1. Psychosexual Issues in General Practice Sheila Long Associate Specialist in GUM 16/11/11

2. My Background GP Principal for 13 years in Luton Changed to GUM full-time in 1995 Gained Diploma of Institute of Psychosexual Medicine in 2007 I see patients on an ad hoc basis in GUM but do not have a specialist psychosexual session I attend IPM Further Training Seminars (4 x 3 hourly group meeting per term)

3. Case History Case History 24 year old Pakistani man c/o PE

4. Groups : Discuss any psychosexual consultations you have had 10-15 minutes

5. What makes these consultations difficult? Dr’s issues Patient’s issues

7. Basic Balint Principals A fundamental belief in the primary and healing potential of relationship, including doctor/patient Valuing the potential of groups within which to explore feelings and the power of many minds they when set to work on an impossible problem The importance of moral courage and the ability to risk anxiety as one seizes the moment including the therapeutic moment Trusting the ‘butterfly effect’, the small change that makes a big difference, whether this be in brief therapy or the small but significant change in personality that a Balint group can induce in its members BMJ 2008; 337:a1549 Personal View J Holmes

8. Neighbour : The Inner Consultation Having two heads in the consulting room Connecting, summarising, clinical process/hypothesis testing, handover, safety- netting and housekeeping in psychosexual consultations

9. Presentations - women Contraception consultation Infertility / failure to consummate Loss of libido Problems with smears Pelvic pain/dyspareunia Menopause symptoms Relationship problems ‘Hand on the door’ Mental health issues

10. Presentations - men Dis-satisfaction with sexual performance ‘Something wrong down below’ General health worries – ‘feeling weak’ Relationship problems ‘Hand on the door’ Mental health issues Diabetics Hypertension consultations

11. Principles of Psychosexual Medicine Psychosexual Medicine is a type of brief therapy, based on psychoanalytical principles, but drawing on medical knowledge and skills, where appropriate. Michael Balint, a Doctor and Psychoanalyst, proposed the basic psychoanalytical principles of this type of therapy. The IPM guided by a contemporary of Balint – Tom Main -have modified and expanded these principles.

12. The first principle of psychosexual medicine : active listening to the narrative of the patient Not only listening to the words, but also noting how they are said, the patient’s non-verbal communications, and what is not said. The listener formulates interpretations, which can be offered or reflected back to the patient based on what has been heard, experienced and observed. The interpretations can be tested by noting the patient’s response and reflecting on this again with the patient. Unlike wide-ranging traditional psychoanalytical therapy, the narrative, interpretation and reflection are focussed onto the sexual difficulty.

13. The second principle : the use of a genital examination, or the possibility of it. Patients bring their whole bodies to doctors, and expect the physical, social, emotional and mental aspects to be examined. During the genital examination, the psychosexual doctor notices what happens, and the emotional responses of both the patient and the doctor. The genital examination is reflected on and interpreted in the same way as the narrative part of the consultation

14. The Third Principle : formulating a hypothesis As the consultation progresses, the practitioner orders the gathered facts into a general rationale that makes sense of them. These hypotheses are constantly tested with the patient, and may be confirmed or discarded as new facts are discovered

15. The Fourth Principle Use of the shared understanding of the facts and feelings to help discover the truth. The collaboration between the patient and the doctor uncovers defences and unconscious factors. Everyone develops defences and unconscious behaviours to protect himself or herself from hurt, and the psychosexual doctor needs to act compassionately in this sometimes painful journey in the unravelling of the patient’s problem. The investigation during the consultation is concerned not only with the narrative and physical examination, but also with feelings produced in the doctor and the patient. The feelings in the doctor are a valuable source of information about what feelings the patient might arouse in other people and how these might be produced. The doctor has to be aware of which feelings, arising within him or herself, are produced by the patient and which feelings are his or her

16. For which type of problem will IPM training help? Vaginismus, loss of libido, difficulties with orgasm Non-consummation and dyspareunia Erectile dysfunction, ejaculatory problems and other penile problems Chronic pelvic pain or genital pain, recurrent discharge with or without a physical cause Emotional and psychosexual sequelae of sexually transmitted infections Contraceptive related problems (including the inability to use any method); repeated requests for abortions; emotional effects on sex life of miscarriage Vasectomy and sterilisation requests with a hidden agenda of sexual problems Emotional and psychosexual effects of surgical interventions, including TOP Psychosexual sequelae of sexual abuse Sexuality and terminal care Effects of ageing disability or illness on sexuality Psychosexual problems related to infertility and ending of fertility

18. Premature Ejaculation The Dr often feels as inadequate as the patient - ?transference How quick is too quick? Lifelong or secondary? Does occur in all settings? Eg with masturbation as well as intercourse Is erectile dysfunction also a problem? What is the partner’s response?

19. PE : possible strategies What are the patients expectations? Exploring the feelings Examination – may need reassurance he is ‘normal’ Stop-start and/or squeeze technique Delay spray or Delay/Performa condoms Anti-depressants (evidence for SSRIs and tricyclics) PDE5 inhibitors Give written info

20. Dhat Syndrome Culture bound syndrome from the Indian sub- continent Dhat comes from the Sanskrit word ‘dhatus’ meaning elixir that constitutes the body In Ayurvedic Medicine, 40 drops of blood give rise to one drop of bone marrow and 40 drops of bone marrow give rise to one drop of semen => semen loss is harmful Patient presents with weakness, palpitations, insomnia, sexual dysfunction, depression and anxiety He may feel the problem is due to nocturnal emissions, excessive masturbation or semen loss in the urine

21. Erectile Dysfunction Guidelines Is there a psychosexual aspect?  Age  Sudden onset rather than gradual  Situational  Any relationship problems You may have to prescribe before you can get at the emotional issues

22. Case History

23. Groups: Discuss Psychosexual Presentations which most disable or frighten you 10 minutes

24. Issues to have in mind Patients appearance and body language Why now? Doctor-patient interaction Emotions in the here and now Psychosomatic examination Every patient’s story is unique – assume nothing Any history of abuse Use of pornography

25. Is there a Psychosexual Issue in the Consulting Room? Increasingly male GPs are opting out of smears, gynae examinations etc. Is this desirable - creeping segregation? What are the implications for training? Why is the reverse not happening for female GPs? Or is it?

26. Positive Transference I moved your thoughts From brain to mouth I moved your feelings From spleen to heart I moved your focus From fear to hope I’ve changed you Now it is your move Hugh Mann, Physician USA