More often than in other areas of medicine, the physician needs to take an active role in initiating the discussion of sexual matters. The inclusion of routine screening questions in the review of systems is one way to ensure that the area is not overlooked. Sexuality can be brought up comfortably after questions about menstrual function in women or questions about urinary function in men. Some clinicians prefer linking questions about sexual function to inquiries about relationships and personal satisfactions. To be effective, screening questions should be nonspecific, should not assume that the patient is heterosexual, and should project a nonjudgmental attitude.
Table gives an outline of the brief sexual history recommended by Ende et al. for screening purposes. Similar guides can be found in standard texts of psychiatry and of obstetrics and gynecology. It is useful to have such a framework in mind when obtaining a sexual history. A detailed guide to the assessment of sexual function has been published by the Group for Advancement of Psychiatry.
Screening questions vary with the age and the circumstances of the patient. Such questions should be routine or the physician may overlook problems, may return to the subject as an afterthought, or may experience tension or show embarrassment when trying to think of a screening question during the history.
When a sexual complaint is elicited or volunteered, a detailed history of the manifestations and associated symptoms should be obtained. The assessment of a sexual problem is similar to the assessment of a problem involving any other system. The history of a sexual complaint necessarily includes information about relationships with partners; tensions, anxieties, preconceptions, attitudes, and interpersonal factors must be taken into account. A complete history that includes careful attention to multiple determinants, a thorough evaluation of the patient as a person, and a consideration of the context of the symptoms usually yields a working diagnosis that enables the physician either to treat the patient or to make an appropriate referral.
The physician has the special responsibility of initiating a discussion of sexuality when coexisting medical problems are likely to affect sexual function. Patients may fear sexual activity after myocardial infarction or episodes of cardiac arrhythmia or may anticipate loss of sexual function after transurethral prostatectomy, hysterectomy, or other procedures or conditions involving the urogenital tract. Other disorders affect sexuality directly or indirectly through loss of libido or changes in body image. By anticipating sexual problems the physician can help the patient make adjustments and can sometimes prevent disorders that are secondary to fears or misconceptions.
Reassurances about confidentiality may be necessary during the discussion of sexual matters even though such confidentiality is ordinarily assumed in the doctor-patient relationship. The assurance of confidentiality is especially important when the physician also treats other members of the family or when the patient needs to discuss extramarital, deviant, or extralegal behavior.
The dignity of the patient should be kept in mind as the history is taken by observing such simple practices as using scientific words for sexual parts and sexual activities. Vernacular or slang expressions, which are sometimes used in a mistaken effort to put the patient at ease, and jokes or other informal remarks should be avoided even with a patient who uses them. Comments that may seem casual to the physician tend to live on in the patient’s mind.
Anticipation of discomfort may lead physicians to choose an evasive route of inquiry while patients might appreciate a direct question. Alternatively, some patients allude to sexual problems indirectly with idiomatic phrases, such as “changing nature” or “problems in relationships”; unless the physician is sensitive to feelings and language the reference may be missed, and the patient may assume that the physician is not interested in further information. Sometimes sexual problems appear indirectly through other complaints relating to the urogenital system.
Two types of patients—the elderly and the homosexual—present special problems in regard to the evaluation of sexual function. The sexuality of elderly patients is often not well understood by physicians. With reasonable health, men retain sexual interest and potency into old age. Impotence at any age is pathologic. Women also retain their sexual response but are more likely to suffer loss of their partner. Physicians may refrain from asking questions because they incorrectly assume that sexual satisfactions can no longer be achieved because of the aging process. Alternatively, patients silently accept a loss of sexual function because of similar misconceptions about the effects of illness or of aging. Depression may be a factor in such instances. Here the questions of the physician, coupled with some reassuring statements about the tendencies of many persons to assume mistakenly they will never be able to enjoy sexual relations again, bring the issue into the open and awaken new hopes in the patient.
Homosexual patients with disorders of sexual function often do not receive sympathetic medical care from heterosexual physicians. In one study of gynecologic care for lesbians a major hindrance in communication was the assumption by physicians that all patients are heterosexual. Homosexual men have similar problems in relating to heterosexual physicians. Some homosexual patients prefer going to homosexual physicians or to clinics run by homophile organizations. Many physicians share with the public at large serious misconceptions about homosexual behavior.
Kinsey and his coworkers showed how common homosexuality is in western societies. In his survey of more than 16,000 American men and women, Kinsey reported that approximately 4 percent of the men and 2 percent of the women are exclusively homosexual throughout their lives, and another 13 percent of the men are predominantly homosexual for at least 3 years of their lives. Occasional or intermittent homosexual contact was common in men and women. Approximately one-third of the men surveyed had had one or more homosexual contacts after puberty. In studies of homosexual men and women no association has been found between homosexuality and family structure, childhood experiences, or parental influences. Early gender nonconformity was the only predictor of homosexual development. Homosexuality was not a conscious choice of the individual but appeared to arise in a predetermined pattern. Homosexuality is also not associated with psychopathology or personality disorder and is compatible with normal productivity in society. In spite of increased acceptance of homosexuality in our culture, gay men and lesbian women often encounter personal rejection and job discrimination. Expectations of rejection may lead patients to conceal homosexuality from their physicians.
With the current epidemic of the acquired immunodeficiency syndrome (AIDS) in homosexual males, it is especially important for the physician to know the sexual orientation of male patients. This information may also provide insight into other disorders to which homosexual men are predisposed, such as hepatitis and proctitis. Homosexual women may also receive better medical care when their sexual orientation is understood. As in other areas of sexuality, a simple direct approach to the issue is generally welcomed by the patient. One experienced clinician advocates asking all patients whether they are homosexual or heterosexual; others simply ask all patients to identify their sexual preference. Whether or not AIDS is a clinical concern, male homosexual patients may be suffering from hidden fears of the disease and would be relieved by an explicit discussion. Even married patients may have covert homosexual activities that have important clinical implications. The parents of homosexual individuals often appeal to physicians for help. They need the reassurance that it is not their fault and that their children can lead satisfying, productive lives while accepting their homosexual orientation. It is important to emphasize that homosexuality is not a disorder and is not associated with psychopathology. It is not a choice taken by the individual and is not amenable to change.