CHAPTER 6
Assessing Sexual Dysfunctions
And Difficulties: The Process

In an age when scientific disciplines are becoming increasingly specialized, it is more and more difficult

to bring together new knowledge in a manner that helps us comprehensively to understand the human

condition. Sexuality is a prime example of the growing need for such a synthesis . . . for the medical

profession, sex provides as good a model of psychosomatic relationships as one can find . . . a proper

understanding of human sexuality demands a truly psychosomatic approach.

Bancroft, 19891

Not all clinicians who specialize in the care of people with sexual

disorders agree on the necessity of the entire process described in

this chapter and for the length of time it involves. For example,

Kaplan2 (pp. 91-92) states that:

• About 60% of her assessments take place in a single 40 minute

session with a couple or a symptomatic patient alone

• A second session is necessary in about 20% of cases

• More time is required when a situation is especially complex

A single history-taking session, while considerably less thorough than

the process described in this and the previous chapter, is particularly applicable to a

primary care setting. If nothing else, it indicates that much can be accomplished with

many patients within a limited period of time.

Window Of Opportunity

Patients often arrive alone when initially visiting a health professional and it is in this

context that a sexual problem typically surfaces—frequently during a discussion of some

other topic. What happens subsequently can develop in one of two

ways:

• The focus immediately shifts to the area of “sex”

• A plan is developed with the patient to talk about this new

topic at another time

The extent to which a patient feels a sense of urgency, the amount of

professional time available, and the clinical skills of the professional

dictate which path is taken. There are benefits to each approach. Talking

about a sexual problem when the subject is broached is appealing,

since it allows an interviewer to take advantage of this “window of

opportunity.” However, the idea of talking at a later time is attractive because it allows

for (presumably) unhurried conversation. Time may be needed to allow for the gradual

unfolding of a painful story that may never have been told.

Some health professionals (especially nonpsychiatric physicians and health professionals

who have a limited amount of time) prefer not to hear a lengthy account of a

sexual difficulty, conduct only a brief assessment, then refer the patient. Part II considers

when referral is reasonable and, conversely, when a sexual problem can be assessed more

elaborately and managed on a primary care level. When undertaking a more comprehensive

assessment, health professionals may want greater structure (outlined later in

this chapter).

The Patient’s Partner

Although patients may be unaccompanied when first seen, another person may be

present in spirit, that is, the patient’s sexual partner. Learning about the existence of

this other person allows for the possibility of their inclusion on a subsequent visit. The

partner may be initially absent for several reasons, including:

1. Involvement of a sexual partner on a first visit is unusual (unless the visit is structured

this way)

2. People tend to blame themselves for sexual problems and therefore may not

understand the necessity of including a partner

3. A patient may be embarrassed to talk explicitly when a partner is present and

thus not want the other person to be present

If the professional thinks it is important to include the partner in discussions of the

problem, this should be explained to the patient.

The rationale for including a partner is twofold:

• Diagnostic

• Therapeutic

While considerable diagnostic (past-oriented) information can be obtained from one

person alone, a partner may have a different point of view. This was demonstrated by

a study that compared separately obtained interview data from men with erectile difficulties

and their wives.3 Frequent discrepancies were found in the information

obtained such that, for example, in 18% of the cases the diagnosis was changed. The

authors provided several examples, one of which follows:

A 59-year-old salesman: “Patient reports that impotence began within the last year,

after years of infrequent sex. He said that in this, his second marriage, he feels desire

but suffers fear of failure with his wife. He reports no erections with masturbation

and partial morning erections. Pertinent medical history is a history of cocaine and

heroin abuse, ending in 1961, and prostatitis. The patient’s wife indicated that this

was his third marriage, and that the potency difficulty began at least three years ago

but that sex had been so infrequent (occurring only at her insistence) that she felt

any erectile difficulties were less important than the low desire.”3

Apart from the issue of diagnosis, the other person often needs to be involved when

trying to effect change (future-oriented). The authors again provided an example:

A 58-year-old accountant: “Patient reported no sexual problems in his first marriage,

which ended with his wife’s sudden death in 1982. He was unable to achieve

intercourse with his new fiancee, despite a close and desiring relationship during

the last 18 months. He has had diabetes for 10 years, and the NPT workup showed

serious erectile abnormalities warranting prosthesis recommendation. Interview

with patient’s fiancee revealed that she was not at all dissatisfied with the status quo

and may have chosen Mr. C in part because of lack of sexual intercourse in the

relationship. Pre-operative conjoint counseling was recommended to explore issues

of mutual motivation for surgery.”3

The above examples demonstrates that, from diagnostic and treatment perspectives,

what can be accomplished might be quite limited if discussions are held with only one

partner.

When the connections between two people are substantial (planning to marry and

living apart; single and living together; married), one should be skeptical when hearing

that the other person does not want to be involved, since the statement may not be

accurate. An invitation extended to the other person may, in fact, never have been

delivered and, if it was, consideration must be given to how it was delivered. Often it

becomes evident that the patient is the one who is reticent, saying that the problem is

one’s own and does not and should not involve the partner.

Interviewing A Solo Patient

The phrase “solo patient” describes someone who sees a health professional

alone. The term reflects any of the following:

1. Absence of a current sexual partner

2. Marital status (unmarried)

3. Living arrangements (living alone)

4. Unwillingness of a partner to be involved

Solo patients referred to a sex-specialty clinic or professional are often

men who have problems with erections or premature ejaculation. These

difficulties are frequently cited as the major reason for the disintegration of a recent

relationship. With the other person absent, this interpretation is one-sided and limited

in scope. The tenacity with which a patient presents a problem needs to be judged. If

the patient is equivocal, this might provide the health professional an opportunity to

assist in reexamining the contribution of sexual problems to the fracture in the rela-

tionship. If the patient is inflexible, a confrontation only may increase the distance

between the patient and his clinician.

A 25-year-old man was referred after the breakup of a two-year relationship with a

woman with whom he had been living. When sexually stimulated, he was unable

to develop a full erection. The same situation existed when he occasionally masturbated

or when he woke up in the morning. The last occasion he recalled having a

full erection under any circumstance was four years before. He was an intensely

introverted man and one of few words. He said that erection problems were usual

for him but worse now because he was depressed over the disruption of a relationship

that he had hoped would end in marriage. He attributed the breakup to his

sexual “performance” and was sure that nothing else (such as his inability to communicate

or excessive drinking) could have contributed. His family doctor chose

not to contradict directly and instead initially discussed the patient’s sexual function

in greater detail, as well as his depressed mood. As the patient’s mood lifted,

other issues were brought into the discussion without difficulty.

Despite being evaluated alone, the initial assessment of a solo man can be quite

useful. He receives the powerful information that he is not alone in having whatever

the problem is and that some of the possible origins can be investigated. In some

instances (e.g., a primarily medical or psychiatric etiology of erection problems), one

can also be therapeutically helpful. However, in some situations, the health professional

may have to insist that for treatment purposes the patient must have a sexual

partner. All too frequently, the patient’s reply is that the very presence of this problem

prevents him from establishing such a relationship, since women “expect” him to “perform”

within a few dates. This dilemma may seem to be a “Catch 22” situation (except

that some men seem to have no difficulty finding sexual partners in spite of their

troubles). The interviewer might then reasonably conclude that personality issues and

“social skills” are included in addition to “performance” problems. In such instances, the

focus of treatment may shift to include these factors as well.

A smaller percentage of solo patients are women who describe trouble reaching

orgasm or having pain with intercourse. They, too, worry about the impact of this on

their relationship. The timing of a request for help is different from men in that solo

women usually ask for assistance in anticipation of the dissolution of a partnership,

rather than after. Their thinking is, typically, that if they are unable to fulfill the sexual

needs of a man, he will leave.

A 22-year-old woman was referred because of vaginal pain that had been evident

since she began to include intercourse in her sexual activities three years before.

She had a regular sexual partner for the previous two years. In that relationship,

her level of sexual desire had not diminished, she lubricated easily, and had no

difficulty coming to orgasm on the rare occasions that intercourse occurred.

Avoidance of coital pain had been high on her list of sexual priorities. She and

her boyfriend were sexually active with one another (not including intercourse)

several times each week but she had become certain that he would not remain in

the relationship much longer if intercourse was not included in their sexual experiences.

Although the boyfriend appeared satisfied with the arrangement, her concept

of the sexual requirements of men was that the absence of intercourse, however

temporary, was unacceptable. She was not reassured by his protestations to

the contrary. She was referred to a gynecologist and was found to have endometriosis

after an examination for laparoscopy. Surgery resolved her dyspareunia;

however, when the relationship ended, she had little choice but to consider nonsexual

factors.

Interviewing A Couple

The word “couple” obviously includes those who are married but it also

includes individuals who are single (in terms of marital status) but living

together, whether in a heterosexual or homosexual relationship.

Given a choice, many health professionals prefer to begin by talking

with a couple together rather than with each person separately,

recognizing benefits and limitations to both arrangements. The advantages

of interviewing a couple together seem to far outweigh the disadvantages.

First, in an initial conjoint visit, the “therapist” is clearly established

as responsible to both parties and therefore aligned with neither. When

an individual is first seen alone, there is always the danger that the

person not initially seen will feel:

• Left out

• That an alliance has been formed between the other two

• That the reason for including the partner is primarily as a target for

blame

Second, an initial visit together presents the clinician with the opportunity to:

• Evaluate the quality of the relationship between partners

• Consider the extent to which conflicts contribute to the genesis of the

sexual problem

• Think about how discord might interfere with resolution of

the problem

Affectionate gestures, sitting arrangements, and facial expressions may

reveal clues about love or its absence.

Third, sexual problems are often complicated by an absence of the

two partners candidly talking together. This reticence may have always

been present or may have become a more recent casualty of their trou-

bles. It is truly remarkable to observe two people sitting in the same room trying

jointly to explain to a third person (a stranger) what happens sexually between them

when they have not talked previously to one another about these very same events.

Although technically part of an “assessment,” this process is almost invariably therapeutic.

In other words, treatment often begins with the first visit.

Limitations of an initial conjoint visit extend to six areas and are self-imposed by

the health professional because the information may be damaging to the couple or ruin

the relationship between the interviewer and one of the two partners (Box 6-1). To be

sure, information in all six areas can and should be gained when each person is seen

individually (Box 6-1).

First, one should avoid asking about other recent or current partners, even if discussed

by the couple before the visit. When previously revealed to the other person,

often only the skimpiest of information was given. One is likely to hear about a third

person in the context of an attack by one partner against the other. It is preferable not

to worsen matters by increasing the high level of tension that may already exist. More

information can be acquired harmlessly simply by asking the other partner (not the

one who was active outside the relationship) what they understand about what had

occurred.

A couple in their 20s and married eight years were referred because of two problems:

• The man’s rapid ejaculation

• The woman’s sexual disinterest

Before the first visit, the woman phoned to ask if she could be seen alone initially

and requested that her phone call not be revealed in any subsequent visits when

she and her husband were seen as a couple. It was explained to her that when an

individual in a long-term relationship was referred, both people were ordinarily

seen together initially and then separately. She agreed to the process and they were

seen together on the first visit. (In retrospect it might have been wiser to reverse

the order.) The husband’s ejaculation difficulty seemed lifelong, and the wife’s sexual

disinterest appeared acquired in that it had existed for about two years. She

stated that about two years before, she had been briefly interested in another man

who was also married. When the husband was asked what he understood about this

relationship, he indicated that:

• The man had been a friend of his

• His friend and his wife had kissed a few times

• The romance lasted a few weeks

• His wife and the other man had not seen one another in over a year

When interviewed alone, the wife told a different story, namely:

• She had been in love with this other man for many years

• The relationship was continuing

• Sexual activities occurred regularly with him

• She was far from sexually disinterested in this other relationship

The wife continued to explain that because of attachments to their children neither

she nor the other man wanted to break up their marriages. She asked if there was

some way her husband’s rapid ejaculation could be controlled and her sexual interest

in her husband regenerated. As a result of the visit, she understood that the

problem with her husband was only partly sexual, that the problem was mostly one

that involved other aspects of their relationship, such as trust and commitment.

She was unsure about what to do and accepted referral to a psychotherapist for

continued exploration of her options.

Second, it is best to avoid asking about past sexual partners. Previous relationships

are generally known to current partners but there is an almost unspoken agreement

between couples not to discuss details, particularly sexual minutiae. Such information

only invites uncomplimentary comparisons (such as penis size or a different way of

coming to orgasm).

Third, the health professional should be very cautious about introducing the subject

of masturbation. For many, this topic is very private, as well as embarrassing. If one

partner introduces the subject, discussions can continue on an abstract level. One can

also discover just how much this has been discussed between the two people. Individual

experiences are best left to individual visits. The health professional should

avoid forcing one partner into a revelation about masturbatory experiences in the presence

of the other. At another time and when talking in confidence, one partner might

be encouraged to reveal aspects of this activity to the other.

Fourth, questions about sexual fantasies should be omitted during an initial conjoint

visit. Masturbation is a private act; what occurs in thought is even more so. Sexual

fantasies often involve a person other than the usual sexual partner and therefore may

be misinterpreted as meaning a lack of sexual desire or love.4

Fifth, although acquiring a history of past STDs is essential it is best to do so when

the patient is seen alone to avoid potentially damaging a current relationship. When

an interviewer asks about past STDs in the presence of a partner, the question may also

entail coercing that person into talking about a past relationship that may have been

private.

Sixth, it is not advisable to ask about atypical sexual practices when both partners

are present. For example, when interviewing a couple, one would not ask a man if he

dresses in women’s clothing. A truthful answer is unlikely and could be damaging if it

were revealed (see “The Second Visit” below in this chapter for further discussion of

“secrets”).

First Visit
(see illustrations provided in Appendices I and II)

Explanation of the Assessment Process

Whenever meeting with a patient in response to a specific sexual complaint, one should

first explain some aspects of what is about to occur. Patients have immediate questions:

Who is this person we are about to talk to? What kind of professional experience do

they have? What should I expect today? What is the matter with me? Can it be fixed?

What will it take to do so? Why am I so nervous? How much will it cost? (As much

related to humiliation and embarrassment as money.)

Some of these questions can be answered immediately (introductions, duration of

visits, purpose of visits, the use of audio-visual equipment such as tape recorders) but

others represent the very rationale for an elaborate inquiry-assessment and therefore

must await the end of the process. Even then, a clear accounting may not be easily

given.

Before discussing the sexual problem that resulted in the visit, the interviewer

should:

1. Describe what is about to occur, since patients do not know what to expect in

spite of any previous explanation

2. Be sensitive to the fact that in such circumstances repetition may be necessary,

since people tend to absorb only a small amount of what is initially said

3. Be aware that talking about sexual matters is usually embarrassing and foreign

4. Be aware that discussing sexual matters with a stranger may be even more embarrassing

and foreign, since the reaction of the stranger is an unknown factor.

Introduction to the First Visit

The introduction to the first visit can begin with the declaration that, while its purpose

is clearly to talk about sexual troubles, the interviewer wants to initially learn more

about the background of the patients. Being explicit about the rationale for background

questions is necessary; otherwise, people may wonder about the reasons for

questions that might seem irrelevant.

The interviewer could then clarify:

• Ages

• Occupations

• Duration of the relationship

• Living arrangements

• Children

• Health (including psychological health)

• Medications

• Use of alcohol, drugs, and tobacco

• Previous efforts at resolving the sexual dilemma(s)

The purpose in asking about past therapeutic efforts of health professionals

is not to denigrate colleagues but to know in a practical sense

what has not worked previously, so that the same ineffective approaches

are not repeated.

In asking about occupation, the interviewer should be aware that

some people are involuntarily unemployed and feel guilty about this,

an attitude one would like to avoid enhancing. One way to approach

this subject is to not actually ask directly about occupation but rather to ask how one

“spends their days.”

Likewise, since some couples choose not to marry or have children (and the

interviewer is best seen as nonjudgmental), direct questions about marriage and children

can be avoided in favor of equally revealing questions about how long the

couple has known each other and who else lives with them. If necessary, more

direct questions can be asked at a later time. A nonjudgmental way to inquire about

the absence of children is to simply ask if this is a result of infertility or a deliberate

decision.

The Chief Complaint

The chief complaint (CC) is a brief and pointed statement of the patients’ main concern.

When, during the conversation, it is reasonable to turn to the specific sexual

trouble, the interviewer may ask about it in (at least) one of two ways:

• Directly—by inquiring of each partner separately what, from their point

of view, is the main reason(s) for the visit

• Indirectly—by asking the patient(s) to retrace the steps that resulted in

the current visit

The latter seems less precipitous and thus somewhat softer. The indirect approach

involves the patient(s) explaining, for example, whose decision it was to talk to a

health professional, what was actually said, what the response was, and, if the partner

was not involved, what feelings he or she had about the outcome. Since each partner

may have a somewhat different perspective, both should be encouraged to state the

chief complaint separately and from their personal point of view.

History of the Present Illness

The history of the present illness (HPI) refers to clarification of the chief complaint.

Given the limitations of a first couple interview described above in this chapter (see

“Interviewing A Couple”), this means the HPI of this relationship. Most of the first visit

is occupied with the HPI and includes four areas of inquiry:

1. Definition of the problem using the outline described in Chapter 4

2. Elaboration of sexual activities that do not include intercourse (using the outline

described in the portion of Chapter 5 titled “Present Context: Immediate Issues

and Questions”)

3. Extent of exchanges of affection between the two partners

4. Quality of the relationship

If the “patient” is a couple, the interviewer should ask frequently if what was just said

by one also represents the opinion of the other.

Second Visit

The portion of Chapter 5 titled “The Context of the Past: Remote Issues and Questions”

is the focus of the second visit, when each of the partners are seen alone. However,

it is usually best to begin by asking the person what their impressions were of the

first visit. It is sometimes revealing to also ask whether sexual activities occurred since

the last visit, and, if so, whether there was any change. Sometimes, talking on one

occasion is sufficiently therapeutic to resolve the troubles. Dramatic change resulting

from one visit is more likely to occur when there is a reformulation of the problem

(e.g., the “problem” becomes a nonissue) rather than any actual change.

A 35-year-old woman was seen because of a concern that she did not have orgasms

with intercourse. She was easily orgasmic in other sexual experiences with her

husband. They lived together in another city but she was taking a refresher course

elsewhere for six weeks and was determined to resolve their sexual difficulties during

that time. It became clear during the first visit that the concerns about orgasm

with intercourse were more her husband’s concern. She was sexually content. Reassurance

about the normality of her sexual response was gratefully received. When

seen one week later, she related that her husband visited her on the weekend, and

in talking together they decided that their sexual concerns had evaporated. As a

result, they had mutually satisfying sexual experiences, including intercourse. The

second visit was also the last visit and did not include a sexual-developmental history,

since the problem had “disappeared.”

Before beginning the sexual-developmental history, the interviewer might also ask

if the patient deliberately omitted anything from the first interview because of not

wanting to hurt their partner’s feelings. This question provides an early opportunity for

the emergence of secrets that may be significant in understanding the sexual problems.

Secrets can include:

• The existence of other partners

• Desire for a form of sexual activity thought to be unacceptable to the

partner

• Thoughts such as sexual fantasies

• Masturbation

Hidden information may be diagnostically important, since it may tell an interviewer

whether, for example, a problem is situational (see introduction to PART II). Likewise,

secret information may be therapeutically important in that it may influence the decision

of the health professional to treat both partners together or recommend that they

be seen separately. The interviewer cannot be neutral when in possession of a significant

secret “belonging” to only one of the partners.

The second (and solo) visit also permits the interviewer to ask questions related to

the six areas avoided on the first visit (see “Interviewing A Couple,” discussed earlier in

this chapter). The interviewer can explain the reasons for previously omitting these

questions and the rationale for addressing these issues in the absence

of the partner. An alternative approach is to integrate these questions

(so they could be asked in context) into a sexual-developmental history

(see Chapter 5).

Third (or fourth) Visit

Meeting with a couple again after each partner is seen separately

can accomplish several objectives.

1. It is always instructive to listen to the results of previous interviews. Treatment is

not separate from other aspects of the whole process and actually begins when

patients are initially seen. In other words, the assessment itself can be therapeutic.

Communication difficulties and the couple’s limitations in solving any problem

together become apparent when previous visits have not promoted substantive

discussion between the partners. For example, previous discussion may have

resulted in:

• Reformulation of a problem so that the initial sexual complaint is now

seen as subsidiary to another problem that requires more immediate

attention (e.g., intense relationship discord)

• The decision that the presence of a third person (e.g., the health professional)

in the endeavor is undesirable

• Making the etiology of the sexual difficulty and therefore what is therapeutically

required more evident than it might have been previously (e.g.,

the effect of a sexual assault in a patient’s past)

• Confirmation that the focus on a particular sexual complaint is, indeed,

correct

2. Focus on the couple’s sexual activity. Their description of any changes that

occurred may also reveal reasons for the shift and provide information about

interfering factors

3. The interviewer is provided with the opportunity to:

• Review the main elements of the history

• Consider the possibility of using other forms of investigation

• Discuss therapeutic options (including the provision of reading materials),

logistics of continued visits, or aspects of referral

Hawton suggested that a “formulation” be presented to the couple at this time in

which predisposing, precipitating, and perpetuating factors are outlined5 (pp.

118-122). He described the four reasons for doing so, as follows. A formulation:

• Provides the partners with further understanding of their difficulties

• Encourages a sense of optimism about the outcome

• Provides a rational basis for treatment

• Enables the therapist to check that the information obtained has been

correctly understood

While providing a formulation is a desirable objective, it is not always easy to

structure information in this way.

A 25-year-old woman was seen with her husband. They were married for two years

and were seen because of her concerns about not reaching orgasm during sexual

activity with her husband. She was regularly orgasmic when masturbating alone, a

fact of which he was unaware until after the first visit. Both were shy and talked

little together about sexual, and nonsexual, issues.

Information gained from meeting separately with the woman follows:

1. She was concerned about her husband leaving her because of her “inadequate”

sexual response

2. She revealed a lifelong self-deprecatory opinion of herself

3. She had brief episodes of depression

4. She sometimes injured herself as punishment

5. She wondered what her husband saw in her

6. Her mother was a harshly critical person who implied that she (the patient)

could not complete tasks productively

7. She talked fondly of her mother and worried only about her husband

8. She hoped that becoming orgasmic with her husband would result in him being

Physical Examination

The main theme of Part I of this book is talk and thus the specifics of

a physical examination are not reviewed here. This information can be

found elsewhere.1,5 (5pp. 111-117)7 While there is disagreement among

sex specialists about the need for a physical examination in all cases of

patients appearing with sexual problems in a specialized setting,1 there

is no difference of opinion about the wisdom of such an examination

by a physician in primary care. The objective of this examination can be

one or a combination of the following:

• Reassurance

• Diagnosis

• Education

An examination can be reassuring, if only to inform a patient that no obvious disease

is present. In addition, the primary care physician is the only health professional

that can provide (initially and before any specialists are involved) diagnostic information

based on a physical examination. Given the frequency with which there is contact

between physicians and the general population, the primary care physician is also in

an excellent position to provide educational input8,9 (see introduction to PART II).

Bancroft reviewed the specific indications for a physical examination in the context

of a specialized setting providing care for those with sexual difficulties1 (p. 417). These

also represent circumstances in which the primary care physician might be particularly

vigilant. In women, the specific indications include the following:

1. Pain or discomfort during sex activity

2. Recent history of ill health or physical symptoms apart from the sexual problem

3. Recent onset of loss of sexual desire with no apparent cause

4. Any woman in the peri- or postmenopausal age group with a sexual problem

5. History of marked menstrual irregularity or infertility

6. History of abnormal puberty or other endocrine disorder

7. When the patient believes that a physical cause is most likely or suspects that

there is something abnormal about her genitalia

In men (p. 424), specific indications are similar except for the additional suggestion

of an examination for all men over the age of 50 with a sexual problem.

It is apparent that talking during a physical examination can provide a dimension

of understanding that is not easily obtained otherwise. Outside of an examination

room, the following dialogue between a sex-specialist and a woman patient is not

unusual:

Q. Do you think that your genital anatomy is in any way abnormal?

A. I’m not sure.

Q. Well, have you ever asked your family doctor about it

during a pelvic examination?

A. Not really. I figured I’d be told if there was anything

wrong.

Q. Well, if nothing is said, a person might worry anyway that

something isn’t right.

A. That’s true. Now that you mention it, there is something I

wanted to ask someone about. . . .

A complete or partial physical examination should, under some

circumstances, be included in the evaluation of a sexual complaint (see introduction

to PART II). However, some humility is required in interpreting negative physical

findings. A patient may conclude that “nothing was found” and therefore depart the

examination room with the thought that “it’s all in my head.” In evaluating negative

structural findings, one must recognize that people are examined in a sexually “resting”

state and that the opposite is true of sexual troubles, namely, that they represent

difficulties with function that often becomes apparent only in the “active” state.

The two situations may not result in the same physical findings. This should be

explained to patients before a physical examination so that the limitations of such an

examination are understood, particularly if (as is often the case) no structural abnormality

is, in fact, detected. The examiner could also explain before the examination

that, if there is an obvious problem, it probably would have been discovered before

the referral. This is said in an effort to diminish unrealistic expectations.

Some sexual dysfunctions such as a lifelong inexperience with orgasm in a woman

and premature ejaculation in a man are rarely a result of disorders of the genitalia or

other body organs and thus do not ordinarily require a physical examination as part

of an assessment. However, in relation to some other sexual complaints, an understanding

of the body’s structural status must be an integral part of an assessment. Two

examples are:

• Erectile dysfunction that is not clearly situational (see Chapter 11)

• Pain or discomfort associated with vaginal entry (see Chapter 13)

When including a physical examination in an assessment, the purpose should be

explained as diagnostic and educational. In relation to the educational “agenda,” the

examiner might also suggest the possible inclusion of the person’s sexual partner (with

the explicit acceptance of both) in the examination room. There may be some hesitation

in responding to this idea because it is, obviously, unconventional and the patient

may be embarrassed as well. After the rationale is explained, the suggestion is often

accepted, since in a harmonious relationship, the partner is an ally rather than an

obstacle. The idea of having a partner present during the physical examination was

first suggested by Masters and Johnson and was discussed by them particularly in relation

to the assessment of vaginismus6 (pp. 262-263). Their explanation of the purpose

was that the partner would then have a clear demonstration of muscular constriction at

the vaginal opening.

In conducting a woman’s pelvic examination, a useful approach is for her to be lying

(at about a 45 degree angle) on an examination table in such a way that she can

observe the examination with the aid of a handheld mirror. The patient is invited to

ask questions (as is her partner) while receiving a brief explanation of the structure and

function of the genitalia. One patient was known to voice her appreciation of this

method by comparing it to the usual alternative where she “would lie on (my) back and

count the flies in the light fixture.” Since this method encourages talk, it is particularly

useful in the problem of intercourse-related vaginal pain in that the patient can describe

exactly what hurts and where.

“Entry dyspareunia” inevitably results in the anticipation of discomfort when anything

is inserted into the woman’s vagina. Understandably, the expectation of pain is

disconcerting to the patient during a physician’s vaginal examination and in sexual

activity with a partner. In an attempt to diminish the fear of anticipated discomfort, the

examiner can explicitly transfer control to the patient by telling her:

You are the “boss” when it comes to your body. I won’t put my finger into your vagina. You hold

my wrist and gently and slowly insert my finger. I don’t want to do anything that will cause you

pain. During a vaginal examination, my intention is to get a clearer idea of the location of your

discomfort and see if I can discover any particular reason for it.

With the “you are the boss” theme, the examiner presents a model of communication

that usually contrasts starkly with what occurs at home with the patient’s partner

and in the examination room with other physicians. In the past, the woman in this

situation typically felt an absence of influence over what occurred sexually and “shut

down” entirely to avoid the inevitable pain. In becoming “the boss” in

the examination room, she exerts control over the amount of vaginal

discomfort she feels and the conditions under which it occurs. After

this occurs successfully in the examination room, the couple can adapt

to her being the “boss” (at least over her vagina) in sexual situations at

home.

The response of women patients to this suggestion is usually spectacular.

A powerful rationale for the inclusion of the partner in the

examination therefore may be as much in the area of couple communication

as a demonstration of the control that the woman could exercise.

This aspect of the physical examination is an example of a diagnostic

procedure that is also therapeutic.

There are at least two problem areas in the genital examination of men:

• Compared to women there is much less organized teaching in medical

schools about practical aspects of examining male genitalia. The pelvic

examination of women is often taught with the assistance of women

volunteers who provide “feedback” during the examination. For reasons

that are unclear, only the occasional medical school provides a program

for teaching genital examinations of men—to the detriment of women

and men physicians and all of their male patients.

One might have legitimate concerns about the diagnostic capabilities

of young physicians in relation to male genitalia. Other than sexual

dysfunctions, cancers of the male genital system represent one fourth of

newly diagnosed cancers in American males.10 Testicular cancer in particular,

although unusual, is the most common malignancy in men 15 to

44 years of age.11

• Examination of the genitalia and anus is one of the reasons patients give

for a preference for a physician of a particular sex (usually for the same

sex—in contrast to “strictly medical areas” in which there was no preference).

12 Even for genitalia and anus examinations, the reasons why

patients want a same-sex physician are not entirely clear. One of men’s

fears might be that of developing an erection during the examination.

Some physicians seem apprehensive about this as well, not knowing

what to do or say in such circumstances. Health professionals who work

with men with spinal injuries know that simply touching a patient’s

penis might result in a reflex erection. Although erections in such men

are often well received in spite of the presence of a health professional,

the same can not be said of able-bodied men. However, something can

be learned from the process of examining men with spinal injuries that

might be of more general value. Professionals who care for these patients

have learned to talk to them beforehand about the possible occurrence

of an erection. With able-bodied men, talking about the possible development

of an erection during an initial examination probably lessens

the chance of it happening and certainly diminishes any potential

embarrassment or self-consciousness if it does. One might say to an

able-bodied patient:

Sometimes a man’s penis gets bigger or erects in nonsexual situations such as during an examination.

This is entirely normal and matches our knowledge that direct touch is an important way in

which erections develop.

Summary And Conclusions

Although assessment is usually differentiated from treatment, the treatment of a sexual

problem often begins immediately when the patient is first seen. In view of the secrecy

that so often accompanies sexual problems, open discussion becomes therapeutic. The

assessment of a sexual dysfunction is influenced by, among other things, whether the

“patient” is an individual or couple. If a substantial relationship exists, both partners

should be seen (otherwise, the clinician may encounter considerable therapeutic limitations).

Ideally, the first assessment visit involves seeing both partners together. This

is advantageous for the following reasons:

1. Both partners are “defined” as patients

2. The health professional is equally committed to both partners

3. The situation encourages partner discussion

4. The clinician can directly observe some facets of the relationship

Limitations of a first conjoint visit include avoidance of six topics:

1. Other recent current sexual partners

2. Past sexual partners

3. Masturbation

4. Sexual fantasies

5. Past STDs

6. Atypical sexual practices

Information about these issues should be obtained when an individual is seen alone.

The content of the first visit concentrates on the “chief complaint” and the “history

of the present illness.” This entails obtaining information about the problem using the

structure outlined in Chapter 4 and in the part of Chapter 5 titled “Present Context:

Immediate Issues and Questions,” asking about non-intercourse sexual activities,

affection, and quality of the relationship. During the second visit, each person is seen

alone, and information obtained relates to another part of Chapter 5, titled “Context

of the Past: Remote issues and Questions.” In the third visit, both partners are brought

together again and the focus of the content is on summarizing information from the

previous two visits, formulating explanations for the difficulties, and discussing treatment

options and approaches. A physical examination is included when this has not

previously taken place or when there is a special need to clarify information obtained

by history-taking.

REFERENCES

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

2. Kaplan HS: The sexual desire disorders, New York, 1995, Brunner/Mazel, Inc.

3. Tiefer L, Melman A: Interview of wives: a necessary adjunct in the evaluation of

impotence, Sexuality Disabil 6:167-175, 1983.

4. Hessellund H: Masturbation and sexual fantasies in married couples, Arch Sex Behav

5:133-147, 1976.

5. Hawton K: Sex therapy: a practical guide. New York, 1985, Oxford University Press.

6. Masters WH, Johnson VE: Human sexual inadequacy, Boston, 1970, Little, Brown and

Company.

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

Brunner/Mazel, Inc.

8. Ferguson KJ, Stapleton JT, Helms CM: Physicians’ effectiveness in assessing risk for

human immunodeficiency virus infection, Arch Intern Med 151:561-564, 1991.

9. Daicar T: The role of the educational pelvic examination, J Soc Obstet Gynecol Can

13:31-35, 1991.

10. Gilliland FD, Key CR: Male genital cancers, Cancer 75(1 Suppl):295-315, 1995.

11. Forman D, Moller H: Testicular cancer, Cancer Surv 19-20:323-341, 1994.

12. Fennema K, Meyer DL, Owen N: Sex of physician: patients’ preferences and stereotypes,

J Fam Prac 30:441-446, 1990.

CHAPTER 6 Assessing Sexual Dysfunctions And Difficulties: The Process