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Sexual life is not just about sexual identity and sexual behavior.
Every person possesses a complexity called sexuality that slowly manifests itself in variable ways from childhood to old age. Sexuality’s two major elements are sexual identity and sexual function, each of which has several components (Table 1). The components evolve predictably over the life cycle, but also may abruptly change in response to personal, interpersonal, mental and physical difficulties, and cultural forces. The most central component is sexual desire, a complexity that represents the energy/motivation to socially express one’s gender identity, orientation, and intention as well as the force that shapes arousal, orgasm, and penetration experiences.
All of the components of sexuality except orientation are used to organize DSM-5 sexual dysfunction and sexual identity diagnoses. A working knowledge of all the components guides the sexual history. DSM-5 sexual diagnoses do not capture the actual sexual dramas of patients’ lives; they only characterize the seemingly negative outcomes of life processes.
As these processes become illuminated by the sexual history, a wide array of influential adversities become apparent. These include medical and psychiatric disorders, infidelity, infertility, preoccupation with commercial sex, childhood abuse and neglect, attachment problems, sexual identity struggles, sexual victimization, marital discord, divorce, grief, medication effects, ignorance, and the like. Sexual life is disrupted by many of the same forces that compromise mental health.
In discussing a patient’s sexual life, consider the following important cautions.
1) Do not consider sexual life separate from what you already understand about biopsychosocial processes during the life cycle. Because we experience our own sexuality as an intensely private subjective matter, we assume that patients do as well. We may not realize that they consider the psychiatrist as more knowledgeable than they are about this frequently problematic realm. They may welcome our inquiries and our attempts to understand and assist them. Clinical sexual expertise grows by the doctor’s interest and emerging personal comfort rather than the accumulation of esoteric knowledge.
2) Do not assume the process of taking a sexual history is a difficult personal process. Ask the patients if they have any sexual concerns that they would like to discuss. When they answer “yes” or when they spontaneously mention a sexual topic, invite them to tell you more: “Please say more about that” or “Tell me what you think it is important for me to know about that.” This shows the patient that you are interested and want to be helpful.
3) Do not make this a matter of gender. While many men and women may prefer to discuss their concerns with a professional of the same gender, others prefer the opposite. Regardless of their preference, the patient’s discomfort quickly dissipates when the psychiatrist asks illuminating questions.
Concepts that foster competence
There is no such thing as a complete sexual history. The clinician’s responses follow from the patient’s’ concern: a 16-year-old who wants to change her social presentation; a 40-year-old who confesses his lifelong premature ejaculation; a 53-year-old woman who has new dyspareunia; a 24-year-old who has never had an orgasm; a 67-year-old gay man with faltering potency; a couple who has not had any sex for three years after the wife’s infidelity; a man caught in a sting operation for watching child pornography; a man in the midst of an affair with little desire for his wife, etc. All of these scenarios would elicit very different history taking.
The sexual history evolves. Clinicians should not burden themselves with the idea that each problem should generate a long list of items that must be covered during that session. Patients expect to have the conversation continue and will provide additional relevant information when the clinician mentions the previous sexual concern.
After the first session, the patient is either impressed or unimpressed with the doctor’s interest. It is not difficult to engage the patient in the topic during the next session. When the concern is the highly prevalent selective serotonin reuptake inhibitors-induced dysfunction, the patient will expect the doctor to follow up on any suggestions.
Of course, there are specific things that we want to know in each situation, but these questions naturally occur to clinicians after the patients tell their stories. If not, it is useful to consult a relevant article, readily found via PubMed by topic, or a book to augment the doctor’s knowledge of the patient’s concern. There are numerous comprehensive texts covering the broad range of sexual concerns, problems, and diagnoses.1,2
Is the problem lifelong or acquired? This distinction guides the search for the causal factors in symptom production (Table 2). Without considering this fundamental distinction, the clinician’s work tends to be unfocused, inefficient, and confusing to both parties. Premature ejaculation and women’s anorgasmia typically tend to be lifelong, whereas erectile inconstancy and women’s desire/arousal problems tend to be acquired.
When problems are acquired, we zero in on what was occurring before the symptom appeared. We want to know if an acquired problem is specific to one partner or is true in all circumstances. Lifelong problems invite a focus on the patient’s family processes, relationship with parents, siblings, and experiences of abuse and neglect. We are interested in the patient’s sense of what historically has influenced the pattern. When “I don’t know” is the response, it is fine to say, “These patterns have multiple influences, but I presume you have considered certain ideas. Can you share them with me?”
Try to formulate the likely pathway to the problem. Understanding the pathways to these problems is often necessary to improving patients’ lives. Psychiatrists can intervene with a phosphodiesterase-5 inhibitor, flibanserin, bremelanotide, and an SSRI to address erectile dysfunction, sexual interest/arousal disorder, and premature ejaculation. These prosexual prescriptions are best provided after careful listening and questioning, which is essential in establishling a trusting therapeutic alliance.
The understanding of pathogenesis can become more complete with each session as we learn more about the patient’s experiences, capacities, and thinking. Such understanding that derives from learning about the person’s sexual struggles does not mean that every psychiatric patient requires a sexual history. But do not be shocked when a patient brings up the topic in the context of a nonsexual problem.
Confronting our rationalizations
When sexuality is relevant to understanding the patient’s problem, some psychiatrists deflect the topic with comments such as “I am not a sexual specialist;” “We don’t have time for that subject;” or “Share that with your psychotherapist.” Such rejecting responses often indicate one or more of the following private concerns of the psychiatrist.
“My personal sexual life is problematic. What do I have to offer patients if I can’t solve my own sexual issues?” The more you know about the universality of sexual concerns, the frequency of sexual problems, and the prevalence of DSM-5 sexual diagnoses, the better you will feel about taking a sexual history. Our difficulties can generate interest as well as empathy. A doctor can feel addicted to pornography, not have sex with her husband, have difficulty ejaculating, or have dyspareunia-yet still be helpful to patients. Helping others exposes you to considerations that can illuminate an avenue of your own concerns.
“I do not know enough about the subject to help.” Often the clinician knows more than they originally thought and can readily acquire more knowledge. Few psychiatrists have in-depth knowledge of all disorders (eg, depression, anxiety, psychosis), and yet we calmly provide care.
“I am afraid of what I may feel while hearing about sexual fantasies and behavior.” Transient arousal, envy, attraction, and disgust may indeed occur during a session. These brief feelings are not disclosed to the patient; however, they are often not discussed with the supervisor either. Each of these feared affects have a different personal meaning that needs to be considered. Envy, for example, teaches the psychiatrist what they might like to personally experience, while disgust informs the doctor what they considers abnormal. No psychiatrist can possibly experience the full range of human sexual behaviors; we should expect a private affective response. These transient internal experiences are stimuli for our professional growth.
“My values preclude my dealing with sexual minority patients in any depth.” The subtle privilege of being a psychiatrist is the opportunity for life-long learning. In-depth patient experience is a powerful source of learning. Your personal values, whatever their sources, create a priori negative judgments that you fear will become evident to the patient. Getting to know the actual person who has a variation in gender identity, orientation, or intention is the best way to overcome such prejudice.
Each new sexual minority patient can be your personal continuing medical education course, if only you allow yourself to be with the patient over time. At one point or another, every psychiatrist wants to run away from patients whose behavior is socially offensive, but it is a developmental task for clinicians to grow comfortable separating themselves from the differing lives of patients and to counter our morally censorious impulses to live up to our time-honored professionalism.
The power of these four rationalizations help psychiatry residents, fellows, and practicing psychiatrists to avoid inquiring or responding to sexual issues and creates a hesitance to use words involving sexuality. In basic seminars, I invite the group to speak a series of sexual words out loud: penis, vagina, clitoris, scrotum, breast, labia minora, labia majora, and nipple. This produces mirth. Then: menstruation, sexual intercourse, ejaculation, orgasm, cunnilingus, anal intercourse, and fellatio. I usually notice some people are skipping some words. It is initially difficult for both patients and doctors to transfer one’s private sexual language into professional language. Then I ask them to repeat words that some patients will use: blow job, eating her, going down, dick, snatch. I end the desensitization by asking the group to call out as many words as possible for the penis and then the breast. This short anxiety-provoking icebreaker precedes a presentation about the sexual history.
The sexual history is undertaken under a variety of circumstances; for instance, the patient’s sexual complaint, report of an individual’s or a couple’s relationship disappointment, a general review of psychiatric symptoms, a joke told to the doctor, a casual “by the way” remark, medication nonadherence, or a lack of mention of this vital aspect of life. Any professional delay of the sexual inquiry should be temporary.
Sexual life is not just about sexual identity and sexual behavior. Sex serves other functions such as the illumination of the relational self, the ability to love, the ability to remain loveable, and the ability to manage one’s emotional life.3 Over time, focusing on sexual life enables doctors to converse with patients about these larger matters. Patients better understand themselves as a result and deeply appreciate their psychiatrist or psychotherapist. Doctors’ growing comfort with the sexual history enables them to understand their patients’ sexual lives and psychiatric diagnoses in a deeper, more individualistic way.
Welcome to the world of clinical sexuality; it all begins with a willingness to be interested!
Dr Levine is Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine where he served as director for the Center for Marital and Sexual Health. He is the author of five books including recently published Psychotherapeutic Approaches to Sexual Problems: An Essential Guide for Mental Health Professionals; he is the senior editor of The Handbook of Clinical Sexuality for Mental Health Professionals. In March 2005, he and two colleagues received a lifetime achievement Masters and Johnson’s Award from the Society for Sex Therapy and Research. He reports no conflicts of interest concerning the subject matter of this article.
1. Binik IM, Hall SK, Eds. Principles and Practice of Sex Therapy, 5th ed. New York: Guildford Press; 2014.
2. Levine SB, Risen CB, Althof SE, Eds. Handbook of Clinical Sexuality for Mental Health Professionals, 3rd ed. New York: Routledge; 2016.
3. Levine SB. Psychotherapeutic Approaches to Sexual Problems: An Essential Guide for the Mental Health Professional. Washington, DC: American Psychiatric Association Publishing; 2019.