Nivedita Dhar M.D. Wayne State University April 25, 2013

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1 Female Sexual Dysfunction Nivedita Dhar M.D. Wayne State University April 25, 2013

2 Outline Define Sexual Health and Wellness and discuss how it is unique to each individual Discuss the current terminology for Female Sexual Dysfunction and review its limitations Propose how a biopsychosocial model can be used to promote sexual well-being Discuss evaluation and treatment of sexual problems Introduce the concept of a multidisciplinary approach in addressing sexual problems

3 What is Sexual Health? Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence WHO Working Definition, 2002

4 The Importance of Sexual Health Integral part of being human Reproduction Relationships Overall Health

5 What is Sexuality? The experience and/or expression of an individual as a sexual being. Involves the complex interplay of: sex gender identity gender roles - one s expression of social and behavioral norms sexual orientation It is important to understand that sexuality can be different for each person and may vary over the course of his/her lifetime.

6 What is Sex? Difficult to define and varies from individual to individual. Assumption of penile-vaginal intercourse, but other activities can be included. Intercourse is not the goal in the sexual functioning of some individuals/couples, nor is it necessary. What is most important is that the sexual encounter is safe, healthy and gratifying.

7 Sexual Response Models Masters and Johnson Linear Model Kaplan Triphasic Model Basson Intimacy-Based Model

8 Masters and Johnson Linear Model In 1966 : Masters and Johnson published their book - Human Sexual Response linear model of sexual response for both men and women composed of four stages

9 Masters and Johnson Linear Model 4 stage model of sexual response Excitement Plateau Orgasm Resolution

10 Kaplan Triphasic Model Built on the work of the Masters and Johnson s model consisting of separate but interlocking phases: desire, arousal, and orgasm. believed that sexual difficulties typically had superficial origins

11 Kaplan Triphasic Model Desire < Excitement > Resolution

12 Basson Intimacy-Based Model Cyclical model of sexual functioning many points of entrance into the female sexual response cycle that often overlap acknowledges that women may initiate or be responsive to sexual stimuli not only because of arousal Of significance is that desire is not always first before arousal or the sole reasoning for engaging in sexual activity

13 Basson Intimacy-Based Model

14 Limitations of Models Focus on physiology sex is so much more than that Based on male models Implies a set paradigm the requirement that normal sexuality consists of desire, arousal and orgasm. If these are deficient, sexual dysfunction is diagnosed; if they are present, there is no sexual dysfunction.

15 The FSD Manifesto Challenges the medicalization of women s sexual problems Sexual equivalency is denied. Women do not separate desire from arousal Women care less about physical than subjective arousal Emphasis on equivalency ignores many inequities, such as sexual violence, access to sexual health care, and social environment. DSM bypasses relational aspects of women's sexuality Relational or cultural conflicts, sexual ignorance or fear cause more sexual problems than physical problems, but they go unstudied, in favor of medicalization of problems.

16 Sexual Problems are Common 43% of women 31% of men Female Sexual Dysfunction Sexual Desire Disorders Arousal Disorder Orgasmic Disorder Sexual Pain Disorders

17 Sexual Desire Disorders Sexual Aversion Disorder: the persistent or recurrent aversion to genital contact with a sexual partner. characterized by a disgust and repugnance towards sexual activity. Hypoactive Sexual Desire Disorder: the deficiency or absence of sexual fantasies and desire for sexual activity. considered to be beyond the normal reduction expected with relationship duration and life cycle. sexual performance may be adequate once activity has been initiated Must cause personal or interpersonal distress

18 Female Sexual Arousal Disorder (frigidity) The absence, impairment, or diminishment of genital responsiveness to stimulation, most notably by lack of adequate lubrication to engage in sexual intercourse. Subtypes combined arousal disorder missed arousal disorder genital arousal disorder Must cause personal or interpersonal distress One of the largest criticisms for female sexual arousal disorder is whether it is an actual disorder or an idea put forth by pharmaceutical companies in order to step into a potentially billion dollar industry

19 Female Orgasmic Disorder The persistent or recurrent delay in or absence of orgasm following a normal excitement phase. It is common for women to be able to achieve orgasm with specific forms of stimulation but not with intercourse, and this is considered within the normal range sexual function. Must cause personal or interpersonal distress

20 Sexual Pain Disorders Dyspareunia: persistent, recurrent urogenital pain that occurs before, during, or after sexual intercourse; the pain is experienced either as occurring on entry to the vagina or deep pain. psychological and biological factors can contribute to the condition. can think of it as a pain disorder that interferes with sexuality as opposed to a sexual disorder characterized by pain.

21 Sexual Pain Disorders Vaginismus: involuntary tightening of the outer third of the vaginal musculature to the extent that vaginal penetration is difficult, despite the woman desiring penetration with a penis, finger, or object. women with this condition can still achieve orgasm and enjoy sexual activity, just not penetration. not always present in all situations although vaginismus is considered a pain disorder, most women don t feel pain since penetration is impossible. Must cause personal or interpersonal distress

22 Problems with Terminology Based on linear sexual response models that focus only on physiology It s negative It s vague and subjective Sexual problems are relative

23 Why We NEED the Terminology Provides a common language for clinical work and research Had to be done to legitimize women s sexual health concerns

24 The DSM-V Efforts to Improve the Terminology New Groupings Sexual interest/arousal disorders Female orgasmic disorder Genito-Pelvic Pain/Penetration Disorder

25 Sexual Interest/Arousal Disorder in Women A. Lack of sexual interest/arousal of at least 6 months duration as manifested by at least 3 of the following indicators: Absent/reduced frequency or intensity of interest in sexual activity Absent/reduced frequency or intensity of sexual/erotic thoughts or fantasies Absence or reduced frequency of initiation of sexual activity and is typically unreceptive to a partner s attempts to initiate Absent/reduced frequency or intensity of sexual excitement/pleasure during sexual activity on all or almost all (approximately 75%) sexual encounters Sexual interest/arousal is absent or infrequently elicited by any internal or external sexual/erotic cues (e.g., written, verbal, visual, etc.) Absent/reduced frequency or intensity of genital and/or nongenital sensations during sexual activity on all or almost all (approximately 75%) sexual encounters B. The problem causes clinically significant distress or impairment. C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

26 Sexual Interest/Arousal Disorder in Women Subtypes Early-onset (lifelong) vs. Late-onset (acquired) Specifiers: Generalized vs. Situational Partner factors (partner s sexual problems, partner s health status) Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity) Individual vulnerability factors (e.g., poor body image, history of abuse experience) or psychiatric comorbidity (e.g., depression or anxiety,) Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity) With medical factors relevant to prognosis, course, or treatment

27 Female Orgasmic Disorder A. At least one of the two following symptoms where the symptom(s) must have been present for at least 6 months and be experienced on all or almost all (approximately 75%) occasions of sexual activity: Marked delay in, marked infrequency, or absence of orgasm Markedly reduced intensity of orgasmic sensation B. The problem causes clinically significant distress or impairment C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

28 Female Orgasmic Disorder Subtypes Early-onset (lifelong) vs. Late-onset (acquired) Specifiers Generalized vs. Situational With concomitant problems in sexual interest/sexual arousal Partner factors (partner s sexual problems, partner s health status) Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity) Individual vulnerability factors (e.g., poor body image, history of abuse experience) or psychiatric comorbidity (e.g., depression or anxiety) Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity) With medical factors relevant to prognosis, course, or treatment

29 Genito-Pelvic Pain/Penetration Disorder A. Persistent or recurrent difficulties for at least 6 months with one or more of the following: Inability to have vaginal intercourse/penetration Marked vulvovaginal or pelvic pain during vaginal intercourse/penetration attempts Marked fear or anxiety either about vulvovaginal or pelvic pain or vaginal penetration Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration B. The problem causes clinically significant distress or impairment C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

30 Subtypes Genito-Pelvic Pain/Penetration Disorder Early-Onset (Lifelong) vs. Late-Onset (Acquired) Specifiers Generalized vs. Situational With concomitant problems in sexual interest/sexual arousal Partner factors (partner s sexual problems, partner s health status) Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity) Individual vulnerability factors or psychiatric comorbidity (e.g., depression or anxiety, poor body image, history of abuse experience) Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity) With medical factors relevant to prognosis, course, or treatment

31 Obstacles in Diagnosis and Treatment of Sexual Problems Reluctance of patients to talk about it Care provider avoidance Lack of time Lack of knowledge Underlying etiologies are poorly understood and often multi-factorial Treatment options are limited

32 The Biopsychosocial Model Sexual problems can develop because of biological/physical factors, psychologic factors, social factors, or a mixture of factors. Biologic factors that may interfere with sexual function include medical problems, hormonal changes, medications, Psychologic factors that may play a role include anxiety, depression, stress, abuse, poor body image. Memories of a sexual trauma can greatly influence how a person functions sexually. Social and interpersonal factors that can affect sexual function include relationship problems, religious beliefs, cultural beliefs, and one s upbringing.

33 Physiological Neurological problems Cardiovascular disease Cancer Urogenital disorders Medications Fatigue Hormonal loss or abnormality Psychological Depression/anxiety Prior sexual or physical abuse Stress Alcohol/substance abuse Interpersonal relationships Partner performance and technique Lack of partner Relationship quality and conflict Lack of privacy Female Sexual Dysfunction Sociocultural influences Inadequate education Conflict with religious, personal, or family values Societal taboos

34 Diagnostic and Management Algorithm for Female Sexual Dysfunction Patient complaining of FSD Basic evaluation Sexual history Medical history Psychological history Focused physical exam Recommended lab tests Findings DO NOT preclude treatment Findings indicate further specific evaluation Patient/partner education shared decision making Treatment Optional and/or specialized tests Hatzichristou D, et al. J Sex Med. 2004;1:49-57.

35 Taking a Sexual History Interview should move from open-ended to closeended questions. Listen carefully to the responses, and ask clarifying questions. Make sure that the patient understands the terms you are using. Modify questions to suit the situation and/or responses. All questions relating to sexual practices must be free of any assumptions of sexual orientation or monogamy.

36 Treatment of FSD Desire Disorders Relationship/Marital Therapy Cognitive Behavioral Therapy Bupropion Flibanserin Tibolone Testosterone Arousal Disorders Sensate focus exercises/masturbation training EROS clitoral therapy device Sildenafil Alprostadil Phentolamine Dopamine agonists Androgens

37 Orgasm Disorders Treatment of FSD Directed masturbation Anxiety reduction techniques Sex education Bupropion ArginMax Pain Disorders Sex Therapy Biofeedback training Pelvic Physical Therapy Surgical intervention Acupuncture Hypnotherapy Amitriptyline Estrogen

38 The Most Important Treatment The 3 E s Your Ear Education Basic anatomy and physiology Realistic expectations The goal should be satisfaction Empathy Recognizing the role of grief and loss

39 So how do we manage these complex problems?

40 Our Answer A university-based, multidisciplinary specialty Center committed to optimizing Sexual Health and Wellbeing through patient care research education

41 Our Providers The members of our team represent multiple specialties, including Obstetrics and Gynecology, Urologist, Psychiatry, Psychology and Physical Therapy. All have demonstrated a commitment and interest in sexual health issues and have experience dealing with sexual problems.

42 Clinic Design Initial appointment with OB-GYN/Urologist Evaluation by Psychiatrist, Sexual Therapist, and Physical Therapist as indicated Interdisciplinary meeting to develop treatment plan Patient given plan and and treatment implemented

43 Contact Information Clinic Location West Twelve Mile Road Southfield, MI (248)

44 Conclusions Sex is an important part of well-being Sexual satisfaction should be the goal Sexual wellness can be achieved by utilizing a biopsychosocial model for assessment and treatment The 3 E s are vitally important There is help for difficult cases

Sexological aspects of genital pain

Sexological aspects of genital pain Annamaria Giraldi, professor, MD, PHD Sexological Clinic, Psychiatric Centre Copenhagen 1 Disclosures Speaker: Eli Lilly, Pfizer Consultant: Eli Lilly,Palatin 2 Agenda