Man of 39 in A Same-sex Relationship with Erectile Difficulties — Free SCA Practice Case

Character Overview: You are Adam, a 39-year-old architect. Over the past year you have found it increasingly difficult to get and keep an erection. You are in a committed relationship with your partner of four years; it is not an open relationship, and you both had full sexual health screening before you got together. You have no urinary symptoms. You have not tried anything from the pharmacy and have never taken medication for it. About seven months ago you raised it with a clinician here and felt brushed off — you were told it was probably stress and to come back if it continued, with no examination or tests — and it took you months to work up to trying again. It is affecting your confidence and putting strain on your relationship. You are articulate but guarded at first; if the doctor takes you seriously you become much more open.

Opening Sentence: "Hello Doctor. I've been having trouble getting and keeping an erection — it's been building over about a year. I did mention it here before, about seven months ago, and I came away feeling it wasn't really taken seriously. It's taken me a while to come back."

History if Asked (Data Gathering Phase)

• ●The problem: "Difficulty getting an erection and difficulty maintaining one. It's come on gradually over about a year and it's getting worse."
• ●Morning erections: "They've become less frequent and less firm than they used to be." (Suggests an organic component.)
• ●Situational or global: "It's the same whatever the situation — it's not just with my partner."
• ●Libido: "My interest in sex is still there, which makes it more frustrating."
• ●His relationship: "I've been with my partner four years. It's not an open relationship. We were both screened before we got together."
• ●The previous consultation: "I was told it was probably stress and to come back if it continued. No examination, no tests. I felt dismissed, honestly."
• ●What he wants: "I want it properly looked into — and if there's medication that helps, I'd like to try it."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

• ●Ideas: Adam is unsure of the cause but suspects something physical, given the gradual onset and the change in his morning erections. "I think something physical is going on — it's been gradual and my morning erections have changed."
• ●Concerns: His dominant concerns are the effect on his relationship and his confidence, and — if explored — a worry that it might indicate an underlying health problem. "It's damaging my confidence and putting a strain on us. And I do wonder if it means something's wrong with my health."
• ●Expectations: He wants to be taken seriously, properly assessed, and to try treatment. "I want a proper assessment — and to try medication if it's appropriate."

If Asked — ED Assessment, Psychological, and Cardiovascular Screen

The patient answers these only when directly asked, and more openly once he feels taken seriously.

• ●If asked about onset (gradual vs sudden): "Gradual, over about a year." (Gradual onset favours an organic contribution.)
• ●If asked about morning/nocturnal erections: "Less frequent and not as firm as they used to be."
• ●If asked about libido: "My libido is normal — that hasn't changed."
• ●If asked about ejaculation and orgasm: "No problems with ejaculation or orgasm."
• ●If asked about penile curvature or a lump (Peyronie's): "No bend and no lumps."
• ●If asked about urinary symptoms: "No urinary symptoms at all."
• ●If asked about mood, anxiety, stress, and performance anxiety: "My mood is generally okay, though this gets me down. Work is busy but not overwhelming. There is definitely performance anxiety now — I worry before sex, which makes it worse."
• ●If asked about the relationship and communication with his partner: "We're solid, but this is straining things. We haven't talked about it as openly as we could."
• ●If asked about cardiovascular risk factors (smoking, exercise, family history, previous BP/cholesterol checks): "I smoke about 10 a day. I don't exercise much — desk job. My father had a heart attack at 58. I haven't had my blood pressure or cholesterol checked in years."
• ●If asked about alcohol and recreational drug use: "I drink a couple of glasses of wine most evenings. No recreational drugs."
• ●If asked about diabetes symptoms (thirst, polyuria, weight change): "No thirst or extra weeing, and my weight's stable."
• ●If asked about medication, including anything bought online: "Nothing at all — no prescriptions, nothing from the pharmacy, nothing online."
• ●If asked about chest pain or breathlessness on exertion: "No chest pain, and no breathlessness beyond being unfit."
• ●If asked about sexual health screening and current risk: "We were both screened before the relationship. Nothing since; there's been no other partner."

Responses to Management (The Negotiation Phase)

• ●If the Doctor validates him and takes the problem seriously — the relational key: "Thank you. That's honestly all I wanted last time — to be taken seriously." (The tested point is validating a patient who felt dismissed.)
• ●If the Doctor explains erectile dysfunction can signal cardiovascular risk: "So this can be an early warning sign for heart and blood vessel problems? I had no idea — especially with my dad's heart attack." (The tested point is explaining ED as a marker of cardiovascular risk and acting on it.)
• ●If the Doctor arranges examination and bloods: "So a face-to-face appointment for examination, and blood tests? Yes — that's what I was hoping for." (The tested point is arranging appropriate assessment, which cannot be done on video.)
• ●If the Doctor explores the psychological dimension: "The performance anxiety is real now. It's become a bit of a vicious circle." (The tested point is screening the psychological contribution without dismissing the physical.)
• ●If the Doctor offers sildenafil: "I'd like to try it. What do I need to know — how to take it, and any risks?" (The tested point is safe PDE5-inhibitor prescribing and counselling.)
• ●If the Doctor raises smoking, alcohol, and exercise: "So stopping smoking, cutting the wine, and exercising would actually help this, not just my general health?"
• ●If the Doctor mentions psychosexual support: "Counselling — for me, or for us both? That might help us talk about it."