Although our teenage children (and grandchildren) find it cringeworthy, sexual activity in middle adulthood and beyond is a frequent part of normal aging [11], and one that is associated both with good health and quality of life [1, 13]. Yet physicians in general [4], and orthopaedic surgeons in particular [3], rarely discuss “it” with their patients.

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Carlos J. Lavernia MD

We should do better. This month in CORR ®, orthopaedic patients—young [12], young at heart [15], and older—tell us “it” matters. Even patients with the most severe kinds of orthopaedic disability report that sexual activity is both possible and important to them [14]. Most kinds of sexual intercourse are safe for orthopaedic patients, even after operations like THA [2], where one might be concerned about potential risks associated with awkward positions. It appears we can give our patients permission to be adventuresome, rather than apprehensive—if only we could start the conversation.

Perhaps Dr. Carlos Lavernia’s group from Miami can help us do just that. Perhaps if we knew that more than 80% of patients considering hip replacement—patients with a mean age of 65, and many older than that—are sexually active. Perhaps if we knew that more than 80% of them have limitations on their sexual activities because of their hip problems. Perhaps if we knew that these limitations affect women more often and more severely than men. Perhaps if we knew that these limitations are severe enough to be associated with diminished overall health. Perhaps if we knew all of that, we could talk about sexual activity with our patients?

Well, now we know. Dr. Lavernia’s research team—no stranger to thought-provoking or controversial research topics [8–10]—gives us some great material to work with as we explore this sometimes-sensitive topic of sexuality with our patients. While on the face of it, this looks like a “hip-surgeon topic,” it is in fact much broader than that. Emotional and physical responses to all kinds of orthopaedic disabilities and musculoskeletal pain can influence body image [5], can affect sexuality [7], and can almost certainly interfere with the sex lives of patients of all ages who cope with chronic musculoskeletal disease, pain, or impairment [6].

We have much to learn about this topic, which is so important to our patients but so rarely discussed with them. While we still have unanswered research questions about sex and the orthopaedic patient, we know enough—and should be sensitive enough—to start the conversation.

Join me as we talk with Dr. Lavernia about how to put theory into practice, in the Take 5 interview that follows.

Take 5 Interview with Carlos J. Lavernia MD, senior author of “High Rates of Interest in Sex in Patients with Hip Arthritis”

Seth S. Leopold MD: Congratulations on another thought-provoking paper, Dr. Lavernia. Sex, race, mental health, poverty—your research team does not shy from the tough stuff. How does your group decide which research topics to take up?

Carlos J. Lavernia MD: I constantly study the uniqueness of my patients. The best thing about being a joint replacement surgeon is that I deal with the gold-medal winners of the geriatric population. These folks get a hip or a knee at age 86 because they want to play golf, swim, and, yes, have sex. To really ascertain the outcomes of any intervention, all dimensions of the whole patient need to be assessed. Wellness is one of the keys to a long life. With this perspective in mind, we frequently end up delving into topics or fields not studied by other surgeons. Our research topics are the logical result of this perspective.

Dr. Leopold: What surprised you about the results in this study, and how has it influenced the way you approach the topic with your patients?

Dr. Lavernia: We were surprised by the high proportion of patients who still engage in sexual activity in this group, in particular the high percentage of the folks older than 80 years of age who remain sexually active. At one point, this topic was not even in the ballpark in terms of conversations between doctors and patients in this age group, and now it is routine. The most surprising finding for folks like you and me is that we have another 25 years to 30 years of fun ahead.

Dr. Leopold: I can think of at least two reasons why surgeons avoid asking their patients about sexual function: (1) As consultants, surgeons may not have longstanding relationships with some patients, and so they may wonder whether there is a sufficient basis of trust to broach the topic, and (2) as people, surgeons may have a natural fear of conversations that might expose them to situations that could become awkward. How do you see this, and, more importantly, how do you overcome it in practice?

Dr. Lavernia: Indeed, the discussion of the subject might lead to awkward situations. The most effective way is a simple question in the written preoperative evaluation. This can help guide a surgeon on the next step. The question should be part of every new-patient questionnaire.

I have gotten around some of the awkwardness by learning and using phraseology that is not socially awkward, phraseology that borders on comedy. This also helps you establish a rapport with your patients.

In Spanish, we have a phrase to describe being intimate with your partner: “Cuchi cuchi.” It is a fun and endearing term for most Hispanics, and it always brings out a laugh in my patients. It certainly gets the message across. In English, when the time is right after surgery, I simply tell them that sex at this time is ok, but please “no acrobatics.” I have never gotten a frown in either language.

I agree that most surgeons avoid the topic with their patients because they feel it is not part of their scope of practice. I think that this is important to overcome this because as our data clearly show, most patients do want to know, and do want to engage in sex early after these surgical procedures.

A specific preoperative preoccupation of a lot of our patients is the ability to have sex. Patients get their hips and knees replaced to be able to improve their quality of life, and that includes sex.

Sometimes patients find clear—and fun—ways to approach the topic. Recently, I had an 82-year-old who requested a prescription for “TID activity.”

Dr. Leopold: The fact that patients are interested in sex is not news. Neither, in fact, is it news that hip-replacement patients are interested. Twenty-five years ago, CORR® published a study that found that 89% of patients undergoing total hip arthroplasty wanted more information about sex than they got [16]. It appears that this need remains unmet even today. What specific steps can physicians, specialty societies, and other responsible entities take to change that? A quarter-century seems a long time to wait.

Dr. Lavernia: I believe that getting familiar with what studies have shown, and understanding that a very large percentage of patients older than 65 years of age remain sexually active, is a start. Surgeons also should include a simple question about sex in the preoperative evaluation. They also should be familiar with the papers that discuss the safety of particular sexual positions after total hip replacement surgery, as these can help surgeons develop the “frequently asked questions” pamphlets that most surgeons have in their offices. Most importantly: The sexual life of patients represents an important sphere of their lives and it should be part of the evaluation.

Dr. Leopold: I cannot wait to see your next study—they are all so interesting—what is your group taking up next, and what do you imagine you will learn?

Dr. Lavernia: The current economic environment poses tremendous challenges both to providers and patients. We are working on studies aimed at determining the impact that such changes are having on arthroplasty. Even with insurance, many patients have no access to an arthroplasty. On topics more closely related to the paper in this month’s CORR ®, we also are studying how many of these patients actually go back to sex after surgery, and the impact that sex has on patients’ feelings of wellness and on their quality of life.