SOUND-BITE SEX:
COLLABORATING TO IMPROVE
SEXUAL HEALTH IN PRIMARY
CARE
Tina Schermer Sellers, PhD, LMFT
Director of Medical Family Therapy and Clinical
Professor, Marriage and Family Therapy
Seattle Pacific University, Seattle, WA
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013 Denver, CO U.S.A.
FACULTY DISCLOSURE
I have no relevant financial relationships
during the past 12 months.
OBJECTIVES
At the conclusion of the presentation, participants
will be able to:
 Identify common sexual dysfunctions that may
present in primary care.
 Examine the advantages of integrated care in
treating sexual problems.
 Consider the benefits of collaborative,
biopsychosocial, and systemic assessments.
 Explore evidence-based treatments through a
brief overview and case example.
LEARNING ASSESSMENT PRE-TEST
How would you define sexual health?
What are the most common male and female sexual
problems?
Name some core competencies of the integrated care
team treating sexual problems.
What are three interventions or treatments
commonly used to improve sexual health?
QUESTIONS…
 How
important is sexual health to the QOL of
your patients? 1-10 (10 most important)
 How comfortable are your patients discussing
their sexual health? 1-10 (10 most comfortable)
 How comfortable are you discussing sexual and
relational health?
 Did you receive comprehensive sex education in
primary education or higher education? Yes or No.
 How often do you take a sexual history with
patients and under what conditions?
DEFINING SEXUAL HEALTH
“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. For
sexual health to be attained and maintained, the
sexual rights of all persons must be respected,
protected, and fulfilled.”
World Health Organization. Gender and human rights. http://www.who.int/reproductivehealth/
topics/gender_rights/sexual_health/en/index.html. Accessed August 15, 2012.
DEFINING SEXUAL HEALTH
“Sexuality is an integral part of human life. It carries
the awesome power to create new life. It can foster
intimacy and bonding as well as shared pleasure in our
relationships. Sexual health is inextricably bound to
both physical and mental health.”
Satcher, D. (2001). The Surgeon General’s Call to Action to Promote Sexual Health and
Responsible Sexual Behavior. http://www.surgeon general.gov/library/calls/sexualhealth/call.pdf.
A BIOPSYCHOSOCIAL PICTURE
BIOLOGICAL
Biologic Sex
Hormones
Puberty & Menopause
Function / Dysfunction
Response Cycle
PSYCHOLOGAL
Subjective Sense of Self
Mental Health
Temperament
Attachment
Fantasy
SOCIAL
Intimate Relationships
Social Supports
Patient-Provider
Religion / Spirituality
Cultural Messages
PREVALENCE OF SEXUAL PROBLEMS
Women
Low Desire
Inhibited Orgasm
Sex Not Pleasurable
Pain with Intercourse
Performance Anxiety
Lubrication Problems
Climax Too Soon
33.4%
24.1%
21.2%
14.4%
11.5%
10.4%
10.3%
National Health and Social Life Survey (1994). N = 1,410, ages 19-59
PREVALENCE OF SEXUAL PROBLEMS
Men
Premature Ejaculation
Performance Anxiety
Low Desire
Erectile Dysfunction
Ejaculatory Inhibition
Sex Not Pleasurable
Pain During Intercourse
28.5%
17.0%
15.8%
10.4%
8.3%
8.3%
3.0%
National Health and Social Life Survey (1994). N = 1,410, ages 19-59
SEXUAL HEALTH IN PRIMARY CARE

Discrepancy between prevalence & disclosure

Patient Barriers
Concern for provider’s comfort
 Personal embarrassment or discomfort


Provider Barriers
Lack of training or skills
 Underestimation of prevalence
 Constraints on time
 Fear of Pandora’s box
 Personal embarrassment or discomfort

Gott, Galena, Hinchliff, & Elford, 2004; Owens & Tepper, 2007; Foley & Wittmann, 2010; Association of
Reproductive Health Professionals. Sexual Health Fundamentals. www.arhp.org/factssheets.
WHY INTEGRATED CARE?
 “Sexual
health services should be incorporated into
primary care and integrated services should be
expanded…including recognition of sexual health
throughout the lifespan.” (p. 1006; JAMA 2010, Vol. 304,
No.9)
 Integrated

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care because:
Multidisciplinary team-based approach
Medical, psychological, and relational expertise
Mutual learning between team members
Assist with time demands of assessment or treatment
PCP preference vs. referral for some
DELIVERY OF INTEGRATED CARE
Considerations…
BH enters BEFORE Medical Provider
 BH enters WITH Medical Provider
 BH enters AFTER Medical Provider

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When to assess sexual health?

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Establishing Treatment, Related to Chief Complaint,
Annual Exam, Reason for Possible Non-adherence,
Education for Co-morbid Condition
Inclusion of Partner or Family Member?
Modeling and Teaching of Well-Child Visits
CORE COMPETENCIES

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Delivery of Patient and Family Centered Care
Comprehensive Sex History Taken Annually
 Connection and pleasure
 Types of sex practices (safe practices), number of
partners, orientation, safety/abuse, STIs, satisfaction,
connection/care, pain (em/phys), concerns, etc.
Awareness of personal biases and implications for possible
counter-transference
Well-child-sound-bite Sex Ed and Appropriate inclusion of
parents in sexual education plans or processes for children
and teenagers
Ability to use basic assessment and treatment strategies,
medical, relational, and cognitive-behavioral
Referral to sex therapist or sexual medicine expert for
complicated cases that exceed scope of practice
KEY CONVERSATIONS WITH YOUTH
1.
2.
3.
4.
The Body (0 - 4)
What is Sex? (4 - 8)
Expect Puberty, Friendship Qualities (8 - 12)
Safety, Responsibility, Pleasure, Connection, and
Choice ( 12 - up)
Yes – 100 / 1 min
No – 1 / 100 min
Richardson, J., & Schuster, M. A. (2003) Everything you never wanted your kids to know about sex (but were afraid they’d ask:
The secrets to surviving your child’s sexual development from birth to the teens. New York: Three Rivers Press.
FOUNDATIONAL KNOWLEDGE: SEXUAL
RESPONSE CYCLE
FOUNDATIONAL KNOWLEDGE: BASSON
MODEL
http://www.arhp.org/publications-and-resources/clinical-fact-sheets/female-sexual-response
STARTING THE CONVERSATION

Start with normalization

“I often ask my patients about…
How their medical conditions are affecting them sexually. What
problems (if any) are you having?”
 If they are having any sexual problems – desire, arousal, orgasm, pain,
pleasure, satisfaction. Are you having any difficulty or concerns?”
 How they are doing in their sexual relationship(s) – connection part
and pleasure part?”


Basics of screening for sexual function:
Are you currently involved in a sexual relationship(s)?
 Are your sexual partners men, women, or both?
 Because sexual health is related to both our sense of
connection and pleasure, do you have any concerns about your
sexual desire, arousal, orgasm, pleasure, satisfaction or sense
of connection to your partner(s).

STARTING THE CONVERSATION
Open ended icebreakers recommended by
ARHP
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Tell me about any sexual concern you would like to
discuss.
How does the problem affect your life and
relationship(s)?
How does the concern present?
Tell me (or us) about your last sexual experience.
How have you tried to manage the problem thus
far?
What are your goals for your sexual [and
relational] health?
Tell me (or us) about the conversation you have
had with your partner so far about this problem.
Association of Reproductive Health Professionals. Sexual Health Fundamentals. www.arhp.org/factssheets.
AREAS OF CURIOSITY
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Desire: Low sexual desire, aversion, too much desire,
discrepancy between partners, change from previous
satisfying relationship
Arousal: Difficulty obtaining erection (porn/ED issue),
difficulty maintaining erection, difficulty with lubrication
Orgasmic: Inability to reach orgasm, premature
ejaculation, delayed ejaculation
Pain: Vaginismus, dyspareunia, male pain problems
Relationship: Level of satisfaction, communication
problems (criticism, defensiveness, stonewalling, contempt),
match between partner’s sexual preferences or skill set,
intimate partner violence, alternative lifestyles
THE OLD/NEW KID ON THE BLOCK …
HIGH-SPEED INTERNET PORN

With men, I ask if they are aware of the
correlation between heavy high-speed internet
porn use and ED?
If ever a problem for you – here are 2 resources:
 Website – Your Brain On Porn
 http://yourbrainonporn.com/about-site-us-users
 British documentary Explaining the
Neurobiological Research – Porn on the Brain
 http://www.youtube.com/watch?v=VOMtXa3vScY

SCREENING INSTRUMENTS
 Decreased
Sexual Desire Screener (DSDS)
 Female Sexual Function Index (FSFI)
 Sexual Interest and Desire Inventory (SIDI)
 Brief Hypoactive Sexual Desire Disorder
Screener
 Male Sexual Health Questionnaire (MSHQ)
 Brief Profile of Female Sexual Function (BPFSF)
 Index of Sexual Satisfaction (ISS)
 Among Others
COLLABORATIVE / SYSTEMIC SCREENING

Scaling questions
Faciliates collaboration between patient, partner or
family, and providers
 Scale motivation, concern, worry over problem, or the
difficulty (hardness of erection, degree of pain,
amount of lubrication, sense of connection, etc.)


Search for BIO PSYCHO and SOCIAL
elements

BH ask about psychosocial components and medical
provider ask about biological, physical components of
problem
FOUNDATIONAL COUNSELING: PLISSIT
dramymarshsexologist.com
SAMPLING OF TREATMENTS
FOR MALE SEXUAL PROBLEMS
Psychoeducation
 Stop-Start Method
 Mindfulness and Relaxation Techniques
 Sensate Focus with Partner
 CBT for Cognitive Restructuring
 Decrease Spectatoring
 Use of Erotic Material
 Vacuum Pump
 Phosphodiesterase Type 5 Inhibitors
 Relational or Sex Therapy
 Identification and Communication of Preferences

SAMPLING OF TREATMENTS
FOR FEMALE SEXUAL PROBLEMS
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Psychoeducation
Information on Lubricants
Mirror for Self-Exploration
Vaginal Hygiene Recommendations
Appropriate use of Kegel Exercises
Mindfulness and Relaxation Techniques
Use of Erotic Material
Sensate Focus with Partner
CBT for Cognitive Restructuring
Pelvic Floor Physical Therapy
Relational or Sex Therapy
Identification and Communication of Preferences
CLINICAL CASE

50 y/o AA male presents with complaint of erectile
dysfunction to his Integrated Care Team.
 Can obtain an erection at hardness of 4, but loses
within a few minutes
 Started on SSRI Zoloft for depression/anxiety
approximately 2 months ago
 Comorbid type 2 diabetes - last HbA1c of 12.4
 Some relational conflict with wife and work stress
 Drinks 2-3 beers per evening
 Able to obtain erection at hardness of 6-7 when
masturbating and can ejaculate
CLINICAL CASE

26 y/o Caucasian female presents with complaint of pain
with intercourse.
 No comorbid medical conditions
 Takes Yaz birth control
 Currently has one partner – sexually active for 2
months, describes relationship as healthy
 Some difficulty with lubrication, but has not tried any
products, thinking of using Vaseline
 Describes many negative messages about sex from
family of origin (e.g. “dirty” “don’t talk about”)
RESOURCES
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American Association of Sexuality Educators, Counselors, and
Therapists (AASECT), www.aasect.org,Search for certified sex
educators or therapists
Society for the Scientific Study of Sexuality (SSSS),
http://www.sexscience.org, Research on sexual education and health
Association for Reproductive Health Professionals,
http://www.arhp.org/ publications-and-resources/clinical-fact-sheets,
Clinical fact sheets
Sex Smart Films, http://www.sexsmartfilms.com, Sex education and
health videos
A Woman’s Touch, http://a-womans-touch.com, Education, resources,
and info about co-morbid medical illness
Joy of Making Love, http://www.joyofmakinglove.com/index.html,
Book recommendations
FURTHER QUESTIONS…
SESSION EVALUATION
Please complete and return the
evaluation form to the classroom monitor before
leaving this session.
Thank you!