Doctors who notice that they are avoiding the physical examination of a patient need to understand the reasons. Perhaps the patient behaves in a sexual way, so that the doctor feels not like a doctor, but more like a potential sexual partner. Although more common between a male doctor and a female patient, awareness of homosexual feelings or fantasies may also be required. Feelings that physical examination is too intrusive, abusive or dangerous may alert the doctor to the possibility of previous sexual abuse, or occasionally to other well-hidden problems, including neurotic or even psychotic fantasies.
Although psychogenic problems are often missed or ignored, it is just as serious to miss a physical or iatrogenic cause for a sexual problem. Oral contraceptives can occasionally cause depression, although other reasons are more common (Herzberg, Draper, Johnson et al., 1971). Sexual desire disappears early in depression, often before there are many other more obvious symptoms. An imbalance of hormones can cause vaginal dryness; it may not be lack of arousal but lack of mucus. Intrauterine devices can cause dyspareunia in either partner. Spermicides, diaphragms and condoms can sometimes cause or exacerbate genital soreness and irritation. Other problems not associated directly with contraception must also be borne in mind – infections, impotence due to medication, endometriosis, diabetes, arthritis; almost any medical condition can affect sexual functioning.
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