32: Sexual Problems

Sexuality encompasses an enormous range of behaviors, beliefs, desires, experiences, and fantasies that patients may want to discuss with their health care providers. Sexuality also may have legal, medical, moral, political, and religious aspects. This chapter intends to give the practicing clinician basic practical knowledge of human sexuality and useful tools for managing common problems.

Patients with sexual concerns report feeling most comfortable discussing these issues with their primary care physician and expect to receive advice and treatment. In large studies of adult patients, more than 70% considered sexual matters to be an appropriate topic for the primary care provider to discuss. Yet, evidence of discussion about sexual problems has been found in as few as 2% of the notes of such providers.

Primary care practitioners are in an optimal position to evaluate sexual problems, as they often have the most comprehensive and long-lasting relationship with the patient. In contrast to most other medical diagnoses, however, it is the patient who usually defines when a sexual problem exists. That is to say, a “problem” exists only if and when the individual or the partner is troubled by his or her level of sexual desire, response, or function.

Levine (2010) posits that sexual issues can be usefully conceptualized within three broad categories: sexual worries, problems, and disorders. Although referral to medical or mental health specialists (or both) may be indicated in more severe situations of disorders and dysfunctions, many worries and problems can be successfully addressed by the primary care practitioner. When questions about sexuality are approached in an open, matter-of-fact manner, most people are relieved and respond positively. They appreciate the affirmation that these issues are valid and important, whether or not they have current sexual concerns or are sexually active (Table 32-1).

To provide patients with helpful responses to their sexual health concerns, health professionals need the following:

• Willingness and ability to discuss sexual topics comfortably.

• Awareness of the range and diversity of human sexual practices and concerns across and within cultures, as well as awareness of the importance of the circumstances or conditions under which individuals function best.

• Ability to separate their own personal beliefs and values from those of patients. Unless the practitioner encounters information indicating objective harm to someone involved, it is important to maintain a nonjudgmental demeanor.

• Skill at taking a history of sex problems in appropriate detail.

• Knowledge of simple interventions such as permission-giving, transmitting accurate information, providing specific suggestions (e.g., for making sex less pressured and more pleasurable), and making referrals to other resources, when appropriate.

As health professionals, we may have personally had limited sexual experience, as well as questions and problems of our own, and consequently may be uncomfortable in discussing particular sexual material. Time, thought, and experience, however, can build confidence and expertise in talking about sexual problems. Health care providers can increase their comfort level by examining their own attitudes, beliefs, assumptions, and experiences; reading the literature; discussing sexual issues with friends and colleagues; and routinely incorporating sexual health questions into the general health assessment of patients.

Of course, no one—patients or caregivers—should be forced to talk about sexuality. It is important for everyone to recognize the limits of their own interest, comfort, and competency. However, sexual health is an integral part of health care. All who deal with patients should be alert to the possibility of sexual concerns and, at a minimum, be able to respond with nonjudgmental listening and reassurance. When in the best interest of the patient, health care providers can refer to a colleague who is comfortable and competent in discussing sexual issues.

Knowledge of human sexuality has expanded remarkably since the modern pioneering efforts of Kinsey and Masters and Johnson—who published some of the earliest evidence-based treatment of sexual problems. While initially focusing on the range of sexual behaviors and the treatment of dysfunctional mechanical problems, the field has grown to include and better understand sexual motivations, the critical importance of sexual excitement and desire, and of the contexts required to produce sexual fulfillment.

Research in human sexuality has burgeoned, as has knowledge of the often-negative effects of long-accepted sex roles. And we are learning more about variations among individuals in terms of the role sexuality plays in life. A particular sexual problem may be perceived as central and significant to one patient, yet be seen by another to be peripheral or minor. Clinicians must be cautious to not make assumptions about the significance of various sexual problems, but rather assess and discover whatever meaning the issue has for that individual or within a particular couple.

Motivations for human sexual expression are complex and numerous. Different motivations exist throughout the life cycle, including variations in times of illness or periods of health. Motivations vary from culture to culture and from individual to individual. They may include the need to express love, the need for physical release, reproduction, recreation, the need to increase self-esteem—or combinations of all the above. Conversely, sexuality can also be used to coerce, control, or degrade others. Sexuality may be the focus of addictive or compulsive behavior.

Sexual worries or difficulties are likely experienced by most people at some period of life, and may result from developmental growth and changes in life circumstances rather than from pathology alone. Sexual problems are sometimes a blessing, such as when they compel a person to get help for symptoms that indicate underlying medical problems, problems with self-esteem, or problems with a relationship. Surprisingly, for some people, seeking help for problems involving erection or orgasm may be more acceptable than seeking help for issues involving self-esteem.

Because the language of sex is broad and varied, primary care practitioners will find it helpful to become familiar and comfortable with the vernacular and to be able to discuss calmly and in detail matters such as masturbation, sexual positions, oral sex, anal sex, penis size, and breast size. The following section discusses a few of the areas in which misconceptions about these subjects can be resolved.

From a medical viewpoint, masturbation is “normal,” universal, and physically harmless at all ages. It is highly correlated with self-acceptance and sexual adjustment, and is often suggested as “homework” in sex therapy to further sexual self-awareness. Some people freely choose not to masturbate, perhaps following personal or religious tenets. Guilt about masturbation, however, continues to affect many patients. Some may use masturbation compulsively to avoid personal or relationship issues. Sex offenders may reinforce their antisocial fantasies via masturbation. Those who are truly addicted to some sexual behaviors may suffer from a variety of life difficulties common to other addictions.

There is no standard for what constitutes acceptable sexual frequency. Individuals who are celibate may still consider themselves sexual beings, whereas others may have sex rarely but find it satisfying and enjoyable when they do. Compulsive, frequent sex can become unrewarding for some, whereas others thrive on a frequent and active sex life. What is “right” for a particular individual or couple must be determined based on the various meanings and expectations they associate with sexuality.

Sexual fantasies are limited only by human imagination and may be enjoyed for their own sake. Fantasies may be exciting to a person who would never want to experience them in real life, or they may be yearned for. Obsessive and intrusive images that cause discomfort may need to be addressed with psychotherapy.

The majority of women enjoy and need direct clitoral stimulation manually or orally to reach orgasm. Unfortunately, many men assume that their female partners are fully satisfied with only intercourse. A result of this overemphasis on intercourse is that many women and men are uncomfortable with genital caressing alone. Couples can benefit from encouragement and permission to learn about and enjoy noncoital sex.

Most gay, lesbian, or bisexual patients do not wish to have their sexual orientation changed or challenged and often present the same concerns as heterosexuals about normalcy, dysfunction, and intimacy.

Life Changes: Menopause, Aging & Sexuality

Sexuality is an all-encompassing term that includes sexual identity, sexual function, and sexual relationships, all of which may be modified by a number of factors including both female menopause and aging.

Aging brings with it a number of recognized and normal changes in sexual response. These include the following:

1. In both men and women, more direct genital stimulation and more time are needed for arousal (lubrication or erection).

2. Women may experience irritation and pain with intercourse, especially after menopause or periods of abstinence.

3. Erections may become less rigid.

4. Orgasm may not occur with each sexual encounter and the urge to ejaculate may become less intense.

5. The refractory period (the time interval between a man’s ejaculation and his next erection) increases.

Many adults in their 70s, 80s, and even later years are willing to experiment in response to changes in their interest, sexual physiology, and partner status. Some older men and women become less focused on intercourse, finding increased enjoyment in petting, oral sex, and masturbation. Others may be happy to have retired from an active sexual life.

Phosphodiesterase type-5 inhibitor (PDE5) oral medications such as tadalafil (Cialis), sildenafil (Viagra), and vardenafil (Levitra) enhance erectile functioning in many men. In women, results of studies looking for positive effects of these medications on sexuality, in general, have been inconsistent, in part because different end points have been used. However, some data show benefit with PDE5 therapy in those women with previously normal sexual function who developed low libido after starting antidepressant therapy. In the future, it may be found to benefit other select groups of women as well.

Testosterone or estrogen replacement may also be beneficial to correct decreases due to aging, and are discussed in greater detail below.

Reasons given by health care providers who are reluctant to address sexual health issues include embarrassment, feeling ill-prepared, belief that the sexual history is not relevant to the chief complaint, and time constraints.

The prevalence of sexual concerns is consistently underestimated by physicians, which contributes to minimizing the importance of sexual health care. Patients report that physician discomfort and anticipated nonempathetic response to sexual problems are the primary barriers to discussing sexual health.

An assessment of problems related to sexual function requires a consideration of all relevant potential etiological factors in order that any appropriate therapeutic measures may be instituted, be they psychosocial, physical, and/or pharmacological.

Some patients may be more reluctant to discuss their diet or exercise patterns than the details of their sexual life, whereas others may feel they risk disapproval or judgment when talking with a medical authority about sexuality, and particularly about their sexual practices. When introducing the topic of sexuality, it is often helpful to acknowledge right away that the patient may feel some embarrassment. By routinely asking questions about sexual health in an initial history taking, a caregiver shows acceptance of sexual health as an integral part of a person’s well-being.

Also, it may be helpful to explain that some diseases and conditions can be major factors in the etiology of sexual dysfunction, among them diabetes mellitus, cardiovascular disease hypertension, immunologic issues, arthritis, chronic back pain, and current and previously treated cancers.

The following is one way to initiate a discussion about sexuality:

As part of the psychosocial component of the general medical examination, a brief sex history should cover the following:

• “Are you sexually active now?” “How many current partners do you have?” If none, “When was the last time you had sex?” “Is that O.K. for you at this point in your life?”

• “Are you sexually active with men, women, both, or neither?” To encourage the confidence of lesbian, gay, or bisexual patients, ask about the patient’s “partner” rather than using the gender-specific terms “wife,” “husband,” “boyfriend,” or “girlfriend.” And ask about “sexual encounters” rather than “intercourse.”

• “How satisfied are you with your sexual experiences and functioning?” (Frequency, variety, who initiates, etc.)

• “Do you experience any problems with lubrication, orgasm, erection, or ejaculation?”

• Rather than assuming contraception is necessary, ask, “Do you have a need for contraception?” Follow-up questions may include asking about the efficacy of or level of satisfaction with any current contraception method in use.

• “Have you ever been diagnosed and treated for sexually transmitted diseases (STDs)?” Discussion of human papillomavirus (HPV) vaccine and its relevance to cancer prevention of cervical and oral cancers can then be included.

• “Have you ever been tested for human immunodeficiency virus (HIV), and if so do you know if you are positive?” “Are you aware of safer sex precautions, such as the use of condoms and barrier protection, even when there is no risk of pregnancy or when other contraceptives (e.g., intrauterine device [IUD] or “the pill”) are used?”

• “Have you ever been/or are you currently in a relationship in which you have been/or are being abused emotionally, physically, or sexually?”

Use questions that show openness to other than the modal heterosexual preferences. Making assumptions about a person’s sexuality based on age, gender, race, ethnicity, marital status, or sexual orientation may be diagnostically misleading and send damaging messages to the individual. For instance, an elderly patient assumed to be sexually inactive may in fact have multiple sexual partners, and important risk factors for STDs and acquired immunodeficiency syndrome (AIDS) may be missed or a monogamous gay male may feel stereotyped or misunderstood if it is assumed that he has multiple partners.

Make sure that the terminology is mutually understood. Overly general or euphemistic terms such as “having sex,” “getting it on,” “making out,” “making love,” or “losing one’s nature” may obscure important details. Terms that are too technical (“coitus,” “copulation,” and “cunnilingus”) or too colloquial (“cunt,” “cock,” and “fucking”) may be inappropriate for use in the professional relationship.

Avoid words that convey moral judgments or indicate little about what an individual is actually experiencing (e.g., “adultery,” “frigid,” “impotent,” “nymphomaniac,” and “perversion”). Clinicians can help patients discard demeaning labels by substituting behavioral descriptions such as “having sex outside of your primary relationship,” “difficulty getting erections or getting aroused,” or “trouble learning to have orgasms.” Again, time and experience with a variety of patients provide a sense of what terms are most useful in conveying information to a given patient.

Patients may bring up vague or psychosomatic-like complaints (e.g., insomnia, fatigue, musculoskeletal aches, indigestion, headaches, or any specific symptoms of depression or anxiety) as a veiled request to talk about sexual concerns. Others mention a sexual concern at the end of a visit in an offhand manner, when there is little time for the problem to be adequately evaluated. The provider may then choose to assess the problem briefly and validate the importance of investigating this as soon as a new appointment can be scheduled.

Because sexual problems are often the result of a distressing gap between the patient’s expectations and experiences, the effective sexual interview aims to elucidate both sides of the equation. If expectations are unrealistic, the treatment is education; if the experience fails to meet realistic expectations, intervention or referral is indicated. Often education and other clinical interventions are combined.

When getting a sex problem history and before proposing solutions, health care professionals need to ask questions about the relative importance of sex in the patient’s life and what their expectations are for a fulfilling sex life.

The language of medicine is clinical, whereas issues of sexuality are associated with feelings and emotional vulnerabilities. Pay special attention to the case reports. They illustrate how cool clinical material can be translated to a warmer doctor–patient approach that allows for better trust and engagement with these vital human issues.

As with any other medical problem, five basic areas need to be addressed for the patient presenting with a sex problem (Table 32-2):

1. Explicit symptom or question

2. Onset and course of the symptom

3. Patient’s perception of the cause and maintenance of the problem

4. Medical evaluation, including medical history, past treatment, and outcome—(Specifically exclude such chronic health problems as diabetes mellitus, cardiovascular disease, hyperlipidemia, hypertension, the arthritides, past or current history of cancer)

5. Current expectations and goals for treatment

Answers to the preceding inquiries can help guide the clinician to specific interventions.

The detailed examination of the genitourinary system should include checking for signs of androgen or estrogen deficiency or excess, neurologic dysfunction, genital abnormalities, genital trauma, infections, condylomata (warts), and vascular disease.

For men, the examination should include the penis (to exclude conditions such as Peyronie disease, penile discharge, warts, other lesions, and hypospadias); testes and scrotum (for masses, atrophy, hernia, or varicoceles); and skin, prostate, and rectum. Testing should be conducted for evidence of gynecomastia, peripheral vascular disease, and neuropathy. Testicular self-examination can also be taught and information about prostate issues provided.

For women, look for evidence of atrophic changes, skin disorders (infectious or otherwise), developmental changes, urinary tract disorders, and general evidence of genital (internal and external) physical abnormalities, pelvic floor weaknesses, and postsurgical conditions. In case of genital pain, the woman should be encouraged to point out specific sites of pain, using a mirror to localize it.

The gynecologic examination provides an excellent opportunity for teaching patients about breast self-examination, discussing safe sex practices, protection against HPV and its consequences, and if appropriate, contraception.

Sexuality issues are rarely as clear-cut as a factual medical approach might yield. Generally, any condition or medication that is debilitating or energy depleting can be a contributory cause of sexual problems. Debilitation and/or anxiety are most frequently the final common denominators resulting in a sex problem. When going through the steps of Annon’s (1976) P-LI-SS-IT model below, look for evidence of these final common pathways as a guide to making the best use of the model.

When pathology can be excluded, patients can be reassured that their genitals look “quite healthy” and are in the normal range. This can help counter the shame that many people feel about these vulnerable areas of the body. Naming specific genital parts, such as the foreskin and glans of the penis and the clitoris and labia as you examine them, may give increased permission for the patient to ask any questions or express any concerns they may have about them. Men concerned about the size of their penis or women with worries that their genitals are somehow abnormal are more likely to voice these concerns after the clinician has comfortably used these words.

In general, few laboratory tests are necessary for patients presenting with the most common sexual problems. For complaints of low sexual desire, patients should be screened for depression and fatigue and also tested for anemia and endocrine, liver, and renal disease; or any other debilitating medical problems suggested by the history and physical examinations. Negative sexual side effects may be caused by gonadotropin-releasing hormone (GnRH) agonists, and narcotics (see “Medications”). Recognized underlying endocrine factors might include low thyroid, low estrogen, low androgen, or high prolactin levels. Whereas checking serum levels of thyroid-stimulating hormone (TSH) and prolactin is generally considered appropriate in women with sexual problems, routine measurement of serum estrogen and/or androgen concentrations generally is not recommended, as their measured serum levels do not correlate with sexual function.

Some authorities recommend evaluation of serum testosterone, TSH, and prolactin levels in all male patients with erectile failure or low libido. Elevated prolactin levels can be the result of many medical conditions, including pituitary tumors; renal dysfunction; sarcoidosis; thyroid disease; trauma; pelvic surgery; or use of medications such as cimetidine, haloperidol, and phenothiazine. If any of these tests is abnormal or other endocrine problems are suggested by the history or physical examination, specific, relevant additional tests should be performed as indicated.

In some men with erectile concerns, testing by a urologist may be indicated. These may include monitoring of nocturnal penile tumescence (NPT) in a sleep laboratory or, more commonly and less expensively, with a home monitoring unit or simple snap gauge. Increasingly, a trial with a PDE5, such as tadalafil (Cialis), sildenafil (Viagra), or vardenafil (Levitra), is recommended for both diagnosis and treatment.

Rather than describing sexual problems with a simple differential diagnosis of either organic or psychogenic etiology, it is useful to identify both categories of causal factors. These can be assessed with the psychosocial history, sex problem interview, physical examination, and laboratory testing. A symptom that is generalized (occurring in all circumstances) may indicate major organic or psychogenic involvement, whereas situational symptoms tend to be psychogenic (Table 32-3).

Organic factors may be suspected when a man reports an absence of nocturnal or morning erections or is unable to get erect with masturbation. In women who find intercourse painful, important situational variables to identify include whether she has been adequately stimulated and aroused prior to penetration, whether precoital lubricants have been used if needed, whether she feels pain with masturbation or when having sex with a partner, and whether she is able to direct the extent and timing of thrusting or is passive. Adequate vaginal estrogenization with local (estrogen) therapy, unless specifically contraindicated, should be ensured. Questioning should include possibilities that the problem is not physiological, but psychological, as is sometimes the case with vaginismus. Asking “under what circumstances have you felt pain?” might elicit “with one partner but not with another,” “since I was raped,” or “it has always been painful.” Organic factors should also be considered when a patient has not responded to an adequate course of sex therapy.

Medical conditions and treatments affecting sexuality are listed in Table 32-4.

As we address the sexual needs of our patients, general health issues such as thyroid dysfunction, cardiovascular disease, and diabetes as well as hypertriglyceridemia, hypertension, neurological disease, genitourinary disease all need to be kept in mind, as do hormonal factors:

1. Effects of low testosterone, primarily in men but occasionally in women with low sex drives: Adequate testosterone is considered necessary for sexual drive and arousal in both genders. It also determines genital health and function in males. Although the traditional testosterone evaluation argues that testosterone levels falling within the “normal range” are not indicative of clinically insufficient testosterone levels, there have been recent suggestions that men who test within the normal range may indeed benefit from testosterone supplementation.

2. Estrogen deficiency in women: Severe estrogen deficiency can be associated with serious atrophic changes in the vagina and external genital tissues, and is a common cause of local dyspareunia, often correctable through adequate estrogen replacement. These changes commonly occur as a result of menopause, antiestrogen chemotherapy agents, wasting conditions such as anorexia nervosa, and even due to normal breast-feeding.

   Recent studies have been elucidating subtle local effects of estrogens at the cellular level, termed “intracrinology.” DHEA (dehydroepiandrosterone), a precursor of androgens and estrogens, shows promise in ongoing studies when used as a vaginal cream by effectively treating hormone deficiencies at the local cellular level.

   While the effects of estrogen deficiency have focused on vaginal genital changes, it should be noted that these changes can also lead to serious pain with oral sex and clitoral masturbation.

3. Centrally acting agents:

   Although the intricacy of sexual functioning in women is not yet completely understood, hormones play an important role. Centrally, two major neurotransmitters, oxytocin and dopamine, are known to be involved in sexual desire and response in women.

Oxytocin, which rises with sexual activity, results in relaxation and bonding, increasing a woman’s interest in sexual activity and reducing her anxiety, as does dopamine, which acts centrally also to reduce anxiety about sexual activity. Both are said to act like an “on/off switch.”

The sexual problems of women may be complicated by the physical and emotional changes of aging and menopause, especially surgical or premature menopause. Although hormone replacement, especially with surgical or premature menopause, may be useful (there is serious controversy about estrogen replacement post natural menopause), it is most often necessary to address the serious emotional and life crisis issues as well.

Medications

Medications of many kinds have been implicated in sexual dysfunction (Table 32-5). Older antidepressants such as amitriptyline (Elavil) and doxepin (Sinequan) have anticholinergic properties that undermine sexual arousal. The widely used SSRIs—antidepressants such as escitalopram (Lexapro), sertraline (Zoloft), and paroxetine (Paxil)—may inhibit orgasm for women and ejaculation and orgasm for men, while decreasing sexual desire for both. Certain cardiovascular and antihypertensive medications have been notorious for causing sexual dysfunction, as can any medication resulting in sedation or depressive effects.

In the case of antidepressants, strategies to alleviate such dysfunction include: (1) reducing the dosage; (2) taking a weekend “holiday” in which the last dose for the week is taken on Thursday morning and the medication is resumed at noon on Sunday; (3) switching to another medication; or (4) coadministering other medications, such as bupropion-SR (Wellbutrin-SR), neostigmine (Prostigmin), cyproheptadine (Periactin), bethanechol (Duvoid), and yohimbine (Yohimex) 1–2 hours prior to sexual activity. It is hoped that antidepressants currently in development will have fewer negative sexual side effects.

Psychological factors often play a causal role in maintaining sexual dysfunction. This possibility should be considered even in cases when a medical condition or use of a medication that is known to cause a problem has been identified as a cause (Table 32-6). For example, a female patient experiencing difficulty reaching orgasm since being treated with an SSRI antidepressant may continue to have this problem even after discontinuing the SSRI because she is now conditioned to performance anxiety.

Following hysterectomy, some women report increased sexual enjoyment because of the relief from uncomfortable physical symptoms and bleeding, whereas others find the surgery difficult and have a psychological response to the loss of these organs and to the loss of their reproductive capacity. These women may then experience a decrease in sexual desire, arousal, or orgasmic responsiveness. This is particularly so when concomitant oophorectomy is done, notably in premenopausal women.

The research is mixed as to the effects of hysterectomy on orgasm in women. It has been proposed that women differ in the extent to which they perceive uterine and cervical contractions during orgasm, with differing sense of loss after the surgery. There is similar variability in men after prostatectomy. For many, orgasm may feel satisfactory even with a “dry” or retrograde ejaculation, with semen going into the bladder, but others may complain of a loss of orgasmic sensation.

Some medical illnesses and treatments are believed to decrease sexual desire or to cause sexual dysfunction directly. Psychosocial adaptations to virtually any medical condition, however, can indirectly affect sexual desire or functioning. For example, fears of rejection by a sexual partner because of a stoma or mastectomy or concerns about sexual functioning may lead to a suppression of sexual feelings and avoidance of sexual opportunities. Of course, many medically healthy men and women either choose to be sexually inactive or refrain out of a sense of inadequacy. The capacity to enjoy one’s sexuality, therefore, cannot be predicted on the basis of medical diagnosis alone.

Psychological problems such as depression or anxiety can be either the cause or the effect of diminished sexual desire or functioning. Both may be true to some degree. In other instances, depression and sexual problems may both be the result of a third underlying factor, such as an endocrine disorder.

Sexual problems might have remote psychological causes, such as childhood trauma or prohibitions about sexual pleasure, but almost all such problems can be seen as having current maintaining variables of anxiety or depression. In general, psychological etiology is primarily suggested when the problem is situational; seems related to performance anxiety, depression, or guilt; is associated with significant relationship and communication problems; or there are indications of trauma from earlier sexual experiences.

A paradigm shift occurred in the treatment of sexual dysfunctions with the publication in 1970 of Masters and Johnson’s signal work on sex therapy. The previous emphasis on the diagnosis and treatment of individual psychopathology, with somewhat poor treatment results for the sexual dysfunctions, gave way to an understanding of the importance of the conditions (internal variables such as attitudes, expectations, and lack of knowledge, as well as external factors related to the partner or the situation) under which people attempt to function sexually.

Education and suggestions for focusing on pleasure rather than on performance were found to lower anxiety and to promote improved sexual functioning and enjoyment.

Anxiety is considered one of the major psychological causes of the sexual dysfunctions, whether stemming from individual or relationship issues. Are patients comfortable, at ease, and feeling close to their partners? Or are they anxious due to lack of information, strained relationships, unrealistic attitudes about and focus on sexual performance goals, or other conditions? In these cases, modern sex therapy commonly provides anxiety-reduction interventions, many of which can be adapted for use by primary care providers. These include validating that most people at some time experience sexual problems and that such problems are often an understandable response to stress, worry, and concerns about performance; encouraging open communication between partners; dispelling maladaptive beliefs about sex; suggesting ways that patients can increase their level of comfort and safety and their ability to relax during sex; and encouraging the view that noncoital sex can be very satisfying and does not have to be considered “second best.”

Annon’s P-LI-SS-IT model is a useful hierarchical guide to anxiety-reduction approaches to sexual problems and can be used by primary care practitioners. The letters in the acronym stand for different levels of intervention.

P = Permission

The fundamental intervention is to give patients permission to discuss their sexual concerns. Empathic listening, including verbal and nonverbal reassurance, helps give patients permission to talk openly about sexual issues and may encourage and enable them to discuss the problem more directly with a partner. Reassurance and permission can help validate that having a sexual problem is normal, rather than pathological. Inquire into positive exceptions: patients can describe those areas of sex about which they do feel good; for example, a woman can appreciate her ability to become aroused despite difficulty reaching orgasm, and a man can be a skillful lover despite his erectile problem. Permission to choose not to be sexually active may be very helpful for patients who feel pressured to have sex or who feel inadequate if they do not care to be sexually active.

LI = Limited Information

Facts can add to the effectiveness of reassurance and can be at the disposal of any clinician who has done basic reading about sexuality and keeps up through the literature or review courses. Keeping responses focused and limited to the expressed concern saves time and does not overwhelm the patient with extraneous information (Table 32-7). Such information gives the patient the choice of maintaining or changing sexual practices or attitudes. A simple explanation of the psychophysiology of sexual arousal and the importance of conditions for relaxation helps “normalize” the symptoms and refocuses attention on conditions that can be changed to alleviate the problem, rather than on trying to determine what is wrong with the patient. One physician conveyed this information by the following “rhinoceros” story about sexuality:

Imagine you are lying on a blanket in a secluded meadow with a loving partner after a wonderful picnic lunch on a beautiful sunny day. You start kissing and feel arousal in your genitals, when, all of a sudden, a rhinoceros charges out of the jungle straight for you. What happens to your arousal (lubrication or erection)? The fight-or-flight response causes a rapid redirection of blood to the brain and large-muscle groups, with a corresponding loss of erection or genital arousal. The rhinoceros represents worrisome thoughts and anxieties about having erections, arousal, or orgasm, or fears that you won’t please your partner or be seen as a good lover. Some simple suggestions can help you keep the rhinoceros out of your bedroom!

SS = Specific Suggestions

Where permission and limited information do not suffice, the patient may benefit from specific suggestions to help overcome a sexual problem. Most sex counseling interventions are designed to help the patient (and partner, if available) communicate better about sex and enjoy increased sexual pleasure by reducing performance anxiety about attaining the goals of arousal, lubrication, erection, and orgasm. Helpful interventions taken from sex therapy include: (1) temporary agreement not to have intercourse; (2) suggestions for focusing on pleasurable touch, genital caressing, Kegel exercises (tensing and relaxing the pubococcygeal [PC] muscles), and progressive muscle relaxation methods; (3) correction of cognitive distortions (“self-talk”); and (4) suggestions to improve emotional and sexual communication.

Even for couples who previously enjoyed certain patterns of lovemaking, predictable repetition over time can lead to sexual boredom. Suggesting that a couple agree, for example, to temporarily forego intercourse or otherwise change their usual sexual pattern often helps them focus on moment-to-moment pleasure. Rather than making assumptions about what the other wants, the couple can communicate their likes and dislikes. Many people remember how arousing and exciting it was when they were younger and were “making out” (sexual petting) without intercourse. If agreeable to both, they can take turns exploring other ways of caressing and pleasuring each other. The sensate focus exercise, from Masters and Johnson, is done for the interest of the person doing the touching, rather than for the pleasure of the receiver. To minimize performance anxiety, each is encouraged to take turns “savoring” the experience of touching and exploring the other’s body, in contrast to worrying about “turning on” or performing for the partner. For many people, permission for genital caressing in this way increases sexual pleasure and satisfaction.

Arranging for follow-up after giving specific suggestions keeps the health care provider informed as to their effectiveness, helps the patient stay focused on problem solving, and informs the clinician about the necessity for further intervention.

IT = Intensive Therapy

This is the last step in the hierarchy and involves referral to an appropriate specialist when the previous three levels of intervention have not been effective (see “Indications for Referral”).

Pamphlets detailing approaches for safe sex for the prevention of AIDS can supplement discussions and should be made readily available for patients. Many good self-help books dealing with common sexual problems enable patients to move at their own pace. Often people who are reluctant to enter counseling or who are hesitant about discussing their problems in depth are willing to read about the problems in the privacy of their home where they can be relaxed and comfortable. Several books are recommended at the end of this chapter. Educational videos are also available and useful for some patients.

Refer patients to an appropriate medical specialist if the brief treatment suggestions in this chapter fail to help or if the history and physical examination suggest primarily an organic component. Refer patients to a mental health specialist trained in sex therapy if the problem is situational, occurring only with a certain partner; if functioning is adequate under certain conditions; or if significant emotional distress is present.

Primary care clinicians can develop a resource list of providers for sex-related problems. Colleagues, teachers, friends, and clinical societies can be asked for recommendations. Identify medical and mental health specialists with expertise in treating sexual issues. Practitioners can be licensed in psychiatry, psychology, social work, psychiatric nursing, or marriage and family counseling. Most states do not license “sex therapists” or “sex counselors.”

Low or Absent Sexual Desire & Aversion

Symptoms & Signs

The range of issues concerning sexual desire is wide (Table 32-8). As the etiology is multi-factorial, the approach to treatment will also need to be broad, ranging from counseling on basic sexual and possibly lifestyle issues, to consideration of pharmacotherapies including hormones.

It must be respected that some people normally put a low priority on sex or choose to not have any active sexual life. Others may be inhibited or find sex aversive, and some are clinically phobic. These problems can be of recent origin or reflect a long-standing pattern. Lack of desire may pertain situationally only to certain sexual partners or practices (such as oral sex). Couples with different levels of desire may disagree as to which partner’s level is “abnormal.” In this situation, each side has valid feelings, and it is important not to stigmatize the patient with the lower level of desire. Most couples occasionally deal with periods of discrepancy in desire or mutually low desire and feel they should have sex more often than they do. Demands of family, career, and friends often take precedence over sex.

Problems with desire or sexual aversion can derive from deeper relational power struggles or reflect childhood sexual, physical, or emotional abuse that requires couple counseling or individual psychotherapy for resolution. The following case example, however, demonstrates how permission and encouragement to talk about sex directly, together with specific suggestions, can have a powerful positive influence.

The physician also recommended a self-help book and offered to refer the couple to a therapist who treats couples, should their attempts to communicate falter.

Management

Permission & Limited Information

For many individuals and couples, not being sexually active can be a choice and, if acceptable to the people involved, should not be judged by others to be dysfunctional.

Others may learn to accept that low desire may be understandable given their immediate circumstances (e.g., the months prior to and after childbirth, recovering from illness) and that their previous levels of desire can be expected to return over time. Validate the patient’s right to say “no” to sex.

When a person presents diminished or lacking sex drive as a problem, questions can explore the conditions under which the person has previously felt the desire for sexual contact and release, and help her or him think about ways to reestablish some of those circumstances.

People raised within traditional sex roles can be helped to identify issues arising from sexual “suppression,” wherein neither women nor men experience their sexual potentials. Questions about desire open the door to sexual fantasies and scripts, and can form reference points for reestablishing desire where it is low or absent. For example, if a woman has experienced desire and excitement during courtship, but none after marriage, the doctor might help her understand why these changes have occurred and suggest potentially simple solutions.

Specific Suggestions

A “prescription” to go away on a weekend or to arrange a sleepover for children with relatives may help couples “break the ice” and reexperience intimacy. Suggest that the patient and their partner set time aside to talk about each other’s feelings and discuss conditions for more enjoyable sex, with each taking an uninterrupted amount of time for self-expression. Self-help books may also be recommended.

Intensive Therapy

An assessment for couples or individual psychotherapy may be indicated when simpler discussions and behavioral changes have been unsuccessful.

Other Medical Interventions

Clearly, comorbid conditions should be excluded and, consideration given to readjusting current medications, if appropriate. Positive results in several domains have been obtained in some studies of postmenopausal women with sexual problems, treated with transdermal testosterone, usually in addition to menopausal hormone therapy (i.e., estrogen ± progestin).

Since none of the studied testosterone preparations has been approved by the Food and Drug Administration (FDA) for use in the United States (nor by Health Canada in that country), there are no approved testosterone products for women in North America. However, the transdermal preparations have been approved by regulatory agencies in Europe and South America where they are available and in use.

Testosterone products are sometimes used “off label” and may be helpful for select individuals, for example women postoophorectomy or those with premature menopause whose testosterone levels may be virtually undetectable. Vaginal or clitoral application of testosterone cream has been suggested for women who seek treatment for a troubling loss of desire following chemotherapy for breast cancer. However, this treatment is NOT universally accepted in the medical community.

DHEA vaginal preparations, currently still in clinical trials, have shown promising results and may prove useful in the future.

Sexual Arousal Problems

Symptoms & Signs

Problems with female arousal are primarily manifested as vaginal dryness and may be reported separately from or together with lack of desire, difficulty reaching orgasm, or pain experienced during intercourse. The most common medical cause in older women is estrogen deficiency with resulting signs of vulvar irritation and atrophic vaginitis. Arousal may be inhibited by anxiety and depression, or shame resulting from early conditioning; it may also be a side effect of antidepressant medication. These possibilities should be explored (see Table 32-5).

Male arousal problems are manifested by erectile problems physically, but also include subjective inhibitions and performance anxiety as well.

Management

Permission & Limited Information

Is the patient getting stimulation in the way that works best for her? Feeling distant from or angry with a partner can inhibit sexual arousal, and such relationship concerns need to be addressed.

Specific Suggestions

Homework may be suggested for her to identify what stimulation works best. The goal is to experience the pleasure of arousal in that mode—not to reach orgasm. Inquiry should be made into the quality of the patient’s relationship. Commercial lubricants (Astroglide, KY Jelly, and so on) and vaginal moisturizers (such as Replens) can be suggested and, if vaginal atrophy is present, a low-dose intravaginal estrogen preparation (cream, pill, or suppository) should be prescribed unless contraindicated.

As has been mentioned, an intravaginal DHEA preparation is undergoing further evaluation as a hormone replacement alternative without the usual contraindications. Labrie et al. (2009) have published extensively on DHEA use. The premise for safety of this cream for patients is that of “intracrinology,” a term coined to describe the fact that DHEA, a relatively inert precursor substance (“a prehormone”) inserted into the vagina, is absorbed and there transformed/converted “on site” in specific cells to active steroids (testosterone, estradiol) which act locally. The DHEA is then locally also deactivated, never entering the circulation, and thus not reaching other tissues. The endometrium which is close by remains unaffected, because it does not possess the necessary converting enzymes to act on the DHEA.

Self-help books also can be recommended, such as ones by Barbach (2000) and Johnson (2008, 2013).

Intensive Therapy

Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).

Other Medical Interventions

Referral to an ob–gyn or other women’s health specialist.

Erectile Problems

Symptoms & Signs

There have been more than a dozen studies in the past 12 years or so showing a growing link between erectile problems and cardiovascular disease in men, including younger populations. If a man presents in primary care setting with erectile complaints, the physician should always assess cardiovascular risk factors as potential contributing factors, and recommend aggressive risk factor reduction (e.g., weight loss, exercise) if relevant.

Generally, a man with a significant psychological component is aware of nocturnal or morning erections, is able to maintain his erection for a reasonable time and then ejaculate with masturbation, or has good erections in some situations but not in others. He may be able to get a firm erection but lose it after penetration or may not get an erection with a partner at any time. The original cause of the problem is often distinct from the maintaining variable, which is generally anxiety. Consider possibilities such as performance anxiety, lack of direct physical stimulation of the penis, conscious or unconscious guilt (e.g., “widower’s syndrome”), anger at his partner or other relationship issues, or childhood issues such as sexual abuse.

Management

Permission & Limited Information

Many patients over 40 years old report previous successful sexual encounters when they were younger in which they became erect without direct physical stimulation of the penis. If their pattern for sexual interaction has rarely or never included direct touching by a partner, it might help them to learn that such touching becomes more necessary as men age, and that it can be an enjoyable part of sex.

Specific Suggestions

Institute a temporary ban on penetration and suggest sensate focus, progressive relaxation, and Kegel exercises. The couple should agree not to attempt penetration or intercourse even if the patient gets an improved erection.

Intensive Therapy

Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).

Other Medical Interventions

Referral to a urologist interested in male sexual functioning.

PDE5 inhibitors. Tadalafil (Cialis), sildenafil (Viagra), and vardenafil (Levitra) are three oral medications popularly known to have revolutionized the medical treatment of male erectile problems. Although contraindicated in men taking organic nitrate medication for angina, these medications have been found to have broad-spectrum effectiveness across men of all ages and medical conditions, including diabetes, hypertension, neuropathy, postprostatectomy, and depression.

An important caveat is that, in spite of the evidence of PDE5 medications’ demonstrated safety and efficacy, approximately 50% of men do not refill their prescriptions. Underlying psychological and interpersonal factors may need to be explored with these patients at follow-up visits.

Testosterone replacement therapy. For men with demonstrated low levels of serum testosterone, hormone replacement therapy may be helpful. This does not seem to benefit men whose serum testosterone is within normal limits, although recent work suggests there may be more subtleties to this. Side effects can be serious, including increase of any existing prostatic cancer, enlargement of the prostate, retention of fluids, and liver damage. Careful monitoring and follow-up prostate-specific antigen (PSA) screening and prostate examinations are necessary.

Antidepressant medication. Antidepressants, especially bupropion-SR (Wellbutrin-SR), can be effective treatment for some, but other patients may find that SSRI antidepressants hinder erection and ejaculation.

External penile vacuum device. With the aid of a vacuum cylinder, a tension ring is placed around the base of the penis after it has become erect. This device may work better for men who clearly have a major organic component to their erectile problem, such as severe diabetes, multiple sclerosis, or spinal cord injury. Although this device can create erections functional for intercourse, men with a more psychogenic etiology may be disappointed when the erections are not as firm as they had been expecting. Side effects may include bruising of the penis.

Intracorporeal penile injections or intraurethral delivery of prostaglandin E₁ (PGE₁). These methods were originally used diagnostically by urologists. However, patients can now be taught to inject themselves prior to sexual encounters, resulting in firmer erections that often do not disappear at orgasm or ejaculation and last about an hour. Side effects are priapism in less than 3% of patients and pain. In addition, scarring may be a concern with repeated injections over time.

Penile implant surgery. Since the advent of effective oral medications, implants with semirigid silicone rods or inflatable cylinders are less commonly utilized. Total costs are high, usually over $20,000. Complications include device failure (requiring additional surgery) and infection. However, for some men, this has been an effective and helpful treatment.

Rapid Ejaculation (Premature Ejaculation)

Symptoms & Signs

Terms such as rapid or early ejaculation are clinically preferable to the established premature ejaculation, as they highlight the subjective nature of the problem and are less pejorative. No absolute measure—either in number of minutes or thrusts—is applicable to the diverse numbers of men presenting with this problem. Factors to be assessed include a patient’s subjective evaluation, degree of sexual satisfaction, and sense of control.

Management

Permission & Limited Information

Point out that early ejaculation is a very common problem—one study found that 35% of married males reported that they ejaculated too quickly. Tell the patient that men with this problem have a high success rate when they try one or more specific suggestions for this problem. Give a brief explanation of the psychophysiologic mechanism.

Specific Suggestions

The patient may need to increase his frequency of ejaculations, alone or with a partner, perhaps masturbating to orgasm earlier on a day that a sexual encounter with a partner is anticipated. Discuss other ways he can please his partner, so he does not feel pressure to do it all with an erect penis. Discuss the importance of muscle relaxation in achieving a prolonged erection. Suggest breathing exercises and progressive muscle relaxation exercises, targeting the PC muscles or those in the buttocks.

In contrast to common attempts by men to diminish sensations in hope of lasting longer, they actually need to increase their tolerance for the good sensations and feelings and can best do this by concentrating on their feelings and getting more “turned on.” Focusing on these feelings in a relaxed “practice” atmosphere can increase the threshold of enjoyment before ejaculation and orgasm.

He and his partner can read about and practice the “stop-start technique.” Encourage the patient to change positions and to go from intercourse to oral or manual stimulation of his partner, and then back to intercourse (following the desires of his partner); changing positions and pleasuring a partner to orgasm without intercourse helps many men last longer.

Intensive Therapy

Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).

Other Medical Interventions

Clomipramine (Anafranil, 25 mg as needed) or SSRI antidepressants help men prolong their erections prior to ejaculation.

Prilocaine-lidocaine cream applied to the penis and then used with a condom has been recommended by some clinicians (although “numbing” of the genitals may detract from enjoyment for both partners).

Orgasm Problems

Symptoms & Signs

Many women do not learn to have orgasms until they are in their 20s, 30s, or even later. A primary anorgasmic or preorgasmic woman is not yet able to reach orgasm reliably either with a partner or by herself. A woman with secondary orgasmic problems was previously able to reach orgasm but is no longer able to do so. Situational orgasmic problem refers to a condition in which a woman can have orgasm with masturbation but not with a partner, or with one partner but not with another. She may reach moderate-to-high levels of arousal without experiencing the pleasure and release of climax. If no arousal or interest is present, she should be evaluated for a desire or arousal problem.

Some males might report delayed or absent ejaculation despite prolonged intercourse or other stimulation. Some report ejaculation without the sensation of orgasm (see Table 32-8).

Management

Permission, Limited Information, & Specific Suggestions

Both men and women may present with difficulties in achieving orgasm because of a repeated pattern of masturbation that does not approximate the stimulation they receive from a partner. Although physical arousal may be apparent (erection or lubrication), these patients may not be feeling excited if they have to forego the fantasies or kinds of stimulation that had worked for them while masturbating. Encouraging them to incorporate the conditions under which they can reach orgasm when alone into their sexual play with a partner is the first step in their expanding their sexual enjoyment. In some instances, use of a vibrator may be recommended to provide the more intense stimulation needed for some people. Explicit communication with the patient’s partner should be encouraged about the need to have enough stimulation prior to ejaculation and orgasm.

Intensive Therapy

Recommend individual or couple therapy with a clinician skilled in human sexuality issues (where appropriate).

Other Medical Interventions

The usual treatment of problems related to female orgasm is a combination of a good sex and psychosocial history, demythologizing, educating, behavioral treatments, and couples work where needed. There is no medication treatment available, since anorgasmia is rarely a physically caused problem.

As noted, Labrie et al. (2009) and the third author have had promising experience with intravaginal DHEA, whereas intranasal oxytocin (20–24 IU) is being studied as a potential stimulator of orgasm in women, and might hold promise for the treatment of delayed ejaculation.

Sexual Pain: Dyspareunia and Vaginismus

Symptoms & Signs

Dyspareunia—pain for women or men associated with genital sex of all kinds may be one of the most common and perhaps most underreported of the sexual dysfunctions. Vaginismus, a specific cause of female dyspareunia, involves the involuntary spasm of muscles around the vagina. Vaginismus can usually be treated by teaching the patient exercises to establish personal vaginal control and remove sources of contributing associated anxieties, such as conditioning to previous genital trauma, fear of penetration, anatomical ignorance, and others.

A gentle, sensitive genital examination and demonstration should always be a part of the evaluation of vaginismus. The use of progressively sized vaginal dilators has been helpful in some cases, but treatment can often be successful without them.

Management

Specific Suggestions

These issues can be approached gradually, by encouraging the woman to speak with her partner about her needs and to be a full participant in the sexual encounter. She and her partner should be educated about the need for sufficient stimulation and arousal prior to attempted penetration, and about the importance of her being in control of the sexual movement, so that she can stop it instantly if pain is felt. Instruction in Kegel’s PC muscle exercises increases the woman’s awareness and control of her vaginal muscles. Vaginal self-dilatation can be accomplished with graduated cylinders or with fingers, from the little finger to multiple fingers, while practicing muscle relaxation and calming mental imagery. The patient should be encouraged to be the one in control by bearing down on the finger(s) or penis as if pushing something out of the vagina, then relaxing. It helps for some women to imagine “capturing” the penis or other object in this manner, instead of being “penetrated.”

Other Medical Interventions

Other medical suggestions include the use of artificial lubricants, such as Astroglide, Gyne-Moistrin, or KY Jelly (not good with latex); vaginal moisturizers, such as Replens; and vaginal and vulvar application of estrogen creams. Further evaluation of vaginismus includes assessment for developmental anatomical abnormalities; if deemed appropriate, surgical revision of the vulvovaginal region and/or excision of abnormal growths in the genital area may prove helpful. Diseases thought to cause the pain, such as vaginitis, condylomata, endometriosis, pelvic inflammatory disease, and other gynecologic or pelvic diseases, may all be treated directly. When painful intercourse has been a long-standing problem, however, medical intervention alone is seldom adequate and should be followed by sex therapy directed at the probable fear and expectation of pain that have been conditioned.

Many sexual issues of those with impactful medical conditions and physical disabilities may be treated like those persons who are nondisabled and healthy. In other cases, culturally competent health practitioners knowledgeable about the social and physical issues of disability may be most effective. Some studies, such as with women following gynecologic cancer surgery, suggest that Internet support groups can be as beneficial as actual group meetings. Other online resources that are appropriately monitored and proctored by health professionals may become available in the near future.

For those patients who have undergone treatment for significant medical conditions such as cancer—with a potential altered body image and an understandable interruption or cessation of their sexual life—the following attitudes may be helpfully communicated to patients by their health care provider(s):

Whenever you are ready to become sexually active again, there are a few things you can keep in mind:

• You are loved for who you are, not just for your appearance. If you felt lovable or sexually desirable before you became ill, chances are that you will be afterward too.

• We are all sexual beings. Sexuality is part of who we are, whether we are sexually active or not. It is not defined just by what we do or how often we do it.

• Survival overshadows sexuality. It is normal and natural for stress, depression, worry, and fatigue to lower your interest in sex after major medical issues. Just coping with basic everyday decisions can seem like a burden. But take one day at a time and be patient. Sexual interest and feelings often come back when the immediate crisis has passed.

• Share your feelings. You may find yourself in the position of having to share your sexual feelings with someone, perhaps for the first time. This may be awkward at first, and learning how and when to talk about sexual issues may not come easily. You may feel shy or nervous about exploring new and different ways of finding sexual pleasure. You may each wait for the other to make the first move to resume sexual activities. This familiar waiting game is easily misunderstood and experienced as rejection by both people. It also may be frightening to think of breaking the silence yourself. Yet, a good move is to make the first move. Try sharing some of the myths or expectations you grew up with about sexuality. This can be humorous and may break the ice in starting a frank discussion about your sexual needs and concerns. Try not to make broad, generalized statements. Talk about what is important to you and about how you feel. The payoff is greater understanding of each other’s needs and concerns, and that is worth the effort.

• Expect the unexpected. When you first have sex after a long time without it, physical limitations or fears about your performance, appearance, or rejection may keep you from focusing on the sheer pleasure of physical contact. On the other hand, you may be surprised by unfamiliar pleasurable sensations. If you expect some changes as part of the natural recovery process, they will be less likely to distract you from sexual pleasure if they do happen.

• Give yourself time. You and your partner may be frightened of, or even repulsed by, scars, unfamiliar appliances, or other physical changes. That’s natural too. But such feelings are usually temporary. Talking about them is often the first step to mutual support and acceptance. Don’t pressure yourself about having to “work on sex.” A satisfactory and enjoyable sex life will happen one step at a time. You may want to spend some time by yourself exploring your body, becoming familiar with changes, and rediscovering your unique body texture and sensations. Once you feel relaxed doing this, move on to mutual body exploration with a partner.

• Take the pressure off intercourse. Almost all of us were brought up to believe that intercourse is the only real or appropriate way of expressing ourselves sexually. Yet sexual expression can encompass many forms of touching and pleasuring that are satisfying psychologically and physically.

  Try spending some time in pleasurable activities—touching, fondling, kissing, and being close—without having intercourse. Reexperience the pleasure of playing, of holding and of being held without having to worry about erections and orgasms. When you feel comfortable, proceed at your own pace to other ways of being sexual, including intercourse if you like.

  Experiment and explore to discover what feels best and what is acceptable. If radiation therapy, for example, has made intercourse painful, try oral or manual stimulation to orgasm, or intercourse between thighs or breasts. If you are exhausted by the disease or movement is painful, just cuddling or lying quietly next to your partner can be a wonderfully satisfying form of intimacy.

• Your sexuality cannot be “diagnosed.” You will never know what pleasures you are capable of experiencing if you don’t explore. Try new positions, new touches, and above all new attitudes.”

Serious sex-related problems may be best dealt with by a psychotherapist or health professional trained in sexual issues. A patient with compulsive sexual behavior or sexual addiction may be suffering from a form of obsessive–compulsive disorder and may require intensive psychotherapy, use of support groups, and medications such as SSRI antidepressants. Patients with gender identity disorders, patients who have experienced spousal abuse, incest, and rape, and patients troubled by paraphilias require referral for specialized treatment. Internet support groups for some people with some sexual problems can create new possibilities for support and provide hope and validation. Infidelity can be an extremely painful issue that affects many couples, yet many of them can be helped by couple therapy to address the pain, anger, and loss of trust.

For every human being, sexuality—like health—is a challenge at some point. Feelings of personal vulnerability are inherent in sexual interactions and help to make sexuality a powerful and unique part of life. Problems of sexual desire, arousal, or functioning can lead us to confront and overcome our fears of not being lovable and to seek better communication and increased intimacy with others. The deepest expressions of love often result from just sharing our vulnerabilities or problems.

The authors thank Linda Perlin Alperstein, LCSW; Jean M. Bullard, RN, MS; Melissa A. Bullard, PhD; Lisa Capaldini, MD; Deborah Grady, MD, MPH; Mary Rodocker, PhD, RN; & William B. Shore, MD for reviewing earlier drafts of this chapter. Finally, we benefitted from the comments on this chapter by Raymond C. Rosen, PhD; his career-long contributions to the study of human sexuality have been inspiring to us.

Readings for Patients

General Reference Articles

American Association of Sexuality Educator Counselors and Therapists Web site. www.aasect.org. Accessed February 2012.

Electronic Journal of Human Sexuality Web site. www.ejhs.org. Accessed February 2012.

International Journal of Transgenderism Web site. www.wpath.org/publications_ijt.cfm. Accessed February 2012.

Journal of Sexual Medicine Web site. http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291743-6109. Accessed February 2012.

Kinsey Institute Web site. www.kinseyinstitute.org. Accessed February, 2012. Accessed February 2012.

North American Menopause Society(NAMS)Web site. www.menopause.org. Accessed February 2012.

Sexuality Information and Education Council of the United States Web site. www.siecus.org. Accessed February 2012.

Society for the Scientific Study of Sexuality Web site. www.sexscience.org. Accessed February 2012.