sex and medicine

sex and medicine

sex and medicine

Gender is fundamental. When a baby is born the motherasks 'Is it alright?', then 'Is it a girl or a boy?'. Gender isintegral to a sense of identity, and this can be threatenedby illness at any of the stages of development.Hypospadism, hirsutism, hernia, delayed puberty, amenorrhoea,infertility, hysterectomy, prostatectomy, diabetes-related impotence are just a few of the manymedical conditions that may threaten the sense of identitythat is rooted in gender and sexual functioning.AttachmentHuman attachment occurs through the body. Even whencommunication is at a distance, hands are, needed to writea letter, a voice to speak on the telephone. Sexual bondingis a powerful and rewarding form of attachment. The adolescentworries whether his or her body is 'good', 'big' orattractive enough to find a partner.Where sexuality is threatened by illness and disability,the patient fears that the basis of his or her attachmentmay be undermined: 'Who will want me i f . . . I have acolostomy ... a mastectomy ... am impotent... ?'Psychogenic symptoms such as lower abdominal discomfort,pruritus or back pain may both arise from andlead to sexual difficulties. Such symptoms may draw attentionto an underlying sexual anxiety, and at the same timeprovide the patient with the care and attention that hefears may be lost through sexual failure. Occasionally, guiltabout masturbation may be based on the misconceptionthat it is 'wrong' or harmful, and this too may lead topsychogenic symptoms.Continuity Psychologically, sex and reproduction may serve as aninsurance against the fear of extinction. The idea of personaldeath is more acceptable if there is family continuity,or if an individual feels he has contributed something:that children, memories, ideas or objects will live on in thenext generation. Threat to this sense of continuity can leadto feelings of anxiety or depression.

Taking a sexual historySex, at least in theory, is no longer a taboo subject, but inpractice both doctor and patient are likely to feel anxiousabout some aspects of their sexuality. It is important thatthe doctor feels reasonably comfortable when asking abouta patient's sexual life. All human beings have a sexual life- in the sense of thoughts, fantasies and feelings about sex- regardless of whether or not they are celibate. The doctorneeds to be sensitive to the common anxieties about sexand to be aware of those that may apply to a particularpatient's age and situation.

SEXUAL AND MARITAL DIFFICULTIES Divorce and family disruption are becoming increasinglycommon. More than one in three marriages in the UK nowends in divorce; in the USA the figure is one in two. Thereis good evidence that in general marital disharmony anddivorce are psychologically damaging for children, who aremore likely to have emotional disorders in adult life andto underachieve academically than their counterparts fromstable families. Nevertheless, single mothers and evensame-sex parents are capable of providing a loving andnurturing environment for their children. Partly inresponse to this, there is now great interest in maritaland family therapy.The commonly encountered sexual difficulties areimpotence, soonly discharge and delayed ejaculation for men, and vaginismus and lack of sexual enjoyment(including anorgasmia) for women. Both sexes may sufferdiminished libido. Transient difficulties are common; it isonly when they are persistent and cause distress that theyconstitute a problem. Sexual problems may be primary, i.e.present from the onset of sexual life, or secondary, i.e.developing after a period of satisfactory sexual functioning.

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