Maurice (12) outlined a brief set of topics that a clinician might cover with the process of history-taking to determine the pattern of any sexual dysfunction (Table 4.1).

Table 4.1 Pattern of a Sexual Dysfunction: What to Ask

1. Duration of difficulty: lifelong or acquired

2. Circumstances in which difficulty appears: generalized or situational

3. Description of difficulty

4. Patient's sex response cycle (desire, erection, ejaculation/orgasm if male; desire, vaginal lubrication, orgasm, absence of coital pain if female)

5. Partner's sex response cycle (see #4)

6. Patient and partner's reaction to presence of difficulty

7. Motivation for treatment (when difficulty not chief complaint)

Reprinted from Maurice W. Sexual Medicine in Primary Care. St. Louis: Mosby, Inc. 1999:53.

Sexual desire in men manifests in three ways: (i) psychologically through thoughts, fantasies, and dreams; (ii) behaviorally in sexual activity with a partner; and (iii) behaviorally in sexual activity with oneself through masturbation or self-stimulation. Topics in Table 4.1 form the basis of the following suggested questions that one might ask when faced with a man who says that he is not sexually interested.

1. Has a feeling of low sexual desire always been a part of your life or was there a time when you were more interested?

Comment: This question will help to determine if the desire problem is one that is "lifelong" or "acquired." Talking about the duration and the past might also allow the man to reflect on times when, for example, he encountered a similar pattern of initial desire followed by disinterest.

2. What kinds of things are you thinking about when the two of you are sexual with each other? and/or What sort of sexual thoughts or fantasies do you have at other times? and/or About how often are you and she/he sexually involved with each other?

Comment: These questions help to determine if the problem is "situa-tional" or "generalized." Understandably, many clinicians object to the idea of asking people about fantasies, or what is going on in a patient's mind. Our society treasures privacy and for most people, nothing is more private than their sexual fantasies. This attitude of psychological intrusion challenges a health professional to separate his/her social self from his/her work function. For example, there is simply no doubt that finding out if a man is thinking about other men or about women in an erotic situation is essential, not elective, in determining his sexual orientation, which may, in turn, help to clarify the reason for his apparent sexual disinterest.

Sexual desire is a feeling which usually (but not always) manifests in sexual behavior. Extrapolating from sexual behavior to determine someone's sexual desire (the third question in #2) can be problematic since there are many reasons for someone engaging in sexual activity apart from being sexually interested (the most common being the idea of wanting to please one's partner).

Other questions that are worth asking in this context include: "When was the last time that any sexual activity took place?" and/or "How often has any sexual activity taken place in, say, the last 6 months?"

3. "Have you had sexual experiences with other women since you have been in this relationship? and "Have you ever had sexual experiences with other men?" and "How often do you have sexual thoughts about other women? and "other men?"

Comment: All four questions might help to clarify whether the desire problem is "situational" or "generalized." For reasons mentioned previously, thoughts can be more revealing than actions.

4. Tell me about your masturbation experiences? How often do you masturbate? Do you look at pictures in magazines at the same time (or videos, or on the internet)? What do the pictures show? Women? Men? Couples? "What are the people doing?"

Comment: Again, these question will help to determine if the desire difficulty is "situational" or "generalized." If, for example, the man is masturbating and thinking about sexual matters but at the same time not sexually interested in his partner, then the desire difficulty is clearly situational. Questions about the content of pictures tell the clinician about the man's erotic focus, be it individuals belonging to the opposite or same sex, or sexual activities that are not mainstream.

5. Some men have sexual thoughts about women in the summertime when their bodies are not so covered. What's your own experience? Comment: This question can be yet another way of finding out if the man finds others to be erotically appealing and who the people might be.

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