When you address sexuality, you open a window to the patient’s psychology. Talking about sex may illuminate important clues about the individual’s capacity to:
- give and receive pleasure
- love and be loved
- be psychologically intimate
- manage expected and unexpected changes throughout adulthood.1
The opportunity to listen to sexual histories over time will help you become proficient in generating causal hypotheses and using them to help your patients.
Patients think—often erroneously—that all psychiatrists are knowledgeable, skillful, and interested in addressing sexual concerns. But psychiatric practice has turned away from clinical sexuality, and most of us learn on our own how to take a sexual history and to bring up relevant topics during subsequent sessions.
These activities are not particularly difficult,2 but they often bump up against one or more clinician fears (Table 1).3 You can master these apprehensions by:
- identifying them in yourself
- thinking about them rationally
- learning about the broad range of human sexual expression
- understanding professional boundaries.4
Table 1
Clinicians’ 5 worst fears about taking sexual histories
| Personal or patient sexual arousal while talking about sex |
| Not knowing what questions to ask |
| Not knowing how to help with patients’ sexual problems |
| Sudden awareness of one’s own sexual concerns |
| Having the patient see our moral repugnance about certain sexual practices |
| Source: Reference 3 |
Assessing sexual complaints
Sexual behavior—normal and abnormal, masturbatory and partnered—rests upon biological, psychological, and interpersonal elements, and cultural concepts of normality and morality.5 These four components also are the sources of sexual problems (Table 2).6,7
To accurately assess individuals’ and couples’ sexual problems, we must consider the four components’ present and past contributions in every case. We may declare a hypothesis of cause after one or two sessions, but the explanation usually evolves and becomes more complex with time.8
Outside of sexuality clinics, we usually learn about a patient’s sexual complaint during therapy for another problem:
- Individuals may bring up cross-dressing, anxiety about possibly being homosexual, concern about violent sexual fantasies, or other issues of sexual identity. Sexual function concerns may include new difficulty attaining orgasm, aversion to intercourse, painful intercourse, too-rapid ejaculation, episodic inability to maintain an erection, or longstanding inability to ejaculate while with a partner.
- Couples may present with difficulty orchestrating their sexual lives. Their complaints may involve discrepancies in sexual desire, inability to bring a young wife to orgasm, cessation of sex, infidelity, dyspareunia, erectile dysfunction in a newly married couple in their 60s, or a wife’s distress over her husband’s use of Internet pornography.
- Referrals may come from a social agency about an individual whose sexual behavior clashes with social values or laws. Judges, lawyers, state boards, clergy, or medical chiefs-of-staff may request assistance with individuals who cross sexual boundaries at work, are accused of sex crimes, or have been sexually victimized.5
4 components of sexual behavior: Where sexual problems may arise
| Component | Related sexual problems (examples) |
|---|---|
| Biological elements | Congenital androgen receptor disorder,9 undiagnosed prolactinoma,10 medical disorders (such as multiple sclerosis), medication side effects, heroin abuse |
| Psychological elements | Developmental processes (neglect, lack of warmth, or physical and sexual abuse from childhood caretakers) or present states (affect disorder, paranoia) |
| Interpersonal elements | Lack of psychological intimacy, marital alienation, disapproval of spouse’s behavior (such as gambling or excessive shopping), disrespect for spouse’s parenting style, past infidelity |
| Cultural concepts of normality and morality | Inability to free oneself of antisexual religious attitudes, homophobia, or belief that masturbation or oral-genital contact is abnormal sexual behavior |
Ask about sexual identity
By the end of adolescence, most individuals have stably in place the three self labels that encompass sexual identity:
- gender identity—the degree of comfort with the self as masculine or feminine
- orientation—the gender of those who attract or repel us for romantic and sexual purposes
- intention—what we want to do with our bodies and our partners’ bodies during sexual behavior.9
Conventional sexual identities do not pose a countertransference problem for most professionals after they become accustomed to discussing sexual matters. But unconventional identities—such as a gender identity disorder, homosexuality, or a paraphilia—can cause anxiety and avoidance for sexually conventional psychiatrists.
Table 3
Ask about 3 components of sexual identity
| Component | Sample questions |
|---|---|
| Gender identify | Are you happy that you are a male (female)? |
| Do you privately feel sufficiently masculine (feminine)? | |
| Orientation | Are you sexually and romantically attracted primarily to males, females, or both? |
| Intention | Are your sexual fantasies focused on unconventional images involving sadism, masochism, exhibitionism, voyeurism, clothing, animals, or children? |