Ulrike Brandenburg, Anneliese Schwenkhagen
The aim of this chapter is, first, to encourage health-care professionals to overcome the awkwardness or embarrassment they might feel in discussing sexual matters with their patients; second, to advocate the value of taking a detailed sexual history; and third, to make clear how taking such a history constitutes, in itself, the beginning of treatment. As a resource for practitioners, the chapter also incorporates a selection of analytic questions that can contribute to developing a thorough sexual history.
Sexual dysfunction is not absolute. It stands in opposition to sexual fulfillment, within the sexual norms of the culture. Sexual dysfunction differs from culture to culture, and from time to time. Similarly, each patient has her individual sexual norms that differ from one time of her life to another, as does her health-care professional. Consequently, any sexual dysfunction will, inevitably, present as an individually defined disturbance (see Chapters 3.1—3.4 of this book).
There is often considerable inhibition that must be overcome before the patient will bring up a sexual problem. The problem may, however, have been troubling her for a long time. Health-care practitioners who do not bring up the topic of sexual health, because of their own uneasiness, contribute to the patient’s suffering.
The challenge of the sexual conversation
Speaking with a patient about sex is very different from speaking with her about high blood pressure, cardiac health or orthopedic problems. In these areas, there are clear definitions, clear questions to ask, and (relatively) clear answers. Physicians do not feel inhibited in bringing up these topics with a patient, quite in contrast to talking about sex. The health-care professional must examine his or her own comfort level in discussing sex, separating the professional side from personal emotions, and putting aside feelings of awkwardness, embarrassment, hesitation, or intimidation from the patient.
The discomfort of the health-care professional in talking about sexual health should help in empathizing with patients, giving some insight into how they are likely to feel when discussing their sexual life. Neither physicians nor patients have learned how to conduct such conversations, as they are not part of cultural training, and are rarely part of professional training.
Waiting for the physician to speak
While speaking with patients about sexual matters is a challenge for many, it is a topic patients are waiting for their healthcare providers to broach. Considering the prevalence of sexual dysfunction among women young and old, the challenge needs to be met. Sexual dysfunction frequently leaves the patient feeling inadequate and deeply flawed as a person. It affects her selfimage more deeply than most medical conditions. For the patient simply to discover she is not the only one with the problem can be a relief, in addition to knowing that there is someone who understands the condition. One woman said, “I was so happy when I finally got to learn that my illness had a name, a diagnosis.”
Many patients have gone from one physician to another, from consultant to psychologist to psychotherapist, struggling to discuss the problem, only to feel frustrated by suggestions to relax, or drink a glass of water, or simply to wait for the right partner. The discomfort the practitioner feels in bringing up the topic of sexual behavior has condemned patients to a fruitless odyssey.
Avoiding the sexual conversation
Sexual problems exist, and they contribute to all manner of symptoms. If the patient is not engaged in the sexual conversation, the physician must be avoiding it. What strategies are used to avoid talking about sex with patients? One gynecologist related a conversation concerning the oral contraceptive pill. As she was leaving the room, the patient said, “Oh, by the way, I don’t have an orgasm.” After catching her breath, the physician responded by suggesting a physical examination. However, as she conducted the examination, the gynecologist felt sure that it was not the appropriate diagnostic intervention. After completing the examination, she told the patient everything was fine, and then found herself able to say, “It’s good that you mentioned this problem. It is something we need to deal with,” and made a further appointment with the woman.
As awkward as it may be to talk to patients about sex, and no matter how helpless or embarrassed it may make the physician feel, patients may be every bit as uncomfortable themselves. The responsibility to initiate the sexual conversation belongs to the professional.
Initiating the sexual conversation
The hardest part of the conversation about sexual health is often simply getting started. Although the patient may bring up a sexual problem, she is often waiting for the invitation from the health-care professional. Frequently, the woman is presenting for other complaints, anything from cardiac problems to chronic osteoporosis. In studies, patients clearly indicate that they would welcome their doctor saying something like, “By the way, I just wanted to mention that if you find yourself having any sexual problems at any point, that is something we should talk about.” In contrast, there are ways to start the sexual conversation in a manner that immediately stops it in its tracks. The direct approach, such as asking, “What about your sex life?”, tends to elicit the response that everything is fine even when that may not be true. Patients seem to experience the direct approach as an attack. They prefer a respectful, low-key invitation. To the earlier question, if they respond by saying, “Well, yes, I actually do have a problem,” you might say, “Tell me about it.” Many patients, particularly older ones, are embarrassed to talk about a sexual problem even though they want to, and therefore may recoil from the idea. But once it has been broached, they feel at liberty to discuss it again in future. It is helpful to be aware of the kind of conversation that will be of most use, both in terms of providing comfort to the patients and a detailed sexual history to the clinician.
Concrete sexual conversation
It is important to talk about sexual problems in a concrete manner. The patient must understand that the purpose of the conversation is to understand the problem, and what it means to the woman, so that the health-care provider can make an accurate diagnosis and recommend an effective course of treatment. When doctors are embarrassed to talk about sexual matters, they rarely take enough time to understand the problem. For instance, many patients present with the complaint that they are unable to achieve orgasm, appearing to have general orgasmic dysfunction. However, when pursuing the matter further, it may turn out that the woman does not have experience in trying to have an orgasm, or has attempted it incorrectly, thus showing a lack of experience rather than a dysfunction.
It may take a lot of courage for an older woman even to mention her orgasm problem. She needs to be encouraged to tell exactly what she has done to attempt to achieve orgasm. Concrete questions may help, such as the following. Have you ever examined your vagina? Have you looked at your labia? Have you seen your clitoris? Have you ever touched these areas? Have you ever caressed them? Have you ever put some saliva on your fingers and tried to arouse yourself? It often turns out that a nonorgasmic woman has done little of the above. She may have tried only coitus.
A similar situation pertains to cases of female sexual desire disorder. Typically, when a patient says she has no desire, she answers no to the query, “Have you had any sexual thoughts or fantasies recently?” But when asked, “Please take a moment more to think carefully. Have you had any sexual thoughts at all in recent weeks?”, she will reply that indeed she did. When asked about masturbation, the answer was also yes. However, when asked, “Have you been attracted recently to any man or woman?”, the response was, “No, of course not.” Obviously, this response is consistent with how the patient presented her problem. While patients express how things are in general, their focus is on the problem that is in the forefront of their minds and they fail to notice the exceptions to the rule. It is often necessary to say, “Please think again, just to make sure you are being completely accurate.” In this case, that question elicited the response, “Oh, yes, there was a man at a party.” Without careful questioning, the patient would not have brought him to mind. She felt guilty in thinking of him, almost denying to herself the attraction she felt toward him. The attraction may have been slight, but the health-care provider’s proceeding in this manner shows the situation to be less black-and-white than when first presented. As a result, the monumental quality of the problem may be undermined and its dependence on technique and situational factors revealed, with the consequence that it becomes more manageable.
Often in cases of lack of desire, when questioned appropriately, the woman remembers a recent instance when she felt some sexual attraction toward her partner, although it does not come readily to mind. Careful questioning can reveal that many women supposedly suffering from hypoactive sexual desire disorder do have sexual fantasies and masturbate from time to time. In such cases, it would be inappropriate to treat them with medication.
Meaningful sexual conversation
Obtaining concrete details concerning the patient’s sexual problem is only half of the problem. There is also the question of what those facts mean to the patient. Physicians tend to be trained to focus on facts; however, these cannot be isolated from their meaning, whether that results in pleasure or discomfort.
It is not the symptoms that cause problems to patients but their significance which determines how they are viewed. Indeed, the doctor may discover a problem that does not distress the patient, who is unlikely to do anything about it. For that reason, a full sexual history needs to incorporate the meaning and significance of any symptom under discussion, and these may not be at all what the practitioner expected. Thus, questions about the significance of symptoms need to be as thorough as the factual questions about the details themselves.
Questions for a detailed sexual history
The diagnostic dimension of a sexual history involves interplay between the facts and their significance. Listed here are a number of suggested questions to address separately sexual function and the meaning of sexual dysfunction. The questions, therefore, comprise three elements: the functional aspect, the meaning of these functional problems for the patient, and the past sexual experiences of the patient and their significance. The questions do not need to be asked in order but should be asked in a comfortable sequence.
• What is the problem?
• When did it begin?
• How often does it (the symptom) happen?
• When it happens, how much or how often does it happen?
• In which situation does it (the symptom) appear?
• In which situation does it not appear?
• From which activities/technique does it appear?
• From which activities/techniques does it not appear?
• In which kind of relationship does it appear?
• In which kind of relationship does it not appear?
• How often do you have sexual desire? arousal? orgasm? satisfaction?
• Do you sometimes masturbate?
• How often?
• What works well for you?
• What does it (the symptom) mean to you?
• Does it lead you to any feelings of shame or frustration?
• Are you anxious about not satisfying your own expectations?
• Do you feel your own sexual potency to be in some way lacking?
• What would it mean to you if it (the symptom) disappeared? What would be different?
• What does (the symptom) mean to your partner?
• Who suffers from what?
• Who do you feel suffers more?
• Do you talk about sex with your partner?
• As a result of it (the symptom), is there any withdrawal from the relationship? On your part or that of your partner? Emotionally, sexually, or both?
• Does your partner feel responsible or guilty in some way because of your having it (the symptom)?
• Do you think your partner has anxieties about not satisfying your expectations?
• What would it mean for your relationship if it (the symptom) disappeared?
• Sometimes it (the symptom) can protect a couple from having to deal with some other issue; if that were the case, what do you imagine it could be for the two of you?
Past sexual experience
• What were your first experiences with sexuality?
• What were your parents’ attitudes toward sexuality?
• What do you remember of your first experiences with masturbation?
• How did you experience puberty and adolescence?
• When did you have your first sexual experiences with a partner?
• Did you ever have any issues regarding whether you were more attracted to men or women?
• When did you have your first experience with sexual intercourse?
• What were the early experiences like for you?
• Have you had children?
• Did you ever want to have children?
• Have you been pregnant?
• Have you had an abortion?
• How have you practiced contraception?
• Have you had any unconventional sexual experiences (ones other people might think unusual or odd)? Have you ever wished to have any such experiences?
• Have you ever experienced sexual violence or sexual misconduct?
While knowing the kind of questions to ask is of considerable help in feeling comfortable and able to start a conversation on sexual matters, the practitioner may be more at ease by recognizing the following:
• Don’t be too focused on finding a solution. Sexual problems can be complex. For instance, there may be relationship issues involved, but simply airing the problem will be bringing some measure of relief to the patient.
• Don’t think that talking about sexual health problems has to take more time than talking about others sorts of health problems.
• Don’t put yourself under time pressure. When a patient finally discusses her sexual problem, the pressure she feels may project onto the practitioner. It is important to remember that sexual problems are usually long-standing, not acute. If time runs out the patient can always return for another office visit.
Talking as a treatment
While such concrete questions have clear value for diagnostic purposes, they can also be of benefit to the patient. Patients have the opportunity to ask questions as diverse as, “Am I disturbed because I don’t feel any desire for sex?”, “Do I have the right kind of orgasms?”, and “Is it okay for me to still be wanting sex when I am seventy-two?” Such questions may have been weighing on the patient’s mind for a long time; the issue can be cleared up quite simply in such a conversation.
Additionally, referring back to the anorgasmic older women who had simply not been using an effective technique, it may not be the so-called problem that requires treatment, and recognizing this may be the end of the matter. Once again, it is a matter of delicate questioning. The patient might be asked, “Now you know that, is it okay for you, or do you want to change anything?” Patients are often satisfied with that new knowledge and do not want to do anything further. Others may prefer to be coached on how to achieve orgasm.
The therapeutic value of the diagnostic conversation is that it often reveals a completely new perspective for the patient. For this reason, it is important to include the partner in the conversation. A more comprehensive understanding of the sexual problem is likely to emerge. However, in general, it is better to have the initial talk with the woman alone to allow her the opportunity to speak about those things she might be reluctant to bring up in front of her partner, such as past sexual abuse or other partners. In a conversation with the couple, the woman’s lack of desire, which may have been viewed as her problem, might be revealed as being much more of an interaction or communication problem between the two people.
Taking a sexual history is usually seen as part of the first diagnostic step on the road toward a solution to the sexual problem. It can be much more than that. The conversation about the patient’s sexual history is actually the beginning of treatment. Feedback from patients often reveals that if they had realized the intimate questions they were going to be asked they would never have had the courage to come. But they also say, “I am so happy we had this talk.” When they come again, it is discovered they have taken the talk as a model of what is possible, that conversation about sexual health is possible, and that they have taken the first step in getting past their paralysis. Many patients use their conversation with their physician as a model to strike up a conversation with their partner, their close friend, or their sister, and report this on their return visit. This is the start of treatment.
The benefit of taking the kind of precise and detailed sexual history advocated here is that it provides a clear basis for any necessary next steps for treatment. For the health-care professional, this provides a very thorough understanding of the situation, rather than wasting time waiting for the information to emerge over time.