Psychosexual Difficulties

1. Psychosexual Difficulties Christa Lloyd Nurse Practitioner Dip PST

2. AGENDA Introductions PowerPoint presentation � Psychosexual difficulties Group work 1st Scenario Resources Group work 2nd and 3rd Scenarios Feedback and finish

3. Learning Objectives Recognition of sexual problems Initial Help Specialist Referral

4. 5 Purposes of sex Reproduction Tension and anxiety reduction Sensual enjoyment and pleasure Self esteem and confidence Relationship closeness and satisfaction Metz & McCarthy

5. Where Problems may be mentioned Posters encourage people to understand that its okay for them to talk about an issue � so think about what is on the walls of the room you are in and the waiting area.Posters encourage people to understand that its okay for them to talk about an issue � so think about what is on the walls of the room you are in and the waiting area.

6. Situations Avoids smear test Never happy with contraception Expresses distaste when contraceptive methods involving touching the genitals are discussed When sexual closeness is mentioned When semen is mentioned Ask � Are you having any sexual problems?Ask � Are you having any sexual problems?

7. Times when problems may be mentioned Pregnancy/childbirth Miscarriage/stillbirth Termination Death of a child Daughter reaching menarche or sexarche Memories of past abuse surfacing Menopause, hysterectomy, sterilisation Relationship breakdown Uncertainty of sexual orientation Violence in the home Infertility � performing on demand Change of body image � colostomy, mastectomy, incontinence Fear of death � cancer treatments, heart disease, loss of parent The evidence from clinical practice is that a significant delay occurs between the onset of symptoms and seeking treatment and may result in a situation where there is no sexual activity either within a relationship or in seeking casual encounters and this can result in partners drifting apart or social isolation. The evidence from clinical practice is that a significant delay occurs between the onset of symptoms and seeking treatment and may result in a situation where there is no sexual activity either within a relationship or in seeking casual encounters and this can result in partners drifting apart or social isolation.

8. What do they complain of? Pain Impotence Its too quick It takes too long Its not happening No or reduced interest Fear of pregnancy or pain Painful sex Erectile dysfunction Premature ejaculation Retarded ejaculation Non-consummation Loss or lack of libido

9. Sexual Dysfunctions

10. How common? Erectile Dysfunction 5% of 40 year old men 25% of 65 year old men Premature Ejaculation 30-40% of men The British National Survey of Sexual Attitudes and Lifestyles (Natsal, 2000)The British National Survey of Sexual Attitudes and Lifestyles (Natsal, 2000)

11. First Steps Check for medical problems History Examination Investigations

12. History Family history (CHD/Stroke/Diabetes) Medical history (previous illness�, operation, accident, obstetric and current medical history) Previous or current mental illness Current medication Recreational drugs (including alcohol, tobacco, cannabis and heroin)

13. Examination Obesity Smell of alcohol or tobacco Mental disturbance e.g. depression, schizophrenia, drug abuse Lack of facial hair in male Evidence of heart disease or peripheral vascular disease or raised BP Evidence of over or under active thyroid Urine for glucose Evidence of neurological disease Rectal examination in male (history of prostate disease) Testes for size etc Female genitalia (confirmation vaginismus/causes of pain during penetration)

14. Investigations Sex hormones � Testosterone/SHBG/Prolactin /LH/FSH Thyroid Diabetes Ultra sound of penis Semen analysis Brain scan SHGB � Sex Hormone binding Globulin LH � luteinising hormone FSH � follicle stimulating hormone SHGB � Sex Hormone binding Globulin LH � luteinising hormone FSH � follicle stimulating hormone

15. Reversible causes of ED Hormone deficiencies Hypogonadism Hyperthyroidism/hypothyroidism Hyperprolactinaemia British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction 2007

16. Partner Sexual Problems Enquiry should always be made about partner sexual health and satisfaction so that co-existing sexual problems in the partner can be identified and addressed.

17. Approaches to Help Physical treatments for men Physical treatments for women Psychological Interventions PLISSIT Psychosexual Medicine Psychosexual therapy

18. ED Possible Physical Treatments* Oral PDE5 Inhibitors Sildenafil (Viagra) Tadalafil (Cialis) Now available as On demand New daily dose Vardenafil (Levitra) Urethral application Alprostadil (Muse) Intracavernosal injection Alprostadil (Caverject) Three recent studies comparing the different PDE5 Inhibitors demonstrate that efficacy ratings are similar for the 3 drugs Studies by Eardley et al and Tolra et al, showed a patient preference for tadalafil due to the ability to get an erection long after taking the drug Alprostadil works by relaxing the muscles in the penis and increasing the blood flow to create an erection PDE5 inhibitors work by vasodilation � in response to sexual stimulation the blood vessels release nitric oxide, which forms cyclic guanosine monophosphate or cGMP. PDE5Is stop the breakdown of cGMP so the erection can develop normally. There is no increase in size or duration.Alprostadil works by relaxing the muscles in the penis and increasing the blood flow to create an erection PDE5 inhibitors work by vasodilation � in response to sexual stimulation the blood vessels release nitric oxide, which forms cyclic guanosine monophosphate or cGMP. PDE5Is stop the breakdown of cGMP so the erection can develop normally. There is no increase in size or duration.

19. Vacuum Pumps And Constriction Rings 90% effective� Drug-free� Non-invasive� Available on prescription for certain conditions Contraindicated in men with bleeding disorders or taking anticoagulant therapy.

20. The following conditions warrant an NHS Prescription: Diabetes Multiple sclerosis Parkinson�s disease Poliomyelitis Prostate cancer Severe pelvic injury Single gene neurological disease Spina bifida Spinal cord injury Severe distress assessed using the following criteria Significant disruption to normal social and occupational activities A marked affect on mood, behaviour, social and environmental awareness A marked affect on interpersonal relationships

21. PE Possible Physical Treatments Antidepressants such as SSRIs Premjact Spray Condoms (with local anaesthetic benzocaine inside the condom to reduce sensitivity � check for allergies)

22. Arousal Problems SSRIs may help with phobic response

23. Low Libido in women Where this is assessed as being post menopausal low libido HRT especially Tibolone Testosterone Intrinsa patches licensed for women

24. Vaginal atrophy (menopausal) Topical oestrogen estradiol tablets � Vagifem � 25microgram in disposable applicators Creams Ortho-Gynest (also as pessary) Ovestin Premarin Ring estring

25. Vaginismus & Dyspareunia Lubricants Sylk Can be prescribed TLC Play/Feel/Heat Yes ID Lubes Local anaesthetic gel Vaginal dilators New first size (not shown in this picture)

26. Remember � psychological support for the individual or couple is usually needed to back up physical treatments

27. Initial Help PLISSIT Model P/LI/SS/IT Jack Annon

28. Permission To talk, to know they are normal, to ask for and receive reassurance Recognise and acknowledge the problem Stay with it and consider examination to reveal what the patient feels about their body as well as clinical information Listen, in a non-judgemental manner, to what is being said and how (non-verbal/body language)

29. Limited Information Giving accurate sexual information can lead to dispelling myths and misconceptions If you love your partner sex will be wonderful Good girls don�t like sex Sex should include intercourse and orgasm for both partners My partner should know what I want Affectionate touching always leads to sex Good sex is spontaneous No one has sexual problems except me

30. Almost all couples will benefit from simple sex education helping them achieve an understanding of their physiological sexual response the effects of ageing the effects of concurrent disease the effects of medications (and the myths) Improved understanding of the similarities and differences in sexual interest and response in men and women may be beneficial Provide simple behavioural advice about foreplay, sexual activity and on the integration of medication into the couple�s sexual behaviour

31. Specific Suggestions Life style changes Encourage intimacy � not always aiming for intercourse When a negative sexual encounter happens encourage the couple to get up, dress and talk at the kitchen table/ whilst taking a walk Self Help Books/Sexual exercises Relaxation � Kegel�s for men and women Review prescribed medication Discuss options Use of drugs/alcohol/tobacco Weight Use of drugs/alcohol/tobacco Weight

32. Intensive Treatment If no relief by the first three steps then need to move to more intensive psychotherapy Reflect on your own reactions when with patients Would you like further training?

33. Psychosexual Medicine Brief psychotherapy with recognition of the doctor-patient relationship and use of the genital psychosomatic examination Patient seen within everyday work of the doctor Specialised training with The Institute of Psychosexual Medicine Contact Dr Deborah Beere for information on local seminars It is often just by being able to reflect on the atmosphere in the room that some insight can be made and offered to the person, which may start the process of healing.It is often just by being able to reflect on the atmosphere in the room that some insight can be made and offered to the person, which may start the process of healing.

34. Psychosexual Therapy Integrates a variety of approaches based on assessed need � extensive assessment & history taking is part of the process followed by a formulation presented to the couple/individual Cognitive Behaviour Programme Includes adapted sensate focus Education Self awareness exercises Homework exercises specific to dysfunction No examination of the body/genitals Couple therapy Individual therapy

35. Training Organisations Institute of Psychosexual Medicine (IPM) 12 Chandos St, Cavendish Square, London W1G 9DR. 020 7580 0631 www.ipm.org.uk British Association for Sexual and Relationship Therapy (BASRT) PO Box 13686, London, SW20 9ZH. 020 8543 2707 www.basrt.org.uk Relate www.relate.org.uk

36. NEPSTIG "The North East Psychosexual Therapy Interest Group (NEPSTIG) is a regional group of practitioners from the statutory, private and independent sectors whose aims are to provide training and support good practice within an ethical framework in the psychosexual field."

37. NEPSTIG - next events November 2010 York Spring 2011 Newcastle If you wish to be put on our mailing list and receive flyer/application form please email me your contact details.

38. Web sites www.bssm.org.uk British Society for Sexual Medicine www.bbc.co.uk Health Relationships Sex therapy www.disabilitynow.org www.vulvalpainsociety.org www.sda.uk.net Sexual Dysfunction Association

39. Web sites 2 www.ErectionAdvice.co.uk (Pfizer) www.Lovelifematters.co.uk (Lilly) www.manmatters.co.uk (Lilly) www.40over40.com (Lilly) www.sortedin10.co.uk (Bayer) www.beecourse.com

40. Reading List � Professional 1 Psychosexual Medicine. An Introduction. Ed Skrine R & Montford H. Arnold 2001 Sexuality and Disability. Cooper E. GuillebaudJ RadcliffeMedical Press 1999. ABC of Sexual Health. John Tomlinson. BMJ Books 2004

41. Reading List � Professional 2 Sex Therapy. A Practical Guide. Keith Hawton. Oxford Medical Publications 2001 Human Sexuality and its problems. John Bancroft. Churchill Livingstone 1999 British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction 2007 � Download from BSSM website

42. Reading List � Self Help 1 Overcoming Sexual Problems A Self Help Guide Using Cognitive Behavioural Techniques. Vicki Ford. Robinson London 2005 The Relate Guide to Sex in Loving Relationships. Litinoff, S. Vermillion 1999

43. Reading List � Self Help 2 New Male Sexuality. Zilbergeld, B. Bantam 1999 How to Overcome Premature Ejaculation. Kaplan, HS. Brunner/Mazel A Woman�s Guide to Overcoming Sexual Fear & Pain. Goodwin, A & Agronin M E. New Harbinger Publications 1997 Becoming Orgasmic: A Sexual & Personal Growth Program for Women. Heiman J & LoPiccolo J. Platkus 1988

44. DVD�s The Lover�s Guides � cover a range of issues The Lover�s Guide: The original guide to love & sex The Lover�s Guide: The essential Lover�s Guide The Lover�s Guide to what women really want The Lover�s Guide to sexual positions The Lover�s Guide to sex play The Lover�s Guide 2: Making sex even better The Lover�s Guide 3: How to intensify lovemaking Available from www.maryclegg.com and www.beecourse.com

45. Lesbian, Gay, & Bisexual Organisations Lesbian Line An information, advice & referral service www.newcastlelesbianline.co.uk MESMAC North East Offers general support & counselling to gay/bisexual men and those unsure of their sexuality www.mesmacnortheast.com FFLAG For families and friends of lesbians and gay men www.fflag.org.uk

46. Transvestite & Transsexual Support Beaumont Society (National) 01582 412220 Cross+Roads GID 0191 2955313 Macgree Helpline 01325 266062

47. Group work GP - Give permission to talk about the sexual issue; explore the sexual issue; what action will you take? Patient � Use scenario and ad lib Observers � note the interactions and be ready to step in to the GP role to try out your ideas Has the GP listened to the patient? Has the GP invited the patient to return? First, many clinicians are less comfortable with exploring problems than with solving them and tend to underestimate the contribution they make to the patient's well-being simply by communicating concern, compassion, and support. Thus, they rush to give information and advice without taking adequate time to hear the patient's perspective. Putting the "Permission" level at the top of the P-LI-SS-IT model interrupts this mad dash. Second, when used properly, the Permission level can invite deeper reflection and move the patient (and professional) away from generalizations about sexuality and into an exploration of the particular problems and needs of the individual/couple. By repeatedly saying, in a warm and understanding tone of voice, whatever subject is being discussed, "Many men/couples feel this way. Tell me how this is a particular problem for you," the professional gives permission for richer disclosures about specific challenges, losses, and emotional responses. Then, and not before then, offering information and suggestions or even a referral for intensive therapy will feel tailor-made to the patient/couple, rather than feeling routine, irrelevant, or, worst, a way to dismiss the patient's real concerns Has the GP listened to the patient? Has the GP invited the patient to return? First, many clinicians are less comfortable with exploring problems than with solving them and tend to underestimate the contribution they make to the patient's well-being simply by communicating concern, compassion, and support. Thus, they rush to give information and advice without taking adequate time to hear the patient's perspective. Putting the "Permission" level at the top of the P-LI-SS-IT model interrupts this mad dash. Second, when used properly, the Permission level can invite deeper reflection and move the patient (and professional) away from generalizations about sexuality and into an exploration of the particular problems and needs of the individual/couple. By repeatedly saying, in a warm and understanding tone of voice, whatever subject is being discussed, "Many men/couples feel this way. Tell me how this is a particular problem for you," the professional gives permission for richer disclosures about specific challenges, losses, and emotional responses. Then, and not before then, offering information and suggestions or even a referral for intensive therapy will feel tailor-made to the patient/couple, rather than feeling routine, irrelevant, or, worst, a way to dismiss the patient's real concerns

48. Thank you Christa.lloyd@nhs.net