Learning objectives
- Distinguish sex assigned at birth, gender identity, gender expression, sexual orientation and sexual function.
- Describe ICD-11 gender incongruence and common sexual dysfunctions without pathologising identity or consensual variation.
- Take a sensitive, structured sexual history and screen for medical, medication, psychological, relationship and safety causes.
- Recognise urgent safeguarding, sexual-violence, endocrine, neurological and psychiatric presentations.
- Plan biopsychosocial treatment, referral, prevention and follow-up.
1. Core language
| Concept | Clinical meaning | What it is not |
|---|---|---|
| Sex assigned at birth | Classification recorded at birth using observed anatomy and other factors. | Not the whole of a person’s gender or health needs. |
| Gender identity | A person’s internal sense of being a woman, man, non-binary person or another gender. | Not a psychiatric symptom. |
| Gender expression | How gender is communicated through dress, behaviour, name, voice or appearance. | Does not prove identity or sexual orientation. |
| Sexual orientation | Patterns of romantic, emotional or sexual attraction. | Not an illness and not changed safely by coercion. |
| Gender incongruence (ICD-11) | Marked and persistent incongruence between experienced gender and assigned sex, often associated with a desire for gender-affirming care. | ICD-11 places it in conditions related to sexual health, not mental and behavioural disorders. |
| Gender dysphoria | Distress or impairment related to incongruence, used in some clinical systems. | Not every transgender or gender-diverse person experiences dysphoria. |
| Sexual dysfunction | Persistent or recurrent difficulty in desire, arousal, orgasm, ejaculation or pain that causes distress or interpersonal difficulty. | Not simply a difference from cultural expectations or a partner’s preference. |
Use the name and pronouns the patient requests where safe and feasible. Ask what body parts, words and examination methods feel acceptable. Confidentiality has limits where there is serious risk, abuse of a child or a legal safeguarding duty; explain these limits before sensitive questions.
2. Sexual history: a safe structure
Ask permission: “Would it be okay to ask some questions about sexual health? They are routine and confidential.” Use the 5 Ps:
- Partners: gender, number, new partners, partner safety and relationship satisfaction.
- Practices: vaginal, anal, oral or other activities, pain, contraception and safer-sex practices; do not assume from identity.
- Protection: condoms, PrEP/PEP, HIV/STI testing, vaccination and exposure risk.
- Past history: STIs, pregnancy, sexual difficulties, surgeries, trauma and treatment.
- Pregnancy intention/prevention: possibility of pregnancy, fertility goals, contraception and reproductive plans.
Then ask about onset, context, desire, arousal, erection/lubrication, orgasm, ejaculation, pain, distress, relationship factors, masturbation, sleep, alcohol/drugs, mood, trauma and medicines. A partner’s report can help only with the patient’s consent. Never insist on sexual details that do not change care.
3. Common sexual dysfunctions
| Domain | Examples | Common contributors |
|---|---|---|
| Desire | Low desire, absent desire, loss of interest or distressing mismatch. | Depression, anxiety, relationship conflict, pain, menopause, endocrine disease, hyperprolactinaemia, SSRIs, antipsychotics, opioids and fatigue. |
| Arousal/erection/lubrication | Erectile difficulty, reduced genital arousal, inadequate lubrication. | Diabetes, hypertension, vascular disease, neurological disease, hypogonadism, medication, smoking, performance anxiety and pain. |
| Orgasm | Delayed orgasm, anorgasmia or distressing reduction in orgasmic sensation. | SSRIs, pelvic pain, diabetes, neurological disease, trauma, inadequate stimulation or anxiety. |
| Ejaculation | Premature, delayed, retrograde or absent ejaculation. | Prostate/neurological disease, diabetes, medicines, anxiety, relationship factors and surgery. |
| Pain/penetration | Genito-pelvic pain, vaginismus, dyspareunia or pain after trauma/infection. | STIs, pelvic disease, endometriosis, menopause, pelvic-floor dysfunction, fear, trauma or coercion. |
Establish whether the problem is lifelong or acquired, situational or generalized, and whether it occurs alone, with a partner or only in a particular context. Distress and consent—not a partner’s demand—determine clinical significance.
4. Medical assessment
History and examination
- Review diabetes, hypertension, cardiovascular disease, renal/liver disease, endocrine symptoms, neurological disease, pelvic/prostate conditions, cancer treatment and surgery.
- Ask about menstruation, menopause, pregnancy/postpartum state, fertility goals, genital pain, discharge, bleeding, urinary symptoms and STI exposure.
- Review SSRIs/SNRIs, antipsychotics, opioids, antihypertensives, finasteride, hormonal medicines, recreational substances and traditional/herbal products.
- Examine only with informed consent: general health, blood pressure, BMI, thyroid, secondary sexual characteristics, genital/pelvic or neurological findings when relevant.
- Consider depression, anxiety, PTSD, psychosis, mania, body-image distress and relationship safety; do not assume a psychological cause before considering disease.
Targeted investigations
Do not order a “sexual dysfunction panel” indiscriminately. Depending on the presentation, consider fasting glucose/HbA1c, lipids, morning total testosterone in a patient with symptoms suggestive of androgen deficiency, prolactin when indicated, thyroid tests, pregnancy test, renal/liver function, STI/HIV tests and urinalysis. Repeat an abnormal hormone result and interpret it with timing, illness and relevant medicines. Refer for pelvic ultrasound, urology, gynaecology, endocrinology or neurology when examination or symptoms indicate.
5. Gender incongruence and gender-affirming care
ICD-11 describes gender incongruence as a sexual-health condition rather than a mental disorder. The purpose of a clinical assessment is to understand the person’s goals, support wellbeing, address dysphoria or distress, and provide or refer for appropriate gender-affirming care—not to test whether the person is “really” their gender.
Assessment
- Use open questions: “How do you describe your gender?” “What support or changes would make healthcare safer and more comfortable?”
- Assess distress, depression, anxiety, trauma, self-harm and suicide risk without assuming these are caused by identity; stigma, violence, rejection and barriers to care are major contributors.
- Discuss desired social, voice, hormonal, surgical, fertility and reproductive interventions. Explain benefits, limitations, costs, waiting times and the need for specialist assessment.
- Provide routine preventive care based on anatomy and exposures: cervical screening when a cervix is present, prostate care when relevant, breast/chest screening, contraception, STI/HIV prevention and vaccination.
Children and adolescents
Use a developmentally appropriate, exploratory approach. A child’s gender expression is not itself a disorder. Assess distress, bullying, family safety, abuse, depression and self-harm; involve caregivers when safe and follow specialist paediatric pathways. Avoid irreversible interventions without appropriate multidisciplinary assessment, informed consent and adherence to current law and guidance.
Hormones and surgery
Gender-affirming hormones and surgery require trained multidisciplinary care, informed consent, baseline assessment, fertility counselling and monitoring. Do not advise self-medication or unregulated hormones. Discuss cardiovascular, thrombotic, metabolic, bone, reproductive and cancer-screening considerations and coordinate primary care with specialist services.
6. Management of sexual dysfunction
General measures
- Explain the likely contributing factors and normalise discussion without minimising distress.
- Treat diabetes, hypertension, thyroid disease, depression, anxiety, pain, pelvic infection and medication adverse effects.
- Encourage sleep, physical activity, smoking cessation, reduced alcohol, management of stress and adequate lubrication.
- Offer individual or couples psychosexual therapy, CBT, sensate-focus exercises, pelvic-floor physiotherapy and trauma-informed therapy where appropriate.
- Use a shared goal: pleasure, comfort, intimacy, fertility, function or reduced fear—not simply performance.
Erectile dysfunction
Evaluate cardiovascular risk; erectile dysfunction can precede vascular disease. PDE-5 inhibitors such as sildenafil may be considered by a trained prescriber after checking contraindications. A common adult starting example is sildenafil 50 mg orally about one hour before sexual activity, adjusted to 25–100 mg and not more than once daily. Never combine with nitrates or recreational “poppers”; use caution with alpha-blockers, hypotension, severe cardiovascular disease and interacting medicines. Priapism lasting more than 4 hours is an emergency.
Premature ejaculation
Clarify lifelong versus acquired pattern, perceived control and distress. Psychosexual techniques, pelvic-floor work and CBT may help. Topical anaesthetic or an SSRI such as dapoxetine where registered, or another SSRI under specialist guidance, may be considered. Explain numbness, condom use, transfer to a partner and SSRI adverse effects; avoid unsupervised tramadol.
Low desire and arousal problems
Correct pain, sleep deprivation, depression, endocrine disease, relationship stress and medication effects. Do not prescribe testosterone or “aphrodisiac” products without documented indication, baseline assessment and monitoring. In postmenopausal genitourinary symptoms, local vaginal oestrogen or other therapy may be considered after assessment of contraindications and patient preferences.
Genito-pelvic pain and penetration difficulty
Exclude infection, pregnancy-related complications, dermatoses, endometriosis, pelvic-floor dysfunction and trauma. Use a stop signal, consent at every step, lubrication, gradual desensitisation, pelvic-floor physiotherapy and psychosexual/trauma therapy. Never force an examination or attribute pain to “fear” before evaluating physical causes.
7. Sexual violence, coercion and safeguarding
Ask privately and believe the disclosure. Ensure immediate safety, treat injuries, offer emergency contraception and HIV PEP when indicated and available, test and treat STIs, preserve forensic evidence according to local protocol, document the patient’s words accurately and obtain consent before examination. Children, people with cognitive impairment, intimate-partner violence and trafficking require safeguarding referral. Do not mediate with an alleged perpetrator or require the survivor to confront them.
8. Medicines and interaction cautions
- SSRIs, antipsychotics, opioids and some antihypertensives may impair desire, arousal or orgasm. Review the indication and consider dose adjustment or alternatives with the prescribing clinician; never stop antipsychotics abruptly.
- PDE-5 inhibitors are contraindicated with nitrates and require caution with alpha-blockers and potent CYP3A4 inhibitors.
- Do not combine serotonergic medicines, tramadol and recreational drugs without specialist review because of serotonin toxicity risk.
- Enzyme-inducing antiseizure medicines can reduce hormonal contraceptive effectiveness. Offer a reliable contraceptive plan and check ART interactions.
- Unregulated sexual-enhancement products may contain hidden PDE-5 inhibitors, steroids or stimulants. Ask without judgement and advise against them.
9. Communication and documentation
Use gender-neutral language until the patient tells you otherwise. Document the patient’s words, consent, relevant anatomy, sexual-health risk, examination offered/declined, capacity, safeguarding concerns, investigations, treatment goals and follow-up. Separate confidential information from unnecessary labels. Never record sexual orientation or gender identity where it could expose the patient to harm without a clinical reason and appropriate privacy.
Clinical cases
Quick self-test
- Why is gender incongruence not equivalent to a mental disorder in ICD-11?
- Name four reversible medical or medication causes of sexual dysfunction.
- What is the most important contraindication to sildenafil?
- What are the first priorities after sexual assault?
- Why should sexual history and examination be consent-based and anatomy-informed?
Answers
- ICD-11 places it in conditions related to sexual health and focuses on access to appropriate care, not pathologising identity.
- Examples include diabetes, vascular disease, thyroid disease, hyperprolactinaemia, depression, SSRIs, antipsychotics, opioids, alcohol, pelvic disease and pain.
- Concomitant organic nitrates or nitrite “poppers” because of potentially dangerous hypotension.
- Ensure safety, treat injuries, provide confidential trauma-informed assessment, consider emergency contraception/HIV PEP/STIs, preserve evidence and follow safeguarding/legal protocol with consent.
- Identity, practices and relevant anatomy vary; consent protects dignity and improves accurate, patient-centred care.
Key take-home messages
- Gender identity and sexual orientation are not mental illnesses.
- Sexual dysfunction is diagnosed by persistent difficulty plus distress or interpersonal impact, after considering medical and medication causes.
- Ask permission, use inclusive language, protect confidentiality and examine only with consent.
- Sexual violence and coercion require urgent medical, psychological, forensic and safeguarding support.
- Gender-affirming care is multidisciplinary, informed-consent based and integrated with routine preventive health.
References and further reading
- World Health Organization. Gender incongruence and transgender health in the ICD: WHO ICD-11 FAQ.
- World Health Organization. Sexual health: WHO sexual-health overview.
- World Health Organization. FAQ on sexual and gender diversity, health and human rights: WHO SOGIE FAQ.
- WHO. Guidelines on the management of health complications from female genital mutilation: WHO guideline.
- World Health Organization. Consolidated guideline on sexual and reproductive health and rights of women living with HIV: WHO guideline.
