It is difficult to establish the prevalence of sexual problems in the population because of the difficulties involved in carrying out surveys of people’s sexual behaviour. The commonest kinds of problems presenting to a sexual dysfunction clinic are,
Low sexual desire 50%
Orgasmic dysfunction 20%
Premature ejaculation 15%
Delayed ejaculation 5%
Low sexual desire 5%
The assessment of sexual dysfunction
Patients with sexual problems initially often complain about other symptoms because they feel too embarrassed to reveal a sexual problem directly. For example, a patient may ask for help with anxiety, depression, poor sleep, or gynaecological symptoms. It is therefore important to ask routinely a few questions about sexual functioning when assessing patients with non-specific psychological or physical symptoms.
In a full assessment, the interviewer should begin by explaining why it will be necessary to ask about intimate details of the patient’s sexual life, and should then ask questions in a sympathetic, matter-of-fact way.
Whenever possible both sexual partners should be interviewed, at first separately and then together.
The assessment should cover the following issues.
- Has the problem been present from the first intercourse, or did it start after a period of normal sexual functioning? Each partner should be asked, separately, whether the same problem has occurred with another partner, or during masturbation.
- The strength of sexual drive should be assessed in terms of the frequency of sexual arousal, intercourse, and masturbation. Motivation for treatment of sexual dysfunction should be assessed, starting with questions about who took the initiative in seeking treatment and for what reason.
- Assess each partner’s social relationships with the other sex, with particular reference to shyness and social inhibition.
- Enquiries should be made about the partners’ feelings for one another: partners who lack a mutual caring relationship are unlikely to achieve a fully satisfactory sexual relationship. Many couples say that their relationship problems result from their sexual problems, when the causal connection is really the reverse. Tactful questions should be asked about commitment to the partner and, when appropriate, about infidelity and fears of sexually transmitted disease, including HIV.
- Assess sexual development and sexual experience, paying particular attention to experiences such as child abuse, incest, or sexual assault that may have caused lasting anxiety or disgust about sex.
- Enquiry should be made about homosexual as well as heterosexual feelings.
- In the medical history, the most relevant things to look for are previous and present psychiatric and chronic physical disorders and their treatment, pregnancy, childbirth, and abortion(s), and use of alcohol or drugs, such as selective serotonin reuptake inhibitors (SSRIs).
- In the mental state examination look especially for evidence of depressive disorder. Physical examination is important because physical illness often causes sexual problems Physical examination of women may require specialist gynaecological help. Further investigations may be necessary depending on the findings from the history and examination (e.g. if diabetes is suspected as a cause of sexual disorder).