Curr Urol Rep (2014) 15:405 DOI 10.1007/s11934-014-0405-6
MEN'S HEALTH (R CARRION AND C YANG, SECTION EDITORS)
Alternative Sexualities: Implications for the Urologist Kathryn Akemi Ando & Tami Serene Rowen & Alan W. Shindel
Published online: 23 March 2014 # Springer Science+Business Media New York 2014
Abstract Urologists routinely deal with sensitive issues of urinary function as well as sexuality in daily practice. Even experienced urologists may encounter patients who engage in sexual practices that are novel, unknown, or perhaps disturbing to the provider. This primer will serve as an introduction to sexual practices and lifestyle choices that may be foreign to many practicing urologists. It is by no means an exhaustive description of alternative sexualities, but will hopefully serve as a useful introduction to the topic and will enhance the ability of providers to care for, or appropriately refer, patients whose sexual practices and lifestyles may differ from their own.
Keywords LGBT . Gay . Lesbian . Transgender . BDSM . Sadism . Masochism . Open relationship . Polyamory . Sexual minority . Disparity . Discrimination
This article is part of the Topical Collection on Men’s Health K. A. Ando Department of Emergency Medicine, San Mateo Medical Center, San Mateo, CA, USA K. A. Ando Project Prepare, San Francisco, CA, USA T. S. Rowen Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA A. W. Shindel (*) Department of Urology, University of California, Davis, Sacramento, CA, USA e-mail: [email protected]
Introduction Urologists are widely acknowledged for their ability to address sensitive health issues with tact, respect, and (when appropriate) good humor. Despite this reputation, even experienced urologists are likely to sometimes encounter unusual and/or very sensitive clinical situations. In particular, urologists who make the care of sexual health problems part of their practice may occasionally encounter patients who engage in non-normative sexual practices or lifestyles. While there is no precise definition of “non-normative” sexual practice (and cultural notions of what is normative are constantly evolving), we find it helpful to loosely group non-normative sexual activities into three categories: 1) Individuals who engage in sexual activity with samegender partners (i.e., lesbian, gay, bisexual) or who do not identify with the gender assigned to them at birth (transgender). These individuals are often grouped together as members of LGBT (lesbian/gay/bisexual/transgender) communities. 2) Individuals who practice bondage, domination, and/or sadomasochism (BDSM, sometimes called “kink” or “paraphilias”). BDSM is often, but not always, practiced in association with sexual activities. 3) Individuals who are in consensually non-monogamous sexual relationships (e.g., swingers, polyamorous individuals, those in open relationships, etc.). It is common knowledge that many ostensibly monogamous persons engage in sexual activity with persons other than their partner. In this manuscript, we will focus on individuals who engage in sexual activity outside their “primary” relationship with the knowledge and consent of their partner(s). A few salient points must be made about this grouping. First, many individuals may engage in some of these activities
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but not identify with a given community. For instance, the success of the “50 Shades of Grey” trilogy has likely motivated some individuals to explore BDSM as part of their sexual repertoire. Although such individuals may engage in BDSM activity, they may not necessarily identify with BDSM communities. Similarly, some persons have engaged in sexual activity with partners of the same gender but do not identify as “lesbian,” “gay,” or “bisexual” [1]. The terms “men who have sex with men” (MSM) and “women who have sex with women” (WSW) are sometimes used as a more inclusive term to refer to behaviors rather than identities. One should not assume group membership based solely on sexual proclivity or practice. Second, while individuals who belong to one of these three groups are statistically more likely to belong to one of the others, this is not always the case (e.g., persons who practice BDSM may or may not be in an open relationship, etc.) [2, 3•, 4]. It is important for providers to recognize that these communities and practices are highly individual, and addressing each behavior separately is necessary to fully evaluate an individual’s sexual health practices. Health care providers may find it professionally and personally challenging to care for patients who engage in non-normative sexual practices. This often stems from unfamiliarity with the types of activities or a belief that such activities/lifestyles are abnormal or even immoral. Providers are certainly not required to condone sexual behaviors to which they have a moral or religious objection or to directly provide care for such patients in non-emergency situations. However, medical professionalism dictates that if a provider is not comfortable caring for a patient because of that individual’s lifestyle, the most appropriate step is a referral to another provider. A provider should not pass moral judgment on or attempt to change a patient’s lifestyle preferences unless 1) the patient requests it or 2) there is imminent danger to the patient’s health and well-being. This includes reportable offenses, any form of nonconsensual abuse, and physical or mental harm. Because some forms of BDSM activity carry the implied or real risk of physical or mental harm, this criterion should be applied judiciously in the setting of BDSM activities between consenting adults. This manuscript will serve as a brief primer for urologists on non-normative sexual practices. We will review terminology and slang related to alternative sexualities, as well as some particular concerns of each population, and we will describe ways to address common concerns for these populations. Readers who desire a more comprehensive discussion are referred to more detailed literature listed in the references.
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Common Issues for Persons with Non-Normative Sexual Behaviors Physical and Mental Health Disparities Most of the physical health (and urologic) issues in people who engage in non-normative sexual practices are the same as those in the general population [5]. However, some sexual practices are associated with greater risks (e.g., HIV transmission with anal sex), and hence some health problems are more prevalent among individuals with non-normative sexual practices [6•]. There are robust data indicating that LGBT individuals experience increased rates of psychological morbidity, substance abuse, and suicide; it is thought that in most cases this higher rate of mental health issues is related to societal stigma and discrimination [7]. These problems are particularly prominent in LGBT youth, who may face rejection from their families and peer groups, resulting in greater burden of mental health issues compared to their heterosexual peers [8, 9]. Although BDSM interest or activity has historically been considered by experts to be a mental disorder, the recently released fifth edition of the Diagnostic and Statistical Manual on Mental Health Disorders states that “a paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention” [10]. There are few convincing data indicating that, after adjusting for other comorbidities, individuals who engage in BDSM have higher prevalence of mental disorders [11]. Data on mental health in individuals in consensually non-monogamous relationships are sparse [12]. Communicating About Sex Many patients, even when they have sexuality-related concerns, are hesitant to discuss sexuality with their providers [13]. It is well-documented that many patients fear being judged for their sexual practices, and this fear is amplified in individuals who practice non-normative sexual behaviors [14, 15]. It is incumbent upon health care providers to facilitate open communication about sex during clinic visits [15]. However, the routine questions providers often ask about sexual activity may not elicit all of the information relevant to persons with non-normative sexual practices [16]. The most common example of failure to elicit a complete sexual history is the assumption that a patient is heterosexual when they are, in fact, lesbian or gay. A more subtle example is an assumption about certain sexual activities in particular individuals. For example, a provider who assumes that all of his gay male patients engage in anal intercourse may not ask the appropriate questions for any given patient’s concerns. In general, it is best not to assume anything about sexual practices, and rather
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to allow the patient themselves to disclose the relevant information, with appropriate prompting as required. When formulating history questions for your patients, consider why the information is important, and share the reasoning with the patient if they are reticent to discuss. Generally it is best to use open-ended questions to elicit sexual health information. Examples are included in Table 1. These may be adapted as appropriate, but care should be taken to ensure that the provider does not make explicit or implicit assumptions when asking questions. Normalizing statements may also be useful in establishing that the provider is accepting of non-normative sexual practices. While it may be difficult to completely avoid statements that offend or bother some patients, most patients appreciate a genuine effort to be inclusive/accepting. It is prudent to discuss confidentiality and mandatory reporting requirements with your patient prior to these questions.
Respecting Sexual Preferences
Terminology
“Coming out” refers to the process of a person communicating their sexual identity to others [21]. This has classically referred to the process of disclosing a non-heterosexual orientation or a transgender identity. However, it may refer to disclosure of other non-normative sexual practices as well, such as open relationships or BDSM. The coming-out process can be a stressful ordeal, and may be ongoing and protracted over the patient’s lifespan as they come out to friends, family, coworkers, landlords, and health care providers. Some individuals never come out, and it may not always be necessary for individuals to disclose their identity or practices publicly and to all persons [21]. Some young members of LGBT communities view “coming out” as outdated because they have a supportive social environment and do not feel shame about their sexual identity [21]. For older LGBT generations or other sexual minorities, shame associated with sexual identity and difficulties coming out may be more prevalent [22].
Part of the respect for preferences is use of appropriate terminology. Terminology for persons with non-normative sexual practices may be fluid and may vary by social group and generation. For example, a young gay male may selfidentify as a “queer,” but a gay male of an older generation may be seriously offended by the term. Terminology is particularly important when speaking to transgendered persons. Many will reject the anatomical names for parts of their body that are discordant with their gender identity (e.g., some maleto-female transgender persons may prefer the term “clitoris” to “penis” when referring to their phallic organ). Terminology is also relevant when speaking about sexual activities. When speaking about specific sexual practices or identities, feel free to (respectfully) ask for clarification of unfamiliar terms and for preferred terminology. Using the patient’s terminology in response may help to build rapport, although caution should be exercised, as using the patient’s terminology may not always be appropriate in a professional setting. It is important to recognize that context and intent, as well as the role of the person uttering a term, have major implications. When in doubt, do not utilize slang terms that could lead to serious offense [5, 17, 18]. Table 1 Opening sexual health questions (adapted from: Wentworth, Ando, Mark & Vade, 2012; Makadon, 2011, Moser 1999 [5, 17, 18]) 1) “I am going to ask you some questions about your sexual health and sexuality that I ask all of my patients. The answers to these questions are important for me to know to help keep you healthy. Like the rest of this visit, this information is strictly confidential.” 2) “Do you have any concerns or questions about your sexuality, sexual orientation, or sexual desires?” 3) “Are you in sexual relationship with a partner? Are there any changes in your sexual life that you want to discuss?”
Sexual preferences are often deeply engrained and not easily changed. A provider who offers suggestions designed to reduce risk is more likely to promote patient wellness than one who admonishes patients to simply avoid cherished sexual or erotic practice(s). This approach is similar to encouraging safer sex with condoms and routine testing for sexually transmitted infections; there are numerous data that support safer sex education as more effective than abstinence-only interventions [19, 20]. If there is an activity that you consider particularly unsafe, ask the patient additional questions regarding how they engage in the behavior. Involve the patient in the discussion and offer harm reduction strategies rather than paternalistic directives. “Coming Out” and Community Identity
LGBTQ Terminology The familiar acronym LGBT stands for Lesbian, Gay, Bisexual, Transgender [23]. In recent years, the letter Q for “queer” has been added to this acronym in some contexts. Queer in this case is an umbrella term for individuals who see themselves outside of a binary gender identity or orientation, but without specifying a particular preference. The letter Q may also stand for “questioning,” an individual who has not yet fully established their sexual orientation or identity. Less commonly, I (for intersex), and A (for asexual, not endorsing sexual interest in any partner) may be added to the LGBT acronym.
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The health disparities such as poor health and reduced access to health care experienced by LGBT persons are well-established. Working to eliminate disparities in care for LGBT populations has been identified as a priority in the U.S. government’s Healthy People 2020 initiative [7, 24]. The first step in discussing LGBT health issues is eliciting information about sexual orientation and interests from patients. Some proposed language to initiate discussion with patients about sexual orientation is outlined in Table 2. Unlike race or gender, sexual orientation is invisible. LGBT individuals are often subject to subtle, inadvertent, or insensitive attacks on their identity. This may be perpetrated even by providers who profess no objection to LGBT sexual preferences. For instance, asking a woman if she has a boyfriend or husband is an assumption with implications of what is normal, and may lead to offense if she is partnered with or prefers women [22]. Use of gender-neutral terms for significant others is advisable until the patient has disclosed the gender of any person(s) with whom they are in a relationship. Culturally competent care and improved understanding of how urinary symptoms and sexual dysfunction affects MSM and WSW are important topics for research and development [25, 26]. Sexuality in MSM has been a topic of great research interest, due primarily to the HIV epidemic. However, peerreviewed publications on topics focused on quality of life,, such as promoting sexual wellness and treating sexual dysfunction in MSM, are scant; similar research on WSW is even less prevalent. In general, it appears that risk factors for sexual dysfunction are similar between heterosexual and nonheterosexual persons, although how dysfunction manifests and the intrapersonal and psychological toll it takes may vary. Trans- and Intersex Transgendered persons merit special consideration separate from lesbians, gay men, and bisexuals in that they have the unique challenge of contending with non-normative gender identity. Social recrimination against transgendered individuals is common and is a source of significant psychological and often somatic morbidity [8]. It is important to distinguish between transgendered, transsexual and transvestite, as these terms are too often used interchangeably, though some individuals simply identify as trans. There are tremendous differences between and within Table 2 Questions on sexual orientation and partner preference 1) “What gender pronoun do you want me to use when referring to you?” (useful for transgendered patients) 2) “Is/are your sexual partner(s) female, male, or both?” 3) “Some people have sex with women, some with men, and others with both men and women. What is the gender of your current sexual partner(s)?”
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these populations. It is critical to elicit a thorough history as wells as the patient’s own feelings regarding their gender identity. Transsexual people feel that they are in the body of the wrong sex and usually desire hormonal and/or surgical treatment to rectify the difference [18]. They are sometimes divided into MTF (male to female) and FTM (female to male), and further classified as pre-op, post-op, or non-op groups, referring to their status regarding gender reassignment surgery [18]. Gender reassignment surgery may also be characterized as “top surgery” (e.g., removal of breast tissue in FTM and placement of breast implants in MTF) and “bottom surgery” (e.g., creation of a neophallus in FTM or creation of a neovagina in MTF). It is important to address both physical and psychological concerns in transsexual persons. Backgrounds, goals, and ability to make a transition to another gender vary among transsexual individuals and may not be apparent from their appearance. Consider asking what their hopes and plans, if any, are for gender transition. Gender reassignment is a very long process that involves psychiatric, endocrinologic, and surgical evaluation [27]. Counseling and hormone therapy are initiated before surgical procedures begin. The process may cause emotional and mental distress and may strain relationships with the patient’s family and friends. Estrogen therapy may carry risks such as thromboembolism and liver abnormalities; androgen therapy may be a risk factor for heart disease, endometrial hyperplasia, and some carcinomas [27]. If the uterus, breasts, or cervix are maintained in FTM patients or the prostate in MTF patients, screening for the relevant cancers is indicated, and additional screening for new risk factors secondary to hormonal treatment may be warranted [28]. Gender reassignment and hormone therapy may lead to changes in sexual interest, responsiveness, and function [27]. Transgender is a term used to describe an identity rather than a permanent physical change [18]. Transgendered individuals often do not see themselves as fitting within the binary constructs of gender and/or sex. A transgendered person’s appearance and gender identity may be fluid or present as androgynous. Some transgendered people are transsexuals who do not want surgery [18]. Transvestites, also known as “cross dressers,” dress in the clothing of the opposite gender. The apparel may be for sexual stimulation or purely for comfort. Transvestites who dress in an exuberant translation of the opposite sex are known as “drag queens” (men dressed as women) or “drag kings” (women dressed as men) and sometimes develop personas for performance or events [18]. Intersex, formerly known as “pseudohermaphroditism,” “hermaphroditism,” or “sex reversal,” is most appropriately known today as “disorders of sex development” (DSD) [29]. The older terms are seen by patients and families as confusing and potentially pejorative. In a consensus statement, Lee et al.
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(2006) proposed that the term be defined as “congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical.” These patients have often undergone genital surgery during childhood, which historically has led to some dissatisfaction on the part of the individual regarding decisions that were made on their behalf. Understanding the anatomy, gender identity, and sexual identity of intersex persons is essential in addressing their specific urologic health concerns. BDSM and Paraphilias Terminology The acronym BDSM can actually comprise three separate terms of two words each. Broken down, it is BD/DS/SM: B/D, bondage and dominance; D/S, dominance and submission; and S/M, sadism and masochism [18]. Other related terms are “kink,” “sadomasochism,” and “leather” or “paraphilia.” BDSM is a broad term and can include a wide variety of preferences and activities that may be performed in a sexual or non-sexual context [30]. Fundamental to BDSM is the concept of power exchange: one partner exerting control or influence over another. Psychological forms of BDSM may include subservience, humiliation, and/or “forced” behaviors. Physical forms of BDSM include spanking, bondage, flogging or whipping, hitting, beating, and piercing [18]. Depending upon context and preference, terms that refer to the person giving up power include “bottom,” “masochist,” “submissive,” “slave,” and “pet” [18]. Corresponding terms for the person who is taking control and/or controlling the experience are “top,” “sadist,” ”dominant,” “master,” and “owner,” respectively [18]. For the remainder of this manuscript, we will use the terms “top” and “bottom” as umbrella terms. “Switch” is a term applied to individuals who may alternate between roles as “top” or “bottom,” depending upon the context. BDSM practitioners will oftentimes characterize non-BDSM practitioners as “vanilla.” This term is not meant to be pejorative, but merely to differentiate more normative sexual practices from BDSM practices [18]. It is important to note that in healthy BDSM relationships, the activity is a consensual exchange; one individual voluntarily consents to give up power/control to another person [31]. Participants will often negotiate an encounter, also known as a “scene,” to discuss mutual interests and activity parameters. A signal or “safe word” indicating that the encounter needs to stop immediately for some reason is generally in place for participant safety and comfort. Either the “top” or “bottom” may use the safe word to abort the encounter at any time. Consensual BDSM differs markedly from abuse in ways that we will discuss shortly. Individuals who inflict pain or restriction on non-consenting partners are guilty of criminal offense and are not the subject of this primer. To be clear, the
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authors do not condone illegal or harmful behavior. We do seek to help providers make accurate assessments and decisions to benefit patients’ health and well-being. A series of questions that may be useful in differentiating abuse from consensual BDSM are presented in Table 3. Psychological Wellness and BDSM Practitioners BDSM interest and practice has long been considered a behavioral or psychological disorder. A common assumption is that members of this group have a history of sexual abuse or are mentally maladjusted [32]. A review of research on persons who engage in sadomasochistic sex found that a small subgroup of individuals who practice BDSM do have a history of sexual abuse [33]. However, an Australian national survey found that the practice of engaging in sadomasochistic sex was not significantly related to a history of sexual coercion or recent sexual dysfunction [3•]. Male participants who engaged in BDSM were significantly less likely to have elevated psychological distress. Female participants did not have higher levels of psychological distress when compared to female non-participants [3•]. As further research is conducted on people who engage in BDSM-related activities, there is increasing evidence that consensual BDSM is not an expression of psychopathology [11]. While people who engage in BDSM are likely to have problems similar to the general population, the recent evidence that has emerged indicates that BDSM practitioners are no more likely to have these issues. The fifth edition of the Diagnostic and Statistical Manual for Psychiatric Disorders (DSM-V) was released this year and is notable for the continued progress toward depathologizing individuals who engage in BDSM practices (classified as paraphilias in the DSM- IV-TR, 2000) with consenting adult partners. This development underscores the dearth of evidence for an association between BDSM practices and higher prevalence of mental or psychiatric disorders [3•, 11, 16]. Prevalence of BDSM It is estimated that 1–10 % of the general population has engaged in activity that could be construed as BDSM [3•, Table 3 Key questions to differentiate BDSM from abuse “Can you stop the activity at any time?” “Do you have a word or signal to stop?” “Will your partner stop as soon as you ask them to?” “What safety measures are you and your partners using? And how do you feel about it/do you feel that that is enough?” “Have things ever gotten out of control?” “Do you have any concerns about the safety with the activities you’re participating in?”
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16, 31]. A cross-sectional study of paraphilias of German men found that 15.5 % had engaged in sexual sadism and 2.3 % in sexual masochism [16]. An Australian national study found that 1.8 % of men and 1.2 % of women in the entire sample had engaged in BDSM [3•]. Several studies have found that individuals who identify with BDSM are generally highly educated and have higher incomes when compared to the general population [30, 33]. Given the diverse expression of BDSM, there are many individuals who may not identify with a BDSM community but have experience with BDSM activities [34]. Examples of BDSM activities that may be more frequently practiced by “vanilla” individuals include use of blindfolds or light restraints, name-calling or “dirty talk,” and sexual role play in which one partner is in a position of authority over the other (e.g., teacher/student).
General Issues Around Safety in BDSM BDSM-related activities, most commonly autoerotic asphyxiation, are sometimes highlighted in a sensational fashion in journals of forensic sciences [35]. Despite a relatively low prevalence of BDSM-associated injuries, the unusual nature of such occurrences tends to portray the risks as much higher than they actually are [36]. Reporting usually occurs when an activity such as breath control or bondage goes very wrong and someone is harmed or dies as a result [37, 38]. However, it appears that a significant proportion of individuals who engage in BDSM-related activities do not experience frequent or notable harm [39]. When discerning whether a BDSM behavior poses undue risk, consider potential physical and emotional harm, issues of consent, the patient’s understanding of risks and steps taken to reduce them, and local legal obligations. Reporting all patients who engage in unusual sexual behaviors may cause unnecessary harm if all parties involved are consenting adults. Laws vary by state regarding the legality of these behaviors, as some states do not permit individuals to “consent to abuse,” even if there are no complaining participants [40, 41]. There are several cases of people who have lost custody of children, security clearances, or jobs, or who have been victims of discrimination and prosecution because of involvement in BDSM behaviors [31, 42]. Whether there were any positive outcomes from these cases is unclear. A risk reduction strategy that respects patient preferences but suggests means to mitigate risk is more likely to succeed than an admonition not to engage in preferred activities. It is crucial to caution against mixing alcohol and/or illicit drugs with BDSM activities, as these substances may impair the ability to engage in these activities safely.
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Activities and Potential Complications BDSM activities that may cause physical harm include striking with a hand or implement, application of low-voltage electrical currents, piercing, and cutting. Complications of impact activities range from mild abrasions and bruises to skin lacerations, internal injuries, and broken bones. Again, it is important to understand that these complications may be the result of consensual activities. A thorough history is necessary to differentiate abuse from consensual BDSM when evaluating a patient who presents with this type of injury. Insertion of objects into orifices including the vagina, rectum, and urethra may be an aspect of BDSM activities for some individuals. A variety of implements may be used for this purpose, such as sex toys and vibrators, as well as household objects not typically intended for insertion or sexual activity. Potential complications include tears or perforations, urethral damage, infection, and loss of object inside the orifice. Safety recommendations include using equipment with a flared base or handle, copious application of lubricant (silicone or water-based) before insertion, and urinating after any activity involving the genitals. Hygiene suggestions include not sharing toys, using condoms as a barrier on toys, washing with soap or a bleach solution, and appropriate storage. Sexual activities that may spread infection include oralanal contact (rimming), urinating on another during sexual activity (golden showers), and urine drinking. It is important to counsel patients on the specific risks of these practices while maintaining a professional and respectful understanding of individual sexual preferences. Under normal circumstances, urine is sterile, so risks from exposure are generally low, assuming that the patient has not been receiving any form of toxic therapy that is excreted via the bladder. Areas of particular relevance for urologists include BDSM activities that involve the genital organs. The term “CBT” (acronym for “cock and ball torture” or “cock and ball titillation”) is an umbrella phrase used to describe various activities performed on the penis, scrotum, or testes. CBT may involve tickling, slapping, biting, impact, bondage, application of constrictive rings on the penis, restraint with chastity belts or devices, urethral sounding, piercing of genital skin, scrotal inflation with saline solution, or other activities. All of these activities carry some risk of genital injury, and therefore urologists should provide advice on risk reduction strategies (clean technique for piercings/sounding/inflation, avoidance of forceful blows against the erect penis, education on risks of restricting blood supply for prolonged periods, buckles or snaps with constrictive rings for ease of removal, etc.). Body modifications include permanent and temporary piercing, branding, cutting, scarification, and tattoos. Urologists are likely to see the extreme and worst cases of modifications and infections when there are complications and adverse outcomes. Most of the body modifications will heal
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without medical intervention, or the individual will go back to the artist for assistance before seeing a physician [18]. If you treat people with body modifications, it may be worth your time to talk with a few of the local artists.
Consensual Non-Monogamy Terminology Monogamy (having a single sexual partner) or serial monogamy (having successive sexually exclusive partners) is the presumed norm for relationships in the United States [43, 44]. Although monogamy in its various guises is the expressed norm, many individuals who are ostensibly monogamous engage in sexual activity outside of their dyad, oftentimes without the consent of their primary partner/spouse [45, 46]. Consensual non-monogamy is a situation in which a person or persons have sexual experiences (not necessarily sexual intercourse) outside of the relationship with their primary partner with the full knowledge and consent of all parties involved. Partners outside the dyad may be referred to as “secondary” or “tertiary” partners, although some experts find that ranking scheme lacking [47•]. The primary distinction between a non-monogamous/open relationship versus infidelity is that all involved parties are informed and consenting [4]. There are several varieties of non-monogamy. 1) The non-specific term “open relationship” refers to any consensual non-monogamous relationship. Many monogamous persons are in open relationships (i.e., allowed to date others) early on in a new relationship and then become exclusive with a primary partner over time. 2) “Swingers” are most typically married heterosexual persons who engage in recreational sex with persons other than their partner. Swingers do not typically seek to establish emotional relationships with their non-primary partners [4, 12]. 3) “Polyamory” typically refers to the practice of fostering more than one sexual relationship at a time. Unlike swinging, emotional attachments are often a part of each relationship [4]. “Polyfidelity” is a related term referring to a group of three or more persons who are sexually/ emotionally intimate with one another but not with persons outside the group.
Common Issues and Information Non-consensual non-monogamy, also known as cheating and infidelity, has been linked to rates of sexually transmitted infections and strains on emotional well-being and physical health [4, 48]. Consensual non-monogamous partners aim for
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the ethical treatment of their respective partners [3•]. They are more likely to discuss STI testing history with their other partner(s), use condoms, and inform their primary partner of the extradyadic encounter [49]. There are usually rules and boundaries set by the central individuals that are negotiated and may change over time [47•]. These may also include safety measures around condoms and exchanging body fluids. An example of rules and boundaries is an individual who can be sexual with other people as long as it is discussed in advance and appropriate safer sex precautions are utilized. Although safer sex practices are more common in consensual non-monogamy than in infidelity, individuals with more than one sexual partner are at higher risk for STI, and routine testing is warranted. This is typically the province of primary care providers but should be considered by urologists as well. Routine tests of import include gonorrhea/chlamydia, syphilis, and HIV.
Putting it All Together Given the rich diversity of human sexual expression, it is impossible for the physician to have an understanding that encompasses every sexual circumstance with which patients may present. However, one need not be an expert on LGBT issues, BDSM, or non-monogamy to provide professionally competent care for patients who belong to these communities. Approach the patient and the topic with respect, creating a safe space for the patient to express him/herself. The provider’s emotional safety is also important, and it may ne necessary to educate patients about omitting unnecessary details. Elicit information about sexual orientation, gender identity, and relevant sexual behaviors through thoughtful, nonjudgmental discussion and history-taking [5]. Establish risk reduction strategies grounded in peer-reviewed literature (when available) or your best judgment as a clinician. Try to find a middle ground with patients. If there is an irresolvable difference of opinion between you and the patient, it may be prudent to refer to another provider. The National Coalition for Sexual Freedom manages a listing of health care providers and other professionals who identify as “kink aware” and are comfortable caring for individuals with non-normative sexual practices (https://ncsfreedom.org/keyprograms/kink-awareprofessionals/kap-program-page.html). Building safe space and rapport involves personal and situational awareness. Creating a safe space for your patient to speak freely includes professionalism from your office staff, privacy from being overheard, and awareness of your judgments and reactions to potentially unpleasant or unusual circumstances. Stay aware of both the patient’s body language and your own. Keep the questions and physical specific and appropriate to the patient’s issue, not to satisfy prurient
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interest. When formulating follow-up questions, consider what information you need and why.
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Conclusions Non-normative sexual practices and identities are common. Urologists will inevitably encounter individuals whose gender identity, sexual orientation, and/or sexual expression differ from cultural norms. Professionalism and respect for each individual patient mandates that urologists and other providers make a good faith effort to provide care that is sensitive to the needs of patients whose sexual practices and lifestyles may differ from their own. Compliance with Ethics Guidelines Conflict of Interest Dr. Kathryn Akemi Ando and Dr. Tami Serene Rowen each declare no potential conflict of interest relevant to this article. Dr. Alan W. Shindel is a board member for SF Center for Sex and Culture, International Society for Sexual Medicine, and Sexual Medicine Society of North America. Dr. Shindel is a consultant for American Medical Systems, Cerner, and groupH. Dr. Shindel received a grant from UC Davis Loss Prevention Program and honoraria from International Society for Sexual Medicine, International Society for the Study of Women’s Sexual Health, Endo, and Elsevier. Dr. Shindel has had travel/ accommodations expenses covered or reimbursed by International Society for Sexual Medicine.
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14. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
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Xu F, Sternberg MR, Markowitz LE. Women who have sex with women in the United States: prevalence, sexual behavior and prevalence of herpes simplex virus type 2 infection-results from national health and nutrition examination survey 2001–2006. Sex Transm Dis. 2010;37(7):407–13. 2. Pathela P, Hajat A, Schillinger J, Blank S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York city men. Ann Intern Med. 2006;145(6):416–25. 3.• Richters J, de Visser RO, Rissel CE, Grulich AE, Smith AM. Demographic and psychosocial features of participants in bondage and discipline, “sadomasochism” or dominance and submission (BDSM): data from a national survey. J Sex Med. 2008;5(7): 1660–8. This-population based manuscript examines the demographic and psychological profile of BDSM practitioners. It was determined that there were no substantial differences in psychological profiles between BDSM practitioners and non-practitioners.
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Barker M, Langdridge D. Whatever happened to non-monogamies? Critical reflections on recent research and theory. Sexualities. 2010;6:748. Makadon HJ. Ending LGBT invisibility in health care: the first step in ensuring equitable care. Cleve Clin J Med. 2011;78(4):220–4. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding [Internet]. 2011. Available from: http://www.iom.edu/Reports/2011/The-Health-ofLesbian-Gay-Bisexual-and-Transgender-People.aspx. Accessed 21 Oct 2013. This Institute of Medicine Report catalogs disparities in health care experienced by members of LGBT communities and addresses key priorities in improving health outcomes for LGBT persons. Healthy people. Lesbian, gay, bisexual, and transgender health [Internet]. 2020. Available from: http://www.healthypeople.gov/ 2020/topicsobjectives2020/overview.aspx?topicid=25. Accessed 21 Oct 2013. Liu RT, Mustanski B. Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. Am J Prev Med. 2012;42(3):221–8. Skegg K. Self-harm. Lancet. 2005;366(9495):1471–83. Diagnostic and statistical manual of mental disorders (DSM) [Internet].; 2013. Available from: http://www.dsm5.org/about/ Pages/DSMVOverview.aspx. Accessed 21 Oct 2013. Wismeijer AA, van Assen MA. Psychological characteristics of BDSM practitioners. J Sex Med. 2013;10(8):1943–52. What psychology professionals should know about polyamory. [Internet]. Available from: http://ego.thechicagoschool.edu/s/843/ images/editor_documents/What%20therapists%20should% 20know%20about%20Polyamory.pdf. Accessed 21 Oct 2013. Meystre-Agustoni G, Jeannin A, de Heller K, Pecoud A, Bodenmann P, Dubois-Arber F. Talking about sexuality with the physician: are patients receiving what they wish? Swiss Med Wkly. 2011;141:w13178. Klitzman RL, Greenberg JD. Patterns of communication between gay and lesbian patients and their health care providers. J Homosex. 2002;42(4):65–75. Durso LE, Meyer IH. Patterns and predictors of disclosure of sexual orientation to healthcare providers among lesbians, gay men, and bisexuals. Sex Res Soc Policy. 2013;10(1):35–42. Ahlers CJ, Schaefer GA, Mundt IA, Roll S, Englert H, Willich SN, et al. How unusual are the contents of paraphilias? Paraphiliaassociated sexual arousal patterns in a community-based sample of men. J Sex Med. 2011;8(5):1362–70. Wentworth K, Ando K, Mark S, Vade D. Sexual history interview questions. In press 2012. Moser C. Health care without shame: a handbook for the sexually diverse and their caregivers. San Francisco: Greenery Press; 1999. Mindel A, Sawleshwarkar S. Condoms for sexually transmissible infection prevention: politics versus science. Sex Health. 2008;5(1): 1–8. Bennett SE, Assefi NP. School-based teenage pregnancy prevention programs: a systematic review of randomized controlled trials. J Adolesc Health. 2005;36(1):72–81. Dewaele A, Van Houtte M, Cox N, Vincke J. From coming out to visibility management–a new perspective on coping with minority stressors in LGB youth in flanders. J Homosex. 2013;60(5):685– 710. Buffie WC. Public health implications of same-sex marriage. Am J Public Health. 2011;101(6):986–90. LGBT terms and definitions [Internet]. Available from: http:// internationalspectrum.umich.edu/life/definitions. Accessed 21 Oct 2013. Diamant AL, Wold C, Spritzer K, Gelberg L. Health behaviors, health status, and access to and use of health care: a populationbased study of lesbian, bisexual, and heterosexual women. Arch Fam Med. 2000;9(10):1043–51.
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James P. National policy and sexual health of men who have sex with men. Br J Nurs. 2009;18(3):181–7. Sandfort TG, de Keizer M. Sexual problems in gay men: an overview of empirical research. Annu Rev Sex Res. 2001;12:93– 120. Mail P, Safford L. LGBT disease prevention and health promotion: Wellness for gay, lesbian, bisexual, and transgender individuals and communities. Clin Res Regul Aff. 2003;20(2):183. Urban RR, Teng NN, Kapp DS. Gynecologic malignancies in female-to-male transgender patients: the need of original gender surveillance. Am J Obstet Gynecol. 2011;204(5):e9–e12. Lee PA, Houk CP, Ahmed SF, Hughes IA. International consensus conference on intersex organized by the Lawson Wilkins pediatric endocrine society and the European society for paediatric endocrinology. Consensus statement on management of intersex disorders. International consensus conference on intersex. Pediatrics. 2006;118(2):e488–500. Moser C, Levitt E. An explanatory–descriptive study of a sadomasochistically oriented sample. J Sex Res. 1987;23:322–37. Moser C, Kleinplatz PJ. Introduction: the state of our knowledge on SM. J Homosex. 2006;50(2–3):1–15. Taylor G, Ussher J. Making sense of S&M: a discourse analytic account. Sexualities. 2002;4:293–314. Sandnabba K, Santtila P, Alison L, Nordling N. Demographics, sexual behaviour, family background and abuse experiences of practitioners of sadomasochistic sex: a review of recent research. Sex Relationsh Ther. 2002;17(1):39–55. Kinsey A, Pomeroy W, Martin C. Sexual behavior in the human male. Philadelphia: Saunders; 1948. Janssen W, Koops E, Anders S, Kuhn S, Puschel K. Forensic aspects of 40 accidental autoerotic deaths in northern germany. Forensic Sci Int. 2005;147(Suppl):S61–4. Sauvageau A. Autoerotic deaths: a 25-year retrospective epidemiological study. Am J Forensic Med Pathol. 2012;33(2):143–6. Garza-Leal JA, Landron FJ. Autoerotic asphyxial death initially misinterpreted as suicide and a review of the literature. J Forensic Sci. 1991;36(6):1753–9. Hazelwood R, Dietz P, Burgess A. Autoerotic fatalities. Massachusetts: Lexington Books; 1983. Ando K. Attitudes and behaviors concerning erotic breath control. 2009. Bergelson V. The right to be hurt: testing the boundaries of consent. George Wash Law Rev. 2007;75(2):165–236. Pa M. Beyond the pleasure principle: the criminalization of consensual sadomasochistic sex. Tex J Women Law. 2002;11:51–92. Wright S. Discrimination of SM-identified individuals. J Homosex. 2006;50(2–3):217–31. Norris AE, Ford K. Sexual experiences and condom use of heterosexual, low-income African American and Hispanic youth
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practicing relative monogamy, serial monogamy, and nonmonogamy. Sex Transm Dis. 1999;26(1):17–25. Jokela M, Rotkirch A, Rickard I, Pettay J, Lummaa V. Serial monogamy increases reproductive success in men but not in women. Behav Ecol. 2010;21:906–12. Laumann EO, Gagnon JH, Michael RT, Michaels S. The social organization of sexuality: sexual practices in the United States. Chicago: University of Chicago Press; 2000. Atkins DC, Baucom DH, Jacobson NS. Understanding infidelity: correlates in a national random sample. J Fam Psychol. 2001;15(4):735–49. Easton D, Liszt C. The ethical slut: A guide to infinite sexual possibilities. Greenery Press; 1997. One of the preeminent sources of information on healthy cultivation of non-mongamous relationships. Lehmiller JJ. Secret romantic relationships: consequences for personal and relational well-being. Pers Soc Psychol Bull. 2009;35(11):1452–66. Conley TD, Moors AC, Ziegler A, Karathanasis C. Unfaithful individuals are less likely to practice safer sex than openly nonmonogamous individuals. J Sex Med. 2012;9(6):1559–65.
Resources for further reading
50. Association of Reproductive Health Professionals (ARHP). 2010. Sexual Health Fundamentals for Patient Care Initiative: Report of a US Consensus Process. Available at: http://www.arhp.org/ uploadDocs/RH10_Dominguez2.pdf. 51. Dibble R, Robertson P. Lesbian health 101: a clinician’s guide. San Francisco: UCSF Nursing Press; 2010. 52. Easton D, Hardy J. The ethical slut: a roadmap for relationship pioneers. Berkeley: Celestial Arts; 2009. 53. Easton D, Hardy J. When someone you love is kinky. Emeryville: Greenery Press; 2000. 54. Eliason MJ, Dibble S, DeJoseph J, Chinn P. LGBTQ Cultures: what health care professionals need to know about sexual and gender diversity. 2009. 55. Family Acceptance Project: http://familyproject.sfsu.edu/. 56. Gay & Lesbian Medical Association: http://www.glma.org/. 57. Human Rights Campaign: http://www.hrc.org/. 58. Parents, Families and Friends of Lesbians and Gays: http:// community.pflag.org/. 59. Taormino T. Opening up: a guide to creating and sustaining open relationships. San Francisco: Cleis Press; 2008. 60. World Professional Association for Transgender health: http://www. wpath.org/. 61. Youth Resource (website by and for LGBT youth): http:// youthresource.com/.
MEN'S HEALTH (R CARRION AND C YANG, SECTION EDITORS)
Alternative Sexualities: Implications for the Urologist Kathryn Akemi Ando & Tami Serene Rowen & Alan W. Shindel
Published online: 23 March 2014 # Springer Science+Business Media New York 2014
Abstract Urologists routinely deal with sensitive issues of urinary function as well as sexuality in daily practice. Even experienced urologists may encounter patients who engage in sexual practices that are novel, unknown, or perhaps disturbing to the provider. This primer will serve as an introduction to sexual practices and lifestyle choices that may be foreign to many practicing urologists. It is by no means an exhaustive description of alternative sexualities, but will hopefully serve as a useful introduction to the topic and will enhance the ability of providers to care for, or appropriately refer, patients whose sexual practices and lifestyles may differ from their own.
Keywords LGBT . Gay . Lesbian . Transgender . BDSM . Sadism . Masochism . Open relationship . Polyamory . Sexual minority . Disparity . Discrimination
This article is part of the Topical Collection on Men’s Health K. A. Ando Department of Emergency Medicine, San Mateo Medical Center, San Mateo, CA, USA K. A. Ando Project Prepare, San Francisco, CA, USA T. S. Rowen Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA A. W. Shindel (*) Department of Urology, University of California, Davis, Sacramento, CA, USA e-mail: [email protected]
Introduction Urologists are widely acknowledged for their ability to address sensitive health issues with tact, respect, and (when appropriate) good humor. Despite this reputation, even experienced urologists are likely to sometimes encounter unusual and/or very sensitive clinical situations. In particular, urologists who make the care of sexual health problems part of their practice may occasionally encounter patients who engage in non-normative sexual practices or lifestyles. While there is no precise definition of “non-normative” sexual practice (and cultural notions of what is normative are constantly evolving), we find it helpful to loosely group non-normative sexual activities into three categories: 1) Individuals who engage in sexual activity with samegender partners (i.e., lesbian, gay, bisexual) or who do not identify with the gender assigned to them at birth (transgender). These individuals are often grouped together as members of LGBT (lesbian/gay/bisexual/transgender) communities. 2) Individuals who practice bondage, domination, and/or sadomasochism (BDSM, sometimes called “kink” or “paraphilias”). BDSM is often, but not always, practiced in association with sexual activities. 3) Individuals who are in consensually non-monogamous sexual relationships (e.g., swingers, polyamorous individuals, those in open relationships, etc.). It is common knowledge that many ostensibly monogamous persons engage in sexual activity with persons other than their partner. In this manuscript, we will focus on individuals who engage in sexual activity outside their “primary” relationship with the knowledge and consent of their partner(s). A few salient points must be made about this grouping. First, many individuals may engage in some of these activities
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but not identify with a given community. For instance, the success of the “50 Shades of Grey” trilogy has likely motivated some individuals to explore BDSM as part of their sexual repertoire. Although such individuals may engage in BDSM activity, they may not necessarily identify with BDSM communities. Similarly, some persons have engaged in sexual activity with partners of the same gender but do not identify as “lesbian,” “gay,” or “bisexual” [1]. The terms “men who have sex with men” (MSM) and “women who have sex with women” (WSW) are sometimes used as a more inclusive term to refer to behaviors rather than identities. One should not assume group membership based solely on sexual proclivity or practice. Second, while individuals who belong to one of these three groups are statistically more likely to belong to one of the others, this is not always the case (e.g., persons who practice BDSM may or may not be in an open relationship, etc.) [2, 3•, 4]. It is important for providers to recognize that these communities and practices are highly individual, and addressing each behavior separately is necessary to fully evaluate an individual’s sexual health practices. Health care providers may find it professionally and personally challenging to care for patients who engage in non-normative sexual practices. This often stems from unfamiliarity with the types of activities or a belief that such activities/lifestyles are abnormal or even immoral. Providers are certainly not required to condone sexual behaviors to which they have a moral or religious objection or to directly provide care for such patients in non-emergency situations. However, medical professionalism dictates that if a provider is not comfortable caring for a patient because of that individual’s lifestyle, the most appropriate step is a referral to another provider. A provider should not pass moral judgment on or attempt to change a patient’s lifestyle preferences unless 1) the patient requests it or 2) there is imminent danger to the patient’s health and well-being. This includes reportable offenses, any form of nonconsensual abuse, and physical or mental harm. Because some forms of BDSM activity carry the implied or real risk of physical or mental harm, this criterion should be applied judiciously in the setting of BDSM activities between consenting adults. This manuscript will serve as a brief primer for urologists on non-normative sexual practices. We will review terminology and slang related to alternative sexualities, as well as some particular concerns of each population, and we will describe ways to address common concerns for these populations. Readers who desire a more comprehensive discussion are referred to more detailed literature listed in the references.
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Common Issues for Persons with Non-Normative Sexual Behaviors Physical and Mental Health Disparities Most of the physical health (and urologic) issues in people who engage in non-normative sexual practices are the same as those in the general population [5]. However, some sexual practices are associated with greater risks (e.g., HIV transmission with anal sex), and hence some health problems are more prevalent among individuals with non-normative sexual practices [6•]. There are robust data indicating that LGBT individuals experience increased rates of psychological morbidity, substance abuse, and suicide; it is thought that in most cases this higher rate of mental health issues is related to societal stigma and discrimination [7]. These problems are particularly prominent in LGBT youth, who may face rejection from their families and peer groups, resulting in greater burden of mental health issues compared to their heterosexual peers [8, 9]. Although BDSM interest or activity has historically been considered by experts to be a mental disorder, the recently released fifth edition of the Diagnostic and Statistical Manual on Mental Health Disorders states that “a paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention” [10]. There are few convincing data indicating that, after adjusting for other comorbidities, individuals who engage in BDSM have higher prevalence of mental disorders [11]. Data on mental health in individuals in consensually non-monogamous relationships are sparse [12]. Communicating About Sex Many patients, even when they have sexuality-related concerns, are hesitant to discuss sexuality with their providers [13]. It is well-documented that many patients fear being judged for their sexual practices, and this fear is amplified in individuals who practice non-normative sexual behaviors [14, 15]. It is incumbent upon health care providers to facilitate open communication about sex during clinic visits [15]. However, the routine questions providers often ask about sexual activity may not elicit all of the information relevant to persons with non-normative sexual practices [16]. The most common example of failure to elicit a complete sexual history is the assumption that a patient is heterosexual when they are, in fact, lesbian or gay. A more subtle example is an assumption about certain sexual activities in particular individuals. For example, a provider who assumes that all of his gay male patients engage in anal intercourse may not ask the appropriate questions for any given patient’s concerns. In general, it is best not to assume anything about sexual practices, and rather
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to allow the patient themselves to disclose the relevant information, with appropriate prompting as required. When formulating history questions for your patients, consider why the information is important, and share the reasoning with the patient if they are reticent to discuss. Generally it is best to use open-ended questions to elicit sexual health information. Examples are included in Table 1. These may be adapted as appropriate, but care should be taken to ensure that the provider does not make explicit or implicit assumptions when asking questions. Normalizing statements may also be useful in establishing that the provider is accepting of non-normative sexual practices. While it may be difficult to completely avoid statements that offend or bother some patients, most patients appreciate a genuine effort to be inclusive/accepting. It is prudent to discuss confidentiality and mandatory reporting requirements with your patient prior to these questions.
Respecting Sexual Preferences
Terminology
“Coming out” refers to the process of a person communicating their sexual identity to others [21]. This has classically referred to the process of disclosing a non-heterosexual orientation or a transgender identity. However, it may refer to disclosure of other non-normative sexual practices as well, such as open relationships or BDSM. The coming-out process can be a stressful ordeal, and may be ongoing and protracted over the patient’s lifespan as they come out to friends, family, coworkers, landlords, and health care providers. Some individuals never come out, and it may not always be necessary for individuals to disclose their identity or practices publicly and to all persons [21]. Some young members of LGBT communities view “coming out” as outdated because they have a supportive social environment and do not feel shame about their sexual identity [21]. For older LGBT generations or other sexual minorities, shame associated with sexual identity and difficulties coming out may be more prevalent [22].
Part of the respect for preferences is use of appropriate terminology. Terminology for persons with non-normative sexual practices may be fluid and may vary by social group and generation. For example, a young gay male may selfidentify as a “queer,” but a gay male of an older generation may be seriously offended by the term. Terminology is particularly important when speaking to transgendered persons. Many will reject the anatomical names for parts of their body that are discordant with their gender identity (e.g., some maleto-female transgender persons may prefer the term “clitoris” to “penis” when referring to their phallic organ). Terminology is also relevant when speaking about sexual activities. When speaking about specific sexual practices or identities, feel free to (respectfully) ask for clarification of unfamiliar terms and for preferred terminology. Using the patient’s terminology in response may help to build rapport, although caution should be exercised, as using the patient’s terminology may not always be appropriate in a professional setting. It is important to recognize that context and intent, as well as the role of the person uttering a term, have major implications. When in doubt, do not utilize slang terms that could lead to serious offense [5, 17, 18]. Table 1 Opening sexual health questions (adapted from: Wentworth, Ando, Mark & Vade, 2012; Makadon, 2011, Moser 1999 [5, 17, 18]) 1) “I am going to ask you some questions about your sexual health and sexuality that I ask all of my patients. The answers to these questions are important for me to know to help keep you healthy. Like the rest of this visit, this information is strictly confidential.” 2) “Do you have any concerns or questions about your sexuality, sexual orientation, or sexual desires?” 3) “Are you in sexual relationship with a partner? Are there any changes in your sexual life that you want to discuss?”
Sexual preferences are often deeply engrained and not easily changed. A provider who offers suggestions designed to reduce risk is more likely to promote patient wellness than one who admonishes patients to simply avoid cherished sexual or erotic practice(s). This approach is similar to encouraging safer sex with condoms and routine testing for sexually transmitted infections; there are numerous data that support safer sex education as more effective than abstinence-only interventions [19, 20]. If there is an activity that you consider particularly unsafe, ask the patient additional questions regarding how they engage in the behavior. Involve the patient in the discussion and offer harm reduction strategies rather than paternalistic directives. “Coming Out” and Community Identity
LGBTQ Terminology The familiar acronym LGBT stands for Lesbian, Gay, Bisexual, Transgender [23]. In recent years, the letter Q for “queer” has been added to this acronym in some contexts. Queer in this case is an umbrella term for individuals who see themselves outside of a binary gender identity or orientation, but without specifying a particular preference. The letter Q may also stand for “questioning,” an individual who has not yet fully established their sexual orientation or identity. Less commonly, I (for intersex), and A (for asexual, not endorsing sexual interest in any partner) may be added to the LGBT acronym.
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The health disparities such as poor health and reduced access to health care experienced by LGBT persons are well-established. Working to eliminate disparities in care for LGBT populations has been identified as a priority in the U.S. government’s Healthy People 2020 initiative [7, 24]. The first step in discussing LGBT health issues is eliciting information about sexual orientation and interests from patients. Some proposed language to initiate discussion with patients about sexual orientation is outlined in Table 2. Unlike race or gender, sexual orientation is invisible. LGBT individuals are often subject to subtle, inadvertent, or insensitive attacks on their identity. This may be perpetrated even by providers who profess no objection to LGBT sexual preferences. For instance, asking a woman if she has a boyfriend or husband is an assumption with implications of what is normal, and may lead to offense if she is partnered with or prefers women [22]. Use of gender-neutral terms for significant others is advisable until the patient has disclosed the gender of any person(s) with whom they are in a relationship. Culturally competent care and improved understanding of how urinary symptoms and sexual dysfunction affects MSM and WSW are important topics for research and development [25, 26]. Sexuality in MSM has been a topic of great research interest, due primarily to the HIV epidemic. However, peerreviewed publications on topics focused on quality of life,, such as promoting sexual wellness and treating sexual dysfunction in MSM, are scant; similar research on WSW is even less prevalent. In general, it appears that risk factors for sexual dysfunction are similar between heterosexual and nonheterosexual persons, although how dysfunction manifests and the intrapersonal and psychological toll it takes may vary. Trans- and Intersex Transgendered persons merit special consideration separate from lesbians, gay men, and bisexuals in that they have the unique challenge of contending with non-normative gender identity. Social recrimination against transgendered individuals is common and is a source of significant psychological and often somatic morbidity [8]. It is important to distinguish between transgendered, transsexual and transvestite, as these terms are too often used interchangeably, though some individuals simply identify as trans. There are tremendous differences between and within Table 2 Questions on sexual orientation and partner preference 1) “What gender pronoun do you want me to use when referring to you?” (useful for transgendered patients) 2) “Is/are your sexual partner(s) female, male, or both?” 3) “Some people have sex with women, some with men, and others with both men and women. What is the gender of your current sexual partner(s)?”
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these populations. It is critical to elicit a thorough history as wells as the patient’s own feelings regarding their gender identity. Transsexual people feel that they are in the body of the wrong sex and usually desire hormonal and/or surgical treatment to rectify the difference [18]. They are sometimes divided into MTF (male to female) and FTM (female to male), and further classified as pre-op, post-op, or non-op groups, referring to their status regarding gender reassignment surgery [18]. Gender reassignment surgery may also be characterized as “top surgery” (e.g., removal of breast tissue in FTM and placement of breast implants in MTF) and “bottom surgery” (e.g., creation of a neophallus in FTM or creation of a neovagina in MTF). It is important to address both physical and psychological concerns in transsexual persons. Backgrounds, goals, and ability to make a transition to another gender vary among transsexual individuals and may not be apparent from their appearance. Consider asking what their hopes and plans, if any, are for gender transition. Gender reassignment is a very long process that involves psychiatric, endocrinologic, and surgical evaluation [27]. Counseling and hormone therapy are initiated before surgical procedures begin. The process may cause emotional and mental distress and may strain relationships with the patient’s family and friends. Estrogen therapy may carry risks such as thromboembolism and liver abnormalities; androgen therapy may be a risk factor for heart disease, endometrial hyperplasia, and some carcinomas [27]. If the uterus, breasts, or cervix are maintained in FTM patients or the prostate in MTF patients, screening for the relevant cancers is indicated, and additional screening for new risk factors secondary to hormonal treatment may be warranted [28]. Gender reassignment and hormone therapy may lead to changes in sexual interest, responsiveness, and function [27]. Transgender is a term used to describe an identity rather than a permanent physical change [18]. Transgendered individuals often do not see themselves as fitting within the binary constructs of gender and/or sex. A transgendered person’s appearance and gender identity may be fluid or present as androgynous. Some transgendered people are transsexuals who do not want surgery [18]. Transvestites, also known as “cross dressers,” dress in the clothing of the opposite gender. The apparel may be for sexual stimulation or purely for comfort. Transvestites who dress in an exuberant translation of the opposite sex are known as “drag queens” (men dressed as women) or “drag kings” (women dressed as men) and sometimes develop personas for performance or events [18]. Intersex, formerly known as “pseudohermaphroditism,” “hermaphroditism,” or “sex reversal,” is most appropriately known today as “disorders of sex development” (DSD) [29]. The older terms are seen by patients and families as confusing and potentially pejorative. In a consensus statement, Lee et al.
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(2006) proposed that the term be defined as “congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical.” These patients have often undergone genital surgery during childhood, which historically has led to some dissatisfaction on the part of the individual regarding decisions that were made on their behalf. Understanding the anatomy, gender identity, and sexual identity of intersex persons is essential in addressing their specific urologic health concerns. BDSM and Paraphilias Terminology The acronym BDSM can actually comprise three separate terms of two words each. Broken down, it is BD/DS/SM: B/D, bondage and dominance; D/S, dominance and submission; and S/M, sadism and masochism [18]. Other related terms are “kink,” “sadomasochism,” and “leather” or “paraphilia.” BDSM is a broad term and can include a wide variety of preferences and activities that may be performed in a sexual or non-sexual context [30]. Fundamental to BDSM is the concept of power exchange: one partner exerting control or influence over another. Psychological forms of BDSM may include subservience, humiliation, and/or “forced” behaviors. Physical forms of BDSM include spanking, bondage, flogging or whipping, hitting, beating, and piercing [18]. Depending upon context and preference, terms that refer to the person giving up power include “bottom,” “masochist,” “submissive,” “slave,” and “pet” [18]. Corresponding terms for the person who is taking control and/or controlling the experience are “top,” “sadist,” ”dominant,” “master,” and “owner,” respectively [18]. For the remainder of this manuscript, we will use the terms “top” and “bottom” as umbrella terms. “Switch” is a term applied to individuals who may alternate between roles as “top” or “bottom,” depending upon the context. BDSM practitioners will oftentimes characterize non-BDSM practitioners as “vanilla.” This term is not meant to be pejorative, but merely to differentiate more normative sexual practices from BDSM practices [18]. It is important to note that in healthy BDSM relationships, the activity is a consensual exchange; one individual voluntarily consents to give up power/control to another person [31]. Participants will often negotiate an encounter, also known as a “scene,” to discuss mutual interests and activity parameters. A signal or “safe word” indicating that the encounter needs to stop immediately for some reason is generally in place for participant safety and comfort. Either the “top” or “bottom” may use the safe word to abort the encounter at any time. Consensual BDSM differs markedly from abuse in ways that we will discuss shortly. Individuals who inflict pain or restriction on non-consenting partners are guilty of criminal offense and are not the subject of this primer. To be clear, the
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authors do not condone illegal or harmful behavior. We do seek to help providers make accurate assessments and decisions to benefit patients’ health and well-being. A series of questions that may be useful in differentiating abuse from consensual BDSM are presented in Table 3. Psychological Wellness and BDSM Practitioners BDSM interest and practice has long been considered a behavioral or psychological disorder. A common assumption is that members of this group have a history of sexual abuse or are mentally maladjusted [32]. A review of research on persons who engage in sadomasochistic sex found that a small subgroup of individuals who practice BDSM do have a history of sexual abuse [33]. However, an Australian national survey found that the practice of engaging in sadomasochistic sex was not significantly related to a history of sexual coercion or recent sexual dysfunction [3•]. Male participants who engaged in BDSM were significantly less likely to have elevated psychological distress. Female participants did not have higher levels of psychological distress when compared to female non-participants [3•]. As further research is conducted on people who engage in BDSM-related activities, there is increasing evidence that consensual BDSM is not an expression of psychopathology [11]. While people who engage in BDSM are likely to have problems similar to the general population, the recent evidence that has emerged indicates that BDSM practitioners are no more likely to have these issues. The fifth edition of the Diagnostic and Statistical Manual for Psychiatric Disorders (DSM-V) was released this year and is notable for the continued progress toward depathologizing individuals who engage in BDSM practices (classified as paraphilias in the DSM- IV-TR, 2000) with consenting adult partners. This development underscores the dearth of evidence for an association between BDSM practices and higher prevalence of mental or psychiatric disorders [3•, 11, 16]. Prevalence of BDSM It is estimated that 1–10 % of the general population has engaged in activity that could be construed as BDSM [3•, Table 3 Key questions to differentiate BDSM from abuse “Can you stop the activity at any time?” “Do you have a word or signal to stop?” “Will your partner stop as soon as you ask them to?” “What safety measures are you and your partners using? And how do you feel about it/do you feel that that is enough?” “Have things ever gotten out of control?” “Do you have any concerns about the safety with the activities you’re participating in?”
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16, 31]. A cross-sectional study of paraphilias of German men found that 15.5 % had engaged in sexual sadism and 2.3 % in sexual masochism [16]. An Australian national study found that 1.8 % of men and 1.2 % of women in the entire sample had engaged in BDSM [3•]. Several studies have found that individuals who identify with BDSM are generally highly educated and have higher incomes when compared to the general population [30, 33]. Given the diverse expression of BDSM, there are many individuals who may not identify with a BDSM community but have experience with BDSM activities [34]. Examples of BDSM activities that may be more frequently practiced by “vanilla” individuals include use of blindfolds or light restraints, name-calling or “dirty talk,” and sexual role play in which one partner is in a position of authority over the other (e.g., teacher/student).
General Issues Around Safety in BDSM BDSM-related activities, most commonly autoerotic asphyxiation, are sometimes highlighted in a sensational fashion in journals of forensic sciences [35]. Despite a relatively low prevalence of BDSM-associated injuries, the unusual nature of such occurrences tends to portray the risks as much higher than they actually are [36]. Reporting usually occurs when an activity such as breath control or bondage goes very wrong and someone is harmed or dies as a result [37, 38]. However, it appears that a significant proportion of individuals who engage in BDSM-related activities do not experience frequent or notable harm [39]. When discerning whether a BDSM behavior poses undue risk, consider potential physical and emotional harm, issues of consent, the patient’s understanding of risks and steps taken to reduce them, and local legal obligations. Reporting all patients who engage in unusual sexual behaviors may cause unnecessary harm if all parties involved are consenting adults. Laws vary by state regarding the legality of these behaviors, as some states do not permit individuals to “consent to abuse,” even if there are no complaining participants [40, 41]. There are several cases of people who have lost custody of children, security clearances, or jobs, or who have been victims of discrimination and prosecution because of involvement in BDSM behaviors [31, 42]. Whether there were any positive outcomes from these cases is unclear. A risk reduction strategy that respects patient preferences but suggests means to mitigate risk is more likely to succeed than an admonition not to engage in preferred activities. It is crucial to caution against mixing alcohol and/or illicit drugs with BDSM activities, as these substances may impair the ability to engage in these activities safely.
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Activities and Potential Complications BDSM activities that may cause physical harm include striking with a hand or implement, application of low-voltage electrical currents, piercing, and cutting. Complications of impact activities range from mild abrasions and bruises to skin lacerations, internal injuries, and broken bones. Again, it is important to understand that these complications may be the result of consensual activities. A thorough history is necessary to differentiate abuse from consensual BDSM when evaluating a patient who presents with this type of injury. Insertion of objects into orifices including the vagina, rectum, and urethra may be an aspect of BDSM activities for some individuals. A variety of implements may be used for this purpose, such as sex toys and vibrators, as well as household objects not typically intended for insertion or sexual activity. Potential complications include tears or perforations, urethral damage, infection, and loss of object inside the orifice. Safety recommendations include using equipment with a flared base or handle, copious application of lubricant (silicone or water-based) before insertion, and urinating after any activity involving the genitals. Hygiene suggestions include not sharing toys, using condoms as a barrier on toys, washing with soap or a bleach solution, and appropriate storage. Sexual activities that may spread infection include oralanal contact (rimming), urinating on another during sexual activity (golden showers), and urine drinking. It is important to counsel patients on the specific risks of these practices while maintaining a professional and respectful understanding of individual sexual preferences. Under normal circumstances, urine is sterile, so risks from exposure are generally low, assuming that the patient has not been receiving any form of toxic therapy that is excreted via the bladder. Areas of particular relevance for urologists include BDSM activities that involve the genital organs. The term “CBT” (acronym for “cock and ball torture” or “cock and ball titillation”) is an umbrella phrase used to describe various activities performed on the penis, scrotum, or testes. CBT may involve tickling, slapping, biting, impact, bondage, application of constrictive rings on the penis, restraint with chastity belts or devices, urethral sounding, piercing of genital skin, scrotal inflation with saline solution, or other activities. All of these activities carry some risk of genital injury, and therefore urologists should provide advice on risk reduction strategies (clean technique for piercings/sounding/inflation, avoidance of forceful blows against the erect penis, education on risks of restricting blood supply for prolonged periods, buckles or snaps with constrictive rings for ease of removal, etc.). Body modifications include permanent and temporary piercing, branding, cutting, scarification, and tattoos. Urologists are likely to see the extreme and worst cases of modifications and infections when there are complications and adverse outcomes. Most of the body modifications will heal
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without medical intervention, or the individual will go back to the artist for assistance before seeing a physician [18]. If you treat people with body modifications, it may be worth your time to talk with a few of the local artists.
Consensual Non-Monogamy Terminology Monogamy (having a single sexual partner) or serial monogamy (having successive sexually exclusive partners) is the presumed norm for relationships in the United States [43, 44]. Although monogamy in its various guises is the expressed norm, many individuals who are ostensibly monogamous engage in sexual activity outside of their dyad, oftentimes without the consent of their primary partner/spouse [45, 46]. Consensual non-monogamy is a situation in which a person or persons have sexual experiences (not necessarily sexual intercourse) outside of the relationship with their primary partner with the full knowledge and consent of all parties involved. Partners outside the dyad may be referred to as “secondary” or “tertiary” partners, although some experts find that ranking scheme lacking [47•]. The primary distinction between a non-monogamous/open relationship versus infidelity is that all involved parties are informed and consenting [4]. There are several varieties of non-monogamy. 1) The non-specific term “open relationship” refers to any consensual non-monogamous relationship. Many monogamous persons are in open relationships (i.e., allowed to date others) early on in a new relationship and then become exclusive with a primary partner over time. 2) “Swingers” are most typically married heterosexual persons who engage in recreational sex with persons other than their partner. Swingers do not typically seek to establish emotional relationships with their non-primary partners [4, 12]. 3) “Polyamory” typically refers to the practice of fostering more than one sexual relationship at a time. Unlike swinging, emotional attachments are often a part of each relationship [4]. “Polyfidelity” is a related term referring to a group of three or more persons who are sexually/ emotionally intimate with one another but not with persons outside the group.
Common Issues and Information Non-consensual non-monogamy, also known as cheating and infidelity, has been linked to rates of sexually transmitted infections and strains on emotional well-being and physical health [4, 48]. Consensual non-monogamous partners aim for
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the ethical treatment of their respective partners [3•]. They are more likely to discuss STI testing history with their other partner(s), use condoms, and inform their primary partner of the extradyadic encounter [49]. There are usually rules and boundaries set by the central individuals that are negotiated and may change over time [47•]. These may also include safety measures around condoms and exchanging body fluids. An example of rules and boundaries is an individual who can be sexual with other people as long as it is discussed in advance and appropriate safer sex precautions are utilized. Although safer sex practices are more common in consensual non-monogamy than in infidelity, individuals with more than one sexual partner are at higher risk for STI, and routine testing is warranted. This is typically the province of primary care providers but should be considered by urologists as well. Routine tests of import include gonorrhea/chlamydia, syphilis, and HIV.
Putting it All Together Given the rich diversity of human sexual expression, it is impossible for the physician to have an understanding that encompasses every sexual circumstance with which patients may present. However, one need not be an expert on LGBT issues, BDSM, or non-monogamy to provide professionally competent care for patients who belong to these communities. Approach the patient and the topic with respect, creating a safe space for the patient to express him/herself. The provider’s emotional safety is also important, and it may ne necessary to educate patients about omitting unnecessary details. Elicit information about sexual orientation, gender identity, and relevant sexual behaviors through thoughtful, nonjudgmental discussion and history-taking [5]. Establish risk reduction strategies grounded in peer-reviewed literature (when available) or your best judgment as a clinician. Try to find a middle ground with patients. If there is an irresolvable difference of opinion between you and the patient, it may be prudent to refer to another provider. The National Coalition for Sexual Freedom manages a listing of health care providers and other professionals who identify as “kink aware” and are comfortable caring for individuals with non-normative sexual practices (https://ncsfreedom.org/keyprograms/kink-awareprofessionals/kap-program-page.html). Building safe space and rapport involves personal and situational awareness. Creating a safe space for your patient to speak freely includes professionalism from your office staff, privacy from being overheard, and awareness of your judgments and reactions to potentially unpleasant or unusual circumstances. Stay aware of both the patient’s body language and your own. Keep the questions and physical specific and appropriate to the patient’s issue, not to satisfy prurient
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interest. When formulating follow-up questions, consider what information you need and why.
Curr Urol Rep (2014) 15:405 4.
5.
Conclusions Non-normative sexual practices and identities are common. Urologists will inevitably encounter individuals whose gender identity, sexual orientation, and/or sexual expression differ from cultural norms. Professionalism and respect for each individual patient mandates that urologists and other providers make a good faith effort to provide care that is sensitive to the needs of patients whose sexual practices and lifestyles may differ from their own. Compliance with Ethics Guidelines Conflict of Interest Dr. Kathryn Akemi Ando and Dr. Tami Serene Rowen each declare no potential conflict of interest relevant to this article. Dr. Alan W. Shindel is a board member for SF Center for Sex and Culture, International Society for Sexual Medicine, and Sexual Medicine Society of North America. Dr. Shindel is a consultant for American Medical Systems, Cerner, and groupH. Dr. Shindel received a grant from UC Davis Loss Prevention Program and honoraria from International Society for Sexual Medicine, International Society for the Study of Women’s Sexual Health, Endo, and Elsevier. Dr. Shindel has had travel/ accommodations expenses covered or reimbursed by International Society for Sexual Medicine.
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11. 12.
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14. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.
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Resources for further reading
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