Sexual Medicine in Primary Care


Sexual Medicine in Primary Care. By William L. Maurice, in consultation with Marjorie A. Bowman. St. Louis: Mosby; 1999. 396 pages. $39.95.

In her preface to this book, Sandra Leiblum points out that “many physicians feel inadequately trained or prepared for dealing with the sexual concerns of their patients. It is not surprising,” she goes on, “that primary care physicians faced with time constraints, managed care demands, and inadequate training often feel unprepared to tackle the topic of sexual health in the detail and with the sensitivity it deserves. And yet, patients are clamoring for information and guidance in dealing with sexual problems and complaints. Questions about the impact of medication on sexual response, safe and unsafe sexual practices, unreliable erections and inadequate lubrication, and even talking to children about sex have become regular currency in physician offices. Most patients expect their health care provider to be an expert in all aspects of sexual health, even if their provider feels ill prepared and leery of the job.” This book is an excellent beginning for the health care provider who wants to respond to this need.

Dr. Maurice is a psychiatrist and sex therapist on the faculty of the University of British Columbia. Dr. Bowman chairs the Department of Family Practice and Community Medicine at the University of Pennsylvania. They have merged their backgrounds and skills here to provide a comprehensive, well-documented, and useful text for the clinician, who may have had no prior exposure to this field.

The volume is divided into three parts, preceded by both a general and a detailed table of contents that will help lead the reader quickly to topics of interest. Part I comprises eight chapters, each one entitled, “Talking about Sexual Issues,” followed by a subtitle reflecting various clinical issues (e.g., screening, history, medical vs psychiatric etiology) and patient characteristics (e.g., gender, aging, sexual orientation). These chapters discuss candidly many of the difficulties faced by physicians in talking with patients about such a sensitive issue and provide specific, pragmatic guidance in approaching these issues and patients. The chapters are well-documented and include discussions of the biopsychosocial nature of sexual problems, basic attitudes and skills important in obtaining sex-related data, and style differences among clinicians.

The five chapters of Part II focus more specifically on the general diagnostic categories of sexual dysfunction—low desire, erectile disorders, ejaculation and orgasm disorders, and intercourse difficulties in women related to pain, discomfort, and fear. Each chapter includes information on etiology, assessment (including sample interview questions), treatment, and indications for referral.

Six appendices (Part III) follow these 13 chapters, the first two of which provide annotated sample interviews with a couple and an individual patient, respectively. A third appendix offers sample case histories for use in interview role play, along with guidelines for role playing. Appendix 4 contains selected annotated websites organized by topic. Appendix 5 lists prescription and non-prescription medications that affect sexual function, organized by the nature of effect and giving rough indications of the extent of effect as well. The last appendix provides a brief list of self-help books, also categorized by topic.

As useful and comprehensive as this book is, I would recommend a few minor modifications in subsequent editions. Of course, the information on medications, treatments, and self-help resources will need to be updated, as they are rapidly changing.

I would add videotapes as a category of self-help resources, along with some guidelines for the use of such materials. Physicians are often concerned about how to address a sensitive issue like sexuality in the brief period of time often allotted to a clinical session. This question could be addressed more directly. Finally, it would be nice to see additional information about how to refer a patient for specialized assistance. How does one come to know who the physicians and therapists are who are trained in sexual matters and comfortable working with them? Where are the good training programs and what kinds of standards might one look for in evaluating such specialists?

Despite these minor omissions, this book is a unique and welcome contribution, not only for primary care physicians but also for specialists and non-physician health professionals who might be in a situation in which sexual questions or concerns arise. It will be useful as a comprehensive reference for the practitioner and as a text in the educational setting as well. However, I would advise the reader to take to heart the advice on page 1 attributed to the American composer, Aaron Copland: “If you want to understand music better you can do nothing more important than listen to it … everything that I have to say in this book is said about an experience that you can only get outside this book.” Our patients will be better served if we can develop the confidence, knowledge, and skill to comfortably discuss sexual issues with them and to respond to their questions and clinical needs, whether directly or by appropriate referral.