Sexual Medicine in Primary Care.

Sexual Medicine in Primary Care. By William L. Maurice. St. Louis, MO: Mosby, 1999, 366 pages. Paper, $39.95.

Recent reports in the lay and scientific literature tell us that patients look to their physicians as resources in the arena of sexuality. Patients are not always comfortable raising the issue themselves, but the vast majority would welcome our asking about their sexual functioning as part of a complete medical examination. The reasons we do not all do an expert job in this regard as primary care clinicians are addressed in this text by Maurice, a physician and associate professor in the department of psychiatry at the University of British Columbia in Vancouver. He postulates that many physicians do not discuss sexual topics in the health care setting because they are uncertain about what the next question should be and are unsure what to offer the patient after all the questions are asked and "Pandora's box" is opened.

Maurice addresses these two challenges to the primary care physician by separating the text into two parts. Part I includes eight chapters and is called "Sexual History-Taking, Interviewing, and Assessment." The final five chapters comprise Part II, which is entitled "Sexual Dysfunctions in Primary Care: Diagnosis, Treatment, and Referral." In addition, the text includes appendixes with several taped and edited interviews from different types of patients, along with Maurice's editorial comments.

Of particular benefit to clinicians is the author's presentation of specific questions that can be incorporated into the taking of a sexual history. For example, in lieu of asking if a patient has a history of "childhood sexual abuse," a term that Maurice contends is neither descriptive, nonjudgmental, nor free of an opinion about consent, he recommends asking the question: "Children sometimes have sexual experiences with other children or adults. Was this part of your experience when you were a child?" (p. 140). Clearly this type of phrasing will likely produce more useful information for the clinician and improved rapport with the patient.

The author makes a particular point of differentiating interviewing from history-taking, and states that how sex-related questions are asked is often more fruitful than what is asked. He goes on to describe interviewing methods that include asking permission of the patient to delve into sexual topics, having the interviewer initiate the discussion instead of relying on the patient to raise the issue, and using language the patient understands but avoiding the use of slang. Interviewing techniques that assume ubiquity, asking "How old were you when you began to masturbate?" instead of "Have you ever masturbated?" and ones that, like the sexual abuse example, use a statement of fact before posing the question, are described as particularly effective.

Conveying a nonjudgmental attitude is also critical to conducting a sexual interview. The author is very clear in his assertions that the meeting between health professional and patient is not a place for proselytizing, which in effect imposes the provider's values on the patient in a covert manner. He goes on to state that "health professionals who have strong beliefs that make it impossible for them to be dispassionate in caring for patients with sex-related concerns should make their philosophical position known beforehand" (p. 37). Perhaps physicians should not be caring for patients with these kinds of concerns if their biases affect their judgment so strongly. Such proselytizing may serve the clinician's needs, but it is unlikely to serve the patient's.

One example in the section on nonjudgmental interviewing techniques is somewhat concerning. Maurice cites the case of a young man who asked him about the "decency" of homosexual behavior, whom he answered by saying that it is not the job of a health professional to give opinions about the correctness of a person's actions. Because the author related to the patient that this is the role of the clergy, he offered to help the young man, who was Catholic, find a priest. Perhaps the patient should have been asked if he felt a priest would be helpful in resolving his mixed feelings on the subject before offering to find one for him, although the majority of priests may not bring a useful perspective to the subject. In addition, in this particular case there was another male involved who was the patient's brother, and who had stimulated him to ejaculation. Maurice fails to describe any discussion about incest or unwanted touching, which seems more germane to the patient's inability to ejaculate during intercourse than that the patient was "repulsed by the notion of homosexual behavior" (p. 37). What if it had been his sister who masturbated him?

Part I includes a number of these case reports from Maurice's clinical files interspersed throughout the text. Many of these cases help to highlight the point being made in the text, but on occasion they raise issues that could be clarified further. In one instance, the case of a married couple is discussed in which the husband's sexual difficulties with the wife were found to be related to the husband's sexual fantasies and occasional sexual experiences with other men. The interviewer (presumably the author) decided to record in the clinical record only brief notes about what the wife "already knew concerning his sexual interest in men" (p. 35). This decision is made based on concerns about the record being subpoenaed in future legal battles, including custody of their children, but it seems to beg the question without providing any clear guidelines for documentation in this difficult arena. The text provides the vaguely confusing assertion that "If a secret is recorded, the special nature of the revelation should be noted in the record" (p. 34). While it may not serve much purpose to complain about the lack of privacy and confidentiality in health care these days, it would have been useful to include a more succinct discussion of the issues with more clearly defined guidelines on what to include and what to exclude from a nonpsychiatric clinical record.

The sexual dysfunctions portion of the text is well referenced and includes a detailed description regarding the use of sildenafil. I believe the author is correct when he states that the ease of use of sildenafil will mean that physicians in primary care, as opposed to specialists, will become increasingly responsible for assessment and management of erectile difficulties in men. In the case of erection disorders, there are distinctions made between situational (psychogenic) erectile dysfunction--primary and secondary--and generalized dysfunction--organic, mixed, or undetermined origin--with flow charts detailing the appropriate evaluations of each. A variety of specific therapies are also well described, although at times they may be beyond the pale of primary care medicine.

The chapter on orgasmic difficulties in women is also quite helpful in aiding the primary care clinician who is called upon to assess a nonorgasmic woman. The complaint is differentiated into lifelong and generalized (primary), lifelong and situational, and acquired and generalized. These distinctions are useful in determining the epidemiology, etiology, and treatment modalities for women with orgasmic difficulties. While some women may require extensive psychotherapy for these problems, many may be well managed by the primary care provider, particularly one who is attuned to this issue. The author quotes Segraves, who comments that women may be less likely to report orgasmic difficulty than men, since they are often more prepared to attribute the problem to an interpersonal conflict than a biological explanation. It is therefore incumbent upon the clinician to ask the questions, because medications, medical disorders, and abuse of substances may all have adverse effects on a woman's sexual response.

The final chapter in the text concerns intercourse difficulties in women. The detailed assessments of vulvodynia and vaginismus are most appropriate for nurse practitioners or physicians in fields like pediatrics, internal medicine, or family medicine. The history and exam that should be performed to evaluate vulvar vestibulitis are described in a cogent manner. Treatment of intercourse difficulties is presented in a way that may help the primary care clinician decide to manage these challenging problems, assuming reasonable time constraints and patients who are motivated to work on these issues.

Maurice's text presents homosexuality in a nonjudgmental and supportive manner, while recognizing that sexual orientation concerns may underlie a host of problems that cause patients to present to a provider. In addition to recommending a list of gay- and lesbian-related web-site support groups and useful publications for patients and health professionals, the author states that it is not enough to have a nonjudgmental attitude. The responsible practitioner needs to convey this attitude to all patients. Toward this end he recommends the use of the word "partner" in place of spouse, husband, wife, boyfriend, or girlfriend with all patients so as to avoid making any assumptions about sexual orientation, to convey an attitude of acceptance, and to implicitly dispel any supposition about orientation with all patients. Maurice wisely recommends asking about sexual orientation before asking about birth control to avoid alienating the patient, and he is quite correct in stating that birth control is not necessarily immaterial because someone is lesbian. The opportunity could also have been taken to suggest that a good way to frame this question is to ask the patient, "Do you have a need for contraception?" after first discovering that they are sexually active.

While this is a very useful text and one that raises important issues for the primary care clinician, it falls short in a few notable ways. The interspersed clinical cases are set apart only by double lines and a slightly smaller font size, and the cases seem to interrupt the flow of the text and do not always fit logically in place. In addition, there are occasional typographical errors that are annoying to the reader. However, my main concern is one that is a hazard for all physicians who write about sexuality, and particularly those based in psychiatry: the perspective of diagnosing disease and dysfunction as opposed to enhancing sexual health. The author comments on the paucity of referrals to sex therapists for the more minor sexual dysfunctions in these times of broader public discussion about sex in the mainstream media, but the primary care clinician still has an important role to play in improving the sexual health of our patients. We need to help clarify the mixed messages and medical inaccuracies about sexuality that abound in the popular press, and we are often asked to help provide a moral framework for our patients' experiences. By the term moral or ethical I am referring to the precepts of honesty, equality, mutual pleasure, and responsibility that have been advanced by organizations like SIECUS. SIECUS has also been very helpful in defining and describing what characterizes a sexually healthy adult or adolescent. These concepts would have been useful to include in a text on sexual medicine for primary care providers.

In summary, this well referenced, thoughtfully written, and topical text deserves a place in the library of primary care clinicians who are concerned about the sexual health of their patients. The same studies that tell us that our patients wish we would ask about sexuality also report that too often we do not do it well. The training in human sexuality in medical schools and medical specialties is frequently lacking, and reflects a high level of discomfort with the topic in society in the United States (and presumably Canada). However, as health care professionals we have both the license and the public sanction to advance the cause of healthy sexuality. This text by Maurice can be considered remedial reading for the responsible health professional whose education and training was bereft of this important information for patient care.

Scott J. Spear, MD, The University of Wisconsin-Madison, University Health Services, 1552 University Avenue, Madison, WI 53705-4085; e-mail: [e-mail].