Initial Evaluation of Sexual Problems

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Many patients would benefit from detection and treatment of sexual problems; however, many clinicians do not ask, and patients may not volunteer the information. In the Global Study of Sexual Attitudes and Behaviors, which surveyed more than 27,000 adults age 40 to 80 in 29 countries, 49% of women and 43% of men reported experiencing at least one sexual problem; fewer than 20% had sought medical assistance for sexual issues (Moreira et al., 2005). Health care providers should proactively and routinely address sexual health.

The sexual health interview may be approached with a screening or abbreviated method, followed by in-depth questioning, if necessary (Nusbaum and Hamilton, 2002) (Box 43-1). The answers on the detailed sexual history then

The clinician can use normalization or universalization techniques. In normalization the clinician introduces emotionally laden or difficult subjects by implying these experiences are quite prevalent: "Many people have been sexually abused or molested as children. Did you have any experiences like that when you were young?" Universalization phrases questions as if everyone has done everything, making an affirmative answer easier for sensitive questions. For example, patients may be asked "How often do you masturbate?" instead of "Do you masturbate?" The clinician should also reassure the patient about physician-patient confidentiality.

Jack Annon in 1976 proposed the PLISSIT model to approach sexual concerns: Permission, Limited Information, Specific Suggestions, and Intensive Treatment (Box 43-2). The clinician can alternatively use the ALLOW acronym: Ask, Legitimize, Limitations, Open up, and Work together (Hatzi-christou et al., 2004), as discussed next.

Ask. Questions regarding sexual functioning should be asked in a matter-of-fact yet sensitive manner. Physicians should avoid terms that make assumptions regarding patients' sexual behaviors. When inquiring about past or recent sexual encounters, the clinician may inquire "with men, women, or both?" Using the term "partner" instead of "husband" or "boyfriend" or "wife" or "girlfriend" may allow patients to discuss their sexual orientation openly. Slang words should be redefined in medical terminology so that the clinician and patient may communicate clearly.

Legitimize. By acknowledging the clinical relevance of sexual dysfunction, the clinician legitimizes the patient's sexual problem. Opening questions also can be linked to the patient's medical problems: "Many people with hypertension and heart disease notice a change in sexual functioning. Have you noticed any change?"

Limitations. The patient's knowledge may have limitations, and patient education may address the patient's perceived sexual dysfunction. For example, an older man with longer time between erections may not know the refractory period normally increases with age. Patient education and

Figure 43-2 Circular model of female sexual response showing cycle of overlapping phases. (From Basson R, Schultz WW. Sexual sequelae of general medical disorders. Lancet 2007;369:409-424.

direct the physical examination and appropriate laboratory testing. A physician may open the sexual history questioning with an inclusion technique: "Sexual health is important to overall health, therefore, I ask all my patients about it. I'm going to ask you a few questions on sexual matters now."

Plateau Phase

precedes both cycles in this model. The phases illustrated are excitement, plateau, and orgasm. The length of the plateau phase is variable. Women may have a brief plateau followed by orgasm (cycle Q or a long plateau with no orgasm (cycle B). Women may have multiple orgasms before resolution, although many do not (cycle A). For men with premature ejaculation, the plateau phase is brief. After ejaculation, men enter a refractory period lasting minutes to hours during which they are unable to ejaculate.

precedes both cycles in this model. The phases illustrated are excitement, plateau, and orgasm. The length of the plateau phase is variable. Women may have a brief plateau followed by orgasm (cycle Q or a long plateau with no orgasm (cycle B). Women may have multiple orgasms before resolution, although many do not (cycle A). For men with premature ejaculation, the plateau phase is brief. After ejaculation, men enter a refractory period lasting minutes to hours during which they are unable to ejaculate.

reassurance may eliminate his perceived "sexual dysfunction." Physicians should recognize their own limitations and, if necessary, refer a patient to the appropriate specialist for further evaluation and treatment of a sexual dysfunction.

Open up, for further discussion and evaluation. A detailed sexual history may be needed to evaluate fully a patient's

Box 43-1 Questions for a Detailed Sexual History

Are you currently sexually active? Have you ever been sexually active? Are your sexual partners men, women, or both? How many sexual partners have you had in the past month? Past 6 months? Lifetime?

How satisfied are you with your (and/or your partner's) sexual functioning?

Has there been any change in your (or your partner's) sexual desire or the frequency of sexual activity?

Do you have, or have you ever had, any risk factors for HIV (blood transfusion, needle stick injuries, IV drug use, STIs, partners who placed you at risk)?

Have you ever had any sexually related diseases? Have you ever been tested for HIV? Would you like to be? What do you do to protect yourself from contracting HIV? What method do you use for contraception? Are you trying to become pregnant (or father a child)? Do you participate in oral sex? Anal sex?

Do you or your partner(s) use any particular devices or substances to enhance your sexual pleasure?

Do you ever have pain with intercourse?

Women: Do you have any difficulty achieving orgasm?

Men: Do you have any difficulty obtaining and maintaining an erection? Difficulty with ejaculation?

Do you have any questions or concerns about your sexual functioning?

Is there anything about your (or your partner's) sexual activity (as individuals or as a couple) that you would like to change?

From Nusbaum MRH, Hamilton CD. The proactive sexual health history. Am Fam Physician 2002;66:1705-1712.

HIV, Human immunodeficiency virus; STIs, sexually transmitted infections; IV, intravenous.

Box 43-2 PLISSIT Model for Approaching Sexual Problems

Permission

For physician to discuss sex with the patient. For the patient to discuss concerns now or in the future. To continue sexual behaviors not potentially harmful. Limited Information

Clarify misinformation. Dispel myths.

Provide factual information in a limited manner. Specific Suggestions

Provide specific suggestion directly related to the particular problem. Intensive Treatment

Provide highly individualized therapy for more complex issues.

Modified from Annon JS. The Behavioral Treatment of Sexual Problems. Honolulu, Enabling System, 1974-1975.

sexual concern (see Box 43-1). If the time constraints limit the current visit, the physician should offer the patient a future follow-up visit.

Work together, to develop a treatment plan. In some cases, simply following the previous four steps may be therapeutic. Many clinical cases can be managed with brief education or limited advice, such as discussing normal physiologic sexual changes with aging or recommending books or products (e.g., water-based lubricant for vaginal dryness). When a referral has been made, scheduled follow-up supports the patient during the process and helps address administrative or adherence issues. Counseling may be extremely important, and the physician should research local resources. The American Association of Sex Educators, Counselors, and Therapists (AASECT) may be contacted for referral information (http://www.aasect.org).

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