Questions About Sex That You Are Too Embarrassed to Ask Denise Rizzolo, PhD, PA-C What percent of people over the age of 45 are satisfied with their sex life? • 19% • 31% • 51% • 61% And the answer is…. • 51% are either somewhat or extremely satisfied • 31% are neither satisfied nor dissatisfied • 23% of men and 14% of women say they are dissatisfied What Women Say About Sex… “Is this the way it’s supposed to be?” “I have very little interest or desire for sex anymore.” “I wait for my husband to fall asleep before I get into bed because he wants to have sex and all I want when we turn out the lights is to go to sleep.” “I never achieve orgasm and it used to be so easy and natural.” “Intercourse is just plain painful.” As you get older, it’s normal to want less sex? • True • False And the answer is ….. • True, as people age, their sexual desire usually decreases. • This is true for men and women, although women are two to three times more likely than men to see their sex drive decline. • Lower hormone levels in women may be responsible for decline. Statistics • Most studies suggest a normative and gradual decline in desire with age. • The prevalence of sexual activity: • 73% of respondents 57-64 years of age • 53% of respondents 65-74 years of age • 26% of respondents 75-85 years of age Decline vs Dysfunction vs Problems • Women admit to a gradual decline sexual desire and activity with age. • Normal sexual decline becomes dysfunction when sexual difficulty persists over time and causes the patient distress for which she requests evaluation and intervention. • Need to differentiate between a true “dysfunction” compared to a “problem” or “decline” • Dysfunctions are much more difficult to treat • No two women are the same! • Matter of interpretation ……. Overview • Sexual Dysfunctions • Persistent or recurrent difficulties in becoming sexually aroused or reaching orgasm. • People with Dysfunctions • Often avoid sexual opportunities • Feel inadequate or incompetent • Find it difficult to talk about Overview •Sexual Problems •Tend to be due to stress, personal issues, depression etc. •Usually easier to identify, discuss and treat. Types of Sexual Dysfunction- Old Model DESIRE AROUSAL/EXCITE Hypoactive sexual MENT desire disorder Female sexual Sexual aversion arousal disorder disorder ORGASM PAIN Female orgasmic Dyspareunia disorder (inhibited orgasm) Vaginismus Types of Sexual Dysfunction- New Model Female sexual Interest/Arousal Disorder Hypoactive sexual desire disorder Combined the top Sexual aversion disorder two into one Female sexual arousal disorder Gentiopelvic ORGASM Pain/penetration Female orgasmic Disorder disorder Dyspareunia (inhibited orgasm) Vaginismus Sexual Desire Disorders: Female sexual Interest/Arousal Disorder • Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person's life. • Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner. • Persistent or recurrent inability to attain, or to maintain typical arousal responses until completion of the sexual activity, an adequate lubrication response of sexual excitement. • The disturbance causes marked distress or interpersonal difficulty. Orgasmic Disorder • Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. • Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. • The diagnosis of Female Orgasmic Disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives. • The disturbance causes marked distress or interpersonal difficulty. Gentiopelvic Pain/Penetration Disorder Dyspareunia Vaginismus • Recurrent or persistent genital pain • Recurrent or persistent associated with sexual intercourse involuntary spasm of the in either a male or a female. musculature of the outer third of • The disturbance causes marked the vagina that interferes with distress or interpersonal difficulty. sexual intercourse. • The disturbance is not caused • The disturbance causes marked exclusively by Vaginismus or lack of distress or interpersonal lubrication difficulty. (www.behavenet.com, 2004) As you get older, it takes longer to get aroused ? • True • False And the answer is…. • True- as individuals age, sexual response time gets slower. • Lubricants and hormone creams can help women. • Couples can also focus more on foreplay. Menopause and Sexuality • Majority of women continue to engage in sexual activity and enjoy it. • Some decline in sexual functioning at menopause. • Vaginal dryness contributes to decline in sexual functioning. • Women's sexual desire may decline as levels of ovarian testosterone decline . Psychological Causes • Sexual or Emotional Abuse • Depression • Relationship Issues •Stress • Self Esteem Sexual or Emotional Abuse •Sexual abuse as a child/adult •Emotionally abusive partner • All lead to a lack of interest in sex Depression • Can reduce a woman’s interest in desire- lack of desire • Unable to feel aroused/excited • Some antidepressants also can decrease interest in sex (Catch 22) Relationships • Fighting, disagreeing, bickering • LACK of COMMUNICATION • Should feel comfortable with partner • Decrease in desire= decrease in arousal=decrease in sex Stress and the Impact on Sexual Desire • High stress factors include workplace stress, social, financial crises or CHILDREN! • Especially during infancy- up all night. • When some women have decreased desire to have sex, it will become more difficult to become aroused and to have an orgasm. • Many women complain of being to exhausted to have sex. • When they are in the “mood” the partners are usually not home. • When their partners are in the “mood” women are usually ready to go to sleep. Stress and Infertility Stress = Infertility Or Infertility = Stress Self Esteem • Weight gain after pregnancy • Stretch marks • Sagging skin • Feeling uncomfortable about oneself = lack of sexual interest Only 35% of PCP’s reported taking a sex history routinely or often Let’s Talk about Sex….. • https://www.youtube.com/watch?v=sw6UetyUuD0 Medical Professional Reported Barriers • Lack of training in taking a sexual history • Insufficient knowledge of about sexual function and dysfunction • Inadequate communication skills • Discomfort with sexual language • Lack of information about treatment options • Time constraints • Embarrassment Sallie Foley Question for audience • How often do you talk to your patients (adult/elderly) about sex? • Is it part of your history taking? Patient Reported Barriers • Although 85% of adults want to discuss sexual functioning with their physicians… • 71% believe their physicians doesn’t have the time • 68% don’t want to embarrass their physician • 76% thought no treatment was available for their problems • They also report… • Non-empathic and/or judgmental responses • Physician discomfort • Concern about privacy and/or confidentiality • Lack of cultural sensitivity Common Complaints from Women • Low/no desire • Inability to lubricate • Low arousal • Illness—e.g. diabetes, breast cancer • Pain on touch of genitals or penetration • Changing body image/vulvar structures • Delayed orgasm/absent orgasm Taking a Sexual History • The chance of a female expressing sexual concerns is influenced by her perception of the health care professional’s level of comfort in discussing the subject. • When diagnosing sexual dysfunction, a sexual function questionnaire can be completed or ask open ended questions? • How often do you have sex? • How do you feel your sex life is? • Do you have trouble with lubrication? • Do you feel dry constantly? • Is sex pleasurable? Painful? • Do you believe you have difficulty with penetration? Physiologic Changes - Women • Labia lose some of their firmness. • The walls of the vagina become less elastic. • The vagina itself becomes drier. • The clitoris can become highly sensitive, even too sensitive. • Uterine contractions with orgasm may at times be painful. • Due to loss of elasticity- penetration can become more difficult. Female Sexual Response Cycle • Masters and Johnson characterized cycle with four phases: • Excitement • Plateau • Orgasmic • Resolution • Kaplan proposed idea of “desire” and a three-phase model. • Desire • Arousal • Orgasm (Berman et. al, 1999) How many older people say treatments for sexual problems have improved their sex life? • 22% • 44% • 64% • 82% And the answer is….. • 64% say that medications, hormones or other treatments have improved their sex lives. • About half the people with a regular partner said treatments for sexual problems had a good effect on their relationship. What about medication side effects? • Fluoxetine vs Sertraline vs Trazodone • 195 patients who met the DSMIV-IR criteria for MDD were enrolled (102 men and 93 women) • Baseline – normal sexual function; + for major depressive disorder • Fluoxetine had the most impairment in desire/drive items (43%–51% and 44%–50%, respectively), while patients receiving trazodone had the least impairment in these items (12%–18% and 23%–24%, respectively). • Sertraline was in the middle (intermediate decrease in desire/drive) Khazaie H, Rezaie L, Payam NR, Najafi F. Antidepressant-induced sexual dysfunction