Today’s Times Weekend focuses on an important yet taboo issue – Infertility. ‘Sex, fertility and commitment: what men really think’ includes in depth interviews with several men about the topic. While it’s right to talk about this issue from a male perspective, there are messages within the feature that are worrying in relation to sex, orgasm, fertility and gender. Not least because the issue of sex is not covered in any depth, but what is discussed about sex and orgasm is misleading.

Part of the feature focuses on an interview with Lord Robert Winston, a recognised pioneer in fertility treatments. He states: “Many years ago I did a study that, to my great regret, was never published. It was on women who were not orgasmic. We showed a clear correlation between women who did not enjoy sex and unexplained infertility. The study indicated that women who didn’t achieve orgasm and were having IVF were more likely to experience unexplained infertility”

This is troublesome for several reasons. Firstly it is always difficult when practitioners talk of research they’ve done but never published. It means we have no idea of assessing the work, and it won’t have been subjected to peer review. If we’re hearing about a study it needs to be treated according to standard academic conventions. Which usually include noting other evidence in the area. As in this case there is an established body of research on sexual functioning and fertility that has been steadily growing since the 1970s. This is not discussed.

The idea of orgasm as something to ‘achieve’ has long been a worry within the sex research community, not least because it sets up sex as something that must end in orgasm and prioritises orgasm as the main focus of sex. It overlooks wider areas of pleasure couples may explore. And in relation to fertility these aspects are crucial.

For couples looking to enjoy sex within the confines of infertility treatment the Times represents sex in a narrow way, with orgasm as end goal, something you ‘achieve’. It does not help the readers appreciate a more varied approach to pleasure and affection which may be vital to a couple where sex is increasingly becoming only about conception. It gives no guidance on how that might be explored. Something we might expect when headlines promise a discussion of sex and fertility.

Moreover it does not fully explore the wider and more complex issues relating to sex and infertility that result in sexual problems. Just a few examples include the stress of treatment, anxiety about fertility, fears of being childless, relationship breakdown, preoccupation with having a baby, and the cost of treatment (if one is paying privately). While these are all talked about within the Times interview they are not really presented as a clear explanation of a complicated problem that contribute to psychosexual difficulties. Instead the piece highlights women’s lack of orgasm/sexual pleasure as a major contributor to infertility.

We know women’s fertility problems and psychosexual issues are intertwined (see here and here). However the nature of this relationship is complex. In some cases psychosexual dysfunctions lead contribute to infertility, while in others it may be the anxiety around fertility problems or undergoing infertility treatment that leads to psychosexual difficulties (see for example here and here).

Men’s psychosexual dysfunctions similarly experienced, regardless of whether it is the man or his partner who has the clinical problem (see here and here). Indeed if a couple is struggling to conceive and the man is unable to get an erection or is struggling with premature ejaculation (during intercourse or masturbation) it adds to the strain they are already under. Given the Times’ feature focuses on men, sex and infertility it is somewhat worrying this issue is not fully explored.

For women and men sexual pleasure is possible without orgasm. And while some theories have argued women need to orgasm to conceive, this is not the case. Discussions that focus on sex only in terms of orgasm miss the wider pleasures couples may experience, and also overlooks more important questions about the general quality of couples’ relationships. The Times could have used this opportunity to explore how couples might experience this, but they sadly failed to do so.

From the reporting of Lord Winston’s comments in the Times report readers could be forgiven for thinking women can control their fertility by making more of an effort to enjoy sex or having orgasms. This massively oversimplifies the wider body of research on this area.

Healthcare professionals, therapists and sex educators also need to take greater responsibility in this area. There is plenty of evidence about psychosexual problems and infertility. What we lack is clear advice programmes for couples that focuses specifically on addressing those problems as they arise, and to combat them in the first place with support and information about pleasure and intimacy that is not goal oriented to the ‘achievement’ of orgasm. We need more research on this topic and more training for professionals working with couples to help them maintain a positive relationship under highly stressful and often very distressing conditions. Part of the reason couples do struggle in this area may well be to do with professionals failing to provide this information in a timely fashion.

The issue of infertility is still taboo and highly emotive. Any practitioner talking about the area needs to do so in a way that fits with current evidence based practice and focuses on couples not women or men. We also must ensure advice given does not make people feel they have contributed to their infertility by a lack of female orgasm, which is likely to scare anyone considering trying for a baby – whether they have fertility problems or not.

The Times undoubtedly covers the male experience of infertility with their case studies. But given its focus was on sex and infertility it fails to engage on this level and misses a vitally important opportunity to help readers with a major worry couples struggle with.

What’s the difference between sexual, reproductive, psychosexual and relationship health?

Sexual health refers to dealing with either sexually transmitted infections, or physical or psychological sexual problems (also called sexual dysfunctions).

Reproductive health refers to your fertility – either advice on getting pregnant, information on contraception, supplying contraception (to prevent pregnancy), or helping you deal with an unplanned pregnancy.

Some clinics specialise in sexual health, sexual problems or reproductive health, other services will offer treatment or advice for any of these issues.

Psychosexual health services tackle deep-seated sexual problems that could be caused by psychological and/or physical factors.

Relationship counselling services help with problems ranging from sexual communication difficulties, to jealousy and coping with arguments or life after infidelity or divorce.

These services are dependent on your location – there may be more services available in certain countries/states. The politics or religion of different countries/states may affect service delivery or approach. Many clinics offer free support and advice, some private clinics do charge a fee, as do some doctors in certain countries – if you live outside the UK check your health care policies for more information.

Many sexual health services particularly those for sexually transmitted infections are often overwhelmed by patient demand. Part of the reason for this is that people pick the wrong service for their needs – so consult the list below to ensure you get the right help at the right time. And tell your friends so they get it right too!

Your Doctor (GP/Family Practitioner)
What can they offer?
• Advice about contraception and prescribe (and sometimes provide) contraceptives for you
• Advice on sexual problems (dysfunctions)
• Health checks relating to sexual problems (e.g. pain during/after sex, loss of erections)
• Information about menstruation, menopause, fertility (getting pregnant), pregnancy and abortion (termination), pregnancy testing
• Physical examinations of your genitals (including smear tests for women or testicular exams for men)
• Referrals to counsellors or other specialists in the case of sexually transmitted infections, sexual dysfunctions, previous or current sexual abuse, genital cancers
• Assessment and testing/treatment for STIs
• Advice about pregnancy/fertility, antenatal and postnatal support
• Advice and referrals for termination of pregnancy (in countries where abortion is legal)

Your doctor or practice nurse can perform external and internal genital checks, swabs and blood tests. They can test and treat you for STIs, or related infections. Depending on your location they may be able to provide you with condoms or refer you to a condom clinic. In many countries, GPs are the main providers of contraceptive services, so they’re not shy about talking about sex. Some people do feel embarrassed discussing sexual health with their doctor, particularly if they’ve known their doctor for a long while – or in cases where they may have an STI through an extra-marital affair or unprotected sex. If you would prefer to see someone you don’t know as well, you can either speak to a different doctor at the practice or go to a Genito Urinary Clinic for STIs or Family Planning/Reproductive Health Clinic for contraception/fertility advice (see below).

Useful links
NHS Choices has a dedicated section on sexual health
Patient.co.uk (links, resources and helpsheets on a variety of health issues)

Genito Urinary Clinic/Sexually Transmitted Infections Clinic
What can they offer?
• Tests and treatment for sexually transmitted infections.
• Advice about contraception (some clinics also prescribe contraceptives and provide condoms – at some clinics these are free).
• Information about safer sex.
• Advice on how to tell a partner you have an STI – some clinics will notify your partner(s) for you.

These clinics (also sometimes known as ‘sexual health clinics or centres’) will test and treat you for STIs, and provide safer sex advice and information. Some clinics work on an appointment basis, others on a ‘drop-in’ system, or a ‘first come, first served’ basis. Some have set times for teenagers, women or men to attend. You may want to telephone first to check appointment times and whether there’s a waiting list for treatment. You shouldn’t have to wait long to get an appointment, but in many countries where there is high demand for services the wait could be longer. You can get condoms from Genito Urinary Clinics.

Useful links
NHS Choices: Sex, worth talking about includes guides to sexually transmitted infections, including locate your nearest clinic and symptoms and signs of STIs
Planned parenthood’s guide to STIs (also available in Spanish)
Go ask alice! (your sexual health questions answered)
STIQ answers common questions about STIs, testing and treatment

Family Planning/Reproductive Health Clinic
What can they offer?
• They can advise you about contraception and give you contraceptives
• Information about how to get pregnant, or options if you have an unplanned pregnancy
• Pregnancy testing and referrals for termination of pregnancy (abortion) if you require it
• Smear tests for women

These clinics can perform smear tests (internal exams for women), and offer contraception and pregnancy advice. They can provide contraception such as birth control pills or injections, or condoms. If you want contraception only, then make an appointment at one of these clinics. If you think you have an STI, it’s better to see your GP or Genito Urinary Clinic.

Useful links
Family Planning Association guide to contraception, pregnancy and STIs
Brook sex advice for under 25s
Planned Parenthood advice on contraception, STIs and sexual and reproductive health – in English and Spanish
Marie Stopes global reproductive health advice source

Your Pharmacist
What can they offer?
• Home pregnancy testing kits (some pharmacies will do the tests for you)
• Over the counter treatments for cystitis, thrush, period pains (menstrual pains), folic acid (for those planning to get pregnant or during pregnancy and breastfeeding)
• Condoms and lubricant
• Give you contraceptives as prescribed by your doctor

In some countries, community pharmacists are taking a more active role in health care. For problems such as thrush or cystitis you can get confidential advice from your pharmacist. You can also get condoms, the morning after pill (emergency oral contraception), and lubricant from many pharmacies. In parts of the UK, US and Europe, you may also be able to be tested and treated for certain STIs by your pharmacist. If you think you have Chlamydia or Gonorrhoea, the pharmacist can provide you with a urine kit, which you return to them or post to a local laboratory. Results are returned in a few days and you’ll be given the all clear, provided with antibiotics by the pharmacist, or referred on to a Genito Urinary Clinic or your doctor if further tests or treatment are required. Not every pharmacy can offer this service, those that do will usually advertise testing with posters or leaflets. All pharmacies should be able to signpost you to your local Genito Urinary Clinic who will be able to help.

Psychosexual Therapy (Also known as sex therapy)
What can they offer?
• Identification and treatment of psychosexual problems (e.g. erectile dysfunction, loss of desire)
• Overcoming sexual problems due to past or present sexual abuse
• Dealing with sexual problems due to worries about sexuality
• Sexually compulsive behaviour
• Referrals to other healthcare services (e.g. urology, gyneacology) if needed

Many countries offer psychosexual advice and services. In some cases, they are free to patients with severe sexual problems, although have to be referred through a medical doctor, and can have a long waiting list. In countries where psychosexual services are free, patients can also book to see therapists privately. This cuts down the waiting time, and will cost money, but allows the client choices who they get therapy from (e.g. a religious person may prefer to have sex therapy from someone who understand and respects their religion; a lesbian or gay client may prefer a ‘pink shrink’). In other countries, psychosexual services are entirely private, and have to be paid for. These services may not be covered by medical insurance, check your policy. Some countries do not offer any services, or a limited number of therapists.

Useful resources
Overcoming sexual problems by Vicki Ford (Constable and Robinson)
Women who love sex: an inquiry into the expanding spirit of women’s erotic experiences by Gina Ogden (Womanspirit Press)
Our bodies ourselves: a new edition for a new era by Boston Women’s Health Book Collective (Touchstone Books)
Sexual health for men by Phillip Kell and Vanessa Griffiths (Class Publishing)
The new male sexuality by Bernie Zilbergeld (Bantam Doubleday)

Basrt (British Association for Sex and Relationship Therapy)
Sexual Dysfunction Association includes advice and support on male and female sexual problems
Women’s Health gynaecological and other women’s health advice
Male health information from the men’s health forum

The above organisations cater to gay or straight couples – however if you’d prefer to see a gay or lesbian-friendly counsellor you can contact:
Pink Therapy
Pace

Relationship Therapy/Counselling (also known as couples counselling)
What can they offer?
Counselling for individuals and couples for issues like…
• Communication skills
• Increasing sexual confidence
• Overcoming common sexual problems
• Dealing with jealousy
• Coping with infidelity
• Reducing arguments
• Planning for parenthood

Relationship therapy is offered in different forms in different countries. In most cases the service is paid for by the client – but is often means-tested, meaning those on a low income may pay less. Medical and psychosexual services can refer clients to relationship therapists, and clients can refer themselves. Many religious groups or other support networks offer relationship therapy – again this may be free or paid for and evidence underpinning advice may be patchy. Medical insurance may not cover costs for relationship therapy – check your policy. Some therapists will tackle domestic violence and reputable therapists will not see a couple together while one party is being violent. If domestic violence is a problem within your relationship you need to alert your therapist to this as soon as you can.

Useful resources
Overcoming relationship problems: a self-help guide using cognitive behavioural techniques by Michael Crowe (Constable and Robinson)
Loving yourself, loving another: the importance of self esteem for successful relationships by Julia Cole (Relate Guides)
Gay relationships: how to find them, how to improve them, how to make them last by Tina Tessina (Jeremy P Tarcher)
Relate
British Association of Counselling and Psychotherapy
Couple counselling Scotland
Relationships Australia
American association of sexuality educators, counsellors and therapists (AASECT)
BBC Relationships has a collection of resources and referrals addressing domestic violence

The above organisations cater to gay or straight couples – however if you’d prefer to see a gay or lesbian-friendly counsellor you can contact:
Pink Therapy
Pace

Hopefully you can work out from the list above what service suits your needs best. If in doubt call the service/clinic and ask if they can help you. If they can’t they should be able to explain a source of support.

Where to get advice about your sexual, reproductive or relationship health by Dr Petra Boynton is licensed under a Creative Commons Attribution-Noncommercial 3.0 Unported License