Sexuality & Silence: What We Are Not Taught to Ask
In medical training, we are taught to ask about chest pain, shortness of breath, bowel habits, sleep, and mood. We are trained to move efficiently through organ systems, to identify red flags, to document carefully.
We are not trained, with the same rigor, to ask about sex.
On March 2, 2026, the SMSNA Northern California Regional Interest Group hosted Marty Klein, Ph.D., for a virtual talk titled “Sexuality: What Your Patients Ask Me That They Don’t Ask You.” Over fifty minutes, Dr. Klein, a psychotherapist and sexuality educator with more than four decades of experience, described the questions patients bring into his office but often leave unspoken in ours.
As a medical student, I found myself thinking less about what patients are not asking, and more about why they are not asking us.
The Silence Is Structural
Sexuality is deeply intertwined with health. It shapes how patients experience chronic pain, whether they adhere to medications, how they navigate menopause or erectile changes, and how they relate to their partners and themselves. It intersects with mental health, trauma histories, religious upbringing, disability, gender identity, sexual orientation, and culture.
Yet in clinic, sexuality is often reduced to a checkbox. Sexually active: yes or no. Contraception: yes or no.
Dr. Klein began with a deceptively simple question: What do people want from sex?
The answer, he suggested, is pleasure and closeness.
But most people are not focused on pleasure or closeness when they are having sex. They are thinking about how they look. Whether they will climax too quickly. Whether they will climax at all. Whether their partner is judging them. Whether they are performing correctly. Whether they are normal.
Many of the questions he hears in his office revolve around normalcy. Am I normal? Is this because of my age? Is this because of porn? Why is my sex life not like what I see online? Can I get an STI from this? What does it mean if I do not feel desire the way I used to?
Underneath these questions is a fear of being outside the bounds of what is acceptable.
For patients whose identities already sit outside dominant norms, this fear can be amplified. Queer and trans patients may wonder whether their experiences will be pathologized. Patients living with disabilities may assume their sexuality is invisible to clinicians. Patients in larger bodies may anticipate that any concern will be reduced to weight. Patients from conservative religious backgrounds may carry layers of shame that make disclosure feel risky.
When sexuality is already stigmatized socially, and marginalized identities compound that stigma, the exam room can feel like a place of exposure rather than safety.
Clinicians Are Not Well Trained to Ask
Part of the silence belongs to patients. Much of it belongs to us.
Medical education often frames sexual health in narrow biomedical terms: infections, contraception, pregnancy, erectile dysfunction. We are taught to diagnose and treat dysfunction, but not to explore meaning. We learn about physiology, but not about pleasure. We discuss risk reduction, but not intimacy.
Dr. Klein emphasized that sexual function is a means, not an end. Better erections or more lubrication do not automatically translate into satisfaction. An overfocus on performance can undermine enjoyment.
What patients often need is not simply improved mechanics, but a different relationship to sexuality. They need space to talk about unrealistic expectations, about confusing arousal with desire, about the impact of exhaustion, alcohol use, medication side effects, or body image on their sexual lives.
We, however, are rarely taught how to hold those conversations.
The PLISSIT model offers one practical framework. It begins with Permission, explicitly signaling to patients that it is acceptable to discuss sexual concerns. It moves to Limited Information, providing accurate, nonjudgmental education. It then progresses to Specific Suggestions, and when necessary, Intensive Therapy with referral to specialized care.
In practice, even the first step can be transformative. Giving permission may be as simple as saying, “Many people notice changes in their sex life when they start this medication. If that happens for you, I want you to feel comfortable bringing it up.” It may mean asking, “Do you enjoy sex when you have it?” instead of only asking whether someone is sexually active.
Permission counters the assumption that we would be embarrassed, dismissive, or rushed.
Expanding What We Mean by Sexual Health
Dr. Klein offered a broader vision of sexual well being. In his framing, sexual health includes the ability to communicate desire, to tolerate awkwardness, to maintain a sense of humor, to hold realistic expectations, and to separate self esteem from performance.
This vision is inherently relational and psychological. It also invites us to think intersectionally.
Self acceptance looks different depending on the body one inhabits. Realistic expectations are shaped by cultural narratives about masculinity, femininity, aging, and desirability. Communication is influenced by power dynamics within relationships, which are themselves shaped by gender roles, economic dependence, immigration status, and histories of trauma.
If we define sexual health narrowly, we risk overlooking how structural inequities influence intimate life. For example, a patient experiencing pain with intercourse may also be navigating inadequate postpartum support, racial bias in pain management, or lack of insurance coverage for pelvic floor therapy. A patient struggling with desire may be contending with antidepressant side effects while also carrying the mental load of caregiving and financial stress.
Sexual concerns do not exist in isolation from social context. They are embedded within it.
Making Room in Limited Time
One of the tensions in clinical care is time. Visits are short. Agendas are long. Sexuality can feel like an added layer we cannot afford.
But Dr. Klein’s talk suggested the opposite. When we ignore sexuality, we may miss key factors affecting adherence, mood, relationship stability, and overall quality of life. Patients may discontinue medications silently because of sexual side effects. They may internalize distress that manifests as anxiety or depression. They may interpret normal variation as pathology.
Creating space does not require becoming a sex therapist. It requires signaling openness. It requires using inclusive language that does not assume heterosexuality, monogamy, or specific anatomy. It requires acknowledging that sexuality is relevant across the lifespan, including for older adults and people with chronic illness.
As a trainee, I am aware that I am still learning how to ask these questions. Dr. Klein’s talk felt less like a set of techniques and more like an invitation to shift posture. To approach sexuality not as a problem to fix, but as a dimension of health to understand.
Patients are already asking questions about sex. If not in our offices, then online, or in therapy, or not at all.
The challenge for us is whether we are willing to give permission for those questions to surface, and whether we are prepared to meet them with curiosity rather than discomfort.
Sex is not separate from health. It is woven through it, shaped by identity and inequality, vulnerability and desire. If we aim to practice whole person care, sexuality cannot remain an afterthought.