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FEMALE SEXUAL DISORDERS: Enhancing Communication Skills

FEMALE SEXUAL DISORDERS: Enhancing Communication Skills. Faculty Disclosure. Linda Burdette, MPAS, PA-C, serves as a consultant for Novo Nordisk, Wyeth, and Boehringer Ingelheim. Learning Objectives. Upon completion of the activity, participants will be better able to:

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FEMALE SEXUAL DISORDERS: Enhancing Communication Skills

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  1. FEMALE SEXUAL DISORDERS: Enhancing Communication Skills

  2. Faculty Disclosure Linda Burdette, MPAS, PA-C, serves as a consultant for Novo Nordisk, Wyeth, and Boehringer Ingelheim.

  3. Learning Objectives • Upon completion of the activity, participants will be better able to: • Describe the prevalence and importance of female sexual disorders (FSDs) • Define FSDs, including hypoactive sexual desire disorder (HSDD), and explain their physiological and psychological components • Outline communication techniques that identify sexual concerns, overcome barriers, and increase patient and clinician comfort level in discussing sexual health

  4. Importance of Screening Prevalence and Definitions Etiology of Female Sexual Disorders Effective Communication Techniques Next Steps Program Overview

  5. IMPORTANCE OF SCREENING FOR FEMALE SEXUAL DISORDERS

  6. PATIENT SCENARIO 1: Postmenopausal Woman

  7. Patient Scenario 1: Mrs. Parker • Postmenopausal woman with well-controlled diabetes • Increased risk for yeast and bladder infections • Potential for vascular disease • Also raises risk for arousal disorder • If concerns are beyond scope of current visit, arrange follow-up or referral for counseling

  8. Why Take a Sexual History? • Sexuality is important to quality of life • Sexual health is a basic human right • World Health Organization (WHO) encourages clinicians to help patients achieve this • Patients may be hesitant to bring up the topic on their own: It is up to YOU! http://www.who.int/reproductivehealth/en/

  9. When Should a Sexual History/ Assessment Be Taken? • Initial evaluation/written patient intake (eg, part of review of systems) • Consultation before and follow-up after surgery/medical procedure • Routine visit for care of chronic illness • Major life events (puberty, postpartum, menopause)

  10. Is Sexual Health the Last Taboo? • Many clinicians recognize the importance of sexual health, but perceive potential barriers: • Embarrassment • Inadequate knowledge/skills • Lack of awareness of comorbid conditions • Consider other issues as higher priorities • Assume reimbursement is poor

  11. Women Believe Clinicians Do Not Care About Their Sexual Problems Patient experience of provider reactions: N=3,807 87 85 75 52 Patients (%) Did Not Want to Hear About Problem(n=1216/2339) Did Not Thoroughly Examine PatientComplaint(n=1696/2232) Did Not Give Diagnosis(n=1907/2218) No Follow-up About Complaint(n=1896/2179) Berman L, et al. Fertil Steril. 2003;79:572-576.

  12. Only One-third of Women With Distressing Sexual Problems Seek Formal Care Type of help-seeking for problems of desire, arousal, or orgasm: N=3,239/31,581 14.5%Did notseek help Formal = clinician Informal = anyone other than clinician Formal 34.5% 9.1%Anonymous Informal41.9% PRESIDE = Prevalence of Female Sexual Problems Associated With Distress and Determinants of Treatment Seeking; HCP = health care provider Shifren JL, et al. J Womens Health (Larchmt). 2009;18:461-468.

  13. Clinician Questioning Increases Patient Reporting of Sexual Problems Gynecologic outpatients: N=887 19 Patients (%) 3 Spontaneous Reporting Reporting After Direct Inquiry Bachmann GA, et al. Obstet Gynecol. 1989;73:425-427.

  14. PREVALENCE AND DEFINITIONS OF FEMALE SEXUAL DISORDERS

  15. DSM-IV-TR Designates Four Categories of Female Sexual Disorders DSM-IV-TR. American Psychiatric Association; 2000.

  16. DSM-IV-TR Criteria for Diagnosis of FSD • Sexual complaint or problem in desire, arousal, orgasm, or sexual pain: • Severity of symptom made by clinician, taking into account factors that affect sexual functioning, such as age and the context of the person’s life • Disturbance causes marked distress or interpersonal difficulty DSM-IV-TR. American Psychiatric Association; 2000.

  17. DSM-IV-TR Criteria for Diagnosis of FSD (Cont’d) • Sexual dysfunction is NOT: • Better accounted for by another primary psychiatric disorder (except another sexual dysfunction) • Due exclusively to the direct physiological effects of a substance (eg, medication or abuse of a drug) or a general medical condition DSM-IV-TR. American Psychiatric Association; 2000.

  18. Additional Considerations in Diagnosis of FSDs • Second International Consensus of Sexual Medicine further defines FSDs • May or may not be associated with distress • Lifelong vs acquired • Situational vs generalized • Basson R, et al. J Sex Med. 2004;1:24-34.

  19. Overlap of Female Sexual Disorders Sexual Desire Disorders Sexual Arousal Disorder Orgasmic Disorder Dyspareunia Vaginismus Basson R, et al. J Urol. 2000;163:888-893.

  20. How Common Is FSD in Your Practice? PRESIDE survey: N = 31,581; response rate = 63.2% Sexual Problem Problem Plus Distress 50 44.2 38.7 40 30 26.1 Patients (%) 20.5 20 12 10 10 5.4 4.7 0 Desire Arousal Orgasm Any complaint Shifren JL, et al. Obstet Gynecol. 2008;112:970-978.

  21. Prevalence of Sexual Problems Associated With Distress PRESIDE: Age-stratified prevalence Desire (2868/28,447) 16 Arousal (1556/28,461) Orgasm (1315/27,854) 14 Any (4356/28,403) 12 10 Patients (%) 8 6 4 2 0 18-44 yrs 45-64 yrs ≥65 yrs Shifren JL, et al. Obstet Gynecol. 2008;112:970-978.

  22. DSM-IV-TR Criteria for Hypoactive Sexual Desire Disorder (HSDD) • Persistent or recurrent deficiency or absence of sexual thoughts, fantasies, and/or desire for, or receptivity to, sexual activity • Causes marked personal distress or interpersonal difficulties • Not better accounted for by another primary disorder, drug/medication, or general medical condition DSM-IV-TR. American Psychiatric Association; 2000.

  23. Components of Sexual Desire • Biological drive • Sex steroids and neurotransmitters play a role in modulating sexual desire, drive, and excitement1 • Cognitive • Expectations, beliefs, and values2 • Motive • Emotional and/or interpersonal factors2 Hull EM, et al. Behav Brain Res. 1999;105:105-116. Levine SB. Sexual Life: Clinician’s Guide. 1992.

  24. ETIOLOGY OF FEMALE SEXUAL DISORDERS

  25. PATIENT SCENARIO 2: Perimenopausal Woman

  26. Patient Scenario 2: Mrs. Andrews • Perimenopausal woman, otherwise healthy, but with features of HSDD • Possibly related to menopause and/or psychosocial factors • Vasomotor symptoms often occur before cessation of menses • Disturbed sleep, fatigue, and behavioral changes may alter sexual desire

  27. Possible Causes of FSDs Cause Sexual Symptoms Hormonal/endocrine Decreased libido/desire, vaginal dryness, lack of arousal Musculogenic Hypertonicity: sexual pain Hypotonicity: vaginal hypoesthesia, anorgasmia, urinary incontinence associated with sexual activity Neurogenic Anorgasmia Psychogenic Decreased libido/desire, decreased arousal, hypoesthesia, anorgasmia Vasculogenic Vaginal dryness, dyspareunia Berman JR. Int J Impot Res. 2005;17(suppl 1):S44-S51.

  28. Variety of Medications Associated With Sexual Problems Antidepressants/mood stabilizers Selective serotonin reuptake inhibitors (SSRIs) Serotonin-norepinephrine reuptake inhibitors (SNRIs) Tricyclics Antipsychotics Benzodiazepines Antiepileptics Monoamine oxidase inhibitors (MOAIs) Cardiovascular agents Lipid-lowering agents Digoxin • Hormones • Oral contraceptives • Estrogens • Progestins • Antiandrogens • Gonadotropin-releasing hormone (GnRH) agonists • Other • Histamine2-receptor blockers • Narcotics • Amphetamines • Anticonvulsants • Antihypertensives • β-blockers • α-blockers • Diuretics Basson R, et al. Lancet. 2007;369:409-424. Kingsberg SA, et al. Urol Clin North Am. 2007;34:497-506.

  29. Psychosocial Risk Factors for FSDs • Relationship quality/conflict • Partner’s sexual health • Prior sexual, physical, or emotional abuse • Stress, anxiety, depression • Alcohol/substance abuse • Cultural/religious influences

  30. EFFECTIVE COMMUNICATION TECHNIQUES

  31. PATIENT SCENARIO 2: Perimenopausal WomanIneffective Approach

  32. Set a Positive Atmosphere • Quiet, private, no interruptions • Introduce yourself • Assure confidentiality • Respect patient’s dignity • Use an interpreter if needed • Avoid assumptions or judgments

  33. Set a Positive Atmosphere • Quiet, private, no interruptions • Introduce yourself • Assure confidentiality • Respect patient’s dignity • Use an interpreter if needed • Avoid assumptions or judgments

  34. How to Conduct the Interview • Use words and body language that put the patient at ease • Open, non-defensive body posture • Sit and maintain eye contact • Avoid nervous gestures • Choose language appropriate to the age, ethnicity, and culture of patients • Practice using sexual terminology • Ask open-ended questions • Use silences to allow the patient to speak

  35. How to Bring Up the Topic • Generic: • “Many of my patients have concerns or questions about their sexuality. I’m going to ask you a few questions about this, and would be pleased to discuss these issues with you.” • Illness-specific: • “Many women notice a change in their sexual desire following (illness). Have you noticed any changes that concern you?” • Consider use of the Brief Sexual Symptom Checklist1 1. Hatzichristou D, et al. J Sex Med. 2004 Jul;1:49-57.]

  36. Brief Screening for FSD • Legitimize importance of assessing sexual function • Normalize as part of the usual history and physical “What concerns or questions do you have about your sexual functioning?” “Are you currently in a sexual relationship?” “Are you having difficulty with desire, arousal, or orgasm?” “If you are not currently sexual, are there any particular problems that are contributing to your lack of sexual behavior?” None “Please feel free to ask in the future.” Adapted from Kingsberg SA, Janata JW. Urol Clin North Am. 2007;34:497-506.

  37. PATIENT SCENARIO 3: Woman in Mid-twenties

  38. Patient Scenario 3: Rebecca • Woman in mid-twenties with features of HSDD • Possibly related to antidepressant medication and/or psychosocial/ interpersonal factors • Lesbian women share same risks for FSD as heterosexual women • Vulvodynia and vestibulitis often neglected in this population • Body-image problems and depression also may be present • Communication techniques include postural echoing

  39. PATIENT SCENARIO 3:Woman in Mid-twentiesIneffective Approach

  40. Patient Scenario 3: Ineffective Interview • Clinician’s unreceptive manner indicated discomfort about patient’s sexual status   • Clinician’s actions were distracting and dismissive

  41. A Few Routine Questions Help Define the Problem • “How would you describe the problem?” • “On a scale of 1 to 10, how would you rate…?” • “How long have you been aware of the problem?” • “Did it begin suddenly or gradually?” • “Do you associate its appearance with any particular event or circumstance?” • “Does it only happen in certain situations, or with certain partners?” Kingsberg SA, et al. Urol Clin North Am. 2007;34:497-506.

  42. Variety of Screening Tools for FSD Tool Assessment Area Female Sexual Function Index1 Desire, arousal, orgasm, and pain Profile of Female Sexual Function2 Desire in postmenopausal women Female Sexual Distress Scale—Revised3 Distress Sexual Quality of Life—Female4 Quality of life in women with FSD Decreased Sexual Desire Screener5 Brief diagnostic tool for HSDD • Wiegel M, et al. J Sex Marital Ther. 2005;31:1-20. • Derogatis L, et al. J Sex Marital Ther. 2004;30:25-36. • Derogatis L, et al. J Sex Marital Ther. 2008;5(2):357-364. • Symonds T, et al. J Sex Marital Ther. 2005;31(5):385-397. • Clayton AH, et al. J Sex Med. 2009;6:730-738.

  43. Decreased Sexual Desire Screener (DSDS): Validated Diagnostic Tool for Generalized Acquired HSDD 1. In the past, was your level of sexual desire/interest good and satisfying to you? No Yes 2. Has there been a decrease in your level of sexual desire/interest? No Yes 3. Are you bothered by your decreased level of sexual desire/interest? No Yes 4. Would you like your level of sexual desire/interest to increase? No Yes 5. Please check all the factors that you feel may be contributing to your current decrease in sexual desire/ interest:A. An operation, depression, injuries, or other medical conditionB. Medications, drugs, or alcohol you are currently takingC. Pregnancy, recent childbirth, menopausal symptomsD. Other sexual issues you may have (pain, decreased arousal, orgasm)E. Your partner’s sexual problemsF. Dissatisfaction with your relationship or partnerG. Stress or fatigue NoNoNoNoNoNoNo YesYesYesYesYesYesYes NO to Q1, 2, 3, or 4 NOT generalized acquired HSDD YES to all Q1–4 and clinician-verified NO to all Q5 factors Generalized acquired HSDD YES to all Q1–4 and YES to any Q5 factor Clinician to use best judgment to determine diagnosis Clinical assessment of patient answers is required. • On average, the DSDS took <15 minutes to complete in a clinical study (N = 921). • DSDS had a sensitivity of 0.836 (84%) and a specificity of 0.878 (88%) (N = 263). Clayton AH, et al. J Sex Med. 2009;6:730-738.

  44. NEXT STEPS

  45. Basic Counseling • Female sexual disorders (FSD) are highly prevalent in clinical practice • NP/PAs are optimally positioned to: • Identify FSD, including hypoactive sexual desire disorder • Integrate sexual history and basic counseling into routine clinical practice

  46. “PLISSIT” Model Annon J. J Sex Ed Ther. 1976;Spring-Summer:1-15.

  47. General Recommendations • Bibliotherapy (erotic reading; instruction) • Date night • Mediterranean diet • Moderate exercise • Self-stimulation • Mindfulness/identifying sexuality cues • Communicating needs • Goal setting • Identity

  48. “Oh, by the way….”Problem Solving • What to say when the patient has concerns that cannot be addressed in the allotted time • Validate the patient’s concerns • Emphasize your desire to help • Schedule a follow-up visit • Be flexible about what you spend time on • Focus on patient priorities • Refer as appropriate

  49. When to Refer to a Specialist • Sexual problems have occurred as a result of trauma • Sexual problems have been chronic • (“I’ve always had this problem”) • Underlying medical or psychiatric problem is out of your scope of practice • You are uncomfortable working with the client or the situation

  50. Types of Interventions • Psychotherapy • Physical therapy • Pharmacologic therapies • Adjunctive and alternative therapies Kingsberg SA, et al. Urol Clin North Am. 2007;34:497-506. Simon JA, et al. Fertil Steril. 2008;90:1132-1138.

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