Editor: Elizabeth M. Fathman; Developmental Editor: Ellen Baker Geisel; Project Manager: Carol Sullivan Weis; Production Editor: Florence Achenbach; Designer: Jen Marmarinos; Manufacturing Supervisor: David Graybill. Copyright© 1999 by Mosby, Inc.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of the publisher. Permission to photocopy or reproduce solely for internal or personal use is permitted for libraries or other users registered with the Copyright Clearance Center, provided that the base fee of $4.00 per chapter plus $.10 per page is paid directly to the Copyright Clearance Center, 27 Congress Street, Salem, MA 02970. This consent does not extend to other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collected works, or for resale. Composition by Clarinda Company Printing/binding by R.R. Donnelley & Sons Company Mosby, Inc. 11830 Westline Industrial Drive St. Louis, Missouri 64146 -- Library of Congress Cataloging in Publication Data Maurice, W. Sexual medicine in primary care / William L. Maurice. p. cm. Includes bibliographical references and index. ISBN 0-8151-2797-9 1. Sexual Disorders. 2. Primary care (Medicine) I. Title [DNLM: 1. Sexual Disorders. 2. Sexual Dysfunctions. 3. Primary Health Care. WM 611M455s 1998] RA427.9.M384 1998 616.85'83—dc21 DNLM/DLC for Library of Congress 98-39997 CIP 99 00 01 02 03 / 9 8 7 6 5 4 3 2 1

To my loving wife, Rosamund, who has been enormously supportive, accepting, patient

(as is usual for her), and tolerant over the missed times together and missed holidays

(not to mention the papers strewn about in my office and elsewhere).

Foreword

Rarely has a book been so timely! With the advent of Viagra and the resulting interest

in female sexuality, questions, concerns, and discussion about sexual function

and dysfunction have come to dominate the media in explicit and sometimes colorful

language. Grandparents and their grandchildren both are suddenly equally interested

in what their genitals are capable of and neither group is willing to settle for anything

less than their “personal best.” The interest in drugs to provoke desire, speed up (or

slow down) arousal, facilitate orgasm, and reduce sexual discomfort has never been

greater, and the pharmaceutical industry is working overtime to meet the demand.

Physicians are in the vanguard of this fever, because patients request and expect sound

advice, thoughtful recommendations, and effective interventions from their primary

care providers — whether covered by managed care or not!

It is certainly the case that the HIV/AIDS epidemic served as the “wake-up call” to

health professionals to begin explicit discussion of sexual behavior in routine office

practice. The recognition that heterosexual and homosexual individuals were often

unwittingly engaging in unsafe sex prompted the introduction of sexual history taking

and sexual education as a means of disease prevention. It is only in the last decade that

physicians have been called upon to initiate sexual inquiry to prevent illness and to

enhance pleasure for their patients. There has been growing recognition that sexuality

plays a significant role in quality of life, that sexual problems cause both emotional and

physical distress, and that sexual inquiry and education are essential components of

responsible and comprehensive health care.

It is also true that many physicians feel inadequately trained or prepared for dealing

with the sexual concerns of their patients. Medical schools have not routinely included

courses in human sexuality in their curriculum, and, in fact, educators are often uncertain

of how best to teach the necessary skills. Even as ubiquitous a subject as physical

examination diagnosis has caused consternation as educators debate whether or not to

use live patients or paid actors for teaching genital examination. In many programs, the

curriculum dealing with the review of systems deals with sexual matters, if it deals with

it at all, in a fairly cursory and perfunctory fashion.

It is not surprising, then, that primary care physicians faced with time constraints,

managed care demands, and inadequate training often feel unprepared to tackle the

topic of sexual health in the detail and with the sensitivity it deserves. Concerns about

offending (or embarrassing) patients, crossing boundaries, and risking legal repercussions

have also contributed to the unwillingness of many physicians to open this particular

“can of worms.”

And yet, patients are clamoring for information and guidance in dealing with sexual

problems and complaints. Questions about the impact of medication on sexual response,

safe and unsafe sexual practices, unreliable erections and inadequate lubrication, and

even talking to children about sex have become regular currency in physician offices.

Most patients expect their health care provider to be an expert in all aspects of sexual

health, even if their provider feels ill prepared and leary of the job.

It is for this reason that Sexual Medicine in Primary Care is such a timely and welcome

volume. All the issues, questions, and concerns that physicians may encounter in dealing

with the sexual concerns of their patients are addressed, including how to initiate

and conduct sexual inquiry, and how to do so in a fashion that respects the privacy and

enhances the comfort of their patients. It deals with such neglected topics as how to

modify questions to include sensitivity to the age, gender, sexual orientation, and

activity level of patients. The inclusion of sample dialogue between physician and

patient illustrates the words to be used and the detail necessary to obtain an accurate

picture of the patient’s sexual behavior and concerns.

This book addresses topics that are often neglected: the distinction between sexual

complaints and sexual dysfunctions, the difference between crossing boundaries and

actual sexual violations, the need to avoid pigeonholing patients as either exclusively

heterosexual or homosexual. It reviews the impact of physical illness and disability on

sexual function and helps clarify how and whether sexual problems are the result of

physical illness or exacerbated by it. Also included are such topics as nonparaphiliac

and paraphiliac sexually compulsive behavior, an increasingly common source of concern

among patients (and their partners), gender identity disorders, and child and adult

sexual abuse.

Clinical vignettes highlight the enormous array of problems and issues that patients

bring to their primary care physician. Dr. Maurice provides suggestions and recommendations

as to how to deal with the myriad of issues presented. Moreover, in each

and every chapter, the available clinical and research literature on the topic under

discussion is reviewed and summarized. The chapters on the assessment and treatment

of male and female sexual dysfunctions provide an outstanding review of common but

often complex problems.

It is unusual to find so much practical information on such a long-neglected topic

in one volume. Sexual Medicine in Primary Care is likely to become one of the books that

primary care physicians not only purchase but actually use in their daily practice. It is

a book that is well worth reading and one that is an excellent source book for consultation

on a subject that touches the lives of all patients.

Sandra R. Leiblum, Ph.D.

Professor of Psychiatry

Co-Director, Center for Sexual and Marital Health

UMDNJ-Robert Wood Johnson Medical School

Piscataway, New Jersey

Foreword

Most primary care physicians lack formal education in the diagnosis and management

of sexual problems, yet patients with concerns about sex visit primary care

physicians regularly. Every day patients seek information and explicit help for sexual

concerns, others hope the doctor will ask them about these personal issues, and still

others seek, with their physician’s collusion of avoidance, explanations for their symptoms

other than a sexual disorder.

Medical schools include courses in human sexuality during the first or second years.

Medical students learn the biology of the sexual response cycle, the endocrinology of

reproduction, and even some psychology and sociology of sexuality. These valuable

courses prepare the student to enter clinical training with a solid factual foundation

about sex. Additionally, courses in medical ethics, physical diagnosis, and medical

interviewing transform the student from a layman to a budding professional. As such,

the student learns that all patient concerns may be respectfully and confidentially

explored, all body parts and cavities examined while the doctor-to-be’s response

remains genuinely human, caring, therapeutic and altruistic. This delicate integration

of human responsiveness and clinical acumen challenges professional development

most when the topic turns to sex. Usually, the young doctor’s knowledge is academic

and experience is intensely personal, not professional. To be fully human in such circumstances

risks, at best one’s acting unprofessionally, and at worst, one’s offending by

appearing to cross a sexual boundary. It is not surprising that the medical profession

remains slow to learn how to help patients with sexual problems, and why so many

doctors simply avoid the topic entirely.

It is easy to understand how training in the clinical skills of interviewing, counseling,

and physical examination applied to sexual problems may not occur during clinical

education. One fortunate outcome of the HIV epidemic has been the systematic education

of physicians to use screening interviews to ask patients about potentially risky

sexual behaviors. Additionally, educational programs now teach primary care physicians

how to counsel patients about safer sex practices. Unfortunately, when it comes

to other sex problems, most physicians, whether in residency training or it practice,

give them glib and superficial focus, a rapid referral, or a quick change in the subject.

The 1998 meteoric rise of Viagra in the pharmaceutical sky empowered physicians,

with a flick of the pen, to help patients with impotence. No interview was needed,

both patient and physician understood “the problem” and believed there was a safe,

quick fix. For the American public, the magnitude of mail erectile dysfunction became

the constant focus for jokes, news stories, and commentaries.

Sexual Medicine in Primary Care could not have been published at a better time. It

combines common sense wisdom and medical facts with an extensive review of a literature

not easily found by the physician-reader. Sexual problem diagnosis, treatment

reports, and scientific studies are uncommonly published in medical literature. Instead,

they are the topics for journals in psychology, social work, and sex therapy. Dr. William

Maurice deftly brings an extensive academic and practical knowledge base within

reach of the average physician and medical student.

Talking about sex is difficult and Dr. Maurice provides model dialogues that guide

the physician between possibly offensive common language of sexual experience and

the jargon of medical physiology. Furthermore, his approach to interviewing a patient

about sex demonstrates the necessary balance between direct questions and openended

facilitation. With medical dialogue about sex, he advises to first ask permission,

then to pose direct screening questions before proceeding to open-ended questions or

facilitation of a patient’s discourse.

The clear description of the medical conditions that interfere with sexual health

provide guidance in diagnostic decision making and treatment. Although it is unlikely

many primary care physicians will learn some of the sex education and counseling

techniques described, the new advances in the use of medications and simple patient

education will vastly increase the physician’s medical effectiveness. Furthermore, the

clear recommendations for referral and the description of the many types of professionals

who may be of service to patients will raise awareness for all physicians. Teachers

of primary care medicine should find this readable text full of useful interview tips,

algorithms for diagnosis and treatment, and models for counseling and referral. The

Appendix V is particularly useful, because it provides an extensive table of the multiple

medications that interfere with sexual function.

As medical care moves increasingly into arenas of health maintenance and even to

health enhancement, the patient’s sexual health will continue to move into the domain

of the primary care physician. The health care professional will need the knowledge,

communication skill, and network of professional specialists to help patients achieve

their desired level of sexual health. Sexual Medicine in Primary Care will certainly contribute

by providing the information and suggestions for physicians’ interaction with their

patients about these problems.

Daniel Duffy, M.D., F.A.C.P.

Senior Vice President

General Internal Medicine

American Board of Internal Medicine

Preface

When, as a young man, I began listening to people talk about sexual problems, I

had a very limited frame of reference, namely, my own personal life experiences, fantasies,

and attractions. Listening for the past twenty-eight years to the sexual stories

of thousands of men and women (individuals and couples, people who were otherwise

physically and mentally healthy, well people and those who were unwell, people

of different ages and from many cultures other than my own) I learned that the

panorama of what is sexual for people extended far beyond my own personal

boundaries.

The element that allowed me the privilege of entering this private sanctuary of

patients* has been the evolving capacity to listen to others talk about sexual difficulties

and developing the ability of speaking to others about this subject in a manner as

neutral as talking about the weather. Use of these listening and talking skills provoked

both greater patient trust (‘here was a person who know what he was talking about’)

and greater interest on my part (evident before, but socially constrained). My personal

curiosity was only satisfied, in turn, by more reading and listening.

Listening and talking skills in relation to sexual issues did not arise (unfortunately)

from my medical school education or my specialty training in Psychiatry. Instructors

in both settings were tongue-tied when considering anything sexual, but then again,

this was the rule rather than the exception during those years. (One wonders how

much has really changed since then beyond the surface. For example, health professionals

can often now talk of “sexual abuse” but many seem unable to go beyond this

phrase, or “chapter title”, to ask about the details). I am thus deeply grateful to Masters

and Johnson for allowing me a unique (literally at that time) opportunity to be in their

clinic and for their generosity in letting a naive psychiatry resident into their midst for

a research and clinical elective. One could not ask for more hospitality, generosity, and

wisdom than I received from them. They helped me in getting my “feet wet” and I have

not looked back since.

Over the years, I’ve learned from patients that sexual desires and actions are a source

of great pleasure, but they may also entail much private pain when a problem exists.

This is the central rationale for the incorporation of questions by a health professional

about this otherwise private area into whatever else is being discussed with that patient.

In my opinion, questions about sexual matters are a necessity for almost all patients.

Those questions are part of the job.

*The word “patient” is used throughout this book simply because that is what I am used to calling people

who consult me for professional reasons. However the content of this book has equal relevance to health

professionals who use some words differently than I do. Some (including some physicians) are used to using

the words “client” or “consumer,” and these words could easily be used as substitutes for “patient” in most

areas of this book.

The pain experienced by patients with sexual difficulties extends in a variety of

different directions — from a fear of becoming infected with HIV, to having erection

problems with a new partner after thirty-five years of monogamous sexual activity

with another who recently died; from having been sexually attacked as a child to a

fear of death during “sex” after a heart attack; and from thinking that one has been

born into the wrong body from a gender viewpoint, to an irresistible impulse to

expose one’s genitalia in public. Those who are professionally engaged in talking to

individuals about these difficulties know that when the inhibitions lift, they are often

told of private thoughts, experiences, and fantasies that have never been revealed to

anyone else, not even a loved sexual partner. Ironically, two people may engage in

what is almost universally acknowledged as potentially the most intimate of human

connections, and at the same time, have trouble talking about what just occurred. As

curious as it might seem, it often seems easier to talk about sexual difficulties with a

stranger, such as a health professional. Whatever the reasons (e.g., trust and no

expectation of being judged), health professionals are in a particularly advantageous

position to hear about those troubles.

Given this unique position of the health professional, one might wonder how medical

and other health professional schools have responded in providing the necessary

educational experiences to their students. The professional school that I know best is

the one to which I’m attached, The University of British Columbia. Judging by informal

conversations with teachers in other medical schools, our program seems to be not

typical. We have an intricate lecture program in Sexual Medicine for our students,

lectures that are integrated into preexisting courses. This is capped by clinical opportunities

for students to practice sex history-taking and interviewing skills with other

students and with simulated patients and for some to participate in the process of talking

to a person or couple referred to a sex-specialty clinic because of a sexual concern.

Residents (physicians in specialty training) in a variety of disciplines have similar experiences.

This book is partly the result of requests from medical students and residents

for a greater degree of preparation before actually being confronted with the unfamiliar

task of talking to a patient about sexual matters.

The main impetus, however, for this book has been my clinical practice. Primary

care physicians have been the source of over ninety percent of the thousands of clinical

referrals that I’ve received over the years. Most commonly, I was sent a brief letter

stating the main sexual problem with some other information about the patient’s health

and physical status. On some occasions, I was able to be extremely helpful in one or

two visits. On other occasions, while the patients indeed had sexual difficulties, I’ve

puzzled over why they were referred to anyone who focuses on sexual issues, since this

seemed quite subsidiary to some other set of difficulties (medical, relational, or intrapersonal).

On yet other occasions, the clinical situation proved more complex in that

the sexual problem turned out to be plural (i.e., problems). In all these situations, I was

repeatedly struck by how much I thought could have been accomplished on a primary

care level with a bit more time and a few more questions. A given patient may never

have had to see me because, for example, the problem was quickly solved or the initial

assessment resulted in a conclusion that the patient should be referred for some other

kind of care, or I might have seen the patient but for a shorter period of time because

of preparatory work that had gone before.

PART I of this book is the result of requests from clinicians, medical students, and

residents for written information on issues of sex history-taking. Topics include what

questions to ask and words to use, how to ask the questions, and what paths to follow

in clarifying some particular concern. However, there is a paradox inherent in the

notion of learning skills from a book. Such phenomena are usually learned in the manner

of an apprentice (see quote from Aaron Copland at the beginning of the Introduction

to Part I). In fact, as helpful as a book might be (and I obviously hope this one

will prove substantially so), nothing substitutes for hearing directly from people about

their sexual thoughts, dreams, fantasies, and hopes; their sexual activities when alone

or with others; their sexual worries, fears, dread, or even terror; and, most of all, the

pain of not feeling like a “normal” woman or man.

Sometimes, the main concern of a patient in a primary care setting is sexual. Most

other times, talking about sexual issues usually involves grafting this topic onto an

interview that is already taking place on some other topic. An assumption made here

is that the reader is familiar with the literature on interviewing in health care generally,

so that little attempt has been made to review this subject in detail. The rationale for

this particular book is that, usually, little is said in general texts on the subject of talking

to patients about sexual matters. One can easily obtain a list of references to general

texts on interviewing by consulting one of the available books.1

As much as one might promote the notion of encouraging discussions with patients

on sexual matters, many primary care clinicians declare unease at raising this issue

without knowing what to do with the answers and without being able to provide some

level of treatment. Caring for patients with sexual difficulties is the purpose of Part II

of this book — the treatment of common sexual dysfunction in primary care. Although

some of the suggestions made may seem mechanistic and cook-bookish, that is not

what is intended. In no other area of human enterprise is there such intricate connections

between mind and body as is the case with anything sexual. It seems so much

easier to write about sexual toys or gizmos than about the human relations part of the

treatment of sexual problems, but there are no therapeutic circumstances in which the

latter do not play a prominent part.

It should not surprise readers that this book is written from a physician’s perspective,

since it represents my own professional background. However, when considering

the care of people with sexual difficulties, physicians may be in a minority. Many sexexperts

have been educated in a variety of health care disciplines apart from medicine,

especially psychology, social work, and nursing. Physicians tend to specialize in particular

areas such as STDs and HIV/AIDS, erectile dysfunction, and gender identity

disorders. Since professional attention to sexual problems is inherently interdisciplinary,

this book was written with much consideration given to clinicians and students in

all of the health sciences. Hence the phrases “primary care clinicians” or “primary care

health professionals” have been used throughout this book.

Finally, I would like to add a comment about the word “sex.” Multiple meanings

for this word is the usual reason for placing it in quotation marks in the text. It

would be a gross understatement to say that defining the word is difficult. When

used in a clinical setting, “sex” generally has two meanings: the nature of the patient as

male or female (although the word “gender” is increasingly being used for this purpose),

and as a synonym for the specific practice of intercourse. When used to describe

one particular sexual practice such as intercourse, it takes little reflection to agree that

the word “sex” really encompasses so much more. When, for example, a man and

woman engage in sexual activity that involves “everything but,” almost everyone still

considers the activity to be sexual. Likewise, when a man and a woman are passion-

ately kissing and both people experience the physical manifestation of sexual arousal

(erection and vaginal lubrication among other things) who would not also call that

sexual? And when a man or woman masturbates alone and is orgasmic, isn’t that also

“sexual”?

What about the definition of the seemingly broader term, sexuality? Is it the same as

“sex” and “sexual”? Of “sexuality” (and it probably could be said of all three words),

“everyone either grasps the definition from contextual cues, assigns it a private meaning,

or simply pretends to understand”.2 “Sexuality” involves physiological capabilities,

sexual behavior, and sexual identity — among other things.2 (pp. 3-4). The reader will

find the word “sexuality” infrequently used here because its meaning seems even less

precise than “sex” and “sexual.” The word “sexual” seems most comfortable and is used

most often, perhaps because being an adjective rather than a noun or verb, it modifies

another word.

REFERENCES

1. Morrison J: The first interview: revised for DSM-IV, New York, 1995, The Guilford Press.

2. Levine SB: Sexual life: a clinician’s guide, New York, 1992, Plenum Press.

W. Maurice

Vancouver, BC

Acknowledgments

I am profoundly indebted to the many patients with sexual problems (who, to preserve

confidentiality, must remain anonymous) that I have treated over the past 28

years. This is more than ritual intellectual appreciation. The emotional part of my

gratitude was “brought home” to me by a phone call I recently received from a woman

asking to see me because of a sexual concern. She explained that her parents consulted

me about 25 years ago, that her call now was on their suggestion, and that, in turn, was

because of their thankfulness at my having been so helpful to them many years before

in preserving their marriage! As appreciative as her parents evidently were, I was

touched and even beholden to them because of what they gave to me.

I am particularly grateful to Marjorie Bowman for having worked as a consultant on

this book, and for the care that she took in scrutinizing what I had written. She provided

the perspective of someone on the “front lines” of family practice, which I, as a

specialist, was obviously unable to do. When I began searching for a consultant, I felt

strongly that whoever filled this position should be a woman in order to provide balance

to the perspective I would inevitably present as a man. I also thought that she

should be an American to provide balance to the cultural perspective that I would

inevitably present as a Canadian. On all three counts, I (and readers) have been generously

rewarded. Above all, her sensitivity to patient needs was repeatedly made obvious

to me, as was her passionate concern for the way women patients, in particular,

should be treated.

Some friends and colleagues read and critiqued parts of the manuscript, and while

no one apart from myself bears responsibility for the finished product, this review

process was particularly valuable to me. My psychiatrist friends and colleagues, Jon

Fleming and Sheldon Zipursky, gave me their considerable wisdom and time. Irv Binik,

Phillis Carr, Sandra Leiblum, Jamie Powers, Ray Rosen, and Ruth Simpkin, provided

detailed and useful comments. Others, Eli Coleman, Bill Coleman, Christine Harrison,

Mike Myers, Oliver Robinow, Tim Rowe, Bianca Rucker, Roy O’Shaughnessy, and

Noelle Vogel, either advised me on specific issues or offered important general observations

on this, or an earlier version of the manuscript. Many medical students and

psychiatry residents offered substantial ideas over the past years and many of these

have been incorporated into the manuscript.

George Szasz (now retired) was a colleague for 20 years, and over that period of

time, we shared so many ideas that it sometimes became difficult to know the source.

I have known my other colleagues in the UBC Division of Sexual Medicine for fewer

years and yet their contributions to my education and this book have also been substantial.

Stacy Elliott was particularly helpful in reading part of the manuscript and

advising me about ejaculatory disorders involving reproduction. As well, Rosemary

Basson, Donna Hendrickson, and Ron Stevenson have all given me useful ideas, more

so than they may even realize.

Laura Hanson, a student in the PhD Psychology program at the University of British

Columbia, provided organized and very helpful work as a research assistant. The

high quality of work and good humor of my secretaries (plural because my office

moved while the manuscript was in preparation) Maureen Piper, Judy Wrinskelle, and

Francesca Wilson made my life immeasurably easier in the process of preparing this

manuscript.

My editors at Mosby have been extremely responsive from the beginning of this

project. Mike Brown as Acquisitions Editor (although not presently working for Mosby)

immediately and impressively responded to my initial proposal and was eventually

responsible for the connection between Mosby and myself. Besides advising me in

many useful ways, he was ultimately helpful in locating Marjorie Bowman. Ellen Baker

Geisel, Development Editor, has been my principal contact at Mosby. Her sense of

humor, good cheer, and helpful advice has been crucial in seeing this project through

to fruition. Florence Achenbach and Jen Marmarinos were invaluable as production

editor and designer, respectively. They brought my manuscript to life.

Finally, the Lady Davis Fellowship Trust allowed me to contemplate and plan much

of the foundation for this book during my treasured sabbatical in Jerusalem and that

debt is one that I cannot ever repay.

Bill Maurice

Foreword

Foreword

Preface

Acknowledgments

Contents

Detailed Contents