How can physicians manage sexual dysfunction problems?
Sexual function for both men and women depends upon the interplay of physical, psychological and relationship factors between each member of the couple. The “10 Minute Sexual History” uses the tradition medical approach to delineate a sexual concern. Taking a focused sexual history of both partners’ functioning once a sexual problem is uncovered can help develop a management plan. The six squares of a 2 X 3 grid cover the main areas of a sexual functional inquiry for the couple. About half of partners of the identified patient will also have sexual dysfunction. A common example is dyspareunia due to postmenopausal atrophy and lack of intercourse for the partner of an aging man dealing with erectile dysfunction.
Most patients with a sexual concern will present on their own. Taking a history around emotionally loaded issues such as abuse, sexual orientation, and affairs may be most easily accomplished individually. But sex is not just a solo sport; usually it is shared with a partner. Treating the couple as the patient generates more diagnostic information from the “consultant” spouse, and allows both partners’ concerns to be addressed. Looking at sexual problems as affecting the couple as a system increases chances for successful outcomes.
Couples are often hungry for information about sexuality. The resources section suggests a number of resources, including “The New Male Sexuality” by Bernie Zilbergeld. Providing sex education is helpful for most couples, and sometimes it is all they need. It can prepare couples for, and is used extensively in more formal sexual therapy. The goal of sexual counselling is to help reduce sexual performance anxiety for both members of the couple, to allow the sexual response to occur without being overwhelmed by stress mediators such as adrenalin. Many physicians are uncomfortable in talking about sexuality with their patients, being afraid of “opening Pandora’s Box”. A graduated approach, using the PLISSIT model can aid physicians with their own comfort levels in helping patients’ sexual concerns.
Permission giving applies both to doctors as well as patients. Patients need Permission to know that sexual health concerns are appropriate topics of discussion in a medical context. Physicians need to understand their own biases and comfort levels in discussing potentially loaded issues such as premarital sex, abortion and abuse. For some, this will mean identifying patient concerns and making appropriate referrals so that patients can receive help for their problems.
Limited information is immensely helpful for patients. The assumption that since the sexual revolution patients are well informed about sexual issues is false. Brief sex education is often indicated. Normalizing issues such as masturbation, and reminding patients of the risks associated with sexual behaviour is often gratefully received. Partners of men dealing with rapid ejaculation and/or erectile dysfunction often feel that the man is “doing this to hurt me”. Helping them understand that the man is not behaving in this way on purpose, but is dealing with a pathophysiological process can be the first step in reducing anxiety for the couple and begin to help them move forward.
Specific suggestions about sexual behaviour are brief interventions that can occur within the context of a regular office visit. For a man with variable erectile dysfunction, suggesting sex earlier in the day, and not after a heavy meal with alcohol; for couples with young children, urging them to put a lock on their bedroom door; or for the man with rapid ejaculation, offering a trial of an SSRI antidepressant on a prn basis are some examples. These suggestions often will be better acted on if the couple, rather than the individual patient, has been present in the office. Most sexual problems, perhaps as many as 75%, can be successfully solved with the above steps.
Intensive therapy is reserved for those in whom briefer interventions have failed. This may be done by the primary care physician themselves, or involve appropriate referral to urologists, psychiatrists, marital and/or sex therapists as needed. Solution-focused, cognitive-behavioural couple sex therapy can often help couples move forward with their sexual concerns. Given the multiple causes of sexual difficulties, a thorough history is imperative to determine whether management should be medical, psychological, relational, or a mixture of these.
Physicians now have more treatment options than ever before to help their patients better deal with sexual dysfunction. The challenge remains to help physicians and their patients discuss sexual concerns as they do other medical problems, in a direct and forthright manner. This will lead to an integration of sexual health within a patient’s overall medical care.