Who should I contact for help with sexual dysfunction and emotional distress after a hemorrhoidectomy and fistulotomy, as a member of the LGBTQ+ community in a state with limited gay rights, when I'm already seeing a pelvic care provider?

Who to Contact for Post-Surgical Sexual Dysfunction and Emotional Distress

You should immediately contact a sexual health specialist or sex therapist, while continuing with your pelvic care provider, and consider adding a mental health professional experienced with LGBTQ+ populations to address the emotional distress you're experiencing. 1

Primary Referrals Needed

Sexual Health Specialist

• Sexual dysfunction after anorectal surgery is multifactorial and requires specialized expertise beyond general pelvic care. 1
• A sexual health specialist can provide comprehensive assessment of physical barriers (pain, anatomical changes from surgery), psychological factors (anxiety, depression, body image distress), and interpersonal concerns. 1
• These specialists can offer specific interventions including pelvic physical therapy coordination, topical anesthetics for pain management, and strategies for adapting sexual practices post-surgery. 1

Mental Health Professional with LGBTQ+ Competency

• Depression and anxiety commonly contribute to sexual dysfunction and are creating significant distress in your situation. 1
• Fear and anxiety about sexual activity after a medical procedure can interfere with your ability to perform and enjoy sex, making early discussion critical. 1
• Cognitive behavioral therapy (CBT) has proven effective at improving sexual functioning and reducing associated distress. 1
• Look for providers who use inclusive language, ask about your pronouns and identity without assumptions, and validate the unique strengths of LGBTQ+ individuals. 1

Why Your Current Pelvic Care Provider Isn't Enough

• While your pelvic care provider addresses physical healing, sexual dysfunction requires a multidimensional treatment plan addressing physiologic, psychologic, and interpersonal issues simultaneously. 1
• Many pelvic floor dysfunction issues contribute to sexual problems after anorectal surgery, but this is only one component. 1
• Approximately 10% of patients experience complications after hemorrhoidectomy including pain, fissure, and functional issues that impact sexual activity. 2
• Fistulotomy carries a 20% risk of continence deterioration, which directly impacts sexual confidence and function. 3

Addressing Barriers in Your State

Finding LGBTQ+-Competent Care

• Patients may avoid discussing sexual issues due to fear of healthcare providers' attitudes toward homosexuality or bisexuality. 1
• Gender stereotyping and assumptions about sexual orientation by healthcare professionals create significant barriers. 1
• Search for providers through LGBTQ+ health directories, community centers, or telehealth platforms that explicitly advertise LGBTQ+-affirming care if local options are limited. 1

What to Expect from Competent Providers

• They should mirror your language about identity, relationships, and body without making assumptions. 1
• They should ask open-ended questions like "Who do you feel sexually or romantically attracted to?" rather than assuming heterosexuality. 1
• Any missteps should be briefly acknowledged and moved past without making you responsible for their education. 1

Specific Clinical Approach for Your Situation

Physical Assessment Needed

• Evaluation of surgical healing, scar tissue formation, anal sphincter function, and pelvic floor muscle tension. 1, 3
• Assessment for pain with specific activities, including receptive anal intercourse. 1
• Topical anesthetics (like lidocaine) may help with pain during sexual activity and have proven effective for genital pain. 1

Psychological Interventions

• Address fear and anxiety about resuming sexual activity, which is preventing you from even discussing this with providers. 1
• Work on body image concerns and feelings about changes in sexual function. 1
• Develop coping strategies for minority stress, including expectations of rejection from healthcare systems. 1
• CBT specifically targeting sexual dysfunction shows large effect sizes in improving sexual function. 1

Relationship/Sexual Counseling

• Even without a current partner, sexual counseling can help you process grief about changes in sexual function and develop strategies for future sexual relationships. 1
• Couples counseling (when applicable) addresses communication about sexual concerns and reduces anxiety in sexual situations. 1

Timeline and Expectations

• Sexual function discussions should occur at regular intervals, not just once. 1
• Recovery from anorectal surgery typically takes 6-12 months for full healing, but sexual function concerns should be addressed immediately, not delayed. 4
• Some studies show improvement in sexual function after hemorrhoidectomy (in the context of erectile dysfunction), but this doesn't apply to receptive anal intercourse concerns. 5

Critical Pitfalls to Avoid

• Do not delay seeking help due to embarrassment—sexual dysfunction causes significant negative impact on quality of life, and effective treatments exist. 1
• Do not assume your surgeon or pelvic care provider will initiate these conversations—providers often lack training or feel uncomfortable with sexual health topics. 1
• Do not accept providers who dismiss your concerns or make you feel uncomfortable about your sexual orientation. 1
• Do not wait for complete physical healing before addressing psychological distress—early intervention prevents worsening of anxiety and depression. 1

Practical Next Steps

1. Request a referral from your pelvic care provider to a sexual health specialist or sex therapist. 1
2. Independently search for LGBTQ+-affirming mental health providers through online directories or telehealth platforms. 1
3. Screen yourself for depression and anxiety—these are treatable conditions that significantly worsen sexual dysfunction. 1
4. Consider joining LGBTQ+ support groups (online if local options are limited) to reduce isolation and connect with others who have navigated similar healthcare challenges. 1