Sex Therapy and Counselling

The likelihood that a person will approach a health professional with a sexual problem has increased over the last few years, due to the greater level of openness in society with regard to sexual issues.

• However many patients still find difficulty with discussing sexual problems. If the patient senses any discomfort on the part of the health care professional they may not be as willing to discuss such a sensitive issue.
• Health care professionals may also be reluctant to pursue sexual issues because they are uncomfortable with the topic, or because they do not feel sufficiently knowledgeable or skilled to address issues that may be raised by the patient.

Effective help therefore depends on providing a comfortable, open and confident environment for the patient to discuss their difficulties and the most course of management.

• About 40-45% of adult women and 20-30% of adult men have at least one manifest sexual dysfunction.¹
• The prevalence of sexual dysfunction increases with age.¹
• Increasing physical activity lowers the incidence of erectile dysfunction.¹

• Psychological problems, e.g. depression, anxiety, substance abuse
• Physical ill-health in either partner
• Job or financial stress
• Relationship or family problems
• Sexual stress and anxiety
• Common physical causes of sexual desire issues include:
  • Endocrine, e.g. hypo-oestrogenism, hypoandrogenism, hyperprolactinaemia, hypothyroidism
  • Drugs, e.g. antidepressants, antiandrogens
• Common psychosocial issues include:
  • Religious and family messages
  • Unwanted sexual experiences
  • Prior dysfunctional relationships
  • Current relationship issues, e.g. fear of commitment or separation, career, having children, role equity, drifting apart, adaptation to life events, affairs

• Sexual Desire Disorders - hypoactive sexual desire disorder, sexual aversion disorder
• Sexual Arousal Disorders - female sexual arousal disorder, male erectile disorder
• Orgasmic disorders - female/male orgasmic disorder, premature ejaculation
• Pain disorders - dyspareunia, vaginismus

• Define the problem - nature, recent or longstanding, how it relates to the individual and the couple in terms of cause and effect.
• Assess sexual drives of both partners.
• Relationship of couple and social relationships in general.
• Sexual development, including traumatic experiences.
• Psychiatric and medical history, including pregnancies, childbirth abortions, drugs and alcohol.
• Assess mental state, especially depression.
• Assess trigger for attendance to seek help and motivation for treatment.
• Relevant physical examination and investigations, depending on context and likely cause(s) of problem.

• Try to develop an honest self-awareness of your own areas of comfort and discomfort with sexual issues.
• It is easy to avoid asking important questions in an area in which we may be uncomfortable. Make a point of addressing such issues in a way that is comfortable for both you and the patient and effective in securing the necessary information.
• Try to refrain from projecting your own values and attitudes onto those of the patient, either verbally or non-verbally. Doing so may reduce the patient's comfort and feeling of acceptance, or introduce inappropriate assumptions into the history.

• Whenever possible, involve both partners in evaluation and treatment.
• All people may have sexual interests or concerns, including the elderly, the disabled, and those with chronic illness.
• Patients may reflect a wide diversity of experiences, values, and preferences. Be sensitive to gender and cultural differences, but do not assume that any one patient necessarily fits a gender or cultural stereotype.
• It takes courage to disclose a sexual dysfunction or a sexual trauma. Such disclosures must be taken seriously and addressed in a sensitive manner.
• Ensure environment of confidence and trust. An empathic approach will convey an attitude of availability and acceptance.
• Ensure clarification that will result in sufficiently specific information and avoid confusion and misunderstanding.
• Be sensitive to the optimal time to ask the most emotionally charged questions.
• Look for and respond to non-verbal cues that may signal discomfort or concern.
• Be sensitive to the impact of emotionally charged words, e.g., rape, abortion.
• If you are not sure of the patient's sexual orientation, use gender neutral language in referring to his or her partner.
• Explain and justify questions and procedures.
• Teach and reassure as you examine.
• Intervene to a level that you are qualified and feel comfortable.
• Refer to qualified medical or mental health specialists as necessary.

• Sex therapist - psychosexual problems, relationship and other psychological issues.
• Couples therapist - when relationship issues are a primary contributor to a sexual dysfunction.
• Individual psychotherapist - when depression, generalised anxiety, or substance use are major issues affecting the patient.
• Physiotherapist - when co-morbidity related to pelvic floor tone is diagnosed.
• Gynaecologist - if female sexual dysfunction requires specialised evaluation or treatment.
• Urologist - if erectile dysfunction requires specialised evaluation and treatment.