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Sex is a problem for everyone.... Indeed, for a couple of weeks or a couple of months, or maybe even for a couple of years, if we are lucky, we may feel that we have solved the problem of sex. But then, of course, we change or our partners change, or the whole ball-game changes, and once again we are left trying to scramble over that obstacle with this built-in feeling that we can get over it, when actually we never can. However, in the process of trying to get over it, we learn a great deal about vulnerability and intimacy and love. .

(Peck, 1993, Further Along the Road Less Traveled)

INTRODUCTION

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).

Table 32-1.Sexual concerns of patients.

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