Context Of Sexual Disorders:
Issues And Questions In The Present
And Past

Of all the topics we consider, the content of sexual action and interaction has received the least scholarly

attention. What people do sexually—alone or with others—and how they think about their sex

lives are subjects that have rarely entered the mainstream of social scientific discourse. . .the level of an

individual’s sexual activity, however indexed over time, is perhaps the most lore ridden (topic) of all.

Laumann et al, 19941



In the process of eliciting information about determinants of sexual dysfunctions,

Kaplan incorporated a cross-sectional and a longitudinal view that included all aspects

of biological, psychological, and social theorizing2 (Box 5-2). She specifically described

psychosocial contributing factors as “immediate” (Box 5-1) and “remote” (p. 118).

In scrutinizing the foundations of a sexual dysfunction, there is no

necessary incompatibility between immediate and remote factors. They

can, and often do, coexist. It is not necessary to theorize about an

either/or issue. Uncovering immediate contributors requires an analysis

of present sexual events. Other than the significant issue of personal

comfort of the health professional, primary care clinicians can easily

acquire immediate information within the time frame ordinarily spent

with patients (although the process may involve more than one visit).

The process of discovering remote causes is considerably more

complex and includes taking a developmental history (the “story” of

the person from birth to the onset of present troubles). Acquiring this information

involves more time than many primary care clinicians are regularly prepared to allow.

In such instances, consulting a mental health professional who is comfortable with the

subject of “sex” and skilled in talking to patients about sexual issues might be a reasonable

alternative. Nevertheless, the section of this chapter on remote issues may be

useful to the primary care health professional for reference purposes on a particular

topic or to develop a better understanding of subjects covered if the patient was

referred to a specialist.


Present Context: Immediate Issues And Questions

The most illuminating method for uncovering immediate contributors to a sexual

dysfunction is through a detailed description of a recent sexual encounter. To be sure,

this is not simple for the patient or the health professional. Describing the nature of,


Other than the significant issue of personal

comfort on the part of the health

professional, primary care clinicians can

easily acquire “immediate” information

within the time-frame ordinarily spent

with patients (although the process may

involve more than one visit).

for example, an erection problem is very different from telling the story of “who does

what to whom” in bed (or anywhere else). The facts involved in the static and crosssectional

description of one’s current sexual problem seem much easier to talk about

than the dynamic and longitudinal view of a sexual encounter involving another person.

Patients who spontaneously describe their sexual experiences run the risk of being

seen as verbal exhibitionists, and health professionals who ask questions about these

events might be viewed as voyeurs. Two factors could prevent either view:

• An attitude of the health professional that sexual function is a proper

dimension of health and therefore a legitimate topic for discussion

• The ethical cloak of the health professional, which defines in whose

interest questions are being asked (the patient’s) and for what purpose


Kaplan referred to the process of asking about the minutiae of a sexual encounter as

the Sexual Status Examination4 (pp. 77-84). Because of the great sensitivity involved in

revealing specifics, it is best not to ask this at the beginning of an initial visit. Patients

should have an opportunity to decide if they feel comfortable disclosing private and

personal information to a particular health professional.


Box 5-1

 “Immediate” Psychosocial Causes of Sexual Dysfunction

1. Sexual ignorance

2. Fear of failure

3. Excess need to please a partner

4. Spectatoring2

5. Failure to communicate sexual preferences

6. Relationship problems

Adapted from Kaplan HS: The new sex therapy: active treatment of sexual dysfunctions, New York, 1974, Brunner/Mazel, Inc.,

pp. 121-136.


Box 5-2

 “Remote” Psychosocial Causes of a Sexual Dysfunction

1. Internal conflict over sexual pleasure

2. Restrictive upbringing

3. Developmental sources of sexual conflict

4. Transference

5. Lack of trust

6. Traumatic early sexual experience

Adapted from Kaplan HS: The new sex therapy: active treatment of sexual dysfunctions, New York, 1974, Brunner/Mazel, Inc.,


Questions can begin with the patient’s (or couple, if both are seen together on a first

visit) practices in being affectionate with a partner and how this is separated from what

is regarded as “sexual.”

The following are initial questions that might be asked of a heterosexual man

(although they apply equally well to heterosexual women and same-sex partners):

Q. In what ways are you affectionate with your wife (husband, partner)?

Q. Is it possible for this to occur without thinking that some sexual event will automatically

occur as a result?

Q. Do you sleep in the same bed together?

Q. What sort of bedclothes do you and your wife (husband, partner) wear?

Q. Do you snuggle together before going to sleep?

Q. Does this involve touching each other?

Q. What are your “geographical” limits to touching?

Q. What are your sexual “signals?”

Q. How do you separate affectionate and sexual signals?

Q. What are you thinking about when something sexual might occur?

Q. What sort of thoughts do you have at that time about the problem that brought

you here today?

Much of the questioning revolves around touching, an aspect of human communication

that is intimately related to sexual behavior5 (pp. 204-236). Answers give the

interviewer some idea of the level of sexual communication between the partners and

also the extent of anticipatory worry about the sexual difficulty. The interviewer often

hears that partners used to be affectionate with each other but that, since the onset of

sexual troubles, sex and affection have diminished. This is often to the chagrin of both

(see “Treatment of HSD” in Chapter 9).

The patient might then be asked to describe the last time that a

sexual experience occurred. When a person is obviously uncomfortable

with the request, the interviewer should quickly offer to ask

specific questions. The focus in particular should be on what occurred

just before attempts at intercourse, since the immediate precursors to

sexual dysfunctions are often discovered with this kind of inquiry.

Illustrative questions concerning sexual practices short of vaginal

intercourse follow (asked, in this example, of a heterosexual man):

Q. Do you recall the last time a sexual experience occurred with your wife


Q. Was the location usual for you?

Q. What occurred before attempt at vaginal entry?

Q. Do you usually touch your wife’s (partner’s) breasts before intercourse?

Q. As far as you know, how enjoyable is that for her?

Q. How does she let you know?

Q. Does she touch your penis?

Q. What are you thinking about when that happens?

Q. Are you clear with her about how you like your penis touched?

Q. Have you ever ejaculated when she rubbed your penis?

Q. How does she feel about the wetness of your semen?


The patient might be asked to describe

the last time a sexual experience

occurred. When a person is obviously

uncomfortable with the request, the

interviewer should quickly offer to ask

specific questions.

Q. Do you touch your wife (partner) between her legs?

Q. What are you thinking about when that happens?

Q. How does she react to that?

Q. Are you aware of where her clitoris is?

Q. Do you stimulate her in this area?

Q. Has she told you how she likes to be touched?

Q. Does she come to orgasm when you’re touching this area?

Q. Does oral stimulation of your penis take place?

Q. Do you stimulate her genital area orally?

Q. How do each of you feel about that?

Q. What are you thinking about when you’re stimulating her orally?

Q. Are there other kinds of sexual experiences that you and your wife (partner)

have together before you attempt vaginal entry?

These questions are explicit enough to uncover the following information:

1. Deficits in knowledge about body parts

2. The range of sexual activities engaged in by the patient and partner

3. Attitudes toward different sexual actions

4. The level of sexual communication between patient and partner

5. What occurs in the patient’s mind as the experience evolves

These questions will reveal immediate problems such as:

• Sexual ignorance

• Fear of failure

• Excessive need to please the partner

• “Spectatoring”

• Insufficient communication

When these factors exist, they often can be quickly and effectively remedied.

Little objective information existed in the past about common sexual practices of

heterosexual, gay, and lesbian couples. The knowledge that HIV/AIDS is usually transmitted

sexually and is therefore potentially preventable has resulted in a need for more

information about what people do sexually with one another. Laumann and colleagues

discussed the occurrence and incidence of various sexual practices (Tables 5-1 and

5-2) used by opposite gender, gay, and lesbian partners1 (pp. 96-109 and 317-320).

Almost 75% of men and women subjects in the Laumann et al. study reported that

fellatio or cunnilingus was performed by an opposite-sex partner at some time in their

lives.1 Rates of experience over the previous year were similar to lifetime experience,

yet only about 25% of the respondents experienced fellatio or cunnilingus during their

last sexual event. The conclusion of the authors was that oral sex was familiar to many

people and that, after experience with this practice, it was at least occasionally incorporated

into a person’s sexual activity for the remainder of their lives (p. 107). They

added, however, that these two sexual activities did not become defining features of

sexual activity between women and men—as was the case of vaginal intercourse, or

perhaps, kissing (p. 101). Among gay men and lesbians, rates of activity increased as

 “homosexuality” was defined more narrowly (see below in this chapter for a discussion

of homosexuality and problems with the definition).

The interviewer can continue with specific questions about vaginal intercourse

(asked, in this example, of a heterosexual woman):

Q. How is a decision made about vaginal entry?

Q. What intercourse position(s) do you usually use?




Q. Is that something that the two of you talk about?

Q. What happens to your excitement level after he enters?

Q. Are you usually wet when he enters?

Q. Does he have any trouble entering because of the stiffness of his penis?

Q. What do you think about when he’s inside?

Q. Does he usually tell you before he ejaculates?

Q. Does he usually ejaculate before you’re ready?

Q. Do you tell him if you want him to delay ejaculation?

Q. Do you usually come to orgasm when he’s inside?

Q. What do the two of you do after he ejaculates?

Q. How do you feel about the wetness of his semen?

Q. What do you think about when you’re lying together?

Q. What is your experience with anal intercourse?

Laumann and colleagues had little to say about vaginal intercourse, since the lifetime

experience of survey subjects with this sexual practice was virtually universal.1

Much more was said about anal intercourse, which differed substantially in heterosexual

men and women when compared to oral sexual activity (see Tables 5-1 and 5-2).

The authors concluded that anal intercourse was “far less likely to become a common

or even an occasional sexual practice once it has been experienced” (p. 107). The

occurrence of anal intercourse among gay men is of particular interest because of its

link to HIV/AIDS transmission. Of interest was the finding that 20% to 25% of the

(narrowly defined) homosexual men reported that they have never experienced anal


The questions outlined above provide details about the nature of the specific

problem and, as well, can reveal information about immediate causes of a sexual



Context Of The Past: Remote Issues And Questions

Some sex therapists say that in the process of assessing someone with a sexual complaint,

one does not need to (indeed, should not) obtain detailed information about

that person’s life history unless obstacles arise6 (p. 416). However, apart from clinical

opinion, some research was conducted on the value of linking past and present. Heiman

and colleagues studied couples defined as “clinical” (on a waiting list for a sex

therapy clinic) and “nonclinical” (obtained from a newspaper ad).7 She found that

issues from “the more distant past” could be important for those with sexual dysfunctions,

especially women. Clinical experience supports this point of view. Experience

rather than research is the major tool guiding the clinician in clarifying when and

under what circumstances detailed exploration of the past should or should not take


Circumstances in which an elaborate investigation of the past may not be necessary

can often be defined in advance. These circumstances represent situations in which, for

example, the focus of care is largely educational (as is often the case in lifelong and

generalized orgasmic dysfunction in women [see Chapter 12]) or when the patient’s

status makes it predictable that the mainstay of treatment will be largely “medical” (for

example, instances of premature ejaculation in which the focus of care is on the use of

medications rather than talk [see Chapter 10]). In the absence of research, two general

concepts serve as a clinical rationale for reviewing the patient’s past.

The first concept is that it is only after the fact that the interviewer knows the items

in a patient’s past history that may be of potential significance in relation to etiology

or treatment. In other words, one does not know if a “smoking gun” is hidden in a

particular field until that area is searched.

The second concept is the common sense notion that personality

characteristics and facets of a relationship are not left outside the bedroom

when people engage in sexual activities. Issues related to personality

and the relationship are of as much concern in the bedroom as

they are in the kitchen or living room. Elements that went into the

formation of both partners need to be explored if one’s concept of “sex”

is such that the body and mind are inseparable. Only when genital

function is the predominant sexual consideration, such as sexual activity

between a prostitute and a client, may personality and relationship

factors be less meaningful.


Sexual-Developmental History

As described here, the sexual-developmental history is a developmental history with a

special focus on the individual’s personal sexual evolution. Comprehensive texts on

interviewing should be consulted in relation to nonsexual aspects of a developmental

history8 (pp. 65-82). The assumption in this book is that the special aspects of sexual

development are “grafted” to the general aspects of a patient’s personal and social

history. As Gadpaille wrote, “Sexual development does not occur separately from all

other aspects of human growth and maturation. To treat it separately is to some

degree a distortion“ 9 (p. 46).

In a sexual-developmental history, the list of sex-related questions

that might be asked is exhaustive to the interviewer and exhausting for

the patient. Inevitably, the interviewer is selective and inquires about

issues that appear to have relevance to the present problem. The key

word is “appear.” Different areas appear to be pertinent to different

clinicians. To some, all areas of inquiry are relevant. To others, there

must be clear and prior justification for particular questions. In either

instance, an interviewer should be able to explain the rationale for any

question asked.

The psychosocial connections between past and present in relation to sexual problems

generally were subjects of speculation and data-oriented research. Intuitive concepts

come from analytically oriented psychotherapists and theoreticians, including

Freud and his disciples.10 Data-oriented observations were derived from sources such


• Experimental research with primates11

• Gender problems in children12

• Intersex problems in children13,14


Personality characteristics and facts of a

relationship are not left outside the bedroom

when people engage in sexual

activities. Issues related to personality

and the relationship are of as much concern

in the bedroom as they are in the

kitchen or living room.


To some clinicians, all areas of inquiry

are relevant. To others, there must be

clear and prior justification for particular

questions. Either way, an interviewer

should be able to explain the rationale

for any question asked.

• Sex-related surveys


There is an inclination to consider sexual dysfunctions as a group when, in fact,

they are heterogeneous. Lumping them together is, to a large extent,

unreasonable (hence the rationale for using the word “dysfunctions” in

the plural). If the syndromes are, indeed, heterogeneous, it would not

be surprising to find that the etiologies are heterogenous as well. Biopsychosocial

issues that relate to girls and women are unlikely to be the

same for boys and men. Sexual dysfunctions that are lifelong usually

have different bases than those that are acquired.Desire disorders are

grouped under the same heading in DSM-IV but their origins may well

be different from other sexual dysfunctions.19 These varied roots result in complex

interpretation of information obtained in a sexual-developmental history. The connections

between past and present may be obscure, may be a matter of speculation, or

may be obvious. Without a diligent search it is not possible to determine which they

might be.

As an interviewer traverses the life span, areas of questioning can be defined for

each part, as well as the specific questions to be asked and the rationale for the




Areas of Inquiry

Areas of inquiry include the following:

1. Family-of-origin practices in the exchange of affection (touching and talking)

2. Gender identity/role issues (feeling of maleness or femaleness as a child, favorite

games, gender of friends)

3. Learning about intercourse from a reproductive point of view

4. Learning about body structure in the context of exploratory games (“playing


5. Reaction of adults to discovering one child investigating another

6. Childhood sexual experience with other children and adults


Suggested Questions

Q. Tell me about where you were born and grew up.

Q. Who was in your family at that time?

Q. Where are they now?

Q. What is the nature of your relationship with them now?

Q. Would family members hug or kiss one another when you were young?

Q. Were you happy with the idea of being a boy (girl) when you were small?

Q. Were your friends in primary school mostly other boys (girls) or mostly girls


Q. What were your favorite games in your primary school years?

Q. Were you teased about anything?

Q. What about?

Q. How did you first learn about “how babies are made”?

Q. Did you play “doctor” games?


The connections between past and present

may be obscure, may be a matter

of speculation, or may be obvious. Without

a diligent search it is not possible to

determine which they might be.

Q. Were you discovered by adults?

Q. How did they react?

Q. Do you recall having sexual thoughts, feelings, or experiences in your preschool

years or before you were a teenager?

Q. Children sometimes have sexual experiences with other children or with adults.

Was this part of your experience when you were a child?


Studies of Childhood Sexuality

Systematic research into childhood sexuality is limited, probably because parents and

schools are circumspect in allowing children to be subjects of study. In spite of this,

there is a substantial amount of accumulated information about childhood sexuality

and preadolescent sexual behavior.9,20-23 Martinson’s review of relevant information

from fetal life to the preadolescent years provides an understanding of the antecedents

to adult sexual thoughts, feelings, and experiences.22 He reflected on the following

manifold developmental experiences of children:

• Sensory responsiveness and maternal attachment of the neonate

• Genital play, questions about sex, sex play among peers, and attitudes

of parents toward touch in the young child

• Dating, masturbation, erection, orgasm, and heterosexual sex play in

preadolescent years


Preadolescent Sexual Play

Kinsey et al. described the specifics of male preadolescent erotic arousal, sex play, and

orgasm15 (pp. 157-193). Their observations clearly established that the minds and

bodies of boys were sexually simmering. They provided similar information in their

later volume on females16 (pp. 101-131) and, as well, commented on the significance

of preadolescent sex play (pp. 114-116). They concluded the following:

1. First information about sex and body parts was often obtained in the context of

play and was therefore of educational significance.

2. “Some of the preadolescent contacts provided emotional satisfactions that conditioned

the female for the acceptance of later sexual activities.”

3. Guilt reactions induced by adults discovering a child engaged in sex play in

many instances “prevented the female from freely accepting sexual relations in

her adult married relationships.”

4. Male preadolescent sex activities were more commonly carried over into adolescent

years than was preadolescent sex activities for females. This “discontinuity”

in girls is more the result of culturally related restraints put on older children

than “biological latency.”

Cross-cultural studies of sexual behavior demonstrate that in sexually permissive societies,

individuals in the middle childhood years are far from sexually disinterested,

inactive, or “latent.”24 The concept of latency in these years seems more accurately

applied to heterosocial rather than heterosexual relationships.


Touch in Childhood

Many of the studies on which Martinson’s review was based were conducted in North

America22 (pp. 57-82). If one considers the variety of attitudes and practices toward

sexual development in other cultures, it seems almost impossible to define universal

preadolescent developmental norms. Montagu particularly emphasized the significance

of touch in early childhood development and its relationship to adult sexual behavior

and problems5 (pp. 204-236). Touching was the subject of experimental investigation

when the Harlows deprived primates of a warm and affectionate mother. It was demonstrated

that primate offspring were so disturbed in their relational abilities that,

among other things, they were unable to mate effectively.11 While one must be cautious

in comparing primates and humans, it is nevertheless interesting to consider the

consequences of human childhood deprivation. Not surprisingly, studies of adults who

were severely deprived in childhood suggest, among other things, substantial negative

repercussions in the areas of relationships and sexual disorders.25


Roots of Atypical Sexual Behavior

The meaning of divergence from whatever norms exist in preadolescent years is often

unclear in relation to adult sexual problems. These differences are particularly blurred

when considering two groups of sexual disorders: sexual dysfunctions and paraphilias.

In contrast, the childhood precursors of some atypical forms of adult sexual behavior

such as same-sex interest and gender disorders have received a greater degree of attention

and seem better defined.26

Gender problems in adult life frequently become apparent in childhood and hence

it is important to ask about this in a sexual-developmental history. Long-term followup

of boys with feminine characteristics shows that half or more are sexually atypical

as adults.27 Girls who behave in a boyish fashion (tomboys) usually develop as typical

women; a small number emerge with a lesbian orientation (p. 155).


Sex Education

There is a certain ritual to the process of asking about “sex education” in a sexualdevelopmental

history. In practice, the answers tend to be largely uniform. Many people

say that sex was not discussed in their parental home and that what was learned as

a child came from “the street.” One has to distinguish between schooling and education

in all matters. The importance of formal sex education courses in schools on adult

sexual expression is difficult to assess. In the opinion of Masters, Johnson, and

Kolodny28 (p. 128), more information is learned by the informal process of a child

watching his or her parents being affectionate with each other.


Child Sexual Abuse

In the Laumann et al. study, 12% of the men and 17% of the women respondents

reported having been touched sexually before puberty or when they were 12 or 13

years old.1 (Only ‘hands-on’ experiences [i.e., touching] were asked about to eliminate

cases of exhibitionism.) Their data suggest the following:


1. That adult-child sexual contact was not occurring more often than in previous


2. Girls were most likely to be touched by adult men

3. Boys were most likely to be touched by adolescent women

4. Genital touching was the most common sexual event

5. The most common age of the girls was 7 to 10

6. The common age of the boys was older

7. Experiences were most likely to occur with one adult (although one third had

experiences with more than one person)

8. The adult was usually a relative or family friend

An evaluation of the effects of sexually abusive childhood experiences on adult life (a

crucial clinical issue) revealed the following:

1. Women respondents answered questions on this topic more often than men

2. More women (70%) than men (48%) reported that the experience affected their


3. Nearly all respondents judged the effects to have been negative

The sexual sequelae of adult-child sexual activity include effects on sexual function and

sexual practices29:

• More sexual partners

• More experience with anal intercourse with an opposite-gender partner

• More oral sexual experience among women

• A greater degree of thinking about sexual issues among men

Significant negative long-term consequences (sexual and nonsexual) to sexual experiences

between an adult and female child have previously been reviewed.30 Given this

information about long-term sexual sequelae, there seems little doubt about the need

to ask questions about this subject in a sexual-developmental history.


Puberty and Adolescence

Areas of Inquiry

Areas of inquiry include the following:

1. Body changes associated with puberty

• Age of body growth

• Pubic hair growth

• Facial hair growth in boys

• Breast development and onset of menstrual periods in girls

2. Changes in the size of genital organs

3. Feelings about the above changes in relation to peers

4. Changes in genital function associated with various sexual stimuli, including


• Erection and ejaculation in men

• Vaginal lubrication and orgasm in women

5. Sexual attraction to and sexual experiences with members of the opposite and

the same sex

6. Reactions to these experiences

7. Repetitive thoughts about being attracted to same-sex individuals without

desire or experience

8. Feelings about important love and sexual experiences through adolescence

9. Appearance of the present sexual problem in early sexual experiences

10. Atypical sexual thoughts, feelings, and experiences

11. Forced sexual experiences

12. Pregnancy

13. Abortion and birth control

14. Sexually transmitted diseases


Suggested Questions

Q. How old were you when you first noticed the development of body changes?

(For example, men: becoming taller, voice changing, needing to shave; women:

breast development, onset of menstrual periods)

Q. How did the timing of this compare to other kids in your class at school?

Q. How did this affect you?

Q. Did you know what to expect (and if so, how)?

Q. (men) Do you recall having erections before your teens?

Q. (men) Tell me about the first time you remember having an erection.

Q. (men) What do you recall about the first time you ejaculated?

Q. (men) Do you remember having “wet dreams”?

Q. Tell me about your experience with masturbation in your teens.

Q. (women) Did you usually come to orgasm?

Q. How did you feel about stimulating yourself?

Q. What did you think about when you masturbated?

Q. What is your experience with masturbation nowadays?

Q. What do you think about when you’re masturbating nowadays?

Q. Boys (girls) often feel a surge of sexual feelings in their teens. What was it like

for you in those years?

Q. Sometimes boys (girls) have sexual experiences with other boys (girls) during

that time. Was that part of your experience?

Q. What about nowadays? Do you find yourself sexually attracted to other men


Q. Have you had sexual experiences with other men (women) since puberty?

Q. Boys in their teens who have trouble dating girls sometimes worry about being

gay, even though they’re not sexually attracted to other boys. Did that happen to


Q. Tell me about relationships that were important to you in your high school


Q. Was there a sexual component to those relationships apart from intercourse?

Q. What actually took place?

Q. Did intercourse take place?

Q. How did you feel about that?

Q. What were your intercourse experiences like?

Q. How did you feel about having intercourse at that time?

Q. Did the problem that you have now appear at that time?

Q. Did you have sexual thoughts or experiences in those years that you thought

were unusual (e.g., being sexually involved with young children)?

Q. Did you have sexual experiences where force was used?

Q. (women) Did you become pregnant in your teens?

Q. (women) Did you ever have an abortion?

Q. Did you ever have a sexually transmitted diseases?


Physical Changes

The timing of the body changes of puberty and the accompanying

feelings are usually well remembered. This is typically a time of magnified

awareness of physical attributes and self-consciousness about every

imperfection. Changes rarely occur in logical fashion. Instead, feet can become larger

before legs become longer. Dissatisfaction is virtually universal. When this sense of

unattractiveness is added to the surge of sexual feelings that typically occur at puberty,

the result is often one of tremendous confusion about romance and “sex.” Memories of

this time remain vivid forever, and sometimes they have a major impact on later relationships.

Developmental deviance from age-mates is a potential source of embarrassment and

bewilderment. The first girl in a class whose breasts are enlarging may simultaneously

be an object of envy from other girls and teasing from boys. Conformity in dress and

physical development is high on the list of adolescent aspirations. On an intuitive

level, delay in physical development has a negative influence on adolescent sexual

experimentation and, because of that, may have a negative effect on adult sexual

behavior as well.

Adolescence is a time for relationship experimentation; biology influences when

this begins and also its extent. Kinsey et al. found that later onset of puberty in boys

(age 15 and over) was associated with a lower level of sexual activity among men in

future years. Conversely, early onset of puberty (by age 11) was connected to a higher

level of sexual activity throughout a man’s life15 (pp. 302-308).

That the hormonal surge of early adolescence has profound biological consequences

is obvious. The onset of menstrual periods in girls can have meanings far beyond the

flow of blood. The event presages the beginning of childbearing potential and, in the

minds of parents, sexual capacity. Parental pride or dread can be transmitted to the

adolescent. Cultural traditions in this area are fascinating. Among some groups in

India, a public celebration occurs for an adolescent girl one week after the onset of her

first menstrual period. Pride and publicity replaces the shame and secrecy that one

sometimes still sees in North America. In more open cultures, the “whole world” knows

that a “rite of passage” has taken place.

Erections in a male child occur regularly from infancy onward but awareness is

often dated from puberty. Ejaculation must await the pubertal biological clock, although

males may report orgasm in response to genital touch for years previously. Spontaneous

nocturnal ejaculation (or “wet dreams”) occur in over 80% of men at some time in

their lives15 (p. 274) but “are primarily a phenomenon of the teens and the twenties”(p.


When a sense of unattractiveness is

added to the surge of sexual feelings

that typically occur at puberty, the result

is often one of tremendous confusion

about romance and “sex.”

243). For those who view nocturnal emissions as entirely a function of biology, it

remains a challenge to explain Kinsey et al.’s finding (p. 277) that the frequency was

higher for better-educated men. The fact that many women also experience orgasm

during sleep is less well known. Over 35% of women contributing to the Kinsey et al.

study experienced nocturnal orgasm by the age of 4516 (p. 196).



The first experience with ejaculation is, for many men, through masturbation. This

activity was so common among male adolescents in the Kinsey et al. study (88% for

single men between ages 16 and 20) that they stopped asking whether it happened or

not and, instead, simply asked at what age it began15 (p. 238). Masturbation was less

usual among females. By age 20, 33% of women had masturbated at least once in their

lives to the point of orgasm16 (p. 173). In a more recent survey, respondents were

asked only about their experience in the last year1 (pp. 80-86). In the age group 18 to

24, 41% of men and 64% of women reported that they didn’t masturbate at all; 29%

of men and 9% of women reported a frequency of once each week. By age 50, over

50% of the men and 70% of the women did not report masturbating.

Apart from frequency, the authors also studied the relationship between masturbation

and marital status. In Laumann’s opinion, Kinsey’s view was that “sexual energy was

channeled to autoerotic or coupled sexual outlets in a kind of zero-sum complementarity

. . . [and thus] . . . the frequency of masturbation decreases in the context of a

stable sexual relationship with an available partner.” In a finding that was somewhat

different from Kinsey and popular notions, Laumann and his co-authors1 concluded

that the two were disconnected in that:

• Rates of masturbation and coupled sexual activity were both high among

young cohabiting individuals

• Masturbation had “no set quantitative relation to other partnered sexual


Laumann et al. opinions about masturbation and sexual drive were also unconventional

and instructive.1 They described the popular belief that “rates of masturbation

rise and fall with the availability of sex partners, suggesting that each individual has a

given level of ‘sex drive’ that needs to be expressed in one way or another.” However,

in their view, “masturbation is driven primarily by . . . social factors . . . [that] can

have complementary, supplementary, or independent status with reference to partnered

sex.” One implication of this view is that a health professional should exercise caution

in interpreting the presence or absence of masturbation activity as an indicator of “sex


The relationship between masturbation in adolescence or later and sexual dysfunctions

is clearer in women than men. Kinsey et al. found that among women who masturbated

to orgasm before marriage about 85% were described as “responsive” in the

first year of marriage16 (pp. 172-173). Of women who never masturbated before marriage

or those who did not come to orgasm with masturbation, about one third did not

reach orgasm “in their coitus” in the first year of marriage, and the same situation

existed for most by the fifth year (p. 172).

The absence of masturbation experience in men or women in the present means,

obviously, the inability to use this information clinically. For example, when asking a

man about his present erections under various circumstances, it would be pointless to

include a question about masturbation erections if this was not part of his recent sexual

experience. Negative attitudes toward self-stimulation can determine whether or not

this kind of sexual activity occurs but, in addition, can also influence treatment suggestions.

For example, it is ethically unreasonable (and from a practical viewpoint ineffective)

to ask a woman who is nonorgasmic to stimulate herself if she regards masturbation

as immoral.


Sexual Orientation

The hormonal surge of early adolescence is responsible for body changes and also

strongly influences sexual attractions and actions that are typically aimed at the

opposite sex, occasionally toward the same sex, and sometimes toward both. The

evolution of “love” feelings and sexual experimentation needs to be explored. In a

controversial finding, Kinsey et al. found that 37% of men “had at least some overt

homosexual experience to the point of orgasm between adolescence and old age”15

(p. 650). Newer data has resulted in more precise understanding of same-gender feelings

and behavior (Table 5-3).

One of the objectives of the study by Laumann and his colleagues was to better

understand this area and its relationship to HIV/AIDS transmission and vulnerability.1

Nine percent of the men and 4% of the women respondents reported at least one

sexual experience with a same-gender person since puberty (pp. 294-296). However, a

critical distinction was made between same-gender sexual behavior before and after

the age of 18. When this separation was made, almost half of the men (42%) who

reported sexual experience with another man said that the experience occurred before

the age of 18 and did not occur again at any time later in their lives (p. 296). The rates




for men who engaged in sexual activity with another man were found to range between

2.7% in the past year and 4.9% with any male partner since age 18 (p. 294).

Any understanding of homosexuality must consider a person’s behavior and how

that individual thinks and feels. Interviewers in the Laumann et al. study inquired about

sexual behavior toward others of the same gender and about how respondents think

of themselves.1 They referred to the latter as “identity” and found that “2.8% of the

men and 1.4% of the women reported some level of homosexual (or bisexual) identity”

(p. 293). In addition to behavior and identity, respondents were also asked about samegender

“desire.” When all three factors were considered together, the authors found

clinically important discrepancies. For example, they found that “about

5% of the men and women in our sample express some same-gender

desire but no other indicators of adult activity or self-identification” (p.

301). The authors concluded that their “preliminary analysis provides

unambiguous evidence that no single number can be used to provide

an accurate characterization of the incidence and prevalence of homosexuality

in the population at large” (p. 371).

In the context of a clinical interview with a patient, after the subject

of homosexuality is “on the table” in the process of asking about early adolescent sexual

behavior, similar questions about adult attractions and experiences with same-sex

individuals can be asked easily.

There are many reasons to ask such questions. Problems in adolescence among

those emerging with a gay or lesbian identity are legion (see Chapter 7). In addition,

worries about homosexuality in boys who are heterosexual but have trouble making

contacts with girls are probably common.31 Obviously, sexual interest in another person

of the same sex may profoundly influence a person’s sexual interest in, and function

with, a heterosexual partner.


Initial Intercourse Experiences

In following the love and sexual experiences of a person throughout their teens and

beyond, the interviewer must also be sensitive to what actually occurred and the

development of sexual problems at those times. Laumann and colleagues wrote that

“first intercourse, especially for women, has traditionally been a landmark event surrounded

by a welter of moral strictures and normative concerns about the meaning

of virginity, the loss of innocence, the transition to adulthood, and the responsibility

for procreation and the next generation”1 (pp. 322-324). Their opinion was that

“much of the research on age at first intercourse during the mid- to late 1980s was

motivated by an interest on contraceptive use and AIDS awareness among teenagers”

and that several surveys (including their own) “overwhelmingly suggest that there has

been a significant change in the early heterosexual life of young women in the United

States.”In their study, 19% of female respondents had vaginal intercourse by age 15,

and 90% of males had intercourse by age 20 to 24 (pp. 326-327). The authors concluded

the following from their own studies on first intercourse, as well as those of


1. First vaginal intercourse is occurring at younger ages


After the subject of homosexuality is

“on the table” in the process of asking

about early adolescent sexual behavior,

similar questions about adult attractions

and experiences with same-sex individuals

can be asked easily.

2. More people are engaging in premarital sexual activity with a partner earlier in

their lives

3. Gender differences are evident in that “men start earlier, have more partners and

are motivated by curiosity and self interest; women begin later, have sex with

spouses or more serious lovers, and use birth control more than men”

Thompson provided a different perspective on first intercourse in young women.32

On the basis of direct interviews of teenage girls, she detailed the elements determining

the outcome of this experience. Girls with negative feelings and opinions


• An absence of former sexual awareness (including lack of preparatory

experiences with petting, masturbation, sexual fantasy, desire, or contraception)

• Lack of control

• Vaginal pain

• Boredom

• Sexual pessimism

In contrast, girls with positive feelings and opinions:

• Approached intercourse with a sense of sexual desire, control, and


• Were contraceptively prepared

• Described mothers who were “open” about their own bodies, intimacies,

and relationships

The positive group anticipated pleasurable intercourse within a mental and physical

life-context that included sexual fantasy, masturbation, and petting. These were sexually

optimistic young women who knew their own minds and bodies.

A study of “clinical” (on a waiting list for a “sex” clinic) and “nonclinical” (obtained

through a newspaper ad) couples found that “sexual and emotional” responses to the

first coitus appeared to be far more significant for women than for men.7


Sexual Function Difficulties

A study of over 1800 English teenagers concerning sexual issues (including problems),

as well as a follow-up study of the same population when they were in

their mid-20s, revealed that about one fourth “had a sex problem which

they had never discussed with anyone.”33 These difficulties included

anxiety over “performance,” guilt feelings, change in sexual interest,

and concern about masturbation. The extent to which concerns were

carried over from adolescence to adulthood was not stated but the likelihood

is that there were many.


Atypical Experiences

There is surprisingly little information about the epidemiology and childhood precursors

of adolescent or adult paraphilias (previously known as perversions or sexual deviations

(see “Nonparaphilic and Paraphilic Compulsive Sexual Behaviors: Sexual Issues


In one study, “over 50% of the various

categories of paraphilias developed their

deviant sexual arousal pattern before

age 18.”35

and Questions” in Chapter 8). An exception to this lack of information is the finding

that those who have been sexually active with children were sometimes themselves the

target of the same kind of sexual behavior when they were children.34 When looking

retrospectively, paraphilic behavior often begins in adolescence.35 In one study, “over

50% of the various categories of paraphilias had developed their deviant sexual arousal

pattern prior to age 18.”35 However, the extent to which paraphilic behavior can be an

occasional and “benign” aspect of adolescent sexual development is unknown. Gender

identity disorders are said to crystallize in this same period also.36


Sexual Assault

Laumann and his colleaguesl (p. 333) asked respondents about “forced sex” rather than

“rape” for two reasons:

• Rape was considered a legal rather than a descriptive term

• They wanted to “cast a wider net for coerced sexual events, recognizing

that meeting the legal standards for rape does not exhaust the category

of women being coerced to have sex”

A small number of men (1%) and a large number of women (22%) reported being

sexually forced by a man (p. 335). In other words, “more than one in five women has

experienced what she considers to be an incident in which she was forced to do something

sexual that she did not want to do”(p. 335). The experience of women in this

survey was described as being consistent with other surveys of sexual assault. The fact

that forced sexual experiences can have profound effects on sexual function in women

and men is well documented.1,37,38 Diminished sexual desire appears to be one of the

main consequences.


Pregnancy and Abortion

The effect of pregnancy and abortion on later sexual function depends on the circumstances.

The results of various birth control approaches on sexual function have been

reviewed39 (pp. 404-410). The sexual impact of birth control pills in particular is

subtle, in that sexual desire may be lessened in some individuals.40


Sexually Transmitted Diseases

The differentiation between Sexually Transmitted Infections and Sexually Transmitted

Diseases (STIs and STDs) is explained by the fact that not everyone with an infection

is symptomatic and therefore may not know they have a disease. Such disorders are

not, of course, limited to puberty and adolescence; however, bacterial and viral infections

occur most commonly in the 18 to 24 year old age group.1 The frequency is

thought to be related to a greater number of sexual partners, which “is the most succinct

measure of the extent of exposure to infection” (pp. 385-386).

An interviewer may have to extrapolate the effect of sexually transmitted diseases

on sexual function, since there is little information on this subject in the medical literature.

One related exception is the modification of sexual practices in homosexual

men in response to the AIDS epidemic. For example, changes are described in the use

of condoms and the exclusion of anal intercourse in sexual activities1 (pp.432-437).41



Areas of Inquiry

Areas of inquiry include the following:

1. Romantic relationships from quantitative and qualitative viewpoints

2. Sexual aspects of romantic relationships

3. Marriages and their sexual components

4. Reasons for the ending of important premarital and marital connections and the

extent to which sexual problems were significant

5. Changes in sexual experiences before and after marriage

6. Covert or overt sexual experiences with other partners during marriage or committed


7. The nature of a person’s sexual response with (other) current and previous sexual


8. Reproductive issues


Suggested Questions

Q. Tell me about previous relationships that meant a lot to you.

Q. What were your sexual experiences like in those relationships?

Q. Why did those relationships end?

Q. Did you ever have the same kind of sexual problem that you have now?

Q. How long did you and your wife (husband, partner) know each other before

living together?

Q. What was your sexual relationship like in those days?

Q. What were your living arrangements during that time?

Q. When your living circumstances changed, what effect did that have on your

sexual relationship?

Q. Sometimes people who have a close relationship also have sexual experiences

with other partners for various reasons; one reason is to test themselves to see if a

particular sexual problem appears with someone else. Have sexual relationships

with others for this or any other reason been part of your experience?

Q. How did you manage sexually on those occasions?

Q. To what extent is your wife (husband, partner) aware of those experiences?

Q. What was her (his) reaction?

Q. (If patient has children) Tell me about your sexual experiences when you were

(your wife was) pregnant.

Q. (If patient has no children) Have you decided against having children or have

you had some fertility difficulty?


Rationale For Questions

Relationships before marriage are interpersonal and sexual testing opportunities.

Problem patterns may become evident as an interviewer explores the reasons for developing

links with others and why they become disrupted, for example:

• Changes in living arrangements may imply alterations in expectations

that, in turn, may have profound effects on a couple’s sexual experiences

• Marriage may result in changes in a couple’s sexual experiences

• Another area is the possible presence of other sexual partners

Kinsey et al. found that about 50% of married men reported having sexual intercourse

with women other than their wives at some time in their married lives15 (p. 585).

Among women, about one fourth had similar experiences by age 4016 (p. 416). Information

on this subject provided in the Laumann et al. study was markedly different1

(pp. 212-216). “Over 90 percent of the women and over 75 percent of the men in

every cohort, report fidelity within their marriage, over its entirety” (p. 214).

Whatever the motivation for other relationships, it is useful to know whether or not

the particular sexual problem that presently exists was present during those other occasions.

When planning treatment, the health professional must also know if another

current relationship is transient or committed. A productive treatment outcome could

be difficult in the presence of an unseen third person with whom the patient has a

substantial relationship.

Issues relating to reproduction can have profound effects on sexual experiences.

Opposing ideas on the topic of having children can disrupt an otherwise harmonious

couple. The process of trying to “make a baby” because of infertility problems results

in sexual experiences that are structured, devoid of passion, and empty of feelings. It is

hardly astonishing that problems might develop in such circumstances.

Most observers describe a constantly diminishing level of sexual interest in women

through the period of pregnancy.42 In contrast, Masters and Johnson described an

increasing degree of sexual interest in pregnant women in the second trimester43 (pp.



The Older Years

Areas of Inquiry

Areas of inquiry include the following:

1. The nature of current relationships

2. How the past and present compare sexually

3. The frequency of sexual activities

4. The range of sexual experiences

5. The extent of understanding and expectation of alterations in sexual function in

the aging process

6. Changes in sexual response

• Extent and speed of vaginal lubrication (women)

• Effective stimuli for erections, the rapidity and stiffness of erections, the

length of time to obtain another erection after ejaculation, and the

length of time required to come to orgasm (men)

7. Experience with the use of postmenopausal hormones (women)

8. Connections between health and sex


Suggested Questions

Q. What has your sexual relationship with your wife (husband, partner) in general

been like in recent years?

Q. What were your sexual experiences as a couple like before the development of

the problem you mentioned?

Q. How often does sexual activity occur now?

Q. What takes place now sexually when you and your wife (husband, partner) are


Q. What sort of sexual changes were you expecting as you became older?

Q. (women) Many women experience changes in the amount or speed of vaginal

lubrication with menopause. What is your experience?

Q. (women) What is your experience with estrogens or other hormones after your


Q. (men) Have you noticed any change in the speed with which you get an erection

compared to, say, five years ago?

Q. (men) Is there any change in the stiffness of your erections now compared to,

say, five years ago?

Q. (men) Is there any change in how long it takes you to have another erection

after you’ve ejaculated once compared to, say, five years ago?

Q. (men) Is there any change in how long it takes you to ejaculate or come to

orgasm now compared to, say, five years ago?

Q. Have health problems influenced your sexual experiences?


Studies of Sexuality and Aging

The Kinsey surveys included very few older people and as a result others researched

this gap in sex-related information.15,16 Pfeiffer and his colleagues studied an elderly

group at the Duke University Center for the Study of Aging and Human Development.

44 Their findings include the following:

• Sex has an important role in the lives of many elderly persons

• There is a tendency toward declining sexual activity with age

Of major consequence is the fact that they also saw exceptions in the form of patterns

of stable, and even increasing, sexual activity.

In an effort to supplement the available information about sex and aging, Consumers

Union (CU) undertook a survey of older readers of the magazine, Consumer Reports.45

The result was the book, “Love, Sex and Aging,” based on written responses to a questionnaire

completed by 4246 people over age 50 (of which 2456 were over the age of 60).

The survey was obviously biased in that the sample:

• Was self-selected

• Consisted of people of higher than average income and education

and better than average health and who had greater

interest in the topic


Clinicians need to guage the overall

quality of the relationship in the assessment

of sexual difficulties.

However, the results are nevertheless significant because they describe what is sexually

positive and possible in men and women as aging occurs.

The CU survey related 15 nonsexual factors (e.g., age, income, and the “empty-nest

syndrome”) to marital happiness. Only one was found to be “closely associated”—the

quality of communication. When the quality was low, sexual activity suffered. This

conclusion may have diagnostic implications and therapeutic ramifications. Clinicians

need to gauge the overall quality of the relationship in the assessment of sexual difficulties.

The nature of sexual activities a couple enjoys may represent vital information,

depending on the problem presented.

In reading through Kinsey’s surveys, it was also clearly evident that the acceptability

of various sexual activities depended at least partly on the era in which a person was

raised. For example, many older couples living in the 90s grew up in a time when it

was considered improper for a woman to touch or stimulate a man’s penis. Given this

culture-based attitude, Masters and Johnson’s observation, for example, of the older

man’s need for tactile stimulation to develop or maintain an erection may result in

major sexual difficulties.43


Sexuality of Aging Men
(Box 5-3)

In relation to men specifically, Kinsey et al. declared that of eleven factors that “are of

primary importance in determining the frequency and sources of human sexual outlet,”

none seems more important than age.15 “Having reached a peak in adolescence, sexual

activity in the male drops steadily from then into old age.” While this finding of diminished

sexual activity in aging men has been confirmed by others, studies46 also show

the following:

1. A wide variation in individual rates of decline

2. Decreased sexual desire (although to a lesser extent than sexual activity)

3. Increased prevalence of erectile dysfunction

4. A general decrease in genital and extragenital reactions to sexual stimulation


Box 5-3

Summary of Sexual Function Changes in Aging Men45-47

• Quality of communication closely associated with marital happiness

• Sexual satisfaction—no difference

• Sexual desire generally decreased but wide variation

• Sexual activity generally decreased but wide variation

• Erection—some required longer time to become erect

• Erectile dysfunction—increased prevalence

• Erection following orgasm—some required increased time

• NPT testing—many aspects decreased

• Bio-available testosterone—decreased

• Luteinizing hormone—increased

• Ejaculation—often longer time from vaginal entry to orgasm

NPT, Nocturnal penile tumescence.

The Duke University study also examined the determinants of sexual behavior in

middle age and old age and found that, among men, many factors influenced the extent

of sexual behavior,44 including:

• Past sexual experience

• Age

• Subjective and objective health

• Social class

In the CU Survey, four specific questions were asked of men about their erections.45

Of the 2402 male respondents the following observations were noted:

• Their refractory period (the time it takes to have another erection after

orgasm) was longer (65%)

• It took longer to get an erection (50%)

• Their penis was less stiff when fully erect (44%)

• They more frequently lost their erection during sexual activity (32%)

Ejaculation and orgasm changes in men were also described in the same survey. Ejaculation

usually (not always) slowed so that there was a longer time from vaginal entry

to orgasm. In addition, orgasms did not occur with every sexual experience.

More recent observations on male physiology have added important information to

our knowledge about sexual changes in aging men. These changes seem to be mediated

by hormonal, neural, and vascular mechanisms. Schiavi and his colleagues took

physiological studies beyond others by examining the sexual function of healthy aging

men.46 Schiavi summarized from this study47 as follows:

1. No reported difference in sexual or marital satisfaction in spite of age-related

changes in the sexual desire and sexual activity of study subjects

2. A wide variation in levels of sexual desire, response, and activity among even the

oldest of the subjects

3. A marked decrease on many aspects of Nocturnal Penile Tumescence (NPT)


4. A highly significant decrease in the amount of bio-available testosterone and an

increase in circulating luteinizing hormone (confirming previous reports of an

age-related decline in gonadal function, but he also noted that “the magnitude

and extent of the hormonal–behavioral correlations observed . . . does not

support the notion that hormonal factors are important determinants of individual


In examining possible causes of changes in erection function specifically, another study

looked at 39 healthy and sexually functional men ranging in age from 21 to 82 and

related the observation of decreasing erectile capacity in aging men to decreasing sensory/

neural and autonomic function rather than hormones.48

Schiavi concluded about sexuality in men that: “aging is associated with a decrease

in sexual desire, arousal and activity even when the effects of illness, medication and

psychopathology are minimized or eliminated . . . [and that] . . . a proportion of

subjects in the oldest age group . . . remained sexually active and had regular intercourse

in the presence of a marked decrement in erectile capacity . . . It would

appear that in these individuals, the value that sexuality had in their lives, the frePart

quency and range of their past sexual behaviors, their motivation and ability to experiment

and develop compensatory sexual strategies and the supportive attitude of their

partners were instrumental in their continuing sexual activity, their sexual satisfaction

and the self-perception of not being sexually dysfunctional.”47


Sexuality of Aging Women

The Duke University study also drew conclusions that were specific to women.44 The

authors believe that the level of activity in women reflected “the availability of a

socially sanctioned, sexually capable partner.” Relatively few factors (compared to

men) were determined to influence the level of sexual activity:

• Marital status

• Age

• Extent of enjoyment derived from sexual experiences in earlier years

In a general population survey of sexual desire in midlife, Hallstrom and Samuelsson

interviewed 497 women living with a spouse, on two occasions, six years apart.49 Ages

of the women were 38, 46, 50, and 54 at the time of the first interview. The research

strategy allowed the authors to study age and cohort effects. Their conclusions were

that sexual desire showed considerable stability over time but that a substantial proportion

of their subjects (27%) experienced a major change in sexual desire, mostly a

decrease. Ten percent of their subjects demonstrated an increase. Decreased sexual

desire was predicted by:

1. High sexual desire at the first interview

2. Lack of a confiding relationship




3. Insufficient support from a spouse

4. Alcoholism in a spouse

5. Major depression

Increased sexual desire was predicted by:

1. A low level of desire in the first interview

2. Negative marital relations before the first interview

3. Mental disorder at the time of the first interview

The CU Survey (Table 5-4) included responses from 1844 women who were 50 years,

or more, old45 (pp. 311-346).

Brecher, the author of the CU report, commented on the apparent inconsistency

between the decline in frequencies of sexual activities in men and women and the positive

qualitative comments that accompanied the returned survey questionnaires.45 “The

enjoyment of sex can and sometimes does increase with age even as the frequency may

decrease . . . [and in addition] . . . respondents . . . have found techniques for

maintaining . . . their enjoyment of sex despite physiological changes . . . ” (p.



Impact Of Hormonal Changes On Sexuality In Aging Women

To understand the effects of aging on sexuality in women, some attention was given

to the hormonal variations that occur in the peri- and postmenopausal years and the

effects of those changes. Sherwin explained that there is a virtual cessation in the production

of estradiol (the principal estrogen) by the ovary at the time of menopause

(before menopause, 95% is derived from this source).50 In addition, testosterone production

from the ovary (a source of about 25% of testosterone in premenopausal years)

becomes negligible at the same time in about 50% of women. Both hormones were

described as having effects on the brain, as well as on peripheral tissues.

In the absence of estrogen, the vaginal epithelium becomes attenuated and pale due

to diminished vascularity. The consequences of this can be atrophic changes, which in

turn, can lead to inflammation or ulceration. All of this can result in diminished vaginal

lubrication, which, in turn, might intuitively be expected to cause discomfort or pain

with intercourse. Vaginal lubrication and pain with intercourse were investigated in the

Laumann et al. study.1 When women age 50 to 59 were asked if “trouble lubricating”

had been a problem within the past year, 46% said “yes.” However, a much smaller

number (16%) of women respondents in this same age group reported “pain during

sex.” Clinically, postmenopausal women who use oral estrogens or estrogen vaginal

cream generally find enhanced lubrication and the elimination of dyspareunia. It

appears then that postmenopausal vaginal atrophy and diminished elimination of discomfort

or pain with intercourse are not necessarily followed by dyspareunia but when

postmenopausal dyspareunia does occur it is frequently accompanied by diminished

vaginal lubrication.

While vaginal atrophy is a consistent finding in postmenopausal women, this is less

so in women who regularly engage in intercourse. This observation may be even more

prominent for those whose sexual activity involves masturbation.51 The relationship

between the thickness of the vaginal mucosa and vaginal lubrication is not entirely

clear. Although the two often are thought to be closely related, Masters and Johnson

described three women who responded with considerable vaginal lubrication in spite

of a thin and atrophic mucosa43 (p. 234).

Studies of the absence of testosterone in women (which occurs suddenly when both

ovaries are surgically removed) and its therapeutic use confirm that testosterone is

associated with an enhancement of sexual desire, interest, and enjoyment of sex in

some postmenopausal women.52 Sherwin concluded elsewhere that “in women as well

as in men, testosterone has its major effect on the cognitive, motivational, or libidinal

aspects of sexual behavior such as desire and fantasies and not on physiological

responses . . . [and that] . . . the likelihood . . . [is that] . . . the mechanisms

impact directly on the brain.”50 From a therapeutic viewpoint, she also suggested treatment

with testosterone in instances of surgically induced menopause, as well as in

instances of natural menopause that is accompanied by a change (decrease) in sexual

desire (see Chapter 9 for a more detailed discussion of the use of testosterone to treat

sexual desire disorders in postmenopausal women).



Investigation of a sexual problem begins with a description. However, understanding

possible origins may entail the following:

• Detailed history-taking

• Physical examination (possibly)

• Laboratory studies (possibly)

Considering the etiology of a problem requires awareness of the context in which it

exists. The interviewer needs a structure for obtaining this contextual information.

Kaplan’s system for arranging explanatory information was to separate immediate

and remote factors that might further understanding of the reasons for a sexual dysfunction.


Immediate issues are best discovered during a patient’s description of details of a

sexual encounter as it takes place in the present. Describing the process of “who does

what to whom” is considerably more disconcerting to health professional and patient

than simply stating the fact that a problem exists and outlining what it is. Nevertheless,

in the absence of objective measures, this process is a necessity, since the health

professional depends entirely on the patient’s words in attempting to understand the

nature of a sexual dysfunction. However difficult talking about sexual details may

appear, practice by the health professional makes this progressively easier.

Remote factors become apparent when reviewing a person’s developmental history,

particularly when the focus is on the evolution of his or her sexual development (hence

the term sexual-developmental history). Although this process may not always seem necessary,

the importance of past experiences may not be apparent until after the fact.

Primary care health professionals are able to acquire information about immediate

factors within the time frame that they usually spend with patients (although the process

may involve more than one visit). However, detailed inquiry into remote factors

is more complex and time consuming and, as a result, may be more realistically undertaken

by a health professional who has a special interest in sexual issues.

The sexual life cycle closely follows the unfolding of the individual. Through childhood,

puberty and adolescence, adulthood and the older years, the interviewer traces

the sexual thoughts, feelings, dreams, and events in the patient’s life, all the while

searching for anything that might help explain the reasons for a dysfunction in the

present and for ways to correct it. Areas of inquiry arise for each period of time, as do

questions. The rationale for the questions asked derive from the data: what is known

about positive and negative happenings during each period.

When talking to an adult about “sex” during their childhood, the health professional

is partly operating in a vacuum, since only a limited amount of knowledge is available.

This lack of knowledge, for example, about sexual norms, probably results from the

reluctance of parents and schools to allow children to be subjects of study. In contrast,

much is known about adolescence—the multicolored picture of this period is a time of

enormous sexual ferment, physically as well as in thought and behavior. Much can be

learned about an adult by carefully detailing what took place in their mind and in their

actions during their teenage years. Ways of thinking and behavior seem to crystallize

at this time. The consolidation of adulthood often provides information about the

appearance of sexual problems in, for example, the context of previous relationships.

Changes in the older years, including sexual alterations, are often a source of confusion.

The virtual conspiracy of silence surrounding sexuality and aging relates partly to

the great difficulty that many health professionals (especially students) find in talking

about this subject to older patients and partly to the self-restraint displayed by those

same patients.

When sexual dysfunctions occur, regardless of age, the health professional needs a

structure within which to organize an assessment. This topic will be discussed in the

next chapter.



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4. Kaplan HS: The evaluation of sexual disorders: psychological and medical aspects, New York, 1983,

Brunner/Mazel, Inc.

5. Montagu A: Touching, ed 3, New York, 1986, Harper & Row, Publishers, Inc.

6. Bancroft J: Human sexuality and its problems, ed 2, U.K., 1989, Churchill Livingstone.

7. Heiman JR et al: Historical and current factors discriminating sexually functional from

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