He sat across from me and said, almost proudly, “Everything works fine for me.” He was 58, generally healthy and in a long-term relationship. His erections were good, he was having sex, he reached orgasm and, in his words, the frequency was “totally reasonable.” By the usual measures men tend to use to assess themselves, he was right. Everything worked.
His wife, sitting beside him, saw things differently. “For years, he has barely touched me unless it is supposed to lead to sex. We don’t kiss. We don’t talk about what feels good to me. And if I don’t want to have sex, he immediately feels rejected.” I looked at him and asked, “So does everything work?” He smiled. This time, a little less confidently.
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Sexual health is more than function: Desire, choice, communication and the ability to adapt
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This is not the story of one particular patient. It is a composite of many couples I have met over the years, and it raises a question we do not ask often enough: What does sexual health actually mean?
There is good reason to talk about it now. Sept. 4 is marked around the world as World Sexual Health Day, and this year’s theme is “Every Body,” a play on words that means both every person and every body. The idea is simple but important: sexuality and sexual health do not belong only to the young, the healthy, the fit or those whose bodies function exactly as they would like.
We live our sexuality in real bodies. Bodies that age, gain and lose weight, go through pregnancy and childbirth, menopause, illness, surgery, injury, medication and sometimes disability. The body changes, and sexuality changes with it.
‘Everything works’ is great. But does it feel good?
Before deciding that everything in your sex life is fine, or that something is broken, it is worth asking a different set of questions. Later, I will offer five simple ones that anyone can ask themselves about their sexual health. And no, “How many times a week do you have sex?” is not one of them.
This is where much of the confusion begins. We tend to mix up sexual function with sexual health. Is there desire? Good. An erection? Great. Penetration? Fine. An orgasm? Excellent. No pain? Even better. All of those things matter a great deal, but they do not tell the whole story.
Medicine has also contributed to this narrowing of the conversation. An erection can be measured. We can ask how long it lasts, whether it is firm enough for penetration and whether it fades midway through sex. We can ask a woman whether she reaches orgasm or experiences pain. What is much harder to measure is whether she is actually enjoying herself.
Does she feel desired? Does he feel safe? Can they talk? Does touch between them feel good, or has it become another obligation? Are they doing what they genuinely want to do, or what they think a “normal couple” is supposed to do?
A person can have excellent erections and still suffer deeply in his sex life. A woman can reach orgasm and still leave a sexual encounter feeling distant. A couple can have sex regularly and still have very little intimacy. The reverse matters just as much. A man with erectile dysfunction can have a wonderful sex life. A woman with a physical disability can experience rich and satisfying sexuality. A couple that does not have penetrative sex can be far more satisfied than one that has it three times a week.
Sometimes the problem begins when we reduce the word “sex” to one narrow script.
I have worked in this field for many years and hold FECSM certification, Fellow of the European Committee of Sexual Medicine, a European qualification for physicians working in sexual medicine. Sexual medicine is still not recognized in Israel as an independent medical specialty. What matters to me is not the letters after the name, but the thinking behind them: sexuality sits at the intersection of medicine, psychology, relationships and society.
Everyone deserves healthy, enjoyable and fulfilling sexuality
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You cannot treat it seriously by looking only at the genitals. But the opposite mistake is also dangerous. Not every sexual problem should automatically be explained as a relationship issue, anxiety or childhood trauma.
A man with reduced erectile function may need an evaluation for vascular disease, medication effects, diabetes or hormonal problems. A woman experiencing pain with penetration should not immediately be told she is “not relaxed enough.” Gynecological conditions, hormonal changes, pelvic-floor problems and neurological disorders may all need to be identified and treated.
Prof. Rafi HerutiPhoto: Yanai YechielAt the same time, normal blood tests do not mean there is no real problem. Performance anxiety can affect erections. Pain that recurs several times can create anticipation of pain, tension and avoidance. Constant criticism inside a relationship can reduce desire. Medication can affect orgasm. A spinal cord injury can change sensation and arousal. Menopause can alter tissue and make touch less comfortable.
In sexuality, everything talks to everything else. So when a patient tells me, “Everything works,” I want to know one more thing: “Does it feel good?” That is a very different question.
Here is the self-check I promised.
1. Do I know what I want?
I am not asking whether you feel desire at every moment. Sexual desire is not an on-off switch. It changes with age, stress, sleep, children, work, illness, mental state, medication, hormones and the relationship itself.
It also does not appear in the same way for everyone. Some people suddenly feel a clear desire for sex. For others, desire appears only after closeness, kissing or touch has already begun. In other words, arousal may come first and desire only afterward. That, too, is completely normal.
It is also important to remember that someone who is not interested in sex and is not distressed by that does not necessarily need treatment. We should not manufacture a problem where the person experiencing it does not feel there is one.
The real question is different: Do I know myself as a sexual person? Do I know what feels good to me, what no longer feels as good, what interests me and what definitely does not? It sounds basic, but many people reach later life without ever seriously asking themselves those questions.
2. Can I really choose?
Can you say “not tonight” in your relationship without it causing an explosion? Can you say, “I used to like that, but I don’t anymore”? Can you ask for something different?
Being in a relationship does not cancel sexual autonomy. The fact that we have done something 100 times does not obligate us to do it for the 101st.
At the same time, real life is more complicated than slogans. In long-term relationships, people sometimes agree to touch or sex even when their initial desire is not especially strong. Sometimes they do it out of affection, closeness, generosity or because they know desire may develop once things begin. There is not necessarily anything wrong with that.
The warning sign appears when someone feels they do not actually have the option to refuse. When saying “no” repeatedly leads to anger, silence, accusations, hurt feelings or pressure, something is wrong. Sex we choose does not always have to begin with overwhelming desire. But it does need to remain something we are allowed to choose.
3. Can we talk about sex?
This is one of the situations I find both amusing and sad in the clinic. People can spend 20 years naked next to each other, doing intensely intimate things, and still find it difficult to say four simple words: “That feels better to me.”
They talk about money, the children, the mortgage, vacations, shopping, politics and why the trash was not taken out again. Then sex comes up and suddenly everyone goes silent.
Sexual communication does not mean holding a formal debrief after every encounter. Nobody needs an evaluation form. Sometimes it is enough to say, “A little more like that,” “I like it when you kiss me there,” “I miss the way we used to kiss,” “That doesn’t feel as good anymore,” or “I want to be close tonight, but I don’t feel like having sex.”
For me, the ability to say something like that and receive a response you can live with is a central part of sexual health.
4. Does physical touch always have to lead to sex?
Think about it for a moment. When was the last time you hugged without the hug being a prelude to something else? When was the last time you really kissed, not a quick goodbye on the way to work, without immediately wondering whether it meant sex was expected later?
Many couples gradually develop an agreement that was never actually negotiated: once sexual touch begins, it has to continue. That can do real damage.
The partner who wants less sex may begin avoiding even the affection they do want. If a small touch immediately creates an expectation of something more, it can feel safer not to touch at all. And then the things nobody intended to lose disappear too: the hug, the kiss, the hand on the back, cuddling in bed.
Sometimes one of the simplest interventions is to allow touch to become just touch again, with no destination required.
5. Can my sexuality change?
In my view, this is the hardest question. We are willing to accept that eyesight changes, hair changes, fitness changes, sleep changes and the entire body changes. For some reason, we expect sex to stay exactly the same.
A 65-year-old man may keep trying to reproduce the erections he had at 25. A woman after childbirth may expect her body to respond exactly as it did before. A couple may repeat the same sexual script for 30 years and then wonder why it is no longer exciting.
Good sexuality sometimes requires an update. After childbirth, people may need to get to know the body again. After menopause, some women may need treatment and adjustments. After illness, surgery or injury, people may need to find different paths to arousal and pleasure.
A man whose erection has become less reliable may keep trying to “succeed” at penetration until every sexual encounter begins to feel like an exam. Sometimes pleasure returns only when success is no longer measured exclusively by penetration.
Over the years, I have seen people whose sex lives actually improved after a major physical change. Not because illness or injury was good for them, but because for the first time they had to talk. What feels good now? What changed? What no longer works? What can we do differently?
The bodies we actually live in
All of this connects directly to this year’s World Sexual Health Day theme, “Every Body.” We are constantly exposed to messages about what a sexual body is supposed to look like: young, smooth, fit, flexible, pain-free, erect and always ready.
Most of us do not live in that body. We live in our own, and that is the body in which we need to find intimacy, pleasure and sexuality.
Sexual health does not mean everything has to be wonderful all the time. Sometimes there is no desire. Sometimes erections are difficult. Sometimes sex hurts. Sometimes partners want different amounts of sex. Sometimes life itself pushes sexuality aside for a while.
The question is not whether difficulties will happen. They will. The question is whether we can identify them, talk about them and seek help when necessary.
It is also important not to overlook the medical side. New pain, a sudden change in sexual function, a significant and persistent drop in desire or another change causing distress deserves evaluation. Sometimes sexuality is even the first place where a medical problem becomes visible.
That is why World Sexual Health Day should not be a day when everyone is told to have more sex. Not at all. The goal should be to stop treating sexuality as an embarrassing subject that somehow exists outside medicine and ordinary life.
A 70-year-old woman should be able to tell her doctor that sex hurts and that she wants to keep enjoying it. A loving couple should be able to admit that they have barely touched each other for months. And someone should also be able to say that sex simply does not interest them right now without everyone immediately searching for something to repair.
We health professionals need to improve too. Doctors and other clinicians ask patients about sleep, appetite, pain, urination and bowel movements. Then sexuality comes up, and they go silent. There is no good reason for that, though that is a subject for another column.
I return to the man from the beginning. At the next appointment, he no longer said, “Everything works fine for me.” Instead, he said: “I think all these years I was checking whether I could have sex. I never asked whether sex was good for us.”
That sentence stayed with me. Sexual function matters greatly. As a physician, I certainly do not dismiss erections, pain, orgasm or desire. But sexual health is broader. It is the ability to know our bodies, understand what we want, communicate, choose, touch, adapt and ask for help when we need it.
In the end, we do not need perfect sexuality. We need sexuality that feels good to live with.