. . . with respect to discourse on sexuality there is major discontinuity between the sensibilities of politicians
and other self-appointed guardians of the moral order and those of the public at large, who, on the
whole, display few hang-ups in discussing sexual issues in appropriately structured circumstances.
Laumann et al, 19941
Clinicians experienced in talking to people about their sexual difficulties would not
question the above quote. When the “appropriately structured circumstances” represent
a health setting, patients display little hesitation in talking about sexual matters
if they are talking with a health professional who knows what questions to ask and
shows no embarrassment. A polished interviewer can often accommodate patient sensitivity
with the topic of “sex” but an awkward interviewer presents a predicament for
the patient. Some patients decide not to continue when they experience obvious interviewer
discomfort and simply find someone else with whom to talk. However, in relation
to sexual worries, a lengthy period of time may (and often does) intervene. Years
(rather than months or weeks) typically transpire between one unsuccessful effort and
a subsequent attempt to talk with a health professional about a sexual problem.
A married couple, both 37 years old, were distressed about their inability to have
intercourse. The man had erection difficulties. While the couple developed mutually
gratifying sexual experiences apart from intercourse, they were unable to conceive.
In the past, they were referred to a physician because of the physician’s
expertise in the treatment of infertility. Both partners described the physician’s
impatient attitude that was directed toward the woman. The physician indicated
bluntly that she could not find anything wrong during the examination and displayed
little feeling for the woman’s obvious fear of vaginal entry. The physician
suggested that surgery would make the vaginal opening larger. Both partners were
uncomfortable with this idea and with the physician’s abrupt manner. They stopped
seeing her after two visits.
Although they thought about consulting a health professional who was experienced
in the treatment of sexual and reproductive difficulties, they were concerned
about a repetition of the experience with the first physician. It was another two
years before they talked with someone else. The new physician’s sensitivity,
patience, and skill in treating vaginismus allowed the couple to eventually have
intercourse, and conception occurred.
“Rapport” is one aspect of the health professional/patient encounter that governs other
elements of the interview. Like an umbrella, it covers the way all information is collected,
rather than one specific issue. Rapport means the development of a physician/
patient relationship based on trust and respect and within which information can be
readily obtained. Developing rapport involves interviewing (the manner in which
information is acquired) more than history-taking (the content of the information
itself). A health professional engenders rapport in ways that include the following:
1. Demonstration of a caring attitude
2. Respect for the patient and the concerns voiced
3. The manner used in asking questions
Rapport seems more fragile around the topic of “sex” than around other issues. The
explanations for this sensitivity are not difficult to find. In talking about sex, the
1. Trustingly reveals something very personal to a health professional
2. Hopes for an empathic and knowledgeable response
3. Really doesn’t know what to expect
If the patient encounters embarrassment, rapport (regarding this subject)
is diminished. Yet, some uneasiness is to be expected from anyone
who is a novice in talking to patients about sexual issues. (With
experience—it is surprising how little is needed—one learns to be more
composed). If discomfort is obvious, candor and honesty by the interviewer
will minimize the loss of rapport. Lack of familiarity with a
sexual word or a sexual practice can be declared candidly with a minimum
loss of respect from the patient, or even the opposite—enhanced
regard because of the willingness to acknowledge one’s limits.
What appears to be missing from interviewing books directed toward health professionals
are suggestions about how to ask sex-related questions (interviewing), quite
apart from what to ask (history-taking). The nature of questions may be less disconcerting
to patients than the way in which questions are asked.
How, rather than what, to ask involves interviewing techniques, some of which are
particularly advantageous when talking specifically about sexual issues. There are at
least ten such methods (Box 2-1). The use of some of the ten methods are illustrated
in Appendices I and II.
It is not unusual for “sex experts” to explain the absence of sex-related questions in an
interview on the “hang-ups” of the interviewer. Health professionals, however, tend to
An interviewer’s lack of familiarity with
a sexual word or sexual practice can be
declared candidly with a minimum loss
of respect from the patient, or even the
opposite—enhanced regard because of
the willingness to acknowledge one’s
“blame” the patient for the sex-information gap by saying that to have asked about this
subject would have risked alienating the person being interviewed. One way to eliminate
blame entirely is for the interviewer to simply request the patient’s permission to
ask a question about this topic.
The permission technique accomplishes the following objectives:
1. It erases the health professional’s worries about being intrusive, since it becomes
the patient’s responsibility to decide on the acceptability of the topic
2. The interviewer shows respect for the patient and sensitivity toward the patient’s
3. Control is explicitly given to the patient by offering the possibility of saying
Chapter 3 offers some suggested responses if, indeed, a patient declines the invitation.
Some will refuse but most will not. Many actually want to discuss sexual concerns with
a health professional. This was illustrated in a random sample survey of 6000 women
in the Canadian province of British Columbia.2 The study pertained to the subject of
physician’s sexual involvement with patients. Among other things, subjects were asked
to respond to the statement that it is “OK for the doctor to ask a question about sexual
problems as part of a general check-up on an adult patient.” The majority (73.6%) of
the 2079 respondents agreed. This opinion was positively correlated with the age respondent,
a finding that was enlightening in view of the particular difficulty that many young
interviewers seem to have when talking about sexual issues with older
people (especially older women).
Of course, asking permission to talk about sex makes this topic
different in any health setting. Some physicians object to asking permission
for this very reason, that is, because one does not ask permission
to talk with a patient, for example, about liver function or
depression. However, tradition seems to allow physicians to ask
about, for example, liver function and depression, whereas talking
1. Ask patient’s permision
2. Interviewer takes initiative
3. Language: medical/technical versus slang
4. Stat ement/Question technique
6. Delay sensitive questions
7. Display nonjudgmental attitude
8. Provide explanation
9. Discuss feelings
10. Promote optimistic attitude
Asking permission may perpetuate the
idea that this topic is something special.
Little appreciation is thus given to the
fact that for many people “sex” is a
special subject. Community attitudes dictate
this distinction rather than health
about the subject of sex in a medical context is to be viewed favorably only when
the justification is proven (as in relation to, for example, diabetes or HIV/AIDS).
Asking permission may perpetuate the idea that this topic is something special.
Little appreciation is thus given to the fact that for many people “sex” is a special
subject. Community attitudes dictate this distinction rather than health professional
behavior. The concept of asking permission reflects a need to be sensitive to popular
feeling and thus becomes a practical (rather than ideological) matter for the
The permission technique can be used effectively in an interview in two ways:
(1) entering the field of “sex” generally and (2) asking about a particular and potentially
sensitive aspect of “sex”:
A 54-year-old man went to see his family physician because of shortness of breath
associated with exertion. The physician conducted a thorough history, during
which he included a “review of systems” (ROS). The physician routinely included
sexual matters in his ROS and used the permission technique to initiate a discussion
on this subject. He typically did this with men after asking about urinary
Q: Do you have any pain when you urinate?
Q: Do you notice any blood when you urinate?
Q: Is it OK if I ask you some questions about your sexual function?
A: No problem
Obviously, the health professional may ask further questions when a positive reply is
given. In the occasional instance when the response is negative, the professional might
say something like (see Chapter 3) “it’s certainly OK with me if we don’t talk about this
now but if you change your mind at any time in the future, we could talk then.”
Only occasionally do patients volunteer information about sexual matters to health
professionals, especially if a problem exists. Patients have mixed feelings about this
apparent paradox. Health problems are the very reason for consulting
a health professional but to not divulge information is patently counterproductive.
Talking about sexual problems can be so embarrassing
that it could paralyze any desire to ask for help. When secrecy exists,
it is obviously deliberate. However, when a person does not tell all of
the truth, it is not the same as lieing. Patients withhold information
only when questions are not asked. Replies are usually truthful when
questions are asked. (There are also other reasons for a person’s lack of
When secrecy exists, it is obviously
deliberate. However, when a person
does not tell all of the truth, it is not the
same as stating a lie. Patients withhold
information only when questions are not
asked. Replies are usually truthful when
patients are asked.
candor, such as being concerned about giving the “right” answer to a question, but this
is less important than questions not being asked.) Therefore to discover the presence
of problems, the onus is very much on the interviewer to ask pertinent questions.
Laumann et al. “. . . discovered that respondents found it very difficult to come up
with language of their own to talk specifically about sexual practices. It was much
easier for them to answer direct, simple questions we posed that asked for yes or no
answers or simple indications of the frequency with which some behavior had
Many mental health professionals use a nondirective method of acquiring information
from patients. This technique involves relative silence by the professional and
spontaneity by the patient in talking about concerns, whatever they might be. Such an
approach directly conflicts with the notion of interviewer initiative. In a nondirective
environment, frankness in talking about sexual issues rarely occurs, especially detailed
descriptions of problems. Although one reasonably begins the inquiry process with an
open-ended style of questioning (“Tell me about . . .”), direct and explict follow up questions
are obligatory when sexual issues are being discussed.
Kinsey and his colleagues cited two possible reasons for the nondisclosure of sexual
• Judgmental attitude on the part of the interviewer
• Illegality of the sexual behavior
A third factor should be added, namely, not asking questions. By taking the initiative,
the interviewer is in a position similar to the poker player who is asked to show his or
her cards first to prove a winning position. It is as if the patient is saying, “prove to me
that you’re not going to tell me that I’m abnormal or that you won’t think less of me
for what I’ve done.” This is apparent in entering the field of “sex,” as well as asking
questions about the details of “who does what to whom” (often called by patients:
A man in his late 20s and married for one year talked with his new family doctor
about his erectile difficulties. Although embarrassed, the patient welcomed the
physician’s questions about this problem. Unknown to the patient’s previous physician,
and in response to direct inquiry from his current physician, the patient
reported that he had never experienced intercourse with his wife or anyone else.
Moreover, he described erections that were full at all times until the point of
attempted vaginal entry, when he would ejaculate. His erection would then
promptly disappear. Since his erectile difficulties seemed to result from his rapid
ejaculation, the treatment focus shifted away from his concern about erections to
the problem of his ejaculation. Using medications to control the timing of his
ejaculation, his virtual panic over anticipated erectile loss diminished greatly. The
conjoined use of sex therapy techniques allowed the patient and his wife to consummate
their marriage within several weeks.
The subject of “sex” is unique in medicine in that there are two languages used to
describe the same phenomena: medical/technical language and slang. When health
professionals talk about the sexual thoughts, feelings, or behavior of their patients, this
usually occurs in the idiom of medical/technical jargon. Such words are almost always
safer than slang in preserving the relationship with the patient. Safety is important in
protecting the patient from the unwitting imposition of unacceptable values by the
interviewer and the subsequent risk of losing that person as a patient.
The following are four potential problems that can arise as a result of using medical/
technical terms; all are related to the element of comprehension.
1. One cannot assume that a patient understands medical/technical jargon. In
clinical practice, problems related to understanding are more likely to arise
when talking to someone from a different linguistic or cultural group. Patients
usually don’t ask for explanations or definitions of words for fear of appearing
ignorant. Men seem more concerned about this than women, especially men
from a third world culture where gender role expectations render embarrassment
as a result of having “lost face” because of “not knowing.” It is diplomatic
for the health professional in this situation to begin by assuming lack
of understanding of medical/technical terms and to take the initiative in providing
2. A comprehension problem may result from embarrassment or discomfort with
the topic of “sex” on the part of the health professional with the consequent
inclination to avoid anything but the most superficial reference to the subject.
A 24-year-old man was referred because of an inability to ejaculate when awake.
The family physician who referred the patient had completed an investigation of
the man’s physical status, blood tests (including a hormonal profile), referral to a
urologist, and urological tests that involved a testicular biopsy. The family physician
suggested previously to the patient that he “masturbate,” since this was not
part of the patient’s sexual experience in the past. The patient reported that this
was ineffective. Referral to a specialty clinic occurred because all the tests were
reported as negative. As the discussion proceeded with the patient about the details
of his attempts at masturbating (number of times, duration of attempts, where
stimulation was applied), he revealed his complete lack of understanding of how
men masturbate and his consequent inability to implement the suggestions of his
family doctor. Permission was then asked of the patient to demonstrate male masturbation
techniques on a rubber model of an erect penis. This was done, and that
evening the patient ejaculated while awake for the first time in his life.
3. Slang (rather than medical/technical words) may help as an alternative form of
communication when comprehension is in doubt but this has to be balanced
against the risk that the health professional may alienate the patient in the process.
If slang is contemplated, a safer method is by the conjoined use of the
permission technique described previously.
A 35-year-old married woman was referred because of her lack of sexual interest
and her husband’s threats to leave the marriage unless this changed. In talking with
her about her sexual desire under various circumstances, it seemed that she did not
understand the nuances of some of the questions. She was consequently asked
permission to use another word for “desire” or “interest”—a word (so it was
explained) that some people find offensive but which everyone seems to understand.
She was told that if she disliked the word, she should indicate this to the
interviewer so that it would not be used again. She agreed to his arrangement. She
was then told that the word was “horny.” She replied that the word was certainly
familiar to her and that she understood what it meant. She proceeded to describe
when she had, in fact, felt this way during her lifetime. However, she added, rather
pointedly, that the word “horny” was frequently used by her husband and that she
herself found it “disgusting” and preferred that it not be used again.
4. Patients sometimes stumble in their attempts to use medical/technical terms. An
example is the use of the word “organism” instead of orgasm. An approach to this
situation is to allow the patient to learn a more accurate sexual vocabulary simply
by the interviewer using the correct word repeatedly. The challenge to the
health professional is to find a way of adjusting what the patient says without
being condescending in the process.
When talking to people about their sexual thoughts, feelings, and behavior, Kinsey
et al. realized that many forms of sexual activity occurred far more often than had
been previously assumed.3 Using the same example and armed with the knowledge
that the vast majority of American men had this experience, Kinsey phrased inquiries
to convey that “. . . everyone has engaged in every type of activity.” This became
known as the ubiquity technique.4 The use of the ubiquity technique avoided the necessity
of asking men: “have you ever masturbated?” and instead proceeded to the next
question, namely, “how old were you when you began to masturbate?” Apart from the
“ubiquity” approach specifically, other methods for asking questions about sensitive
issues in general have also been suggested.5
A variation or alternative to the “ubiquity” technique is not to make assumptions but
to preface a question by a statement phrased in such a way that the interviewer is talking
of “most” or “many” people rather than everyone. Furthermore, this preliminary
statement outlines the subject of the subsequent question. The interviewer then asks
the person if their personal experience includes what was just described.
A couple in their mid-20s was referred because the woman was nonorgasmic in
sexual activity with her husband. When seen alone, the woman revealed that she
regularly came to orgasm through masturbation and that her husband was unaware
of this. The fact that “many” women had difficulty in giving explicit directions to a
sexual partner was mentioned, and the interviewer asked whether this conformed
to the woman’s own experience. She answered by saying that she also found it
awkward to be completely candid in spite of the fact that her husband was receptive
and, in fact, had asked her on many occasions what she “wanted.” (What she
wanted was to be able to tell him what she wanted.) She felt reassured in knowing
that the problem of “communication” was not only hers. She was encouraged to
discuss her masturbation experiences with her husband and was told that men usually
appreciate such information. As a result of very explicit discussions with her
husband she developed a considerably higher level of arousal with him than ever
This method of stating something factual followed by a question about the person’s
own experience seems extremely useful in talking about “sex” for several reasons. First,
many people seem to be perennially hungry for sex-related information, especially
about the minutiae of what people “do,” think, and feel. Since people generally do not
talk candidly about these subjects or read the many relevant books and magazine articles
available, the statement part of this technique provides a way of disseminating information. Second,
the initial information statement indicates to the patient that if the description is
part of their own personal experience, they should not feel alone, since “many” others
are “in the same boat.”
However, “many” or “most” does not mean “all,” and what is being discussed may not
have been part of the life experience of the person interviewed. In that situation, the
person could say so without feeling deviant and could also know that they, too, had
lots of company. In other words, the interviewer “normalizes” the patient’s sexual
behavior. This approach provides a “win-win” opportunity for the patient.
• Privacy: the property of the individual; a right to control the disclosure
of information about oneself
• Confidentiality: the extent to which information is disclosed to a third
• Security: the physical property of the system used to process and store
In the medical system, privacy relates to the patient, confidentiality relates to the
behavior of the health professional, and security relates to the method of protecting
the information obtained. All are associated with keeping information secret (expected
in any health system but secrecy and “sex” are particularly linked).
An example in which the privacy of sex-related information becomes problematic is
when a patient is well known to a health professional because of a long association
between the two but the subject of “sex” was never discussed. This circumstance sometimes
results in a patient consulting with another health professional solely for the
purpose of obtaining a referral to a sex-specialist and doing so without the embarrassment
of talking about this subject with his or her usual doctor.
A 35-year-old woman with multiple sclerosis (MS) was referred because of orgasm
difficulties that had begun recently. Symptoms of MS began seven years earlier.
The patient experienced two episodes of illness, neither of which resulted in any
permanent disability. She was married and never previously experienced sexual difficulties.
Two months earlier, she found it progressively more difficult to come to
orgasm. She was a patient of her family doctor since her teens. She became socially
friendly after they met at a swimming pool. Neither her family doctor nor her
neurologist ever talked with her about her sexual function. When sexual problems
appeared, she found it impossible to discuss the problems with either. As a result,
she went to the medical clinic at the university where she worked and asked for a
referral to the “sex clinic.”
Clinical problems in relation to confidentiality generally arise when one partner does
not want information given to the other. Most often this pertains to sexual activity
with another person or atypical sexual behavior. In this situation, it is not unusual for
patients to ask for an explicit statement of assurance of confidentiality when divulging
information that is regarded as potentially damaging. (In providing such reassurance to
a patient, health professionals must consider any legal reporting obligation that may
exist in their jurisdiction such as a child in need of protection and serious risk of harm
to another person or to oneself.)
A couple was referred because of the woman’s lack of sexual interest. They both
were 28 years old. They were married three years ago and had known each other
for two years before their marriage. Her sexual interest lessened in the last year.
In talking with her separately, she was asked questions that attempted to clarify
whether her diminished sexual interest related to her husband specifically or was
more general. She specifically asked if the conversation was just between the interviewer
and herself or whether the information revealed would be given to her
husband. She was reassured that anything discussed would be strictly confidential.
Two other statements were added. First, the “right” was reserved to tell her that if
what she was about to explain was something that her husband should probably
know this opinion would be given directly to her rather than her husband. Secondly,
she was informed that in the legal jurisdiction in which the interview was
taking place, courts had the power to subpoena medical records and that she should
be aware of that in case she was about to reveal something that was illegal.
She then proceeded to disclose the following:
• She had fallen in love with another man
• Sexual disinterest was not a problem with her new partner
• She wanted to separate but was concerned about her husband’s anger and
wanted to tell him in the presence of a health professional present
They were subsequently seen together and when she revealed this information to
her husband, he was neither angry nor surprised (although upset), and indicated
that for several months, he wondered whether she had become interested in someone
Security of medical records represents a special problem that has legal and ethical
ramifications. The fact that medical records can be subpoenaed by the courts or medical
licensing authorities in many legal jurisdictions can place a very real restraint on
the ethical obligation of the health professional to maintain patient
confidentiality. Because written documents remain in files for long periods
of time and medical records can become legal evidence, the health
professional may be justified in keeping skimpy notes. However, when
records are not complete and thorough, the interviewer may be handicapped
by forgotten information and imprecise memories. Also, information
omitted from a medical record is, obviously, unavailable to
other health professionals in an emergency situation. If a secret is
recorded, the special nature of the revelation should be noted in the
record. Some clinicians, especially those working in hospital in-patient
settings where many people have access to the medical record, keep a
second set of records available only to themselves. A second set of
notes preserves security in a medical, but not a legal, sense. While charts remain the
property of the clinician, recent regulations enacted in many jurisdictions in North
America allow patients to have legal access to their medical records. Presumably, this
access applies to a second set of records as well.
A married couple in their early 30s with two young children was seen in consultation
because of an impending separation, due, according to the referral source, to
sexual difficulties. When the husband was seen alone, he spontaneously talked
about having long-standing and frequent sexual fantasies involving men, occasional
sexual experiences with men, and a desire to develop a sexual relationship with a
particular man with whom he worked. In talking with his wife by herself, she was
obviously aware of her husband’s wish to form a relationship with a male workcolleague
but felt that it was unacceptable for him to have any sexual relationship
outside of their marriage. She recalled that before their marriage, he said something
(she could not remember the details) about having sexual desires for men as
well as women. She thought then that his interest in men was unimportant and not
something that would interfere with their development as a couple.
A second set of records preserves security
in a medical, but not a legal, sense.
While charts remain the property of the
clinician, recent regulations enacted in
many jurisdictions in North American
allow patients to have legal access to
their medical records. Presumably, this
access applies to a second set of records
The interviewer puzzled about what to record in the chart, since he recognized
the possibility that he might have to account for what he had written if there was
a legal contest between the two partners in the future over, for example, custody of
their children. In view of the explicit discussion between the two about the husband’s
current interest in developing another relationship (which was thus not private
information) the interviewer concluded that he could incorporate this into the
record without problem. However, the interviewer also believed that, since the
husband was given assurance of confidentiality when he was seen alone, the husband
may have revealed aspects of his history that might otherwise not have
emerged. Therefore the interviewer felt that it would not be proper to record
details of the man’s past sexual history and wrote only brief notes about what his
wife already knew concerning his sexual interest in men.
In an ordinary medical history, the sensitivity of patients to particular questions is often not
of primary concern to the interviewer. For example, in asking about abdominal discomfort,
one is not ordinarily concerned about how the person is going to react to the
question. However, in a “sex” history, some topics elicit an almost predictably hesitant
response from people. In the interest of preserving the relationship with the patient,
questions concerning such subjects need to be approached with tact and sensitivity.
One method for obtaining the required information while simultaneously maintaining
rapport is to delay asking questions about a delicate topic until later in an interview or
in a subsequent interview after a greater degree of trust is established. (Although waiting
before asking “sensitive” questions is intuitively appealing, research support is
One example of delaying sensitive questions is in talking to people about the details
of a sexual experience. Doing so is quite unlike simply telling someone about the presence
of a particular problem, such as ejaculating quickly or not experiencing orgasm.
Describing the events of a sexual encounter, however helpful that may be to an interviewer
in understanding a problem, is quite alien to most people. Sexual partners may
even find it painful to talk so explicitly with one another, in spite of the fact they were
both there when the events occurred! In reviewing the dynamics of a sexual circumstance,
it is infinitely easier to describe, for example, the preliminary courtship invitations
or initial sexual signals than the later circumstances in bed, such as which part of
a man’s penis his partner usually stimulates with her fingers. While talking about sexual
minutiae is never easy, it is less stressful when a greater degree of trust is established
between patient and interviewer.
A couple in their early 30s was referred because the woman was nonorgasmic.
They were reluctant to discuss this, as well as details of their sexual experiences as
a couple, pleading lack of experience in talking with others about their personal
experiences and not expecting to have to talk so explicitly during the appointment.
The interviewer felt it unwise to pressure them into revealing detailed information
before they were comfortable. Discussion initially concentrated on nonsexual relationship
On the second visit, the couple was only slightly more forthcoming. When
they realized their concerns were not being addressed, they became more receptive
to explicit questions about their lovemaking. Discussion took place about their
“signal system,” what would happen before vaginal entry, and aspects of intercourse.
They revealed that she was regularly orgasmic with clitoral stimulation
when masturbating or when her husband was stimulating her with his fingers. They
also explained that he would regularly ejaculate quickly, often before entry. He was
particularly embarrassed about this and had told his wife not to reveal information
about his ejaculation to the interviewer. She felt that she simply did not have
enough time to come to orgasm before he ejaculated.
Another example of the need to delay sensitive questions is when there is the possibility
that someone has engaged in an atypical form of sexual behavior.
A couple, married for 10 years and each 39 years old, was referred to a “sex” clinic
because of the man’s sexual disinterest. His wife discovered a cache of sexually
explicit magazines in the trunk of their car one year earlier and, since then, sexual
experiences between the two partners had been almost nonexistent. When subsequently
seen alone, the husband described an interest in such magazines extending
back to his teens, but he did not consider this to be a problem since it hadn’t interfered
with his sexual experiences with his wife in the past. The magazines were
heterosexually oriented and his chief interest was in looking at pictures of women
undressed. He spent several hours each week looking for such magazines and about
$500 each month in purchases. He masturbated almost every day while looking at
the pictures. His wife was unaware of these details.
The interviewer wanted to inquire about other atypical forms of sexual interest
but felt that his relationship with the man was tentative, particularly since the
referral was initiated by the man’s wife. On the next visit, the man was asked about
some paraphilic behaviors. It emerged that since his teens he had sometimes privately
dressed in women’s clothes and stole women’s undergarments from clotheslines
at night. He was not sexually interested in children, had never exhibited his
genitalia in public, and had not engaged in any sexually violent behavior toward
others. He never discussed any of his sexual behavior with anyone before and,
while he was concerned about his wife discovering his private sexual interests, he
felt relieved at being able to discuss these issues with another person. On the
fourth visit, and in response to specific questions, he described (with palpable hesitation)
having tied a ligature around his neck on several occasions in his life to
become more sexually aroused. The last time was several years ago but he was
concerned that this might happen again and that there might be life-threatening
consequences. He was immediately admitted to hospital and referred to a psychiatrist
who was expert in the assessment and treatment of paraphilias.
The injection of personal values into discussions about sexual behavior was a major
issue for Kinsey and his co-workers.3 Their interviewing observations concentrated on
two issues: (1) confidentiality and trust and (2) the interviewer’s attitude. They displayed
particular sensitivity toward the intrusion of the interviewer’s values into the
process of questioning when they wrote that “. . .there are always things which seem
esthetically repulsive, provokingly petty, foolish, unprofitable, senseless, unintelligent,
dishonorable, contemptible, or socially destructive. Gradually one learns to forego
judgment on these things, and to accept them merely as facts for the record. If one
fails in his acceptance, he will know of it by the. . .quick conclusion of the story.”3
P atients who describe their private sexual thoughts or experiences and who are also
in psychological pain as a result are not usually asking others for an opinion or approval.
Rather, such a person is seeking a listener rather than a judge, someone to assist in the
process of change. If the patient wanted a right/wrong opinion, they would have consulted
a clergyman instead of a health professional. If the interviewer
cannot function in a helpful way and without judgment, the patient
should be referred elsewhere. The meeting between health professional
and patient is not the place for proselytizing. The problem is not a
matter of the nature of one’s personal values.Indeed every health care
professional operates within a personal value system. The problem is
one of imposing these values on a patient and, in particular, doing so in
a covert manner. In a welcome departure from tradition, Bancroft
included a statement of his personal values within the introduction to
his text “Human Sexuality and Its Problems.”8 Health professionals who have strong beliefs
that make it impossible for them to be dispassionate in caring for patients with sexrelated
concerns should make their philosophical position known beforehand.
Occasionally, patients ask for an opinion about the propriety of sexual experiences
or relationships. One can be precise in answering without simultaneously telling
patients how they should manage their lives.
A 22-year-old man was referred because of an inability to ejaculate in attempts at
intercourse. His current sexual partner was his first intercourse partner. He experienced
noncoital sexual activities with her in the previous three years during which
he had no difficulty with ejaculation. The same was true with masturbation.
In the course of talking with him, he revealed, with much reluctance, an event
when he (the patient) was 15 years old in which his brother stimulated him to
ejaculation. He regarded this as evidence of homosexuality, about which he was
persistently distressed. All his subsequent sexual experiences were with women and
his sexual fantasies consistently related to women. He described himself as repulsed
by the notion of homosexual behavior. He asked the interviewer if his (the patient’s)
earlier life experience was an indication of homosexuality and the interviewer’s
opinion about the “decency” of homosexual behavior. The interviewer reassured
him by placing the sexual event with his brother in the context of the sexual evolution
of a heterosexual adolescent boy; the event seemingly had little or no rele-
vance to the issue of his sexual orientation as an adult. To that was added a statement
that the determinants of homosexual and heterosexual behavior were unclear
but that, in any case, the “job” of a health professional was to assist in helping to
understand and solve problems rather than to give opinions about the correctness
of a person’s actions. The latter was described as being more a matter for the clergy.
An offer was made to help find a priest (the patient was Catholic). The suggestion
Health professionals who have strong
beliefs that make it impossible for them
to be dispassionate in caring for patients
with sex-related concerns should make
their philosophical position known
Health professionals, especially physicians, are not renown for giving jargon-free
explanations to patients about their difficulties. The impact on patients of information
about the nature of a disease varies. However, when talking about sexual disorders in
particular the impact can be immense, since lack of information, or misinformation,
can be a critical factor in the origin of the problem. Tiefer observed that “the major
source of information for the young has been the mass media, both because of parents’
silence and because of the dearth of sex education . . . advice in the nonfiction media
reinforces the impression that sex is very important without providing the kind of
information that ordinary readers or viewers can actually use.”9 Given these circumstances,
the provision of information by a health professional can be therapeutically
A 57-year-old man was referred because he repeatedly delayed the prostate surgery
that was recommended by his family doctor and urologist. He had symptoms of
prostate gland enlargement and was diagnosed as having “benign prostatic hypertrophy.”
He previously had used an oral medication to diminish the size of his
prostate and found that it helped initially but that his symptoms were worsening.
The suggested treatment at this point was transurethral surgery (TURP), which
involved the removal of prostatic tissue obstructing the flow of urine through his
urethra. The patient was concerned about possible impairment of sexual function
as a result of surgery and was not reassured by what he perceived to be bland
encouragement by his physicians.
He had been divorced for three years and was sexually active with a woman in
her early 40s. They had talked seriously about marriage. He saw, on a TV talk
show, information about the use of a penile prosthesis as a treatment for “impotence”
after prostate surgery and wanted assurance that this would be available to
him after his operation. In a specifically structured visit involving the interviewer
and the patient’s urologist, the details of the surgery were reviewed with the patient.
This was done with the help of a rubber model of the male genitalia, which showed
internal and external organs. The mechanism of expected impairment of ejaculation
with a TURP procedure was explained, as well as the method by which erections
occurred. The reasons for not expecting erectile impairment were also
explained. The patient underwent surgery and experienced retrograde ejaculation
as a result, without associated erectile difficulties. Neither he nor his partner
ceived this as a major interruption of their sexual experiences and did not ask for
Health-related histories generally contain questions about experiences or behavior, not
about feelings. However, sexual disorders often require an understanding of all three.
Feelings surrounding sexual issues may be etiologically, diagnostically, or therapeutically
prominent. In a developmental history, it may be useful to determine when a
particular event occurred and also how the person felt about that experience. Feelings
may provide a crucial link between the past and the present.
A couple in their early 40s was referred on the initiative of the husband and because
of a lack of sexual desire on the part of the wife. This extended to a time shortly
after their marriage and began in relation to her first pregnancy about 15 years
In the course of talking to the woman alone and in the context of a developmental
history, she was asked about her intercourse experiences during each of her
three pregnancies. She described diminishing sexual interest as her first pregnancy
evolved. This was the opposite of her prior sexual enthusiasm. She related that her
disinterest was the result of the prolonged morning sickness and bloating associated
with the pregnancy. She denied particular feelings connected to specific sexual
experiences that occurred at that time. However, at the end of the interview and in
response to a question about whether there was anything else of importance in
relation to her sexual concerns, she tearfully recalled the last time she and her
husband had intercourse prior to her first delivery. This occurred hours before her
“water broke” and the delivery of a stillborn child. Since that time, she believed
that “sex” was the main cause of the death of her child but had only recently stated
this to her family doctor. Before the current visit, she had not seen the possibility
of a connection between feeling responsible for the death of the baby and the
disappearance of her sexual desire. She accepted the suggestion of exploring this
idea in psychotherapy.
The interviewer must consider feelings from the past as well as feelings in the present,
including during the interview itself. In any discussion of sexual matters, it is reasonable
to assume that the patient is uncomfortable (in a psychological sense). To suppose
otherwise is to not acknowledge the strangeness of talking to someone else about
something usually considered private. Embarrassment is to be expected. Indeed, if
there is no embarrassment, the interviewer must ask why—at least to him or herself, if
not to the patient as well. One way of assessing the patient’s feelings about the interview
is simply to ask, and to reassure the patient about the usualness of uneasy feelings.
The need to do this may extend beyond the first visit. Patients often return on a second visit
and say that when thinking about the first visit they could not believe they
said “those things.”
Life problems often seem worse than they actually are. Hope is one of the most
powerful weapons in the armamentarium of any health professional.10 Changing the
patient’s perspective on a problem can be a mechanism for engendering
optimism. This is the basis of the proverbial story of the man
who cried because he had no shoes, until he saw another who had
On the surface, sexual problems are no different. However, patients
tend to think of themselves as not simply having a sexual problem;
they also think they are less of a man or woman in the process. That
is, people often perceive a sexual difficulty (especially something that
impedes intercourse) in a global way rather than as a limited disorder.
Sexual problems thus become reflections of masculinity or femininity.
Therefore the impact of a health professional’s optimism can extend far
beyond the sexual problem to the entire view of oneself.
Patients also tend to magnify the extent of a sexual disability and not to balance this
with positive thoughts. Men and women seem to share this inclination equally. This
negative point of view is apparent when a problem is first revealed and is also seen
repeatedly when treatment benefits are quickly “taken for granted” and put aside in
favor of worry over remaining problems. Patients seem to be concerned that they may
be prematurely “dismissed,” or perhaps, fear that the leftover troubles may be insoluble.
Optimism of the health professional may be the major factor that keeps the patient in
the treatment process.
A couple in their early 30s described a problem of nonconsummation of their fiveyear
marriage. They both wanted children. This reproductive “agenda” was the
main motivation for seeking medical care. Intercourse for the purpose of bonding
or cementing their relationship was of secondary importance—at least initially.
The sexual diagnoses were vaginismus and retarded ejaculation, both of which
were life-long. He ejaculated with “wet dreams” but not otherwise. The vaginismus
was treated with the classic Masters and Johnson method, which relies heavily on
vaginal “dilators.”11 Over a period of two months, the woman became increasingly
confident about inserting dilators into her vagina. Fear of “objects” in her vagina
and pain with insertion of the dilators gradually disappeared. Eventually, she was
able to introduce her husband’s penis into her vagina. They were impassive when
it finally occurred. In discussing this attitude, they talked regretfully of the fact that
he had not yet ejaculated inside. The clear implication was that perhaps he never
would. They were reassured that this would likely happen soon. They remained
skeptical until ejaculation did, in fact, occur several weeks later.
People often perceive a sexual difficulty
(especially something that impedes
intercourse) in a global way rather than
as a limited disorder. Sexual problems
thus become reflections of masculinity
or femininity. The impact of a health
professional’s optimism can extend far
beyond the sexual problem to the entire
view of oneself.
Talking to people about “sex” requires knowing the questions to ask and consideration
of the ways in which to discuss the subject. In other areas of talk between patients and
health professionals, methods of asking questions can affect the quality of information
obtained. In relation to sexual issues, techniques of inquiry may affect the quality and
the quantity of the information gathered. In this chapter the methods suggested for use
in asking sex-related questions have the potential to enhance both.
The following interviewing methods have particular application to the topic of “sex”:
1. Ask permission
2. Assume the initiative
3. Use “language” that fits a particular situation
4. Convey a sense of trust and confidentiality
5. Use a form of questioning that involves providing information followed by a
6. Display an attitude of nonjudgmentalism
7. Delay inquiry into obviously sensitive areas
8. Provide information by way of explanation
9. Ask questions about feelings in addition to experiences
10. Promote an optimistic attitude
These ten techniques may be useful when interviewing patients generally; however,
their use in talking about sexual issues specifically may critically alter the quantity and
quality of the sex-related information obtained.
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