Learn to ask about erotic fantasies, knowing that occasionally you will encounter behaviors or thoughts that are contrary to your own values. Knowing that you will encounter paraphilia enables you to anticipate and work through any private moral outrage before you meet the patient.3
Ask about sexual function
Desire, arousal, and orgasm are the three dimensions of sexual function listed in DSM-IV-TR. Sexual dysfunction may be classified as lifelong (since onset of sexual activity) or acquired (after a symptom-free period). If a patient’s sexual dysfunction is acquired, determine whether it occurs in all sexual encounters or is situational (with only one partner or present sometimes with a partner). These distinctions allow you to rationally pursue the cause (Table 4).
If a patient complains of loss of desire for sex, determine if it is manifested by:
- absence of sexual thoughts, fantasies, attractions, or masturbation (as might be seen in acquired hypogonadal states)
- lost motivation to approach his or her partner for sex (as commonly occurs when partners become alienated).10
Common sexual dysfunctions such as premature ejaculation, female anorgasmia, hypoactive sexual desire disorder, and arousal dysfunctions often have no significant genital findings. Erectile dysfunction in middle-aged and older men indicates the need to do a workup for early vascular disease and metabolic syndrome.
Desire versus arousal. Differentiating sexual desire and arousal can be complicated because they overlap, particularly during middle age or as individuals settle down with a consistent partner. Desire is also complicated by a vital gender difference.11 Most women in monogamous relationships eventually notice that the arousal stimulated by sexual behavior precedes their intense desire for sex, whereas most men report that their desire for sex precedes their arousal through much of the life cycle. Understanding these concepts will shape your follow-up questions about desire and arousal experiences.
Table 4
Ask about 3 components of sexual function
| Component | Sample questions |
|---|---|
| Desire | Are you ever “horny”—that is, have spontaneous feelings of mild sexual arousal? |
| Tell me what motivates you to have sexual behavior with your partner | |
| Arousal | Explain what is it like for you during lovemaking. |
| Do you get excited? Do you stay excited? | |
| Orgasm | Please tell me about your concerns about attaining orgasm |
Adult Sex Life: 6 Stages
Sexual dysfunction symptoms may be the same throughout the life cycle, but their meanings to patients vary dramatically. For example:
- A psychological stress that creates erectile dysfunction in a 60-year-old might not affect a 25-year-old because biological capacities for arousal are different at these life stages.
- Anorgasmia in a 22-year-old does not have the same psychological and biological sources as anorgasmia in a 62-year-old.
Stage 1: Sexual unfolding usually corresponds with adolescence and single adulthood. It is characterized by growing awareness of individual identity and functional characteristics and experiments in managing sexual drives, sexual opportunities, and relationships through masturbation and partner sex. It ends when a person depends on one partner for sexual expression.
Stage 2: Sexual equilibrium is established as part of a monogamous partnership. This equilibrium, which shapes the couple’s unique pattern of sexual expression, is formed by the interaction of their individual identity, desire, arousal, and orgasmic attainment characteristics.
The power of this interaction can be seen in previously functional men and women who quickly become dysfunctional in a new equilibrium because they discern their partner’s displeasure, lack of satisfaction, or lack of interest in particular sexual acts. Their perception of their partner’s unhappiness can quickly induce performance anxiety during sex, anger about sex, or a sense of hopelessness about getting one’s needs met.
The sexual equilibrium’s power is evident in previously dysfunctional individuals who quickly become comfortable and capable when they sense that their partners are pleased with them as partners. Inhibitions gradually lessen, and the couple’s sexual life begins on a good footing.