THE PROBLEM NOBODY TALKS ABOUT
When sex is going badly, your doctor should be the second to know
There is no area where communication between doctors and patients is more difficult to achieve than in that of sex. Most patients are naturally embarrassed to discuss the most intimate part of their lives with their doctors, but there are occasions when it can be vital to do so. A woman may go to her doctor complaining of tension, irritability, general dissatisfaction with her home life or family, and even physical symptoms such as headaches, backache, constipation or pelvic pain. She may not realize that any or all of these symptoms may be caused by some flaw in the sexual pattern of her life; or she may suspect that this is so but be too shy or ashamed to mention it to her doctor.
Similarly, a man troubled by impotence may feel so inadequate that he daren’t consult a doctor for fear of being ridiculed.
The problem can be compounded by the fact that the doctor may have sexual hang-ups, too. He may be even more embarrassed than his patient. And often he is no better equipped to deal with sexual problems than a priest or a plumber. Studies carried out at the University of Pennsylvania disclosed that 20% of medical students believed a woman must have an orgasm before she could conceive a baby. And another survey, carried out in five medical schools in Philadelphia, turned up the incredible fact that 50% of their students —and 20% of their teachers — believed masturbation caused mental illness.
The new openness with which sex is discussed today should help to dispel some of the harmful ignorance of sexual matters, but the sheer torrent of books and magazine articles on what might
best be called sexual gymnastics may have confused as many people as it has helped. Allegedly Oriental works that suggest you can find nuptial bliss only in a lily pool and novels whose heroes appear to be blessed with the stamina of a mountain ram, and similar instincts, have turnêd many people in on themselves, with unfortunate results. Sex for them becomes an ordeal approached in an atmosphere full of tension. Some women worry themselves into the doctor’s office because they don’t always achieve orgasm with their husbands; and the husbands, in turn, may figure life is over the first time they are unable
to achieve an erection. It is well to remember that people in real life seldom measure up to fictional heroes. And reading a 300page book on sex — even “fully illustrated” — is not likely to turn the average couple into Anthony and Cleopatra, any more than reading a book on Beethoven will teach you how to write a symphony.
I recall one couple coming timidly to my office wondering why they were so abnormal. They were very much in love and had tried hard to achieve a full and happy relationship. After two years of marriage, they appeared to have succeeded, and were quite satisfied with their sexual life. Then out of curiosity they joined the millions who have rushed out to buy one of the latest books on sex. Some of the things it suggested couples should do didn’t seem natural to them. But they didn’t like to think of themselves as “squares.” If something new was going on in the bedrooms of the nation, they felt they ought to try it. So they followed the author’s advice, but found they were not enjoying sex as much as before; in fact, some of the book’s suggestions' were downright repugnant. Finally they decided to come to me, to see how their marriage could be salvaged if they could not adjust to the new thinking. It didn’t take me long to convince them that they were perfectly normal and that they should revert to their “old-fashioned” ways.
Copyright ® 1975 by W. Gifford-Jones Limited. From the book, The Doctor Game, by W. Gifford-Jones, MD, published by McClelland and Stewart.
Intercourse was painful for Mary, not because of an emotional hang-up but because she had an easily remedied tipped uterus
It has been said that sex is 99% above the neck and \% below it. And it is true that most sexual problems have an emotional rather than a physical cause. Everyone knows that too much emotional tension is not good for one’s health. Some patients get stomach ulcers. others tension headaches or high blood pressure. It is not so widely realized that an incompatible bedroom can cause a condition aptly called “pelvic toothache.”
Some doctors dislike this term and say the condition it is supposed to describe just doesn’t exist. They accuse their colleagues of using it as a “breadbasket diagnosis” when they can’t find anything more specific to explain their patients’ symptoms. But those who believe in its existence feel it is a real diagnosis, and that the condition results from pelvic congestion or engorgement of the female organs. It is particularly likely to occur if, in addition. the patient has a tipped uterus so that even under normal circumstances there may be a slight congestion of the pelvic organs.
Regardless of that controversy, few doctors would deny that what goes on in the bedroom can have significant effects on the total well-being of both men and women. That is why patients who are frustrated by their sex life should summon up their courage and confide in their doctor. It may help him (or her) to pinpoint their trouble.
I remember a young couple I shall call John and Mary who came to my office a few months after their marriage. Their problem was simple, but no less distressing for that: Mary always experienced severe pain during intercourse. She had been raised in a strict home and was convinced this was the underlying cause of her trouble. She was not the type of shy, retiring girl you would expect to be embarrassed by sex, and she told me that despite her rigid home life she loved her husband very much and thought she could enjoy sex if it were not for the terrible pain. Could I give her a tranquilizer or some other drug to help her?
When I carried out a pelvic examination, Mary’s problem was obvious. She had a severely tipped uterus which was lying against the end of her vagina. During intercourse it was repeatedly being struck and each time a pain would shoot through her abdomen. The uterus was firmly held in its abnormal position by adhesions resulting from a common condition called endometriosis. Mary
needed surgery to remove the adhesions and restore the uterus to its normal position, but afterward she was free of pain and their sexual life became normal and enjoyable.
It is not only during the early stages of marriage that patients encounter sexual difficulties that doctors may be able to resolve by simple medical treatments. The bodily changes that occur toward the end of a woman’s childbearing years can also cause physical problems that may be mistaken for emotional ones. Martha was a 60-year-old woman who had been a widow for 10 years. She had reconciled herself to a lonely life when.
on a trip to Florida, she met Charlie, a lively and good-humored 70-year-old. Within a few months they were married, and Martha soon realized that Charlie was much younger sexually than she had thought. But she experienced a good deal of pain every time they had intercourse. She knew how lucky she was to have found Charlie, though, so she was putting up with the pain.
Luckily, Martha went for a routine checkup a few months after their marriage. She was surprised when, during the examination, her doctor asked her, “Do you find intercourse painful?” She was embarrassed to discuss it but wisely confessed that yes, she had been having problems. The doctor explained that she was suffering from a common condition known as “senile vaginitis.” resulting from her lack of the female hormone estrogen. He gave her an estrogen cream to be used nightly, which soon restored the vagina to its former healthy state, and then put her on a course of daily estrogen tablets to keep the condition from recurring.
Estrogen has been called the hormone that makes a woman a woman. It is produced by the ovaries during the first two weeks of the menstrual cycle and among the many things it does is to thicken the lining of the uterus to prepare it for the arrival of the fertilized egg. With the onset of the menopause and the end of a woman’s childbearing years, the ovaries decrease their production of estrogen. This can sometimes have unfortunate results for the woman, since another of the functions of estrogen is to keep the vaginal lining thick and healthy. When the body fails to produce enough estrogen, the delicate lining of the vagina becomes thin and small sores may appear, making intercourse painful. It is understandable that women may shy away from sex under such circumstances, but the condition is entirely physical, not mental. And it is easily corrected in as little as a week by the nightly insertion of estrogen cream. Unfortunately, not all doctors agree on the wisdom of pre-
Fears of impotence haunt middle age
scribing estrogen, and some of the controversy has lapped over into the lay world, so that some women fail to take advantage of a simple and harmless remedy for the ills of the menopause.
Reports have said that hormones cause cancer in mice. It is rarely emphasized that massive dosages are used, over a prolonged period of time — enormous amounts that would never be prescribed for humans. Female hormones such as estrogen have never been known to cause cancer. In fact, one study by a leading university showed that women who were taking estrogen had less chance of getting breast or pelvic cancer than those who weren’t.
It is a tragedy that so many women still experience physical and mental difficulties during the menopause, since they can so easily be treated with estrogen. No such easy treatment is available for men. who may experience equally disturbing difficulties during their middle years. Some authorities deny there is such a thing as the male menopause. Certainly men do not experience the horrible hot flush and chills that beset some women; nor do their bodies undergo hormonal changes; their glands go on producing the male hormone, testosterone, in adequate quantities well into their seventies. But the psychological difficulties that can occur during the “depression forties” are no less real for that.
Many men advancing into middle age see their former goals evaporating. Life is passing them by. And then comes the coup de grace; one night they are unable to get an erection. Their single failure was probably the result of unusual fatigue, too many worries or too much alcohol. No matter. Their fear of impotence is such that it begins to dominate their thoughts. Perhaps they blame their wives. Some merely buy themselves a hairpiece or suddenly arrive home in a flashy sports car, but others seem to have to prove their virility. The younger woman enters the scenario and momentarily the mid-life blues are over. In fact, some men are Such tigers with their mistresses they do become impotent with their wives. This merely substantiates their conviction that their wives are to blame; they themselves are a long way from the end of the road. Unfortunately, the magic is usually short-lived. Heartache and broken marriages last longer than the bloom on a peach.
Since what ails these men is lost hopes, not lost hormones, there is little a doctor can do for them except urge them to be realistic. You can’t be young for-
ever but you can be practical for as long as you live. Impotence almost always has a psychological rather than physical origin. But there is one organ in the man’s reproductive apparatus that earns many marks as a cause of the fear that can lead to impotence: the prostate, a gland about an inch and a half across which surrounds the neck of the bladder and the beginning of the urethra which is the tube that conducts urine from the bladder. The prostate’s main function is to produce the fluid that carries the sperm to the outside at the time of ejaculation. And men fear any disturbance in its operation as some women fear the menopause or a hysterectomy.
Jeff, a 32-year-old engineer, had always enjoyed good sexual relations with his wife. His company received a lucrative foreign contract and Jeff found himself posted to South America for a sixmonth stint. It was the first time he had been separated from his wife and he missed her, and to take his mind off his loneliness he threw himself into his work with even more than his usual energy.
After a couple of months he developed a dull, burning sensation between his legs and found that while he was making more frequent trips to the toilet he seemed to have difficulty urinating. He went to the doctor, who told him he had prostatitis, a common condition among men separated from their wives for any length of time, in which the prostate becomes inflamed and congested, either from infection or lack of regular intercourse. The doctor gave Jeff a course of prostatic massage, told him to take a sitz bath daily and avoid alcohol, and assured him all would be well on his return home.
Unfortunately, it wasn’t. The word “prostatitis” had set off a chain reaction in Jeffs mind. How' w'ould it affect his virility? Would he be able to get an erection? What would his wife think if she found out about it? Would she think he had been playing around and had picked up some disease? Of course, the predictable happened: he w-as unable to get an erection the night he arrived home. The first time he was able to plead overtiredness from the long journey. But with the seed of doubt planted. Jeff failed again the next night. And now he really began to think the game was over.
Fortunately. Jane had read an article which explained that sailors, priests and other men deprived of intercourse for long periods develop prostate trouble and she was soon able to extract Jeffs secret from him. This open communication and Jane’s sympathetic attitude cured Jeff the same night, and getting back to a regular sexual pattern cleared up his prostatitis in a few' weeks.
Removal of the prostate gland does not mean an end to a man’s sexual potency
Most urologists believe that common prostatitis has relatively little effect on sexual function. Cases have been cited in which men who believed they had prostatitis began to experience sexual difficulties, yet on examination were found not to have the disease at all.
But the effect on a man’s morale can be catastrophic if he learns he needs a prostatectomy, the removal of the prostate by surgery. This can be necessary, for instance, when cancer develops, or the gland becomes unduly enlarged. One reason men dread this operation so much is that it is known as “the old man’s operation.” They fear it is the end of the line, and communication with the doctor, which can be difficult enough at the best of times, becomes virtually impossible when a man believes his virility is involved. Also, the surgeon may be reluctant to assure a patient that all will be well with his sexual performance after the operation, since so much of sex is controlled above the neck. Then, if the surgeon hedges when the patient asks if it means the end of his sex life, a little doubt is sown — and doubt is the seed of impotence.
Males who are about to have a prostatectomy must realize this important point. If they do, there is every chance they will be just as successful sexually after the operation as before it. They should be prepared, however, for one difference that may occur. The prostatectomy is usually done because the gland has become so enlarged that it has partially blocked the outflow of urine. Removing the gland or part of it relaxes and opens up the entrance to the bladder. Normally, when a man ejaculates, the bladder opening clamps down, forcing the prostatic fluid and sperm to the outside via the penis. After a prostatectomy, the bladder cannot close itself off efficiently, so that a reverse orgasm may occur, in which the ejaculatory discharge flows into the bladder rather than to the outside. This is harmless, and tht feeling of orgasm is not affected, so men should not let themselves worry about it. They should remember that even after a prostatectomy the testicles go on producing sex hormones and sperm.
I hope I have shown that there are times when it is imperative for a patient to talk sex in the doctor’s office. What should your approach be on these occasions? First, be realistic about your doctor. Do you feel comfortable with him? Does he spend enough time with you? Does he have a “down to earth” manner? If the answer to these questions is “yes,” call up and ask to see him for a
checkup. If you suspect a physical reason for your sexual problem, this may provide the answer. If not, tell the doctor you have a sexual problem you would like to discuss with someone. Ask him if he would ever have the time to talk it over with you, or would he prefer to refer you to someone else. This approach lets your doctor off the hook if sex is an area of medicine he prefers to leave alone.
There’s a good chance he will give you a return appointment which will permit enough time to explore what is wrong. Or he may sit back and ask you to tell him the trouble then and there. Be prepared for this and explain your problem as briefly as possible. If yon find it difficult to talk about it directly, take the time before your appointment to write down a short paragraph outlining the problem. This will give your doctor a quick, bird’s-eye view of the situation and enable him to ask you questions. You may well find that answering questions about your difficulties comes easier than spelling them out to the doctor from scratch, no matter how good a listener he is. Be prepared, though, to hear him say he wants to send you to a urologist, a gynecologist or a marriage counselor — and take his advice if he does so.
There may be occasions when you
yourself will decide it is no good going to your usual doctor with a sexual problem and that you ought to make a temporary change. You may never feel completely at ease with him. even when discussing something far removed from sex. Or you may find yourself in quite the opposite situation. You may have one of the finest general practitioners in town. He has always been a great friend and counselor. And now it has reached the point where you almost know one another too well. In this case, you may find it easier to discuss intimate matters with a complete stranger and it may be a good idea to change doctors temporarily. Men may decide to seek out a urologist. women a gynecologist. Or either sex may feel the need for psychiatric counseling, without knowing how to go about getting it.
If you live in a large metropolitan area, put in a call to the nearest university hospital and ask for the secretary of the head of the department of psychiatry. Tell her you are anxious to have some sex counseling and could she refer you to a reliable doctor or marriage counselor. You can use the same approach with any large hospital. Patients in a small town may not find it too easy to obtain help, but it is worth writing to or calling the nearest large hospital, even if it means traveling a long distance for an assessment of your problem. With sexual difficulties, as with other medical matters, it always pays to find the best advice, even at the cost of some personal inconvenience.
There is another situation that calls for a change of doctors. Let’s say you are a woman in your middle years and you are bothered by hot flushes, occasional cold spells, pins-and-needles sensations in your hands, difficulty in sleeping, and perhaps painful intercourse. But your doctor just smiles and says, “It’s only the menopause. Just grin and bear it for another year or so and everything will settle down.” You can ask him whether you wouldn't benefit from a course of estrogen treatment, but he will probably reply: “No, I don’t believe in estrogen. It’s one of those passing fancies. You’re better to let nature take its course.”
It is then time to try someone else. Don’t try to change your own doctor’s mind; it won’t work. Seek out another doctor, but before making your appointment ask his nurse if he prescribes estrogen, because you don’t want to waste his time if he opposes it. Your chances will be better if you consult a gynecologist, because more gynecologists than general practitioners are convinced of the value of estrogen treatment. The point is to keep trying; you will always find a doctor who does prescribe estrogen and your troubles will very likely be a thing of the past.