Women's Postpartum Sexual Health Program: A Collaborative and Integrated Approach to Restoring Sexual Health in the Postpartum Period

Transcription

1 Journal of Sex & Marital Therapy ISSN: X (Print) (Online) Journal homepage: Women's Postpartum Sexual Health Program: A Collaborative and Integrated Approach to Restoring Sexual Health in the Postpartum Period Hillary Lianna McBride, Sarah Olson, Janelle Kwee, Carolin Klein & Kelly Smith To cite this article: Hillary Lianna McBride, Sarah Olson, Janelle Kwee, Carolin Klein & Kelly Smith (2016): Women's Postpartum Sexual Health Program: A Collaborative and Integrated Approach to Restoring Sexual Health in the Postpartum Period, Journal of Sex & Marital Therapy To link to this article: Accepted author version posted online: 22 Jan Submit your article to this journal Article views: 45 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at Download by: [University of California, San Diego] Date: 18 March 2016, At: 11:46

2 POSTPARTUM SEXUAL HEALTH PROGRAM Women s Postpartum Sexual Health Program: A Collaborative and Integrated Approach to Restoring Sexual Health in the Postpartum Period Hillary Lianna McBride Masters 1,*, Sarah Olson 2, Janelle Kwee 3, Carolin Klein 4, Kelly Smith 5 1 University of British Columbia, Educational and Counselling Psychology, Vancouver Campus, 2125 Main Mall, Vancouver, British Columbia, V6T 1Z4 Canada 2 South Hill Family Health Centre, Vancouver, British Columbia, Canada olson.se@gmail.com 3 Trinity Western University, Langley, British Columbia, Canada drjanellekwee@gmail.com 4 Vancouver General Hospital, Vancouver, British Columbia, V5Z 1L5 Canada Carolin.Klein@vch.ca 5 University of British Columbia, Vancouver, British Columbia, Canada smithkellybrook@gmail.com * Corresponding Author hillarylmcbride@gmail.com Abstract The postpartum period presents unique challenges to couples' relationships and sexuality, yet these factors are often left unaddressed by health care providers. The Women s Postpartum Sexual Health Program (WPSHP), a four session group- and couples-based program delivered by 1

3 an interdisciplinary care team at a family practice centre, was designed specifically to address common concerns among postpartum women and their partners. The interrelated, biopsychosocial aspects of women s sexuality in the postpartum period are summarized, followed by a detailed description of the WPSHP content and structure. This information is intended to serve as a practical resource for implementation and adaptation of the WPSHP across different practice settings. KEYWORDS postpartum; sexual health; sexual function; biopsychosocial; intervention 2

4 The postpartum period is a time of great transition for parents, who are learning, either for the first time or again, how to adjust their lives to care for their new infant. While this can be a time of joy and intimacy, it can also be rife with challenges (Collier, 2010). Parents are tasked with negotiating new priorities in life which can be at odds with spending quality time together as a couple (Alves & Vieira, 2008; Demyttenaere, Gheldof, & Van Assche, 1995). In addition to negotiating changes in the relationship, women also must adjust to how their postpartum bodies look and function differently than they did before childbirth. Sleep deprivation, hormonal changes following childbirth and as a result of breastfeeding, and potentially painful and/or prolonged recovery from a vaginal or Cesarean delivery can all impact physical as well as emotional health. These factors come together to make the postpartum period a time when many couples struggle to have a healthy, regular, and enjoyable sex life (Alves & Vieira, 2008). In one study investigating postpartum sexual activity, 83% of 484 participants reported sexual challenges within the first three months of giving birth, and dyspareunia resulting from vaginal dryness was a primary concern (Barrett et al., 2000). Health care providers often neglect discussing postpartum sexuality with patients (Barrett et al., 2000). This can contribute to women s feelings of isolation, sadness, failure, and shame, and worries that there is something wrong with them (Johnson, 2011; Leeman & Rogers, 2012). Women s sexuality is complex and encompasses more than physiological and hormonal responses (Basson, 2000). While the literature speaks to hormonal and physical changes resulting from childbirth, there is a lack of data about psychosocial factors that contribute to women s postpartum sexual health concerns (Abdool, Thakar, & Sultan, 2009). Further, the existing 3

5 solutions to address these concerns are insufficient (Hipp, Kane Low, & Van Ander, 2012). Proposed solutions have generally been limited to the physical or biological domain; consequently, there is a need for interventions to incorporate the relational and psychological components of women s postpartum sexuality (Abdool, Thakar, & Sultan, 2009; Collier, 2010; Demyttenaere, Gheldof, & Van Assche, 1995; Leeman & Rogers, 2012). While providing care at the South Hill Family Health Centre, a family practice located in Vancouver, Canada, it became clear that better support for women navigating the unique challenges of postpartum sexuality was needed. South Hill Family Health Centre is unique in that it brings together an interdiscliplinary team, including family physicians, a nurse practitioner, dieticians, and a clinical counselor, who have experience with group medical care during pregnancy and postpartum and for well-baby visits. Given that the Centre grew out of a maternity care practice, postpartum women make up a large proportion of the patient population. These women frequently report struggling with sexual concerns, including significantly decreased or absent sexual desire and/or the presence of pain with penetration, and resulting negative impact (e.g., self-image, relationship satisfaction). In order to provide adequate care to women and partners, we created the Women s Postpartum Sexual Health Program (WPSHP), a multidimensional curriculum that includes group- and couple-based sessions. The purposes of this article are to summarize the biopsychosocial factors that can impact women s postpartum sexuality and informed the development of our program, and to describe the content and structure of the WPSHP. The WPSHP addresses the biological, psychological, and relational components of women s sexuality, and has been designed specifically to address the gap in treatments identified in the literature (Abdool, Thakar, & Sultan, 2009; Demyttenaere, Gheldof, 4

6 & Van Assche, 1995; Handa, 2006; Hipp, Kane Low, & Van Ander, 2012; Johnson, 2011). This information is intended to serve as a resource for implementation and adaptation of the WPSHP across different practice settings. Women s Sexuality The traditional understanding of human sexuality stems from the groundbreaking work of Masters and Johnson (1966), who suggested that the human sexual response cycle follows a linear model progressing through four phases: excitement (i.e., arousal), plateau, orgasm, and resolution. This model was subsequently expanded by Kaplan (1979) to include an initial sexual desire phase. While this model has been useful for understanding the sexual response cycle, it lacks important components that are important for understanding female sexual response (Basson, 2000). With the introduction of Basson s (2000) non-linear model of female sexual response, two essential components missing from Masters and Johnson s original conceptualization---emotional intimacy and relational dynamics---were added. These factors, as identified by Basson (2000), contribute to women s sexual desire, sexual motivation, and sexual response. Additionally, whereas Masters and Johnson s model implied that normal sexual desire is spontaneous, Basson s (2000) model highlights that sexual desire in long-term relationships is more often responsive than spontaneous (Basson, 2000). It has been argued that acceptance of the original Master s and Johnson model has led to clinical and societal misunderstandings about female sexuality, resulting in a tendency for overdiagnosis of sexual disorders in women (Basson, 2000, 2005). Further, women who compare themselves to the original model may feel shame due to a lack of spontaneous desire to engage in 5

7 sexual behavior. Basson s model has implications for understanding and providing care to women who report sexual concerns such as low desire. Specifically, there is a need for recognition that women s sexual response more commonly stems from intimacy needs rather than a need for physical sexual arousal (Basson, 2000, p. 51). This information can normalize women s experiences and reframe what is often thought of as low sex-drive. This process is particularly important as, when women feel shame, low self-worth, or guilt for not desiring sexual activity with their partner as they believe they should, their ability to desire and engage in sexual behavior freely is further diminshed (Basson, 2005). Considering the role emotional intimacy has in women s sexuality, it is important that psychological and relational factors be a central focus of treatment for postpartum women s sexual concerns. Hormonal and Physical Changes in the Postpartum Period Significant neuroendocrine changes occur postpartum that can contribute to decreased sexual interest during the first six to 12 months following childbirth (Rupp et al., 2013; LaMarre et al, 2003). Some of these changes likely occur within the amygdala, which is related to both sex drive and emotion and rewards processing, and postpartum women have been shown to exhibit decreased amygdala responsiveness (Rupp et al, 2013). Elevated prolactin and oxytocin levels associated with breastfeeding can also be associated with low sexual desire in postpartum women (LaMarre et al, 2003). (Altemus, 1995; Carter et al., 2007; Rupp et al., 2013). Finally, breastfeeding can lead to postpartum dyspareunia, as high levels of prolactin and low levels of estrogen often cause changes including decreased vaginal lubrication (Johnson, 2011; Barrett, 2000). 6

8 Several potential complications resulting from pregnancy and delivery can also make resuming regular sexual activity more difficult and/or less desirable. These complications include perineal pain, vaginal or uterine prolapse, and weakened pelvic floor muscles. While perineal pain due to trauma is associated almost exclusively with vaginal deliveries, the latter two issues also arise among women who have had Cesarean deliveries (Abdool, Thakar, & Sultan, 2009; Acele & Karaçam, 2012; Alves & Vieira, 2008; Phillips & Monga, 2004). Phillips and Monga (2004) reported that perineal trauma affects up to 85% of women following a vaginal delivery, and this risk is increased by the use of forceps, episiotomy and certain methods of perineal repair. Women with pre-existing genital pain are at increased risk of worsening pain symptoms following delivery (Nguyen et al, 2012). Although the percent of women who have sexual challenges post-natally is high, only 15% of women report discussing them with their health care providers (Barrett et al., 2000). Studies have found that, in spite of biological contributors for sexual challenges and the frequency with which they are experienced in the postpartum period, women feel uncomfortable bringing up these issues with their care providers, and care providers feel unsure about how to address the issues within routine visits (Abdool, Thakar, & Sultan, 2009; Barrett et al., 2000; Jha & Thakar, 2010; Johnson, 2011). In addition to lack of sleep and the stress of caring for a newborn, these physical and hormonal factors can contribute to sexual challenges. Further, these factors can affect and be affected by psychosocial challenges in the postpartum period, highlighting the important interplay between a woman s biology and her psychosocial functioning. 7

9 Psychosocial Contributors to Postpartum Sexual Concerns Sexual satisfaction and functioning are highly influenced by psychological factors, including stress, mood, anxiety, sense of self/self-esteem, body image, past traumatic experiences and general well-being (Altho & Needle, 2013; Mickelson & Joseph 2012). Although it is unknown which occurred first, Basson (2005) found high correlations between women s low sexual desire and low mood, low self-esteem, and anxiety or worry. As well, negative life experiences, and how they are handled, can contribute to or predict sexual difficulties (Althof & Needle, 2013). Even when mental health issues do not occur at a clinical threshold, routine hassles from daily life are sufficient to create distraction and distress that can impair, for example, a woman s sexual desire (Basson, 2005; Carvalho & Nobre, 2010). The postpartum period can present specific psychological challenges. New mothers have been found to experience psychosocial difficulties, such as isolation, role and identity challenges, and anxiety. Up to 85% of these women report baby blues and approximately 20% meet diagnostic criteria for postpartum depression (Bueno, 2010; Zers, Washke, & Ehler, 2008). Leeman and Rogers (2012) reported that 40% of women with depression report challenges with sexual desire, arousal and orgasm, and that depression, specifically, has been found to be associated with low sexual desire and low rates of intercourse at weeks postpartum. Even without the experience of acute mental health issues, adjusting to a new baby is challenging due to factors such as fatigue, increased responsibilities and housework, stress resulting from decreased finances, and/or poor self-image related to increased weight gain (Alhof & Needle, 8

10 2013; Basson, 2000; Collier, 2010; Demyttenaere, Gheldof, & Van Assche, 1995; Hipp, Kane Low, & Van Anders, 2012; Mickelson & Joseph, 2012; Petch & Halford, 2008). Relational Factors As highlighted by Basson (2000, 2001, 2005), relational components play an important role in women s sexuality. Emotional intimacy can enhances sexual satisfaction, which in turn further increases emotional intimacy, creating a positive cycle of physical and relational closeness (Basson, 2001; Leiblum, 1998; Tiefer, 1991). This is particularly true for the women for whom sexual desire is largely responsive as opposed to spontaneous. A woman s desire to engage sexually with her partner is influenced by how desired, attractive, and appreciated she feels in her relationship (Basson, 2005). Likewise, sexual desire is negatively influenced by feelings of guilt about not satisfying a partner, as well as lack of emotional safety, tenderness or respect (Basson, 2001). Due to the significant relational changes that can occur after having a baby, many couples experience decreased relationship satisfaction associated with their sexual relationship (Petch & Halford, 2008). Issues with privacy and conflicting schedules also affects couples' relationship and sexual intimacy (Althof & Needle, 2013). There is even evidence that a women s perception of their partner s sexuality have more influence on postpartum sexuality than do physical factors (Hipp, Kane Low, & Van Anders, 2012). There is a clear link between sexual difficulties in women and couples' relationship challenges, including having an unsatisfactory relationship or experiencing ongoing relationship challenges; however, the direction of causality is not always clear (Althof & Needle, 2013). 9

11 Moreover, when relationship and sexual difficulties are treated as interrelated, treatment yields significantly improved results compared to when these issues are addressed separately (Althof & Needle, 2013; Basson, 2001; Johnson, 2011). Relationship skill-building, including psychoeducation about sexuality, practicing supportive and encouraging behaviors, and improving conflict management skills, has been shown to assist couples in their transition to parenthood, ultimately leading to increased relationship and sexual satisfaction (Petch & Halford, 2008). Women s Postpartum Sexual Health Program (WPSHP) In light of the above review, which outlines the need for integrated solutions to address women s postpartum sexual health concerns, the WPSHP was created. The WPSHP provides support for and focuses on addressing the multidimensional aspects of women s postpartum sexual concerns. Although the program aims to address the complex nature of women s postpartum sexuality, it is not designed to comprehensively treat pain, low desire, other sexual concerns, or ongoing relational conflicts. Instead, the WPSHP is meant to provide psychoeducation, an introduction to skills and interventions that can enhance sexual and relationship satisfaction, and group support, offering a safe space for participants to obtain information and discuss the challenges of postpartum sexuality with other women. Participants are encouraged to try the various introduced skills in order to determine which may best suit their individual and relational needs. Continued skills practice is encouraged upon completion of the group, including through additional support via individual or couples sex and relationship therapy. WPSHP Structure 10

12 The WPSHP is designed for adult women in the postpartum period who are in a committed relationship and who are experiencing subjective sexual concerns following the birth of their child(ren). We have defined the postpartum period as the first year following childbirth. The WPSHP is designed to occur over approximately eight weeks in two-week intervals, for a total of four sessions. There is, however, room for flexibility, and it is possible for therapeutic interventions to occur three to four weeks apart, as long as program continuity and commitment can be maintained. The first three sessions are conducted in a group format, with each session lasting 120 minutes. Groups range in size from six to twelve women, with eight being an ideal number that is small enough to promote a sense of connection between group members yet large enough to demonstrate that participants are not alone in their experiences. The fourth session is a 90-minute couple s session. The structure of each session includes, home activities review, introduction of a new topic and/or skill, discussion, and homework. Homework is designed to provide continuity between sessions, help participants to further consider and retain information provided in session, and give strategies and techniques to begin addressing factors that are negatively impacting sexual intimacy and well-being. Group sessions are facilitated by one or more clinicians who have a background in women s sexual and post-natal health and who have experience facilitating groups and presenting material of a sensitive nature. These facilitators may include gynecologists, obstetricians, family doctors, nurses, nurse practitioners, social workers, or psychologists/counselors. A co-facilitator is also present to provide continuity and additional 11

13 group support. The couple s session is facilitated by a social worker, psychologist, or counselor with experience helping couples navigate sexual and relationship concerns. To enhance participants' abilities to concentrate on the session content, as well as to provide a break from parenting, participants attend sessions without their children. This childfree attendance also affirms women s identities as not only mothers, but also as individuals and partners who are multidimensional sexual beings. To facilitate attendance, on-site childcare is provided. The session-by-session content of the Women s Postpartum Sexual Health Program is summarized in Table 1 1. Conclusion This WPSHP was designed to aid women and their partners struggling with postpartum sexual concerns using multidisciplinary service delivery. This program introduces women and couples to a range of topics and skills to help address such concerns. Our intent in sharing the structure and content of the program is to provide a practical resource for implementation and adaptation of the WPSHP across different practice settings. Qualitative and quantitative evaluation research is currently underway to examine the effectiveness of the WPSHP and to guide refinement of the program if needed. 1 Readers interested in materials used during the WPSHP may contact the corresponding author directly. 12

14 References Abdool, Z., Thakar, R., & Sultan, A. H. (2009). Postpartum female sexual function. European Journal of Obstetrics & Gynecology and Reproductive Biology, 145(2), doi: /j.ejogrb Acele, E. Ö., & Karaçam, Z. (2012). Sexual problems in women during the first postpartum year and related conditions. Journal of Clinical Nursing, 21(7 8), doi: /j x Altemus, M.(1995). Neuropeptides in anxiety disorders: Effects of lactation. Annals of the New York Academy of Science, 771, Althof, S. E., & Needle, R. B. (2013). Psychological and interpersonal dimensions of sexual function and dysfunction in women: An update. Arab Journal of Urology, 11(3), doi: /j.aju Alves, M. & Vieira, R. (2008). Facts that influence the feminine sexuality after childbirth. Sexologies, 17, Barrett, G., Pendry, E., Peacock, J., Victor, C., Thakar, R., & Manyonda, I. (2000). Women s sexual health after childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 107(2), doi: /j tb11689.x Basson, R. (2000). The female sexual response: A different model. Journal of Sex &Marital Therapy, 26(1), doi: /

15 Basson, R. (2001). Using a different model for female sexual response to address women s problematic low sexual desire. Journal of Sex & Marital Therapy, 27(5), doi: / Basson, R. (2005). Women s sexual dysfunction: Revised and expanded definitions. Canadian Medical Association Journal, 172(10), doi: /cmaj Basson, R., Brotto, L. A., Carlson, M., Driscoll, M., Grabovac, A., & Smith, K. B. (2012). Moving on with our sexual lives despite painful penetration from provoked vestibulodynia and pelvic muscle tension: A mindfulness-based approach. Unpublished manuscript. Beck, A. T. (1979). Cognitive therapies and the emotional disorders. New York, NY: Penguin Books. Burns, D. (1980). Feeling good: The new mood therapy. New York, NY: Harper Collins. Bueno, J. (2010). Life after birth. Therapy Today, 21(4), Carter, C.S., Pournajafi-Nazarloo, H., Kramer, K.M., Ziegler, T.E., White-Traut, R., Bello, D., & Schwertz, D. (2007). Oxytocin: Behavioral associations and potential as a salivary biomarker. Annals of the New York Academy of Science, 1098, Carvalho, J., & Nobre, P. (2010). Predictors of women s sexual desire: The role of psychopathology, cognitive-emotional determinants, relationship dimensions, and medical factors. Journal of Sexual Medicine, 7, Collier, F. (2010). When a couple wants a baby: What are the consequences on their sexuality?. Sexologies, 19(3), doi: /j.sexol

16 Demyttenaere, K., Gheldof, M., & Van Assche, F. A. (1995). Sexuality in the postpartum period: A review. Current Obstetrics & Gynaecology, 5(2), Handa, V. L. (2006). Sexual function and childbirth. Seminars in Perinatology, 30(5), doi: /j.semperi Hipp, L. E., Kane Low, L., & van Anders, S. M. (2012). Exploring women s postpartum sexuality: Social, psychological, relational, and birth related contextual Factors. The Journal of Sexual Medicine, 9(9), doi: /j x Jha, S., & Thakar, R. (2010). Female sexual dysfunction. European Journal of Obstetrics & Gynecology and Reproductive Biology, 153(2), doi: /j.ejogrb Johnson, C. E. (2011). Sexual health during pregnancy and the postpartum (CME). The Journal of Sexual Medicine, 8(5), doi: /j x Leeman, L. M. & Rogers, R.G. (2012). Sex after childbirth: Postpartum sexual function. Obstetrics and Gynecology, 119(3), doi: /AOG.0b013e Leiblum, S.R. (2000). Redefining female sexual response. Contemporary Obstetrics and Gynecology, 45(11), Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston, MA: Little, Brown. Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. London, Churchill. Mickelson, K. D. & Joseph, J.A. (2012). Postpartum body satisfaction and intimacy in first-time parents. Sex Roles, 67, doi: /s

17 Nguyen, R. H., Stewart, E. G., & Harlow, B. L. (2012). A population-based study of pregnancy and delivery characteristics among women with vulvodynia. Pain and Therapy, 1(1), Petch, J. & Halford, W.K. (2008). Psycho-education to enhance couples' transition to parenthood. Clinical Psychology Review, 28, doi: /j.cpr Phillips, C. & Monga, A. (2004). Childbirth and the pelvic floor: The gynaecological consequences. Reviews in Gynaecological Practice, 5, doi: /j.rigp Rupp, H. A., James, T. W., Ketterson, E. D., Sengelaub, D. R., Ditzen, B., & Heiman, J. R. (2013). Lower sexual interest in postpartum women: Relationship to amygdala activation and intranasal oxytocin. Hormones and Behavior, 63(1), doi: /j.yhbeh Tiefer, L. (1991). Historical, scientific, clinical and feminist criticisms of the human sexual response cycle. Annual Review of Sex Research, 2, Weiner, L. & Avery-Clark, C. (2014). Sensate Focus: Clarifying the Masters and Johnson s model. Sexual and Relationship Therapy, 29 (3), doi: / Zaers, S., Waschke, M., & Ehlert, U. (2008). Depressive symptoms and symptoms of posttraumatic stress disorder in women after childbirth. Journal of Psychosomatic Obstetrics and Gynaecology, 29(1), doi: /

18 Table 1 Women s Postpartum Sexual Health Program Session Content Summary Session 1: Female Sexual Response and the Postpartum Period The first WPSHP session is designed to introduce women to the group, normalize their postpartum experiences by reviewing the many reasons sexual intimacy can be compromised in the postpartum period, and introduce Basson s (2000) model of female sexual response. The goal of the latter is to increase understanding and to shift women s postpartum expectations of themselves and their sexual relationship. Welcome and Introduction Participants are introduced to the program, to each other, and to (15 minutes) the facilitators. Barriers to Sexual Intimacy During the first session, the facilitator asks participants to list in the Postpartum Period potential contributors to postpartum struggles with sexual (20 minutes) intimacy. Participants are also asked to try to classify each contributing factor as biological (i.e., physical or hormonal), psychological, relational, or some combination of each. The purpose of this exercise is to help women better understand the myriad of ways that the postpartum period can present challenges to sexual intimacy, as well as the difficulties with trying to classify factors as biological, psychological, or relational given their complex and interrelated nature. 17

19 Basson s (2000) Non- Linear Model of Female Sexual Response (50 minutes) Women are first introduced to Masters and Johnson s (1966) linear model of sexual response. Next, Basson s (2000) nonlinear model, in which sexual desire is acknowledged as more often being responsive than spontaneous and as highly impacted In-Session Reflection (15 minutes) by intimacy and relational factors, is presented. In discussing Basson s (2000) model, participants are provided with examples of how the factors identified in the previous section can interfere at each stage of the model and the complexity of women s sexuality is highlighted. Providing participants with normalizing information about female sexual response can lead to a profound realization about how their (and their partner s) prior beliefs and understanding of sexuality have negatively impacted feelings about themselves and their relationship. In line with Basson s (2000) model, participants are asked to consider and write down reasons that motivate them to be sexually intimate with their partners. Participants are also asked to consider factors that de-motivate or deter them from being sexually intimate with their partners. Finally, participants are asked reflect on where in the model they believe they and their partners experience the most difficulty. 18

20 Homework and wrap-up (20 minutes) Session 2: Addressing Biopsychosocial Factors that Impede Postpartum Sexuality Session 2 is designed to provide psychoeducation and strategies to begin addressing common biopsychosocial impediments to women s sexual relationship. Home Activities Review (15 minutes) Biological Changes in the Postpartum Period (30 minutes) Session 2 begins with psycho-education about how and why hormones fluctuate after childbirth. This includes information on how hormones related to breastfeeding can affect arousal and contribute to vaginal dryness which, in turn, can result in decreased subjective sexual arousal and pleasure. Women are given information on birth-related perineal injury and healing, and those who have concerns about their healing or who are experiencing ongoing pain are encouraged to book a visit with their primary care provider. In addition, information on postpartum dyspareunia is provided. Potential solutions, including lubricants and/or topical estrogen cream for vaginal dryness, and pelvic floor physiotherapy for some causes of dyspareunia, are briefly discussed. Importantly, the complexity 19

21 of women s sexual response is highlighted, as is the need for integrated solutions that go beyond pharmacological approaches and addressing psychosocial contributors to sexual concerns. The Role of Thoughts and Behaviours (40 minutes) To begin addressing the psychosocial contributors to sexual concerns, participants are provided an overview of how thoughts and feelings affect sexual functioning, sexual satisfaction, and intimacy, including an introduction to the ABC s of Rational Emotive Behavioral Therapy or Cognitive Behavioral Therapy. This includes a description of a cognitive snowball (Basson, et al, 2012). Participants are provided with a worksheet to then begin identifying their own snowball of underlying beliefs and emotional consequences, and the impact these have on their behaviors. Participants are also introduced to common cognitive distortions (Beck, 1979; Burns, 1980). They are asked to consider which of these they experience most frequently, both in general and as it relates to their sexual relationship, particularly the avoidance of sexual behavior or self-blame. The facilitator then demonstrates the strategy of cognitive restructuring, and, as practice, alternative thoughts are generated in the group. They are provided with a worksheet to practice identifying an event, the underlying belief(s), and the emotional consequence(s), 20

22 followed by possible alternative thoughts. Introduction to Sensate Focus (15 minutes) Participants are then introduced to sensate focus, designed to decrease anxiety and enhance awareness of pleasurable physical sensations during physical and sexual intimacy (see Weiner & Avery-Clark, 2014 for a description). This exercise is introduced to help couples begin to overcome avoidance and re-establish physical and, ultimately, sexual connection (Masters & Johnson, 1970). The facilitator normalizes that it can be difficult to resume sexual intimacy after a period of avoidance and/or disappointing or upsetting sexual experiences. Similarly, when resuming sexual activity, it can be difficult to remain in the 21

23 present moment, setting aside worries and negative expectations about the sexual experience or about how the baby is doing. Participants are oriented to the rationale and first stage of sensate focus (full-body touch, excluding breasts and genitals, where the giver touches the receiver according to the giver s own curiosity while receiving feedback from the receiver), and are encouraged to discuss and then practice this stage with their partners at least three times before the next session. The importance of scheduling time for this practice is emphasized, and detailed instructions are provided. Homework and wrap-up (20 minutes) Session 3: Intimacy and Effective Communication The final group session builds on previous material by focusing more specifically on intimacy. This session continues to orient participants to sensate focus, discusses the importance and principles of effective communication for both sexual and non-sexual topics, and discusses ways to maintain desire in long-term relationships. Home Activities Review (15 minutes) 22

24 Sensate Focus Continued (15 minutes) The remaining stages of sensate focus are described, including the rationale and potential benefits of each stage. Possible barriers are also briefly discussed and problem-solved. Participants are encouraged to consider discussing significant barriers to this exercise in their upcoming couple s session. Effective Communication (50 minutes) Maintaining Desire in Long-Term Relationships (20 minutes) Because many couples struggle to openly discuss sexual issues with one another, communication skills including active listening and I statements are introduced, as is the topic of emotional flooding and strategies to reduce such flooding during communication. Examples are provided and participants are given the opportunity to practice with a fellow group member. The facilitator provides information about the inverse relationship between comfort/routines and sexual desire, and the need to balance sexual and non-sexual routines with novelty. In addition, the importance of maintaining an atmosphere of romance in the relationship (e.g., continuing to make time together as a couple and to show affection on a regular basis) and possible aids for enhancing desire (e.g., erotic books) are highlighted. Homework and wrap-up 23

25 (20 minutes) Session 4: Couple s Session The purpose of the couple s session is to provide brief, personalized support to each participating woman and her partner. This support may involve answering questions from partners or questions that women did not feel comfortable asking in the group sessions, helping couples better understand relational issues that may be contributing to and/or resulting from sexual concerns, and/or providing additional recommendations and strategies to those discussed in the group sessions. Couples are encouraged to share their homework experiences from the group sessions, including areas of struggle. The session ends with inquiry regarding what women and partners have learned in the WPSHP, and what they believe they need to continue working on in their sexual relationship. Couples interested in pursuing further relationship and/or sex therapy are provided with a list of suitable resources, including contact information for local therapists. 24

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