The Art and Science of Sexual Medicine and Counseling

1. The Art and Science of Sexual Medicine and Counseling Dr. Serena McKenzie Holistic Physician | Integrative Medicine Provider Sexual Medicine Specialist |Certified Sex Counselor October 2013

2. Introduction: Who I Am • I am a naturopathic physician. I am in private practice at and medical director of Whole Life Medicine in Kirkland. I work alongside gynecology, urology, and other holistic providers. • I practice holistic primary care with an emphasis on the integration between conventional and complimentary care. I specialize in sexual medicine. • I am a nationally licensed Sex Counselor through the American Association of Sex Educations, Counselors, and Therapists (AASECT). I have been working in the area of sexuality for 18 years.

4. Discussion Topics: • What is sexual medicine and sex therapy and why they are important fields of study • Most common sexual dysfunctions and over view of medical, complimentary, and talk therapy treatments • Considerations for lesbian, gay, bisexual, and transgender individuals • Non-monogamous relationships, sex worker, and BDSM/kink healthcare • Characteristics of sexual wellness

5. What is Sexual Medicine versus Sex Therapy • Sexual medicine embraces the physical and psychological study, diagnosis, and treatment of sexual concerns. It is a medical specialty that addresses all matters related to sexuality • Sex counseling and therapy provides evaluation and treatment for sexual dysfunction utilizing methods involving counseling, psychotherapy, sex education and behavior modification

6. The Importance of Sexuality Healthcare • Sexuality plays a significant role in quality of life; sexual problems can cause both emotional and physical distress. • Multiple studies have found the prevalence of sexual dysfunction to be 43% of the population, however, individuals “distressed” by their dysfunction can be cited as much lower 1/10. • Studies indicate that less than half of patients’ sexual concerns are known by their physicians.

7. Evaluation of Sexual Dysfunction: Key Pieces • DURATION of sexual difficulty. • CIRCUMSTANCE in which difficulty appears. • DESCRIPTION of difficulty. • The PATIENT as well as his or her PARTNER’S SEX RESPONSE CYCLE. • PATIENT AND PARTNER’S REACTION to current difficulty. • MOTIVATION FOR TREATMENT.

8. Medical Evaluation of Sexual Dysfunction • The first step in the evaluation of any sexual dysfunction is to consider the following: • Whether the symptom is result of a general medical condition • Is the result of drug abuse or the side effect of a medication • Whether the symptoms are better accounted for by a mental disorder • Most sexual dysfunctions are a result of both physical and psychological contributions and to isolate a single cause rarely occurs. Sexual dysfunction is almost always multi-factorial.

9. Human Sexual Response • Human sexual response consists of a sequence of 4 physical phases that are the same for men and women: • Excitement • Plateau • Orgasm • Resolution • Healthy sexual response entails a smooth passage through these 4 phases. Sexual dysfunction is most commonly found in the excitement and orgasm phases.

10. Traditional Human Response Cycle

12. An Intimacy-Based Model for the Female Sexual Response Cycle

13. Emotional Contributing Factors

14. Relationship Contributing Factors

15. Most Common Sexual Dysfunctions • Low Libido (Hypoactive Sexual Desire Disorder) • Ejaculation & Orgasm Disorders in Men • Orgasm Difficulties in Women • Intercourse Difficulty Disorders in Women • Erectile Disorders in Men

16. LOW LIBIDO IS THE MOST COMMON SEXUAL COMPLAINT

17. Low Libido Case Study • “If Brad Pitt walked into the room..” • Sarah 23 yo: Started seeing in 2007, “just not interested”. On birth control pill for acne. Uncomfortable with body. Difficulty talking about sex. Medicated for anxiety. High life stress. “I’m with who I think I should be, but I don’t really love him”.

18. Hypoactive Sexual Desire Disorder (HSDD) • Lack of sexual desire, or sexual disinterest, is the most common sexual complaint heard by health care professionals. • HSD is more common in women than men. Men with HSD are significantly older than women with similar complaints. • Desire disorders often coexist with other sexual dysfunctions, such as pain with intercourse or erectile dysfunction, and commonly in conjunction with other medical diagnoses such as depression.

19. Hypoactive Sexual Desire Disorder (HSDD)Characteristics • Sexual desire is subjective and there are no standards. It is important to clarify a low libido is in comparison to. • Identical levels of sexual desire in sexual partners rarely occurs. It is normal for one partner to desire sex more frequently than another. • Most couples “work out” differing sexual appetites with acceptance and compromise.

20. Treatment of HSDD • Treatment of underlying medical conditions • Sex therapy/couples therapy • Hormone therapy: Estrogen and progesterone in menopausal women, DHEA, testosterone • Management of medications with sexual side effects (removal of or mediation) • Cognitive behavioral therapy: reconstructing the thought process around sex is critical. Life prioritization around sex is imperative.

21. Techniques to Enhance Desire • Identify and promote activities that increase sexual desire. • Sensate focus • Physical sports or dance • Intimate talks, cuddling, romance • Use erotic stories, videos, fantasies • Treat relationship conflict and depression • Change meds that could interfere • Treat sexual pain or vaginal dryness

23. Testosterone Therapy in Women • Not FDA approved treatment for women in the US – is used in Europe. • Testosterone therapy has been researched almost predominantly for post menopausal women who have low levels and are symptomatic. • T is a teratogen and therefore contraindicated in women who may conceive. Physiological level should be normal in younger women. • Long term safety inquiry is related to breast cancer and cardiovascular disease.

24. Return to Case Studies • Sarah: Elevated SHBG associated with birth control pill decreases availability of testosterone, utilize other treatments for acne management. Talk therapy, exercise, improve sleep for stress management remove need for anti-anxiety meds. Self exploration around body imagine and compatible partnership.

25. Ejaculation & Orgasm Disorders:Premature Ejaculation in Men • General definition is when a man ejaculates before, during, or immediately after vaginal penetration. Average time is generally 1 – 3 minutes. • Most men who have PE with intercourse are able to control ejaculation timing during masturbation. • The etiology of PE can be organic (most commonly diabetes or alcoholism) or may involve multiple psychological factors including: hypersensitivity to stimulation, early experiences of sexual haste, and performance anxiety. • Often co-exists with erectile dysfunction.

26. PE Case Study • Zack 24 yo male: First sexual encounter at 18 yo “didn’t go well”, emotional upset and penis discomfort. Anxiety about sexual performance, “what is wrong with me?” Girlfriend gets angry, feels rejected, critical. Focus on intercourse as only sexual activity. Concurrent ED.

27. Ejaculation & Orgasm Disorders:Premature Ejaculation • Talk therapy is 97% effective in the treatment of PE. • There are multiple techniques such as frequent “pauses” during sexual activity to facilitate time duration of ejaculation. • Antidepressants that interfere with ejaculation as a side effect are sometimes prescribed. • Lidocaine spray, double condoms use, breathing and distraction techniques, education regarding phases of arousal. • Ignoring concurrent psychological issues in the counseling process decreases the potential for good outcomedespite frequent patient resistance.

28. Return to Case Studies • Zack: Family history of CVD, medical work up, initiation of medication for cholesterol and blood pressure. Sex therapy, improve relationship communication, address girlfriend body issues. Viagra briefly useful. Reduction of alcohol useful. Anxiety management.

29. Ejaculation & Orgasm Disorders:Orgasm Difficulties in Women • Inability to reach orgasm is one of the most common problems cited by women worldwide, and is the second most common problem among US women (24%). • All women have the ability to experience orgasm unless they have been circumcised. Failure to achieve orgasm can be due to anxiety or fear of losing control. Lifelong orgasmic dysfunction is considered a “skill deficit”. • Many women who have never experienced an orgasm have never tried masturbation, consider themselves sexually under educated, and state they have talked to virtually no one about these subjects.

30. Anorgasmia Case Studies • “Not sure if I have ever..” versus “Not like they used to be..” • Andrea 26 yo female: Able to orgasm with self stimulation but never with a partner. Good general health. Has never been in a long term relationship. • Edith 82 yo female: “Bucket list” goal to have an orgasm.. Two marriages, lifelong faking orgasm. Does not masturbate and unwilling to. Will not talk with husband regarding matter.

31. Anorgasmia in Women: Sex therapy • “Directed masturbation” is the preferred treatment method and involves body awareness and self exploration. Book, video recommendations. Anatomy instruction. • Women are encouraged to experience an orgasm by self stimulation before expecting it to happen with a partner – then teach her partner to stimulate her in the same way she stimulates herself. • Set realistic expectations: 95% of women of require clitoral stimulation for orgasm. Normalizing stimulation required for orgasm is important to effective treatment outcomes.

32. Anorgasmia: Medical Treatments • Antidepressant medications can impair a women’s ability to orgasm . Most common cause for acquired anorgasmia. • Vagina DHEA: Study suggested 76% increase in orgasm (vs clinical experience contrast). • Arousal creams: Zestra, compounded products, warming liquids. • Eros Pump: the only therapy approved by the FDA for female orgasmic disorder. • Intranasal oxytocin, intranasal testosterone gel, Viagra, arginine, botanical therapies, exercise (wearing socks!)

33. Return to Case Studies • Andrea: Sex therapy, Sex for One book, Betty Dodson video, sex toy recommendations, how to date coaching. • Edith: Low dose Viagra, vibrator recommendations, but unwilling to disclose to husband, start sex therapy, unlikely improvement.

34. Intercourse Difficulties in Women:Terminology • Vulvodynia: chronic discomfort or pain in vulvar region not necessarily related to intercourse. • Dyspareunia: pain associated with sexual intercourse. • Vaginismus (V): disorder of vaginal spasm. • Vulvar vestibulitis (VVS): severe pain of the vestibule during attempted entry.

35. Vaginal pain Case Studies • Elizabeth 22 yo: After a party “my vagina hurts”, doesn’t remember what happened, only had one drink. • Lucy 33 yo female: Virgin, has never been able to have pelvic exam, uncomfortable with sex.

36. Date Rape Drugs: Rohypnol or "roofies“ • Fast acting sedative drug that is tasteless and odorless, easily administered into a drink at party unknowingly. Causes strong amnesia after event. • If Rohypnol exposure is to be detected, urine samples need to be collected within 72 hours and subjected to sensitive analytical tests. • Always party with buddies watching your back! Never leave drinks unattended, or accept drinks from people you don’t know. Watch for friends who appear drunk without having drank any alcohol.

37. Intercourse Difficulties in Women:Vulvar Vestibulitis/Vulodynia • Etiology is unknown. Theories include various infectious agents, neurovascular dysfunction, pain sensation dysfunction. • Sex therapy techniques: Sensate Focus, dilator use, pain management. • Medical treatment treatment options include: treating infection, topical anesthetic or steroid products, vaginal estrogen, oral medications to reduce neuropathy/pain, steroid injections, pelvic floor PT, cognitive behavioral therapy. • Surgical removal of vestibule success ranges from 40% - 100%, with the majority more than 60%. Surgery has improved outcome when combined with counseling.

38. Intercourse Difficulties in Women:Vaginismus • Vaginismus represents an involuntary spasm of muscles surrounding the outer third of the vagina, resulting in pain or inability to allow vaginal penetration. • Causes include: Lack of education about sex, fear of intimacy, thinking sex sinful, lack of anatomical awareness, homoerotic feelings, dislike of semen, or aversion to men or sex in general. • Hypertonicity of pelvic floor muscles can be palpated during a pelvic exam. There are different stages of vaginismus severitygraded 1 - 4

39. Intercourse Difficulties in Women:Vaginismus Treatment • Both partners should be involved in treatment. Education in sexual skills and functional anatomy is critical. Vaginal dilators or “accomodators” are commonly used in progressively increasing sizes. • The average 5 year success rate for behavioral and talk therapy is 80-100%, and is effective treatment for VVS and vaginismus. • Vaginal botox treatment is a controversial medical treatment for advanced and resistant to other treatment cases of vaginismus.

40. Vaginal Atrophy • Due to decreased exposure of estrogen to the vaginal tissues. • Most common in menopausal women, but can occur in post partum women lactating, and some women using the birth control pill. • Estrogen replacement in cream, suppository, or ring is main treatment (research on DHEA) • Non hormonal options include: Vaginal moisturizers (Replens, Luvena, Vitamin E) or various varieties of lubricants.

41. Return to Case Studies • Elizabeth: We were unable to detect any evidence of date rape drugs in her urine, too long to report. Ran STD testing. Emotional counseling. • Lucy: Stage 3 vagnismus. Within 9 months pelvic floor PT able to have first pelvic exam. Year of sex therapy started dating for first time, successful relationship, condition resolved.

42. Erectile Disorders (ED) in Men • Definition of ED: persistent inability to attain erection adequate to complete sexual activity. • Organic and psychogenic etiologies contribute to ED. Organic factors may serve to make erections more vulnerable to emotional disturbances. • In younger men cause is usually related to alcohol use, mood disorders, medications side effects or performance anxiety. • In older men, ED can be an initial symptoms of developing cardiovascular disease, and can have 64% increased risk of having a heart attack.

43. ED Treatment • Viagra type medications. • Replacing low testosterone levels in men can improve erections for some. • Botanical treatments exist that are efficacious in some men for treating erectile dysfunction. • Sex therapy often indicated as adjunct to medical treatments. • Treating cardiovascular disease if it exists.

44. LGBTQ Healthcare • LGBTQ community is disproportionately uninsured and has far greater difficulty obtaining appropriate healthcare. • Affordable Care Act includes clauses to improve healthcare access for LGBTQ. • Research suggests that LGBTQ individuals face health disparities linked to societal stigma and discrimination, linking LGBTQ persons with increased rates of psychiatric disorders and substance abuse.

45. Harry Benjamin Guidelines for Gender Transition • Protocol outlining requirements for individuals who wish to undergo hormonal or surgical transition to the other sex. • Different assessment for children versus adults. • Qualified mental health professional provides letter documenting various requirements fulfilled including: sound mental health, duration of time living as desires gender (typically 6 months), duration of time on HRT if is seeking “top” or “bottom” surgery, etc. • Flexible guidelines – area of debate

46. Conscientious Non-Monogamy Lifestyles • Monogam-ish: Dan Savage, specific negotiated exclusions to monogamous relationship. • Polyamory/open relationship: Meaning “many loves” it is the practice of having more than one intimate relationship at a time with the knowledge and consent of all involved. • Swinging: Typically heterosexual couples that switch female sex partners or engage in group sex together. • Hooking Up: “I’m not a slut I just love love”

47. BDSM/Kink Sexual Practices • BDSM is a catch-all acronym which includes a wide range of kink activities such as: • bondage and discipline  (B&D or B/D) • dominance and submission (D/s, such as Jim/ann), “top, bottom, switch” • sadomasochism or sadism and masochism (S&M or S/M), enjoyment of pain • Kink is a colloquial term for ‘non-normative’ sexual behavior, however, this is ambiguous and unique to each individual. 50 Shades of Grey.

48. Sex Workers and Healthcare • Difficulty finding non-judgmental, appropriate healthcare options. Refusal to be treated by some physicians. Often not getting STD testing or mental health care because not disclosing true activities. • Different needs between “street walkers” and “escorts”, strip club dancers, pornography film actors. • Some sex workers are safe sex experts and have lower prevalence of STD’s than average population.

49. BDSM/Polyamory/Sex Worker Case Studies • Bill 64 yo male: Involved in BDSM, 3 female sexual partners, anxiety, ED, medical history of cardiovascular disease. • Sally 26 yo female: Sex worker since 17 yo, escort, endometriosis, pelvic pain, anorgasmia, multiple mood disorders.

50. Kink/Alternative Sexuality Healthcare • No standard of care for STD testing in individuals with multiple sexual partners who are sex workers or otherwise non-monogamous. • Nature of sex work or BDSM activities allow selection of proper STD testing – blood exposure etc • Importance of being able to disclose true sexual activity to healthcare provider allow access to needed care.