Detailed history taking in Psychosexual/Sexual Medicine

1. History Taking in
Psychosexual Medicine
Dr. Arpit Koolwal
JSS Medical College
Mysore

2. “In high-quality health-care provision, sexual health should be
integrated with all aspects of patient … care and should hold equal
status with physical, spiritual, social, and emotional care.”
Wilson H, McAndrew S. Sexual health: foundations for practice. New York: Baillière Tindall, 2000:xi.

3. Why Sexual History?
1. Prevalence of Sexual Dysfunction –
• Sexual dysfunction is as high as 31 percent in men and 43 percent in women
• Sexual concerns in 75% of couples seeking marital therapy
2. Indicator of Organic or Psychiatric Disease
• ED symptoms as harbingers of later cardiac disease.
2. Common side effect of medication or surgical treatment
3. Association of past sexual events with current psychiatric problems
4. Lifelong sexual function
5. Association with happiness –
• Frequency and enjoyment of sexual intercourse are significant predictors of longevity
7. Opportunity for Primary prevention –
• STDs, unintended pregnancies
8. Strengthens the therapeutic alliance

4. Despite that
• An international study of 27,500 men and women revealed –
50% of all sexually active participants had at least one sexual problem;
Only 19% had sought medical care
9% reported being asked about sexual health in the previous 3 years
• Only 2% British practitioners recorded sexual concerns or problems in
their notes.
• 1 in 4 Gynaecologists and 38% primary care physicians were “not at
all” confident in assessing and managing sexual concerns.

5. Barriers in taking Sexual History
• Patient related
• Clinician related

6. Patient related
• Lack of opportunity
• Sense of embarrassment and shame
• Societal taboo against open discussion of sexuality
• Not feeling optimistic about the outcome of such a discussion
• Uncertain whether sexual problems/concerns are part of health
concerns
• Uncertain which speciality treats sexual problems/concerns

7. Clinician Related
• I'm in a hurry.
• It isn't pertinent to this patient's illness.
• The patient didn't mention any sexual complaint.
• I respect the patient's privacy whenever possible .
• If I ask sexual questions, the patient may think I'm a pervert or a nut .
• The patient might be embarrassed.
• I will next time.
• Her gynecologist takes care of that.

8. • I really don't know how to go about it.
• I never ask sexual questions.
• I forgot because I was more "interested in" (comfortable with) the other
problem.
• I would be embarrassed.
• I often forget that patients have sexual lives that are important to them.
• Nobody's sex life is perfect, my own included.
Most patients believe it is the responsibility of the doctor to address sexual
concerns and are pleased or grateful when their physician initiates the
discussion.

9. Even asking patients one question regarding their sexual health signals,
that now, or in the future, the clinician is interested in this aspect of life
and that the individual may safely raise sexual concerns in the future.

10. Some important aspects during history taking
• Interview setting – Comfortable and ensuring privacy
• Patient centered model –
1. Empathic perspective – Getting in the patient’s shoes
2. Avoiding disease centered paternalistic model
3. Biopsychosocial Approach – Avoiding overly narrow focus on performance
issues and addressing psychological concerns and influence of other health
factors, medications and lifestyle.
By addressing these issues one arrives to a more comprehensive
understanding of the determinants and conditions surrounding sexual
problems and dysfunctions.

11. • Clinicians should anticipate the embarrassment of patient and
acknowledge that it could be difficult talking about such issues.
For example, the clinician may say,
“Most people find it difficult to talk about these things and may feel a bit
embarrassed. I’d just like to reassure you that everything you say is confidential and
that I’d like to help you if I can. The first step is to find out exactly what’s going on
so that we can figure out how to make things right again. Please feel free to be
open with me and to ask questions whenever you have any doubt.”

12. LANGUAGE
1. Medical terms – One way to communicate clearly without forfeiting professionalism,
by use of slang terms, is to gently teach the patient the correct terms, by linking them
with the terms used by the patient or use of anatomical drawings.
Ex – Patient – I take too long to come.
Physician’s response – When did you first noticed this problem with delayed
ejaculation?
2. Crude terms – Can be used if the clinician is of the opinion that the patient will be
comfortable and when some rapport and mutual respect has been established.
Comfort of the patient and proper communication between the patient and the doctor
are of prime importance.
• Never accept a sexual term at face value until you are sure what the patient means by it.
Patient: I'm impotent .
Physician : Do you mean that you have trouble getting an erection, have trouble keeping
the erection long enough to use it, or something else?
Or, "What do you mean by that? What does the term `impotent' mean to you?

13. • When your patient seems confused by terminology, it may be helpful
to use several different terms in a series to convey the idea . The
terms selected are usually the least "loaded" words known .
Doctor : Are you having any pain or discomfort in your vulva - your
female organs – your privates?
• Use of anatomical drawings to understand the patient’s knowledge –
Imperative to make sure the sexual problems are not the result of lack
of proper sex education or unrealistic expectations.

14. • Assumptions/Biases –
The examiner's own biases may distract the direction of history taking .
Common biases are :
1. All people are straight – Better to ask the sexual orientation at some point during the interview
2. All people are monogamous – Better to use the term ‘partner’ rather than wife or spouse
3. Young people aren't sexual yet.
4. Old people aren't sexual anymore.
5. Dignified, mature men and women can't be very concerned about their sexuality.
6. Married people can't have venereal disease.
7. "Nice" people don't enjoy sexual variations.
8. Girls who dress sexy are sexy.
9. Effeminate men are gay.
10. You can always tell gay people by the way they act.

15. 11. Sick people aren't sexual.
12. Blind, deaf, cerebral palsied, and paraplegic people aren't sexual.
13. Women aren't gay.
14. Nobody over 35 ever heard of fellatio and cunnilingus, much less tried them.
15. Patients never get sexually interested in their doctors.
16. Doctors never get sexually interested in patients.
17. Fat people aren't sexual.
18. Ugly people aren't sexual.
19. Mentally disabled people aren't sexual.
20. There are two kinds of women : the good kind, mothers and sisters, and the other
kind.
Acting from these or similar biases can erase much of the effectiveness of any history
taker. All people have biases of some sort, determined by their learned concept of what
the world is like. Setting aside biases is a conscious act requiring practice and at best can be
only partial.

16. • Try taking the history from both the partners, separately.
• Female attendant while evaluating a patient of opposite gender.
• Cultural Competence – Consists of –
1. Overcoming language barriers
2. Improving communication between clinician and patients
3. Understanding patient’s viewpoints on their complaints
4. Ensuring that the patient understands the range of proposed treatment options.
• Although sexual dysfunction may occur in isolation, but there may be co-existing
problems contributing to the dysfunction –
1. Physical illness
2. Psychiatric illness
3. Relationship difficulties
Prioritize the treatment of the comorbidity in such cases.

17. • Non-judgemental attitude
• Taking permission – Especially patients whose primary complaint is not sexual.

18. Objectives
• To understand the type of dysfunction or disorder
• To differentiate between potential organic and psychogenic causes in
the etiology
• To evaluate the potential role of underlying or comorbid medical or
psychiatric conditions or any ongoing medications
• To study the effect of the dysfunction or disorder on relationships and
day-to-day functioning

19. Two types of patients
• Patients whose primary complaint is not sexual problem
• Patients whose primary complaint is sexual

20. Patient’s whose primary complaint is not
sexual
• Sexual questions should not feel like ‘coming out of the blue’.
• In males – Following questions concerning frequency and ease of
urination.
• In females – Sexual history might be linked to questions about
menstrual cycles, birth control, menopausal status, or urinary
concerns.

21. • Prospective Opening questions –
1. Are you sexually active? Any concerns do you have regarding your sexual life?
2. Are you satisfied with the quality of your sexual life? What might make it better? OR---
In what ways are you not satisfied with the quality of your sexual life?
3. Are there any sexual problems or worries that you would like to discuss with me
today?
4. Sometimes people who suffer from_______(diabetes, hypertension, depression, or
are on beta blockers, SSRIs) have sexual issues. Are there any concerns you would like
to discuss with me?
These questions can serve as an entry to more in-depth assessment if required.

22. In-depth History
A. Patient: B. Marital Partner:
• Name:
• Age:
• Gender:
• Marital Status:
• Education:
• Occupation:
• Income:
• Social Class:
• Rural / Urban:
• Religion:
• Address:

23. • Chief Complaint
Chronological Order
• Predisposing Factors –
• Precipitating Factors –
• Maintaining Factors –

24. History of Present Illness
• Onset
• Progression
• Continuous or intermittent
• Diurnal Variation
• Lifelong or acquired
• Generalised or Situational
• With all partners or with one partner only
• Any precipitating event
• Aggravating Factors
• Relieving Factors
• When was the last satisfactory intercourse?

25. History of Present Illness
• Performance anxiety
• Effect of the dysfunction on –
1. Relationship or –ships – Reaction of the partner?
How did you feel about the reaction?
How are you and your partner getting along now?
Self-esteem
2. Day to day functioning
3. Frequency of intercourse
• Any treatment taken or self medication? Effect of those medications?

26. Depending on the phase of the sexual response cycle
• LIBIDO/INTEREST
1. Do you look forward to sex?
2. Do you enjoy sexual activity?
3. Do you fantasize about sex?
4. Do you have sexual dreams?
5. How easily are you sexually aroused (turned on)?
6. How strong is your sex drive?

27. HOPI Contd.
• Arousal/Performance –
1. How often do you have difficulty with erections?
2. How did you your problem start - gradual or sudden?
3. Do you tend to lose an erection too soon or is it difficult to get an erection
from the beginning?
4. How long have you noticed this?
5. Does it occur each time you want to have intercourse or is it just
sometimes?
6. Does the problem seem to be getting worse, better, or staying the same?
7. Is there a significant bend in your penis?
8. Do you have difficulty getting an erection when you masturbate, or is it only
when you are about to have intercourse?

28. 9. Do you ever wake up in the morning with an erection? Or you wake
up in the night sometimes with erections?
10. Have you noticed any change in your interest in or your reaction to
sexual thoughts or to sexy books or pictures?
11. Can you remember the first time you ever noticed any difficulty
with erections? At that time, what else was happening in your life,
at work, or in your marriage?
12. Do you experience pain while having erection?
13. Do you have difficulty in certain sexual positions?
14. Do you feel subjectively excited when you attempt intercourse?
15. Does your vagina become sufficiently moist? (for females)

29. • Ejaculation/Satisfaction –
1. Do you ejaculate when you have sex?
2. Do you ejaculate when you masturbate?
3. Do you ejaculate before you want to?
4. How often you ejaculate before you want to?
5. How often do you ejaculate before your partner wants you to?
6. How does your partner react if you ejaculate before your partner wants you to?
7. Do you take too long to ejaculate?
8. How much time or pushes before you ejaculate? How long you think you should last?
9. Do you feel like nothing comes out?
10. Do you experience pain with ejaculation?
11. Do you see blood in your ejaculate?
12. Do you have difficulty in reaching to orgasm?
13. Is your orgasm satisfying?
14. What percentages of sexual attempts are satisfactory to your partner?

30. • ORGASM/SATISFACTION (females)
1. Are orgasms absent and/or very delayed and/or markedly reduced
in intensity?
2. Is there adequate and acceptable stimulation with partner and/or
with masturbation?
3. Is the degree of trust and safety, you feel you need, present?
4. Is there fear of letting go of control?
5. What do you fear may happen that could be negative?

31. • DYSPAREUNIA/VAGINISMUS (females)
1. Where does it hurt?
2. How would you describe the pain?
3. When does the pain occur (with penile contact, once the penis is partially in, with full entry, after some
thrusting, after deep thrusting, with the partner’s ejaculation, after withdrawal, with subsequent micturation?)
4. Does your body become tense when your partner is attempting, or you are attempting to insert his penis?
5. What are your thoughts and feelings at this time?
6. How long does the pain last?
7. Does touching cause pain?
8. Does it hurt when you wear tight clothes?
9. Do other forms of penetration hurt (tampons, fingers)?
10. Do you recognize the feeling of pelvic floor muscle tension during sexual contact?
11. Do you recognize the feeling of pelvic floor muscle tension in other (non-sexual) situations?
12. Do you feel subjectively excited when you attempt intercourse?
13. Does your vagina become sufficiently moist?
14. Do you recognize the feeling of drying-up?

32. Ruling out organicity in Sexual Dysfunction
Remember in many cases organic and psychogenic factors can co-exist and
presence of organic condition does not rule out psychogenic factor.

33. Ruling out organicity in Erectile Dysfunction

34. • Situation of the intercourse – Has there been any recent change? Concern about privacy?
• Cognitive distractions – The content of thoughts patients experience during sexual activity -
1. Psycho-social stressors
2. Privacy
3. Body image concerns
4. Negative self schemas
5. Sounds and smells
• Concern regarding the size of the penis or bend in the penis
• Dhat syndrome –
1. Nocturnal emissions
2. Passing of semen in urine
3. Has the patient heard of dhat or dhatu? What concept of dhat does the patient has?
4. Beliefs regarding masturbation
5. Has there been passage of per vaginal white discharge?
6. Does the patient attribute the sexual problem or any physical problem to loss of semen/fluid or
masturbation?

35. Typical Sexual Interaction
• Manner of initiation –
1. Verbal or physical
2. Which partner initiates
3. Foreplay –
i. Present or absent
ii. Type
iii. How long does it last?
4. Intercourse – Penetrative or non penetrative
5. Positions
6. Verbalisations during sex

36. • Head injury
• Seizures
• Mood symptoms
• Anxiety symptoms
• Biological functions –
1. Sleep
2. Appetite
3. Bladder and Bowel habits
• Substance use
• Is the patient on any medicines currently or was on when the problem first started?
• What does the patient think is the reason for the sexual problems? How does the patient think
the problem can be solved?
• What are the patient’s expectations?
• Assessing sexual knowledge and attitudes

37. Looking for the Medical Causes
• Prostate
• Diabetes mellitus
• Hypertension
• Hormonal problems
• Urinary tract infections
• Sleep apnea
• Neurological problems
• Trauma to genital regions
• Joint pains

38. Past History
• Any h/o psychiatric complaints/treatment in the past?
• Any h/o sexual complaints/treatment in the past?
• Any h/o long term illness or treatment in the past?
• Any h/o injury, accidents or surgeries in the past?

39. Family History
1-Parents:
• Age: Father: Mother:
• Date of death & ages at death:
• Marital Status (married, separated, divorced, and remarried):
• Religion:
• Education:
• Occupation:
• Consanguinity:
• Feeling toward parents:
• Any disputes
2. Siblings:
3. Children:
• Number:
• Ages:
• Sex: Male: Female:
• Problems regarding children

40. • How does the patient gets along with the family members?
• Any ongoing disputes?
• How many people live with the patient in the same house?
• Socioeconomic status
• Pedigree Chart
• SEXUAL GENOGRAM

41. Personal History
• Childhood Sexuality –
1. Parental attitudes about sex - Degree of openness
2. Parental attitude about nudity and modesty
3. Learning about sex –
A. From parents –
i. Initiated by child’s questions or parent volunteering information?
ii. Which parent?
iii. What was the age of the child?
iv. Subjects covered (pregnancy, birth, intercourse, menstruation, nocturnal emission,
masturbation)
B. Books, magazines, friends or school?
4. Viewing or hearing Primal Scene – Reaction?

42. Childhood
• Genital self stimulation before adolescence - Age? Reaction if apprehended?
• Sex play with another child? Type of activity? Reaction if apprehended?
• Childhood neglect or abuse
• Sexual abuse
• Childhood Sexual Theories or Myths -
1. Thoughts about conception and birth
2. Functions of male and female genitals in sexuality
3. Roles of other body orifices or parts (such as umbilicus) in sexuality and
reproduction
Development of sexual desirability and sexual adequacy

43. Adolescence
• Age of onset of puberty –
1. Development of secondary sexual characteristics
2. Age of menarche
3. Nocturnal emissions
• Body image
• Acceptance by peers
• Sense of sexual desirability
• Onset of coital fantasies

44. • Sexual activities -
1. Masturbation –
i. Age begun
ii. Ever punished or prohibited?
iii. Frequency
iv. Methods used
v. Patients own beliefs and attribution for sexual problems
2. Homosexual activities
3. Dating
4. Experiences of kissing, necking, petting (‘Making out or fooling around’)–
i. Age began
ii. Frequency
iii. Partners
5. First coitus

45. Adult Sexual Activities
• Pre-marital sex –
1. Types of sex activities
2. Frequency
3. No. of partners
4. Contraception
5. First coitus

46. Marriage
• Assess each marriage separately if multiple marriages including
reasons for divorce and remarriage
• First sexual interaction with the partner –
1. When
2. Situation
3. Was it satisfactory or disappointing
• Honeymoon –
1. Setting
2. Duration
3. Frequency
4. Pleasant or unpleasant
5. Sexually active

47. Assessing the Current Relationship
• Quality of relationship between partners in non sexual areas
• Do they get along in most issues or is there conflict?
• Who is dominant in the relationship or is there general equality?
• Communication between partners
• Level of commitment to each other
• Security in sexual role
• Partner’s general health
• Any sexual dysfunctions in partner

48. • Infidelity –
1. No. of incidents
2. No. of partners
3. Emotional attachment to the extramarital partners
4. Reasons for extramarital affairs
5. Feelings about the extramarital affairs
• ‘Timetable of the Relationship’
• Post marital masturbation – Desire Discrepancy
• Do you find your partner attractive?
• Spousal abuse

49. Assessing Body Image
• Are you ashamed of your body or some part of your body?
• Do you often think about this feature?
• Do you often check this feature?
• Do you think about this feature during intercourse?
• What are your expectations regarding this feature?

50. Special Areas
• H/o rape, sexual or physical abuse
• H/o STDs
• Fertility issues or concerns
• Abortions, miscarriages, or unwanted or illegitimate pregnancies
• Gender identity conflict – Transexualism, Transvestism
• Paraphilias

51. • Premorbid Personality

52. Questionnaries
• Brief Sexual Indices –
1. Brief Index of SF for Women
2. Brief Sexual Function Questionnaire for Men
• Sexual Satisfaction –
1. Couple Satisfaction Index
2. Index for Sexual Satisfaction
• Erectile Function –
1. Erection Hardness Score
2. International Index of Erectile Function (IIEF)
3. Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS)

53. • Female Sexuality –
1. Female Sexual Arousability Index
2. Female Sexual Function Index
• Sexual Interest –
1. Sexual Interest Questionnaire (SIQ)
2. Sexual Interest and Satisfaction Scale
• Sexual Distress –
1. Sexual Symptom Distress Scale
2. Female Sexual Distress Scale Revised (FSDS-R)
• Sexual Knowledge – Sexual Attitude and Knowledge Questionnaire
• Body Image – Body Image Questionnaire (BIQ)

54. References
• Comprehensive Textbook of Psychiatry
• Textbook of Clinical Sexual Medicine
• Althof SE, Rosen RC, Perelman MA, Rubio-Aurioles E. Standard operating procedures for taking a sexual
history. The journal of sexual medicine. 2013 Jan 1;10(1):26-35.
• Nusbaum MR, Hamilton CD. The proactive sexual health history. American Family Physician. 2002 Nov
1;66(9):1705-22.
• Brotto L, Atallah S, Johnson-Agbakwu C, Rosenbaum T, Abdo C, Byers ES, Graham C, Nobre P, Wylie K.
Psychological and interpersonal dimensions of sexual function and dysfunction. The journal of sexual
medicine. 2016 Apr 1;13(4):538-71.
• Avasthi A, Grover S, Rao TS. Clinical Practice Guidelines for management of sexual dysfunction. Indian
journal of psychiatry. 2017 Jan;59(Suppl 1):S91.
• Clark VL, Kruse JA. Clinical methods: the History, Physical, and Laboratory examinations. Jama. 1990 Dec
5;264(21):2808-9.
• PGI Chandigarh Proforma for Psychosexual History Taking.