked in primary medicine (Owens & Tepper, 2007). Studies reveal that only 10%-30% of primary care physicians obtain sex histories (Lewis & H, 1987)(Gemson, Colombotos, & Elinson, 1991). Challenges to the progression of sexual health care range from a significant lack of sexual education for most ‘would be’ medical providers, a lack of adequate sexual education in medical school and residency, a shared ignorance and unease about sexual health between patient and provider, a lack of time (Morreale & Arfken, 2010; Foley, Wittmann, & Balon, 2010) and a complex set of biopsychosocial issues playing into a person’s sexual health and sexual satisfaction (Geraci, 2010). What role does integrated and collaborative care play in overcoming these challenges? How can medical and mental health providers working in tandem create small ripples of change that may lead to larger changes in our current rates of STIs, teenage pregnancy rates, and reports of relational discord?

We propose that integrated care and intensive collaboration between providers should be the rule rather than the exception when addressing sexual health. Providers can work together to: screen for sexual concerns (Are you currently sexually active? Are your partners men or women? Are you satisfied with your sexual life? How can I be helpful to address any sexual or relational problems you are having?); provide education on most common problems (desire, premature ejaculation, performance anxiety, erectile dysfunction, etc.); and frame intimacy/sexuality as part of a larger relational and cultural picture (How did what your parents or culture tell you about sex influence your current preferences?).

Due to the biopsychosocial nature of sex, it requires multiple providers who are wearing "different hats.” For instance, a patient with erectile dysfunction needs a thorough evaluation of current medical concerns and medications, psychiatric comorbidities, automatic thought prior and during sexual activity, and current relational satisfaction. Patients who are parents of young children also need our guidance providing age appropriate sex education to their children. Research shows that youth need 100 one minute conversations about sexuality versus one 100 minute conversation (Martino, MN, Corona, DE, & MA, 2008). The vast majority of our patients grew up in homes that were silent and often reactive to sexual curiosity. This leads to parents of young children who are unaware of how sexual curiosity is expressed by children and ill-equipped to provide ongoing sex education. This anxiety often leads to repeating the cycle, becoming mostly silent and reactive to the sexual interest of their children.

In our opinion, integrated care delivered by systemically minded professionals is an ideal place to facilitate this dialogue. In other words, let’s talk about sex with our patients…they want us to!


Kenny Phelps
Kenneth Phelps, Ph.D., LMFT is an Assistant Clinical Professor in the Department of Neuropsychiatry and Behavioral Science at the University of South Carolina School of Medicine. He is a member ofthe Collaborative Family Healthcare Association (CFHA)and Co-Chair of the Membership Committee. He is also a member ofthe American Association of Sexuality Educators, Counselors, and Therapists (AASECT) and working toward Certification as a Sex Therapist. Contact info:
Tina Schermer Sellers
Tina Schermer Sellers, Ph.Dc., LMFT, the director of the Medical Family Therapy Post-graduate Certificate Program in the Department of Marriage and Family Therapy at Seattle Pacific University. She has been a member ofthe Collaborative Family Healthcare Association (CFHA)since 1993, is a past board member and is currently on the CFHA Advisory Board. She is also a Certified Sex Therapist with the American Association of Sexuality Educators, Counselors, and Therapists (AASECT). Contact info:;


Foley, S., Wittmann, D., & Balon, R. (2010). A Multipdisciplinary Approach to Sexual Dysfunction in Medical School Education. Academic Psychiatry, 386-389.

Gemson, D., Colombotos, J., & Elinson, J. (1991). Acquired immunodefiniency syndrom prevention: knowledge, attitudes, and practices of primary care physicians. Archives of Internal Medicine, 1102-1108.

Geraci, R. (2010). Sex in the Fifties. Washington, DC: AARP.

Haeberle, E. (1983). Education and Treatment in Human Sexuality: The Training of Health Professionals Report of a WHO Meeting. In Workbook Part 1 for Associate in Sex Education and Clinical Sexology Certificate. Exodus Trust.

Lewis, C., & H, F. (1987). The sexual history taking and counseling practices of primary care physicians. Western Journal of Medicine, 165-167.

Martino, S., MN, E., Corona, R., DE, K., & MA, S. (2008). Beyond the "big talk": the roles of breadth and repetition in parent-adolescent communication about sexual topics. Pediatrics.

Morreale, M., & Arfken, R. (2010). Survey of Sexual Education Among Residents From Different Specialities. Academic Psychiatry, 346-348.

Owens, A., & Tepper, M. (2007). Sexual Health - State of Art Treatment and Research. Westport: Praeger.

Reid, R., Coleman, K., Johnson, E., Fishman, P., Hsu, C., Soman, M., et al. (2010). The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout for Providers. Health Affairs, 835-843.

Satcher, D. (2001). The Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior.

Tsimtsiou, X., Hatzimouratidis, K., & Nakopoulou, E. (2006). Predictors ofPphysician' Involvement in Addressing Sexual Health Issues. Journal of Sexual Medicine, 583-588.

Wimberly, Y., Hogben, M., Moore-Ruffin, J., Moore, S., & Fry-Johnson, Y. (2006). Sexual History-Taking Among Primary Care Physicians. Journal of the National Medical Association, 1924-1929.

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Matthew P. Martin says...
Posted Tuesday, November 20, 2012
Very important, often neglected topic. Hard to think of an issue that is more biopsychosocial-spiritually oriented than sexuality. I find that patients are surprised when I begin asking them questions about sex. Some remain shy about the topic but others become very interested in sharing and learning more. Collaboration does seem key as you both mention. However, it may be tempting for some physicians to think that sex belongs on the psychosocial/behavioral health side. Yet I believe that patients are just as willing if not more so to talk about sexuality with physicians than with behavioral health providers. Thoughts?
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Kenneth W. Phelps says...
Posted Tuesday, November 27, 2012
Good points Matt. I often find that the physicians I work with are often able and willing to bring up sexual topics. I really think the key is not relegating the topic to only behavioral health or only medical providers. Instead, working collaboratively is the gold standard with sexual health.
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