History taking for a person with sexual difficulties

A biopsychosocial assessment is vital to understanding sexual concerns.

If a person does wish to discuss sexual issues, ask about current sexual history including:

• all phases of the sexual response (interest, arousal, erectile function, orgasm) because problems affecting multiple sexual function domains may coexist and interact
• situations—whether symptoms are situational or generalised (eg specific to a partner or activity, or generalised to all situations, including self-stimulation)
• distress associated with any symptoms, experienced by the person or their partner
• duration and severity of symptoms—distressing symptoms of any duration warrant assessment and possible intervention; those lasting 6 months are considered chronic and are required to meet the criteria for a diagnosis of a sexual dysfunction
• sexual pain and whether the person is continuing to have painful sex (as this can prolong the problem)
• their range of current sexual practices—aspects to consider include:
  • which body parts are used for receptive or insertive sex
  • safe use of sex toys (adequate use of lubricant and cleaning between changing sites reduces risk of injury and infection)
  • use of contraception and measures to protect against sexually transmitted infection
  • safe use of drugs to enhance sexual pleasure (eg amyl nitrite, which can cause profound hypotension if used with phosphodiesterase inhibitors)
  • whether the person undertakes sex work or is a client of sex workers as this may affect their other sexual relationships
• sexual consent—ask whether the person feels free to choose when or how to have sex or whether there is a sense of duty or obligation; this is particularly relevant for sex workers, trans individuals and anyone whose practices include consensually relinquishing or exerting control (bondage, domination and sadomasochism [BDSM]).

Ask about previous sexual experience to understand:

• previous sexual symptoms
• previous efforts to seek help for any sexual symptoms
• concerns regarding gender identity or sexual orientation, including the recognition that both can change over time
• concerns about primary or secondary sexual characteristics; some may be indications of intersex variation¹
• experience of sexual education
• beliefs and myths about what is ‘normal sexuality’.

Take a social history to assess:

• relationship status
• contributing stressors related to work, finances, family (including worries about infertility)
• partner sexual difficulties
• any experience of emotional, physical or sexual trauma or abuse.

Ask about a person’s feelings for their partner(s), gender of partner(s), and any relationship difficulties. It may be appropriate to suggest that a partner also consider a consultation.

Ask about any experience of emotional, physical or sexual trauma or abuse, including female genital mutilation. Risk factors for sexual abuse include being a cis woman, having a trans or gender diverse (trans) identity, and having a diverse sexual orientation. See the Royal Australian College of General Practitioners (RACGP) guideline on sexual assault for more information on vulnerable groups and guidance on approaching the issues.

For patient support, resources include the national helpline for sexual assault and domestic and family violence 1800 RESPECT, the ReachOut website and a range of links available at the TransHub website.

Ask about other underlying health conditions that may contribute to or accompany sexual concerns. Issues to consider include:

• mental health concerns such as
  • anxiety
  • depression
  • eating disorders 
  • concerns about body image; this can include distress related to specific conditions (eg hirsutism) or specific body parts
• medications (including over-the-counter products such as antihistamines). Common examples of drugs that can cause sexual difficulties include selective serotonin reuptake inhibitors, opioids and adjuvant endocrine medications (eg antiandrogens, tamoxifen, aromatase inhibitors, androgen deprivation therapy for prostate cancer)
• alcohol and recreational drug use—see Alcohol and other drug problems
• endocrine causes, such as
  • diabetes
  • thyroid disorders
  • causes of amenorrhoea including polycystic ovary syndrome
  • menopause—in some same-sex relationships this can cause heightened stress if both partners experience this at the same time
  • androgen deficiency
  • changes due to gender-affirming hormone therapy; see links to resources for Trans and gender diverse healthcare
  • pregnancy or postpartum changes—trauma from delivery and low estrogen (due to breast feeding) can cause sexual pain; postpartum depression is a serious health risk
• risk factors for cardiovascular disease  (especially in those with erectile dysfunction)
• neurologic diseases—neuromuscular disorders, multiple sclerosis, spinal cord injury
• previous genital surgery (including episiotomy, gender-affirmation surgery or other abdominopelvic surgery)
• other genitourinary conditions such as
  • pelvic floor tightness causing vaginismus
  • deep infiltrating endometriosis
  • pelvic inflammatory disease
  • chronic prostatitis, which may contribute to premature ejaculation
  • benign prostatic hyperplasia causing poor stream, frequency, nocturia, urgency and terminal dribbling of urine; can coexist with erectile dysfunction
  • anal pain, fissures and spasm, which can make anal sex painful
• cancer diagnoses and treatments (which can affect body image and hormonal balance).

Trans and gender diverse individuals  may experience any of the symptoms that occur in cisgender people. If a person has gender-affirming treatment (medical or surgical), effects of therapy also need to be considered. Libido may be low, for example, with feminising hormone therapy, and vulvovaginal atrophy can occur with masculinising hormone therapy. For more advice on taking a sexual history in trans individuals, see the section on sexual health on the TransHub website. For advice related to managing sexual concerns that may arise with gender-affirming hormone therapy, or gender-affirming surgery, see advice for clinicians on the TransHub website.

For additional guidance on healthcare issues for people of diverse sexual orientation, see A guide to sensitive care for lesbian-gay-and bisexual people attending general practice at the Rainbow Health Victoria website.

Further assessment includes general medical examination, guided by features in the history.