Illustrations by Maia Boakye
By Lauren Vogel
A new sexual revolution is underway, transforming who and how we date and mate. Rigid definitions of sexuality and identity are dissolving. Our relationship with technology is becoming more intimate. And awareness of a universal right to sexual well-being is growing. So, too, are the clinical and ethical challenges these changes pose.
But when sex comes up, too often, doctors shut down.
“A lot of physicians are uncomfortable with it,” says Professor Kerry Bowman (MSW ’87, PhD ’97), a clinical ethicist and assistant professor of Family and Community Medicine. “Twenty-first-century society is evolving quickly, and the ground is moving under our feet.”
Recent generations of Canadians have tended to define sexuality, gender and relationships in binaries. From dating profiles to health records, our society sorts by checkboxes: male or female, gay or straight, single or married. However, a growing number of people don’t fit these boxes — or any boxes.
“We’re seeing already that as many as one in six of the next generation, Generation Z, identifies somewhere in the queer community,” says Markie Twist, a Wisconsin- and Nevada-based sex researcher, educator and therapist. But that no longer necessarily means they’re lesbian, gay, bisexual or transgender. Many people are embracing more fluid notions of sexuality and gender, creating their own labels or rejecting them entirely. The diversity of these emerging identities defies easy classification under “alphabet soup labels,” like LGBTQ, Twist says. “It’s really a shift in the world view that’s happening.”
Sext
a sexually explicit message or image sent by cellphone
Tinder/Grindr
mobile dating tools (apps)
Digisexual
a sexual identity entwined with technology
Sex-tech
technology designed to enhance sexuality
Medicine has a lot of catching up to do. Despite growing societal acceptance of sexual diversity, many physicians seem to struggle with the basics. Multiple surveys show doctors don’t routinely initiate conversations about sex, and when they do, those conversations tend to be brief and focused on pregnancy and infections. The needs of seniors and people with disabilities are often overlooked. And sexual minorities continue to face discrimination and disparities in health care.
The culture of medicine may contribute to the problem. Many providers assume their patients are heterosexual. And almost half of medical students surveyed in a 2017 study reported anti-LGBTQ jokes, rumours or bullying by fellow trainees and other members of the health care team. For sexual minority patients, fear of judgment remains a major barrier to care, says Twist. “The feeling is like it’s not going to be safe. I’m going to get shamed. I’m not going to get the help I need.”
Yet there’s much to discuss. Sexually transmitted disease rates are on the rise in Canada. According to a 2018 paper published in the Journal of Sexual Medicine, up to a quarter of Canadian men experience premature ejaculation, and among the few who seek treatment, most are unsatisfied with the results. Meanwhile, roughly 41 per cent of women worldwide have sexual dysfunction, including trouble achieving orgasm.
Both doctors and patients undervalue how these issues impact overall well-being, says Jess O’Reilly (BA ’05, BEd ’06), a U of T-trained sexologist. Research links sexual satisfaction and healthy relationships to longer lives, as well as better physical and mental health. But when we lose our mojo, “relationships dissolve, and when relationships dissolve we know the health outcomes are less positive,” she says.
Medical training doesn’t prepare physicians to address the wide range of sexual issues patients are facing,
O’Reilly adds. Most medical schools in Canada and the United States spend just three to 10 hours on sexuality across four years of training, according to a 2002 study in the International Journal of Impotence Research.
At U of T, medical education has shifted away from a traditional lecture model that can be counted by hours, says Professor Marcus Law [BSc ’96, MD ’00, PGME ’02 (Family Medicine), MEd ’13], Director of Foundations in the MD Program. Sexuality and sexual health are integrated throughout training and taught using a variety of methods, from case-based learning and small group tutorials to early clinical exposure and shadowing opportunities. “When you teach everything in silos — five hours on this, six hours on that — students cannot incorporate different elements into patient care.”
Gaps in training can have devastating consequences for patients. O’Reilly recalls receiving an email from a plastic surgeon who didn’t understand why his patient was unable to orgasm after surgery on her labia that included reducing the hood of the clitoris. “He said it couldn’t have to do with the surgery because he didn’t touch her clitoris, because he saw her clitoris as solely the head. Imagine if we treated the penis like that.”
According to Twist, sexual health education would ideally be continuous and evolve with sexuality. The biggest challenge for doctors may be letting go of the idea that they need to have all the answers, Twist says. “Even just opening a dialogue and providing resources will go a long way.”
Patients with fluid sexuality will require more flexible physicians and health systems, Twist adds. That can be as simple as leaving a blank space on forms to allow patients to self-identify. When Twist’s own doctor did this, “it made me feel like she was a safe provider to talk to.”
Changing definitions of relationships could pose further challenges to rigid systems. For example, doctors may not think to provide screening for sexually transmitted infections (STIs) to a married but non-monogamous couple unless their patients bring it up. Meanwhile, existing laws don’t allow people in polyamorous relationships with multiple partners the same access to information and decision-making powers as married couples, which can cause problems in emergency situations.
Medical training doesn’t prepare physicians to address the wide range of sexual issues patients are facing
Dawn of the Digisexual
As concepts of sexuality, identity and relationships expand, they’re becoming increasingly intertwined with technology. The recent marriage of a Japanese school administrator to the hologram of a popular anime character sparked international curiosity in digisexuality, an emerging identity in which sex is (sometimes literally) wedded with technology.
The term is new, but the phenomenon is not, says Neil McArthur, a professor of philosophy and sexuality at the University of Manitoba. Technology already plays an integral role in the sex lives of many Canadians, whether they’re swiping potential matches on Tinder or sexting a long-distance lover. To that extent, most people who came of age with the internet, smartphones and social media are what McArthur describes as “first-wave” digisexuals. “We take it for granted that we are all in some way dependent on technology for our relationships.”
Four in 10 Canadian teens have sent sexts and more than six in 10 have received them, according to a report by the non-profit organization MediaSmarts. Many children are also accessing pornography online at young ages. A recent study in the Journal of Adolescent Health found that one in five youth as young as age nine encounter unwanted sexual material online. A report by the Australian government linked exposure to porn to earlier and riskier sexual activity among teens, as well as sexist attitudes and sexual aggression. Yet, research and sexual education on these issues remain limited and politicized.
Mental health care providers are increasingly concerned about people’s health and well-being in virtual relationships. “Young people who ‘talk’ online but have never physically met can become depressed — or worse — when that person disappears,” says psychiatrist Allan Kaplan, who practices in the field of eating disorders. “We need to study this behaviour and understand its long-term consequences.”
There is also rising concern about the health impacts of increasing social media use. Public health experts in Canada, the U.S. and the U.K. have attributed spikes in the rates of STIs to dating app use, although no studies have confirmed the link. In response, the popular gay hookup app Grindr announced it will send users regular reminders to get tested.
Meanwhile, expanding access to health information online can be a double-edged sword. While today’s patients are more engaged in their care than previous generations, they may be less trusting of doctors, says O’Reilly. Misinformation on social media may also be difficult to uproot, as the anti-vaccination movement has proven.
The increasing monopolization of the internet by a handful of tech companies may also undermine its usefulness as a source of sexual health information. “I’m totally concerned about the politics of algorithms and content moderation online,” says Patrick Keilty, Director of U of T’s Sexual Representation Collection in the Faculty of Arts & Science. “Very wealthy companies that dominate the internet have waged, if not a war, a very anti-sex, anti-queer campaign on their platforms.”
The recent pornography ban on Tumblr is a case in point, Keilty says. Since the ’90s, the microblogging platform had been a haven for queer and niche sexual subcultures, where pornographic and sexual health content were often intertwined. The porn ban severed those networks overnight.
Part of the problem right now is when you do get someone who is somewhat outspoken about their needs or interests, people giggle and are uncomfortable, or they shut them down
Virtual Reality Porn, Sex Robots: The Next Wave
The role of tech in sex will become more complicated with the emergence of “second wave” digisexuals who may replace or displace human partners with technology. There’s a lot of marketing hype around virtual reality pornography and sex robots, says Keilty. Currently, this sex-tech is clunky and expensive.
With better, cheaper models, however, it’s likely some people will opt for artificial lovers over flesh-and-blood partners, says McArthur. “The way in which women are represented through this technology and the way that will impact people’s views of women are worth worrying about.” Whether and how these technologies model consent is also a concern, he says. “We just don’t know whether it’s going to be a net positive or negative.”
That said, a lot of pornography already contains distorted depictions of women and consent, McArthur says. Meanwhile, it’s not inherently unhealthy to opt out of human intimacy. “We don’t pathologize single people. We tell them it’s OK not to be in relationships, so why would we pathologize people who are basically using technology instead of being single?”
The birth control pill and sex toys sparked similar moral panics, but those fears were largely overblown, he notes. “My view would be not to panic and see the opportunities.”
Artificial intelligence and virtual reality technology could be harnessed to create the equivalent of a flight simulator to teach consent and healthy sexual relationships. Sex robots may be a useful therapeutic tool for people who have experienced sexual trauma. Moreover, advances in sex-tech could close gaps in access to intimacy, especially for people with disabilities.
There’s a tendency to see people with developmental disabilities as asexual or “forever children,” says Kevin Reel (BSc ’91), an ethicist, occupational therapist and assistant professor in the Department of Occupational Science and Occupational Therapy. Families may try to shelter them from sexuality long after their bodies mature. However, “if they’re out in the world, they’ll see sex all around them,” often outside its appropriate context, says Reel. As a result, “you end up with a dreadfully high number of people with developmental disabilities who end up encountering the law because they’ve done something that is considered indecent in a place that’s not appropriate because they don’t recognize the fact that it’s OK in a film… but it’s not OK in real life.” They’re also much more vulnerable to sexual exploitation and abuse.
Although the World Health Organization now recognizes a universal right to a fulfilling sex life, Reel says that progress to close gaps in intimacy for people with disabilities is “very fragile” for these reasons. New technology could offer legal, safe outlets to explore sexuality and may address physical limitations in ways that human partners cannot. Health providers can help close gaps in access to intimacy, says Reel. “The simple first step is the willingness to engage. That means giving patients permission to talk about sex, permission to be sexual, permission to enjoy it.” Health providers can also support patients by providing information, from the very general to the “nitty gritty,” such as the right sex toys for people with physical limitations. At a minimum, he says, they should know where to refer patients for more information.
Seniors are another group whose sexual needs are often overlooked. “If having relationships, if being intimate, if exploring your sexuality is important, it’s going to continue,” says Sylvia Davidson (BSc ’91, MSc ’03, Dip Gerontology ’96), an occupational therapist working with older adults, who has a special interest in dementia care.
Ignoring this reality creates problems for seniors and long-term care facilities, she says. “Someone wakes up in the middle of the night, crawls into bed with somebody else, and all of a sudden we have a crisis. Families have to be called and we have to separate these people, and we never stopped to think about whether that might be a reasonable expectation from someone who hasn’t slept alone since they were a kid.”
Recent spikes in STIs among older Canadians “reopened the discussion,” says Davidson. However, “part of the problem right now is when you do get someone who is somewhat outspoken about their needs or interests, people giggle and are uncomfortable, or they shut them down.” For some sexually diverse seniors, that has meant going back in the closet when they enter long-term care.
Without shared processes and policies around intimacy and sexual expression, “there are little pockets of excellence” but no consistency in staff response, says Davidson. For example, in the case of a resident who was masturbating in the dining room, staff redirected him to his room with a magazine. “But there will be colleagues of the people who came up with that strategy who will disapprove,” she says. “Once, I was asked to come in and help address a problem on a night shift in a home, and the problem was that a woman was watching porn on her TV in her private room with the door closed… I mean, come on now.”
Rising rates of dementia are also creating new challenges: Inappropriate sexual behaviour is common as people lose social inhibitions and the ability to communicate when the disease progresses. “People with dementia are coming into long-term care homes in far greater numbers than the staffing is prepared to deal with,” says Davidson.
In some cases, practitioners misinterpret behaviours as sexual because residents are unable to communicate their other needs. For example, they might put their hands down their pants because they don’t know how to tell a caregiver they need to pee, or they may remove all their clothes because they’re hot. “These behaviours mean something, but not necessarily the label we attach to it,” Davidson explains.
Health care providers have an important role to play in preparing patients and their families for these changes. “Too many of them will allow themselves to be shut down if the system doesn’t allow them the space to talk about their concerns. And in many cases that does start with the physician,” Davidson says. She recalls a woman who suffered for years from her husband’s increasing sexual demands as his dementia progressed. “She came in contact with many different care providers during those years, and nobody ever created an atmosphere where she even thought she could broach the subject.”
More open conversations about the intersections of sexual diversity, technology, disability and dementia are essential, Davidson says. “If we were all more willing to talk about that, we would really be looking at addressing a growing problem that is just like an avalanche coming towards us.” ?
