Screening For Sexual Problems

The most basic, and also most difficult, aspect of studying sexuality is defining the subject matter.

What is to be included? How much of the body is relevant? How much of the life span? Is sexuality

an individual dimension or a dimension of a relationship? Which behaviors, thoughts, or feelings

qualify as sexual—an unreturned glance? Any hug? Daydreams about celebrities? Fearful memories of

abuse? When can we use similar language for animals and people, if at all?

Tiefer, 19951


Defining the subject matter of “sex” is, indeed, difficult but nevertheless crucial, since

its meaning will determine which difficulties one is searching for in the process

of screening. The definition and the screening mechanism must be broad enough to

encompass problems with sexual function and sexual practices. Problems with sexual

function are reported by patients rather than observed by health professionals. In

contrast, some sexual practices may be seen only as problematic by health professionals.

In both instances, the onus remains on the health professional to elicit the


Problems with sexual function have been classified in DSM-IV2—a system heavily

influenced by the research of Masters and Johnson3 and Kaplan’s revisions.4 On the

basis of direct observation of physiological changes associated with sexual arousal,

Masters and Johnson described a “sex response cycle” that included four phases3 (pp. 3-8)

(Figures 3-1 and 3-2):

• Excitement

• Plateau

• Orgasm

• Resolution

Kaplan added a prior “interest” or motivational phase to Masters and Johnson’s system4

(pp. 3-7). In so doing, she reconceptualized the sex response cycle from four parts into

three, which she renamed:

• Interest

• Response

• Orgasm

Kaplan referred to her revision as a “triphasic model” (Figure 3-3).


Screening Content: Dysfunctions Versus Difficulties

While ideas based on the sex response cycle are widely used, they have not been universally

accepted. One criticism is that when considering sexual function, the cycle

seems to progress from one step to another but that this is not how sexual response is

always ordered. For example, clinicians will sometimes encounter the occurrence of

orgasm in a woman who does not feel any preexisting sexual desire. The reality of this





particular observation of the disconnection between desire and orgasm has been established

in a research context.5

A second critique relates to gender and the different meanings of “sex” to men and

women. In an exquisitely detailed and incisive analysis, Tiefer examined the entire

concept of the sexual response cycle and the extent to which women have been absent

in the formulation of sexual disorders in the various versions of the DSM1 (pp.

41-58, 97-102). She faults the DSM classification system for the following:

1. Excessive “physiologizing”

2. Viewing sexual expression as consisting of reactions of body parts

3. Being “genitally focused”

4. Thinking of “heterosexual intercourse as the normative sexual activity, repeatedly

defining dysfunctions as failures in coitus”

From Tiefer’s perspective, the sexual concerns of women are different and have

been sufficiently outlined in popular surveys, questionnaire studies, political writings,

and fiction to include such issues as: intimacy, communication, emotion,

commitment, pregnancy, conception, and getting old. “. . . women rate affection

and emotional communication as more important than orgasm in a sexual relationship.

. . “1 (p. 56).

One well-executed, frequently quoted, and revealing questionnaire study referred

to by Tiefer and which serves to buttress her argument was conducted by Frank and

her colleagues.6 One hundred predominantly white, well-educated, and “happily married”

volunteer couples were questioned concerning the frequency of sexual problems.

The authors found that in addition to the fact that 40% of the men and 63%

of the women reported sexual dysfunctions, 50% of the men and 77% of the women

reported “difficulty that was not dysfunctional in nature.” The “difficulties” are outlined in

Box 3-1. Most importantly from the point of view of screening, the number of difficulties

reported was more strongly and consistently related to overall sexual dissatisfaction than the number




of dysfunctions.” If one therefore accepts the argument and evidence presented by

Tiefer, a useful screening system must consider sexual problems to be impairments in

physiology (sexual dysfunctions) and impairments in the “human relations” part of

“sexual experiences” (i.e., difficulties or consequences of the ways people conduct

themselves sexually).


Epidemiology of Sexual Problems in Primary Care

Apart from what one looks for in screening (sexual “dysfunctions” and/or “difficulties”)

a major rationale for the inquiry process is how common the detected phenomena are

in general (epidemiological information about specific dysfunctions are included in

Part II). The extent of sexual problems found in medical practices has been studied on

several occasions.

One widely quoted study of sexual issues in general medicine practice was described

in detail in Chapter 1.7 Another study used a questionnaire (whose validity and reliability

was previously tested) that contained items concerning dysfunctions and difficulties.

8 Of the 152 patients who were asked to complete the questionnaire, almost all

did so (93%). The majority of patients (56%) identified at least one sexual problem on

the questionnaire, and this compared to 22% having a marital or sexual problem found

by simply examining the patient’s medical record. Multiple reasons were cited for the

discrepancy, including:

1. The physician did not ask relevant questions

2. The patient did not spontaneously report problems

3. The physician did not record the information in the patient’s


Although identification of a problem by 56% of patients may appear to

be an overwhelming number to a clinician, one must remember that

not all people with sexual problems want treatment.9


Box 3-1

Sexual “Difficulties”

• Partner chooses inconvenient time

• Inability to relax

• Attraction(s) to persons other than mate

• Disinterest

• Attraction(s) to persons of the same sex

• Different sexual practices or habits

• ”Turned off”

• Too little foreplay before intercourse

• Too little “tenderness” after intercourse

Adapted from Frank E et al: Frequency of sexual dysfunction in “normal” couples,
N Engl J Med 299:111–115, 1998.

Although identification of a problem by

56% of patients may appear to be an

overwhelming number to a clinician,

one must remember that not all people

with sexual problems want treatment.9

creening Criteria

Given the immense numbers of patients with sexual problems, the need becomes obvious

for a triage system whereby the nature of a problem and its impact can be evaluated

and proper action taken: (1) further assessment and treatment or (2) referral. The

beginning of this process requires a reasonable, respectful, and regular practice by

which the presence of sexual problems can be identified with just a few questions. For

reasons discussed in Chapter 1, it is a “given” that patients be provided the opportunity

to discuss a sexual issue if they desire. To accomplish this goal, some sort of sexscreening

question must be included in an assessment.

Other than considering specific sexual practice issues involved in STD and HIV/

AIDS transmission, the idea of including general sex-screening in a health assessment

has been considered only briefly by a few authors. Concepts vary from an elaborate

“screening history” requiring 30 minutes10 to a small number of specific screening

questions.11The rationale for choosing particular questions was not always clear.

Useful screening questions in any area should observe at least four rules:

1. Screening questions should encompass a wide spectrum of common problems

A variety of sexual problems may exist in any community, ranging from frequent

(concerns about genital function, sexual practices, or emotional communication) to

unusual (confusion about one’s status as a man or woman). A screening system must be

sufficiently sensitive to at least “pick up” problems that are common. Freund’s opinion is

that “a problem must be sufficiently common to justify investigation of an entire population

of patients.”12 Sexual dysfunctions and difficulties, as well as problems related to

STDs and child sexual abuse, are far more numerous than other sexual disorders and

these must be uncovered in any practical sex-screening process13 (pp.43-55).

2. To be practical, screening questions should be few in number

A small number of questions recognizes the limited amount of time

that health professionals (especially nonpsychiatric physicians) spend

with patients and the reticence that many patients have in spontaneously

talking about sexual issues. Realistically and reasonably, only a

small amount of health professional time will be used to ask questions

about sexual matters when the patient’s major concern is elsewhere.

Suggesting more than a few screening questions dooms the entire process

from the start.

3. The problem must be of sufficient severity to justify the effort of asking questions of

the population12

The consequences of sexual problems must be considered from individual and social

perspectives. In some instances, the severity of the impact on an individual is easy to

discern (e.g., STDs) but in others the effect may be more subtle (e.g., repercussions on

a relationship of a coexistent sexual dysfunction). Without “quality of life” information

in the area of sexual problems, it becomes difficult to provide clear evidence about the

effect of some problems on the individual. The existing literature on the effects of


Realistically and reasonably, only a

small amount of health professional

time will be used to ask questions about

sexual matters when the patient’s major

concern is elsewhere. Suggesting more

than a few screening questions dooms

the entire process from the start.

sexual dysfunctions on individuals and relationships, as well as clinical impression, suggest

substantial repercussions13 (pp. 52-55). The outcome of some sexual experiences

such as child sexual abuse are well documented.14 Newspapers have well reported the

social disruption caused by STDs and HIV/AIDS, pedophilia, and child sexual abuse.

4. There must be effective treatment for problems that are common

The treatments of sexual dysfunctions and their usefulness are reviewed in Part II.

These four screening criteria can be applied, for example, to one of the screening

systems commonly used in medical practice. Part of any medical evaluation includes

asking a series of questions about the function of different parts of the body. This brief

health questionnaire has been variously called the “Review of Systems” (ROS) or “Functional

Inquiry” and includes a few questions about each body system. It is meant to

accomplish two objectives, as follows:

• To provide more information about concerns not obviously connected

to the patient’s main complaint

• To uncover undiscussed problems that the patient may have thought to

be irrelevant or unimportant

Until recently, questions about sexual issues were not usually part of a medical

screening process. Questions relating to this subject were not asked or were buried in

questions about other body systems. For example, questions about sexual function

were included with questions about a man’s urinary function.

There is no universally applicable sex-screening formula. Several

approaches can be used, depending, for example, on such factors as the

comfort and skill of the interviewer or the age of the patient. Screening

questions asked of adolescents might well differ from questions asked

of elders.

With the understanding that variety and flexibility in sex screening are

desirable, one general method is described below. This approach can

be incorporated easily into the assessment of any patient whose main concern is not

primarily sexual, specifically, into the medical “review of systems.” (The ROS concentrates

on body function or dysfunction; therefore sexual practice issues can be included

easily.) When judging the usefulness of the proposed sex-screening process, one should

recall the four criteria mentioned previously, that is, questions should:

• Cover a wide spectrum of common problems

• Be few in number

• Justify the severity criterion

• Be concerned with problems that have effective treatments

Questions should include an additional criterion as well, namely, practicality.

When health professionals choose sex-screening approaches, the selection is not

usually between systems that are brief or lengthy. The choice is usually between (1) a

system that is brief and comfortable to the clinician and inoffensive to the patient or

(2) a complete absence of any sex-related screening questions whatsoever.


There is no universally applicable sexscreening

formula. Several approaches can be used.



The older style sex-screening approach used to be: “How’s your sex life?” While this

fulfilled the wide spectrum and brevity criteria, it was also nebulous and indefinite.

Being so general, it usually elicited an equally vague answer (“fine”), which was undoubtedly

inaccurate on many occasions. In addition, the question potentially covered the

whole of a patient’s current sexual experience rather than concentrating

on what was problematic and required attention.

A preferred approach (Figure 3-4 and Box 3-2) begins with the question:


This is not really a “sex” question but rather preliminary to other questions that

might follow. Use of the permission technique was discussed in Chapter 2.

The answer to a permission question is usually “yes.” After consent

is given, the interviewer naturally continues to the next question. However,

in the unusual situation that the patient says “no,” the interviewer


The answer to a permission question is

usually “yes.” After consent is given, the

interviewer naturally continues to the

next question. However, in the unusual

situation that the patients says “no,” the

interviewer has no ethical alternative

but to respect the patient’s decision and

continue to the next subject.

has no ethical alternative but to respect the patient’s decision and continue to the next

subject. Before proceeding, some of the implicit issues mentioned above should be

made explicit. In particular, the interviewer should explain the rationale for asking the

question in the first place. Reasons given may include the following:

• That this area is legitimate for discussion in a medical setting even if

unconventional from the patient’s point of view

• That the interviewer’s response is one of understanding rather than


• That the patient is free to raise the topic at any time in the future


The second screening question asks the patient: “ARE YOU SEXUALLY ACTIVE?”

This question is common especially in relation to HIV/AIDS prevention. The question

could be made sharper if a time frame is added. For example, it might be phrased:


revision might be useful particularly in situations where sexual activity may be regular

but not necessarily frequent, as for example, in the elderly.

The meaning of the phrase “sexually active” could be more specific if it included

some definition of the word “active.” “Active” might refer to actions with a partner,

with oneself (masturbation), or both. If a patient has a partner, couple sexual activities

should be the focus of this question, so that the question might be: “HAVE YOU


If the patient does not have a sexual partner, the definition of “active” might logically

include solo sexual experiences. However, since the subject of masturbation is often a

sensitive one for patients and clinicians and, since it is infrequently reported as a problem

with sexual function or practice, one might reasonably refrain from asking about

this specific subject in the context of screening questions.

There are two potential problems with the word “active”:

• Teenagers may not understand what the word encompasses. Talking

with teenagers may be one instance in which the word “sex” is useful,

since teens (unlike adults) often have a broader definition than simply

intercourse. In using this approach, the health professional must clarify

what practices are entailed within the word “sex.”

• Some people interpret the word “active” concretely and consider themselves

“passive,” so that even if sexually involved with another person

they might answer the question in the negative. It might be better to


Box 3-2

Sex Screening Questions

1. Can I ask you a few questions about sexual matters?

2. Have you been sexually active with a partner in the past six months?

3. With women? men? both?

4. Do you or your partner have any sexual concerns?

use the word “involved” instead of “active” in such situations. (A strong

counter argument is that the word “active” has become part of the English

lexicon and that professionals and adult patients are adjusted to

its use.)

The final version of the second sex-screening question might therefore be: “HAVE



A “yes” answer to the question of sexual activity results naturally in the interviewer

proceeding to the next item, which may be about the gender of the partner—opposite

or same sex. (Questions are formulated by using the words, “men” and “women,” rather

than “opposite” and “same”[see immediately below].) Acquiring information about sexual

orientation is vital for reasons outlined in Chapter 7 (see “Sexual Orientation: Issues

and Questions”).

The third sex-screening question is actually an extension of the second and attempts

to determine with whom the patient has been sexually active. The question is asked

only if the patient says “yes” to the second question and can be phrased (e.g., when



Following a “no” answer to the question of whether or not a patient is sexually

active, an attempt should be made to discover whether or not the person’s inactivity

is a concern. If it is, this requires some exploration by the interviewer and an explanation

from the patient. This, in turn, leads into a diagnostic process. If sexual

inactivity is not a concern, the interviewer could naturally proceed to the fourth

and last screening question, which is: “DO YOU OR YOUR PARTNER HAVE


The utility of a question about “concerns” lies in the fact that it is open-ended and

problem-oriented. However, one problem with this question is its subjectivity. A more

direct, objective, and still open-ended and problem-oriented version would be, “DO


is the same question but with some added specific examples. The question

could then become: “(for a man) DO YOU OR YOUR PARTNER HAVE ANY




PAIN?” These examples are of sexual dysfunctions. A clinician could, if desired, substitute

other examples such as STDs.

Any of these four questions should fulfill the four criteria for screening questions

described above. If the screening professional can ask only one question, the fourth is the

most desirable.



A screening system for “sex” questions is a necessity for health professionals. The

arrangement must be comprehensive (encompassing problems with sexual function

and sexual practices), the questions few in number, and the problems sufficiently severe

and treatable. Practicality also helps. There is not much use in proposing a system that

no one will use.

Screening questions about sexual issues are a vital part of the health professional’s

intake procedure. However, screening questions cannot be definitive. The question

inevitably arises: “What do you do if you get a positive answer?” One does, of course,

the same as one would do with any other subject. In the practice of a health professional,

this means allowing the patient to talk and ask more questions as part of a

diagnostic process. This, in turn, leads to a conclusion and to a treatment plan. The

next chapter discusses the first of these two steps.



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applications, New York, 1988, The Guilford Press, pp 42-43.

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