1. Powered by Introduction to Psychosexual Medicine: Session 5

2. COURSE OBJECTIVES To be familiar with different approaches to the treatment of sexual dysfunction To understand the use of the ‘doctor-patient relationship’ in psychosexual medicine To have confidence to manage presentations of sexual dysfunction in your normal practice

3. SESSION 5 Revision of session 4 Managing consultations Case discussion

4. SESSION 4: REVISION Basic psychoanalytic principles: 1.Transference and Countertransference 2.Defence mechanisms

5. Session 5: By the end of this session you will be able to: Describe situations in which psychosexual problems may present Understand the difference between open and closed questions Begin to phrase observations rather than questions

6. Presentation of sexual problems Direct requests Sexual difficulties (attributed to physical problems) Fear/avoidance of being examined Anxiety about STI/discharge Infertility/fear of pregnancy Contraceptive problems During history taking ‘when did you last have sex? ’ ‘is there any pain when you have sex?’

7. Taking a Psychosexual History Gives structure to consultation Relieves anxiety Provides information about facts and feelings Opportunity to take notes Makes you ask/justifies difficult questions

8. Sample psychosexual consultation Introductions (space to allow patient to set agenda) Fixed questions Open questions Physical Examination Ending

9. What questions should I ask? 1.Direct questions: at appropriate stage, once sexual problem has been established 2.Open questions: allow patient to take the lead, may open up a discussion of feelings 3.Observations: let the patient feel heard, helps them to express what they are feeling

10. Open Questions Allow exploration Enable feelings to emerge Give control to patient “ Doctor-patient relationship ” can develop

11. Open Questions What do you think is the cause of the problem? What do you think is causing the discharge? How are you feeling about that test result? What was happening when it started? What were you hoping would happen today? What is it like for you to talk about this?

12. Make observations About emotions: It sounds as if this is difficult to talk about You seem a bit embarrassed That must have been difficult for you You seem very relieved about that You sound as if you might be angry about that

13. Make observations 2 Summarise what you think is going on: It seems as if you don’t want to be examined All these tests are negative but you still seem worried Perhaps you are telling me you don’t think there is anything I can do to help you

14. “ No wonder you don’t feel like having sex if: it hurts so much” you are so angry with your partner” you are so afraid of getting pregnant” you think it will tear” you find it difficult to get an erection” you think you have an infection”

15. Observations before/during the examination “What do you think is wrong ?” “What are you expecting/fearing/hoping for.. from this examination?” “Is this how you are when you have sex with your partner?”

16. Ending the Consultation Summarise what has emerged so far Information : “ This problem does not always have a physical cause ” Management: investigations, treatment, referral Follow-up “ to give results, to see how you are, to decide what to do next, to discuss more ”

17. Role Play 1.Claire is attending for more pills. She is 28 and you note she has never had a smear. She is reluctant and starts making excuses. 2.During routine questioning Brenda is asked when she last had sex. She says it is over a year. You notice she is in a long term relationship and wonder why this might be. 3.John attends the GUM clinic for STI testing. He says he is in a long term relationship with a woman. You note he has attended several times this year. All his tests have been negative. He asks for hepatitis immunisation but can’t explain why.

18. Session 5: By the end of this session you will be able to: Describe situations in which psychosexual problems may present Understand the difference between open and closed questions Begin to phrase observations rather than questions