What can I expect when seeking help for female sexual problems?

How might my healthcare provider respond?

Negative experiences when seeking help for female sexual dysfunction (FSD) are unfortunately common. Remember, however, that these negative experiences are often the result of the discomfort, lack of knowledge, and systemic barriers faced by both women and their healthcare providers, and that this web-based guide provides you many tools to combat these barriers. I will let you know a range of responses you could experience and how you can respond.

There are few studies investigating women’s experiences seeking help for sexual dysfunction. In one study, many help-seeking women experienced frustration, anxiety, disgust, shame, and devaluation, while significantly fewer women experienced validation, hope, relief, assurance, optimism, confidence, and satisfaction. About half said that that their doctor was willing to hear their concerns, that their doctor listened carefully to them, and that their doctor was not reluctant to address and treat their issues, while few women felt that their doctor appreciated the importance of their concern, tried to reduce their nervousness, or asked if they had ever received mental health care. Some women have been told that these problems are to be expected with aging, parenting, and/or marriage. This study found that many doctors did not adequately assess women’s psychological history or relationship quality, perform a thorough physical examination and appropriate medical tests, make a diagnosis, develop a treatment plan, or follow up with them.

In another study, many women had doctors who seemed disinterested, rushed, impersonal, and embarrassed; however, most women said that their doctor seemed concerned, cared about them, and treated them professionally. Other sources have confirmed that it is common for women to be told that their problems are all in their heads, that they just need to relax, that they should have a glass of wine, that desire/arousal/orgasms are not necessary for women, or that they do not need treatment because they do not have a sexual partner. Some healthcare providers have rejected the materials that women brought in to help them learn about their conditions.

Recent research on healthcare experiences of people with PGAD/GPD and PSSD has shone light on other experiences of help-seeking for FSD. People with PGAD/GPD, PVD (provoked vestibulodynia), or PSSD have approached several healthcare providers, sometimes six or more. Two thirds of PGAD/GPD patients received a formal diagnosis, it took over a year for 20% to receive their diagnosis, and one third of women with PVD waited three or more years for a diagnosis. Many women had healthcare providers who weren’t knowledgeable or understanding about PGAD/GPD or PSSD, who responded uncomfortably (e.g., avoiding eye contact) or inappropriately (e.g., laughing), and who didn’t acknowledge the distress and harm that these conditions can cause.

Given that women’s negative experiences seeking help for PGAD/GPD seem to be associated with a lack of research on the condition, it is expected that women will have similar or worse help-seeking experiences when seeking help for conditions for which there is a similar lack of research. Indeed, Queens Sex Lab, which has done significant research on PGAD/GPD, shared a blog which shares an anecdote about healthcare provider’s dismissiveness when a woman sought help for PSSD.

It is unacceptable for healthcare providers to be dismissive of women’s sexual health concerns. As some women believed that asking for referrals or reading about PGAD/GPD on their own was a useful help-seeking strategy, I recommend this as a proactive strategy. Ask for a referral (to one of the healthcare providers you’ve read about) or consider changing healthcare providers if you don’t feel that your healthcare provider is invested in helping you.

If your provider lacks knowledge but appears to take your concerns seriously and appears interested in reading the material(s) you brought to inform them, consider staying with them for now (and accept their referrals if they seem reasonable). Because some conditions are less common (e.g., PGAD/GPD, PSSD, FOIS), healthcare providers may not be familiar with the condition, but they can learn.

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Why aren’t some healthcare providers good at helping?

You may be surprised to find that healthcare providers face barriers to help-providing that are similar to the barriers women face when seeking help.

They may avoid the topic

Healthcare professionals may not bring up the topic of sexual functioning with patients for several reasons, including that they may expect patients to be assertive and bring up complaints, they are embarrassed, or they do not want to be intrusive. Physicians are less likely to have these discussions about sexual health when patients differ from them in gender, age, marital status, education, race, or ethnicity. Biases such as ageism may also prevent healthcare providers from discussing sexuality and screening older women for sexual dysfunctions. Doctors may also simply be dismissive of women’s concerns or believe that sexual function problems are not serious. A healthcare provider’s communication skills can also be a barrier.

The main way to combat these barriers is to be proactive by bringing up your concerns instead of waiting for your healthcare provider to ask. You may be uncomfortable, but you can prepare yourself by reading the webpage on How do I seek help?.

They probably had inadequate training

Not only did your healthcare providers probably have the same poor sex ed that you did throughout primary and secondary school, they also usually had poor or absent sexual health education in their healthcare training programs. Both medical professionals and mental healthcare professionals face this barrier. It’s also likely that many medical professionals are unaware of what treatment options are available for FSD. Further, healthcare providers may not know where to refer you for your concerns or there may be limited referral options in your area.

Because of the lack of sexual health training, mental healthcare professionals rely on consultation and referral when faced with clients with sexual concerns. Sex positivity is also missing in counsellor training, inhibiting counsellors’ willingness to bring up sexual topics, their willingness to treat sexual problems, and their clients’ comfort with disclosing sexual concerns. These problems, caused by a lack of sex positivity training, are likely faced by medical professionals as well.

To combat these barriers, you can educate yourself on healthy sexual function, read to understand how your symptoms match sexual dysfunction definitions (When should I seek help?), and read (and ask your provider) about possible treatment options.

They face systemic barriers

Like patients, physicians and OB/GYNs often state that limited time with patients prevents discussions on sexual health. A shortage of sex therapists and psychologists can cause long waiting times, and medical providers may be unsure of therapy options. A lack of research on women’s sexual dysfunctions and treatments means that healthcare providers cannot even recommend many evidence-based treatments. One consequence of this lack of research is the fact that, in the United States, significantly fewer drugs have been approved for premenopausal FSDs than for male sexual dysfunctions. Postmenopausal women face a different issue: misinformation claiming that hormone therapy is dangerous for menopausal women (i.e., causes cancer) has prevented many doctors from prescribing treatments that would benefit these women.

To combat these barriers, you can be proactive by educating yourself about healthy sexual function, maximize your time with your provider by preparing for the appointment (check out How do I seek help?, and read (and ask your provider) about possible treatment options.

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What are possible referral options?

Your family doctor is likely not a sexual medicine specialist (and that’s a good thing). Unless you specifically seek out someone with expertise in sexual health, you are unlikely to see someone with that expertise. Sometimes, the sexual health expert you seek out still needs to refer you to someone else. You may also need referrals for diagnostic tests. Hopefully, I can give you some idea of what to expect with referrals.

Your healthcare provider may refer you for diagnostic tests, such as MRI scans and CT scans. If you are referred for an MRI scan or CT scan through Alberta Health Care, expect to wait (and make sure to keep your appointment because you don’t want to wait even longer). Wait times for MRI scans can be long (39 to 53 weeks), as can those for CT scans (14 to 34 weeks). You may be able to get these services earlier if you are willing to pay for an MRI or CT scan at a private facility (e.g., the University of Lethbridge has the most powerful MRI in the region for a fee). Referrals for other services (e.g., vaginal interventions, pelvic interventions) can also take a long time (14 to 53 weeks), though it is not clear what these interventions are or how relevant they are to FSD diagnosis and treatment.

You may be referred for pelvic floor physiotherapy—either to rule out pelvic floor problems or to treat them. Pelvic floor physiotherapy is unlikely to be covered by Alberta Health Care, but it may be covered by your personal health insurance. It’s a good idea to look up pelvic floor physiotherapists before your appointment so you can request the best one for you.

You could be referred to counselling (e.g., couples counselling, psychotherapy, sex therapy). Outside of Alberta Health Care, you are free to choose whichever provider you prefer, at your own cost (potentially covered by your personal health insurance). Some clinics (e.g., the Haig Clinic in Lethbridge) have free short-term counselling available, but you will not get to pick your counsellor’s specialty. Alberta Health Care does offer some mental health services for free, and you can call them yourself or have your medical practitioner refer you.

You may also be expected to travel for your referral, especially if you live in a rural area. For example, Lethbridge has a pelvic floor clinic, but women can only be referred there for incontinence or pelvic organ prolapse, not for sexual pain, which is a common symptom of pelvic floor dysfunction. However, the pelvic floor clinic in Calgary may accept women with a more broad range of symptoms.

You may not qualify for services that are available. A friend of mine was refused referral to Lethbridge’s aforementioned pelvic floor clinic for sexual pain because they only accept referrals for incontinence or pelvic organ prolapse. Another friend was refused a referral to a gynecologist for sexual pain because she was not pregnant. You may also struggle to find a urologist who can help you. Members of Calgary’s Southern Alberta Institute of Urology or Edmonton’s Alberta Urology Institute appear to primarily treat male sexual problems and all of their doctors appear to be men. However, if you think you may be referred to a urologist, I would recommend contacting an individual doctor (just click Our Surgeons or Our Physicians and then click any doctor’s name) and asking if anyone has any training or expertise with FSDs or your specific symptoms. You can then ask your doctor for the best urology referral or ask for a different type of referral. Dr. Gary Gray has listed female urology as a sub-specialty interest, so he may be familiar with FSDs.

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What are possible treatment options?

As FSDs are so varied and each one has many different possible causes, the treatment options that are relevant to you depend on your presenting concern, what is available to you in your area, what you can afford, and what you are willing to do. Your healthcare provider may recommend treatment of physical causes, education, couples counselling, psychotherapy, and/or sex therapy.

A variety of treatment options exist for FSD (though women may not necessarily receive the treatments that are available). The most common medical treatments for women’s sexual function problems are prescription hormone injections, topical creams, or gels; changing birth control method or medication; and starting, changing, or ending hormone replacement therapy. Healthcare providers may recommend sildenafil/Viagra (despite a lack of evidence), antidepressants (despite the fact that they can cause sexual dysfunctions), and herbal supplements infrequently. OB/GYNs commonly recommend education and practical tips, the use of dilators and/or dildos, and self-help resources such as literature, videos, and sex shops. OB/GYNs use other approaches less frequently, including physical therapy, hypnosis, exercise, homeopathic medicine, and permission-giving for self-exploration. Doctors can recommend the Eros Therapy Device to help increase blood flow to the female genitals, though this device may also be purchasable without a prescription. Women are infrequently referred to other professionals or treated by the OB/GYN from whom they initially sought help. Few women receive nondrug therapy such as marriage therapy, sex therapy, counselling, or behaviour therapy, and many women do not receive any treatment for their problems. Research has also demonstrated that some natural products and treatments may be effective in treating FSD (particularly in postmenopausal women), including L-arginine, ginseng, maca, DHEA and DHEAS, black cohosh (cimicifuga racemosa), chasteberry fruit (vitex agnus-castus), acupuncture, and yoga. See the table below for a list of possible treatment options and important considerations for specific DSM-5 FSD diagnoses.

You might be prescribed ineffective treatments (e.g., antibiotics or antifungal medications for pain). Sometimes this is because a healthcare provider wants to try safer, cheaper, or more common treatments first; sometimes it is because they do not know what else to do; and sometimes it is because they do not believe their patients. It may be difficult for you to tell the difference. I recommend that you trust your instincts, and lean toward trying their treatments. We are experts on ourselves, but medical providers have much more knowledge about bodies than we have. As long as the treatment they are recommending does not cause harm, it may be a useful diagnostic tool (i.e., some conditions can now be ruled out, as your symptoms did not respond to the treatment).

Adapted from Thomas & Thurston (2016) and Dording & Sangermano (2018)

Note that this list is by no means complete. It does not include possible treatments for all kinds of less common causes of sexual dysfunctions (e.g., Tarlov cysts), but it does include many common treatments.

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