Sexuality encompasses an enormous range of behaviors, beliefs, desires, experiences, and fantasies that patients may want to discuss with their health care providers. Sexuality also may have legal, medical, moral, political, and religious aspects. This chapter intends to give the practicing clinician basic practical knowledge of human sexuality and useful tools for managing common problems.

Patients with sexual concerns report feeling most comfortable discussing these issues with their primary care physician and expect to receive advice and treatment. In large studies of adult patients, more than 70% considered sexual matters to be an appropriate topic for the primary care provider to discuss. Yet, evidence of discussion about sexual problems has been found in as few as 2% of the notes of such providers.

Primary care practitioners are in an optimal position to evaluate sexual problems, as they often have the most comprehensive and long-lasting relationship with the patient. In contrast to most other medical diagnoses, however, it is the patient who usually defines when a sexual problem exists. That is to say, a “problem” exists only if and when the individual or the partner is troubled by his or her level of sexual desire, response, or function.

Levine (2010) posits that sexual issues can be usefully conceptualized within three broad categories: sexual worries, problems, and disorders. Although referral to medical or mental health specialists (or both) may be indicated in more severe situations of disorders and dysfunctions, many worries and problems can be successfully addressed by the primary care practitioner. When questions about sexuality are approached in an open, matter-of-fact manner, most people are relieved and respond positively. They appreciate the affirmation that these issues are valid and important, whether or not they have current sexual concerns or are sexually active (Table 32-1).

To provide patients with helpful responses to their sexual health concerns, health professionals need the following:

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  Willingness and ability to discuss sexual topics comfortably.

  
  
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  Awareness of the range and diversity of human sexual practices and concerns across and within cultures, as well as awareness of the importance of the circumstances or conditions under which individuals function best.

  
  
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  Ability to separate their own personal beliefs and values from those of patients. Unless the practitioner encounters information indicating objective harm to someone involved, it is important to maintain a nonjudgmental demeanor.

  
  
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  Skill at taking a history of sex problems in appropriate detail.

  
  
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  Knowledge of simple interventions such as permission-giving, transmitting accurate information, providing specific suggestions (e.g., for making sex less pressured and more pleasurable), and making referrals to other resources, when appropriate.

As health professionals, we may have personally had limited sexual experience, as well as questions and problems of our own, and consequently may be uncomfortable in discussing particular sexual material. Time, thought, and experience, however, can build confidence and expertise in talking about sexual problems. Health care providers can increase their comfort level by examining their own attitudes, beliefs, assumptions, and experiences; reading the literature; discussing sexual issues with friends and colleagues; and routinely incorporating sexual health questions into the general health assessment of patients.

Of course, no one—patients or caregivers—should be forced to talk about sexuality. It is important for everyone to recognize the limits of their own interest, comfort, and competency. However, sexual health is an integral part of health care. All who deal with patients should be alert to the possibility of sexual concerns and, at a minimum, be able to respond with nonjudgmental listening and reassurance. When in the best interest of the patient, health care providers can refer to a colleague who is comfortable and competent in discussing sexual issues.

Knowledge of human sexuality has expanded remarkably since the modern pioneering efforts of Kinsey and Masters and Johnson—who published some of the earliest evidence-based treatment of sexual problems. While initially focusing on the range of sexual behaviors and the treatment of dysfunctional mechanical problems, the field has grown to include and better understand sexual motivations, the critical importance of sexual excitement and desire, and of the contexts required to produce sexual fulfillment.

Research in human sexuality has burgeoned, as has knowledge of the often-negative effects of long-accepted sex roles. And we are learning more about variations among individuals in terms of the role sexuality plays in life. A particular sexual problem may be perceived as central and significant to one patient, yet be seen by another to be peripheral or minor. Clinicians must be cautious to not make assumptions about the significance of various sexual problems, but rather assess and discover whatever meaning the issue has for that individual or within a particular couple.

Motivations for human sexual expression are complex and numerous. Different motivations exist throughout the life cycle, including variations in times of illness or periods of health. Motivations vary from culture to culture and from individual to individual. They may include the need to express love, the need for physical release, reproduction, recreation, the need to increase self-esteem—or combinations of all the above. Conversely, sexuality can also be used to coerce, control, or degrade others. Sexuality may be the focus of addictive or compulsive behavior.

Sexual worries or difficulties are likely experienced by most people at some period of life, and may result from developmental growth and changes in life circumstances rather than from pathology alone. Sexual problems are sometimes a blessing, such as when they compel a person to get help for symptoms that indicate underlying medical problems, problems with self-esteem, or problems with a relationship. Surprisingly, for some people, seeking help for problems involving erection or orgasm may be more acceptable than seeking help for issues involving self-esteem.

Because the language of sex is broad and varied, primary care practitioners will find it helpful to become familiar and comfortable with the vernacular and to be able to discuss calmly and in detail matters such as masturbation, sexual positions, oral sex, anal sex, penis size, and breast size. The following section discusses a few of the areas in which misconceptions about these subjects can be resolved.

From a medical viewpoint, masturbation is “normal,” universal, and physically harmless at all ages. It is highly correlated with self-acceptance and sexual adjustment, and is often suggested as “homework” in sex therapy to further sexual self-awareness. Some people freely choose not to masturbate, perhaps following personal or religious tenets. Guilt about masturbation, however, continues to affect many patients. Some may use masturbation compulsively to avoid personal or relationship issues. Sex offenders may reinforce their antisocial fantasies via masturbation. Those who are truly addicted to some sexual behaviors may suffer from a variety of life difficulties common to other addictions.

There is no standard for what constitutes acceptable sexual frequency. Individuals who are celibate may still consider themselves sexual beings, whereas others may have sex rarely but find it satisfying and enjoyable when they do. Compulsive, frequent sex can become unrewarding for some, whereas others thrive on a frequent and active sex life. What is “right” for a particular individual or couple must be determined based on the various meanings and expectations they associate with sexuality.

Sexual fantasies are limited only by human imagination and may be enjoyed for their own sake. Fantasies may be exciting to a person who would never want to experience them in real life, or they may be yearned for. Obsessive and intrusive images that cause discomfort may need to be addressed with psychotherapy.

The majority of women enjoy and need direct clitoral stimulation manually or orally to reach orgasm. Unfortunately, many men assume that their female partners are fully satisfied with only intercourse. A result of this overemphasis on intercourse is that many women and men are uncomfortable with genital caressing alone. Couples can benefit from encouragement and permission to learn about and enjoy noncoital sex.

Most gay, lesbian, or bisexual patients do not wish to have their sexual orientation changed or challenged and often present the same concerns as heterosexuals about normalcy, dysfunction, and intimacy.

Life Changes: Menopause, Aging & Sexuality

Sexuality is an all-encompassing term that includes sexual identity, sexual function, and sexual relationships, all of which may be modified by a number of factors including both female menopause and aging.

Aging brings with it a number of recognized and normal changes in sexual response. These include the following:

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   In both men and women, more direct genital stimulation and more time are needed for arousal (lubrication or erection).

   
   
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   Women may experience irritation and pain with intercourse, especially after menopause or periods of abstinence.

   
   
3. 
   

   Erections may become less rigid.

   
   
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   Orgasm may not occur with each sexual encounter and the urge to ejaculate may become less intense.

   
   
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   The refractory period (the time interval between a man’s ejaculation and his next erection) increases.

Many adults in their 70s, 80s, and even later years are willing to experiment in response to changes in their interest, sexual physiology, and partner status. Some older men and women become less focused on intercourse, finding increased enjoyment in petting, oral sex, and masturbation. Others may be happy to have retired from an active sexual life.

Phosphodiesterase type-5 inhibitor (PDE5) oral medications such as tadalafil (Cialis), sildenafil (Viagra), and vardenafil (Levitra) enhance erectile functioning in many men. In women, results of studies looking for positive effects of these medications on sexuality, in general, have been inconsistent, in part because different end points have been used. However, some data show benefit with PDE5 therapy in those women with previously normal sexual function who developed low libido after starting antidepressant therapy. In the future, it may be found to benefit other select groups of women as well.

Testosterone or estrogen replacement may also be beneficial to correct decreases due to aging, and are discussed in greater detail below.

Reasons given by health care providers who are reluctant to address sexual health issues include embarrassment, feeling ill-prepared, belief that the sexual history is not relevant to the chief complaint, and time constraints.

The prevalence of sexual concerns is consistently underestimated by physicians, which contributes to minimizing the importance of sexual health care. Patients report that physician discomfort and anticipated nonempathetic response to sexual problems are the primary barriers to discussing sexual health.

An assessment of problems related to sexual function requires a consideration of all relevant potential etiological factors in order that any appropriate therapeutic measures may be instituted, be they psychosocial, physical, and/or pharmacological.

Some patients may be more reluctant to discuss their diet or exercise patterns than the details of their sexual life, whereas others may feel they risk disapproval or judgment when talking with a medical authority about sexuality, and particularly about their sexual practices. When introducing the topic of sexuality, it is often helpful to acknowledge right away that the patient may feel some embarrassment. By routinely asking questions about sexual health in an initial history taking, a caregiver shows acceptance of sexual health as an integral part of a person’s well-being.

Also, it may be helpful to explain that some diseases and conditions can be major factors in the etiology of sexual dysfunction, among them diabetes mellitus, cardiovascular disease hypertension, immunologic issues, arthritis, chronic back pain, and current and previously treated cancers.

The following is one way to initiate a discussion about sexuality:

As part of the psychosocial component of the general medical examination, a brief sex history should cover the following:

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  “Are you sexually active now?” “How many current partners do you have?” If none, “When was the last time you had sex?” “Is that O.K. for you at this point in your life?”

  
  
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  “Are you sexually active with men, women, both, or neither?” To encourage the confidence of lesbian, gay, or bisexual patients, ask about the patient’s “partner” rather than using the gender-specific terms “wife,” “husband,” “boyfriend,” or “girlfriend.” And ask about “sexual encounters” rather than “intercourse.”

  
  
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  “How satisfied are you with your sexual experiences and functioning?” (Frequency, variety, who initiates, etc.)

  
  
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  “Do you experience any problems with lubrication, orgasm, erection, or ejaculation?”

  
  
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  Rather than assuming contraception is necessary, ask, “Do you have a need for contraception?” Follow-up questions may include asking about the efficacy of or level of satisfaction with any current contraception method in use.

  
  
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  “Have you ever been diagnosed and treated for sexually transmitted diseases (STDs)?” Discussion of human papillomavirus (HPV) vaccine and its relevance to cancer prevention of cervical and oral cancers can then be included.

  
  
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  “Have you ever been tested for human immunodeficiency virus (HIV), and if so do you know if you are positive?” “Are you aware of safer sex precautions, such as the use of condoms and barrier protection, even when there is no risk of pregnancy or when other contraceptives (e.g., intrauterine device [IUD] or “the pill”) are used?”

  
  
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  “Have you ever been/or are you currently in a relationship in which you have been/or are being abused emotionally, physically, or sexually?”

Use questions that show openness to other than the modal heterosexual preferences. Making assumptions about a person’s sexuality based on age, gender, race, ethnicity, marital status, or sexual orientation may be diagnostically misleading and send damaging messages to the individual. For instance, an elderly patient assumed to be sexually inactive may in fact have multiple sexual partners, and important risk factors for STDs and acquired immunodeficiency syndrome (AIDS) may be missed or a monogamous gay male may feel stereotyped or misunderstood if it is assumed that he has multiple partners.

Make sure that the terminology is mutually understood. Overly general or euphemistic terms such as “having sex,” “getting it on,” “making out,” “making love,” or “losing one’s nature” may obscure important details. Terms that are too technical (“coitus,” “copulation,” and “cunnilingus”) or too colloquial (“cunt,” “cock,” and “fucking”) may be inappropriate for use in the professional relationship.

Avoid words that convey moral judgments or indicate little about what an individual is actually experiencing (e.g., “adultery,” “frigid,” “impotent,” “nymphomaniac,” and “perversion”). Clinicians can help patients discard demeaning labels by substituting behavioral descriptions such as “having sex outside of your primary relationship,” “difficulty getting erections or getting aroused,” or “trouble learning to have orgasms.” Again, time and experience with a variety of patients provide a sense of what terms are most useful in conveying information to a given patient.

Patients may bring up vague or psychosomatic-like complaints (e.g., insomnia, fatigue, musculoskeletal aches, indigestion, headaches, or any specific symptoms of depression or anxiety) as a veiled request to talk about sexual concerns. Others mention a sexual concern at the end of a visit in an offhand manner, when there is little time for the problem to be adequately evaluated. The provider may then choose to assess the problem briefly and validate the importance of investigating this as soon as a new appointment can be scheduled.

Because sexual problems are often the result of a distressing gap between the patient’s expectations and experiences, the effective sexual interview aims to elucidate both sides of the equation. If expectations are unrealistic, the treatment is education; if the experience fails to meet realistic expectations, intervention or referral is indicated. Often education and other clinical interventions are combined.

When getting a sex problem history and before proposing solutions, health care professionals need to ask questions about the relative importance of sex in the patient’s life and what their expectations are for a fulfilling sex life.

The language of medicine is clinical, whereas issues of sexuality are associated with feelings and emotional vulnerabilities. Pay special attention to the case reports. They illustrate how cool clinical material can be translated to a warmer doctor–patient approach that allows for better trust and engagement with these vital human issues.

As with any other medical problem, five basic areas need to be addressed for the patient presenting with a sex problem (Table 32-2):

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   Explicit symptom or question

   
   
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   Onset and course of the symptom

   
   
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   Patient’s perception of the cause and maintenance of the problem

   
   
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   Medical evaluation, including medical history, past treatment, and outcome—(Specifically exclude such chronic health problems as diabetes mellitus, cardiovascular disease, hyperlipidemia, hypertension, the arthritides, past or current history of cancer)

   
   
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   Current expectations and goals for treatment

Answers to the preceding inquiries can help guide the clinician to specific interventions.

The detailed examination of the genitourinary system should include checking for signs of androgen or estrogen deficiency or excess, neurologic dysfunction, genital abnormalities, genital trauma, infections, condylomata (warts), and vascular disease.

For men, the examination should include the penis (to exclude conditions such as Peyronie disease, penile discharge, warts, other lesions, and hypospadias); testes and scrotum (for masses, atrophy, hernia, or varicoceles); and skin, prostate, and rectum. Testing should be conducted for evidence of gynecomastia, peripheral vascular disease, and neuropathy. Testicular self-examination can also be taught and information about prostate issues provided.

For women, look for evidence of atrophic changes, skin disorders (infectious or otherwise), developmental changes, urinary tract disorders, and general evidence of genital (internal and external) physical abnormalities, pelvic floor weaknesses, and postsurgical conditions. In case of genital pain, the woman should be encouraged to point out specific sites of pain, using a mirror to localize it.

The gynecologic examination provides an excellent opportunity for teaching patients about breast self-examination, discussing safe sex practices, protection against HPV and its consequences, and if appropriate, contraception.

Sexuality issues are rarely as clear-cut as a factual medical approach might yield. Generally, any condition or medication that is debilitating or energy depleting can be a contributory cause of sexual problems. Debilitation and/or anxiety are most frequently the final common denominators resulting in a sex problem. When going through the steps of Annon’s (1976) P-LI-SS-IT model below, look for evidence of these final common pathways as a guide to making the best use of the model.

When pathology can be excluded, patients can be reassured that their genitals look “quite healthy” and are in the normal range. This can help counter the shame that many people feel about these vulnerable areas of the body. Naming specific genital parts, such as the foreskin and glans of the penis and the clitoris and labia as you examine them, may give increased permission for the patient to ask any questions or express any concerns they may have about them. Men concerned about the size of their penis or women with worries that their genitals are somehow abnormal are more likely to voice these concerns after the clinician has comfortably used these words.

In general, few laboratory tests are necessary for patients presenting with the most common sexual problems. For complaints of low sexual desire, patients should be screened for depression and fatigue and also tested for anemia and endocrine, liver, and renal disease; or any other debilitating medical problems suggested by the history and physical examinations. Negative sexual side effects may be caused by gonadotropin-releasing hormone (GnRH) agonists, and narcotics (see “Medications”). Recognized underlying endocrine factors might include low thyroid, low estrogen, low androgen, or high prolactin levels. Whereas checking serum levels of thyroid-stimulating hormone (TSH) and prolactin is generally considered appropriate in women with sexual problems, routine measurement of serum estrogen and/or androgen concentrations generally is not recommended, as their measured serum levels do not correlate with sexual function.

Some authorities recommend evaluation of serum testosterone, TSH, and prolactin levels in all male patients with erectile failure or low libido. Elevated prolactin levels can be the result of many medical conditions, including pituitary tumors; renal dysfunction; sarcoidosis; thyroid disease; trauma; pelvic surgery; or use of medications such as cimetidine, haloperidol, and phenothiazine. If any of these tests is abnormal or other endocrine problems are suggested by the history or physical examination, specific, relevant additional tests should be performed as indicated.

In some men with erectile concerns, testing by a urologist may be indicated. These may include monitoring of nocturnal penile tumescence (NPT) in a sleep laboratory or, more commonly and less expensively, with a home monitoring unit or simple snap gauge. Increasingly, a trial with a PDE5, such as tadalafil (Cialis), sildenafil (Viagra), or vardenafil (Levitra), is recommended for both diagnosis and treatment.

Rather than describing sexual problems with a simple differential diagnosis of either organic or psychogenic etiology, it is useful to identify both categories of causal factors. These can be assessed with the psychosocial history, sex problem interview, physical examination, and laboratory testing. A symptom that is generalized (occurring in all circumstances) may indicate major organic or psychogenic involvement, whereas situational symptoms tend to be psychogenic (Table 32-3).

Organic factors may be suspected when a man reports an absence of nocturnal or morning erections or is unable to get erect with masturbation. In women who find intercourse painful, important situational variables to identify include whether she has been adequately stimulated and aroused prior to penetration, whether precoital lubricants have been used if needed, whether she feels pain with masturbation or when having sex with a partner, and whether she is able to direct the extent and timing of thrusting or is passive. Adequate vaginal estrogenization with local (estrogen) therapy, unless specifically contraindicated, should be ensured. Questioning should include possibilities that the problem is not physiological, but psychological, as is sometimes the case with vaginismus. Asking “under what circumstances have you felt pain?” might elicit “with one partner but not with another,” “since I was raped,” or “it has always been painful.” Organic factors should also be considered when a patient has not responded to an adequate course of sex therapy.

Medical conditions and treatments affecting sexuality are listed in Table 32-4.

As we address the sexual needs of our patients, general health issues such as thyroid dysfunction, cardiovascular disease, and diabetes as well as hypertriglyceridemia, hypertension, neurological disease, genitourinary disease all need to be kept in mind, as do hormonal factors:

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   Effects of low testosterone, primarily in men but occasionally in women with low sex drives: Adequate testosterone is considered necessary for sexual drive and arousal in both genders. It also determines genital health and function in males. Although the traditional testosterone evaluation argues that testosterone levels falling within the “normal range” are not indicative of clinically insufficient testosterone levels, there have been recent suggestions that men who test within the normal range may indeed benefit from testosterone supplementation.

   
   
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   Estrogen deficiency in women: Severe estrogen deficiency can be associated with serious atrophic changes in the vagina and external genital tissues, and is a common cause of local dyspareunia, often correctable through adequate estrogen replacement. These changes commonly occur as a result of menopause, antiestrogen chemotherapy agents, wasting conditions such as anorexia nervosa, and even due to normal breast-feeding.

   
   

   Recent studies have been elucidating subtle local effects of estrogens at the cellular level, termed “intracrinology.” DHEA (dehydroepiandrosterone), a precursor of androgens and estrogens, shows promise in ongoing studies when used as a vaginal cream by effectively treating hormone deficiencies at the local cellular level.

   
   

   While the effects of estrogen deficiency have focused on vaginal genital changes, it should be noted that these changes can also lead to serious pain with oral sex and clitoral masturbation.

   
   
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   Centrally acting agents:

   
   

   Although the intricacy of sexual functioning in women is not yet completely understood, hormones play an important role. Centrally, two major neurotransmitters, oxytocin and dopamine, are known to be involved in sexual desire and response in women.

Oxytocin, which rises with sexual activity, results in relaxation and bonding, increasing a woman’s interest in sexual activity and reducing her anxiety, as does dopamine, which acts centrally also to reduce anxiety about sexual activity. Both are said to act like an “on/off switch.”