Sexual Hz 11 05 2008
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Sexual Hz 11 05 2008

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Sexual Screen, Sexual History, Sexual Dysfunction

Sexual Screen, Sexual History, Sexual Dysfunction

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Sexual Hz 11 05 2008 Sexual Hz 11 05 2008 Presentation Transcript

  • Sexual History and Sexual Counseling in Primary Care Treatment of the Female Patient Special Communication Competencies Oakwood Hospital and Medical Center Family Medicine Residency Program Lawrence R. Fischetti, Ph.D. November 5, 2008
  • Sexual Dysfunction and Sexual Difficulties in Primary Care
    • Frank, Anderson, Goldstein (1978)
      • 40% of men and 63% of women -- dysfunction
      • 50% of men and 77% of women -- difficulties
      • Number of difficulties was more strongly related to overall satisfaction with sexual life
    • Tiefer (1995)
      • Among women, affection and emotional communication were valued more than orgasm
  • Sexual Consultation in Primary Care
    • Nease and Liese (1987)
      • 70% of patients identified FP as professional they would most likely consult
      • 11% had consulted their FP
    • Factors related to consultation
      • Confidentiality
      • Willingness to discuss sexual matters
      • Factual knowledge
      • Considers sexuality as important in health
      • Compassion
  • Sexual Consultation in Primary Care
    • Researcher:
      • “ I’m conducting a study of the sex lives of older Americans … I’d like to ask a few questions …”
    • Elderly Man:
      • “ I guess that would be okay …”
    • Researcher:
      • “ Sir … could you tell me how old you are?”
    • Elderly Man:
      • “ I’m 85 years old …”
  • Sexual Consultation in Primary Care
    • Researcher:
      • “ Very good … and are you married?”
    • Elderly Man:
      • “ Yes I am!”
    • Researcher:
      • “ And are you sexually active at this time?”
    • Elderly Man:
      • “ YOU BET!”
  • Sexual Consultation in Primary Care
    • Researcher:
      • “ And how often would you say you have sex?”
    • Elderly Man:
      • “ Don’t you think that’s a personal question?”
    • Researcher:
      • “ I appreciate that sir … but it’s all for science …”
    • Elderly Man:
      • “ Well in that case … FOUR times a week …”
    • Researcher:
      • “ FOUR times a week … that’s really impressive!”
  • Sexual Consultation in Primary Care
    • Elderly Man:
      • “ Yes sir … just don’t tell my wife!”
  • Sexual Consultation in Primary Care
    • Other factors related to consultation
      • Physician self-awareness and sexual health
      • Tolerance of differences
    • Ende et al. (1984)
      • Specific skills, e.g., screening, detailed history, information, limited counseling
      • Internists with training in screening: 82% vs. 32%
      • 98% of patients viewed screening as appropriate
  • Hypoactive Sexual Desire Disorder
    • National Health and Social Life Survey (1994)
      • 33% of women in the last 12 months
      • Low sexual desire in women is among the most common sexual complaints in PC
    • Diagnosis
      • Absence of sexual thoughts/fantasies
      • Lack of interest and receptivity
  • Hypoactive Sexual Desire Disorder
    • Lifelong
      • Rare -- Lack of experience, strong cultural or religious taboo, sexual abuse
    • Acquired
      • Most common and usually psychosocial
      • Women attribute to hormonal factors vs. more likely emotional and interpersonal
  • Hypoactive Sexual Desire Disorder
    • Psychosocial Causes
      • Emotional : depression, anxiety, life stress
      • Interpersonal : relationship conflict, poor communication regarding sexuality, attraction for a third party, “best friends”
      • Abuse : current or past sexual abuse, violence
  • Hypoactive Sexual Desire Disorder
    • Physical Causes
      • Medications : SSRIs, other psychotropics, antihistamines, antihypertensives, cardiovascular, narcotics, oral contraceptives
      • Substance Abuse/Dependence : alcohol, sedatives, stimulants
      • Vascular and Hormonal Illness : thyroid deficiency, Addison’s and Cushing’s Disease, pituitary disorders, hyperprolactinemia, low testosterone following surgical menopause
  • Female Arousal Disorder
    • National Health and Social Life Survey (1994)
      • 19% of women in the last 12 months
    • Diagnosis
      • Reduced swelling of external genitalia
      • Inadequate vaginal lubrication interfering with intercourse
      • May be uncorrelated with subjective arousal
  • Female Arousal Disorder
    • Lifelong
      • Rare -- Lack of experience, strong cultural or religious taboo, sexual abuse
    • Acquired and Generalized
      • Often medical or other physical factor
    • Premenopausal Women
      • Usually secondary to low desire
  • Female Arousal Disorder
    • Physical Causes
      • Medications : SSRIs, other psychotropics, antihistamines, antihypertensives, cardiovascular, narcotics, oral contraceptives
      • Substance Abuse/Dependence : alcohol, sedatives, stimulants
      • Vascular and Hormonal Illness : occasional causes; postmenopausal: atrophic vaginitis secondary to loss of estrogen leading to reduced lubrication
  • Female Arousal Disorder
    • Psychosocial Causes
      • Emotional : depression, anxiety, life stress, “spectatoring” (performance anxiety)
      • Interpersonal : relationship conflict, poor communication regarding sexuality, attraction for a third party
      • Abuse : current or past sexual abuse, violence
  • Female Orgasmic Disorder
    • National Health and Social Life Survey (1994)
      • 24% of women in the last 12 months
      • 29% reported “always” orgasmic w/ intercourse
      • 40% high level of physical satisfaction
      • 39% high level of emotional satisfaction
    • Diagnosis
      • Persistent delay or absence of orgasm
      • Assumes normal arousal and adequate stimulation
  • Female Orgasmic Disorder
    • Lifelong
      • Lack of experience and very responsive to treatment
    • Acquired and Generalized
      • Often medical or other physical factor
    • May be secondary to arousal
  • Female Orgasmic Disorder
    • Physical Causes
      • Medications : SSRIs, drugs that affect ANS
      • Nervous System : surgeries, trauma
      • Illness : diabetes, MS
    • Psychosocial Causes
      • Emotional : depression, anxiety, life stress
      • Interpersonal : relationship conflict, poor communication regarding sexuality
      • Abuse : current or past sexual abuse, violence
  • Female Sexual Pain Disorder
    • National Health and Social Life Survey (1994)
      • 14% of women painful intercourse in 12 months
      • Introital dyspareunia: tenderness, pregnancy-related injuries, muscle tension in pelvic floor, Candida and other infections
      • Vaginal dyspareunia: inadequate arousal and lubrication
      • Deep dyspareunia: inadequate arousal, pelvic disease
  • Treatment of Sexual Problems in Primary Care
    • Fagan et al. (2003)
      • 75% of reversible sexual problems are treatable
      • Assessment skills, knowledge of biology and psychosocial factors, counseling skills
    • Phillips (2000)
      • Similarly optimistic
      • Treatment of low sexual desire can be difficult
      • Referral: chronic, multiple problems, sexual abuse, unknown etiology, poor initial Tx response
  • Treatment of Sexual Problems
    • Permission:
      • Ask about sexuality
      • Convey a permissive attitude re: sexual expression
    • Limited Information:
      • Provide information about prevalence of sexual concerns, sexual response cycle, medical aspects
    • Specific Suggestions:
      • Assess previous efforts, communication, encourage exploration of treatment strategies
    • Intensive Treatment:
      • Refer for more complex problems
  • Small Group SP Interviews
    • Patient Background
      • Patient is new to clinic
      • Requesting to restart oral contraceptive
    • Interview Tasks
      • Establish rapport
      • Set the agenda
      • Obtain a brief reproductive and medical history
  • Small Group SP Interviews
    • Conduct a Sexual Health Screen
      • Request permission to ask about “sexual health”
      • Listen for Clues/Feelings for concerns/problems
      • Review Appendix I: Sexual Screening Questions
    • Detailed Sexual History
      • Review Appendix II: Detailed Sexual History
      • Lifelong vs. Acquired, etc.
      • Refer to Checklist
  • Small Group SP Interviews
    • Small Group Discussion
      • Diagnostic Impression
      • Likely factors
      • Formulate a plan
    • Intervention
      • Offer impressions
      • Propose a plan
      • Consider how to involve husband