Marlene Dietrich once observed that "in America sex is an obsession, in other parts of the world it is a fact."

While that may be true, sex is never terribly easy to discuss, no matter what your longitude and latitude. The purpose of this article is to help you to assess your patient's sexual issues in a professional and thorough way, with an emphasis on knowing when you need to refer to a PCP to rule out organic problems.

Every clinician has a different way of broaching sexuality with patients. Many simply interweave it into the context of the HPI (History of Present Illness). It's pretty easy to tag it on to a list of questions about the neurovegetative symptoms of depression: "For many people, depression may affect sexual functioning. Has that been true for you?" (Note that this phrasing also normalizes the problem, rendering patients more likely to open up without feeling embarrassed.)

You can also add sexual topics to a list of questions relating to habits or medical issues: "Do you smoke? Do you take any medications? Do you have any medical problems? Any cardiac problems? Any urinary problems? Any sexual problems?"

Once you've broached the issue of sexuality, you may or may not need to proceed any further, depending on the patient's response. Many patients have healthy sexual lives and make it quite clear, but if you sense some discomfort and conflict in response to your screening questions, move on to more specific questions.

Before giving you some suggested questions to ask, we should first discuss what it is you are trying to diagnose. Sexual problems are commonly classified using the following scheme:

I. Sexual Dysfunction

• Erectile dysfunction (men only)


• Low libido


• Orgasm dysfunction
  
  
  
  • Premature (men only)
  
  
  • Delayed or absent
  
  
  
  

II. Sexual Problems

• Sexual identity conflict (patients who are uncomfortable with their sexual orientation)


• Inappropriate sexual behaviors, such as pedophilia

In order to diagnose any of these specific problems, you'll need techniques to sensitively extract sexual detail without coming across as lurid or overly fascinated. Many find it helpful to adopt a clinical, matter-of-fact approach, using graphic anatomic terms such as "penis,", "vagina," and "erection." This communicates your comfort with the topic and has the added benefit of giving your patient permission to discuss their sexuality using the same terms.

A good open-ended question to begin a more detailed discussion is, "What happens when you try to have sex?" Depending on how much information your patient divulges freely, you may need to follow up with a specific question such as, "Do you usually achieve orgasm when you have sex?" You can ask men, "Is your penis usually hard enough to go inside your partner?" and women, "Is your vagina relaxed and moist enough to feel comfortable during intercourse?"

Once you diagnose a specific type of sexual dysfunction with these questions, you can get a sense of whether the sexual problem is possibly organic by asking the following questions:

• "Do you have (erections or orgasms) when you masturbate?"


• "Have you been able to have (erections or orgasms) with partners besides your regular one?"

For men:

• "Do you have morning erections and are they firm enough for penetration?"

An affirmative answer to any of these make an organic problem less likely, because it indicates that your patient is capable of normal sexual function given the right circumstance.

In terms of specific organic causes of sexual dysfunction, even the experts (usually, urologists) have difficulty making definitive diagnoses. They usually speak of "risk factors" rather than causes. Common risk factors are divided into three groups:

I. Primarily relevant for men:

1. Diabetes


2. Hypertension


3. Hyperlipidemia


4. Coronary artery disease


5. Hypogonadism (may be caused by pituitary adenomas, but testosterone levels also decrease normally with age, to the tune of 1% per year after age 40)

II. Relevant for women:

1. Peri- or post-menopause (including surgical menopause after an oophorectomy)

III. Relevant for both sexes:

1. Tobacco smoking


2. Excessive alcohol or opiate use


3. Obesity


4. Medication effects, especially antidepressants, antihypertensives, and digoxin.

Recommended lab tests include: glucose (to diagnose diabetes); a lipid profile (for hyperlipidemia); total and free testosterone (for hypogonadism; since most testosterone is protein bound, the free testosterone level may be more revealing than the total); prolactin (to diagnose a prolactin-secreting tumor of the pituitary).

Of course, unless you're double-boarded in medicine as well as psychiatry, you're probably not qualified to systematically assess for these medical problems. Nonetheless, keeping this list in mind is helpful for basic screening purposes. If your patient has one of the organic risk factors, but also has a probable psychogenic sexual problem, a common approach is to start psychiatric treatment in addition to making a referral to a primary care doctor. You and the PCP will likely work together to make things better.

TCR VERDICT:
Sexual dysfunction: Ask frank questions for frank answers.