Sexuality is a powerful and very human experience that influences and is in turn influenced by social and interpersonal milieus. As urologists, our focus is largely on the biological factors that contribute to sexual issues and the biomedical interventions that we apply to mitigate sexual dysfunction. Sex is fundamentally a physical act, but it occurs in a psychosocial context. The experienced urologist knows that a patient’s psychological, social and cultural milieus influence not only their perception of sexual issues, but also their willingness to address them.

Religion is an important aspect of culture that is seldom discussed in sexual medicine consultations but has enormous implications for treatment efficacy and acceptability. All religious traditions articulate rules and traditions about when, how and with whom sexual activity is appropriate for an adherent.

Approximately three-quarters of Americans endorse a religious affiliation, with almost half of Americans identifying as Protestant Christian. It is a certainty that the religious affiliation (or lack thereof) of a medical provider may differ from that of their patient. Health care providers cannot expect to be fully versed in the nuances of the various religious traditions they may encounter in practice; even patients with whom the provider shares a religious tradition may have a different level of adherence or understanding.

While a thorough understanding of all the world’s religious traditions is not a practical goal for practicing urologists, some basic understanding of how different religious traditions view sexuality can be of great value in optimizing patient adherence and well-being. At the 2020 Annual Fall Meeting of the Sexual Medicine Society of North America (SMSNA), an expert panel of sexual medicine clinicians provided remarks on 4 major religious traditions. Each speaker was an adherent of a specific nonProtestant Christian tradition and provided information about their religious tradition, how their tradition views sexuality and the appropriate contexts for sexual expression, and in many cases how their religious belief informs their practice of sexual medicine.

Yonah Krakowsky of the University of Toronto opened the session with a discussion of his experience of Judaism and how it informs his practice and his care of patients. Sexuality as a sin that must be restricted is a pervasive theme in Jewish writing, especially in orthodox circles. This was an intensely personal story about adhering to tenets of Judaism but understanding how in some cases flexibility in interpretation is permissible. Discussion with religious leaders and delineation of intent emerged as key factors in reconciling faith with the real-world treatment of issues in sexual well-being. Dr. Krakowsky reminded us that what may be common sexual knowledge to us may be a completely foreign idea to others, and that simple recommendations we make as sexual medicine practitioners may be a life-altering request for a patient from a more orthodox background.

Amjad Alwaal of Marshall Health in Huntington, West Virginia, continued the session with information about sexuality in Islam. Intercourse is encouraged between couples and described as a “good deed.” While marriage is strongly encouraged and celibacy is condemned, premarital and extramarital sexual affairs are a punishable crime. A variety of misconceptions exist about sexuality in Islam, particularly the sexuality of women. Dr. Alwaal made clear that the central sacred text of Islam (the Koran) differs from various regional practices that are commonly associated with the religion, such as female genital cutting (FGC). FGC is not a practice that is prescribed in the Koran and most likely represents a regional custom that was integrated into Islamic practice as the religion spread in its early years. Interestingly, urology has a dedicated chapter in one of the early Islamic surgical texts written in 1233.

Brian Christine of Urology Centers of Alabama in Homewood next described in large part how his Catholic faith informs his approach to patient care. The Catholic Church is frequently in the news due to well publicized stances on contraception, abortion and lesbian/gay/bisexual/transgender (LGBT) issues. While some may interpret these stances as not being “pro-sexual,” what is less frequently recognized by critics is the Catholic Church’s express commitment to caring for fellow humans and the intrinsic value of human life. Dr. Christine made clear how this commitment compels him to at all times to care for patients who come to him for help, sometimes bringing him into conflict with colleagues who may hold negative views and not feel compelled to meet the needs of patients.

Anand Shridharani of the University of Tennessee Urology in Chattanooga concluded the discussion with a review of sexuality in Hindu and Jain traditions. Hindu sexual practices have been a topic of great and somewhat prurient interest in Western countries for decades, if not centuries. The famed text, the “Kama Sutra,” is commonly known among the American public. Dr. Shridharani put this historical work in context; while the Kama Sutra is treated in Western countries as a catalog of exotic and sometimes dangerous sexual positions, the original intent of this work was to detail what was and was not appropriate in terms of sexual interactions between persons. The role of sex changes during the different stages of life. Sex is confined to marriage during the householder stage and pleasure is encouraged. However, British colonialism influenced cultural perceptions of sex for pleasure and led to the adaptation of more puritanical views. Dr. Shridharani’s discussion of Jainism was also of import, as sexuality is seen as appropriate primarily for procreative rather than recreational purposes. One of the 5 great vows of Jainism is brahmac ryam, an abstinence from self-indulgence, and sexual intercourse is included in this. Sexual passion or indulgence is thought to lead to misdeeds, and homosexuality is considered to be self-indulgent. This understanding of sexuality may be of particular importance when consulting with patients in interfaith marriages involving a Jain person who may be partnered with someone who prioritizes sexuality for pleasure.

The informative lectures by Drs. Krakowsky, Awaal, Christine and Shridharani laid out the basic practices and beliefs of these religious traditions. They elucidated the importance of considering the patient’s religious and cultural background when making a treatment plan for their sexual or reproductive function.