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10 - Psychopathology and sexuality in aging
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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Summary
The distinction between the natural changes of aging and the clinical symptoms of disease is particularly relevant when considering mental changes in late life. Clinical and research advances in geriatric psychiatry document that cognitive impairment and depressed mood, for example, are not intrinsic characteristics of growing old but that they can be indicative of mental illness. Epidemiological investigations applied to psychiatric problems have shown that mood disorders, dementia, schizophrenia, and alcohol-related disorders account for why the aged use psychiatric services so much (Blazer, 1995). The prevalence of depression has been estimated at between 2% and 4% in representative samples of noninstitutionalized individuals older than 65. The rates reach 15% and even higher when subclinical depressions are included in the sampling of older age groups (Gatz, Kasl-Godley and Karel, 1996). Depression and dementia are very prevalent among elderly patients in psychiatric units and nursing homes (Anthony and Aboraya, 1992; Gurland, 1996). Depression, as a nosological entity or as a psychiatric symptom, commonly occurs during primary medical care and ambulatory medical settings. The association between affective disorders and physical illness is manifested in a wide range of medical problems including stroke, Parkinson's disease, arthritis, endocrine disorders and renal and hepatic failure, as noted in Chapter 9. Among US community residents 65 years and older, the rate of dementia is estimated as 4.5%, with Alzheimer's disease and multi-infarct disorders accounting for the majority of cases of dementia. The prevalence of dementia rises rapidly with age, reaching 20% in patients older than 80. Alcohol abuse and dependency are also frequently detected among older men in psychiatric services and hospital and outpatient medical clinics.
7 - The social context
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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Sexuality evolves throughout our lives, and is shaped by social conventions that give meaning and significance to life events and influence individual responses in keeping with the values and expectations prevailing at that time. According to lifespan developmental theory (Baltes, 1987), people move through identifiable phases or periods requiring adaptation to personal or environmental changes that alter social roles, personal identity, and expectations. Individual adaptation to life events is not just a passive phenomenon, but a dynamic process that is influenced by the social context in which adult transitions take place. Socialization processes, with their implied expectations, norms, and values, help shape the sexual thoughts, interest, and activities of older individuals. The aged may incorporate these normative sanctions and perceive them not only as external constraints but also as a reflection of their personal values and preferences.
Social attitudes toward aging and sexuality
Cultural stereotypes about the sexuality of aging people are embedded in general negative attitudes towards the aged. Several authors have written about negative beliefs that prevail in Western societies concerning the aged (Hendricks and Hendricks, 1977; Rogers, 1979; Hultsch and Deutsch, 1981). Butler (1969) coined the term ‘ageism’ to indicate prejudicial attitudes toward older people, as well as discriminatory practices against this social group. Sexuality is popularly viewed as a youth-oriented activity. Prevailing social stigmas are that sexual interest and activity among the aged is inappropriate, that elderly people are either uninterested or unable to engage in sex and that they are physically unattractive and therefore sexually undesirable (Riportella-Muller, 1989).
Contents
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4 - Psychological aspects of aging males' sexuality
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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The viewing of aging and sexuality through the prism of behavioral frequencies and erectile function inherent in much current research has led to the neglect of potentially important psychosexual determinants and correlates. Clinical and phenomenological reports emphasize the importance of studying the meaning and significance of sexuality for aging individuals, but there is little systematic research into the relevant motivational, cognitive, and affective influences on this population. While this chapter focuses on the psychology of aging and sexuality, we should remain aware of the pitfalls of viewing the psychological aspects separately from the biological, interpersonal, and sociocultural contexts that shape the individual experience.
Sexual interest and motivation
The terms sexual interest, desire, motivation, and drive are frequently mentioned without addressing their underlying conceptual underpinnings. Some investigators assume that an innate drive exists, mediated by neuroendocrine mechanisms that motivate sexual behavior, while others emphasize psychosocial factors to the exclusion of biological ones. Some retrospective investigations note that men, as they age, retain characteristic levels of sexual interest and activity compared with other men. While men's interest in sex declines overall with age, variation between individuals persists through life and thus accounts for a significant proportion of the variation of sexual functioning in the elderly (Pfeiffer and Davis, 1972; White, 1982; Botwinick, 1984a).
Preface
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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Sexual anatomy and function have become frequent subjects of discussion in the media following the recent approval and commercial availability of a new oral agent for the treatment of male erectile difficulties. Behind the decline of the taboo concerning sexual topics and humorous comments, there is the clinical reality that, increasingly, older men approach health-care professionals with the hope of enhancing their sexual function. Demographic and social changes as well as advances in sexual knowledge have led to a more open attitude by the aged about their sexual lives. The age structure of the Western World population, which is gradually evolving from a young to an aging society, has been accompanied by an evolution in the experience of adulthood and old age. The prolongation of life, improvements in health-care and a more proactive attitude concerning quality of life, reinforced by the American ‘baby boom’ generation now beginning to reach later adulthood, have all contributed to the increased importance of sexuality for contentment as age progresses. In parallel with these developments, considerable progress has been made, over the last twenty years, in our knowledge of sexual physiology and the deleterious effects of disease and drugs on male sexual function. Although this information has permitted valuable therapeutic interventions, it has also contributed to a distorted picture of aging and sexuality centred on medical illness and organic pathology. The original emphasis on the psychological determination of erectile difficulties has given ground to the current and equally undocumented view that most erectile disorders have an organic basis and to an evolving armamentarium of laboratory and biomedical approaches to diagnose and correct erectile failure.
8 - The nature and prevalence of sexual disorders in the aged
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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The nosological system for sexual disorders incorporated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994) characterizes sexual dysfunction as disturbances in sexual response denned to include four phases: desire, excitement, orgasm, and resolution. This classification, psychophysiologically based and oriented towards sexual performance, does not fully encompass the experiences and problems of the aging male. Aging is mostly neglected in DSM-IV as an associated feature of sexual dysfunction and its subjective aspects, which become more salient as age progresses. However, a significant improvement in the DSM-IV edition should be recognized. The diagnostic criteria for sexual dysfunction now require that the disturbance causes marked distress or interpersonal difficulties (Table 8.1). Consequently, age-related declines in a man's sexual function may not be categorized as dysfunctional unless they are problematic for the individual or his partner.
Sexual problems and concerns, not classifiable as dysfunctional according to DSM-IV diagnostic categories, are highly prevalent in the aging population. Their importance as a source of dissatisfaction and as a determinant of help-seeking behavior has been frequently ignored. The large body of data on sexual problems in the aging male is remarkable for its almost exclusive focus on erectile disorders. Regrettably, the health-care delivery system in the Western world tends to focus on the functional decrements in erectile capacity with limited attention given to underlying individual and interpersonal difficulties. In this chapter we shall summarize information from selected surveys, representative samples of the community at large and clinical populations. Among the latter we shall describe our clinical experience over a 17-year span at the Human Sexuality Program at Mount Sinai Medical Center.
9 - Impact of medical illnesses on sexuality
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Community surveys and studies of patients in medical and sex therapy clinics, summarized in Chapter 8, make abundantly clear the high prevalence of medical illnesses associated with erectile disorders in aging men. Any illness that is accompanied by weakness, fever, pain, malaise, and limited mobility is likely to have a generalized, nonspecific effect on sexual function. Medical disorders may also have direct actions by interfering with vascular, neural, and endocrine processes that mediate the sexual response. Their sexual effects are frequently multifactorial, involving physiological mechanisms interacting with psychological processes. Aging contributes significantly to the nature of this interaction; a person's age not only influences the probability of being affected by a specific illness but also determines their biobehavioral response to the medical problem (Mulligan, 1989). The effect of illnesses on individual sexual responses is also influenced by factors such as prior experiences of, and attitudes to, sex, coping styles, personality characteristics, and the nature of ongoing relationships. Regretfully, little empirical, systematic data on these critically important aspects are available for determining the effect of illness on sexual satisfaction.
A wide range of chronic organic conditions are associated with male sexual disorders (Table 9.1). The following is a discussion of the most prevalent diseases and surgical interventions that affect the sexual life of aging men. Coping and adaptive responses, as well as diagnostic and management issues will be considered in subsequent chapters.
Index
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1 - Aging and sexuality: concepts, issues, and research methods
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Population dynamics and socioeconomic developments during the second half of this century have had a profound impact on the aged. The substantial increase in the rate of growth of elderly populations has been accompanied by an enhanced awareness of the aged as a distinct demographic group. The rapid change in social structures with emphasis on economic development and productivity has brought about a redefinition of how the aged are characterized. The view of old age as a repository of wisdom, tradition, and cultural memories has been replaced by a conceptualization of the aged as a problematic social group. The aged have been variously described as disengaged from the community, lacking in self-esteem, sexless and unattractive, burdened by physical and mental disorders, as well as dependent and passively expecting economic and social support (Brown, 1990a).
These stereotypical notions are being challenged by a wealth of information from social scientists, psychologists, biologists, and clinical investigators working in the field of gerontology, a relatively new discipline devoted to the study of aging processes. Models of aging characterized by physical and mental decline and emotional isolation are being replaced by models that incorporate concepts such as growth, competence, successful adaptation, and personal satisfaction. Increasing attention is given to factors that promote health, prevent disease and disability, and contribute to the self-esteem and quality of life of the aged.
It is in this context that changes in societal attitudes about sexuality need to be considered. The prevailing emphasis on sex, driven in part by our youth-oriented culture, has not been without consequences for the older population.
3 - The neurobiology of aging males' sexuality
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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Age-related physiological changes contribute to the variability of the sexual function and behavior of older individuals, even when the confounding effects of medical illness and drugs are considered. There is little information on the mechanisms that mediate age-dependent differences in the sexual function of healthy individuals. This chapter provides a brief update on the neurobiology of male sexual function, and discusses the role of neurological, hormonal, and vascular processes possibly involved in sexual changes during nonpathological aging. It also summarizes the results of a multidisciplinary study of healthy aging men conducted in our laboratories.
The biology of sexual function
Sexological research has been oriented by conceptual models that help organize information about processes and mechanisms that underlie behavior. Sexual arousal is an encompassing concept implicit in Kinsey's research (Kinsey, Pomeroy and Martin, 1948) that unifies all physiological phenomena, central as well as peripheral. Masters and Johnson (1966) elaborated this notion further by structuring their observations along a progressive sequence of phases: excitement – plateau – orgasm – resolution, which they labeled the sexual response cycle. Kaplan (1979), based primarily on clinical evidence, incorporated a cognitive/motivational component in what she called the ‘triphasic’ model of sexual desire, arousal and orgasm, postulating that each of these phases is subserved by separate but interrelated physiological systems. Everitt and Bancroft (1991) criticized the validity of this model because of a lack of scientific evidence and the difficulty of operationally distinguishing between sexual desire and arousal.
Frontmatter
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12 - Role of psychosocial factors; coping and adaptation
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The sexuality of aging is best understood by considering physiological evidence, personal history and beliefs, individual circumstances, and sociocultural expectations, throughout the individual's life. Aging is viewed traditionally in the Western world as a decline and loss: decline of functional capacities and loss of close attachments, health, and social status. This pessimistic, but culturally ingrained, view is consistent with several studies which found that the most common major life events reported by the aged are medical problems and illness or death of the spouse (Ruth and Coleman, 1996). Decline models of aging have been balanced most recently by models that emphasize processes of adaptation, as reflected by the perceived quality of life of people in their older years. This adaptation, positive or negative, is shaped by personal commitments, cognitive appraisal and coping responses, in keeping with the significance of events in the context of the person's life.
We have discussed, in preceding chapters, the impact that a wide range of medical illnesses and drugs have on male sexual function. We will now elaborate on the relationship between aging and disease as well as the processes of adaptation and their relevance to individual well-being, contentment, and health-care behaviors. There is a vast amount of literature in these areas, most of it recently published. However, its relevance to human sexuality has been neglected and there is virtually no research on psychosocial geriatrics and health–behavior relationships pertinent to male sexuality. The discussion that follows is oriented by a model pictured in Figure 12.1.
15 - Summary and conclusions
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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Aging has emerged as an important area of social concern, first in industrialized countries and now in the less developed regions of the world. Demographic changes caused by increased life expectancy and declines in birth rates have resulted in a dramatic shift, with the proportion of older people increasing rapidly to form a substantial segment of the population. This demographic reality and the growing awareness of the aged as a definable social group have led to gerontology developing as a multidisciplinary endeavor. Initially, much gerontological research was biologically oriented, and only recently has its interaction with psychosocial factors, as they influence health and behavior, become a focus of concentrated attention. While sexological research in the field of aging has made significant advances, moving from the descriptive and epidemiological to the physiological and more recently to the biomedical and clinical, it has yet to fully integrate psychosocial perspectives in its studies. A review of data points to several methodological problems, not all limited to sexological studies, that need to be considered when interpreting the results. Much of the research is cross-sectional in design, confounding the effects of aging with differences in the attitudes, values, and behavior that characterized the different age cohorts as they grew up. Longitudinal studies, on the other hand, are undermined by selective attrition, biasing the results in the direction of the healthier, stable, and cooperative participants. Conclusions are frequently drawn from small, unrepresentative and nonrandom samples of white, middleclass and well-educated volunteers who are probably more liberal in their sexual attitudes than their counterparts who decline to participate in sexological research.
2 - Sexuality in the aged male; research evidence
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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A point of departure from the exploration of the sexuality of aging males is an overview of the evidence of age-related changes in sexual behavior. This review incorporates a range of approaches: quantitative analysis of the frequency of sexual acts; phenomenological descriptions derived from nonrepresentative surveys based on nationally distributed questionnaires; systematic assessments of representative samples from the community at large; and objective measurement of sexual responses in the laboratory. The most relevant methodological aspects of these studies are summarized elsewhere (Schiavi and Rehman, 1995). This overview concludes with a brief discussion of the main findings on male aging and sexual behavior.
Aging and sexual behavior
Sexual activity in nonrandom subject samples
In the USA, the scientific approach to research into human sexual behavior started with Kinsey's pioneering studies in the 1940s. Kinsey, Pomeroy and Martin (1948) included over 14 000 men in their cross-sectional survey of male sexual behavior, but only 106 were over 60 years old. A progressive decline in sexual activity beginning at adolescence was noted, with nearly 30% of men completely inactive by the age of 70. The weekly frequency of total ‘sexual outlets’ (intercourse, masturbation, nocturnal emissions) in the active population decreased from a mean of 3 at ages 26–30 to 1 at ages 61–65, and to 0.3 in those aged 71–75 years. There was considerable variability in the frequency and range of sexual behaviors within every age group. Some of the men continued to report masturbation and nocturnal emissions well into the 76–80 age group. The percentage of erectile impotence remained less than 7% until the age of 60, when 18% of white males reported erectile failure.
5 - Aging and marital sexuality
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The substantial increase in life span since the beginning of the twentieth century has had notable consequences for the social relationships of older individuals. As society norms and attitudes have become less restrictive, there has been increased fluidity in the development and realignment of partnerships encompassing marriage, separation, divorce, remarriage, extramarital, and same-sex relationships. Although this range of possibilities has greatly expanded sexual options, marriage remains the most prevalent social arrangement within which normatively sanctioned sexual experiences take place. Because women have a longer life expectancy and men tend to be older when they marry, and marry more frequently, there are marked age-related gender differences in opportunities for sexual partnerships (Figure 5.1). The percentages of men married at ages 55–69, 75–79 and 85 and older are 93, 82 and 80% respectively. In contrast, the percentages of women who are married within the same age spans are 66, 40 and 18% respectively (US Bureau of the Census, 1985).
Marital status is associated with marked differences in the number of sexual partners. In a full-probability cross-sectional survey of the adult population of the United States conducted in 1989 (Smith, 1991), the widowed reported the fewest sexual partners during the preceding year (a mean of 0.21), followed by the married (0.96), the divorced (1.31), the never married (1.84) and the separated (2.41). There was a gradual decline with age in the mean number of sexual partners from 1.7 partners among individuals younger than 30 years of age to 0.35 among those older than 70. The age-related decreases in the number of partners and the frequency of intercourse remained significant even when marital status and gender were controlled for.
14 - Management and treatment of sexual problems
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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The general considerations for treatment outlined in the National Institutes of Health, Impotence Consensus Statement (1992) remain valid to this day:
1 Psychotherapy and/or behavioral therapy may be useful for patients with erectile dysfunction without evident organic origin or as an adjunct to medical/urological interventions.
2 Treatment should be individualized to meet patient's desires and expectations, preferably including both partners in treatment plans.
3 Although there are several effective therapies, their long-term efficacy is relatively low and there is a high rate of voluntary discontinuation for all forms of erectile dysfunction treatment.
The sexual problems and concerns that lead aging men to approach health-care professionals are not limited, however, to erectile difficulties. As mentioned in previous chapters, life events such as medical illness or retirement, psychological problems such as depression and marital difficulties may induce sexual dissatisfaction which may, or may not, be accompanied by erectile difficulties. The generic model developed by Baltes and Baltes (1990) named selective optimization with compensation, described in Chapter 1, includes a set of propositions that help organize our views about the management and treatment of the sexual problems of aging individuals. The element of selection refers to concentration on those domains that are of high priority for the individual, which may or may not include, depending on the circumstances, sexual expression. It may also entail adjustment of goals and expectations to maximize sexual satisfaction and the sense of control. The element of optimization may involve enhancing the quality of sexual experiences by cognitive, emotional or interpersonal interventions or by modifying life-style factors in accordance to the priority given to sexuality.
Aging and Male Sexuality
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Awareness of the importance of sexuality and its disorders in the aging population is increasing as the proportion of older people grows. Based in part on the author's clinical experience and research at Mount Sinai Medical Center in New York, this book presents an up-to-date overview of the sexuality of aging men in health and illness, within a multidimensional conceptual framework, and taking account of physiological, psychological, interpersonal and social influences. Also discussed are the impact of medical illness, psychopathology and drugs, with a review of coping strategies in shaping individual sexual responses to aging and disease. Many case studies and vignettes are incorporated, and a chapter is devoted to the sexuality of older gay men. A balanced account of medical and psychosocial evaluation and treatment concludes the book, which will be of broad interest to clinicians and students interested in sexuality and aging.
6 - Aging and homosexual relationships
- Raul C. Schiavi, Mount Sinai School of Medicine, New York
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The relationship between aging and the psychosocial adjustment of homosexual individuals has been neglected as a topic of research. Accurate information about the aging and adaptation of homosexuals is important, not only to correct pervasive stereotypical notions, but also for the general understanding of the social context of sexual diversity and the health-care needs of an important portion of the aging population.
Aging homosexual individuals are variously described as lonely, isolated from other homosexual males because of the over-emphasis on youth in the gay subculture, thinking of themselves as middle-aged and old before their heterosexual counterparts, unable to sustain close relationships, dysfunctional, unhappy, and lacking in self-esteem (Kelly, 1977; Berger, 1980; Pope and Schulz, 1991; McDougall, 1993). Descriptive studies, conducted mostly during the 1970s and 1980s, do not support these stereotypical beliefs. Weinberg and Williams (1975), who analyzed questionnaire data from a subsample of men aged over 45 as part of a survey of over 2000 homosexual volunteers, found that younger and older respondents did not differ on several measures of personal adjustment. Older men had more stable self-concepts and were less likely to desire psychiatric treatment. Kelly (1977) also noted that most older participants in his investigation reported satisfactory social and sexual lives. Berger (1980), in a study of 112 homosexual men aged 41–77, found that the majority of respondents lived in stable relationships, had many friends, scored within the normative range in all measures of psychological adaptation and life satisfaction and that older men, in comparison to younger homosexuals, had lower levels of depression and psychosomatic symptoms.
11 - Effects of drugs and medications
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Older persons consume a disproportionately high quantity of prescription and nonprescription drugs. Thirty-one per cent of all medications are prescribed to patients older than 65 while they comprise less than 12% of the total US population (Lamy, 1980). The high prevalence of chronic illness and elevated use of health-care services among the aged, and socioeconomic factors such as mass media promotion of medication use, to the exclusion of nondrug alternatives, contribute to the increased drug use. Heart disease, hypertension, and arthritis are common chronic conditions that, among others, afflict four out of five aged persons and occur about five times more frequently than in younger age groups (Soldo and Agree, 1988). Physician visits markedly increase with patient age, as do the frequency and total number of medications prescribed per visit (Stewart, 1988).
The ranking of specific drug categories administered to patients over 65 years of age has remained consistent over the years. Table 11.1 lists the most common drug classes identified in two studies of prescription drugs or combined prescription and nonprescription medication use in older persons (Task Force on Prescription of Drugs USDHEW, 1968; May et al., 1982). Most of the top-ranked drug categories are commonly associated with adverse reactions including sexual dysfunction.
Adverse drug effects have been reported two to three times more frequently among the aged than in the general population (Wade and Bowling, 1986). The risk of toxic drug reactions to specific drugs in the elderly requires that altered pharmacokinetics and age-related changes in organ response are considered. (Andrews, 1992).
13 - Assessment of sexual problems
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Population surveys have consistently shown in cross-sectional analysis a decrease in sexual function, primarily erectile capacity, associated with aging in men. Individual responses, as discussed in the previous chapter, are variably shaped by attitudes and expectations that contribute personal significance to the sexual change. Although the aged with sexual complaints approach the health-care system in increasing numbers, the majority of older men do not seek sexual help, even though they may experience significant decrements in sexual function (Feldman et al., 1994). Slag et al. (1983) screened over 1000 patients in a medical outpatient clinic for the presence of erectile dysfunction and found that half of the patients with erectile difficulties declined to be examined for this problem. The investigators speculated that older age and the greater number of medical problems noted in this subgroup of patients may have contributed to their lack of interest in pursuing evaluation of their sexual difficulties.
There is limited information on the reasons that lead men to seek clinical assistance for their sexual concerns. Perez, Mulligan and Wan (1993) conducted a large survey of a random sample of male veterans aged 30–99 to assess variables that may contribute to their interest in a sexual evaluation. A hierarchical regression analysis that included measures of sexual function, emotional state, physical state and demographic characteristics showed that the perception of erectile and orgastic difficulties only partially predicted the desire to be referred for medical assessment. Diminished sexual interest and demographic traits (older age, never married, and nonwhite) had significant negative effects on men's motivation to seek a sexual evaluation.