Once a sexual complaint has been elicited, a detailed history of specific behavior should be obtained. Terms for sexual disorders may be misused, exaggerated, or misunderstood by patients. Other sexual complaints reflect misconceptions, ignorance, or fears, and the problems prove to be nonexistent when the behavior is explored in detail. Patients may overestimate or underestimate the extent of a problem, depending upon their psychological orientation. For example, one woman believed herself to be frigid because her sexual partner, for neurotic reasons of his own, compared her in a disparaging way to his previous partners. Much can be learned from the first instance of a sexual problem, from the pattern of behavior after the onset of symptoms, and from inquiring whether the problem is present consistently or varies with the circumstances or nature of the sexual practice. In every disorder there is a complex interaction between the physical and the emotional, and every sexual symptom needs to be evaluated in the context of the relationships between the patient and the sexual partners and in the context of the sexual practices and attitudes of the patient. A past history, including early experiences, attitudes of parents, and attitudes toward childhood sexuality, development, marriage, and pregnancy may be relevant. Establishing the relationship of sexual function to general health is of fundamental importance, and it is essential to take a complete drug history on every patient, both in regard to drug abuse and to use of prescribed drugs. An understanding of the daily habits of a patient may provide important clues to diagnosis. Fatigue, anxiety, and stress, as well as the timing of the use of alcohol, drugs, and medications, can provide insight into the underlying cause.
A general physical examination with special attention to an examination of the genitalia is essential. At times patients conceal or are unaware of abnormalities of the genitalia. On the other hand, otherwise sophisticated patients may harbor irrational misconceptions or feelings of shame about their bodies and may require concrete reassurance about the adequacy of the genital apparatus. Even if the diagnosis is that of a psychogenic basis for the sexual dysfunction, the patient may disregard assurances that there is no organic basis unless the workup for possible medical causes of the complaint has been thorough.
Appropriate laboratory tests to screen for systemic illnesses together with the specific test for various endocrinopathies, neurologic conditions, and other systemic disorders that may present with sexual problems may be indicated. Attention to the mental status, including assessment of mood, affect, thought content, use of alcohol, and the midlife depressive syndrome that is often related to secondary impotence may be further complicated by alcohol abuse. Barbiturates and opiates also can cause reduced libido and impotence. Antihypertensive agents, tranquilizers, hypnotics, analgesics, and sedatives may also impair sexual function, particularly in the male.
Sexual disturbances may develop after traumatic incidents. For example, impotence can develop after cystoscopic examination or after vasectomy, even though neither procedure has any direct physiologic effect upon sexual function. An automobile accident, assault, pregnancy, contraceptive difficulties, disturbing sexual encounters, and a host of other emotionally significant episodes may cause sudden changes in sexual functioning. In women, either sexual assault or childhood sexual abuse can lead to long-standing sexual inhibition and dysfunctions. Many women are reluctant to share the history of a rape or of an incestuous experience; others may have little memory of traumatic events, especially when they occurred in childhood, although these events may exert a profound effect on adult sexuality.
The diligent physician may inadvertently overdiagnose sexual disturbances. Most patients have self-doubts and sexual dissatisfactions even though they are functioning adequately. It is well to have in mind the concept of a threshold of disturbance to separate the normal vicissitudes from problems that require treatment.