Who to see, and when

The principle: one symptom, one front door

Most sexual difficulties can be treated, and most people who suffer from them see nobody — or see the wrong person, come out with an “it’s all in your head” or an “it’s your age”, and never go back. This page works the opposite way from a dictionary of diseases: it starts from what you feel, says who to turn to first, what that professional will look for, and when to move on to the next one.

One simple rule covers almost everything that follows: the first appointment is with the family doctor (general practitioner, primary-care physician, depending on the country). They examine, order the first tests — blood sugar, lipids, hormone levels —, go through your medicines, and know which specialist to refer you to. In many countries it is also the condition for the specialist’s visit to be reimbursed. Two exceptions: the emergencies described below, and the situations where you already know the problem is relational or psychological — then you can go straight to a sex therapist or a psychologist.

The professionals, and what each one does

• The family doctor — the front door. They treat a good share of problems themselves (urinary infection, thrush, a first treatment for erectile dysfunction, adjusting a medicine) and refer for the rest.
• The urologist — surgeon and physician of the urinary tract in both sexes (kidneys, bladder, urethra) and of the male genital organs (penis, testicles, prostate). This is who to see for burning on urination that persists, blood in the urine or the semen, a painful curvature of the penis, testicular pain, the prostate, and erectile dysfunction of physical origin once the family doctor’s options are exhausted.
• The andrologist — specialist in male sexual and reproductive health: hormones, fertility, erection. Depending on the country, the title is held by a urologist or an endocrinologist.
• The gynaecologist — physician of the female genital organs: pain during sex, bleeding, infections, dryness, contraception, menopause, endometriosis. The obstetrician also follows pregnancy and childbirth.
• The midwife — pregnancy, childbirth, the weeks after birth and, in a growing number of countries, preventive gynaecological care, contraception and pelvic-floor rehabilitation.
• The endocrinologist — hormones: low testosterone, thyroid, diabetes, high prolactin. When desire or erections collapse together with unexplained tiredness, weight gain or loss of body hair, the answer is often found here.
• The sex therapist (sexologist, psychosexual therapist) — specialist in functional and relational sexual difficulties: premature ejaculation, absence of orgasm, vaginismus, flagging desire, blocks, disagreements within the couple. The title covers very different trainings from one country to another: some sex therapists are doctors and can prescribe, others are psychologists, others again have only a short training. Ask which.
• The psychologist and the psychiatrist — performance anxiety, depression, trauma, abuse suffered, obsessions, compulsions. The psychiatrist is a doctor: they also adjust an antidepressant that kills desire or delays orgasm.
• The pelvic-floor physiotherapist — vaginismus, pelvic pain, a pelvic floor that is too tight or too weak, urinary leaks, rehabilitation after childbirth or after prostate surgery.
• The dermatologist-venereologist — spots, ulcers, warts, itching, patches on the genitals; historically also the specialist for sexually transmitted infections.
• Sexual health and testing clinics — STI testing, often free or anonymous, contraception, treatment after an exposure. Their names and conditions differ from country to country: your country’s sheet on STIs lists them.
• The relationship counsellor or couple therapist — when the sexual difficulty is the symptom of a couple problem more than a matter of the body.
• The pharmacist — emergency contraception, lubricants, drug interactions, and a first opinion on a side effect.

Symptom by symptom: who to go to

Erections

• Erections gradually less firm, including on waking, especially after forty or with smoking, excess weight, diabetes, high blood pressure: family doctor first, then urologist. The problem is most often vascular, and it precedes the first signs of coronary disease by two to five years on average: a cardiovascular check-up is part of the path, and a cardiologist may be called in. See erectile dysfunction.
• A sudden failure that depends on the situation — the erection is there alone or on waking, but not with the partner: the cause is almost always psychological (performance anxiety, stress, conflict). Sex therapist or psychologist, not necessarily via tests.
• Since a new medicine — antidepressant, beta-blocker, diuretic, prostate treatment, anti-androgen: the prescriber. Never stop it on your own; it gets replaced or adjusted.
• An erection that will not go down after more than four hours (priapism), painful or not: emergency department, without waiting. Beyond a few hours the erectile tissue is permanently damaged.
• A recent curvature of the penis, pain on erection, a hard lump under the skin: urologist (Peyronie’s disease). The earlier treatment starts, the better the result.
• A cracking sound during sex, followed by immediate loss of the erection, pain and purple swelling: emergency department — this is a penile fracture, operated on within hours.

Ejaculation

• Too fast since always — within about a minute, from the very first experiences: sex therapist (behavioural techniques, work as a couple), and a doctor for a supporting treatment if needed — some countries have an on-demand medicine, others use low-dose antidepressants or local anaesthetics. See premature ejaculation.
• Become too fast when it was not before: doctor then urologist, because an inflamed prostate, an overactive thyroid or early erectile dysfunction can be the cause.
• Delayed, impossible, or absent despite orgasm (retrograde ejaculation: the semen goes into the bladder): urologist. Diabetes, prostate surgery and certain medicines — antidepressants above all — are the classic causes; cloudy urine after orgasm is a clue.
• Blood in the semen: doctor then urologist. Benign in the great majority of cases, but it gets investigated, especially after forty or if it recurs.
• Pain on ejaculation: urologist (prostate, urethra, infection).

Desire

• Low desire in a man, with tiredness, fewer morning erections, loss of strength or body hair, a growing belly: doctor for a morning blood test (testosterone, prolactin, thyroid, blood sugar), then endocrinologist if a deficiency is confirmed. With no physical sign: sex therapist.
• Low desire in a woman: doctor or gynaecologist first, because hormonal contraception, breastfeeding, menopause, the thyroid, depression or an antidepressant are often involved and can be corrected; sex therapist next, alone or as a couple. Female desire is more often “responsive” than spontaneous: not wanting sex out of the blue is not an illness as long as it does not cause suffering.
• Very different levels of desire in the couple: it is nobody’s disorder, it is a gap. Couple sex therapist or relationship counsellor.
• Intrusive desire, compulsions, pornography use that escapes control: psychiatrist, psychologist or addiction specialist.

Pain

• Pain at the entrance of the vagina, on penetration, superficial burning: gynaecologist or midwife (infection, thrush, dryness, vestibulodynia, atrophy after menopause, episiotomy scar), then pelvic-floor physiotherapist if the muscle tightens against your will (vaginismus). See pain during sex.
• Deep pain, at the far end, in certain positions, sometimes with very painful periods: gynaecologist, with ultrasound or MRI — endometriosis, a pelvic infection or an ovarian cyst are the first causes to look for.
• Vaginal dryness: gynaecologist or midwife (contraception, breastfeeding, menopause, certain medicines); the pharmacist for lubricants and moisturisers in the meantime.
• Pain in the penis during sex: urologist (short frenulum, phimosis, curvature, infection); dermatologist if the skin is the cause.
• Sudden, intense testicular pain, with or without nausea, especially in a teenager or young adult: emergency department immediately. A twisted testicle is saved within six hours.
• Dull testicular pain, discomfort, a lump: doctor then urologist, with ultrasound. A hard, painless lump gets shown without delay.
• Chronic pelvic pain in a man, discomfort in the perineum, burning with no infection found: urologist (chronic pelvic pain syndrome), and often a pelvic-floor physiotherapist.

Urine, discharge, bleeding, lesions

• Burning when urinating, urgent and frequent needs: doctor (urinary infection, very common in women); urologist if it comes back, if you are a man, if there is fever or blood.
• Discharge from the urethra, unusual vaginal discharge, odour, itching: testing clinic, doctor or gynaecologist — the typical picture of an STI (chlamydia, gonorrhoea, trichomonas) or of thrush; partners get treated too. See STIs and which test, and when.
• Bleeding after sex in a woman: gynaecologist, always. Most often it is the cervix (ectropion, polyp, infection) or atrophy, but it is also the sign of cervical cancer that must not be missed — a smear or an HPV test settles it.
• Spot, ulcer, wart, patch, plaque on the genitals: dermatologist-venereologist or testing clinic. A painless ulcer is syphilis until proven otherwise.
• Blood in the urine: urologist, even once, even without pain.

Orgasm and pleasure

• No orgasm, or no orgasm any more: if it began with a medicine (antidepressants above all), the prescriber; if it has always been so or depends on circumstances, sex therapist — one of the complaints where sex therapy works best. Gynaecologist or urologist if there is also pain, loss of sensation, surgery or a neurological disease.
• Vaginismus — penetration impossible or very painful because of a reflex contraction: pelvic-floor physiotherapist and sex therapist, hand in hand; the gynaecologist first rules out a physical cause.
• No pleasure after childbirth: midwife (pelvic-floor rehabilitation, scars, breastfeeding hormones), then sex therapist if desire does not return once the body is well. See desire after a birth.

Ages and stages of life

• Adolescence and first sex: doctor, midwife or sexual health clinic, where the visit is often free and confidential — contraception, HPV vaccination, questions about the body.
• Pregnancy: midwife or obstetrician for any question about sex during pregnancy; it is possible and safe in most pregnancies, unless advised otherwise.
• Menopause — dryness, pain, low desire, hot flushes: gynaecologist (local, hormonal or non-hormonal treatments). Andropause — the slow fall in testosterone after fifty: doctor then endocrinologist or urologist; it is treated only when the deficiency is confirmed by two measurements and accompanied by symptoms.
• After cancer or surgery — prostate, bladder, breast, cervix, rectum: ask for an onco-sex therapist or the team’s sex therapist; the urologist has second-line treatments for erection (injections, pump, prosthesis) when tablets are no longer enough.
• Disability, chronic illness, neurological disease: rehabilitation physician, urologist, sex therapist; sexuality is part of rehabilitation, and it is legitimate to ask for it.

When the difficulty is not in the body

• Performance anxiety, fear of failure, avoidance: sex therapist or psychologist — behavioural therapies get good results here in a few sessions.
• Sexual violence, past or recent: psychologist or psychiatrist trained in psychological trauma, and the specialist associations; for a recent assault, see the emergencies below. The page on violence within the couple lists the options.
• Questions about orientation or identity: psychologist or specialist centre, to accompany — not to “change”, which the learned societies condemn and several countries prohibit.
• The problem is the couple — unequal desire, reproaches, infidelity, silence: relationship counsellor or couple therapist. See a rough patch, or a real problem?
• Alcohol, cannabis, medicines or other substances involved — desire, erection and mood are often the first to suffer: family doctor or addiction service, free, with no prior diagnosis, open to relatives too. See getting help with addiction.

Emergencies: do not wait until tomorrow

• Sudden testicular pain — possible torsion; six hours to save the testicle.
• An erection lasting more than four hours — priapism.
• A crack, pain and bruising of the penis during sex — penile fracture.
• Intense pelvic pain with fever, or with a late period and faintness — upper genital infection, or ectopic pregnancy.
• Unprotected sex or a burst condom with a risk of HIV — post-exposure treatment starts within 72 hours, ideally within 4 hours, at a hospital or a testing clinic; emergency contraception is taken within 72 to 120 hours depending on the method, and the copper IUD remains possible for five days.
• Sexual assault — hospital or dedicated service within 72 hours if possible, before washing, for care, prevention of infections and pregnancy, and evidence collection if you decide, now or later, to press charges.
• Inability to urinate, heavy bleeding, high fever with back pain — emergency department.

Sex therapy, in practice

Who sex therapists are — doctors, psychologists, psychosexual therapists —, what they treat, how a consultation unfolds, how many sessions it takes and how to choose someone serious: that is the subject of the page Sex therapy.

Frequently asked questions

Further reading

• WHO — sexual health — international definition and reference framework
• ISSM — International Society for Sexual Medicine — clinical answers written for the public
• European Association of Urology — patient information — erectile dysfunction, ejaculation, pain, prostate

Verified links to official or reference sources. They open in a new tab.