Take two sex questions and call me in the morning. If only talking to your doctor about sex felt that easy. You rehearsed the question in the waiting room. Then the doctor walked in, and you swallowed it. Not because it stopped mattering, but because you weren't sure what asking would say about you. Dr. Sheila Wijayasinghe is a family physician and medical educator who brings sexual health into everyday care. She and Michelle Fischler talk about the questions patients swallow, the assumptions clinicians bring into the room, and why asking about pleasure belongs alongside asking about pain. You don't need the perfect words to begin.
Take two sex questions and call me in the morning. If only talking to your doctor about sex felt that easy.
You rehearsed the question in the waiting room. Then the doctor walked in, and you swallowed it.
Maybe it was about STI testing. Pain. Pleasure. A change in your body. Something you worried would sound strange, embarrassing or too personal for a medical appointment.
Dr. Sheila Wijayasinghe is an academic family physician, medical educator, Menopause Society Certified Practitioner, longtime health expert on CTV's The Social, and co-host of The Doc Talk Podcast. She and Michelle explore how shame follows us into the exam room, how a provider's tone can open or close a conversation, and why sexual healthcare should make room for pleasure, not only pain or problems.
Sheila offers a place to start when the words will not come: "I'm feeling embarrassed, but I'd like to talk about this."
You don't need a polished explanation. You only need an opening.
Instagram: @drsheilaw
Got a story you want to tell on GETSOME? Email michelle@getsome.ca
Follow @getsome_podcast on Instagram.
Produced by Katie Jensen at Vocal Fry Studios.
getting tested doesn't say anything about your masculinity or morality or your sexual behavior. Like it's more information about your health,
and now with a lot of sort of the manosphere and these spaces that are emerging and growing in popularity, there's even more of a furthering and, like, gendering of, how things should be, and that's really unfortunate. And it takes away, sort of the normalization that this is part of your healthcare.
do we really want men to come in using the same ideas about masculinity that may have kept them away from the care in the first place?
I'm Michelle Fischler, certified sex therapist, and this is GETSOME. this season I wanna talk about men, what they're told they should be, and what happens in bed when they can't be it.
There's a societal expectation that men and masc individuals will, like, already know everything about sexual health, and be sexually experienced, and remain in control, and not appear anxious, and not admit to vulnerabilities when life is vulnerable, and these are the things that are important to get support for. And I think that's deeply unfair to have that expectation placed upon you, and that's where it can limit when people are seeking out support.
My guest today is Dr. Sheila Wijayasinghe, a family doctor in Toronto, and she says the questions people are too ashamed to ask her out loud are going somewhere else.
I mean, right now it's online, it's AI chatbots. That's what we're seeing a lot in healthcare right now because it's an anonymous space that you can go into and you're not being judged. And I think a lot of the shame that I see in our office, in our clinic, is a fear of judgment.
So if you're wondering how to bring up the topic of sexual health with your healthcare provider, Sheila has some tips for when you struggle to get the words out.
You don't have to tell your story perfectly. Start somewhere, and if you're worried, like that's what we're there for, and it's okay to ask for that kind of support and say, "I'm worried about this, and I'd like to know what we can do to help my worry and to reduce my worry." whether that's STIs, whether that's pain with sex, whether that's reduced libido, whatever it may be, that is okay for you to say it. But I do think there's power in naming what your concern is if you're able to do that.
If you've ever rehearsed a question in a waiting room and then swallowed it when the door opened, this episode's for you. We talk about STI testing, pain and pleasure, what happens to care after 60, and the first thing you can say out loud when you're too embarrassed to say anything.
Here's my conversation with Dr. Sheila Wijayasinghe
What is the question patients almost never ask you directly and what do they do instead?
Yeah, I mean, when it comes to sexual health or talking about STIs and testing or anything to do with sex in our offices, one, I don't think that people bring it up because it's an area that isn't always seen as part of healthcare. But what I do think that people will often kind of skirt around is sort of like, "Is this normal?"
And I appreciate that because it o-offers, like, an opportunity to talk about it. What I wish that people would say and be really direct and open about it, but again, this often depends on your relationship with your healthcare provider at the time, and we know that we're not taught this really readily, and we also cause our patients to maybe not feel as comfortable for different reasons in our own actions or inactions.
I wish that people could just sort of say directly, "I have a sexual health question," or, "I have a question related to my sexual health, and I hope you can help me with it." And I just wish that it was direct, but I realize that because of the shame associated with this area, of healthcare, it's often not brought up.
I've been caring for some of my patients for almost 20 years. And so I've seen some of them as children, and now they're into adulthood. Some I've seen as in midlife, and now they're into their senior years. And so it's really interesting to have this long-term relationship. I'm a family doctor, and so when I'm working with my patients, I try to talk about sex really openly as part of regular routine health, in many conversations.
what does that look like? Can you tell me what is your question that seems to really open up the space
Yeah. So I really nor- I try to normalize it as much as possible. And I say, "Listen, I, believe sexual health is part of your r- overall health, and I think it can be a really important piece to discuss with your doctor, your nurse practitioner." For me, it's as a doctor. "And, if you're comfortable, we can talk about this.
If you're not, I'll leave the door open for you to come back at any point." And, it's surprising to me, Michelle, sometimes even if I've had like a 15-year relationship with a patient, they'll sort of be like, "Hmm, okay. I don't wanna talk about that." But then like maybe in two or three visits, they'll kind of be like, "Do you remember when you brought up that question about my sexual health, and I kinda didn't ask anything, but I actually do have questions?"
So I think sometimes as clinicians, what's helpful is to just like keep an open door, know that it may not happen. It may not happen even related to when you're seeing a patient for a sexual health-related issue. So I think whenever I'm teaching my residents and medical students, I often will say like, "Let's be opportunistic in the some of the things that we're talking about."
So if someone's coming in for their HPV or Pap test, let's use this as an opportunity to find out a little bit more if they would like to talk about things a little bit more in terms of their overall sexual health. And so ask them questions around their sexual lives, and do they have pleasure? Do they have pain?
We often focus on pain because we often look for pathology in healthcare settings rather than looking for the other side of things, which is like, do you find this enjoyable? And that's a big one that's hard to like kinda get around, 'cause patients often, and even clinicians, we're not y- accustomed to asking about pleasure in our healthcare spaces, but I think it's such an important thing to ask about.
In the middle of like a HPV test or a Pap test, there's a like, that's a really clear opportunity to whenever we're doing a routine sexual history. So if we're about to ask somebody about, "Would you like to have STI testing done?" Clearly there's like a laid out algorithm that we have that we ask questions of like, "When were you last sexually active?
When was your last period if you're a menstruating individual?" We have specific questions, and then I add on the other ones, right? Like around the pleasure and otherwise. I also ask a specific question around like, "Is there anything that you would like to talk about that you're wondering if it's related to your sexual health?"
But it may not be, but you're wondering about it. Like, let's start from a place of curiosity so we can sort of explore that and see what I can do to help. Because what I have as a family doctor is a toolkit of options for my patients. And so depending on what they're coming in with, I'm able to offer that.
And I actually have a physical toolkit in my office where I work with my patients, and I say, "This is what lubrication looks like. This is what a dilator looks like. This is what a toy looks like." I prescribe vibrators in my practice because some insurance plans cover it as a medical tool, right? So this is where you can do these things and actually open up this conversation.
I realize that this is not necessarily the standard that happens. I just really find it in a space that has offered me opportunity to speak to my patients in a way that, one, often they're surprised because they're like, "Oh, I didn't-- I thought you just talk about blood pressure and other things." But this is an important part of our patients' lives, and I really think that we need to shift the narrative from, like, sexual health being a separate thing to our overall health, to, like, really seeing it as a part of our entire healthcare journey.
What kinds of sexual health worries do people wait too long to bring up?
So I think pain is a really big one that comes up, because we normalize pain often, especially in our patients. I do a lot of work in perimenopause and menopause, and as we age, there's sort of this thought that we stop being sexually active, for example. And so, pain is very common, especially because of the symptoms that happen postmenopausally, and, and it's something called genitourinary syndrome of menopause, where there's changes to the body, and it leads to dryness and discomfort during intimacy.
So I think pain is a really big one. again, it breaks my heart when a patient will tell me, "Oh, I, I've been dealing with this for, like, years," when I wish that we had talked about it earlier because we do have really good options to support our patients through, whether it's referring to someone like yourself in terms of a sex therapist, or to pelvic floor physio, or there's medications, or there's lubrication discussions or moisturizers and all sorts of other pieces.
A decrease in desire is a really big one that also people struggle to come forward with. Because it's so multifactorial, there's so many aspects to that, that it can feel overwhelming to bring it up.
but as a family doctor, especially because I've often been caring for a patient for a long time, I can see the other moving parts of their life that may be contributing to that. So I'm able to be like, "Yeah, you have a five-year-old who needs a lot right now, and you have a parent who's just been hospitalized for something else, and you're in the middle of these two different worlds while also managing your own career, while also managing if you're in a relationship."
Like, all of these pieces come together. Maybe you also have a chronic medical issue that might affect things. I may have prescribed you a medication that might have affected your desire or libido, and changed how your sexual health is as well. So, we're well-suited to be a good source of information for our patients.
But again, it's not something that people often come forward with. But yeah, I think... worries around STIs, because of the shame related to that. Often when patients have changes that are physically visible, they sort of will understandably feel embarrassed about that, and then they'll stop intimacy, as a result and sort of leave it and kinda not know what to do.
So with, HPV-related, like warts, for example, or herpes changes, or any of the STIs that has a physical presence, that can be very difficult, for people to come forward. And again, I wish people would because we have options to support them.
Pediatricians are now being told to start sexual health conversations as early as age five, framed around consent, not mechanics. That's decades earlier than most parents assume. what does sharing information and starting those conversations that early actually look like in practice?
Yeah. So, I get to see a lot of kids in my practice, lots of newborns growing up. It's really wonderful part of my, as being a family doctor. And I think it's important to emphasize, I start the conversations around consent early with my little patients. And it's really not about, like, the sexual mechanics that I'm teaching about.
It's about consent, and it's about teaching body autonomy, at this young age. And so, even in the exam room when I'm seeing a young child, if I'm doing an exam on a child, I ask permission Like, I ask them permission, not their parent permission. I use it as an opportunity with my younger children to sort of talk about, "You get to decide who gets to give you a hug."
And parents often... Like, we do that all together, and, and in my own life, I can see that with our own kids. Like, it's very much like, "You get to decide if you don't like being tickled. You can change that discussion, like, in the middle of... You said yes at the beginning. You can stop at any point that you're not comfortable.
You can change your mind. You can make decisions about your own body." And then teaching also, at a young age is really important to teach about, like, the correct terms, like, the correct anatomical terms, for body parts, because that's really critical as well. So we're, we're using the proper terms of penis and vagina and vulva and all of those things as well, and I think that can be taught at a really young age.
And there's really wonderful books that I share with my patients that I'm happy to give you the list that I share as well, with parents in my practice, just to be able to have those conversations, just because it's helpful to have kind of something in front of you to hold and show, I just think having a consent conversation and talking about this as a teenager it's almost too late, which is why it's so wonderful that we're recognizing why it's so important to talk about it early. We had this opportunity if I can share, like, a little story.
My son when he was younger, he had come home, and one of their friend's h- parents had, had told us that there was, like, a kiss that had happened at school from a classmate to him. And so when we were chatting with him at night, we sort of said, "Oh, did, your classmate ask permission to give you a kiss?"
And he says, "Yeah. Sh- no, no, she did. She asked me permission." And I said, "Okay, and how did that feel to you? Were you okay with that?" And he said, "Yeah. I said yes." And I said, "Okay." And then he paused, and he said, "Well..." She said, she asked me in her head. And so I'm like, "Oh, she didn't use her words." And she goes, he said, "No, she didn't use her words."
And I said yes in my head back. So it was a very interesting opportunity because it was very sweet and very cute, and also I was like, okay, here's our opportunity to talk about like what consent looks like in terms of like a verbal out loud discussion. And so then I started to like talk about it in that way, but also it was just, it was very sweet, but it gave us an opportunity.
So there's all these opportunities that will present themselves to families and like how do you talk about it? But I always go back to, I think people are very scared off by talking about it because they worry that it's too much information, too young. But it's very much about body autonomy and, knowing what your rights are
Yeah, The American College of Gynecologists, the ACOG, recommends a first gynecological visit between 13 and 15, whether or not someone's sexually active. Why start that early if there's no exam, happening yet?
Yeah, so we don't have the same guidelines here. But what we do is I can think of examples in my own practice with teenagers that I'm suggesting like, "Listen," and I do this with the parents and we talk about it openly. I said, "You're welcome to come and see me at any point, that you feel comfortable.
I'm happy to see you on your own." When parents are there, we'll sometimes, especially with our teenage patients, like we will try to see them separately just so that the teenager has an opportunity to speak and share what's going on in their life because they may not always share. I have the luxury of working in a teaching practice, so I have residents and medical students working with me, and so sometimes my patients, my younger patients, because I also see their parents in my practice, they may not wanna talk to me about some of these things out of a fear that it'll come out even though it won't.
But They'll get booked with my resident, for example, just so that they have a bit of d- space to be able to be more open. that young age is important because it allows us to talk about things openly. So we're talking about things like contraception, like infection checks, all these other things, what to look out for, these other pieces, and what their goals are. And, are they having symptoms? Like is it painful?
Are they able to consent without feeling coerced? Like what does that look like to them? And these are conversations, again, I think as clinicians, we have a role to play in supporting our patients to be able to move through life in that way and be that safe space to just have a non-judgmental space that they can be themselves and be really honest.
Yeah.
So if the American College of Gynecologists recommends a first gynecological visit between 13 and 15, whether or not they've been sexually active, what is it in Canada?
Yeah, so in Canada, there's no necessarily like some specific guidli- guidance around this, but I wanna emphasize that like when we are seeing our patients, the first thing that we do is a history taking, or having a conversation first.
We don't jump to a physical exam. And when it comes to sexual health, unless somebody's having specific symptoms, pain, abnormal bleeding, abnormal discharge, any of those sorts of things, then there's value in doing an ex- actual examination. But if someone's coming in and they just wanna talk to us, or they wanna do some routine screening, and there's a lot of non-invasive screening that we can do.
I think a lot of people are afraid to get STI screening, especially younger individuals, because they're worried that it's gonna be like a Pap test, right? So we're putting a speculum inside, and it can be really uncomfortable. But if someone is asymptomatic and they're looking for routine screening, we can do that with urine testing, for example.
And so it's a non-invasive test. It's easy to do. of many things of the pandemic that have happened, one of the benefits has been that we know that we can do a lot of things virtually. And patients will call in, and that sometimes having that little bit of a barrier in helps them disclose more at times, depending.
They'll make a phone call, and also it makes it easier for them to access care. And they'll just say, "Hey, Dr. Sheila," like, " I had a new sexual partner. I'm curious about getting tested." I'll ask them all the questions over the phone, and if they're asymptomatic, then I send them a requisition by email to do the testing.
So it's meant to be low barrier, and I think that's where, especially for our younger patients who may not have been yet fully sexually active or they're nervous about their first examinations, and some people think like even to get contraception, for example, they think, oh, it's a prerequisite.
You have to have an examination to get that. You don't need to. You don't have to do that. The one test that we like to do if you're on a estrogen-containing birth control pill, for example, is your blood pressure, but nothing internal needs to be done. It's really based on your symptoms that we make that decision.
Hmm. On the opposite end, STI rates among older adults has been rising for years. So what would the average person be genuinely surprised to know about the sexual health of adults over 60?
Well, I think people don't just stop being sexual as they get older, and I think that's one of the assumptions that's made, and we make that assumption as healthcare providers that as, as a result, we just stop asking them about it. There's a lot of work that we can do as clinicians, so patients over 60 and above, like, they date, they have new partners, they have multiple partners, they use dating app, they masturbate, they want intimacy and they experience desire, and they can also acquire STIs.
And I think this is where that's an important discussion to have. What might change, you know, are because of physical conditions or medications that as we get older, we tend to have more physical conditions or medical conditions that happen. We may be on more medications that can affect our sexual health in different ways.
Those things can change, and as I mentioned earlier, like the menopause symptoms can also affect lubrication and skin changes and otherwise. So mobility can also change, which can change how intimacy happens. I think the other piece, like sometimes when relationships change, either through divorce or widowhood, that can also change sexual health, and that's where also that might be the first time that someone's navigating, like, the conversations around getting tested for STIs or pleasure in a different way.
And so that's where, we see that there can be a knowledge gap from when if they've been in a monogamous relationship for many years, and now they're, they're new again, that's where it's important for us as their clinicians to offer a space to have those conversations. I always tell my patients, I'm like, "Sexual health doesn't have an expiry date."
it's something that throughout your life, if it's something that's important to you, then that's something that I'll do my best to support you in making sure that that's something that we can do. But, it does involve sometimes more challenging conversations in terms of like when you, you asked me the question around difficult conversations that don't come up
Mm-hmm.
And one of them is around, like, the medical changes that can happen in the body.
So physically erectile dysfunction is one thing that we often see, and that can create... And I'm sure you see this in your therapy sessions too, that that can create a lot of shame and difficulty. And it's always interesting 'cause people can get their prescriptions for ED online very quickly.
But I do wish that we could have more of a conversation around it, just because ED itself is not just a sexual health issue, it's actually a heart disease issue 'cause it's a blood vessel issue. And it offers us an opportunity then , to say, "Okay, well, we should also screen you for diabetes, and blood pressure, and cholesterol at the same time, and we have treatment options available too.
And we can go through that." So that's one of the, parts of aging. But then also, like with menopause and vaginal estrogen is something that I will often use to support the tissues, not just for sexual health, but also for bladder health as well.
Yeah. For men and masculine identified patients, what messages about strength, control, performance, performance or, almost like an invulnerability, how do they get in the way of sexual healthcare?
Yeah, I think it can increase the shame that comes with seeking out care and makes it more difficult sometimes to seek out care because there's a societal expectation that men and masc individuals will, like, already know everything about sexual health, and be sexually experienced, and remain in control, and not appear anxious, and not admit to vulnerabilities when life is vulnerable, and these are the things that are important to get support for.
And I think that's deeply unfair to have that expectation placed upon you, and that's where it can limit when people are seeking out support. And in healthcare in general, so separate from sexual healthcare questions that come up, but in healthcare in general, like, we see our patients in our practices as kids routinely every year until they're about six, seven, eight years old, and then they kinda age out of seeing us because they get their vaccines at school, potentially, depending on where you live in the country.
And then we then start to see people again as they become sexually active, but we tend to then see those who may need contraceptive support. So then we'll see them, and then we'll see , our cisgendered female patients coming in for their Pap test, or our trans male patients with cervixes come in for their Pap test, but then we'll see them routinely.
And then if pregnancy happens, then we'll see people through pregnancy routinely. But for male patients, we don't see them as often. So after that early stage of life, they drop off from coming in for routine care. And then when they do present, there is a symptom, but we don't get to see them as often for preventative care discussions and sexual health discussions as well.
Fascinating, because in 2014, there was an STI testing campaign called Man Up Monday that told men to get tested after a risky weekend, and it actually worked. Testing rates went up 200%, but researchers later pointed out that it also leaned on the same masculine norms linked to worse mental health and avoiding care in general.
How do we invite men into testing without that trade-off?
Yeah. This, I mean, this is fascinating 'cause it did seem to work, right? Like, this is where people did come in, and they did come in, and it was seen as a masculine thing to do,
and it worked for men, and it worked
because more women came in too, because the women would go with them get tested
Yeah.
I mean, I think The question I have here is like, do we really want men to come in using the same ideas about masculinity that may have kept them away from the care in the first place? And ideally, we would normalize rather than moralize these situations and really support people to come in because it's important to come in.
You know, Michelle, right now in the world, like there's so much being sold to people, and the marketing techniques that are being used are really very sort of like exciting and dramatic. Like, "Your doctor's not telling you this, but we're gonna tell you this, so you can buy it for this much," or whatever it is.
And so the marketing techniques that are used are very flashy and interesting, and so like the Man Up campaign is super catchy. And it continues to perpetuate what has caused some of the issues in increasing access to care. And so I think instead of saying like, "Real men get tested," which is what Man Up to me sort of signifies, I think just kind of being like, "STI testing is routine healthcare."
But it's just not very catchy. Like this is where it's tricky. And getting tested doesn't say anything about your masculinity or morality or your sexual behavior. Like it's more information about your health, and that's where, wow, like I'm, I'm really glad. Anything that increases testing, I'm always really grateful for.
I think it's really wonderful. I think we have under-testing happening, and we really need to make it much easier for people to get tested, and if this is what did it, that's part of what we could do. But I do think there's like some pieces that I wish it w- could be a little bit different.
whose job is it to break the stigma, right? Whose job is it to challenge that gendered shame?
Yeah. I mean, and now with a lot of sort of the manosphere and these spaces that are emerging and growing in popularity, there's even more of a furthering and, like, gendering of, how things should be, and that's really unfortunate. And it takes away, I think, the normalization that this is part of your healthcare.
I do think that it is really that we need to do a better job with our public health campaigns ourselves, as clinicians just sort of emphasizing like, yeah, get tested. Like, it's just important to get tested just like you would get your blood pressure checked. Like, why wouldn't you get your STI status done,
like, at the same time?
getting tested is hot.
Yeah.
100%, right? Like, there's nothing better than just knowing that someone is taking responsibility, and they wanna keep you safe too. , And I think that's where when you're having conversations with younger people in your life who may be emerging into, like, the relationship spaces and try to navigate these things, like, that's where having those conversations around, like, it's really nice when someone is looking out for their own safety and your safety.
It's hot. I mean, you may not wanna use - those terms with your kids maybe, but, like, that's where It's
a thoughtful act.
it's a very thoughtful, attractive,
trait.
You worked at a mobile clinic doing
STI screening, Pap smears, and birth control consults. What was that like?
Oh my gosh, it was awesome. It was like my favorite day of every week that we would have. So I used to work at Immigrant Women's Health Centre, which is now termed IWHC here in Toronto and, we would take this giant Winnebago bus and it was just this awesome scene where we would go... We had this lovely, Anna was our, like, she coordinated everything and she drove the bus and she was tiny, like she could hardly see over the steering wheel.
And we would drive across the GTA, so the Greater Toronto Area, to all these different communities. So we would go to a factory where where we went, went were places where people couldn't leave to come in to see their healthcare provider which is a really big issue with access to care because people have two, three jobs at the same time and doctor's hours are 9:00 to 5:00 which is very inconvenient.
So we wanted to go to people where they are and so we would go to ESL programs, we would go to factories, we would go to spaces in the city where people may, struggle to access care. And we would work with community agencies, specifically that were safe spaces for their community members where they would gather, they would provide educational opportunities around general health topics and we would come in and provide the medical services and depending on the community we were known to know-- be like the sexual health bus.
For some communities that wasn't very comfortable and so we would be the cancer screening bus because we'd be doing pap tests, looking for pre-cancerous changes of the cervix. w- it was really wonderful that we would be able to sort of land in a different community every week, see people on site.
Some days we'd see a few people but the impact is huge. Some days we'd see 25 to 30 people and so it just really varied. We went to, colleges too and other spots so like it was just like this really wonderful opportunity, in a judgment-free zone to offer care where people were living and working.
And, the bus doesn't exist anymore so I'm really sad that that doesn't exist, because that was really providing an option and a lot of the work that I do in outreach, here in Toronto is going into the community and providing care in communities where people feel safe, because coming into a hospital setting or going into a clinic isn't always the safest environment.
This layered upon layer with like the intersectionality of who we all are in terms of we know our Black and Indigenous patients, our,, newcomers, our under-housed individuals, like the struggles that come in for different reasons and they're not always treated well in the healthcare system.
They're often not treated well in the healthcare system and so being able to go out into community and provide care especially for such a stigmatized topic like sexual health was awesome.
You mentioned calling visits cancer screenings
instead of sexual health just to get people comfortable enough to come in. What were some of the ways you reassured patients to make them feel more comfortable seeking care?
I think it goes back to the beginning of our conversation of, like, normalizing that this is part of your overall health. and it really is. Like, STI testing is part of your overall health. If you have an untreated STI, it can lead to very severe complications in certain circumstances, depending on the infection, and we have treatment options for you.
So that's where it wasn't meant to scare people. It was really meant to be like... Again, it goes back to, like, I'm checking your blood pressure. I'm also checking to make sure that there's no other infections happening. If I'm checking your iron, If you'd like, I can check for HIV or syphilis at the same time, 'cause those are blood-borne illnesses that we're checking for.
So it was very much like wrapping it in general healthcare rather than what often happens is like, oh, I go there for my sexual health. I come here for my other health. Whereas I, I'm hopeful that, like, ideally we'd just be able to do that for everybody all in the same space.
Yeah.
Because that's not possible in many spaces, though, I have to do a shout-out to, like, all the sexual health clinics that exist across the country that are doing incredible work.
I've worked at Hassle Free Clinic here in Toronto and Bay Centre for Birth Control. Like, these are great centers that focus specifically on sexual reproductive healthcare services, and these are very needed. So I'm an idealist that I wish that this could happen in family practices, so it increases access to anyone if you have a family doctor, which again, over six million Canadians don't.
But We need these clinics because our own doctor's offices aren't always the safest place either to have these conversations. So I'm really grateful for those spaces.
Have you ever caught yourself realizing your own comfort level, or just assumptions that were affecting the room?
Sure. Yeah, I'm a human and I have my own biases and I, try to check those and be aware of them. Especially early in my career, when I was working at a sexual health clinic more frequently, the demographic we'd see was a younger population, and occasionally like uh, individual in their 60s or 70s would come in and I would just be like a little bit surprised.
And now again, now it's normalized for me and , I've been like, "No, this is an important piece."
when I have people come into my practice who are, you know, 80s, 90s. I'm like,
Yeah. Listen, I love it. I remember this wonderful patient, she was like, "Tell everybody," where she came in, I think she was 80, and her partner was in his 50s, she brought her granddaughter in to translate, and she came to the sexual health clinic. And so we were sitting there and chatting, and she was actually just coming for, like, some routine screening, and she was due for...
She'd never had a Pap test, actually, and so we don't routinely do Pap tests after age 69, but she'd never had one, so I'm like, "We should do one." And she was a very healthy 80-year-old. And so we were sitting there and chatting, and she started telling me about her sexual life, and I just was like, "
What about her granddaughter?
And her
granddaughter was just, like, translating, and it was very wonderful, actually, to see this kind of, like, interplay happen. she shared And so then when I got to the exam piece, when I was going to do the exam, I said, "Okay, she's post-menopausal. I wanna make sure that she's comfortable."
We do that with all our patients, but especially for those post-menopausal, we wanna make sure that they're comfortable, 'cause it can be really uncomfortable to even have a, like, to have a speculum exam. And so I sort of went through my usual spiel, and then when I was doing the exam, I was like, "Oh, are you on vaginal estrogen?
Like, what's happening here?" 'Cause it's very healthy tissue. And so I assumed that she was on vaginal estrogen. And no, she was not on anything. She was just like, "No, I just have a lot of sex." And, and it was sort of this really interesting sort of, like, I had my own assumptions that like, oh, okay, most people do need a bit of this estrogen or otherwise to sort of help with the tissue integrity, but she didn't. So I'm always like, I love doing sexual health and, , the joy that I feel when people are feeling good in their bodies and able to sort of be themselves and seeing this as part of their overall health, it is very empowering to them, and they feel aligned, and they're able to get that support.
But I do think the gaps exist in having those conversations. And I'm really very aware that there are many populations that don't get this sort of support. With my, like, trans and non-binary patients, we have safe spaces that happened, like specialized clinics.
But again, in sort of general practices, it may not be something that we really discuss as often. But I'm really grateful, again, the sexual health clinics and these specialized clinics that do excellent work are options.
What can someone say in the first 30 seconds to open a conversation they're ashamed of?
Yeah. So I have like specific things that I think are, are helpful just to kinda start the conversation. If you're feeling embarrassed, you can s- name it. "I'm feeling embarrassed, but I'd like to talk about this. I think I need to talk about this." "Something happened and I'm a little bit worried about my STI risk.
Can I tell you a little bit more about what happened so you can, we can go through if there's any testing that I need?" So it's very specific. "I'm having a problem with sex. I don't know if it's physical, psychological, or both." One of my patients once said it to me, and I thought it was...
I really appreciated the honesty and the vulnerabil-bility that they came forward with, but they just sort of said, "I don't know how to say this, Dr. Sheila, but I'm just gonna say it, and I might say it badly, but I just wanted you to hear this question." And then they just asked me, what it was.
that's a tactic. That's like having a hard conversation or if you're gonna give somebody feedback, you first say, "I'm gonna tell you something. I'm gonna poke you a little bit." And it prepares them to then accept it.
100%. And I think patients can come with these different questions, but we have to do a better job ourselves, right, in the clinical spaces that we offer our patients and safety. And Michelle, it's not just that what we say matters, but like doctors notoriously interrupt our patients within a couple seconds of them starting their conversation, even though we're supposed-- we teach to kind of like have an open-ended start to conversation, we interrupt right away.
W- we feel the pressure of like having to see another 10 people in your day or whatever it might be, but we have to be with a present with our patient in that moment. We may look away to type something, and that could be taken as like a, "Oh, - this is something shameful that I shouldn't be talking about," from the patient's side.
So there's all these things that we do as well. So patients can come in with these questions around like open and honest and try to get that help, but we also have a lot of work to do from the clinical side. I just always think like the only-- the main advice that I give to patients is, you don't have to tell your story perfectly.
Start somewhere, and if you're worried, like that's what we're there for, and it's okay to ask for that kind of support and say, "I'm worried about this, and I'd like to know what we can do to help my worry and to reduce my worry." Whether that's STIs, whether that's pain with sex, whether that's reduced libido, whatever it may be, that is okay for you to say it. But I do think there's power in naming what your concern is if you're able to do that.
What would change if sexual health care felt less like punishment and more like ordinary care?
Oh, I mean, that would be the dream, wouldn't it? Like, just to be proactive about all aspects of your care, to feel like non-judgmental spaces are opening up for you just to be able to feel safe to come forward with very human experiences that we all will experience at some point. Like, that would be the dream, to be able to have spaces that recognize that this is part of our routine healthcare.
It's not anything specialized when we're talking about sexual health. It's really routine care And obviously, like, I'm not an expert in relationship dynamics or specific, like, sexual health concerns that really would benefit from a pelvic floor physio or a sex therapist as yourself. But that's where when we normalize these conversations, we also then build our teams around us to be able to sort of offer wraparound care to our patients in a way that they feel fully supported.
So they know, okay, Dr. Sheila not gonna be able to necessarily sit down and go through sort of some of the past pieces that are emerging here, but she's been able to connect me to someone like Michelle, and to be able to have that conversation so I can delve in a little bit further and have some tools to get that.
and then maybe I'll go back to Dr. Sheila to get some of that. And it becomes this, like, seamless process where we all work collaboratively to support the individual in front of us as they navigate the messiness of life, right? So this is where I just think that would be really wonderful.
And Shame is such a limiting piece, and a lot of the work I do is around HPV care as well, and it's really fascinating. Michelle, there's a study done it was done in Quebec, looking at HPV-related warts and HPV-related cancer, and the emotional distress score that happened with a diagnosis of cancer versus a diagnosis of warts.
The wart diagnosis carried such an enormous burden of shame compared to an actual cancer diagnosis. And this is where HPV is so common, and we have excellent preventative tools now with vaccination and otherwise, but, like, our vaccine uptake is very low. And it's similar to when Hep B came out as a vaccine.
Hep B is also sexually transmitted, like HPV is sexually transmitted, and it's a cancer preventing vaccine. These are both cancer preventing vaccines, and this is where, like, because of the stigma and the shame associated with the topic of sex and that they're sexually transmitted, it limits access to this cancer prevention option that we have available to us.
Yeah. So much shame and fear about being sexual.
Just really so dependent on what you learned, what you experienced growing up, and just the information that was given to you, and what a huge difference. Like, I can't even imagine walking into my family doctor, as a 14-year-old and having my doctor ask me questions about sex.
Like, it was something that you had to intentionally prepare to bring up and cross your fingers that they weren't gonna give you a, look like
Mm-hmm. 100%. And it's so interesting because, like, we see teenagers in our practice on occasion, and we have a specific acronym that we're taught to ask questions. It's called the HEDS acronym, and it goes through home environment, education, like school, bullying, all sorts of, drug use, and sex is part of that We're taught to ask these questions. But they don't always happen.
we're all impacted by shame,
regardless if we're a doctor, a sex therapist, a teacher, a parent
So much. I talk about sex a lot in public spaces, on TV, or in podcasts, and otherwise, and it's so fascinating because my parents are really wonderful and they're really open, but they-- whenever I t- I'm on in some space talking about sex, I don't tell them about it. Like, even though it's s- like a very big passion of mine that I love to talk about, and I'm really happy to talk about it openly, but I still...
Like, if I'm talking about the heart, yeah, I tell my parents. I'm like, "Oh, I'm gonna be on TV at this time." If I'm talking about sex, I just don't tell them that I'm on TV that day. And it's just, , also my own shame. I never grew up talking about sex. I didn't learn about it. I learned about it through my friends and through school versus, like, my parents ever talking to me about it, because it was sort of like a, "Well, that's not something that we do until you're, like, the traditional time."
And, I think that's why I really love talking about it now, because it was something that was sort of not emphasized to me very much growing up. But clearly, that I still shy away from sharing those specific episodes or segments or topics with my parents. Yeah, I just don't
before I let you go, Sheila, what do you want people to know about what you're interested in right now, what you're doing?
Where can we find you?
This has been such a lovely conversation, and it makes me so happy to talk to you, Michelle. I'm a big fan of your work, and I can't wait to see, to listen to all of your episodes this season coming up. I think what I would love to share is that I am continuing my work in public spaces to support Canadians with navigating the healthcare system.
It's complex, it's difficult to be a patient, and my goal has always been, like, let's make this a little bit easier by patients knowing what their rights are. And so I'm gonna continue doing that. I have my own podcast with my wonderful podcast, partner, Shaz- Dr. Shazma Muthani. She's out in Edmonton, which is where I'm from originally.
And she's an emerge doc. I'm a family doc, and so we, we tackle topics together. I just took on a role at the University of Toronto, in the Department of Family and Community Medicine as a co-lead for our mature women's health, curriculum development. So for, it's a five-year plan that we have coming forward, where we're really building a curriculum because women's health is really underfunded, under-discussed, and under-researched, and so we are hoping to change that.
The Department of Family and Community Medicine in Toronto is one of the largest in the world. We graduate about 200 residents every year. We have over 2,000 faculty members, and it's our goal is to really start to create a robust learning curriculum for people where sexual health will also be included as part of, this, topic area, too.
And then just continuing some of the fun. I have, like, two young kids. I'm in practice full-time with in my family practice, and continuing to, like, connect with people like yourselves who do really important work that just, like, lights me up to hear what you're doing to change how people access care in really meaningful ways and reduce shame and just support them through their own journeys.
And I'm at, on Instagram, and I'm also just, like, personally trying to move my body more and strength train. I'm perimenopausal. I'm 48, coming up in a couple weeks, and I, am feeling it, and so really focusing on sleep and the things that I recommend to everybody, just getting fiber in my life.
That's my other area of focus is fiber.
I am on the train with you. Sheila, thank you so much for all the work that you do. it is so heartwarming and reassuring to know that you are training other physicians to incorporate questions around sexual health into their practice. Your work is powerful, and you're so passionate, and you're saving people's lives, and Thank you,
Thank you, Michelle