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Sex Coaching for Physicians: Combination Treatment for Patient and Partner

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International Journal of Impotence Research (2003) 15, Suppl 5, S67–S74 & 2003 Nature Publishing Group All rights reserved 0955-9930/03 $25.00 www.nature.com/ijir Sex coaching for physicians: combination treatment for patient and partner MA Perelman1* 1New York Weill Cornell Medical Center, New York, USA Physicians dealing with sexual dysfunction (SD) must consider the psychological and behavioral aspects of their patient’s diagnosis and management, as well as organic causes and risk factors. Integrating sex therapy and other psychological techniques into their office practice will improve effectiveness in treating SD. This presentation provides information about the psychological forces of patient and partner resistance, which impact patient compliance and sex lives beyond organic illness and mere performance anxiety. Four key areas are reviewed: (1) ‘Sex coaching for physicians’ uses the ‘Cornell Model’ for conceptualizing and treating SD. A 5-min ‘sex status,’ manages ‘time crunch’ by rapidly identifying common causes of sexual dysfunction (insufficient stimulation, depression, etc). (2) Augmenting pharmacotherapy with sex therapy when treating erectile dysfunction (ED) specifically, or SD generally is stressed. Sex therapy is useful as a monotherapy or an adjunctive treatment and is often the ‘combination therapy’ of choice when treating SD. The following therapeutic integrations are highlighted: modifying patient’s initial expectations; sexual pharmaceuticals use as a therapeutic probe; ‘follow-up’ to manage noncompliance and improve outcome; relapse prevention. (3) Issues specific to the role of the partner of the ED patient are described. The physician must appreciate the role of couple’s issues in causing and/or exacerbating the ED and the impact of the ED on the patient/partner relationship. Successful treatment requires a supportive available sexual partner, yet partner cooperation may be independent of partner attendance during the office visit. Preliminary data from a survey of SMSNA members practice patterns, regarding partner issues, is presented and discussed. The importance of evoking partner support and cooperation independent of actual attendance during office visits is emphasized. (4) Finally, the need for more patient and partner educational materials to assist the physician in overcoming a patient/partner’s emotional barriers to sexual success in a time efficient manner are discussed. International Journal of Impotence Research (2003) 15, Suppl 5, S67–S74. doi:10.1038/sj.ijir.3901075 Keywords: combination therapy; sexual dysfunction; sex therapy; erectile dysfunction; partner issues; follow-up; relapse prevention Introduction sex lives beyond organic illness and mere perfor- mance anxiety. There were four key areas of focus: A. ‘Sex coaching for physicians’ used the ‘Cornell Physicians dealing with sexual dysfunction (SD) Model’ for conceptualizing and treating SD. A 5-min must consider the psychological and behavioral ‘sex status,’ managed ‘time crunch’ by rapidly aspects of their patient’s diagnosis and management, identifying common causes of sexual dysfunction as well as organic causes and risk factors. Integrating (insufficient stimulation, depression, etc). 1,2 sex therapy and other psychological techniques into B. Augmenting pharmacotherapy with sex ther- their office practice will improve effectiveness in apy when treating erectile dysfunction (ED) specifi- treating SD. This presentation provided information cally, or SD generally was stressed. Sex therapy is about the psychological forces of patient and partner useful as a monotherapy or an adjunctive treatment resistance, which impact patient compliance and and is often the ‘combination therapy’ of choice when treating SD. The following therapeutic inte- grations were highlighted: modifying patient’s in- itial expectations; using sexual pharmaceuticals as a *Correspondence: MA Perelman, Co-Director, Human therapeutic probe; using ‘follow-up’ to manage Sexuality Program, Clinical Associate Professor of Psy- noncompliance and improve outcome; relapse pre- chiatry, Reproductive Medicine & Urology, The New York 2–4 Presbyterian Hospital, Weill Medical College of Cornell vention strategies. University, 70 East 77th Street, Suite 1C, New York, NY C. Issues specific to the role of the partner of the 10021, USA. ED patient were described. The physician must E-mail: [email protected] appreciate the role of couple’s issues in causing and/ Sex coaching for physicians MA Perelman S68 or exacerbating the ED and the impact of the ED on couple/individual in the privacy of their own the patient/partner relationship. Successful treat- homes. These exercises were designed to correct ment required a supportive available sexual partner, dysfunctional sexual behavior patterns as well as yet partner cooperation may be independent of positively altering cognitions regarding sexual atti- partner attendance during the office visit. Prelimin- tudes and self-image. This ‘home play’ modified the ary data from a survey of SMSNA members practice immediate causes of the sexual problem, allowing patterns, regarding partner issues, was presented the individual to have mostly positive experiences and discussed. The importance of evoking partner creating a powerful momentum for a successful support and cooperation independent of actual treatment outcome. The individually tailored ex- attendance during office visits was emphasized. ercises acted as therapeutic probes and were D. Finally, the need for more patient and partner progressively adjusted until the individual or educational materials to assist the physician, in couple was gradually guided into fully functional overcoming a patient/partner’s emotional barriers to sexual behavior.2,3 sexual success in a time efficient manner was discussed. Do physicians ask? Sex coaching for physicians The sexual dysfunctions each manifest a cluster of critical symptoms that point the way towards key Incorporating sex therapy and other psychological questions which must be asked, and indicate which techniques into office practice improved effective- questions will not be as immediately important. The ness in treating SD. Our ‘Cornell Model’ of sex most important information can be obtained in a therapy was based on the development of a treat- reasonable amount of time; physicians must discuss ment plan conceptualized from the rapid assess- sex with their patients. Numerous CME programs ment of the immediate and remote causes of sexual have addressed the problem of encouraging physi- dysfunction while maintaining rapport with the cians to both initiate and discuss sexual issues by patient.1,2 This sex therapy approach integrated the emphasizing the importance of ED as a biological work of Masters and Johnson as well as Helen marker of disease among other reasons. Physicians Kaplan, using a four-phase model of human sexual were taught to ‘bring up sex’ directly or use segue response: desire, excitement, orgasm and resolu- techniques.8–10 tion.3,5,6 Sex therapy is the diagnosis and treatment Many physicians learned about the statistically of disruptions in any of these four-phases and/or the significant increase in the incidence of depression sexual pain disorders. These dysfunctions occur in men with SD. Treatment of SD may improve mild independent of each other, yet they frequently reactive depression, while depressive symptoms cluster. Personal distress and the impact of these might alter response to therapy of SD.11 A physi- dysfunctions on quality of life, is an important cian’s history taking must parse out this ‘chicken or diagnostic consideration and has become a signifi- egg problem:’ Is SD causing depression or, is cant issue in sex research. depression and its treatment (eg, SSRIs), causing the SD? The value of direct questioning about sex became especially clear here. If physicians did not Sex therapy overview ask, the patients may not tell. When asked direct questions, SSRI patients reported an increase, from 14 to 58%, in the incidence of SD versus sponta- Sex therapy is an ‘efficacious’ treatment for primary neous report. True incidence was probably under- anorgasmia in women, some erectile failure in men, estimated as PDR data were based on patient and is ‘probably efficacious’ for secondary anorgas- spontaneous report. To manage adverse effects of mia y vaginismus in women and premature medication, physicians learned to adjust dose or, ejaculation in men.7 Clinical experience supports combine with other drugs, to ameliorate the pro- efficacy in treating hypoactive sexual desire, sexual blem.12 For instance, many might reduce the SSRI aversions, dyspareunia and delayed orgasm in men. and supplement with buproprion or try sildenafil as Despite its potency, sex therapy receded as a a possible adjunct. While intrapenile injections or a treatment of choice during the 1990s as medical ‘combination approach’ might be effective, sex and surgical approaches performed by urologists therapy enhanced all these strategies. established hegemony over the treatment of ED, in Sex status: A ‘sex status’ or focused sex history is particular. the sex therapists most important tool. Both sex Sex therapy is an amalgam of individual and therapists and physicians have used the ‘sex status couple’s therapy specifically focused upon improv- exam,’ becoming ‘sex detectives,’ who juxtaposed ing sexual functioning. The sex therapist assigned detailed questions about the patient’s current structured erotic experiences carried out by the and past
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