Sexual Medicine in Primary Care was written by Dr. William L. Maurice, MD, FRCP(C); Associate Professor at the Division of Sexual Medicine, Department of Psychiatry, University of British Columbia, Canada, in consultation with Dr. Majorie A. Bowman, MD, MPA; Chair at the Department of Family Practice and Community Medicine, University of Pennsylvania, USA.

Dr. Maurice brings nearly 30 years of experience to the field of treating patients with sexual problems. As a psychiatric resident he had the outstanding opportunity to be introduced to the field of human sexuality during a clinical elective in Masters and Johnson's clinic. Three decades later he now passes on his vast knowledge about assessing, interviewing, diagnosing, and treating people with sexual problems or concerns.

Dr. Bowman has served as a consultant for the book. With a background in family practice, she adds an important dimension to Sexual Medicine in Primary Care, emphasizing issues relevant to primary care health professionals.
 

The Books Audience:
Dr. Maurice teaches at the University of British Columbia, Canada, where medical students have the privilege of undergoing a thorough training in Sexual Medicine. Not unlike other medical schools worldwide, the fundamentals of human sexuality are introduced during the initial years: the sexual response cycle, the endocrinology of reproduction, sociology of sexuality and often some psychology. The University of Columbia Medical School, however, distinguishes itself from other facilities by offering students the possibility to gain clinical experience in addition to their fundamental understanding of human sexuality. Students are guided through the art of sexual interviewing skills, and ultimately have the opportunity to practice their skills in a sex-specialty clinic. Sexual Medicine in Primary Care was in part written in order to provide students with written materials and guidelines for this part of their clinical training.

From personal experience, I know how crucial it is to receive this medical training before entering the real world and it's real problems. I studied at the University of Copenhagen Medical School, Denmark, and a course in human sexuality offered  during our clinical training period was essential in allowing us to graduate as physicians capable of addressing sexual concerns with our patients. We also learned how to treat some of the less complicated sexual problems, and felt comfortable in doing so after the course.

Sexual Medicine in Primary Care will provide many clinicians with basic skills required for dealing with patients concerned about sexual problems. The information presented applies to a wide field within the health sector, and not only medical students, but nurses, social workers, psychologists and other health professionals may benefit from reading this book.

The book can be read from cover to cover, or it may be used as a quick reference guide. A detailed list of contents quickly guides the reader to relevant chapters and paragraphs. Sexual Medicine in Primary Care furthermore provides a rich source and an excellent basis for a course or a lecture series in human sexuality.

Style & Contents:
Part One of the book deals with sexual history taking, interviewing skills, and assessment of sexual concerns. Part Two focuses on diagnosis, treatment, and referral criteria for patients with the following sexual dysfunctions: low sexual desire (chapter 9), ejaculation/orgasm disorders (chapter 10), erectile disorders (chapter 11), orgasmic difficulties in women (chapter 12), and intercourse difficulties in women; pain, discomfort and fear (chapter 13).

The book is organized sensibly and thoroughly. Exhaustive and up-to-date reference lists follow each chapter. A large number of case stories provide examples of what type of cases a clinician may encounter and serve as welcome breaks in the information-rich text. Periodically, essential phrases are highlighted and visually emphasized in small boxes. This feature, together with the very detailed list of contents, may aid the hurried reader in quickly extracting pertinent information from the book.

I found many of the illustrations extremely informative and well suited for instruction. The assessments of various sexual dysfunctions are illustrated in diagrams that provide important visual aids to comprehending the wealth of information presented in the text.

Each chapter ends with a final summary, repeating and emphasizing the most essential messages from the chapter.

Appendix I (p.299): "First Assessment Interview With A Heterosexual Couple", and Appendix II (p.313): "First Assessment Interview With A Solo Patient" provide examples of dialogue between Dr. Maurice and clients. His comments on why and how to ask particular questions make these appendices valuable reading, especially for less experienced health care professionals.

Appendix IV (p.335): "Sex-Related Web Sites For Patients/ Clients/ Consumers And Health Professionals" lists a large number of relevant Internet resources.

Appendix V (p.341): "Medication & Sexual Function,"  summarizes sexual side effects of commonly used drugs.

Most Important Features:
In my opinion, the following features of the book are highly valuable:

1) Dr. Maurice has provided a detailed list of examples of questions to ask at an initial visit. Even more important, he has included questions not to ask.

2) There are also many good examples of dialogue and suggestions for responding to certain questions.

3) The book offers guidelines for:
  a) ordering labs,
 b) determining whether a patient can be dealt with in the primary care setting,
 c) when to transfer someone to a sex-specialist.

4) The following sections provide highly essential information for students and clinicians. If you do not have time to read anything else in this book, these pages are highly recommended:
 a) Box 9-1 (p.171): "Common Medical Conditions That May Decrease Sexual Desire,"
 b) Box 9-2 (p.174): "Commonly Used Pharmacological Agents That May Decrease Sexual Desire,"
 c) Box 11-2 (p.238): "Causes Of Generalized Erectile Dysfunction,"
 d) Appendix V (p.341): "Medication & Sexual Function"

Praise & Criticism:
Some comments are inclined to be too specific, limiting their more general application. Consider two questions on page 177:
 ".....Suggested Question when Talking with a Heterosexual Man/Woman: "About how often are you and she/he sexually involved with each other?"....." , or
  ".....Additional Suggested Question when Talking with a Heterosexual Man/Woman:  "What kind of  thoughts do you have before or during your sexual experiences?"....."
By leaving out the specification "Heterosexual Man/Woman" the questions would have been more general, since they may be addressed to anyone, regardless of their sexual orientation.

As a practitioner in the field of sexuality and chronic disease, as well as medical and physical disabilities, I found chapter 8: "Talking About Sexual Issues: Medical, Psychiatric, and Sexual Disorders (apart from dysfunctions)" very useful. However, so much information is compressed into this particular chapter I sometimes lost my orientation.

Chapter 8 may have benefited from being broken into three separate chapters (I - III), such as:
   I) Sexual Issues In The Context Of  Medical Disorders
  II) Sexual Issues In The Context Of  Psychiatric Disorders
  Here I would in particular have liked to find more details on separate disorders which may be encountered in a primary care setting, such as depression,  schizophrenia, manic/depressive episodes, and personality disorders. However, this may have exceeded the scope of the book.
 III) Sexual Issues In The Context Of  Sexual Disorders

On page 145 in the section "Sexual Disorders (Apart From Sexual Dysfunctions) Sexual Sequelae of Child Sexual Abuse in Adults: Sexual Issues and Questions," Dr. Maurice mentions the breach of confidentiality if sexual abuse of children is suspected. Perhaps this information should have been highlighted in a separate box, or even been presented earlier in the more general section (Part One) of the book. During discussions of sexual concerns with a patient/client, a situation may develop where confidentiality may have to be breached. I find it important to warn both the health professional who is conducting the interview and the patient about this possibility.

Female sexual problems and concerns are well covered in chapter 9 (Low Sexual Desire in Women and Men), chapter 12 (Orgasmic Difficulties in Women), and chapter 13 (Intercourse Difficulties in Women; Pain, Discomfort, and Fear).

In chapter 10 (Ejaculation/Orgasm Disorders) pharmacological treatment of premature ejaculation (PE) is discussed. The fact that some antidepressant drugs, such as paroxetine (Paxil), sertraline (Zoloft), and clomipramine (Anafranil), have the sexual side effects of inhibiting ejaculation is considered an advantage when treating PE. I do not have any reservations about this statement, but I believe that it would have been appropriate to point out that the same drugs all may have yet another sexual side effect: decreased sexual desire (T.L. Crenshaw & J.P. Goldberg, "Sexual Pharmacology; Drugs That Affect Sexual Function", Norton, 1996). It is important to know that when treating PE with these drugs, sexual desire may be negatively affected. Part of this information is found later in the book, and clomipramine is listed in Appendix V (p.341): "Medications & Sexual Function" under "Decreased Sexual Desire." However, neither paroxetine nor sertraline are included here, and perhaps should have been.

Chapter 11 (Erectile Disorders) provides an outstanding source of information. This topic clearly has been the focus of much recent research. Thoroughly reviewed topics include: anatomy and physiology of erections, epidemiology, etiology, history taking, physical examination, laboratory investigations, treatment options and referral criteria. Every primary care health professional should be familiar with the information outlined in this chapter.

My only minor criticism of chapter 11 involves a comment made on page 233: ".....Rather than the communication exercise it is, sensate focus is sometimes mistakenly thought of as a way of allowing one to discover previously unappreciated physical feelings in particular body areas....." True, sensate focus may primarily be an exercise for improving communication skills. However, when someone becomes more aware and appreciative of different sensations during the process, I find this an important part of the exercise, and it should not be de-emphasized. Perhaps this never was Dr. Maurice's intention, but nevertheless I found the wording unfortunate.

The list of Internet resources (mainly web sites) in appendix IV (p.335) includes many good references that may serve as starting points for doing more in-depth research of various topics on the Internet. Due to the constantly changing nature of the World Wide Web, it is impossible to provide a complete list of web sites. However, I was surprised to find the web sites for AASECT (American Association of Sex Educators, Counselors and Therapists; http://www.aasect.org) and ABS (The American Board of Sexology; http://www.sexologist.org) missing from the list. On the other hand, I was introduced to several excellent and useful web sites.

Conclusion:
At least two facts place primary care health professionals in extremely important positions, encouraging them to be able to deal with sexual concerns:

1) They are in the unique position to prevent HIV/AIDS by talking to their patients about sexual practices, by providing information about safe-sex measures, by giving advice, and by reaching some patients before infection may occur.

2) ".....Sildenafil (Viagra)........will likely result in a substantial shift in the treatment of men with erectile difficulties away from specialists and towards physicians in primary care....." (p.247/248)

I highly recommend this book to anyone in the health sector. Needless to say, I hope that teaching facilities will incorporate it in their suggested or required reading materials.

As we move into a fresh millennium, the fact that sexual problems often constitute a part of life should no longer be ignored. Primary care health professionals must be able to address sexual concerns with their patients. This book will teach them how.

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More Information:
More information about this book (including detailed Table of Contents) can be found at the following web site that was created for this purpose: http://www.interchange.ubc.ca/maurice/

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