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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
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