White Coat Black Art26:30Sex medicine doctors are putting women’s health, and pleasure, first
A small number of Canadian doctors specializing in women’s sexual health is trying to address what they say is a near-total lack of support for those suffering from common problems such as low libido, difficulty achieving orgasm and pain during intercourse.
“In terms of the juxtaposition with men’s sexual functioning, we are behind and it’s really frustrating,” said Dr. Stephanie Finn of Oakville, Ont.
Finn is one of five Canadian doctors trained by the International Society for the Study of Women’s Sexual Health (ISSWSH), based in Burnsville, Minn.
While help for male sexual dysfunction has been widely available since erectile dysfunction drug Viagra burst onto the scene — approved for use in Canada in 1999 — women’s sexual health has remained largely shrouded in secrecy.
“When’s the last time your doctor has asked you about your clitoris? Like never, and that’s fascinating, right? We ask men all the time about their penises and their function, sexual functioning and such,” she told White Coat, Black Art.
“I think that there is generally a lack everywhere of interest in women’s sexual functioning, and I’m happy to say that I think that’s beginning to change.”
Originally a family doctor, Finn found that so many of her female patients needed help with sexual issues that she decided to focus on sexual medicine, opening her clinic about a year ago.
Part of that work is simply teaching women about their bodies, she says.
“It is really common for women to have almost no understanding of their own anatomy,” Finn said.
“I’ve had women who really haven’t a good idea about where their clitoris is. I’ve had people say, ‘Oh, I’ve always wondered,’ and sometimes I’m slightly surprised by that response in women who are in their 50s.”
Finn offers her patients the option of holding a mirror while she gives them a guided tour of their genitalia. Or she’ll use a 3D model to show patients things such as how the clitoris is actually a wishbone-shaped organ, with only the clitoral bulb visible externally.
A study published in the Journal of Sexual Medicine in 2023 found that the bulb has around 10,000 nerve endings. That’s compared to about 7,800 at the tip of the penis, according to a paper published in the same journal in February.
A culture of shame
Some of that knowledge gap and reluctance among women to seek help for sexual-health issues is tied to cultural shame, says Dr. Stephanie Hart from Okotoks, Alta., another ISSWSH-trained family doctor.
“In North America, vaginas are dirty. Like, I actually had somebody say that to me yesterday,” said Hart, who opened her specialized clinic in 2019.
For some women, that’s simply because they are grossed out by bodily fluids, including those that come out of the vagina, she says.
But for others, it’s a morality issue: “You know, ‘sex is shameful.’ That’s a very common attitude that I see people [have]. And kind of unsurprising that people would then have sexual dysfunction when they feel that way about it.”
Despite people’s difficulty talking about their sex lives, these clinics are busy. Hart says she sees 250 new patients every year in her practice, 75 to 80 per cent of them being women, but is referred around 400.
“So every six months, I’m another three months behind.”
Finn said she sees about 15 new patients every week at her Oakville clinic.
Most Canadian women do not have access to a doctor who specializes in sexual health. Existing clinics where women have traditionally sought care for sexual health are focused on contraception and infection, says Hart.
These kinds of clinics refer patients to her when they bring up difficulties like pain during sex or low libido, Hart says, as do specialists such as gynecologists.
Help for low libido
Carolina Jara, 57, says she used to be a very sexual person, but since menopause, her libido has tanked.
“My libido went somewhere. I don’t know, maybe back home,” joked Jara, who is originally from Peru, but lives in Vancouver.
She says she’s worried about how that can impact her relationship with her husband of eight years. And that part is not a laughing matter.
“He still wants it, but I don’t get ignited, I don’t get an orgasm for many years. So it feels more like a duty, more than something that I enjoy.”
There are two medications approved for use in Canada that can be used to increase sexual desire in women: a pill called flibanserin, and a self-injectable called bremelanotide.
Unlike Viagra, which is used on an as-needed basis and acts by increasing blood flow to the penis, both of these drugs impact the brain chemicals that influence mood and sexual appetite. Flibanserin must be taken daily and has been shown to have serious potential side effects.
Critics have argued that libido problems are more a matter of mismatch between the sexual appetites of partners that would be better addressed with relationship counselling.
A non-medical tool for addressing low libido or difficulty achieving orgasm is a class of sex toys sometimes referred to as clitoral suction devices.
“We have wonderful studies actually now showing improved clitoral blood flow and pelvic floor blood flow using these devices,” said Finn. “We know they can make a huge difference for women when they are attempting to achieve orgasm.”
Pain during sex
But sexual-health issues are by no means the exclusive domain of older women, says Finn, whose patients range in age from teenagers to octogenarians.
Talia Steele, 34, suffered for years from pain during sex, stemming from a series of problems that started with a common urinary tract infection.
Eventually she got surgery to address the issues. But all the poking and prodding, and her history of painful sex, has had lasting effects.
“There’s always that bit of anxiety, never being able to be fully in the moment, always in your head about what’s going on,” said Steele, who is married and also lives in Vancouver.
“Even though I don’t have that pain, those feelings and thoughts still enter my brain at times, and it can be challenging to try new things or come out of my comfort zone.”
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One of the challenges with getting care for women’s sexual-health issues is that there’s no established medical specialty for them.
“You take these women with pain [during] sex, for example, and you send them to the gynecologist who would say, ‘Well, it’s not endometriosis,'” said Hart. That might be the end of the road if the doctor doesn’t know about other options that might help.
Hart says she’s on a mission to teach other doctors how to help, starting with asking patients the right questions.
“Like, actually ask if somebody has pain with sex and then know what to do about it if the person says yes. Because patients won’t always volunteer the information if they don’t know that there’s something that can be done.”
Produced by Colleen Ross