1. Powered by Introduction to Psychosexual Medicine: Session 3

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 3 Revision of session 2 CBT approaches Physical treatments

4. SESSION 2: REVISION List the causes of superficial and deep dyspareunia Appropriately manage a presentation of dyspareunia including an explanation of vaginismus

5. By the end of this session you will be able to: List the approaches to psychosexual problems used in CBT Describe and explain “Sensate Focus” Describe treatments for male sexual dysfunction

6. COGNITIVE BEHAVIOUR THERAPY Problem-orientated Doctor takes “expert role” Specific aims established “Homework” set Both partners attend therapy

7. Cognitive behaviour therapy for psychosexual dysfunction 1.Sensate focus 2.Desensitisation 3.Fantasy training/erotic exposure/communication training/cognitive restructuring

8. Sensate Focussing Patient develops heightened awareness of sensations rather than focussing on performance Immediately achievable goals set – to “enjoy touching” rather than to “achieve penetration” Explicit instructions given “non-genital pleasuring” “genital pleasuring” “containment without thrusting”

9. “Ground rules” Choose a time and place acceptable for both of you, where you won’t be disturbed.  Make the surroundings as pleasant as possible, choosing music, lighting and aromas to suit you.  Turn off the phone and, if necessary, lock the door.

10. Take turns giving and receiving touch, allowing equal time for each of you.  The goal is enjoyment and pleasure. Enjoy the journey rather aiming towards any specific destination.  Take as long as you want over each phase. Often, the slower you take it, the more you will get out of it.  Only move from one stage to the next when both partners agree

11. Instructions When it is your turn to touch, take plenty of time to explore the other person’s body. Experiment with different sensations and types of touch. Take pleasure in experiencing the texture, form and temperature of the other person’s body. When it is your turn to be touched, make sure you let the other person know what you like and what you don’t

12. Desensitisation 1.Vaginal dilators and/or digital self examination 2.Squeeze technique

13. Vaginal dilators

14. PDE5 Inhibitors Inhibit the degradation of cyclic GMP so enhance smooth muscle relaxation allowing increased blood flow in to penis

15. PDE5 inhibitors Sildenafil ‘Viagra’ now off license 100, 50 and 25mg Vardenafil ‘Levitra’, quicker mode of action Tadalafil ‘Cialis’ longer half life “le weekend”, also 5mg daily dose Avanafil ‘Stendra’ Newest Side effects: facial flushing, headache, disturbance of colour vision Contraindication: Nitrates

16. Intra cavernosal injections: Alprostadil, P&P

17. Premature Ejaculation SSRIs - dapoxetine Local anaesthetics - performa condoms, emla Squeeze technique

18. By the end of this session you will be able to: List the approaches to psychosexual problems used in CBT Describe and explain “Sensate Focus” Describe treatments for male sexual dysfucntion

19. HOMEWORK: DEVELOPING FREE-FLOATING ATTENTION 1.During a consultation When you are with the patient notice: What is she (he) like? How is she sitting? What are her opening words? How are you feeling? Do you find yourself behaving differently from normal? Try and notice exactly what is said, what is her particular choice of words How does the consultation end? How do you feel afterwards?

20. HOMEWORK: DEVELOPING FREE-FLOATING ATTENTION 2.During an examination When you examine a patient notice: How she behaves before you examine her, what she says, can you detect any emotions How does she hold herself on the couch? What does she say? What do you say? How do you feel when you examine her? Is it different from usual? What happens afterwards? Her words, her manner. Has the atmosphere in the room changed? If so, how?

21. PRESENTING A CONSULTATION Describe what happened in detail, setting, referral, opening words, appearance of patient, what you were thinking/feeling Try and report what was said by you and your patient rather than a traditional ‘medical history

22. GROUP DISCUSSION Listen carefully to the presentation, noticing what you are feeling about the patient Try not to bombard the presenting doctor with questions (some questions are fine) but rather try and express your thoughts and feelings abut the case, the patient, and the interaction Think about how the consultation (doctor patient relationship) and the patient’s story might relate to their sexual problem