. . . .most sexual problems are currently considered the net result of a complex interaction among physical,
psychological, and interpersonal factors. Increasingly, clinicians are feeling “baffled” about the etiology
and treatment of the sexual complaints greeting them....the increased awareness of the dangers as well as the
delights of sexuality are dominating popular consciousness and cooling the sexual climate . . . Sexual
attitudes in [the] age of AIDS are markedly different from those in the previous “Age of Aquarius!”
Leiblum and Rosen, 19891 (pp. 1-2)
Health professionals can hardly avoid talking about sexual issues in view of the widespread
appearance of sexually transmitted diseases, sexual aggression toward children and adult women,
teenage pregnancies, and sexual dysfunctions. Indeed, in some circumstances, it is even hazardous
to not talk about these issues (see second case history in the introduction to PART I). The
first part of this book explored one of the more common reasons given by health professionals
for circumventing the topic of “sex,” that is, not being sure of the next questions to ask if the
answer to a sex-screening question is ‘yes’. PART II examines a second reason: the need for health
professionals to know what they can do about a problem before a sexual inquiry takes place. The
focus of PART II is on sexual dysfunctions rather than other sexual disorders. The reasons for the emphasis
are twofold. First, sexual dysfunctions are widespread in the community (see Chapter 3 and the
epidemiology sections of Chapters 9 through 13). Talking with people about such problems
provides almost every health professional the ability to assist those patients directly. Second,
talking to people about sexual dysfunctions provides the health professional with an excellent
opportunity to rehearse the process of talking to patients about many other sexual issues such as,
for example, STDs and their prevention.
Having the capacity to listen to stories of sexual distress and knowing what to do about common
sexual problems and when to refer the patient to another health professional, is, for many, a
prerequisite to asking sex-related questions. While high-quality guides for the treatment of sexual
disorders exist for the specialist health professional,1,2 there are few guidelines for those working
in primary care between those texts and the popular press. PART II attempts to provide this intermediate
level of information by reviewing the following five common sexual dysfunctions:
Low sexual desire in women and men (Chapter 9)
Ejaculation/orgasm disorders in men (Chapter 10)
Erectile disorders (Chapter 11)
Orgasmic difficulties in women (Chapter 12)
Intercourse difficulties in women (Chapter 13)
Each is considered from a primary care perspective, providing information about the disorder,
diagnostic questions to ask, treatment suggestions, and describing circumstances in which referral
might take place.
Patterns of practice in primary care vary greatly. Some physicians see patients with their partners
if, for example, the couple is retired or flexible work schedules allow for conjoint visits. Others
may be seen with other family members or friends, rather than with a partner. When patients are
seen alone, a partner may be invited to attend at a later time in response to a request or need.
Visits to physicians are often short: 10 to 15 minutes in a family practice setting; the total number
of appointments are often limited as a result of other responsibilities, demands, and interests
of the professional; and goals of treatment vary from being quite specific to those that are not.
With other health professionals such as nurses, psychologists, and social workers visits may be
longer and greater in number. However, like physicians, the goals of the other professionals vary
One of the “guiding principles” of the primary care version of The Diagnostic and Statistical Manual
of Mental Disorders, is that it is “user-friendly . . . with technical jargon removed or explained . . .”3
(p. xii). It includes a section on “Sexual Dysfunction” within a category of “Disorders That Commonly
Present in Primary Care Settings.” With a complaint that falls into the area of sexual
dysfunctions, the reader is instructed to first consider several issues:
(a) “. . . whether the presenting symptom is due to the direct physiological effects of a
general medical condition” (p.5)
(b) “. . . whether the presenting symptom is the direct physiological effect of a drug of
abuse (or) a medication side effect. . .” (p. 6)
(c) “. . . whether the symptoms are better accounted for by another mental disorder.” (p. 7).
As with the parent version of DSM-IV-PC, readers are directed to use a subclassification
scheme in which problems are subdivided into those which are (1) lifelong (having always existed)
or acquired (following a period of unimpaired function) and (2) generalized (existing under all sexual
circumstances) or situational (existing only under specific circumstances).4 For any health professional, this subclassification provides some direction in thinking about cause(s) and treatment.
For example, dysfunctions that are acquired and generalized suggest an alteration in the biological
capabilities of the individual. In contrast, the situational occurrence of a sexual dysfunction
usually bespeaks the integrity of body systems and points to psychosocial difficulties within
the patient or between that person and their partner. However, it is possible for a serious medical
illness to appear as a situational sexual dysfunction.5 In addition, a sexual dysfunction that is
generalized may begin as one that is situational. In an attempt to overcome diminished sexual
response, the patient, for example, may deliberately enhance sexual arousal by various psychological
and physical means.
Clinicians should be aware that the diagnoses of some sexual dysfunctions are themselves
problematic. First, a patient’s subjective concern must be considered, not only objective reality.
For example, an erectile dysfunction may objectively exist but be dismissed by the patient as
unimportant because of his own sexual disinterest or the uninvolvement of his partner. Second,
some definitions on which diagnoses are based are quite unstable in that they “. . . are dependent
on social expectations which change over time and across cultures . . . [The DSM-IV system]
. . . indirectly acknowledge(s) this by leaving much to the judgment of the therapist
. . . ”.6
The three elements of a medical examination that result in a diagnosis7 are:
(b) physical examination
(c) laboratory examination
In the assessment of a sexual dysfunction conducted by any health professional, the history-taking
portion of the examination is essential, so much so that on some occasions it may be all that is
necessary diagnostically and therapeutically. The explanation for this is that sex history-taking can
itself be healing, especially when it involves unburdening oneself of sexual secrets and, in the process,
receiving acceptance and reassurance instead of the anticipated news that one is “abnormal.”
Physical examination is essential diagnostically if a sexual problem could be the result of a
disorder of a body system that itself is integral to the function of the genitalia. Like sex historytaking,
a genital examination may also be therapeutic in providing a special opportunity to
explain and answer questions about the structure and function of the genitalia (see “Physical
Examination” in Chapter 6). Health professionals who for one reason or another do not conduct
a physical examination (e.g., mental health professionals) but who wish to integrate concepts
related to sexual anatomy and physiology into patient care may use paper and pencil self-drawn
schematic diagrams (easy and inexpensive) or plastic/rubber models of genitalia for effective and
Laboratory examinations can sometimes be used to add information when a biomedical problem
is suspected as a result of the other two parts of the investigation.
Other than masturbation, sexual activity always involves another person. Therefore when sexual
function in one partner becomes disrupted the other partner is also affected. One consequence
is to view at least some aspects of the solution to a sexual dysfunction in the context of both
people (apart from who actually appears with the problem). Correcting whatever difficulty exists,
therefore, requires the goodwill, caring, and cooperation of the two people. “Few . . . enjoy
the effort or pain [of treatment], but love and commitment can make the work bearable”8 (p. 92).
If these elements are absent (e.g., when one of the partners is secretly sexually involved with
another person), the sexual complaint usually becomes an issue of lesser priority than the context
within which the sexual activity occurs, that is, the relationship. Treating a sexual dysfunction in
primary care (or, indeed, on any level) assumes that the relationship has a reasonably strong
A treatment approach should be based on (a) specific discovered cause(s). This guideline often
seems easier to follow when an exclusively biomedical explanation is evident. However, in thinking
about psychosocial causes of a sexual dysfunction, Hawton suggested three groups of factors9
that one might consider:
1. Predisposing factors, including traumatic early sexual experiences and disturbed family
relationships (these are issues from the distant past that often require considerable time,
effort, and skill in overcoming and as a consequence are best treated by mental health
professionals with comfort in this area)
2. Precipitating factors, including infidelity and problems related to childbirth (sex-specialists
and mental health professionals both see such patients)
3. Maintaining factors, including anticipation of sexual failure, poor partner communication,
and inadequate information (these are issues related to the present, often seen by a sexspecialist,
but usually quite treatable in primary care)
Not long ago, education in the treatment of sexual dysfunctions primarily meant explanation of
1. Aspects of the anatomy and physiology of the genital function of men and women
2. Norms of sexual behavior
3. The epidemiology of sexual problems
Although these are often still necessary, education also now includes other elements such as learning
about sexual communication (e.g., partners explaining their sexual desires to one another).
“Self-help” books can be of great educational value in many areas but are best used as an
adjunct to the health professional rather than as a substitute. The most striking and consistent
response of patients to self books is the recognition of “not being alone,” that is, there are others
with the same problem. Althof and Kingsberg provided health professionals with guidance
through the maze of self-help “sex” books for professionals and patients on the subjects of sexual
and marital problems.10 Such books can be specific to a particular problem or generic (such as In
Touch: The Ladder to Sexual Satisfaction, written by the well-known and popular physician-couple
Beryl and Noam Chernick, and available through Sound Feelings Limited, 205-648 Huron Street,
London, Ontario, NY5 4J8, phone  672-5420). Specific chapters in this book (Sexual medicine:
primary care) include suggestions usually located within the ‘treatment’ sections on self-help
books that have been published in recent years or are older but have ‘stood the test of time.’
Also, Appendix IV lists Web sites that are informative on several sex-related subjects. One must
be aware that, in spite of the information available, books (for example) are often not read the
very by people who might have the most to gain. Hence the need for the knowledgeable health
Although many sexual problems can be handled within primary care, some should be referred to
specialists, but only after an in-depth diagnostic assessment is completed by the primary care clinician. Referral
may be for consultation only (that is, for one or several visits to provide the patient and referring
professional with an expert second opinion) or, alternatively, for continuing care (i.e., to transfer
the patient’s care to another health professional).
Obviously, the purpose in requesting consultation from another health professional is for the
consultant to provide the referring person with diagnostic knowledge or skill that he or she does
not have. In the inherently multidisciplinary area of the assessment and treatment of sexual
problems, consultation can be enormously valuable and should be exploited.
One of the reasons for referral when the purpose is that of transferring care to another health
professional is the character of the disorder itself. It makes little sense to attempt treatment
within primary care for a problem that sex-specialists, themselves, find management difficult.
Such is the case, for example, with the lifelong and generalized absence of sexual desire.
A second justification for referral for continuing care is complexity of the case. Complexities
may exist when, for example, there is coexistence of sexual and psychiatric disorders. The intricacies
involved in managing two concurrent issues may require care that extends beyond the
usual pattern of practice, interest, or level of professional expertise found in primary care.
A third opportunity for referral (at least for consultation and possibly for continuing care) is
when treatment at the primary care level was attempted but did not help resolve the major concerns
of the patient.
The choice of the kind of health professional to whom referral is made depends, obviously,
on the reason for the referral. For the evaluation of possible medical contributors to a sexual
dysfunction, the opinion of a specialist physician would be desirable. When considering the
contribution of psychological factors to a sexual dysfunction, or the integration of biological
and psychological issues, consultation with a health professional who has had supervised
training and experience in the care of patients with sexual problems and also a background
in the behavioral sciences would be advantageous. Such professionals, from several academic
health-related areas such as medicine (psychiatrists, gynecologists, urologists, family physicians),
psychology, nursing, and social work over the past three decades, established a discipline
that is now known as “sex therapy.” The skills of these clinicians, and the extent of the
field, has developed over the years to include patients with sexual dysfunctions, as well as
individuals with various sexual problems associated with medical, psychiatric, and other sexual
1. Leiblum SR, Rosen RC: Introduction: sex therapy in the age of AIDS. In Leiblum SR,
Rosen SC (editors): Principles and practice of sex therapy: update for the 1990s, New York, 1989, The
2. Bancroft J: Human sexuality and its problems, ed 2, Edinburgh, 1989, Churchill Livingstone.
3. Diagnostic and statistical manual of mental disorders, ed 4, primary care version, Washington, 1995,
American Psychiatric Association.
4. Diagnostic and statistical manual of mental disorders, ed 4, Washington, 1994, American
5. Schwartz MF, Banman JE, Masters WH: Hyperprolactinemia and sexual disorders in men,
Biol Psychiatry 17:861-876, 1982.
6. Binik YM et al: From the couch to the keyboard: psychotherapy in cyberspace. In Kiesler
S (editor): Culture of the Internet, Mahwah, 1997, Lawrence Erlbaum, pp. 71-100.
7. Hampton JR et al: Relative contributions of history-taking, physical examination, and
laboratory investigation to diagnosis and management of medical outpatients, Br Med J
8. Zilbergeld B, Ellison CR: Desire discrepancies and arousal problems in sex therapy. In
Leiblum SR, Rosen SC (editors): Principles and practice of sex therapy, ed 1, New York, 1980, The
Guilford Press, pp. 65-101.
9. Hawton K: Sex therapy: a practical guide, Oxford, 1985, Oxford University Press.
10. Althof SE, Kingsberg SA: Books helpful to patients with sexual and marital problems: a
bibliography, J Sex Marital Ther 18(1):70-79, 1992.