1. Let’s Talk about Sex: Addressing Sexual Health using Integrated Care Kenneth W. Phelps, Ph.D., LMFT; Assistant Clinical Professor; Department of Neuropsychiatry and Behavioral Science; University of South Carolina School of Medicine Tina S. Sellers, MS, LMFT, CST; Director of Medical Family Therapy Program and Instructor of Marriage and Family Therapy; Seattle Pacific University Collaborative Family Healthcare Association 14 th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Session # D6b October 6, 2012

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives At the conclusion of the presentation, attendees will be able to:  Identify common sexual dysfunctions that may present in primary care.  Examine the advantages of integrated care in treating sexual problems.  Consider the benefits of collaborative, biopsychosocial, and systemic assessments.  Explore evidence-based treatments through a brief overview and case example.

4. Learning Assessment Pre-test How would you define sexual health? What are the most common male and female sexual problems? Name some core competencies of the integrated care team treating sexual problems. What are three interventions or treatments commonly used to improve sexual health?

5. Questions… How important is sexual health to the QOL of your patients? 1-10 (10 most important) How comfortable are your patients discussing their sexual health? 1-10 (10 most comfortable) How comfortable are you discussing sexual health? Did you receive comprehensive sex education in primary education or higher education? Yes or No. How often do you take a sexual history with patients and under what conditions?

6. Defining Sexual Health “State of physical, emotional, mental and social well- being in relation to sexuality; it is 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 of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.” World Health Organization. Gender and human rights. http://www.who.int/reproductivehealth/http://www.who.int/reproductivehealth/ topics/gender_rights/sexual_health/en/index.htmltopics/gender_rights/sexual_health/en/index.html. Accessed August 15, 2012.

7. Defining Sexual Health “Sexuality is an integral part of human life. It carries the awesome power to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health.” Satcher, D. (2001). The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior. http://www.surgeon general.gov/library/calls/sexualhealth/call.pdf.

8. A Biopsychosocial Picture BIOLOGICAL Biologic Sex Hormones Puberty & Menopause Function / Dysfunction Response Cycle PSYCHOLOGAL Subjective Sense of Self Mental Health Temperament Attachment Fantasy SOCIAL Intimate Relationships Social Supports Patient-Provider Religion / Spirituality Cultural Messages

9. Prevalence of Sexual Problems Women Low Desire 33.4% Inhibited Orgasm24.1% Sex Not Pleasurable21.2% Pain with Intercourse14.4% Performance Anxiety11.5% Lubrication Problems10.4% Climax Too Soon10.3% National Health and Social Life Survey (1994). N = 1,410, ages 19-59

10. Prevalence of Sexual Problems Men Premature Ejaculation28.5% Performance Anxiety17.0% Low Desire 15.8% Erectile Dysfunction10.4% Ejaculatory Inhibition8.3% Sex Not Pleasurable8.3% Pain During Intercourse3.0% National Health and Social Life Survey (1994). N = 1,410, ages 19-59

11. Sexual Health in Primary Care Discrepancy between prevalence & disclosure – Patient Barriers Concern for provider’s comfort Personal embarrassment or discomfort – Provider Barriers Lack of training or skills Underestimation of prevalence Constraints on time Fear of Pandora’s box Personal embarrassment or discomfort Gott, Galena, Hinchliff, & Elford, 2004; Owens & Tepper, 2007; Foley & Wittmann, 2010; Association of Reproductive Health Professionals. Sexual Health Fundamentals. www.arhp.org/factssheets.

12. Why Integrated Care? “Sexual health services should be incorporated into primary care and integrated services should be expanded…including recognition of sexual health throughout the lifespan.” (p. 1006; JAMA 2010, Vol. 304, No.9) Integrated care because: – Multidisciplinary team-based approach – Medical, psychological, and relational expertise – Mutual learning between team members – Assist with time demands of assessment or treatment – PCP preference vs. referral for some

13. Delivery of Integrated Care Considerations…  BH enters BEFORE Medical Provider  BH enters WITH Medical Provider  BH enters AFTER Medical Provider  When to assess sexual health?  Establishing Treatment, Related to Chief Complaint, Annual Exam, Reason for Possible Non-adherence, Education for Co-morbid Condition  Inclusion of Partner or Family Member?

14. Core Competencies Delivery of Patient and Family Centered Care Comprehensive Sex History Taken Annually – Types of sex practices, number of partners, frequency of acts, orientation, abuse, STIs, satisfaction, concerns, etc. Awareness of personal biases and implications for possible counter-transference Appropriate inclusion of parents in sexual education plans or processes for children and teenagers Ability to use basic assessment and treatment strategies, medical, relational, and cognitive-behavioral Referral to sex therapist or sexual medicine expert for complicated cases that exceed scope of practice

15. Key Conversations with Youth 1.The Body (Birth to Four) 2.What is Sex? (Four to Eight) 3.Expect Puberty (Eight to Twelve) 4.Safety, Responsibility, Pleasure, and Choice (Twelve and Up) Yes – 100 / 1 minNo – 1 / 100 min Richardson, J., & Schuster, M. A. (2003) Everything you never wanted your kids to know about sex (but were afraid they’d ask: The secrets to surviving your child’s sexual development from birth to the teens. New York: Three Rivers Press.

16. Foundational Knowledge: Sexual Response Cycle

17. Foundational Knowledge: Reed’s Erotic Stimulus Pathway Seduction Surrender Sensation Reflection

18. Foundational Knowledge: Basson Model http://www.arhp.org/publications-and-resources/clinical-fact-sheets/female-sexual-response

19. Starting the Conversation Start with normalization – “I often ask my patients about… How their medical conditions are affecting them sexually. What problems are you having?” If they are having any sexual problems – desire, arousal, orgasm, pain. Are you having any difficulty?” How they are doing in their relationship(s)?” Basics of screening for sexual function: – Are you currently involved in a sexual relationship? – Are your sexual partners men, women, or both?

20. Starting the Conversation Open ended icebreakers recommended by ARHP – Tell me about any sexual concern you would like to discuss. – How does the problem affect your life and relationship(s)? – How does the concern present? – Tell me (or us) about your last sexual experience. – How have you tried to manage the problem thus far? – What are your goals for your sexual health? – Tell me (or us) about the conversation you have had with your partner so far about this problem. Association of Reproductive Health Professionals. Sexual Health Fundamentals. www.arhp.org/factssheets.

21. Areas of Curiosity Desire: Low sexual desire, aversion, too much desire, discrepancy between partners, change from previous satisfying relationship Arousal: Difficulty obtaining erection, difficulty maintaining erection, difficulty with lubrication Orgasmic: Inability to reach orgasm, premature ejaculation, delayed ejaculation Pain: Vaginismus, dyspareunia, male pain problems Relationship: Level of satisfaction, communication problems (criticism, defensiveness, stonewalling, contempt), match between partner’s sexual preferences or skill set, intimate partner violence, alternative lifestyles

22. Screening Instruments Decreased Sexual Desire Screener (DSDS) Female Sexual Function Index (FSFI) Sexual Interest and Desire Inventory (SIDI) Brief Hypoactive Sexual Desire Disorder Screener Male Sexual Health Questionnaire (MSHQ) Brief Profile of Female Sexual Function (B-PFSF) Index of Sexual Satisfaction (ISS) Among Others

23. Collaborative / Systemic Screening Scaling questions – Faciliates collaboration between patient, partner or family, and providers – Scale motivation, concern, worry over problem, or the difficulty (hardness of erection, degree of pain, amount of lubrication, etc.) Search for BIO PSYCHO and SOCIAL elements – BH ask about psychosocial components and medical provider ask about biological, physical components of problem

24. Foundational Counseling: PLISSIT dramymarshsexologist.com

25. Sampling of Treatments for Male Sexual Problems Psychoeducation Stop-Start Method Mindfulness and Relaxation Techniques Sensate Focus with Partner CBT for Cognitive Restructuring Decrease Spectatoring Use of Erotic Material Vacuum Pump Phosphodiesterase Type 5 Inhibitors Relational or Sex Therapy Identification and Communication of Preferences

26. Sampling of Treatments for Female Sexual Problems Psychoeducation Information on Lubricants Mirror for Self-Exploration Vaginal Hygiene Recommendations Appropriate use of Kegel Exercises Mindfulness and Relaxation Techniques Use of Erotic Material Sensate Focus with Partner CBT for Cognitive Restructuring Pelvic Floor Physical Therapy Relational or Sex Therapy Identification and Communication of Preferences

27. Clinical Case 50 y/o AA male presents with complaint of erectile dysfunction to his Integrated Care Team. – Can obtain an erection at hardness of 4, but loses within a few minutes – Started on SSRI Zoloft for depression/anxiety approximately 2 months ago – Comorbid type 2 diabetes - last HbA1c of 12.4 – Some relational conflict with wife and work stress – Drinks 2-3 beers per evening – Able to obtain erection at hardness of 6-7 when masturbating and can ejaculate

28. Clinical Case 26 y/o Caucasian female presents with complaint of pain with intercourse. – No comorbid medical conditions – Takes Yaz birth control – Currently has one partner – sexually active for 2 months, describes relationship as healthy – Some difficulty with lubrication, but has not tried any products, thinking of using Vaseline – Describes many negative messages about sex from family of origin (e.g. “dirty” “don’t talk about”)

29. Resources American Association of Sexuality Educators, Counselors, and Therapists (AASECT), www.aasect.org,Search for certified sex educators or therapists Society for the Scientific Study of Sexuality (SSSS), http://www.sexscience.org, Research on sexual education and health Association for Reproductive Health Professionals, http://www.arhp.org/ publications-and-resources/clinical-fact-sheets, Clinical fact sheets Sex Smart Films, http://www.sexsmartfilms.com, Sex education and health videos A Woman’s Touch, http://a-womans-touch.com, Education, resources, and info about co-morbid medical illness Joy of Making Love, http://www.joyofmakinglove.com/index.html, Book recommendations

30. Further Questions…

31. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!