When is sexual health not sexual health

[brightlywoven]

A while ago I was studying for my next exam, reading the endocrinology module (ie hormones). There was 2 pages on the diagnosis and management of hirsuitism (hairiness) in women (including an entire page on grading womens' hairiness by counting hairs), which concluded that although it occasionally implied an underlying medical disorder, the problem was 'largely a social one' and 'treatment was largely unsatisfactory'.

Then there was 3 pages on male sexual dysfunction. This went on at length about how many different medical problems might contribute to erectile dysfunction, and how important it was therefore to seek out these symptoms, as they may not be volunteered. This was not to be done in order to diagnose/treat the underlying condition, but in order to improve the symptoms of the patient.

While a small number of the conditions listed were specific to men (eg radical prostate surgery), most were common diseases which impede blood flow - diabetes, hypertension, high cholesterol, smoking - or those that damage nerves - lumbar spine disease, parkinsons. None of these (very common) conditions have a major gender disparity.  Not once did my textbook mention that diminished blood flow to the arteries of the pelvis, or diminished function of pelvic nerves might impede the sexual dysfunction of the other half of the population.

Then today I was doing the 'smear clinic' (as pleasant as it sounds). 40% of our patients mentioned having pain on intercourse so significant they had stopped having sex in their relationships. This only came up in the context of trying to assess whether speculum insertion was likely to be difficult/uncomfortable.

Why is there a fortune to be made in sustaining the sexual function of one half of the heterosexual couple, and a society/profession wide blind spot over the other half? (This is of course, not even beginning to address the massive heteronormativity of what we do.)

And why is sexual health for women largely about preventing disease and managing fertility, while sexual health for men is about disease and orgasms?

Comments

[vampire-kitten.livejournal.com]

Silly girl, women don't enjoy sex. We only do it to keep men happy and make many babies.

[dr-biscuit.livejournal.com]

Sigh. I know you're right. I'll stop asking stupid questions now..

[vampire-kitten.livejournal.com]

Exactly! Why are you talking when you should be having babies? Next you'll be voting!

Go please your husband in a socially approved mannor NOW (but don't enjoy it)

[sebastienne.livejournal.com]

....40%.

40%!

I just.. wow. In my sheltered little corner of the world full of sexually liberated women.. this is a sobering read. Thank you.

[dr-biscuit.livejournal.com]

granted, where n=5 the p value is probably pretty high, but yeah, it was pretty staggering. Especially to talk to a 25 year old woman who doesn't particularly want to seek advice about why she finds sex so painful since 'her relationship is really past that stage, y'know'!

The area I'm working is reasonably 'deprived' in economic terms, and I wonder if that plays a role. It's a bit miserable if being poor means you're less likely to be able to enjoy one of the few free entertainments!

[emily-shore.livejournal.com]

Especially to talk to a 25 year old woman who doesn't particularly want to seek advice about why she finds sex so painful since 'her relationship is really past that stage, y'know'!

Oh dear me. *shakes head*

[dr-biscuit.livejournal.com]

Yep. Apparently after 25 you stop wanting to have sex. Ever.

[overconvergent.livejournal.com]

This is news to me!

[rustica.livejournal.com]

There is a school of thought that says that doctors have a vested interest in ensuring that their payments for maternity and pediatric care continue; and that that is why health care for women revolves around women getting and being pregnant. I say here that I do not believe this :). But I *can* see how other women have drawn this conclusion.

IME, doctors will say, "You can't have X (usually sterilisation, in my case) but you can have Y (IUD, injection etc)". It's nurses who are the ones who have done all that they could to ridicule and dismiss my concerns about the effectiveness of the mini-pill. And then they get really upset when you mention how difficult it will be to rearrange your work schedule for the abortion... *evil snicker*. Not that I *wanted* to be such a dick, but when shocking people is the only way of getting access to sensible information and services *G*. And even then, I don't think it was a conspiracy, just a bunch of stupid women who had been given power in excess of either their intelligence or their capacity to imagine that other peoples' lives might follow a different course to their own.

I have a crazy belief that medicine owes its origins to women caring for other women during pregnancy/childbirth right back to the time of the dinosaurs(!), so I'm not wholly surprised that women's health care revolves around it. (And I studied medieval history, so I have lots of figures and stories to reinforce my already-existing tocophobia!) Preganany and childbirth is a big thing, and I can see why that is.

I certainly don't think male impotence is a trivial matter, either for man or for his partner. But I could cry for the 40% of women you talk about. I can only assume that their issues get dwarfed by the bigger (though hopefully shorter-term) issues directly related to pregnancy. How terribly, terribly sad for them. How can a relationship even survive if sex causes that much pain to one person??

Had these women already had children - was it a post-childbirth problem? - or were they nulliparious? I have no axe to grind here, just lots of self-interest!

[dr-biscuit.livejournal.com]

I like your theories.

I know the Royal Women's Hospital largely became what it is today after an 'epidemic' of gas gangrene of the uterus, which arose from 'septic abortions' being performed in an unregulated way. So I like to think that at least some of the obs/gynae aspect of women's health had its origins in good things for women.

(there is also a theory that the part of the hippocratic oath which mentions not helping women secure abortions was a reference to the fact that this was the provence of midwives, who were specialists in such things)

Nurse clinics are a difficult thing. (I'm sitting in a lot of them this week - 6?). And in this practice they take on a lot of protocol driven but reasonably simple tasks - doing pap smears, helping women choose contraceptive options, baby immunisations, stop smoking advice, weight loss advice, asthma checks, diabetes checks. It's useful, but I think protocol driven encounters have their limits (like not being able to cope with a nulliparous woman wanting tubal steri).

I absolutely agree that male impotence is not trivial. Sex is relationship glue, and excellent recreation. Of the 40% (and I have to admit, this was 2 of 5, not some wonderfully high n), 1 was 8 months post caesarean (age 40), and one was nulliparous (age 25). So the events I would expect to be at 'fault' (vaginal delivery trauma/stitching) were excluded. I wonder if the younger woman had a degree of endometriosis.

And here is maybe where a good GP or practice nurse could be helpful. Particularly if she's a she, it's maybe more acceptable to the average woman to talk about how she could get better sex with another woman than with a middle aged guy.
(Though middle aged guys have their uses. I could see from the distraught look on one guy's face today that he'd be a lot happier if I disappeared while someone else looked at his testicle.)

[rustica.livejournal.com]

"I could see from the distraught look on one guy's face today that he'd be a lot happier if I disappeared while someone else looked at his testicle."

Lol - in my old age I have become much better at saying, "Actually, yes, I do mind having an observer in the room" when it does bother me (which it doesn't always, but on the days that it does, it does). But I guess it takes people different lengths of time before they become difficult patients like me :)

"like not being able to cope with a nulliparous woman wanting tubal steri"

I am outside the definition of average, I know! But I still think a nurse should be able to give information on better forms of contraception than ones with about a 1:10 failure rate per year in the field (as it were). Even women who want children eventually don't always want them *now*!

On a (slightly) related note, I was absurdly pleased to see an advertising hoarding promoting LARC. Ah, gone are the days when the pill and the condom were the only options anyone would discuss with a woman who didn't already have 2 kids :D

[vescoiya.livejournal.com]

Well ouch. Those are not good stats.

Clearly the world needs more doctors like you who think about these things.

[dr-biscuit.livejournal.com]

Yeah, but it doesn't seem like such a hard call, does it? Does it????

[vescoiya.livejournal.com]

Plenty of evidence to suggest people will do the personally disadvantageous thing if it allows them to keep up social prejudices. Social blindspots are *really* large endemic things. It shouldn't be a hard call, and yet somehow it gets twisted into one.

And yeah no one should have to suffer through sex unless that's their thing.

[dr-biscuit.livejournal.com]

Yeah, that sounds like the kind of crappy thing people would do.

yeah no one should have to suffer through sex unless that's their thing.
*chortle* I did have this moment where I was trying to emphasise to this patient that help could be there for her. 'Because,' I said authoratively, 'it's important'. Paused, and thought - what if she just doesn't like sex? So hurriedly added 'if it's bothering you'

[vescoiya.livejournal.com]

Well reading the description I did wonder if they were maybe asexual which ties into your maybe not liking sex theory. Even if that's true it certainly can't hurt for them to know that help is available should they want it.

[emily-shore.livejournal.com]

And yeah no one should have to suffer through sex unless that's their thing.

Classic.

*uses Brian icon*

[(Anonymous)]

As a 30 year old woman diagnosed with both vaginismus and vestibulodynia at age 23: oh god, I hear you on this.

Smears are not quite so necessary for me because I've never successfully had penetrative sex, but still a source of fear. I just got a letter from my new GP saying it's that time again, and I'm really not looking forward to it! I will have to explain the whole damn thing over again (never a good experience), and I don't even know if that will get me out of having the smear. I guess I'll find out soon...

I have had such mixed treatment from the NHS, and it's not strictly gender-related: some wonderfully sympathetic male doctors, and some blunt and unkind female doctors who made me cry.

[I am on your flist, but I'm very selective about revealing such personal details non-anonymously. I'm sure you understand...]

[dr-biscuit.livejournal.com]

Thank you for such a personal reply. Even anonymously, I applaud your bravery.

I really don't believe it's only the gender of doctors/nurses that determines how good the care is you get. As women it's fully possible for us to accept the doctrine (women get diseased bits, men get sexual dysfunction) and 'subject' other women to it.

I hope your next battle is more of a joint endeavour than a fight.

[shehasathree]

I really don't believe it's only the gender of doctors/nurses that determines how good the care is you get.

gender sensitivity is much more important - and for that it's neither necessary nor sufficient to be a woman, in my opinion!

[vampire-kitten.livejournal.com]

As women it's fully possible for us to accept the doctrine (women get diseased bits, men get sexual dysfunction) and 'subject' other women to it.

And I think more easier for women to fall prey to "I didn't have a problem with this, and I'm told by society it is a myth, hence no-one ever has a problem with this" and end up even less sympathetic than men.

The first female doctor I had told me that period pains where a myth, that she had never experienced them and so I must be just imagining them. (Which was weird, because you'd think when pre-teens come in complaining of v.v. lots of pain in their abdomen and you don't believe in period pains you'd assume there was something actually wrong and investigate it).

[dr-biscuit.livejournal.com]

Ahah, yes, because women may have evidence of absence based on a subject sample of 1, whereas men have absence of evidence.

[shehasathree]

thank-you for making this post.

i'm currently taking a subject in the Key Centre for Women's Health as part of my Gender studies Honours (lucky, luck me! *g*) - "Gender & Health: Critical Perspectives" - so i've been thinking quite a lot about this stuff.

yesterday we had a talk from Philomena Horsley on the history of the women's Health movement in Australia, and she mentioned this research. prostate surgery? sure, we've gotta be really careful not to screw up any nerves down there! surgery on a woman? cut away, there's nothing important down there! grrr.

[dr-biscuit.livejournal.com]

Have you read 'sex and suffering'? I've only dipped into bits, but it's a very good historical look at women's health movement in Victoria.

There is a joke which goes like this.
Q. What are the three operations that gynaecologists do?
A. Cut the left ureter, cut the right ureter, cut both ureters.

I found gynae surgery deeply discomforting, at least partly because the attitude of the surgeons seemed to be so very brutal. Much more so than the attitude in general surgery. There was this sort of pervasive anger, as though these women were being annoying for presenting with their prolapses, incontinence and pelvic pain. As for the ones having babies, well they got themselves into this situation, didn't they???

All of which is to say - as a profession, we certainly don't seem to see women's sexual function as important or worthy of clinical time. But maybe this is at least partly a reflection of the way society views that same function. More women need to be lining up for their version of the little blue pill, dammit!

[shehasathree]

eep! that's quite disturbing, isn't it?

i haven't read Sex and Suffering yet, but i keep coming across it in the library (and once or twice in the bookshop, and it always jumps out at me from the shelves now). i'd definitely like to read it at some point... maybe in the Winter holidays...

[foreverdirt.livejournal.com]

Grah. Thank you for writing about this. I have no brain right now, but I do have some rage.

[dr-biscuit.livejournal.com]

Thank you for you rage :)

Sexual dimorphism ...

[overconvergent.livejournal.com]

why is sexual health for women largely about preventing disease and managing fertility, while sexual health for men is about disease and orgasms?

The lazy answer is probably something to do with the vexed question of external genitalia; where a woman could suffer through "succesful" sex a man just wouldn't be able to perform, but one would hope that medical specialists could get beyond the brute physics of the act and make it actually pleasurable for both parties!

Re: Sexual dimorphism ...

[dr-biscuit.livejournal.com]

In general you may be right. However in this case discomfort was so great to have actually made sex impossible, so the 'brute physics' weren't even sorted!