Sexuality andandSexuality Multiple Sclerosis:Sclerosis:Multiple Tips from a SexTips Sex TherapistTherapist
Stanley Ducharme, Ph.DStanley Ph.D.. Rehabilitation Medicine and UrologyRehabilitation Urology Boston University Medical CenterBoston Center
VA MS Centers of Excellence Webinar July 10, 2012 – 4pm ET – VANTS 1.800.767.1750, 43157# Learning ObjectivesLearningObjectives At the conclusion of this learning activity,Atthe activity, the participant should be able to:the to:
1.1. Explain the primary and secondary effects ofofExplain MS on sexual dysfunction.dysfunction.MS 2.2. Describe the impact of psycho--socialpsychoDescribe effectssocialeffects on sexual function.function.on 3.3. Identify basic approaches to manage MSMSIdentify related sexual problems.problems.related 4.4. Discuss the role of the multidisciplinary teamteamDiscuss in sexual/medical communication withwithinsexual/medical patients.patients. Sexuality and Physical Disability:Disability:Sexuality The PastThePast
People with disabilities were seen as asexual andandPeople received no information on sexuality.sexuality.received Health care providers felt uncomfortable with thetheHealth topic and had little to offer to people with MS.MS.topic Sexual functioning was not consideredconsideredSexual an important aspect of rehabilitation and medicalmedicalan care.care. The idea of sexuality for people withwithThe disabilities was academic with nonodisabilities agreement as to who, when and howhowagreement services should be provided.provided.services No effective treatments available.available.No
Nature of Sexual Problems with MSNature MS
Lack of interestLackofinterest Lack of erectionsLackoferections Inability to experience orgasmInability orgasm Decreased sensationDecreasedsensation Inability to have intercourseintercourseInability secondary to problems ofsecondary of spasticity, fatigue and musclemusclespasticity, weaknessweakness Incidence of Sexual Issues with MSMSIncidence
NotNot all sexual difficulties may be due to thetheall MS.MS. MedicationsMedications, lifestyle factors and psychologicalpsychological,lifestyle issues may contribute as well.well.issues May result from the demyelination of thetheMay sexual pathways or coexist with cognitivecognitivesexual dysfunction and brain involvement.involvement.dysfunction MenMen ––More than 75% experienceexperienceMore sexual difficultiesdifficultiessexual WomenWomen ––More than 50% at somesomeMore time after diagnosisdiagnosistime Sexuality and MSMSSexuality
Sexual difficulties may occur earlySexual early in the course of MS.MS.inthe Predictive factors of sexualPredictive sexual dysfunction include:dysfunctioninclude: ––Increased disease activityIncreased activity ––Depression and fatigueDepression fatigue ––Long duration of diseaseLong disease ––Spasticity, bladder andSpasticity, and bowel symptomsbowelsymptoms
Sex Therapy Tip Number 1SexTherapy 1
LearnLearn About Your BodyBodyAboutYour andand HowHow itit RespondsResponds totoSexual StimulationSexualStimulation Genital Response ininGenital MenMenwith MSwithMS
Approximately 25 to 40% of men with MSMSApproximately between the ages of 18 and 50 typically havehavebetween some form of erectileerectilesome dysfunction.dysfunction. Varies from man to man and from time to time.time.Varies Each sexual experience may be unique.unique.Each Is often dependant on the length of time sincesinceIs diagnosis.diagnosis. Majority of men are able to achieve erectionserectionsMajority although sustaining the erection may bebealthough difficult.difficult. Intercourse may be a problem without somesomeIntercourse medical assistance.assistance.medical Genital Response inGenital in WomenWomen with MSwithMS
Less likely than men to report sexualsexualLess dysfunction.dysfunction. Movement of the pelvic area is limited.limited.Movement Lubrication may be limited or absent.absent.Lubrication Pain may be present during intercourse due totoPain diminished lubrication.lubrication.diminished Numbness of the genital area and difficultydifficultyNumbness with orgasm arearewith common.common. Manual and oral pleasuringpleasuringManual ofof erotic areasareaserotic areare encouraged as an alternative to intercourseintercourseencouraged alone.alone. Sex Therapy Tip Number 2SexTherapy 2
Be Aware Of Issues That AreAreBeAware Specific ToSpecificTo WomenWomen Women’s Sexual ResponseResponseWomen’s
Women have many reasons (motives) for havinghavingWomen sexsex——sexual desire is often not the primaryprimarysexual motivation, especially in long termtermmotivation, relationshipsrelationships
Women may typically sense desire once a sexualsexualWomen experience is underwayunderwayexperience
Psychological and biological factors influenceinfluencePsychological women’s arousabilityarousabilitywomen’s
Women’s sexuality is highlyhighlyWomen’s contextualcontextual
Arousal is not primarily about the degree ofofArousal vulval and vaginal vasocongestionvasocongestionvulval Women with MSWomen MS-- Conceptualizations of SexualitySexualityConceptualizations
Most women conceptualized their sexuality ininMost a way that transcended the physical andandaway genital aspects of sexuality.sexuality.genital
Most women discussed relationships,relationships,Most communication, trust, concerns related totocommunication, physical changes and lost independence.independence.physical
Women noted the importance of physicalphysicalWomen closeness and intimate touchtouchcloseness regardless of whether intercourseintercourseregardless was still enjoyable.enjoyable.was
Leibowitz, Rehabilitation Psychology, Feb 2007 Fertility for Women with MSMSFertility
HandHand tremor, lack of coordination or hiphiptremor, spasticity may make it difficult to insert ororspasticity remove mechanical contraceptive devise.devise.remove
MS is not a contraindication to currentlycurrentlyMS available contraceptives.contraceptives.available
ManyMany women fear that pregnancy will increaseincreasewomen the progression of the disease.disease.the
Gynecological services,services,Gynecological mammograms and reproductivereproductivemammograms health are important afterafterhealth diagnosis.diagnosis. Sex Therapy Tip Number 3SexTherapy 3
See a Urologist / Physician for AssistanceAssistanceSee with Improving SexualSexualwith FunctioningFunctioning Male Sexual Dysfunction with MSMSMale
Disorders of libido/desireDisorders libido/desire Disorders of arousalarousalDisorders Disorders of ejaculation/orgasmDisorders ejaculation/orgasm OtherOther--Not necessarily disabilityNot disability relatedrelated ––Sexual pain disorderSexual disorder ––DeformityDeformity ––Peyronie’s DiseasePeyronie’sDisease ––PriapismPriapism Physiology of Normal ErectionsErectionsPhysiology
Erections are a complex event,Erections event, requiringrequiring ––Intact Neurological SystemIntact System –– Intact arterial and venous systemIntact system ––Normal hormonal factorsNormal factors ––Psychosocial adaptationsPsychosocialadaptations ––Functioning erectile tissue (the penis)Functioning penis)
Abnormalities in any or all of these will lead to ED.
Oral Medications: Sildenafil (Viagra)OralMedications: (Viagra)
Relaxes the smooth muscle in thetheRelaxes chambers of the penis allowing greaterchambers greater blood flow into the penis. Adverse effectsblood effects include:include: HeadacheHeadache Sinus and nasal congestioncongestionSinus FlushingFlushing Blue visionvisionBlue There is a lack of clinical evidence as totoThere the effectiveness of Viagra with men whowhothe have MS and erectile dysfunction.have dysfunction. Future double blind, placebo controlledFuture controlled trials are neededtrials needed SildenafilSildenafil (Viagra) vsvs(Viagra) Tadalafil (Cialis)(Cialis)Tadalafil
The advantage of TadalafilTadalafilThe over Sildenafil isover is not generally influenced by degree ofnot of demyelination in men with MS.MS.demyelination UsualUsual dosage is 10dosage 10 to 20to20 mg 2 hours beforemg before sex.sex. ––EffectiveEffective up to 36upto36 hourshours ––HeadacheHeadache, joint pain,pain,,joint congestioncongestion CialisCialis now available in 2.5 and 5 mg dailydailynow dosage.dosage. AvanafilAvanafil ((dubbed “Son of Viagra”)Viagra”)dubbed
Presented at the AUA, San Francisco, AugustAugustPresented 20102010 NextNext generation medication for E.D.E.D.generation Considered to be an “on demand medication”medication”Considered that works in 15 minutes.minutes.that Clinical trials with 646 menmenClinical demonstrate effectiveness of 64%,64%,demonstrate 74% and 77% over placebo withwith74% doses of 50mg, 100 mg and 200mg.200mg.doses No studies yet with disabilities.disabilities.No ErectionsErections Generic Viagra: Just Around thetheGeneric CornerCorner
Pfizer patentPfizerpatent expired MarchexpiredMarch 27, 2012201227, Drug companies expected to floodDrugcompanies flood the market with a generic brand.brand.themarket How will Pfizer fight back?back?How ––Over the Counter Viagra.Viagra.Over ––The “Super Viagra” longer lasting andThe and quicker acting.quickeracting. –– The “tried and true” Viagra that menmenThe will not want to leave.leave.will Viagra andViagraand MS: A Side NoteNoteMS:
Animal studies in BarcelonaBarcelonaAnimal have reported that dailydailyhave Viagra use has been effectiveeffectiveViagra in reducing symptoms of MS.MS.inreducing
ViagraViagra reduced the infiltrationinfiltrationreduced of inflammatory cells into thetheof white matter of the spinalspinalwhite cord thus reducing damage totocord the axon and facilitatingfacilitatingthe myelin repairrepairmyelin Sex Therapy Tip Number 4SexTherapy 4 Be Aware of How Health and LifeLifeBeAware Style AffectStyleAffect Sexual FunctionSexualFunction
Life style Factors
Diabetes Obesity Hypertension Cholesterol
Sex Therapy Tip Number 5SexTherapy 5
Be Aware of the PsychologicalPsychologicalBeAware Issues that Affect How You FeelFeelIssues about YourselfaboutYourself Successful Sexual AdjustmentAdjustmentSuccessful
The ability of the person totoThe ––resolveresolve the emotional issues of thethe the diseasedisease ––taketake emotionalemotional risksrisks ––valuevalue new sexualnewsexual abilitiesabilities –– communicatecommunicate..
Successful resolution of any difficulties or sexualsexualSuccessful dysfunction prior to onset ofofdysfunction MSMS
Ability to regainregainAbility selfself--esteemesteem ––Body image changes effects on men and womenBody women Psychological Responses with MSMSPsychological
Fatigue and fear of increasing fatigue can leadleadFatigue to decreased participation in sexual activities.activities.todecreased
FearsFears –– ThatThat sex may lead to a progression of thesex the diseasedisease ––By partner that sexual activity may worsen theBy the diseasedisease ––Of rejection and loss of sexual attractivenessOf attractiveness
CognitiveCognitive changes may impact communicationcommunicationchanges and the quality of the relationship..relationshipand Psychological Points to ConsiderConsiderPsychological
EncourageEncourage emotional intimacy beforebeforeemotional sexualsexual activityactivity..
NegativeNegative thinking can intensify or exacerbateexacerbatethinking physical difficulties.difficulties.physical
When sex is stressful, people avoid it.it.When
The goal is for every sexualsexualThe encounterencounter to betobe enjoyableenjoyable. Eliminate.Eliminate the idea ofofthe failure.failure.
Involve the multidisciplinary MS teamteamInvolve to address sexual dysfunction concerns.concerns.toaddress Sex Therapy Tip Number 66SexTherapy Be AttentiveBeAttentive of RelationshipofRelationship Issues with YourYourIssues Significant OtherSignificantOther Addressing Relationship IssuesIssuesAddressing with MSMSwith
Be realistic realizing that good sex takestakesBerealistic time, practice and confidence.time, confidence. Realize that past issues may stillstillRealize get in the way of sexualgetin sexual enjoyment.enjoyment. ––Issues of trusttrustIssues ––Sexual addictionaddictionSexual ––Rape, sexual abuse historyhistoryRape, PartnerPartner issues need to be addressed..addressedissues ––Unresolved anger or resentmentresentmentUnresolved ––DisappointmentDisappointment ––PrePre--existing conflictconflictexisting Relationship Issues To ConsiderConsiderRelationship
DepressionDepression by one member of thethebyone relationship.relationship. Difficulty switching roles between carecareDifficulty provider and lover.provider lover. Loss of partner’s libido.Loss libido. Lack of privacy and fatigue.fatigue.Lackof Avoidance or withdrawal.Avoidance withdrawal. Adjustment of partner may takeAdjustment take longerlonger thanthan the person with MS.the MS. Fears of causing pain.Fears pain. Sex Therapy Tip Number 7SexTherapy 7 Be Aware of the Practical IssuesIssuesBeAware Involved in a Positive SexualSexualInvolved AdjustmentAdjustment Positions Sensation Bladder & Bowel Safety Issues Sexual PositioningPositioningSexual
Limited mobility is a major physical andandLimited emotional issue.emotionalissue. Pain and spasticity may be an issue.issue.Pain Personal Care Assistants may bePersonal be an option.anoption. Creativity, experimentation, andandCreativity, communication are critical.communication critical. Using a wheelchair for sexualsexualUsing activity can have distinctactivity distinct advantages for both partners.advantages partners. Positioning AidsAidsPositioning
Liberator shapes Love Bumpers
Thigh Sling Practical & Safety ConcernsConcernsPractical
Once home, avoid a hospital bed ififOnce possible.possible. ––ConsiderConsider a King bed with separate controls forforaKing each sideachside.e. If using the wheelchair for sex, insure that ititIfusing does not exceed the 250 pound maximum.maximum.does Be cautious of slippery and fragile showerBecautious shower chairs for sex.chairs sex. Be aware of skin related issues during sex.sex.Beaware Understand medications and theirUnderstand their impact onimpacton sexual functioning.sexualfunctioning. How to Compensate forforHowto Decreased SensitivitySensitivityDecreased
30% Stated that they fantasized and30% and thought about how sex felt in the past.thought past. 22% Reported that they kissed, touched22% touched and caressed erogenous and other zonesand zones of the body.of body. 6% Watched the sex act directly or with6%Watched with the help of a mirror.the mirror. 5% Longer foreplay or stronger5%Longer stronger stimulation.stimulation. 21% Unsure what to do.do.21% (N=356)(N=356) Bladder and BowelBowelBladder ManagementManagement
Accidents are commonplace.commonplace.Accidents LimitLimit fluid intake prior to sexualfluid sexual activity.activity. Timing of sexual activity aroundaroundTiming bladder and bowel routines.bladder routines. Empty bladder prior to sexualEmpty sexual activityactivity Preparation and communicationPreparation communication are critical.arecritical. Using a Vibrator for Pleasure, Orgasm ororUsing EjaculationEjaculation VibratoryVibratory stimulationstimulation ––Pleasurable for both menPleasurable men and women withand with diminished sensationdiminishedsensation ––Is not invasiveIs invasive ––Can be enjoyed by bothCan both partnerspartners ––Ejaculation frequentlyEjaculationfrequently occurs within severaloccurs several minutesminutes Sex Therapy Tip Number 8SexTherapy 8
Communicate, Communicate,Communicate,Communicate, CommunicateCommunicate The Best Thing a SexualSexualTheBest Partner Can DoPartnerCanDo
38% of women stated caressing, kissing38% kissing or licking areas with sensation.or sensation. 14% Take your time and extend foreplay.foreplay.14% 7% Give a massage.massage.7%Give Most women wanted a partnerMost partner to be warm, tender and romantic.romantic.tobe Qualities that were importantimportantQualities were acceptance, honesty andwere and understanding.understanding. For Men: The Best Thing aaForMen: Partner CanPartnerCan DoDo Not put demands ororNot expectations.expectations. Be Supportive and reassuring.reassuring.BeSupportive Put no pressure regardingregardingPutno erections or performance.erections performance. Help the man feelfeelHelp secure in the relationship.relationship.secure Talking about the IssuesIssuesTalking
Feeling unattractive and unwanted bybyFeeling either member of the relationship.either relationship. Fears of rejection.Fears rejection. Inability to continue initiatinginitiatingInability sexual intimacy. Libido.sexual Libido. Shifting of roles, fatigueShifting fatigue depression of partner.depression partner. Emotional distance andEmotional and avoidance of affection.avoidance affection. Sex Therapy Tip Number 99SexTherapy Open Your Mind to NewNewOpenYour Possibilities of Getting andandPossibilities Receiving SexualSexualReceiving PleasurePleasure Learning about Your BodyBodyLearning
Masturbation andandMasturbation self pleasuring is ananself important means totoimportant learning about youryourlearning body. Share withwithbody. partner.partner.
Explore other eroticeroticExplore areas of the body.body.areas
Explore sensate andandExplore insensateinsensate areas.areas. Enhancing Sexual PleasurePleasureEnhancing
Utilizing memory and fantasy to enhanceenhanceUtilizing the experience of orgasm.the orgasm. Becoming more attuned to other bodilyBecoming bodily indications of sexual arousal.indications arousal. Incorporating other sensual stimulationIncorporating stimulation such as visual, auditory and verbal.verbal.such Exploring the potential of other eroticExploring erotic body areas where some sensation may bebebody present.present. Don’t try to reDon’t re--create the past.create past. Sex Therapy Tip Number 1010SexTherapy
FindFind WaysWays ofofIntegrating SexualSexualIntegrating EducationEducation andand CounselingCounseling intointo YourYour Clinical PracticeClinicalPractice Take HomeHomeTake MessagesMessages for HealthCareforHealthCare ProvidersProviders
Be aware of your own issues related totoBe sexuality.sexuality. ––Your approach sets the tone for patients feelingYour feeling comfortable to discuss their concerns with you.you.comfortable TakeTake the initiative to bring up the topic.topic.the –– Don’tDon’t wait for thethewait patientpatient ––Discuss sexual dysfunction as a possible MS symptomDiscuss symptom Encourage patient to have open discussion withwithEncourage partner.partner. Role of sexual intimacy in a relationshipRole relationship Changing roles in sexual activityChanging activity Role of care giving and intimacyRole intimacy Adapting to changes in positioning aids and devicesAdapting devices Take HomeHomeTake MessagesMessages for HealthCareforHealthCare ProvidersProviders (cont.)(cont.)
Providing information about common sexualsexualProviding problems helps to “normalize” the problem.problem.problems
Be sensitive to the emotional and relationshiprelationshipBe issues as well as the physical changes.changes.issues
Revisit the topic on a regular basisbasisRevisit ––Especially after changes in physical or cognitiveEspecially cognitive functioningfunctioning
Redefining “sexuality” can be addressed by allallRedefining MS team membersmembersMS ResourcesResources
http://stanleyducharme.com/
Sexuality and Reproductive Health in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health Care Professionals. Stanley H. Ducharme, PhD, Chairman, Clinical Practice Guideline Development Panel, Consortium for Spinal Cord Medicine
http://www.webmd.com/multiple- sclerosis/guide/multiple-sclerosis-maintaining-intimacy
http://www.nationalmssociety.org/about-multiple- sclerosis/what-we-know-about-ms/symptoms/sexual- dysfunction/index.aspx
http://www.va.gov/MS/articles/MS_Self_Report_Questi onnaires_Fatigue_and_Sexual_Function.asp
http://www.va.gov/MS/articles/Sexual_Dysfunction_an d_Multiple_Sclerosis.asp