1. WHY VA CLINICIANS SHOULD TALK ABOUT SEX: AN OVERVIEW OF DIAGNOSTIC FEATURES, ASSESSMENT, & TREATMENT OF SEXUAL DYSFUNCTION Athena Yoneda, PhD

2. Objective s 1) Review phases of the sexual response cycle and diagnostic features of corresponding sexual disorders. 2) Provide information and generate discussion about sexual health in the veteran population. 3) Provide an overview of frequently used assessment measures and treatments for the more common sexual dysfunction disorders.

3. Let’s Talk About Sex SELF-ASSESSMENT

4. Let's Talk About…  Sex  Orgasm  Masturbation  Clitoris  Anal Sex  Cunnilingus  Pornography  Sex Toys  Erection  Penis  Lubrication  Vagina  Nipples  Arousal  Foreplay  Fellatio

5. Which of these statements best describes your approach to discussing sexuality with clients:  I always ask questions regarding level of sexual satisfaction or functioning during an intake.  I wait until I have established a good rapport with the client before bringing up issues of sexuality.  I wait until the client brings up a problem related to sexuality.  I only discuss sexual problems with my clients who are in relationships.  I rarely discuss issues of sexuality with my clients.  I have never discussed sexuality with any of my clients. (Bogey, 2008)

6. Barriers  Three factors contributing to clinicians’ avoidance of sexual topics:  Knowledge deficits  Personal emotional reactions  Discomfort using sexual language (Risen, 1995)

7. Sexual Response Cycle Diagnostic Features Risk Factors and Implications Prevalence Rates SEXUAL DYSFUNCTIONS

8. Sexual Response Cycle  Phase 1: Desire  Phase 2: Excitement  Phase 3: Orgasm  Phase 4: Resolution (APA, 2000)

9. Sexual Dysfunction  Characterized by:  Disturbance in sexual desire and the psychophysiological changes that characterize the sexual response cycle or  Pain associated with sexual activity  Cause marked distress or interpersonal difficulty  Not better accounted for by another Axis I disorder  Not due solely to a medical condition or substance (APA, 2000)

10. Subtypes  Onset:  Lifelong Type Acquired Type  Context:  Generalized Type Situational Type  Etiology:  Due to Psychological Factors Due to Combined Factors (APA, 2000)

11. Sexual Desire Disorders  Hypoactive Sexual Desire Disorder (302.71)  A deficiency or absence of sexual fantasies or desire of sexual activity  Most common sexual disorder in women  Sexual Aversion Disorder (302.79)  Aversion to/active avoidance of genital sexual contact with a sexual partner (APA, 2000)

12. Sexual Arousal Disorders  Female Sexual Arousal Disorder (302.72)  Persistent/recurrent inability to attain or maintain adequate lubrication-swelling response of sexual excitement (until completion of sexual activity)  Male Erectile Disorder (302.72)  Persistent/recurrent inability to attain or maintain an adequate erection (until completion of sexual activity) (APA, 2000)

13. Orgasmic Disorders  Female Orgasmic Disorder (302.73)  Persistent/recurrent delay in/absence of orgasm following normal sexual excitement phase and adequate stimulation  Male Orgasmic Disorder (302.74)  Persistent/recurrent difficulties in attaining orgasm following normal sexual excitement phase and adequate stimulation  Premature Ejaculation (302.75)  Persistent/recurrent ejaculation with minimal sexual stimulation (APA, 2000)

14. Sexual Pain Disorders  Dyspareunia (302.76)  Genital pain associated with intercourse  Vaginismus (306.51)  Persistent, involuntary spasms of the vagina; interferes with intercourse (APA, 2000)

15. Others  Sexual Dysfunction Due to a General Medical Condition  Clinically significant sexual dysfunction exclusively due to a general medical condition  Substance-Induced Sexual Dysfunction  Clinically significant sexual dysfunction exclusively due to substance use  Differential: Substance Intoxication  Specifiers used to describe predominant symptoms  Sexual Dysfunction NOS (APA, 2000)

16. Risk Factors  What do you think are risk factors for developing a sexual dysfunction?  Emotional problems/Poor psychological health  Stress  Relationship dissatisfaction  Physical health problems  Low SES and lower levels of education  Age  Childhood abuse (sexual/emotional/physical)  Trauma history  Medications (Heiman, 2002; Laumann et al.,1994; Lewis et al., 2010)

17. Impact on Well-Being  Sexual dysfunction can negatively impact:  Romantic relationship functioning  Ability to form intimate relationships  Self-esteem and self-image  Mental health  Quality of life  Healthy sexual functioning predicts:  General well-being  Physical health  Healthy intimate relationships (Heiman; 2002; Kauth, 2012)

18. Prevalence Rates: General Population  Sexual Difficulties (Laumann et al., 1999) Women = 43% Men = 31%  Sexual Dysfunction in Females Hypoactive Sexual Desire Disorder: 17-55%; ~33% Female Sexual Arousal Disorder: 8-28% ; ~20% Female Orgasmic Disorder: 7-25% Dyspareunia: ~ 15%  Sexual Dysfunction in Males Hypoactive Sexual Desire Disorder: 0-7% ED: 12-19%; ~10% Premature Ejaculation: ~ 27 % Dyspareunia: ~ 3 % ( APA, 2000; Heiman, 2002; Lewis et al., 2010; Simons & Carey, 2000)

19. Sexual Dysfunction VETERANS

20. Veterans  What do rates of sexual dysfunctions look like for veterans?  Do veterans’ sexual health and functioning concerns differ from the general population?  Probably  Majority of studies look at:  Medication effects SSRIs impact on desire and arousal in male veterans  Effects of Military Sexual Trauma (MST) Impact of MST on female veterans’ sexual satisfaction (Kauth, 2012)

21. Sexual Functioning in Veterans  OEF/OIF veterans  Sexual problems uniquely contribute to mental health problems (Nunnink, Fink, & Baker, 2012)  30.5% males with PTSD reported sexual problems (Nunnink et al., 2010)  Male combat veterans with PTSD report more sexual problems (vs. those without PTSD) (Cosgrove et al., 2002)  Less sexual satisfaction  More orgasmic difficulties  More erectile problems

22. Sexual Assault and Sexual Functioning in Veterans  Female veterans  Those with MST history report greater dissatisfaction with their sex lives (50% vs. 34%) (Skinner et al., 2000)  Those who endorsed pain during sexual intercourse more likely to have lifetime history of sexual assault (67% vs. 45%) (Sadler et al., 2012)  OEF/OIF veterans with MST history (Turchik et al., 2012)  More likely to have sexual dysfunction diagnosis Especially if have diagnosis of depression (males and females) or PTSD (males only) Males: Sexual Desire Disorder, Sexual Arousal Disorder Females: Sexual Desire Disorder, Sexual Pain Disorder, Sexual Arousal Disorder

23. Discussion  Experiences/thoughts about sexual dysfunction in veterans based on clinical experience?

24. Sexual Dysfunctions ASSESSMENT

25. Assessment: Considerations  What are important factors to consider when assessing sexual dysfunction?  Physical health  Substance use/Medications  Mental health  Age  Trauma history  Relationship status and quality  Sexual orientation  Sexual history  Culture, beliefs, and expectations (APA, 2000; IsHak et al., 2005)

26. Clinical Interviews  Structured Diagnostic Method (SDM; Utian et al., 2005)  Structured Clinical Interview for DSM-IV-TR, Axis I Disorders (SCID-I; First et al., 1994)  Women’s Sexual Interest Diagnostic Interview (WSID; DeRogitas et al., 2008)

27. Self-Report Questionnaires  Female Sexual Function Index (FSFI; Rosen et al., 2000; Wiegel et al., 2005)  International Index of Erectile Function (IIEF; Rosen et al., 1997)  Sexual Desire Inventory-2 (SDI-2; Spector et al., 1996)  Brief Index of Sexual Functioning for Women (BISF-W; Taylor et al., 1994)  Arizona Sexual Experiences Scale (ASEX; McGahuey et al., 2000)  Quality of Sexual Function (QSF; Heinemann et al., 2005)  Brief Sexual Functioning Questionnaire for Men (BSFQ-M; Reynolds et al., 1988)  Sexual Function Questionnaire (SFQ; Quirk et al, 2002)

28. Assessment  Other factors to consider?  Setting: Mental health vs. Primary care  Clinician x Patient characteristics  Others?  Thoughts?

29. Sexual Dysfunctions PSYCHOSOCIAL INTERVENTIONS

30. Sensate Focus  No sex (yet…)!  Focus on sensations being experienced  Structured  Sensate Focus I  Sensate Focus II  Sensate Focus III  Erectile Dysfunction, Female Orgasmic Disorder (Leiblum & Rosen, 2000)

31. Treatment Overview  Assessment  Interview and questionnaires  Remember to assess for other Axis I disorders and possible medical/substance-related causes  Psychoeducation  Identify unrealistic expectations  Therapeutic intervention specific to sexual dysfunction (Leiblum & Rosen, 2000)

32. Interventions: Desire and Arousal  Individual or couples therapy  Cognitive Behavioral Therapy  Sensory awareness training  Insight-oriented treatment  Behavioral exercises  Sensate focus (Leiblum & Rosen, 2000)

33. Interventions: Orgasmic Disorders  Females (Heiman, 2007)  CBT  Directed masturbation  Males (Heiman, 2002)  CBT  Sensate focus  Premature ejaculation: “Squeeze” and “Start-Stop” techniques

34. Interventions: Pain Disorders  CBT  Individual or couples  Biofeedback and relaxation therapy (IsHak et al., 2005; Leiblum & Rosen, 2000)

35. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Bogey, L. A. (2008). Addressing sexuality with clients: A manual for therapists in training. (Doctoral dissertation). Retrieved from ProQuest. (UMI Number 3308670) Cosgrove, D. J., Gordon, Z., Bernie, J. E., Hami, S., Montoya, D. Stein, M. B., & Monga, M. (2002). Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology, 60, 881 – 884. DeRogatis, L. R., Allgood, A., Rosen, R. C., Leiblum, S., Zipfel, L., & Guo, C. (2008). Development and evaluation of the Women’s Sexual Interest Diagnostic Interview (WSID): A structured interview to diagnose hypoactive sexual desire disorder (HSDD) in standardized patients. Journal of Sexual Medicine, 5, 2827–2841. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV). Washington, D.C.: American Psychiatric Press, Inc. Heiman, J. R. (2002). Sexual dysfunction: Overview of prevalence, etiological factors, and treatments. The Journal of Sex Research, 39 (1), 73-78. Heiman, J. R. (2007). Orgasmic disorders in women. In S. R. Leiblum (Ed.), Principles and practices of sex therapy (4 th ed., pp. 84-123). New York, NY: Guilford Press.

36. References Heinemann, L. A. J., Potthoff, P., Heinemann, K., Pauls, A., Ahlers, C. J., & Saad, F. (2005). Scale for Quality of Sexual Function (QSF) as an outcome measure for both genders?. Journal of Sexual Medicine, 2, 82–95. IsHak, W. W., Mikhail, A., Amiri, S. R., Berman, L. A. C., Vasa, M.(2005). Sexual dysfunction. Focus: The Journal of Lifelong Learning in Psychiatry, 3(4), 520-525. Kauth, M. R. (2012). Introduction to special issue on veterans’ sexual health and functioning. International Journal of Sexual Health, 24, 1-5. Laumann, E. O., Paik, A., Rosen, R. C. (1994). Sexual dysfunction in the United States: Prevalence and predictors. Journal of the American Medical Association, 281, 537-544. Leiblum, S. R., & Rosen, R. C. (Eds.). (2000). Principles and Practice of Sex Therapy, 3 rd Edition. New York, NY: The Guilford Press. Lewis, R. W., Fugl-Meyer, K. S., Corona, G., Hayes, R. D., Laumann, E. O., Moreira, E. D.,...Segraves, T. (2010). Definitions/epidemiology/risk factors for sexual dysfunction. Journal of Sexual Medicine, 7, 1598-1607. McGahuey, C. A., Gelenberg, A. J., Laukes, C. A., Moreno, F. A., & Delgado, P. L. (2000). The Arizona Sexual Experience Scale (ASEX): Reliability and validity. Journal of Sex & Marital Therapy, 26, 25-40.

37. References Nunnink, S. E., Fink, D. S., & Baker, D. B. (2012). The impact of sexual functioning problems on mental well-being in U.S. veterans from the Operation Enduring Freedom and Operation Iraqi Freedom OEF/OIF) conflicts. International Journal of Sexual Health, 24, 14-25. Nunnink, S. E., Goldwaser, G., Afari, N., Nievergelt, C. M., & Baker, D. G. (2010). The role of emotional numbing in sexual functioning among Veterans of the Iraq and Afghanistan Wars. Military Medicine, 175(6), 424 – 428. Quirk, F. H., Heiman, J. R., Rosen, R. C., Laan, E., Smith, M. D., & Boolell, M. (2002). Development of a sexual function questionnaire for clinical trials of female sexual dysfunction. Journal of Women’s Health and Gender-Based Medicine, 11, 277-289. Reynolds, C. F., Frank, E., Thase, M. E., Houch, P. R., Jennings, J. R., Howell, J. R.,...Kupfer, D. J. (1988). Assessment of sexual function in depressed, impotent, and healthy men: Factor analysis of a brief sexual function questionnaire for men. Psychiatry Research, 24(3), 231-250. Risen, C.B. (1995). A guide to taking a sexual history. The Psychiatric Clinics of North America, 18, 39-53. Rosen. R., Brown, C., Heiman, J., Meston, C., Leiblum, S., & Shabsigh, R. (2000). The female sexual function index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. Journal of Sex & Marital Therapy, 26, 191-208.

38. References Rosen, R. C., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick, J., & Mishra, A. (1997). The International Index of Erectile Function (IIEF): a multidimensionalscale for assessment of erectile dysfunction. Urology 49, 822–830. Sadler, A. G., Mengeling, M. A., Fraley, S. S., Torner, J. C., & Booth, B. M. (2012). Correlates of sexual functioning in women veterans: Mental health, gynecologic health, health status, and sexual assault history. International Journal of Sexual Health, 24, 60-77. Simons, J., & Carey, M. P. (2001). Prevalence of sexual dysfunctions: Results from a decade of research. Archives of Sexual Health Behavior, 30 (2), 177-219. Skinner, K. M., Kressin, N. R., Frayne, S., Tripp, T. J., Hankin, C. S., Miller, D. R., & Sullivan, L. M. (2000). The prevalence of military sexual assault among female Veterans’ Administration outpatients. Journal of Interpersonal Violence, 15, 291 – 310. Spector, I. P., Carey, M. P., & Steinberg, L. (1996). The Sexual Desire Inventory: Development, factor structure, and evidence of reliability. Journal of Sex and Marital Therapy, 22, 175–190. Taylor, J. F., Rosen, R. C., & Leiblum, S. R. (1994). Self-report assessment of female sexual function: Psychometric evaluation of the brief index of sexual functioning for women. Arch. Sex. Behav. 2, 627–643.

39. References Turchik, J. A., Pavao, J., Nazarian, D., Iqbal, S., McLean, C., & Kimerling, R. (2012). Sexually transmitted infections and sexual dysfunctions among newly returned veterans with and without military sexual trauma. International Journal of Sexual Health, 24, 45-59. Utian, W. H., Maclean, D. B., Symonds, T., Symons, J. Somayaji, V., & Sisson, M. (2005). A methodology study to validate a structured diagnostic method used to diagnose female sexual dysfunction and its subtypes in postmenopausal women. Journal of Sex & Marital Therapy, 31(4), 271-283. Weigel, M., Meston, C., & Rosen, R. (2005). The female sexual function index (FSFI): Cross- validation and development of clinical cut-off scores. Journal of Sex & Marital Therapy, 3, 1- 20.

40. Directed Reading Nunnink, S. E., Fink, D. S., & Baker, D. B. (2012). The impact of sexual functioning problems on mental well-being in U.S. veterans from the Operation Enduring Freedom and Operation Iraqi Freedom OEF/OIF) conflicts. International Journal of Sexual Health, 24, 14-25.