By Julia Soudat

In honour of Dr. Powell, we asked five primary care physicians about the most commonly asked sex questions they get from their patients, and how they answer them.

Do you have a sex-related question you’ve been wanting to ask a doctor? Submit your questions here — anonymously! Our experts, Drs. Sheila Wijayasinghe, James Owen, Kymm Feldman, Charlie Guiang and Andrea Lobo will be happy to answer.

Feature question:

Q: Do you recommend that all males that have casual sex with males are on PrEP, regardless of the consistency with which condoms are used?

PrEP is not for everybody. PrEP requires very good adherence, has potential short and long term side effects, should be combined with other prevention strategies, and must be monitored periodically by your care provider that includes regular HIV testing. Canadian PrEP guidelines exist, developed by Dr. Darrel Tan (University of Toronto, St. Michael’s) and team, that have specific recommendations for Men Who Have sex with Men (MSM).

There is evidence that supports use of PrEP in MSM (high quality evidence) and transgender women (moderate quality of evidence) and they include those who report condomless anal sex within the last six months and who have any of the following: syphilis or rectal sexually transmitted infection (STI) – such as Gonorrhea and/or Chlamydia; more than one time use of nonoccupational postexposure prophylaxis (nPEP); ongoing sexual relationship with HIV-positive partner with substantial risk of transmissible HIV (viral load that is “detectable” or greater than 40 copies per ml); there is moderate quality of evidence that supports not recommending PrEP in the context of a stable closed relationship with a single partner with no or negligible risk of having transmissible HIV (“undetectable” viral load less than 40 copies/ml)

Top Sex Questions our Family Doctors are Asked

Dr. Sheila Wijayasinghe has a special interest in women’s and sexual health. She is the Medical Director of Primary Care Outreach at Women’s College Hospital and the Medical Director at the Immigrant Womens’ Health Centre in Toronto. Dr. Wijayasinghe has a family practice at St. Michael’s Hospital and works as a staff physician at Hassle Free Sexual Health Clinic. She is a Lecturer in the Department of Family and Community Medicine, has written for the Globe and Mail and is one of the Health Experts on CTV’s The Social.

Q: How do I find a sex-positive primary care physician?

There is no specific database of which doctors are sex-positive so sometimes it requires meeting a doctor and seeing if you feel comfortable with them. Another option can be to go to a designated sexual health clinic. They’re usually staffed by primary care doctors who are sex-positive.

If you’re looking specifically for a regular ongoing provider, ask about sexual health and their approach. You’ll know fairly quickly from their reaction and response whether they’re sex-positive or not. I’ve definitely been asked that before and it’s a great question that lets me know what my patients are looking for.

Q: Can birth control cause infertility?

No, that is a myth. But sometimes, if you’re taking the pill or have an IUD that contains hormones, there can be a short delay in return to regular ovulatory cycles – but it does not cause infertility. The only types of birth control that can affect fertility are permanent methods, such as the surgical procedures of having a tubal ligation or a vasectomy.

Q: Do I have to get a Pap test if I’m not sexually active?

If you’ve never been sexually active or had any form of penetration – that could mean fingers, toys, genitals — the risk of HPV transmission is very low so no Pap needed. The current guidelines are to have a Pap once every 3 years starting at age 21 for anyone who has a cervix in those who have any form of penetrative sexual activity.

Q: What types of medications have the biggest impact on sex drive?

There are many medications that can impact sex drive including:

antihistamines/decongestants (can affect erection/ejaculation)

antidepressants

antipsychotic medications

blood pressure medications

hormonal therapy, including the birth control pill/patch/ring

Dr. James Owen is a family physician at St. Michael’s Hospital and an Assistant Professor in the Department of Family and Community Medicine. He is the LGBTQ2S Health Theme Lead for the U of T MD Program and the course director for “Complexity and Chronicity” in the second year of the Foundations Curriculum. His clinical practice at 410 Sherbourne St. focuses on HIV primary care and prevention, LGBTQ2S health, and the care of vulnerable populations. Dr. Owen is a member of the Board of Directors of Casey House Hospital and the Casey House Foundation.

Q: I’m HIV-positive and my partner is HIV-negative, and I’ve been taking HIV medications for years. Can we have condomless sex? It would really help with intimacy and connection.

Yes! We now have a large amount of evidence that couples where one partner is HIV-positive, and one is HIV-negative can have condomless sex as long as the HIV-positive partner has a consistently undetectable viral load. This can be easily achieved now through current HIV medications. This is a really important and ground-breaking finding for both heterosexual and same-gendered couples, and this has the potential to really reduce HIV stigma.

Q: The last time I was tested for sexually transmitted infections, my doctor swabbed my throat too! What’s up with that?

Testing for sexually transmitted infections (STIs) can involve tests at many different sites on the body. Some tests are blood tests (such as syphilis and HIV). For gonorrhea and chlamydia, many people know you can do a urine test or, if you have a cervix, do vaginal or cervical swabs. But some people should have testing at other sites, too. If you have receptive anal sex, you may need a rectal swab, and if you have provided oral sex to a partner, your doctor can also do a throat swab.

Q: I get tested for sexually transmitted infections frequently, but someone recently reacted negatively when I told them I was “clean”. What’s wrong with that?

“Clean” is a loaded term, because it suggests someone with a sexually transmitted infection (STI) is “dirty.” Anyone who has had sex could be at risk of an STI, and there shouldn’t be any shame in getting tested or detecting an STI. Being tested regularly is one way of showing that you are being responsible about your health. Also, words like “clean” can be particularly uncomfortable and stigmatizing to people living with HIV, since there is nothing “dirty” about living with an HIV diagnosis. I really encourage people to avoid these words altogether.

So, what should you say? I encourage you to let any potential partners know if and when you were last tested and how often you are tested. If you ever have a positive test for things like gonorrhea or chlamydia, get treated, and let your recent partners know they should be tested and treated as well.

Dr. Kymm Feldman is a medical educator at Women’s College Hospital, where she also works as a family physician at the Bay Centre for Birth Control. She is the Program Director of the Women’s Health Enhanced Skills program at the University of Toronto. Her research and academic interests are in sexual health, women’s health and medical education.

Q: I find sex painful, is that normal?

Most people find sex uncomfortable the first time around, but ideally sex is meant to be pleasurable. Painful sex is a common concern for patients and many factors can contribute. You need to get comfortable with yourself and your partner(s) — for people with vaginas, this lets vaginal muscles relax and allows the production of lubrication. Experimenting with different positions, engaging in more foreplay or using lubricant can also help. I always tell people that it’s important to experiment on their own and then teach their partner what feels good for them, as it can be hard for someone else to figure it out without feedback! Sometimes painful sex can come from other factors including sexually transmitted infections, structural differences or a history of prior trauma, all of which can be addressed with your health care professional.

Q: I don’t feel like having sex as often as my partner, is there something wrong with me?

Most couples will have differences in their level of sexual interest or desire and this may fluctuate over time and circumstances. This can be affected by many factors, including: medical conditions, medications, relationship factors, surroundings, hectic schedules, fatigue, children and for people who menstruate — even timing in the menstrual cycle. Addressing underlying issues can go a long way in diminishing the impact of these differences. This could mean focusing on definitions of intimacy for each individual, improving communication and committing to solutions or compromises. A small percentage of people are thought to have clinical ‘hypoactive sexual desire disorder’ which causes individuals a great deal of distress and is not explainable by other circumstances. If you suspect you might have it, talk to your doctor about it.

Dr. Charlie B. Guiang is a family physician and an Assistant Professor in the Department of Family and Community Medicine. He is a staff physician at St. Michael’s Hospital and also works at Hassle Free Men’s Clinic, Covenant House Health Services, and as an on-call physician at Casey House. His clinical and academic interests include Sexual Health/STIs, HIV Primary Care, and LGBTQ Health, along with bread and butter family medicine and academic medicine.

Q: What are common sex related injuries you see in your practice?

I see a lot of cuts, bruises, scrapes and tears that result from sexual activity. A lot of people worry that they’re STIs, but usually they’re just related to trauma and are pretty mild and easy to treat. Something less common – but something I hear about once in a while — are things like priapism, which is a prolonged, painful erection that could be a result of taking too much medication for erectile dysfunction or using similar medications improperly. Priapism has to be treated right away, and treatment involves evacuating the blood from the penis — which is usually done as a procedure in the ER.

Q: How often do I need to get an STI test?

It depends on how often you’re sexually active or having unprotected sex. Protected sex with condoms is a pretty good barrier to STIs, but not foolproof. Periodic testing is always a good idea if you’re sexually active, and especially if you’re having unprotected or condomless sex. Sometimes it’s once a year, sometimes it’s every three months. For example, I recommend that patients on PrEP who have some unprotected sex get tested every three months — it’s part of guideline recommendations.

Q: Does PrEP prevent me from getting anything other than HIV?

No, it doesn’t. PrEP only protects against HIV. If you’re on PrEP and having unprotected sex, you can still get other STIs, which is why routine testing and counselling on safer sex is recommended.

Dr. Andrea Lobo is a primary care physician at Queen Spadina Medical Centre and Planned Parenthood Toronto, where she has been working since 2004. At Planned Parenthood, Dr. Lobo specializes in providing primary, sexual and reproductive health care to youth between the ages of 13 to 29. Her clinical interests include women’s health and sexual health.

Q: What is the best method of birth control (aside from abstinence)?

IUDs (copper and hormonal) are becoming very popular choices for birth control. There are 5 and 10-year options and they are the most effective form of contraception. The Canadian Pediatric Society recently endorsed IUDs as a first line option of contraception for youth.

Q: What’s the difference between a medical abortion and Plan B?

A medical abortion is composed of two medications taken orally to induce an abortion. These medications are called mifepristone and misoprostol. It is an option for pregnancies less than 9 weeks of gestational age. Plan B is emergency contraception to help prevent pregnancy. It is a one dose pill composed of progesterone to help prevent pregnancy. It can be used up to 3 days after unprotected sex but is more effective if taken as soon as possible. Plan B is not an abortion pill. It won’t work if you’re already pregnant.