Women‘s sexual health shouldn’t be tabo‪o‬

Sally: Good afternoon, Dr. Johnson and Dr. Kingsberg. Welcome to the NCL podcast we can do this. We’re delighted to have both of you with us. And we would love of course to see you in person but we’re going to have to wait till we all get our COVID vaccines. I’m going to start by introducing Dr. Crista Johnson-Agbakwu. She is an assistant research professor and director of the Office of Refugee health at Arizona University Southwest Interdisciplinary Research Center. She is also an obstetrician-gynecologist at Maricopa Integrated Health System, where she is founder and director of the Refugee Women’s Health Clinic. Crista has been chosen to receive the children’s Action Alliance Jacques Steiner Public Leadership Award. This is an award that is representative of her dedication to address the medical needs of the refugee population in Arizona.

Dr. Sheryl Kingsberg is the chief of the Division of Behavioral Medicine at McDonald Women’s University Hospitals Cleveland Medical Center, and professor in reproductive biology and Psychiatry at Case Western Reserve University. Her areas of clinical specialization include sexual medicine, female sexual disorders, menopause, pregnancy, postpartum mood disorders, and psychological aspects of infertility. So I’m so delighted to welcome you both to NCL podcast. And we’re here today to discuss a topic that maybe top of mind both of you, but I’m guessing too often flies below the radar for the general public. It’s the topic of women’s sexual health. I think a lot of people would be surprised at how broad this topic is. So let me start with you Dr. Keansburg, can we ask you what the issue of women’s sexual health actually encompasses?

Dr. Kingsberg:  Well, first of all, hi, Sally, it’s great to hear you if not see you and I really want to thank you for devoting a podcast to women’s sexual health. It really, to me is an appropriate topic for consumer advocacy so, good for you for talking about it. You know, male sexual function has been front and center to consumer advertising, think about all those Viagra commercials and media attention. But women’s sexual health has lagged, unfortunately, way far behind despite the high prevalence of sexual problems and women. All right, so to your question, what is women’s sexual health encompass? Well, broadly speaking, the topic covers both healthy and dysfunctional sexual health. So both ends of the spectrum, I think deserve attention and some discussion. So on the healthy end of the spectrum, the topic and comfort that we encompass is really vast. and I mean, a vast range of what can and what should be accepted as healthy sexual function.

So first, can we dispel the rigid Western cultural norms that quote, healthy normal female sexual health would simply be sort of bending to the will of their heterosexual male partners. and let’s focus on pleasure on pleasing and embracing and empowering women to take on their own sexual health. So, I think this podcast goes a long way to do that and I’m sure Crista will join me in that one. And so, you know, Sally I know you, I can read your mind and you’re saying, Well, tell me more. So, let me break sexual function into four categories to make it sort of visual for you. So we have desire, we have arousal, we have orgasm, and we have freedom from pain. And this can be actually flipped on its back and no sexual innuendo intended to describe the categories of female sexual dysfunction. So we have problems with desire arousal, orgasm, or pain with sexual activity. So that’s how we sort of encompass what’s healthy and dysfunctional, to keep it into these categories, I think will help us talk about what’s going on. So Did that answer your question?

Sally: Yeah. Thank you. Well, sexual health is almost always thought of as reproductive health to most of us, but it truly entails so much more beyond procreation.

Dr. Kingsberg: Wait, Sally, let me just say, you know, sex for procreation is one of the hardest hits on sexual health because it is no fun trying to procreate when it’s not happening. And so now it becomes an effort and so, you know, I work in fertility clinics so I know the stress on trying to conceive. and now you’ve got tonight’s the night syndrome, you’ve got intercourse, if it’s a heterosexual couple tied to failure if they don’t conceive. and let’s remember that procreation isn’t just for heterosexual couples, so that often entails fertility treatments anyway. so sorry, I just wanted to make sure that we keep sexual health and procreation despite the fact that we need to have mostly have intercourse actually, you don’t really even need that anymore to have children. You know, sex for pleasure is very different.

Sally: No I think that’s important to put those categories in place so that we understand, and also the idea of sex for procreation is probably what your people in your field would consider kind of old fashion. So, let me turn to you, Dr. Johnson, you work with a largely immigrant Somali community. Can you tell us what challenges girls, teens and women in these communities face when it comes to their sexual health? I just want to finish and then I’ll let you answer. Violence against women is usually associated with sexual assault and shame is a problem across the board. And would you say that as the stigma is a greater barrier in immigrant communities?

Dr. Johnson-Agbakwu: Yes. So I want to first thank you, Sally for having me and it’s an honor for me to be on this podcast with Dr. kingsberg. And as you said, I work with a very large refugee and immigrant population from all over the world, who have been experienced many forms from human rights atrocities, sexual violence of the forms of gender based violence, cultural practices, such as female genital mutilation and cutting. And so in the purview of my work, sexual health is an important consideration. In fact, when you look at the World Health Organization’s definition for sexual health, it is a state of physical, emotional, mental and social wellbeing. So it’s not just the mere absence of disease or dysfunction, but it is a positive and respectful approach to sexuality and sexual relationships. And it’s the ability to have pleasurable and safe sexual experiences, free of coercion, free of discrimination and free of violence. And what’s so critical, especially when working with vulnerable and marginalized communities is that there should also be advocacy, to ensure equitable access to sexual health care. And so in the populations that I work with, you have to also consider that there are historical legacies that might impact the way in which sexual health is valued and addressed.

You know, for communities of color, women of color in the United States, you have the historical legacy of slavery where systemic rape was prevalent; you have the eugenics movement, where women did not have control over because they were forced to undergo sterilization for instance, in terms of selective breeding. you have even current modern day times you’ve seen in recent years, attention to this status of immigrants in detention facilities where they were forced to undergo hysterectomy without consent. So we see a lot of assault on women’s bodies or women’s ability to have control over their sexuality. There is a lot of historical, racial profiling, where there’s labeling of a black woman’s bodies, hyper sexualized, etc. And so this all impacts trust. This impacts women’s willingness to participate in research studies. This influences whether women would be likely to seek care when they experience concerns or have concerns around their sexual health. And so we really have a lot of work to do to address the challenges.

So, you know, shame stigma, we’re just beginning to touch the surface. There’s a lot of ways that health systems could do a better job in creating safe spaces, to be able to reach communities, especially communities of color and engage in respectful care. open dialogue, embracing cultural humility, things, such as ensuring that there’s gender concordance, and cultural and linguistic concordance, depending on the needs of the community or patient population that you’re serving. So these are all the things that have become huge barriers to care within refugee and immigrant communities. And it’s something that remains a challenge, especially in training the next generation of clinicians and scientists to be mindful and inclusive, in regards to making sure that sexual health care and attention to sexual health is truly equitable, and is truly safe, and free of discrimination and coercion.

Sally: Right. And that’s a great segue to the next question I had. And I had the pleasure of meeting you, Dr. Johnson, a few years ago, when I attended a conference in Phoenix, at which Dr. Kingsberg was invited to speak to a group of medical students. So, I’ve got a question for both of you. Sheryl, I’ll ask you to answer this first. our medical students well trained to discuss issues related to sexual health, I imagine, you know, they spend a lot of time studying about it and thinking about it and understand how to talk to women and men about sexual health. I could be wrong about that. So, let me start with, what’s the training for medical students? And, you know, if you could set up an ideal sort of protocol for them what would that look like?

Dr. Kingsberg: Sally, the simple answer to your question about medical education is, no, there isn’t a lot. And you know, one of the first grants I ever got was, and I hate to admit how long ago, it was 2001. And Case Western Reserve was granted one of seven grants and this was sponsored by Pfizer at the time to change the sexual health curriculum, to add to it. and we were one of seven schools and the truth is, we were already one of the best in terns, which is probably why we got the grant to provide sexual health education. And here’s what happens in medical schools. Every few years, they come around, and they change the curriculum. So what changes I’ve put in place went away and now a case we have very few hours of sexual health in the curriculum and that is across the board. I will tell you that a week ago, some of the female medical students in the Chicago area put together their own Symposium on female sexual health and sexual dysfunction because they recognize the limitations and what they were getting.

And so they asked many of us who are you know, essentially experts in the field, to you know, volunteer our time. we spent a Sunday giving them lectures and symposia and breakout sessions, because they took it upon themselves. They recognize the need for this and let me say this goes beyond medical school training into OB-GYN residents. OB-GYN residency, we have very little training in sexual health too and primary care as well. So the area is ripe for education, we are trying to create an atmosphere where in education and even beyond in practice, clinicians are learning to put sexual health in their review of systems so that it isn’t so awkward. So it’s in the electronic medical record as a review of systems. And it’s not hard it can be easily incorporated without taking up a lot of time. As part of my review of systems, I ask everybody about their sexual health because we know it’s important to your quality of life and to your health.

What sexual concerns Do you have Are you having any concerns with desire arousal, orgasm pain, and to you know, to Crista’s point, we want to you know, embrace the fact that there’s a lot of concern and fear about opening up about anything. I just spent the morning in a train the trainer on GLBTQIA to train our University Hospitals in all the departments about how to be encompassing for transgender. for non-binary, for various sexual orientations and to incorporate that into our health care in simple as forms. So that is not are you a male, are you a female? to allow for the fact that there’s a huge variety and to open the door so that people can tell us what their sexual concerns are.

Sally: Dr. Johnson-Agbakwu, you have some difficult conversations, it sounds like because of cultural issues you have your patients from over 60 different ethnic backgrounds and countries. And so the question is, you know, how do you start a conversation with these patients? What kinds of questions should patients expect to be asked or to ask you? and it’s always a tough one, because I know patients are embarrassed to bring up sexual health and often healthcare providers are embarrassed to raise it with patients. So how do you approach that conversation?

Dr. Johnson-Agbakwu: So yes, it’s a very critical one that needs to be addressed and one of the first things I do is really make sure that we create a safe and welcoming space where women feel comfortable that they can speak in their native language. So we have Cultural Health navigators, who speak up to 18 languages, reflecting the various regions of origin of our patient population. And we have been able to nurture and sustain trust and trusted relationships with our communities for many years, we are able to do that trust, make sure that women understand that we will respect their privacy and comfort and uphold the confidentiality at all times. we make sure that these discussions occur in their native language, so they can feel comfortable expressing themselves however they feel they want to convey their concerns. And we also universalize, for instance, we see many women who’ve experienced gender based violence with rape as a weapon of war, especially those coming from the Democratic Republic of Congo.

And in that context, I use a universalizing statement stating, you know, we serve many women from this region of the world and we understand that we may have experienced violence in various forms. And I kind of normalize that this is something that they can feel comfortable expressing because it’s something that we are very familiar with, and that we serve. and that we seek to create a safe space where women can feel when they’re ready, that they can begin to share experiences, I have many patients, some of them have lived here for many years. And it’s not until they come to our clinic, that there for the very first time, they’re able to open up and talk about their experience of sexual violence, for instance, or suddenly break down from not receiving the right interventions or behavioral health therapy, but they are finally able to feel comfortable talking about their experiences and willing to do to seek help. So I think being able to create that environment where women feel that there any trusted and safe space, will set up the grounds for being able to have meaningful discussions to arrive at ways that we can help them.

And it’s not something that happens with just the very first visit, you have to nurture and sustain that trust and that might take several visits and its okay. But the more that you’re able to show compassion and empathy and treat them with respect and value their voice and give them that space that whenever they feel comfortable, we are here and we are here to help them. I think that’s that approach that has really had the greatest success over these years and us meeting the needs of this very vulnerable population.

Sally: One additional question, you’ve got an older generation and you’ve got the young people who were born in this country, and are certainly part of their communities, but they have a very different experience growing up as Americans from different ethnic backgrounds. but they’re American kids, and I’m sure they’ve adopted a lot of American values and ideas. does that help translate some of these issues to the older generation or is there a real gap there? And, you know, parents and kids don’t really like to talk about sex together we know that. And maybe you see this younger population, do you think there’ll be some changes as a result of millions of immigrants here, even from these populations who are born and raised as American kids?

Dr. Johnson-Agbakwu: Yes, that’s a great question. I think those tensions still persist. We definitely see even in terms of my work around female genital cutting, where you see the parents who may have had more severe forms of cutting or may have cultural mores and norms that they brought with them to this country that were upheld, based on their socio cultural context. but their children are a US born and very Americanized, and may have very different perspectives on dating and relationships And they’re those tensions rear its head. especially that there’s an ever present tension of grappling with the duality of living in two worlds, so to speak, and how do you navigate that across the generational divide? And it’s something that we have tackled from the research side, when we’ve engaged in work in the local Somali community around female genital cutting. we had a federal grant where we were able to engage in discussions across generations with youth, with their parent, their mother’s and elders; we even engaged men and young adult men as well, as well as religious leaders.

And we brought them together as a larger group but we also made sure that we created those safe spaces within those generational enclaves to really have frank and open discussions around genital cutting and what this means around their families, as well as seeking care, and health and wellness. And it’s interesting; you clearly see those generational divides even within those spaces of men and women talking around this issue. But I think it’s something that we can continue working towards in terms of helping to bring about greater dialogue and I think that’s the critical piece. Because, oftentimes as you mentioned, those silos exist where it’s not common for men and women to talk about some of them deep issues, especially around sexuality. And being able to engage in those discussions will also help enhance the advocacy and advocacy that even men can do on behalf of their sisters and their mothers or their wives. So, I think we have a ways to go but I think it’s an opportunity for us to continue working and engaging the community across these various spaces and across generations to advance sexual health equity for this population.

Sally: Dr. Kingsberg, I want to turn to the issue of (HSDD), which I’m going to ask you to explain. It’s a condition that one in 10 women experience, it’s essentially loss of sex drive, but will you tell us what it is and whether there are treatments for it, and explain why (HSDD) differs from just being a matter of a woman’s age or attraction to a partner, or being in a long term relationship?

Dr. Kingsberg: Sure. I just wanted to add something to what Dr. Johnson said, though, because I have admired what she does for years and years, I could listen to her lecture all the time. at the International Society for the study of women’s sexual health, we do a three day training course for non-sexual medicine practitioners and she always, you know, you could hear a pin drop when she gives her lecture. But, you know, even in a broader sense with gesture every day, sort of typical American woman who has not undergone all the abuse and the fear and the displacement. even that needs to be, you know, these women need to be given that safe space and be encouraged that their sexual life is to be respected. and they’re entitled to it because I certainly see so many women, particularly as they’re aging thinking, well, you know, I’m in my 60s, I probably should just give up my sex life. and we want to make sure that practitioners don’t inadvertently give that same message because they’re young and they’re thinking, Well, my mother doesn’t have sex so, clearly this 65 year old woman isn’t having sex.

We need to empower women and practitioners to be, you know, more accurate in their terminology. You know, this podcast is one way we can combat shame and embarrassment. we’re going to use accurate terminology, we’re going to say clitoris, we’re going to say vagina, we’re going to say orgasm, right? You’re not going to edit that out. Are you?

Sally: No.

Dr. Kingsberg: No. Good.

Sally: Keep going.

Dr. Kingsberg: Good. So with that, let me just say that the (HSDD) is Hypoactive Sexual Desire Disorder. It is a mouthful and, you know, it’s a lot harder to say, than (ED), right, Erectile Dysfunction. But Hypoactive Sexual Desire Disorder is the most common sexual complaint of women of all ages, if you exclude issues that are related to pain, which tend to be, you know, medically related. Women have pain, because there there’s a problem so, psychologists [inaudible 50:26] Vinick has always been quoted as saying, is the sex painful or is the pain sexual? and 99% of the time, it’s that sex is painful because of an underlying medical reason. But the most common sexual dysfunction is Hypoactive Sexual Desire Disorder, which you did get right Sally; it is the loss of interest in wanting to be sexual. So, women who have (HSDD) will say, they’ve lost the wanting, and they want to back they’re distressed by this. So in order to meet the criteria for having this disorder or dysfunction, you have to be bothered by it, you have to be distressed. So, women will come in and if you ask them, Do you have any sexual concerns, and they say, I’ve no interest and I miss it, that is HSDD.

So, you know, women who are in relationships, for the most part are having sexual activity, usually out of duty sex, or because they know their partner will, you know, will enjoy it, or they feel like it might break their relationship if they don’t but what women are missing is the drive the wanting to want. And so just like I broke down the categories of sexual dysfunction into four categories, let me break down the concept of desire into what we call a psycho biological approach. Whereas there are biologic factors that contribute to desire or wanting, there are psychological factors that contribute to healthy wanting or not wanting. there are cultural and religious factors that can contribute to the desire problems, and there are interpersonal factors that can contribute to problems with desire. And clinician simply needs to kind of look at these four factors with women who are very smart, they can tell you that, you know, I don’t want to have sex because I hate my partner. And no amount of, you know, any biologic issue is going to fix that right?

So, women are smart. If you ask them the right questions, they can think the two of us can help figure out what’s going on are their underlying biological factors. And we know that hormones can be contributing to sexual desire, as well as neuro chemistry. So neurotransmitters, for example, dopamine, which is the neurochemical of desire isn’t involved. So there are biologic factors, health risks, health conditions, but they’re also psychological factors, depression, for example, and cultural values, which Dr. Johnson can talk a lot about. which is why she’s got, you know, women from 60 countries having all kinds of different cultural values that could either support or inhibit sexual desire and again, the quality of the relationship. if there are biological factors, for example, you know, we look at (HSDD) similar to how we look at depression, right. So there are biologic factors underlying depression, and we have antidepressants that would treat that by virtue of essentially rebalancing neuro chemistry.

When we think about treating the underlying biologic factors with Hypoactive Sexual Desire Disorder is a very similar approach. We have two FDA approved pharmacologic treatments for pre-menopausal women and don’t get me started on the frustration with the fact that these non-hormonal treatments are only approved in pre-menopausal women, but they are approved in pre-menopausal women. and then we have an off label meaning we use it but it is not an FDA approved indication of testosterone for postmenopausal women. So, those are the biologic treatments that the pre-menopausal treatments are called addyi A- D- D- Y- I and vyleesi V- Y- L- E- E- S- I and they proof for pre-menopausal women. they’re very different in how they’re delivered but the goal is the same to improve the wanting. And women will say it’s a subtle shift from going from not even thinking about it. It’s like, think about it like appetite you know, you walk into your favorite restaurant, and no matter how much you would like to be hungry to enjoy your favorite meal, you have no appetite. Well, women who have HSDD will say, I want to want, I missed that anticipation, the enjoyment and these treatments add to that by subtly shifting from no appetite to some and that’s what women want back is their ability to have some appetite.

Sally: So Sheryl, let me just interrupt so we can make sure we’re absolutely clear. So HSDD doesn’t have to do with your age, you’re not attracted to your partner, you’re in a long term relationship and you’re bored. It’s something; I think you said psychosexual or psycho biological?

Dr. Kingsberg:  Yeah, we want to look at it as a psycho biological component.

Sally: its brain chemistry?

Dr. Kingsberg: Well, HSDD can have different ideologies. Loss of desire can have different ideologies. But the source, there are different ways in which loss of desire can occur. They can occur either from biologic factors from psychological factors from cultural factors, or from interpersonal factors. When we are thinking about treating it with a pharmacologic with a drug, we want to look at the biologic factors and to see if that’s the source.

Sally: Right. So when you’re with the patient, what you say is, let’s break this down and see what’s going on here. When you say the etiology, let’s find out what’s happening. It isn’t some things, but it might be others. And you’re saying it could be biological. And so a patient will come in, and you have to tease that out and figure out this is really HSD? And if so, the treatments that are available will be appropriate for this particular patient?

Dr. Kingsberg: Yes, Sally, and as much as I just tried to make it sound as complicated as I absolutely could, it doesn’t have to be that complicated. And there is actually a screening tool that the FDA had wanted for exactly the reason of figuring out who would benefit from a medicine versus something else, called the decreased sexual desire screener, which women can find on their own online and see. because it asks about, you know, changes in desire, and it gets to factors that might be contributing, that may or may not be related to Hypoactive Sexual Desire Disorder. like, you know, when I say there could be psychological factors, if, for example, you have depression, and as a result of depression, you lose interest in all things, including sex, that would not be Hypoactive Sexual Desire Disorder, right? That would be depression. And if you are having interpersonal issues, it may be that the relationship conflict is more the culprit than it is a loss of desire. On the other hand, there are many women who will come in and say, my relationship was great, but because I’ve lost my desire for sex, if I don’t fix what’s going on with my sexual life, I think I’m going to lose my relationship.

So it sounds complicated, but you really just have those four buckets to be able to look at so that you can tease out what might be going on. And then that helps you design a treatment. And so when it looks like the underlying cause of the loss of desire is more biological, you kind of rule out the other things, it’s not your relationship. It’s not that you’re depressed or have other psychological factors. It’s not that your religious and cultural beliefs get in the way and it’s kind of an exclusionary conclusion, then you can look at well, are there pharmacologic options that might help? I certainly do psychotherapy to help shift, you know, belief systems and help couples who’ve become sort of bored in their relationships. And there are ways in which psychotherapy can help, even when there’s a biologic cause, but we also want to make sure that women have treatment options too, pharmacologic options. I get a lot of pushback that we are pathologizing a normal experience for women to lose their desire and I’d say that’s not true. There are many women who come in and they’re terribly distressed they missed this and they would like a treatment to be able to fix it and while psychotherapy and sort of good at it can help some of those women just like the depression.

I can’t treat everybody who has depression with just psychotherapy and so we’d like to have those pharmacologic options available to these women and let women choose. And let’s not be so paternalistic that we say, oh, well, since drugs are not for everybody, we shouldn’t let anybody have them. We really want to give women options. And so we have two treatments that are approved for pre-menopausal women, one that we use off label for postmenopausal women with good data, and women and their providers can figure out what’s going to be best for them.

Sally: Okay, well that’s great. And Dr. Johnson, I want to know if you see (HSDD) in the population you treat as well. But before, why don’t we put that together in the next question I’m going to ask you, which is, let’s say you do have a problem with your sexual health, you’re a female, you’re going to go see either your primary or you’re going to see an OB-GYN, which would you recommend if you’ve got a problem with sexual health, who should you talk to? Should it be your primary? Should it be your OB-GYN? And what if you sense that your healthcare provider isn’t comfortable discussing this topic? Crista, why don’t you go first?

Dr. Johnson-Agbakwu: Sure, I guess the one thing would be empowering our patients to not to give up, and if they find that their primary care provider is reluctant or may give condescending reply or is really not insightful, perhaps seeking another provider. I know, something that I always stress is that it does take a village that I seek to surround myself with an army of expertise in terms of it might not just be one provider, you may need to engage with pelvic floor physical therapist or a sex therapist or behavioral health counselor in addition to a primary care provider, I lean heavily on parent support peer advocates, often a see through our cultural health navigators, these peer advocates help support women, it just empower them that they can seek resolution to the concerns that they have, or they can seek care and seek help. Because again, this is often so stigmatizing that they’re often reluctant to even take that first step. So I would say, for women to not give up being persistent and that we want to build the capacity of providers across fields, especially OB-GYN.

Because we are often the frontline providers for women. So it’s incumbent upon us within this field to be the most knowledgeable to be able to provide sexual health care in a culturally appropriate and empathic manner. But I think we also need to do a better job as Dr. Kingsberg mentioned earlier, in terms of how can we nurture those pipelines for students and residents in training to get exposure to Sexual Medicine. through mentorship through clinical opportunities where they can gain more exposure to sexual health interviewing strategies. whether that we can support and mentor trainees who can go to conferences such as Israel, to gain more exposure to the field and potentially become those attending physicians and scientists who can then train those who come. So, I think we really need to lift the cadre of training among physicians across the primary care fields, especially OB-GYN, so that they can be respectful and understand that and be able to ask those sensitive questions so that women can feel supported and that concerns are validated.

And I think we also need to work to even enhance the way in which we open those doors of communication. I know for my population, I rely less on pamphlets and handouts, but I use a lot of audio visual aids and imagery. My colleague in Geneva, Dr. Jasmine Abdulkadir is working on a 3d model of the clitoris to be used by clinicians to help in the counseling and education of their patients around genital anatomy. so that they can even understand perhaps, you know, the root causes of sexual health concerns and that could aid in clinical decision making and counseling with the patients. So I would say it really takes an army and we need to reach out across the aisle and take a multidisciplinary and holistic lens, to how we engage our patients. So that if we don’t just rely on one provider to be the end all be all, but we really seek to engage a team based approach to providing patient centered care around sexual health and wellness.

Sally: You know, I think that is a really interesting idea to have. Women probably and men, I mean, the last time I remember looking at a graph, or a chart with a with the body parts was in eighth grade health class. And of course, everybody giggled and was really embarrassed. But I think probably for many, if not most women, and probably men as well. But you know, women have no idea what their various body parts look like down there and may or might not want to know, but it’s actually a really important lesson for people to understand what’s going on, I would think. let me make sure listeners understand who should bring this topic of sexual health? Should it be the health care provider or should it be the patient? And if the healthcare provider brings it up, what kinds of questions should they be asking? And lastly, if you have these questions, is there a resource for women who want to make sure they’re not going to talk to somebody who’s going to, as one of my OB-GYN seemed very embarrassed, I think. he turned like four shades of red when I raised the question of women’s sexual health, and he was clear, he had no comfort level talking about it. Is there a resource where, like, you know, a list of physicians who or healthcare providers, generally, psychologists who are available to talk about these issues?

Dr. Johnson-Agbakwu: Sheryl, do you want to take that question?

Dr. Kingsberg: Sure. earlier when you were describing the importance of the anatomy, and those women and girls need to understand their own anatomy you’ve talked about down there so, that’s number one. One of the things we need to change is to change the down there. And to help, you know, little girls and women be comfortable with describing their genitals and their vulva and their vagina and their clitoris.

Sally: So how should I say it? so they should be comfortable describing their genitals or vulva, their glitters? We should just get comfortable with those words.

Dr. Kingsberg: Yes, yes.

Sally: Okay, that’s very helpful.

Dr. Kingsberg: And the answer to that should bring it up, it really is the responsibility of the healthcare professional. Dr. Johnson had talked earlier about the (WHO) and the fact that, you know, sexual health is a basic human right. And it goes on to say, and it is the responsibility of healthcare providers in reproductive health, at the very least, but health care providers to address the sexual health of their patients. And so it is up to the clinician to bring it up, they should bring it up they should, which is again, what we’re trying to do is to encourage clinicians to get comfortable with it. Can I tell you how many gynecologists are comfortable talking about smelling discharge, but they can’t actually ask about orgasm? That is crazy. But they are uncomfortable with it. So part of the reason is that they don’t really feel well trained to address sexual concerns but we are trying again to change that. But even if they can’t be comfortable with treating it, they need to at least bring it up so that they can then refer out which gets to your second question of where should they refer but they should be the ones to bring it up.

And let me tell your listeners or patients or whoever, if your clinician doesn’t bring it up, find another one. There are many, many primary care and Gynecologists who really can at least ask that’s all they need to do is just ask, and if there is a problem, what sexual concerns do you have? Even yes or no. Do you have any sexual concerns? And if you say yes, I have This problem or that problem, I am not the one to treat this but I’m so glad you brought it up, let me help get you a referral. And I will tell you one of the only benefits of COVID has been the blossoming of telehealth so that even though there may not be somebody in your town or in your city, at this point, you got to stay within your license of state, you can find somebody who then can treat you. And so that’s part you know, at least you can get that telehealth consult. Where should people go to look the International society for the study of women’s sexual health? again a mouthful which is isswsh.org has a find a provider by state, by city.

Sally:  Wow, that’s really helpful.

Dr. Kingsberg: Yep. The Society for sex therapy and research, which is sstar.net has clinicians and researchers that specialized in Sexual Medicine, you can find (ASECT) which is the association for sexual educators and counselors and the North American Menopause Society, you know, full disclosure. I’m a former president of (NAMS) North American Menopause Society and that the premier society for midlife women and you said a sexual concerns or HSDD are only in younger women? No, it’s across the board. And midlife women can seek help with the North American Menopause Society. And they have certified menopause practitioners on their website, which is menopause.org. Crista, any other societies you would recommend?

Dr. Johnson-Agbakwu: So part of the US (NFGM) network and as part of that network, we have a national clinician database of clinicians across the United States who have expertise in the care of women and adolescents affected by female genital mutilation and cutting. And so we are spread out across the US and we have a moderated listserv, where clinicians can receive support. but also those who are working in regions of the country where there has been some local expertise, say, academic center where you have a clinical site with a provider serving this population. they can have access to our national repository of resources and expertise to gain insight on the care of their patient. whether it’s surgical care whether it is psycho psychosexual counseling, whether it’s ethical dilemmas mandatory reporting, I mean, it runs the full gamut and so my email address is cejohn11@asu.edu. So if anyone who’s interested can reach out to me and I can connect you with the moderator of that network, because it is something that we want to be widely accessible to clinicians who are working in any part of the country who may be grappling with the care of patients affected by this practice.

Sally: Well, I’ve come to the end of my questions. Do you guys have anything else you’d like to add anything that we have not focused on that you think is particularly important and women’s sexual health?

Dr. Kingsberg: I’m thrilled you brought it up. You are doing the podcast, Sally, thank you for allowing us to express the importance of women’s sexual health. And, and I do think it’s a consumer advocacy issue. So thank you for jumping right on it.

Sally: We’re delighted to have had two national experts coming from very different geographic and very diverse populations, talking about a really important issue to women. So Woody, is there anything else that we need to do? I think you too, have to hang on for a little bit. Thank you, Dr. Johnson. Thank you, Dr. Kingsberg, for the wonderful work and your dedication to the women populations of patients that you serve. It’s so important to get these conversations out here, as uncomfortable as they might be for many people apparently including me. But I’ve learned that I can do better and I think all of us can do better when having these conversations while being open about issues that are very real for many millions of women.