The WHO defines sexual health as a state of psychological, emotional, mental and social well-being in relation to sexuality – not merely the absence of disease or dysfunction. What is the situation in Switzerland?

Bernard Surial: People talk about sexuality much more today than they used to, even in our clinic. But I have to be honest: I don’t know the exact figures, and we mainly talk about it when problems come up. However, as a specialist dealing with infectious diseases, my perspective on the topic is somewhat narrowed, because people usually come to us when they have noticed symptoms of a disease or have tested positive for an infection and need treatment.

Stefanie Gonin-Spahni: From a psychological perspective, I think we have a good infrastructure here and good opportunities to access therapy and counselling on this topic. Nevertheless sexual health remains the domain of specialized services, and to take advantage of these services, you have to know they exist. For example, it’s not standard practice to discuss sexual health with your gynecologist or GP. In short: the topic hasn’t yet made its way into primary care.

Can you give us any figure showing this?

Stefanie Gonin-Spahni: There’s data from the representative population study “Health and Sexuality in Germany.” Put simply, according to that study, one in two women and one in three men experienced sexual problems in the past twelve months. If we narrow that down to those with severely impairing sexual dysfunction, we’re still looking at more than ten percent! These prevalence rates are higher than those for depression – and yet people hardly ever talk about it.

In my view, sexual dysfunction in and of itself isn’t the decisive factor, because some people are able to compensate well for it, maintaining – or perhaps even improving – their well-being. But the number of people who suffer from it is still alarmingly high. And I think it’s terrible that some people resign themselves to it and suffer for years because they think, “I just don’t function properly, or I’m just not the sexual type.” It should be part of primary care to recognize that sexual functioning and experience can be changed.

What differences are there between the genders and various age groups?

StefaStefanie Gonin-Spahni: Women are more frequently affected by sexual dysfunction than men – for example, by tension or pain during sex, or by problems reaching orgasm. We could spend hours debating what might be causing this… Overall, such disorders increase starting in middle age, such as difficulties with sexual desire or erectile problems. What’s interesting is that premature ejaculation was long considered a problem exclusive to young men, but that’s a myth. Prevalence rates are relatively stable across all age groups.

Younger people often face different challenges, such as the consumption of substances and sexuality or also pornography consumption. Another topic for them is sexual violence, though that is a phenomenon that cuts across all age groups.

What about sexually transmitted infections (STIs)? Do they primarily affect younger people, or do they also occur across all age groups?

Bernard Surial: According to figures from the FOPH, STIs most predominantly affect people between the ages of 15 and 35. However, sexual behavior and testing habits are the decisive factors, not age. In our clinic, we see STIs in all age groups.

The European Centre for Disease Prevention and Control (ECDC) has reported an increase in sexually transmitted infections in recent years. Do you also see this increase in your clinic and at the testing center?

Bernard Surial: Yes, we’re seeing an increase in chlamydia and gonorrhea. That said, it’s important to note that the vast majority of infections are asymptomatic. The number and types of cases we see depend heavily on who actually gets tested. Fortunately, we’re seeing fewer and fewer HIV infections, and new cases of viral hepatitis aren’t very common either.

So are we seeing an increase because we’re testing more, and not because there are actually more new infections?

Bernard Surial: More frequent testing certainly accounts for a large part of the increase, especially for chlamydia and gonorrhea. For example, we’re seeing an increase among homosexual men: they get tested significantly more often than other groups, in part because they’re easily reached through prevention programs and community structures. Young women, on the other hand, are harder for us to reach. Yet this is important, as undetected chlamydia infections could lead to fertility problems. Primary care providers – gynecologists and GPs – need to be made more aware of this issue.

To what extent is shame still a barrier to getting tested for sexually transmitted diseases today?

Stefanie Gonin-Spahni: I think shame is still a major issue. That’s why it’s so important to have testing centers where people can get tested anonymously, without their GP or gynecologist – who knows them – finding out. I still hear from many people that they’re asked to explain themselves when they want to get tested by their GP. They get confronted with questions like: “Why do you want to do that? You’re in a relationship, you don’t need that. Or have you had any high-risk contacts?” We’re still a long way from STI testing becoming as routine as a blood pressure check.

Bernard Surial: I think people feel less shame today than they did ten or fifteen years ago. Particularly young people often no longer come to us anonymously. Despite this, shame does remain a major issue. The existence of anonymous testing sites remains important – for example, for people in committed relationships who don’t want to explain themselves, but also for everyone else who simply doesn’t want their test results to reach their GP.

“Talking professionally about sexuality takes practice.” 

Bernard Surial

Are there any other barriers?

Stefanie Gonin-Spahni: Another hurdle is funding. Ideally, everyone who has unprotected sex or multiple sexual partners should get tested. But if you aren’t exhibiting any symptoms, basic health insurance doesn’t cover it…

Bernard Surial: Funding for the tests is indeed a problem. They’re expensive, and young people in particular often have a high deductible and end up having to pay for them out of pocket anyway. As part of the FOPH’s National Action Program, certain testing centers like ours do offer these tests for HIV, syphilis, chlamydia and gonorrhea at a lower cost, e.g. our center offers the tests at a cost of 150 francs, including counselling. But for many people – especially younger ones – even that is still a lot of money.

HIV has lost much of its stigma. Does that contribute to people being less careful overall about protecting themselves against STIs?

Bernard Surial: HIV is also a success story: treatment today is simple and effective, usually consisting of taking one pill a day or getting two injections every two months. Life expectancy is the same as for people without HIV, and those who are well-treated can have sex without a condom without transmitting HIV and can have children naturally.

As a result, HIV has naturally lost its aura as a looming threat, which can lead to changes in risk behavior. Surveys show that condom use during sex with casual partners has declined across all population groups. This makes other prevention options, such as “HIV PrEP”, all the more important. I think it’s important that the disease isn’t forgotten. We must continue to raise awareness and talk about it without scaring people.

Sexual content is readily available online and very prevalent, whether through pornography, AI-generated images or other content shared on social media… What role do digital media play in sexual health?

Stefanie Gonin-Spahni: On the one hand, the fact that the topic is so prevalent is positive: there’s a broad discussion about consent, an awareness of how important it is to talk about the topic, to be mindful of one another and to communicate what we like and what we don’t… In movies – whether pornographic or romantic Hollywood films – people never actually talk; everything just happens naturally. But in real life, sex isn’t like that; we’re constantly communicating, both physically and verbally. At the same time, there are studies, for example, that show that heavy pornography consumption has a negative impact on genital self-image. This is because what’s shown in mainstream pornography doesn’t reflect the actual diversity of genitals.

You’re also conducting research on genital self-image yourself. What exactly does that mean, and why is it important for sexual health?

Stefanie Gonin-Spahni: Genital self-image is part of body image. It’s about whether I feel that my genitals look the way they’re supposed to and function the way they’re supposed to. While we all know how different noses, ears or hands can look, people are often unaware that vulvas, penises and testicles can also look very different. Sometimes I’m not taken very seriously for focusing my researcher on whether people are satisfied with their genitals, but this has very real impact on people’s lives!

“Whether people are satisfied with their genitals has very real implications for their sexual health.”

Stefanie Gonin-Spahni 

Can you be more specific?

Stefanie Gonin-Spahni: Wer ein negatives genitales Selbstbild hat, ist oft auch weniger zufrieden mit seiner Sexualität, erlebt weniger Orgasmen, empfängt weniger Oralsex. Aber es geht über das sexuelle Wohlbefinden hinaus: Menschen mit negativem genitalen Selbstbild gehen auch weniger oft in Vorsorgeuntersuchungen und schützen sich weniger gut beim Geschlechtsverkehr, weil sie sich nicht exponieren möchten. 

What knowledge gaps does the CAS in Sexual Health programme, which you lead, aim to fill among healthcare professionals?

Stefanie Gonin-Spahni: Especially in primary care, but also in gynecology, urology and psychotherapy, sexual health is still an afterthought. It’s not just about the technical, medical knowledge, but about how they can integrate the topic into their everyday work in the surgery. Many, for example, have never learned how to conduct a professional discussion about sexuality. They lack the technical language appropriate for medical or psychological practice.

Bernard Surial: That’s a very important point! Talking about sexuality in a professional manner is extremely important, and it takes practice. Once we reach this professional level, we can ask practically anything. In my practice, for example, I ask the patient in every consultation: “do you have sexual encounters outside of a committed relationship? If so, with or without a condom?” And many other aspects that are important for infectious disease medicine. If I ask this in a completely professional manner, most people have no problem answering more or less honestly.

If you could change one thing to improve sexual health in Switzerland, what would it be?

Bernard Surial: For me, it would be free access to prevention: condoms, birth control, pre-exposure prophylaxis (PrEP) and STI testing – these should be accessible to everyone, not just those who can afford them. In many countries, this is already a reality.

Stefanie Gonin-Spahni: I agree. I’d just like to add that sexual counselling should also be low-threshold and widely accessible. In many cases, what’s needed isn’t therapy, but simply more knowledge about sexuality. Young people in particular should be taught that sexuality, like everything else, is learned and can therefore be changed. It’s normal to face difficulties and challenges sometimes – and there are professionals who can provide support. We could make a huge difference here with very little effort!