Despite the importance of issues relating to sexuality, many women find it difficult to talk to their physicians about sexual concerns and many physicians are uncomfortable discussing sexual issues with their patients. In one survey, 71% of adults said they thought their doctor would dismiss any concerns about sexual problems they might introduce, and 68% said they were afraid that discussing sexuality would embarrass their physician (84). Through the use of a structured questionnaire and review of the records of 1,065 women who consecutively attended 37 family practices in areas of high, medium, and low socioeconomic status, 40% of women had at least one form of sexual dysfunction according to diagnostic criteria of the International Statistical Classification of Disease (ICD-10). Only 4% had a prior entry in their medical record relating to sexual problems (85).
There are numerous reasons physicians are reluctant to discuss issues relating to sexuality with their patients. Anxiety about physicians’ perceived inability to treat sexual problems, unwillingness to spend the time required to accurately assess sexual concerns, personal discomfort when discussing sexual matters with patients and distress arising from their patients’ history of sexual-related violence are all potential barriers. Not asking about sexual function suggests to patients that sexuality is not important and should not to be discussed. Moreover, many gynecological interventions and a number of gynecological conditions interrupt sexual function, necessitating the inclusion of sexual health in gynecological assessment. Asking about sexual concerns gives physicians an opportunity to educate patients about the risk of STDs, encourage safer sex practices, evaluate the need for contraception, dispel sexual misconceptions, and identify sexual dysfunction. Many sexual concerns can be resolved by providing factual information and reassurance. Management of sexual dysfunction requires appropriate biopsychosocial assessment and intervention. Even when patients currently have no sexual problems, when gynecologists routinely inquire about sexual health, they can teach that future sexual issues can be addressed in a professional, confidential, and nonjudgmental setting.
Interviewing Techniques To be sufficiently comfortable to establish rapport and trust with patients, physicians need to be familiar with the components of a sensitive, detailed, sexual assessment and the general principles of management of dysfunction. Good listening skills and attention to nonverbal cues are helpful. The use of straightforward language that patients can understand and
Nonsexual rewards: emotional intimacy, well-being, lack of negative effects from sexual avoidance Willingness to find/be receptive Sexual stimuli with appropriate context Sexual satisfaction +/− orgasms Subjective Arousal psychological biological Arousal & responsivedesire Spontaneous “innate” desire Processed
Figure 11.2 Algorithm for screening sexual dysfunction.
acknowledge, and the recognition that many people find it difficult to discuss these sensitive, intimate, and extremely common issues are necessary.
A few open-ended questions can initiate the subject of sexual function (Fig. 11.2). Sexual inquiry is part of the medical history taken during a routine gynecologic assessment. There is evidence that an introductory sentence would greatly increase the chance a woman will identify her sexual problem. Listed in Table 11.3 are some examples of screening questions related to particular obstetric–gynecologic circumstances.
Optimally, the detailed assessment is obtained from both partners. Questions can be directed to the couple or the individual partners, depending on the circumstances (Table 11.4). When dyspareunia is present, detailed questioning is necessary (Table 11.5).
Physical Examination Routine pelvic examination is an essential component of general medical care; this is not the case with women who seek care for sexual concerns. Given the prevalence of negative past sexual experiences, including abuse, a pelvic examination should be performed only in the presence of a definite indication, and the procedure should be clearly explained to the patient (Table 11.6). Management of dyspareunia mandates careful vulvar, vaginal, and pelvic examination. A physical examination can confirm normal anatomy and the healthy nonaroused state of the genitalia, it does not confirm healthy sexual function. Nevertheless, such an examination can be both instructive and therapeutic.