The Interview with: Dr Tonia Mezzini, Sexual Health Physician

How did your pathway in medicine lead you to being a Sexual Health Physician? 

When I was working as a General Practitioner, I started getting patients – particularly those experiencing cancer – coming through asking me sexual health questions. I felt my GP training and my oncology background was a good start – but it wasn’t enough. I didn’t know enough to talk to people about their sexual health during or after treatment. And so, I did the training as a Sexual Health Physician because I wasn’t able to meet the needs of the patients who were coming through my clinic doors.

Does the medical professional – generally – find starting these conversations with patients difficult? And if so, why?

These can be difficult conversations for all human beings to have! Conversations about sexual difficulties are very challenging – high emotional stakes for patients and a specialist area of medical practice for doctors.

These conversations take time, skilful management and a solid knowledge base. The research tells us that patients want their clinicians to ask them about their sexual health, but we don’t…and then clinicians think that if the patients aren’t asking it must all be OK. Cancer clinicians are busy and there are pressing medical and surgical issues that need to be dealt with, often in appointments that are a bit short.

As clinicians we know that we can, and should do more, but we often don’t have the time, access to training resources and staff that we need. I think that the pressures of COVID have made that even worse – we now have to include conversations about vaccines etc, etc, into an already jam-packed consult.

What’s a typical scenario? 

As an example, radiation oncologists, medical oncologists, surgeons tend to be very much focused on treating the cancer (as they should be!), and the survivorship issues are assumed to be dealt with by the GPs. But the GPs don’t necessarily have the oncological knowledge to be able to know what those survivorship issues are going to be.

Meanwhile, the oncologist may assume the nursing staff - breast care nurses and radiation oncology nurses - are talking to patients about survivorship issues and managing their sexual and hormonal concerns after treatment. The doctors assume the nurses are doing it; and the nurses are assuming the GPs are doing it, and the GPs are assuming the oncologists are doing it. So, no one ends up doing it! But everybody is doing their best with the resources that they have. Our model of care is a bit too fragmented and time poor.

Sexual health, relationship, mental health and wellbeing issues are the ‘elephant in the room’, everybody wants to talk about it, but nobody knows where to start. The patient is hoping the clinician will ask them because then they have permission to raise it, and the clinician is thinking well if they want to talk about it, they’ll ask me.

This pattern, or dilemma has been demonstrated by research over the years. What also stops clinicians is they are not necessarily trained on how to have these conversations, how to help people to work towards solutions.

But no one doctor or nurse can do everything…but it would be great if they had more confidence to at least raise the issue, start the conversations and then direct people to the best clinicians and resources for their particular needs.

So how do you start these conversations with your patients? Can you take us through an example.

You need to get ‘permission’ to open up the topic. It’s a bit easier for me – the job title is a bit of a giveaway!

I find one of the most useful strategies to start the conversation is to ask them ‘how things are going at home?’.

You gradually gain permission and unpeel the layers by asking more and more direct questions. So, a great way for doctors and nurses to be able to ask this question is to say: how are things going at home? It’s open, it’s broad and it’s neutral.

Patients will interpret it whichever way they like, and whichever way they are ready for. Then you might ask them about their family – ‘How are the kids? How is your partner…. How are you as a couple? How is your intimate relationship?’

So, you gradually gain permission to get closer to these sensitive topics. If you are watching people and not the computer screen or your notes and read their body language – you’ll know if it’s an OK topic to pursue. If patients are ready and want to have that conversation, then they’ll interpret that question as ‘now is the time’ and away you go.

And in an ideal world – what is your wish?

I would like to see a health care system where cancer clinics have a Sexual Health Physician on staff as part of the team.

And so, for example, at a patient’s final appointment with the oncologist they are given a pamphlet or a flyer or a card to consider. So that patients know that there is a doctor who can provide some help with their ongoing wellbeing and sexual and hormonal health. Actually, they need that card at the beginning of their treatment and then a reminder at the end.

Every woman is different in when they might want some help with oestrogen deficiency symptoms. The reason I contacted BCNA is to offer what I can, from my training and experience, to help clinicians to up-skill and support their patients as they navigate this next stage of their lives.

I’d would also like to see formal training options for doctors in the survivorship space – not just in sexual health – but more generally. We can always improve on the care that we provide.