Health science students and professionals can practice sex history-taking and interviewing skills in a seminar format using the interviewing principles described in Chapter 2 and the topic model in Chapter 4. The case histories provided below are in the form of dialogue between "patient" and "professional" and can be used in role-playing. Preferably, each student should have the opportunity to be interviewER and interviewEE. Previously formulated case histories are used to save students and professionals the potential embarrassment of disclosing personal information.
1. The interviewer is given only identifying information and the sexual chief complaint by the instructor. All others in the seminar read the entire dialogue.
2. One of the main objectives of the seminar is for the interviewer to clarify the sexual problem declared by the patient (or discovered by the interviewer in the screening process) by using the model described in Chapter 4.
3. A second objective of the role-play is to practice using the interviewing techniques described in Chapter 2.
4. The interviewer is in the position of a generalist professional rather than a specialist in sexual disorders.
5. The duration of the "interview" is about 5 to 10 minutes.
6. Information about sexual issues should be elicited by the interviewer rather than volunteered by the person being interviewed. The purpose of this is not to apply more pressure to the interviewer but to reflect the reality of sex history-taking in that patients usually volunteer little information. The onus for acquiring this information rests mostly on the shoulders of the person asking the questions (see Interviewer Initiative, Chapter 2).
7. Some ad libbing by the patient is often necessary, since the case histories are incomplete.
8. Simulations are more "real" when done by individuals of the same gender as the patient described in the case history. Therefore, whenever possible, women and men should role-play a sexual problem manifested by someone of their own gender.
Case History "A"
IDENTIFYING INFORMATION: 32-year-old woman,- married for three years,- one child ten months old.
CHIEF COMPLAINT: "I'm not interested in sex" HISTORY OF THE PRESENT ILLNESS Diagnostic Topic #1 (lifelong versus acquired)
No problem with sexual desire (as manifested in her sexual activity or thoughts) in relation to two previous sexual partners, or with husband, until birth of child.
Diagnostic Topic #2 (generalized versus situational)
Not interested in sexual activity with husband. Does not masturbate. Does not have sexual thoughts involving other men. Has never been sexually interested in or had sexual experiences with other women. Has no dreams with sexual themes. Occasionally fantasizes about sexual activity with a (usually unrecognizable) man. Enjoys romantic stories in print or movies but is unresponsive to the sexual aspect of these tales. Her lack of sexual interest in men, greatly diminished sexual fantasy involving men, and unresponsiveness to erotica in books or movies all represent a major change from her past experience.
Diagnostic Topic #3 (description)
Sexual activity with husband used to occur two to four times each week. Now about once a month. Usually occurs on the initiative of her husband. Occasionally she will begin a sexual encounter because she feels that "enough time has gone by."
Diagnostic Topic #4 (patient's sex response cycle)
Does not get vaginally wet now and is not orgasmic. No problem with either in the past when sexually interested. Some vaginal discomfort associated with "prolonged" intercourse. No discomfort with vaginal entry.
Diagnostic Topic #5 (partner's sex response cycle)
No problem with husband's sexual interest, erections, ejaculation, and orgasm. Diagnostic Topic #6 (patient and partner reaction)
She is concerned that husband will lose patience and will want to leave the marriage. He has not said so explicitly. He has, however, suggested to her that she see her doctor about this. He is irritable sometimes and she thinks that her lack of sexual desire is the reason. While she is seemingly unconcerned about the impact of the absence of sexual interest on herself (she says that she could live the rest of her life without sex), she does regard this as a problem and as abnormal. They have not talked about his feelings toward the changes in the level of their sexual activity.
Diagnostic Topic #7 (motivation for treatment when sexual problem not a chief complaint)
Wanting treatment because of concern about marriage disruption, which she does not want to happen. Says that she loves her husband.
Case History "B"
IDENTIFYING INFORMATION: 48-year-old man,- married (second) 10 years,- two children (from his first marriage)
CHIEF COMPLAINT: "I have trouble with my erections." HISTORY OF THE PRESENT ILLNESS
Diagnostic Topic #1 (lifelong versus acquired)
Problems with erections only in the past five years.
Diagnostic Topic #2 (generalized versus situational)
Morning erections are full and stiff (i.e., no problem). No current sexual partners other than his wife. No erection problems in first marriage. Full erection with masturbation (a few times each month).
Diagnostic Topic #3 (description)
Erections full until intercourse attempted. Erection diminished (to about 60% of usual) in process of attempting vaginal entry. This pattern occurs on all occasions. On most attempts, is not able to gain vaginal entry.
Diagnostic Topic #4 (patient's sex response cycle)
Sexual interest and ejaculation unchanged compared to time before problem. Sexual interest, ejaculation, and orgasm also unchanged when masturbating.
Diagnostic Topic #5 (partner's sex response cycle)
Wife sexually interested. No problem with vaginal lubrication when interested. Usually orgasmic, and has no coital pain.
Diagnostic Topic #6 (patient and partner reaction)
Patient says that as a result of this problem, he feels that he is not "a man" anymore. Wife supportive. Says that her feelings for him have not changed.
Diagnostic Topic #7 (motivation for treatment when sexual problem is not a chief complaint)
Patient wants treatment. Has read about Sildenafil (Viagra) in the newspaper. Is interested in this for himself. He believes that his problem is "physical" (i.e., that it is "not in my head").
Case History "C"
IDENTIFYING INFORMATION: 30-year-old man,- married 10 years. CHIEF COMPLAINT: I've got Premature Ejaculation." HISTORY OF THE PRESENT ILLNESS Diagnostic Topic #1 (lifelong versus acquired)
Ejaculation fast with all sexual partners since first attempt at intercourse (including all four before marriage).
Diagnostic Topic #2 (generalized versus situational)
No current sexual partners other than his wife. Ejaculates quickly when masturbating but this is voluntary. He experiences no lack of control in this circumstance. When masturbating, he has warning that the feeling associated with ejaculation is about to occur so that stopping the further development of this sensation is entirely possible.
Diagnostic Topic #3 (description)
No warning before ejaculation when attempting intercourse. Ejaculation sometimes occurs before entry but usually after. Occurs within a few seconds (pushes or thrusts) after entry. Has tried several control methods (including distracting thoughts, anaesthetic creams, and condoms) but found that none of them were helpful. Neither emission nor orgasm is different compared to previous experience.
Diagnostic Topic #4 (patient's sex response cycle)
Interest is usual (high). Erections not a problem.
Diagnostic Topic #5 (partner's sex response cycle)
Wife interest unchanged. Usually experiences vaginal lubrication when interested. Orgasmic with touch. Non-orgasmic with intercourse, which she thinks is a result of him ejaculating quickly. No coital pain.
Diagnostic Topic #6 (patient and partner reaction)
Patient is concerned that wife wants to separate. He attributes this to sexual difficulties. Wife often angry. Says to patient that he is ejaculating fast purposely.
Diagnostic Topic #7 (motivation for treatment when sexual problem is not chief complaint)
Patient wants assistance, including immediate referral to specialist if necessary.
Case History "D"
26-year-old woman,- married 2 years,- no children.
CHIEF COMPLAINT: "It hurts when I try to have intercourse." HISTORY OF THE PRESENT ILLNESS Diagnostic Topic #1 (lifelong versus acquired)
Husband was first intercourse partner. Intercourse attempted first time on honeymoon. Did not achieve vaginal entry then or during subsequent attempts.
Diagnostic Topic #2 (generalized versus situational)
Never used tampons. Doctors have tried to do "internal" examinations but not able to. Never inserted own finger into vagina and also hurts when husband tries.
Diagnostic Topic #3 (description)
Pain located at vaginal entrance (versus deep),- burning in character,- not felt in particular area but rather all over, only occurs when vaginal insertion attempted and stops immediately after.
Diagnostic Topic #4 (patient's sex response cycle)
Before marriage was sexually interested, was wet when excited, and was orgasmic with husband's touch. Now, not interested, wet, or orgasmic with husband.
Diagnostic Topic #5 (partner's sex response cycle)
Husband usually sexually interested and does not have problems with erections, ejaculation, or orgasm.
Diagnostic Topic #6 (patient and partner reaction)
Patient feels incomplete as a woman and unfit as a wife. Is fearful of intercourse attempts. Husband quietly supportive.
Diagnostic Topic #7 (motivation for treatment when sexual problem is not chief complaint)
Referral to specialist previously suggested to patient but she was (and still is) apprehensive of what this would entail, especially if this involves a pelvic examination.
Case History "E"
IDENTIFYING INFORMATION: 23-year-old woman,- single,- has a sexual partner (male) of two years
CHIEF COMPLAINT: "I don't have an orgasm." HISTORY OF THE PRESENT ILLNESS Diagnostic Topic #1 (lifelong versus acquired)
Pattern has always been the same since the first intercourse experience at age 18. Does not experience orgasm during intercourse.
Diagnostic Topic #2 (generalized versus situational)
Has had orgasm with self-stimulation (masturbation) since age 15. Has not had orgasm with any sexual partner with intercourse or with touch.
Diagnostic Topic #3 (description)
Usual pattern with partner is brief genital stimulation before intercourse. Sexual arousal increases after entry but not to high level. Shy about giving directions to sexual partner. Usual pattern with masturbation is rapid arousal, vaginally wet, and orgasmic within a few minutes. Partner does not know that she is orgasmic when alone.
Diagnostic Topic #4 (patient's sex response cycle)
Often sexually interested, usually wet, and no coital pain.
Diagnostic Topic #5 (partner's sex response cycle)
Current male partner is sexually interested and does not have problems with erection, ejaculation, or orgasm.
Diagnostic Topic #6 (patient and partner reaction)
Patient feels her experience is not normal. Partner feels that patient is "missing something." She was previously pleased with intercourse experiences and unconcerned about not having orgasms with partner.
Diagnostic Topic #7 (motivation for treatment when sexual problem is not chief complaint)
Patient wants change. Is unsure what a referral involves.