Behind closed doors: stigma in sexual medicine
- Aringas Vagonis
- 2 days ago
- 11 min read
Interview with sexual medicine specialist and psychiatrist Dr. Giedrė Jonušienė
Is stigma still an issue in the field of sexual medicine today? We ask sexual medicine specialist and psychiatrist Dr. Giedrė Jonušienė. She has extensive clinical experience in psychiatry within the mental health care systems of both Lithuania and Norway.
Aingas Vagonis: Everything related to sexuality has, at various times and in various cultures and societies, been marginalized and even sometimes denied. Can we say that in our culture, sexuality and the aspects of life associated with it are stigmatized?
Giedrė Jonušienė: Stigma manifests itself from the conflict between an individual’s and society’s attitudes as a deep, discrediting feeling that one “does not conform to the norm.” Thus, when delving into what attitudes our society shapes, it is important to remember who and how shaped society itself. In what melting pot of cultures, religions, and political systems did it take shape, and what scars were left by occupation and genocide.
Baltic culture integrated and normalized sexuality through its relationship with nature; this was inseparable from fertility, life, and abundance. Despite Christianity, which set clear boundaries for the expression of marital sexuality, sexuality in folklore and songs was boundless, vibrant, and conveyed through symbols, e.g., a wreath of rue or a garden, the watering of a horse or disobedience, and so on. With the Soviet occupation came a definition of civil marriage, but it did not normalize intimacy itself; rather, it hid it even further behind closed doors, leaving it to wither alongside the fading folklore.
At that time, intimacy was framed through threats, punishments, and consequences: forced treatment for sexually transmitted diseases, and the denial of the ability to have children for those with mental illnesses.
The teaching of sexual health disciplines was not sufficiently consistent or in-depth. Generations of doctors grew up without knowing how to address patients’ sexual health or how to assist with such complaints. The qualification of a sexual health specialist in Lithuania was, and unfortunately still is, obtained abroad.
And what about the wider context?
As early as the 18th century, the progressive world reclassified autoerotic behavior from a sin to a medical problem, and in 1907 an interdisciplinary approach to sexual problems emerged, although most sexual dysfunction was still viewed from a psychiatric perspective. In 1973, homosexual sexual orientation was removed from the list of mental disorders in the U.S., and in 1992 from the WHO classification. In 2018, in the 11th International Classification of Diseases, sexual health was demedicalized with a scientific focus on the preservation of sexual health. In our country, unfortunately, the sexual revolution was not destined to take place, which would have reprogrammed old beliefs and set off changes.
Are sexual disorders still stigmatized?
Absolutely. When sexual dysfunction arises and there is a lack of knowledge, incorrect attitudes and interpretations form in that vacuum. Functioning means “normal,” and being abnormal is unbearable. The person masks, hides, or otherwise alleviates the emotions and states they are experiencing, tries to compensate for the symptoms, and not necessarily in the most appropriate way—for example, by testing their erection with different partners. Stigma creates the false illusion that sexual function is a self-evident and easily attainable process for other members of society, and that the individual experiencing difficulties is the exception. However, clinical experience reveals the opposite reality—sexual health disorders are a widespread phenomenon, but due to systemic social pressure and shame, they remain in a latent state, outside the scope of society and official statistics.
Can we say that sexual medicine is stigmatized among other medical fields? And within the field of general psychiatry itself?
Sexual medicine, although grounded in and adhering to strict clinical research-based algorithms in diagnosis and treatment, still faces what I would call a specific stigma. Possibly due to the same historical, cultural, and professional reasons. To this day, it is a discipline that specialists in traditional
specialties consider a “light” discipline, focused solely on improving quality of life, pleasure, or entertainment. After all, erectile dysfunction isn’t a direct cause of death, is it? However, sexual medicine physicians know that it is a symptom of a lethal chronic cardiovascular disease, and timely intervention is life-saving.
And what about issues related to sexual function of a person fighting for their life?
Generations of doctors were raised in a society where sexual health was devalued and knowledge about it was very limited. Their own attitudes toward sexuality, a lack of knowledge on how to collect data, how to diagnose, and how to treat, did not contribute to the promotion of sexual medicine as a field. The spread of stigma is also fueled by a narrow view of sexual problems, such as the belief that only male sexual dysfunctions can be cured because medications exist for these disorders. Consequently, the rest of the population is stigmatized when a pill does not help, and the only solution is the application of the biopsychosocial model, where the problem is viewed much more broadly and many more treatment options emerge. In modern medicine, the individual’s complaints and symptoms are undervalued, everything is objectified through laboratory or visual examinations, therefore sexual medicine is a rather uncertain field where the doctor loses control, and recovery is often linked to the individual’s psychological development or the couple’s dynamics. The stigma is deepened by the still-prevalent view among specialists that this is solely a matter of the psyche and that it is not appropriate to inquire into this function; this attitude can lead to underdiagnosis and missed opportunities for disease prevention.
"Humans are the only living beings who shame, stigmatize, and punish sexual needs and impulses. We grew up in an environment where sexuality was associated with secrecy, fear, shame, and disgust."
Can we speak of a stigma surrounding sexuality in our lives?
Humans are the only living beings who shame, stigmatize, and punish sexual needs and impulses. We grew up in an environment where sexuality was associated with secrecy, fear, shame, and disgust. This creates conditions for internal stigma to form, where a person feels ashamed when fulfilling their
sexual needs. People often feel “corrupted” or “depraved” if their desires do not align with the imagined norm. Stigma can also be exacerbated by body shame, especially in a society that emphasizes physical aesthetics and youth, thereby deviating from the true purpose of intimacy—satisfaction and the relationship. In the absence of adequate sex education, young people turn to pornography for knowledge, which creates unrealistic expectations about sex and the body and further reinforces feelings of inadequacy. Stigma often hinders open communication within a couple, as partners do not express their needs out of shame and shift responsibility for decisions onto each other, or, in hidden conflicts, the couple sinks into personal hurt, thinking “you don’t love me or aren’t trying for me.” In our society, there is a strong stigma that sexuality belongs only to the young, healthy, and “perfect,” thereby discriminating against older people and people with disabilities, because it is “inappropriate.” “Normal sex” is organ-centered, and if it doesn’t work out that way, is it abnormal? It has been observed that social media and popular culture create a new stigma—the obligation to enjoy oneself. If a person’s life does not meet the standard of intense, constant sexual activity, they may feel “left behind,” i.e., abnormal.
Are shame and stigma concepts similar here, or are they the same?
These concepts are not the same, though they are very closely related. Stigma forms when a certain trait or behavior—such as sexual orientation, gender identity, sexual needs and impulses, or health challenges, is labeled “abnormal” or “defective.” This manifests through discrimination and stereotypes. Shame is an emotional experience in response to stigma. When a person internalizes stigma, they begin to believe in their own inadequacy. Shame causes withdrawal, silence, and hiding. In the relationship between stigma and shame, a two-way feedback loop often emerges.
From the perspective of your experience, how do your patients experience stigma?
Stigma can act as a barrier for seeking help, as a person may be afraid or ashamed to speak about the challenges arising during relationships, because doctors won’t know how to help, won’t understand, will feel embarrassed themselves, or because such complaints might make the patient seem “abnormal.” Patients report that they have experienced doctors ignoring the sexual problems they’ve brought up. According to them, there are specialists who don’t even engage in a discussion, ignore the question, or suggest “look at the passport!” and at best version - prescribe medication. Patients feel as though the problem they’ve voiced is secondary or even “non-medical.” This reinforces the feeling that sexual dysfunction issues in a clinical setting are embarrassing and shouldn’t be discussed. Even when they decide to seek help, patients experience stigma simply because they are seeing a sexual medicine specialist or sexologist. People hide these visits from family members or friends more than visits to any other doctor. They fear labels such as “promiscuous,” “problematic,” or “mentally ill.” Shame and fear prevent them from obtaining treatment, which leads to delayed management of the condition.
Stigma can manifest as silence in relationships. It acts as a filter, preventing them from talking to their closest partner about the most intimate matters. When dealing with sexual dysfunction, I often encourage my patients to share their fantasies, which may hold the keys to improv function and preserving the relationship. However, when I encourage couples to share those fantasies, I most often hear “shame” or “what will my partner think of me?” Patients also fear that admitting to sexual difficulties will be interpreted as: the end of love, their partner’s lack of attractiveness, or a threat of betrayal.
Members of the LGBTQ+ community experience stigma. These individuals are afraid to seek help due to fears of rejection and discrimination, comments from healthcare professionals, or the disclosure of health information. The literature defines “minority stress,” where stigma leads to discrimination, social and medical exclusion, and chronic stress, which deteriorates mental and physical health and results in premature fatal outcomes.
The “tyranny of sexuality” convinces people that any deviation from the “norm” (lower libido, erectile dysfunction, delayed orgasm, painful intercourse) is a personal failure. For example, men often equate erectile dysfunction with a loss of masculinity, while women equate a decreased libido with a decline in their feminine worth. Because of this, people also delay seeking help for years or even decades, until the problem becomes chronic.
In what situations is this stigma felt most acutely?
The face of stigma becomes most apparent when a person is at their most vulnerable—when seeking help. Although one would like to believe that patients first share their sexual problems with their family doctors, the reality is different: doctors don’t ask, and patients don’t speak up. Thus, the person leaves the visit with an unspoken message: “My sexual health isn’t a serious medical problem, since no one even asks about it.” Data shows that only about 10 percent of family doctors ask about a patient’s sexual function during a visit. According to U.S. data, among obstetrician-gynecologists in practice, the figure is 40 percent, but when working with the LGBTQ+ community, it drops back down to the same 10 percent.
In cases of chronic diseases (oncology, diabetes, cardiovascular disease), stigma manifests through desexualization. Upon diagnosis of a severe illness, all attention is focused on survival, while sexual function is effectively “amputated” from the medical system as unimportant. The patient is made to feel guilty for caring about intimacy when they “should be happy to be alive.” This creates a gap between physical health and quality of life. When sexual health issues are neglected, not only do couple relationships suffer, but depression, anxiety, and insomnia also develop. In progressive healthcare systems, patients who develop sexual dysfunction following radical medical procedures are provided with timely assistance ranging from medication to prostheses or devices that improve function.
The double stigma experienced by individuals with mental health disorders deserves special attention. They are often rejected due to the stereotype that they cannot fall in love or form relationships. Here, the symptoms of the illness are mistakenly interpreted as character traits, and sexual behavior is viewed solely through the lens of psychopathology, completely ignoring the sexuality of a “normal” person. Life-saving treatment can negatively affect sexual function, but priority is given to mental stability, while the person’s concerns about their sexual function are downplayed. Members of the LGBTQ+ community also experience a double stigma. In our culture, there is also a stigma surrounding older people— they are automatically considered “asexual.” An older person seeking help often encounters the attitude of those around them, or even medical professionals: “you don’t need sex at that age.” Thus, older people are left without help, even though their sexual function is directly linked to mental health and longevity. People with a tendency toward deviant sexual behavior experience shame and fear of rejection, which stops them from seeking professional help, so assistance is provided to them too late.
Which consequences of stigma have the greatest impact on them and on all of us?
The greatest harm is that stigma robs us of the opportunity to feel healthy and whole. We are forced to “split” ourselves into a public self and a hidden, shameful self. Because of shame and isolation, when a person does not seek help, precious time is lost and necessary medical care is not provided in a timely manner. When one individual suffers, it is no longer just a personal inconvenience—it becomes a health issue for the entire family, “tribe,” and society.
Sexual health disorders, such as erectile dysfunction, are often an early indicator of cardiovascular disease. Libido disorders in both men and women can signal problems with the endocrine system, while pain during sexual intercourse may indicate organic changes in the body. Due to the prevailing stigma, people do not seek help in a timely manner, so doctors are forced to treat not the initial stage but severe consequences, which directly increases mortality and the burden on the healthcare system.
Loneliness and isolation while carrying a secret lead to depression, anxiety, low self-esteem, and attempts to cope with problems through the use of psychoactive substances, which destroys relationships within the family. In social media and internet culture, sexuality is portrayed in an exaggerated manner, and this creates a secondary stigma: a person begins to believe that if his erection does not last an hour or she does not experience multiple orgasms, there is something “wrong” about that. Due to this “organ-centered” and “orgasm-centered” approach, there is no room for the “Good Enough Sex” model (McCarthy B, Metz M, 2007).
Is sexual medicine accepted and valued in the same way as other medical fields? By patients and other specialists?
On the one hand, colleagues in other specialties view this as an interesting and intriguing field—perhaps because it deals with the most intimate, “naked” aspects of human existence. However, on the other hand, this field is still heavily undervalued because it is mistakenly viewed as not saving lives.
Meanwhile, patients and the community view sexual medicine with far greater respect. To them, it is a legitimate field of study. Those who have sought help directly acknowledge that it is an exceptionally broad specialization, requiring a doctor to possess a vast body of medical knowledge. It is worth noting that an increasing number of colleagues are reaching out for collaboration: they seek a second opinion or even supervision regarding clinical cases that are unclear to them. This is clear evidence that attitudes are changing—sexual medicine is beginning to be recognized as a serious and necessary interdisciplinary field.
From your perspective, what could we, as psychiatrists, do to reduce the burden of stigma?
From a sexual health perspective, psychiatrists are crucial partners who can “validate” a patient’s sexual experiences. Sexual function is often an indicator of overall mental health, so your role here is essential. Be proactive in asking questions: patients rarely initiate conversations about sexuality themselves due to shame. If a psychiatrist asks during a routine consultation (as one might ask about sleep or appetite) “How has your sex life been lately?” or “Have you noticed any effects of the medication on your sexuality?”, they give permission for this topic to exist in the doctor’s office. The doctor’s confirmation that the patient’s behavior (e.g., masturbation) or the difficulties experienced are common and understandable inherently reduces the sense of pathologization. Discuss the effects of antipsychotics and antidepressants; patients often discontinue treatment due to side effects on sexual function (e.g., erectile dysfunction or anorgasmia) without mentioning this to the doctor. Openly addressing these risks demonstrates that the doctor considers the patient’s quality of life and pleasure to be just as important as symptom control. Instead of dismissing a sexual complaint as merely a “side effect” or a “symptom of depression,” help the patient view his or her sexual function through a biopsychosocial model, showing how his or her experienced social shame or partner dynamics interact with biology. Avoid judgmental terms (e.g., “rape,” “perversion,” “hypersexuality”), and use terminology that focuses on the individual’s subjective discomfort rather than moral judgment.
Thank you, Giedre, for the conversation, which allowed us to take a closer look at the behind-the-scenes aspects of the stigma surrounding sexuality.
Thank you for your interest in this topic! Because once stigma is named, it loses its power. To overcome stigma, we need education, public awareness, and systemic changes (such as revising medical school curricula). To overcome shame, we need psychological work on ourselves, self-acceptance, and a safe space to speak openly. □
