Sexual Dysfunctions and Sex Therapy

FOCUS | CLINICAL

Sexual dysfunctions and sex therapy

The role of a general practitioner

Vijayasarathi Ramanathan, HEALTHY SEXUAL FUNCTION within one’s sample of approximately 20,000 adult Margaret Redelman expected norm and desire for sexual activity men and women. According to the is an important aspect of sexual health.1 2013 Australian Study on Health and According to the American Sexual Health Relationships, lack of interest in sex was Background Medical management is undeniably an Association, sexual function is the ability to the single most common sexual difficulty 4 important therapeutic intervention for experience sexual pleasure and satisfaction for both men and women. selected sexual dysfunctions, but it does when desired. It is an important component Sexual dysfunctions have many not serve as a stand-alone approach to of quality of life (QoL) as it is associated mediating factors including psychological treat many common sexual dysfunctions with physical and mental wellbeing and and sociocultural factors, lifestyle such as lack of interest in sex, sexual relationship satisfaction (if applicable).2 factors and health (especially obesity, performance anxiety, inability to reach orgasm or too quick an orgasm. Sexual function is influenced by a person’s sleep disorders, anxiety, depression, biology (physical and physiological), chronic disease and side effects of Objective psychology (feelings and thoughts) and medications).5 Erectile dysfunction can The aim of this article is to highlight society (interpersonal, cultural, literacy precede cardiovascular symptoms by the role of general practitioners (GPs) in and contextual factors).3 The importance 2–3 years and cardiovascular events by recognising sexual problems, encourage 6,7 initiation of conversation about sexual of sexuality varies between people and 3– 5 years. Therefore, paying attention dysfunction with patients and raise fluctuates in individuals’ lives. It is to sexual function is relevant to broader awareness of sex therapy and important to understand the patient’s needs health outcomes and an opportunity presentations that may benefit from and not impose a burden of expectation for aggressive intervention. For optimal referral to sex therapists. that the patient does not want. However, management of sexual dysfunctions, Discussion as sexuality is often viewed as intercourse, biomedical management options are GPs in Australia have a significant role there is room to introduce patients to a an important therapeutic intervention in addressing sexual health concerns broader sexuality involving outercourse, but cannot serve as a ‘stand-alone’ despite practice-related and doctor– masturbation/self-pleasure and sensual intervention.8 patient-related barriers, thereby touch. This fits well with ageing, chronic or In Australia, general practitioners (GPs) promoting the healthy sexuality of disabling diseases and disabilities. play a key part in initiating discussions Australians. Sex therapy is a specialty comprised of various medical, cognitive, Nomenclature is not standardised about sex and sexual difficulties with emotional and behavioural interventions. well in the field of sexuality. ‘Sexual their patients; however, there are barriers Sex therapists, who are healthcare problem’ is an umbrella term to refer between patients and GPs that make professionals with tertiary training in to sexual concerns, sexual difficulties, it difficult for both to commence the human sexuality, can share care with sexual dysfunctions and sexual disorders. discussion.9 This article’s intention is GPs to help individuals and/or couples A useful distinction between the two three-fold: 1) to highlight the vital role of understand, improve and resolve their most commonly used terms is a time a GP in recognising sexual problem(s) in sexual dysfunctions. factor, with a sexual difficulty lasting their patients; 2) to provide some practical <6 months and a sexual dysfunction guidance on how to initiate a conversation lasting >6 months. In Australia, there about sexual dysfunctions with their are research data on sexual difficulties, patients and 3) to raise awareness about but not on sexual dysfunctions, collected ‘sex therapists’ and the significance of sex from a large national representative therapy in the optimal management of

412 | REPRINTED FROM AJGP VOL. 49, NO. 7, JULY 2020 © The Royal Australian College of General Practitioners 2020 SEXUAL DYSFUNCTIONS AND SEX THERAPY FOCUS | CLINICAL

common sexual dysfunctions. Sex therapy Box 1).14 Each level requires greater Limited Information techniques and strategies for specific knowledge, confidence and counselling It is not uncommon for patients to be sexual dysfunction are beyond the scope skills. The first two stages (Permission and influenced by misinformation about of this article. Limited Information) are highly applicable sexual functioning and misled by claims in the general practice setting for the about ‘normalcy’ and ‘quick fixes’ that management of sexual dysfunction. in turn could precipitate or perpetuate The role of a general practitioner sexual problems. This second step involves in recognising sexual problems Permission providing factual and sometimes statistical Sexual dysfunction is considered a GPs can raise the topic of sexual concerns information about healthy sexual function medium priority by GPs,1 and sexual directly or indirectly. Ways in which or dysfunction in a customised way using dysfunctions are not a common problem practices can make it easier for patients to a ‘question and answer’ style, bearing in managed by Australian GPs.10 Yet, raise the issue of sexual function include mind the patient’s health literacy level. For continuity of care in a good and trusting having sexuality-positive posters in the example, a male patient whose intravaginal relationship places the GP in an ideal waiting room and/or a notice on the GP’s ejaculatory latency time (IELT) is position to initiate a discussion about desk indicating that they are happy to approximately seven minutes could be sexual problems, when relevant, but also discuss sexual concerns. Humour may distressed by the fact that he has no control to assess and plan the interventions and also assist with lowering sexual anxiety; over his ejaculation and wonder whether it follow-up needed to ensure that sexual however, it must be appropriate to the could be due to some underlying medical problems are addressed, ameliorated as doctor–patient relationship and context. It is problem on the basis of his limited sexual possible and potentially resolved. GPs also important to include questions related knowledge obtained from pornography. A can find addressing sexuality issues to sexual function in routine history-taking GP could address this patient by reassuring difficult for many reasons categorised for other medical conditions, especially him that the normal range of IELT in men as doctor barriers (lack of knowledge/ cardiac function, diabetes and depression. is between two and six minutes, and that training), patient barriers (sense of In this way, the message is clearly given his ejaculatory experience (subjective embarrassment), doctor–patient that the GP considers sexual function premature ejaculation) is not related interaction issues (different genders, important and relevant. Consequently, to a medical condition.15 Many sexual cultures, ages) and contextual concerns when the patient has a sexual concern, they problems are not caused by specific sexual (lack of time).11–13 All the above mean are likely to be more comfortable raising it. dysfunction in a patient but are due to that sexual communication between In the direct approach, the GP introduces interpartner misconceptions, assumptions individuals, and individuals and GPs does questions about the patient’s sexuality and outcomes. This conversational and not consistently address patients’ sexual as part of routine history-taking. They collaborative approach with the patient concerns. This can significantly affect the may ask, ‘Have you noticed any changes can be therapeutic in its own way as it can QoL of patients with flow on effects to with your sexual function?’ or state, ‘We generalise/normalise some of the concerns relationships, family life and productivity know that sexual problems are sometimes that the patient has, which may be all in society. Another aspect of this field experienced by patients/with these sort that is required. There can be a gradation is helping patients navigate sexuality in of conditions/taking these medicines’ of involvement in addressing the sexual difficult circumstances. One example etc. By doing so, it establishes that it is dysfunction, but the most important of this is when a partner dies and the appropriate to discuss sexual matters in step is raising the issue with the patient surviving partner seeks new relationships that consultation and, more importantly, and thereby signalling that it is a valid, in a changed environment, especially expresses the GP’s willingness to clarify any legitimate area of medical concern that can regarding sexually transmissible doubts, answer questions and/or initiate infections. Alternatively, a partner may treatment. A 2017 article authored by have moved into a facility that has strict Goodwach provides a good framework Box 1. The PLISSIT model to help the rules for enabling/permitting sexuality. and a list of questions to initiate discussion physician conceptualise their approach14 about sexual difficulties as part of routine medical history.9 While elements of 1. Permission: take a pro-sexual stance and encourage sexual questions and concerns Sexual dysfunctions: sexuality (and sexual difficulty) differ from General practitioners 2. Limited Information: give scientifically that of a general history, the practice of validated information in the framework of a and the PLISSIT model history-taking is one of the core strengths biopsychosocial approach to sexual problems 11 GPs who are not trained in sexual medicine/ of a GP. The initial embarrassment/ 3. Specific Suggestions: provide basic sex therapy but would like to address sexual discomfort of doing something new quickly information about addressing the most (dys)function issues with their patients can becomes confidence and habit when the common sexual problems use different stages of the Annon’s PLISSIT patient’s appreciation of the doctor raising 4. Intense (sex) Therapy: refer to a qualified model (Permission, Limited Information, an important issue is shown and positive sex therapist and, in most cases, reinforce the couple approach (where applicable) Specific Suggestions and Intense Therapy; benefits follow.

be addressed with a GP. Then – depending varies among sex therapists depending of patients and their intimate partners. on personal inclination, time, experience on their primary profession. However, when a sexual problem is and education – the matter can be dealt with Ideally, sex therapists should be addressed in a suboptimal or rushed by the GP and/or referred for sex therapy. healthcare professionals with some manner (whether it be during a medical training in human biology, physiology, intervention or sex therapy), the impact psychology and individual and couple can be detrimental to the individual/ What is sex therapy? Who are counselling; psychotherapy skills; and couple. It can result in a relapse of the sex therapists? a specific tertiary qualification/training sexual problem17 and/or trigger new Psychosexual therapy, commonly referred in human sexuality. In addition, sex sexual/non-sexual problems. as sex therapy, is a specialty comprised therapists should have undergone values It is important to emphasise that no one of cognitive-behavioural interventions, and attitudes reassessment training needs to be an expert in sexual medicine mindfulness techniques, systems/couple to provide inclusive care. Gender, age, to provide meaningful care. Most patients interventions and psychotherapy. The aim cultural background and sexuality of a simply need a health practitioner who is of sex therapy is to help individuals and sex therapist are not relevant in terms of aware of the sexual aspects of lifestyle couples understand, improve and resolve provision of professional care, although factors and medical conditions, as well their sexual difficulties. These difficulties the specific preference of the patient as sexual side effects of medications; can involve performance anxieties, arousal should be taken into account. inquires about sexual changes and and orgasmic difficulties, sexual pain, In Australia, sex therapy is not a problems; provides proper information fear or aversion to sexual behaviour or recognised professional category with and explanations to reduce anxiety; and relationship issues; these can be influenced standardised professional accreditation prescribes an appropriate medication by family of origin and past and present and registration to protect patients. This and/or makes an appropriate referral to a sexual experiences. means that anyone can call themselves sex therapist. Patients need recognition of Sex therapy is not a panacea solution for a sex therapist/sexologist. The primary/ their basic right to remain a sexual being achieving idealised sexual performance. referring health professional needs to take despite disease, disability or ageing, and Rather, it aims to restore as much on the responsibility of ensuring that the GPs have a significant role in this area functional capacity as possible, using referral is to an appropriate, professionally of medicine/health. In fact, one of the multifaceted strategies to facilitate competent sex therapist. The Society most important aspects that the GP can satisfying long-term sexuality. Patients are of Australian Sexologists (SAS) is provide is acknowledgement that a sexual given education, strategies and exercises the professional body representing dysfunction is a valid area of concern and to do at home. Some of the common issues sexologists across Australia. ASSERT that help is available. treated with sex therapy include lack of NSW is a similar organisation in NSW. interest in sex, desire discrepancy between In Australia, Sydney University and two individuals and the fallout from this Curtin University in Perth provide Key points difference, erectile dysfunction, painful postgraduate programs in sexology • GPs play a significant part in recognising penetration, vaginismus, past sexual and sexual health. Both universities the need and appropriate timing to abuse, concerns relating to gender identity work collaboratively with the national address sexual problems and initiate and sexual orientation, orgasm difficulties, professional body (SAS) to establish sex-related discussions with their patients. fear and anxiety about sexual performance and evolve professional standards of • Considering partners, when and concerns about penis size or specific sexologists in Australia. Self-education applicable, in the management of sexual behaviour. Patients may have through reading, attending relevant sexual dysfunctions is of great clinical preconceived incorrect ideas about sex workshops, talks and conferences, and relevance and importance because therapy, such as believing that sex therapy membership of SAS or ASSERT NSW when one partner has a problem, then involves some form of physical/sexual provide a segue into this field. A list of two individuals have a problem. contact with the therapist during the useful professional and patient resources • GPs can choose the extent of their session, which in turn may stop patients is provided at the end of this article. clinical involvement (bearing in mind from accessing sex therapy. A GP can the PLISSIT model) to correspond with clarify such misconceptions, explain that their capabilities and time constraints. sex therapists are professionals who deal Conclusion • Sex therapy aims to restore as much with human sexuality and its problems, Sexual functioning is a multifaceted functional capacity as possible. and/or refer patients to appropriate process that requires coordinated • Sex therapists are healthcare websites that contain detailed information functioning of many body systems and professionals who manage various about the profession and sex therapists’ an adequately healthy state of mind and sexual problems, and the website code of practice. Fee structure, concession emotions.16 Effective, holistic medical of professional bodies hosts a list of for Health Care Card holders and access care includes addressing sexual health certified sex therapists in addition to to bulk billing or private health insurance concerns. This has a major role in the QoL their qualifications/credentials.

414 | REPRINTED FROM AJGP VOL. 49, NO. 7, JULY 2020 © The Royal Australian College of General Practitioners 2020 SEXUAL DYSFUNCTIONS AND SEX THERAPY FOCUS | CLINICAL

Resources Competing interests: None. 7. Billups KL. Erectile dysfunction as an early sign Funding: None. of cardiovascular disease. Int J Impot Res 2005;17 • Textbooks Provenance and peer review: Commissioned, (Suppl 1):S19–S24. doi: 10.1038/sj.ijir.3901425. externally peer reviewed. 8. McCarthy B. Sex made simple: Clinical strategies – Wylie K, editor. ABC of sexual health. for sexual issues in therapy. Eau Claire, WI: PESI 3rd edn. Chichester, WS: John Wiley Acknowledgements Publishing & Media, 2015; p. 1–11. 9. Goodwach R. Let’s talk about sex. Aust Fam & Sons, 2015. The authors would like to thank Dr Michael Lowy, Physician 2017;46(1):14–18. Men’s Health Physician, The Male Clinic, NSW. – Howard JR. Helping people with 10. Cooke G, Valenti L, Glasziou P, Britt H. Common general practice presentations and publication sexual problems. Hawthorn East, Vic: References frequency. Aust Fam Physician 2013;42(1–2):65–68. IP Communications, 2010. 1. Humphery S, Nazareth I. GPs’ views on their 11. Ross MW, Channon-Little DL, Rosser BRS, editors. management of sexual dysfunction. Fam Pract Sexual health concerns: Interviewing and history • Referral information 2001;18(5):516–18. doi: 10.1093/fampra/18.5.516. taking for health practitioners. 2nd edn. Sydney: – 2. Mitchell KR, Mercer CH, Ploubidis GB, et al. Sexual MacLennan & Petty, 2000. The Society of Australian Sexologists, function in Britain: Findings from the third National 12. Dyer K, das Nair R. Why don’t healthcare professionals www.societyaustraliansexologists.org.au Survey of Sexual Attitudes and Lifestyles (Natsal-3). talk about sex? A systematic review of recent Lancet 2013;382(9907):1817–29. doi: 10.1016/S0140- qualitative studies conducted in the United Kingdom. – ASSERT NSW, www.assertnsw.org.au 6736(13)62366-1. J Sex Med 2013;10(11):2658–70. doi: 10.1111/j.1743- Websites 3. Brotto L, Atallah S, Johnson-Agbakwu C, et al. 6109.2012.02856.x. • Psychological and interpersonal dimensions of sexual 13. Nusbaum MRH, Gamble GR, Pathman DE. Seeking – Professional updates: European function and dysfunction. J Sex Med 2016;13(4):538–71. medical help for sexual concerns: Frequency, Society for Sexual Medicine, doi: 10.1016/j.jsxm.2016.01.019. barriers, and missed opportunities. J Fam Practice 4. Richters J, Visser RO, Rissel CE, Simpson J, Grulich 2002;51(8):706. www.essm.org AE, Smith AMA. Sex in Australia: Sexual difficulties in 14. Annon JS. Behavioral treatment of sexual problems: a representative sample of adults. Proceedings of the Brief therapy. Hagerstown, MD: Harper & Row Medical – Patient resources: International Society 42nd annual meeting of International Academy of Sex Department, 1976. for Sexual Medicine, www.issm.info Research, 29 June 2016; Malmo, Sweden. 15. Waldinger DM. Problems of ejaculation and orgasm in 5. Schlichthorst M, Sanci LA, Hocking JS. Health and the male. In: Wylie K, editor. ABC of sexual health. 3rd lifestyle factors associated with sexual difficulties in edn. Chichester, WS: John Wiley & Sons, 2015; p. 73–76. Authors men – Results from a study of Australian men aged 18 16. Bronner G, Korczyn AD. The role of sex therapy in the Vijayasarathi Ramanathan MMed, GDipSexHlth, to 55 years. BMC Public Health 2016;16(Suppl 3):71–80. management of patients with Parkinson’s Disease. PhD, FECSM, Lecturer in Sexual Health, Faculty doi: 10.1186/s12889-016-3705-6. Mov Disord Clin Pract 2017;5(1):6–13. doi: 10.1002/ of Medicine & Health, University of Sydney, NSW; 6. Jackson G, Boon N, Eardley I, et al. Erectile mdc3.12561. President, Society of Australian Sexologists, NSW. dysfunction and coronary artery disease prediction: 17. McCarthy B, McDonald D. Sex therapy [email protected] Evidence–based guidance and consensus. Int J failures: A crucial, yet ignored, issue. Margaret Redelman OAM, MBBS, MPsychotherapy, Clin Pract 2010;64(7):848–57. doi: 10.1111/j.1742- J Sex Marital Ther 2009;35(4):320–29. Medical Sex Therapist, The Male Clinic, NSW 1241.2010.02410.x. doi: 10.1080/00926230902851330.