Sexual problems

Sexual problems are common in the general population. In one study of healthy, married, middle-aged couples, 40 percent of the men and 63 percent of the women had sexual dysfunctions, primarily impotence and premature ejaculation in men and inability to achieve orgasm in women. In another study 53 percent of outpatients in a general medical group practice described sexual problems when the issue was brought up by the physician during a medical evaluation.

These surveys also showed that patients tend to be reticent about sexual concerns unless they are asked about sexual function by their physicians. Only a fraction of those who were impotent had complained spontaneously of the problem in previous medical contacts. Even those patients who develop erectile dysfunction after taking medications frequently fail to report the problem. Married couples with sexual dysfunctions tend to modify their behavior to compensate for the problem rather than seek medical help.

The reason that many patients find it difficult to discuss sexuality with physicians has not been studied systematically. Some may be inhibited by shyness, embarrassment, guilt, shame, anxiety, or feelings of inadequacy. Old attitudes tend to persist in spite of the current openness about sexuality in general. A common finding in surveys of sexual dysfunction is that patients are often grateful when they are asked about their sexual function and generally perceive the physician as being more competent, thorough, and caring after such questions are asked.

The physician in turn may inadvertently discourage the patient from bringing up sexual concerns by subtle indications of discomfort, disapproval, or embarrassment or by failing to ask appropriate and timely questions. Physicians may avoid the subject because of fears of starting an emotionally charged discussion with insufficient time to resolve it. In truth, most physicians can make an initial assessment of sexual symptoms, and a brief inquiry seldom leads to the need for a lengthy discussion.

An objective approach to sexual issues reduces tensions and enables both patient and physician to deal with sensitive material. Often patients harbor fears and misconceptions that may be relieved by open discussion. Sexual symptoms may be the first manifestation of organic disorders, and a change in sexual function at any time of life is an indication for a thorough medical evaluation. Thus, it is the responsibility of the physician to establish an accurate and complete diagnosis including both physiologic and psychological factors and to evaluate the significances of sexual problems in the context of the patient’s background and lifestyle. The yield from this aspect of a general medical evaluation can be high in terms of relieving suffering, understanding the patient’s medical status, and achieving a good doctor-patient relationship.

An outline of the sexual history recommended for the initial data base
Introductory question
/ Have you noticed any problems in your ability to have and enjoy sexual relations (sex)?
If positive response, have patient elaborate, then continue with questions. If negative response, continue with questions. Men
2 Do you have any problems having or maintaining an erection? If so, in what situations?
3 Do you have any problems having an orgasm (ejaculating) (coming) (too soon, or not soon enough)? If so, in what situations?
Women
2 Do you have any pain during penetration?
3 Do you have any difficulty coming to orgasm? If so, in what situations? Men and women
4 Are you sexually active?
5 Has your present illness affected your sexual functioning?
6 Do you have any questions or concerns about your sexual functioning? Clarification of problems
1 How much of a problem is this?
2 How long has this been a problem? When was it better or worse?
3 Do you have any ideas about what causes this problem?
4 Have you ever sought help for this or any other sexual concerns?
5 How do you feel about getting some help now?