Understanding & Discussing Women's Sexual Functioning: How to ...

Understanding & Discussing
Women’s s Sexual Functioning:
How to talk with your patients
Karin E. Larsen, Ph.D.
Assistant Professor
Obstetrics Gynecology and
Women’s s Health
University of MN
klarsen@umphysicians.umn.edu
Sexual Dysfunctions/Disorders
Desire
Disorders
Hypoactive
Sexual Desire
Disorder (302.71)
Sexual
Aversion
Disorder (302.79)
Arousal
Disorders
Orgasm
Disorders
Female Sexual
Female
Arousal Disorder
Orgasmic
(302.72)
Disorder (302.73,
formerly
Male
Inhibited Female
Erectile Disorder
Orgasm)
(302.72, formerly
Impotence)
Male
Orgasmic
Disorder
(302.74, formerly
Inhibited Male
Orgasm)
Premature
Ejaculation
(302.75)
Pain
Disorders
Dyspareunia
(302.76)
Vaginismus
(306.51)
Overview
Sexual function and dysfunctions
– DSM-IV Diagnostic Categories
– Definition of sexual health
Talking about sexual functioning
– Difficulties talking w/patients about sexual functioning
– Strategies for talking w/patients about sexual health
Theory/model of human sexual fxn
Theories/models of sexual functioning
Establishing realistic ideas around “normal”
sexual functioning
Hypoactive Sexual Desire
Disorder (HSDD) (302.71)
A. Persistently or recurrently deficient (or absent) sexual
fantasies and desire for sexual activity. The judgment of
deficiency or absence is made by the clinician, taking
into account factors that affect sexual functioning, such
as age and the context of the person’s s life
B. The disturbance causes marked distress or
interpersonal difficulty
C. The sexual dysfunction is not better accounted for by
another Axis I disorder (except another Sexual
Dysfunction) and is not due exclusively to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition
BR
Sexual Aversion Disorder (302.79)
A. Persistent or recurrent extreme
aversion to, and avoidance of, all (or
almost all) genital sexual contact with a
sexual partner
B. The disturbance causes marked
distress or interpersonal difficulty
C. The sexual dysfunction is not better
accounted for by another Axis I disorder
(except another Sexual Dysfunction)
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Female/Male Sexual Arousal
Disorder (302.72)
A. Persistent or recurrent inability to attain,
or to maintain until completion of the
sexual activity, an adequate lubrication-
swelling response of sexual excitement
B. The disturbance causes marked distress or
interpersonal difficulty
C. The orgasmic dysfunction is not better accounted for
by another Axis I disorder (except another Sexual
Dysfunction) and is not due exclusively to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition
Vaginismus (306.51)
A. Recurrent or persistent involuntary
spasm of the musculature of the outer
third of the vagina that interferes with
sexual intercourse
B. The disturbance causes marked distress or
interpersonal difficulty
C. The disturbance is not better accounted for by
another Axis I disorder (e.g., Somatization Disorder) and
is not due exclusively to the direct physiological effects
of a general medical condition
Female Orgasmic Disorder (302.73)
A. Persistent or recurrent delay in, or absence of,
orgasm following a normal sexual excitement phase.
Women exhibit wide variability in the type or intensity
of stimulation that triggers orgasm. The diagnosis of
Female Orgasmic Disorder should be based on the
clinician’s s judgment that the woman’s s orgasmic
capacity is less than would be reasonable for her age,
sexual experience, and the adequacy of sexual
stimulation she receives.
B. The disturbance causes marked distress or interpersonal
difficulty
C. The orgasmic dysfunction is not better accounted for by
another Axis I disorder (except another Sexual Dysfunction) and
is not due exclusively to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general
medical condition
Factors affecting sexual functioning
Medical Conditions
– Genitourinary
– Vascular
– Neurological
– Endocrine
Medications
– Psychotropic (e.g. SSRIs)
– OCPs
Psychosocial factors
– Sexual history (eg(
trauma)
– Messages about sexuality
– Dyadic stress
– Body Image
– Mental Health (eg(
depression, anxiety, “stress”)
Dyspareunia (302.76)
A. Recurrent or persistent genital pain
associated with sexual intercourse
B. The disturbance causes marked distress or
interpersonal difficulty
C. The orgasmic dysfunction is not caused exclusively
by Vaginismus or lack of lubrication, is not better
accounted for by another Axis I disorder (except another
Sexual Dysfunction) and is not due exclusively to the
direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition
Prevalence of Female Sexual
Dysfunctions
For women (as opposed to men) Hypoactive Sexual Desire Disorder
(HSDD) decreases with age
Vaginismus
– 1% prevalence
Dyspareunia –
– 18-72% (US)
– Likelihood may increase post-menopause
Orgasmic disorder
– Kinsey (1953) 10% lifetime prevalence anorgasmia
– Laumann et al (1999) 24% 1-yr 1
prevalence of problems
– Depending on definition: 4-24% 4
– Lower SES and less education related to lower likelihood to experience
orgasm. (Laumann(
et al, 1994)
Sexual Arousal disorder
– Problems with lubrication:14-43% 43% US, (1-yr prevalence); 6% Iceland
(lifetime prevalence); 8% Sweden (1-yr prevalence)…..
– Increases with age for both men and women
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Defining Sexual Health
The World Health Organization (WHO) definition of sexual health
is "A state of physical, emotional, mental and social well-being
related to sexuality; not merely the absence of disease, dysfunction
or infirmity. Sexual health requires a positive and respectful
approach to sexuality and sexual relationships, as well as the
possibility of having pleasurable and safe sexual experiences, free f
of coercion, discrimination and violence. For sexual health to be b
attained and maintained, the sexual rights of all persons must be b
protected, respected and fulfilled".
“Thus the notion of sexual health implies a
positive approach to human sexuality, and the
purposes of sexual health care should be the
enhancement of life and personal relationships,
and not merely the counseling and care related
to procreation or sexually transmitted diseases”
Reasons physicians do not take
a good sexual history
Discomfort or embarrassment of physician
A belief that a sex history is not relevant to
chief complaint
Not adequately trained
Merrill, JM, Lau, LF and Thornbby, , JI Why doctors have difficulty with sex
histories. South Med J, 1990, 83, 613-618.
618.
Taking a
Sexual History
Talking About
Sex
Kinsey’s s rule
Never invite a negative answer or
a closed ended answer
e.g., NOT...
– Have you ever
Instead...
– When was the last time
– How many times
– When did you begin
Some history on sex talk
Surgeon Generals
– Joycelyn Elders-1993
apptd Surgeon General
by Clinton, ’94 spoke out on masturbation, ’94
“fired” by Clinton
More Strategies
Before “talking sex” with patients, work on
– Developing sexual language
– Not assuming that people know what sex
words mean
– David Satcher – 2001 -The Call to Action to
Promote Sexual Health and Responsible
Sexual Behavior
When “talking sex” with patients, work on
– Teaching and role modeling: Use explicit &
specific sexual terms and descriptions.
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“Assessment” Feedback
Assessment
Identify factors that appear to be
responsible for the development and
maintenance of the problem
– Medical conditions
– Medications
– Psychosocial factors
Interviewing Strategies
Start with easy questions
– Leave challenging (sexual) ones for later
Some questions to start the discussion
– What kinds of questions do you have about
your sexuality or what concerns do you have
about your sex life
– What is your sex life like at this point Is that
where you want it to be
– How happy are you with your sex life Is your
sexual activity pleasurable
“Assessment” Feedback (cont
(cont’d)
Review problem and normalize it; providing
some education
It’s normal for someone to
– avoid doing something that is painful, anxiety-
provoking, very difficult etc.
– have difficulties with sexual functioning after a really
stressful (traumatic) experience
– have difficulty with sexual function when you are
really down/depressed/sad/stressed out.
– have difficulties with sexual functioning when you are
having difficulties in your relationship
Illness-related Questions
What sexual changes, if any, have you noticed
– Since your illness/injury
– Since you began taking your medications
What questions or concerns do you have about
these changes
Would you like to talk with anyone further about
these changes
Adapted from: Villeneuve & Ozolins, , AXON, 1990
“Assessment” Feedback (cont
Invite feedback
Provide education: address any
medical/sexual misinformation
– Also consider “good enough sex” model
(cont’d)
Outline treatment components (e.g.
medication changes, psychotherapy/sex
therapy, sexual medicine, psychiatric, etc.)
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Theories and Models around
Sexual Functioning
Improving Sexuality –
sex is not just intercourse
Broaden definition of sex beyond genitals
and goal-oriented oriented sexuality. What does
sex mean to you
“I’m m suggesting we call sex something else,
and it should include everything from
kissing to standing close together”
-- Shere Hite
BR
Quality of Good-Enough Sex in Well-
Functioning, Satisfied Couples
McCarthy, J of Sex & Marital Therapy, , 1984, McCarthy Conference (2007) in
Bloomington, MN; McCarthy & Metz, 2008, p. 108
35-45%
20-25%
25%
15-20%
Very satisfying. Both partners will be aroused &
involved, experience is very good for both
partners
Good (at least 1 partner). Both partners will enjoy
sex but one will be much more aroused and
involved.
Okay, not remarkable
5-15%
Unsatisfying, mediocre failures or “blah”
**Normal duration of sexual intercourse is 7-10 minutes
Women’s s Sexual Response
Cycle
(Basson,, 1999)
Intimacy
BR
Sex contributes to relationship
satisfaction
Positive physical and
emotional outcome
Sexual desire
Arousal
Intimacy needs
stimuli
Sought stimuli
processed
Sexuality adds 15-20% to couple satisfaction
BUT
a troubled sexual relationship plays a 50-75% role
in marital dissatisfaction.
---McCarthy, B, & McCarthy, E. (2003). Rekindling desire: A step-by-step
program to help low sex and no-sex marriages.NY: Brunner-Routledge.
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General Guidelines for a Satisfying
Sexual Relationship
Realistic expectations: cannot re-live initial “passion, passion,” demand equal
desire, mutual orgasm, etc.
Personal responsibility/intimate team model
– You are responsible for your own desire and orgasm. It is not
your partner’s s responsibility to know what pleasures you, it is
your responsibility to communicate and work towards your own
pleasure and listen to your partner’s s desires and respond to
them or propose alternatives.
Giving and receiving pleasurable touch is essential for sexual
satisfaction
Eroticism and arousal can lead to intercourse, but intercourse is not
necessary for a satisfying sexual experience.
Satisfying sexuality integrates, intimacy, non-demand pleasuring
and eroticism
Resources
McCarthy, B, & McCarthy, E. (2003). Rekindling desire: A step-bystep
program to help low sex and no-sex marriages.NY: Brunner-
Routledge
www.sexual
sexualityandu.ca/
is committed to providing you
credible and up-to
to-date information and education
on sexual health. This web site is administered by
the Society of Obstetricians and Gynaecologists of
Canada.
http://www.aasect.org/ The American Association of
Sexuality Educators, Counselors and Therapists
(AASECT)
Program in Human Sexuality, University of Minnesota
http://www.fm.umn.edu/phs
www.fm.umn.edu/phs/
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