The Focused Sex History

A focused sex history is the clinician's most important tool in evaluating SD, as it is most consistent with the "review of systems" common to all aspects of medicine. This limited history gives clinicians critical information in <5 min. Both sex therapists and physicians juxtapose detailed questions about the patient's current and past sexual history unveiling an understanding of the causes of dysfunction and noncompliance. A good, focused sex history assesses all current sexual behavior and capacity. The interview is rich in detail, providing a virtual "video image," clarifying many aspects of the individual's behavior, feelings, and cognitions regarding their sexuality. A flood of useful material emerged when actively and directly evoked. A focused sex history critically assists in understanding and identifying the "immediate cause"—the actual behavior and/or cognition causing or contributing to the sexual disorder. Armed with this information, a diagnosis could be made and a treatment plan formulated. These sexual details provide important diagnostic leads. Significantly, the sexual information evoked in history taking will help anticipate noncompliance with medical and surgical interventions. Kaplan's "Cornell Model" heuristically used immediate, intermediate, and remote causal layering to help determine timing and depth level of intervention (7). Modifying immediate psychological factors results in less medication being needed for men and women, regardless of their specific SD. Sex therapist's interventions are exercises and interpretations. In general, physicians will intervene with pharmacotherapy and brief "sex counseling," which address "immediate causes" (insufficient stimulation)

directly, intermediate issues (e.g., partner) indirectly, and rarely focuses on deeper (e.g., sex abuse) issues. Nonpsychiatric physicians typically manage current obstacles to success, which are both organic and psychosocial in nature. In fact, when deeper psychosocial issues are the primary obstacles, it is usually time for referral (4).

Many clinicians learned about the statistically significant increase in the incidence of depression in individuals with SD. Treatment of SD may improve mild-reactive depression, whereas depressive symptoms might alter response to therapy of SD (44). A clinician's history taking must parse out this "chicken or egg problem": Is SD causing depression, or is depression and its treatment (e.g., SSRIs) causing the SD? Here, the value of direct questioning about sex becomes clear in particular. If clinicians did not ask, the patients may not tell. When asked direct questions, SSRI patients reported an increase, from 14% to 58%, in the incidence of SD vs. spontaneous report (45). True incidence was probably underestimated as PDR data was based on patient spontaneous report (46). To manage adverse effects of medication, physicians must adjust dose or, combine with other drugs, to ameliorate the problem. For instance, many might reduce the SSRI and supplement with bupropion or try sildenafil as a possible adjunct (43,47). Although "alternative medicine" (herbs, etc.) or other treatment approaches might be effective, sex therapy enhances all of these strategies. In particular, teaching immersion in the sexual experience through fantasy is helpful to eroticize both the experience and the partner. However, fantasy could be about anything erotic; masturbatory fantasies are usually quite effective. Fantasy of an earlier time with the current partner may be especially helpful for those who feel guilty about fantasizing in their own partner's presence. Referral to a sex therapist can help when extensive and specific discussions of masturbation are useful to develop, recalibrate and/or restore the sexual response (20).

The focused sex history allows the clinician to initiate therapy with the least invasive method available; literally an "oral therapy." For this author, one question helps pin down many of the immediate and remote causes: "tell me about your last sexual experience?" Common immediate causes of SD are quickly evoked by the patient's response. The most important cause of SD is lack of adequate friction and/or erotic fantasy, in other words, insufficient stimulation. Sex is fantasy and friction, mediated by frequency (20). To function sexually, people need sexy thoughts, not only adequate friction. Although fatigue may be the most common cause of SD in our culture, negative thinking/anti-fantasy, whether a reflection of performance anxiety or partner anger, is also a significant contributor. Of course, the clinician initiating the discussion of sex with the patient, in a mutually comfortable manner, transcends the importance of which question is asked. The clinician follows-up, with focused, open-ended questions to obtain a mental "video picture." Inquiries are made about desire, fantasy, frequency of sex, and effects of drugs and alcohol. Did arousal vary during manual, oral, and coital stimulation? What is the masturbation style, technique, and frequency? Idiosyncratic masturbation is a frequent hidden cause of ED, as well as RE (41a,41b). The clinician becomes implicitly aware of the patient's sexual script and expectations, leading to more precise and improved recommendations and management of patient expectations (20). For instance, a clinician would improve outcome by briefly clarifying whether a patient was better-off practicing with masturbation, or reintroducing sex with a partner? A recently divorced man, who was using condoms for the first time in years, was probably better-off masturbating with a condom rather than attempting sex with his partner, the first time he tried a new sex pharmaceutical.

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