The diagnosis of a sexual problem can be difficult as there is often more than one component, e.g. dyspareunia due to a painful gynaecological condition may lead to loss of desire. Alternatively, lack of arousal may lead to lack of lubrication and subsequent superficial dyspareunia. A woman who has extreme vaginismus and in fact non-consummation of her relationship may have no loss of libido and may be orgasmic with non-penetrative sexual activities. Patients may not use medical words to describe their problems and professionals need to understand their complaints and be prepared to use non-medical language when discussing sexual matters.
It is important to establish when a problem started, i.e. is it primary or secondary. Although there is seldom time for a lengthy history, it is worth establishing if sexual function has been better in a previous relationship and why the woman has come to the doctor at this juncture, as these may be crucial factors in the diagnosis and treatment.
Female sexual problems
Female sexual dysfunction cannot be studied without some understanding of male problems. A woman may complain of loss of libido or lack of orgasm when in fact the problem lies with her male partner. It may not be until close questioning that this is disclosed. Discussion as to what actually happens during sexual activity may elucidate matters. If the woman presents, she is “the patient”, i.e. she is the one complaining. Sometimes after a short time, it becomes obvious that the man may need to be seen himself, but work with the woman can be relayed back to her partner. This is especially relevant if the man refuses to attend, although this in itself is a poor prognostic factor.
Male sexual problems
Couple therapy is outside the remit of most general practitioners (general practitioners) and other doctors dealing with women’s health in the clinic situation. It is very time consuming and needs specialist skills. Even if not seen, the other member of the couple must be considered and discussed. It may transpire that the problem is primarily within the relationship and referral to an agency such as Relate can then be suggested. If patients are seen as a couple, then observations of their behaviour towards each other in the consulting room can give useful hints regarding the source of the sexual difficulty. These observations can be related back to them.
If they present as a couple, they can be seen together, but often better work is done if they are separated. Once alone with the doctor, the patient can be completely honest and the therapeutic doctor/patient relationship can be employed. Treating both halves of a couple can be difficult if one partner divulges a secrets, e.g. that he is having an affair and has no sexual difficulty with his mistress. Confidentiality is of paramount importance.
Doctors must remember that all patients are not heterosexual. Patients may find their sexuality difficult to disclose to their doctors, especially to their general practitioners whom they may have known for years. Discussion may be easier in the relative anonymity of the genitourinary clinic. The National Survey of Sexual Behaviour in Britain published figures relating to the prevalence of homosexual activity in men and women between the ages of 16 and 59. This part of the study was done on face-to-face interview and completion of a booklet. Numbers amongst men and women admitting to some homosexual experience were higher in the subsidiary written questionnaires. Overall 6.1% of men and 3.4% of women admitted to having had some homosexual experience. Substantial proportions of those reporting same-sex partners also reported opposite sex partners.
Sexual difficulties in homosexuals may arise from the same fears and phobias, relationship difficulties, life changes, and physical problems as in heterosexuals. There are particular problems associated with the break-up of long-term same-sex relationships, which may have been kept secret from friends and family.
Problems in people without partners
Not all patients with a sexual difficulty have a partner. They may not have a partner because of the problem or they may not wish to have a partner and can be treated as individuals. For example, the initial treatment of vaginismus by examination by the doctor, followed by self-examination and use of tampons, may allow a woman to embark on a relationship. Full success cannot be claimed until penetration is achieved, if this is the aim. Many fulfil their sexual needs by masturbation. Changes in desire or response may occur. This also constitutes a sexual difficulty, sometimes with as much distress for the man or woman as loss of function within a relationship. It is worthy of help and may, especially with men, give them confidence to seek a new partner.