Some sexual problems resolve spontaneously during the evaluation process, especially during an extensive workup. With those problems that persist, the physician must decide whether to treat the patients or to refer them elsewhere. The management of sexual dysfunction due to organic causes; sexual problems related to such physical illnesses are appropriately handled by the same physician who treats the physical disorder. Generally, the secondary or reactive psychogenic disorders are most amenable to brief counseling, especially when they occur in response to stress. Patients with more deep-seated problems may best be handled by psychiatrists.
The technique for counseling by the family physician cannot be mapped in a formal way. Sufficient time, a relaxed atmosphere, and genuine interest shown by the physician are necessary. The patient should be encouraged to tell the full story with careful attention to the circumstances surrounding the onset of symptoms, to the attitudes of the patient and partner, to the nature of the patient’s relationships, and to factors that might lead to anxiety or depression. Although it may be necessary to review the physical details of the sexual practices, resolution of symptoms may occur with only indirect reference to sexual techniques. Sexual inadequacies often produce anxiety, which in turn leads to further defeats and to inhibition of libido. Without reduction of anxiety and lifting of depression, the process cannot be reversed.
Some physicians choose not to attempt sexual counseling, while others find it a satisfying aspect of practice. In either case, physicians should be familiar with the resources in their communities and understand the capabilities and limitations of various treatments. Physicians who do not undertake sexual counseling themselves usually have referral relationships with gynecologists, urologists, and psychiatrists. In addition, many communities have family services and counseling services. Referral should be tailored to the problems and to the lifestyle and personality of the patient. Some patients prefer to discuss the intimate details of a sexual problem only with a gynecologist or urologist. Others should be directed to a reputable clinic where behavioral approaches to the treatment of sexual dysfunctions are available.
Referral is often a difficult transition for a patient because it implies turning to a stranger after having confided in a physician who has understood the problem. A previously eager patient may lose motivation when referred elsewhere. Some physicians have counselors associated with them in their offices. This system has the advantage of maintaining the personal relationship between counselors and physicians but has the disadvantage of encouraging physicians to rely judgment, and reality testing, enables the physician to determine whether the sexual symptom is an aspect of a mental disorder. Rarely, sexual problems, especially loss of libido, may be the presenting sign of a disorder of the central nervous system; an examination of mental status can reveal early signs of dementia or of other organic brain conditions.