Disclosures Learning Objectives Top Three “Hand on the Doorknob

5/27/2014
Advanced Female Sexual Anatomy:
Tips and Skills to Support Your
Patient’s Sexual Health
Disclosures
• Advisory Board
– Teva; ParaGard, LeCette
– Actavis; Levosert IUD in
development
• Trainer/speakers’ Bureau
Patty Cason MS, FNP-BC
Assistant Clinical Professor
UCLA School of Nursing
Learning Objectives
• Explain the health benefits of
addressing sexual function
• List 4 cornerstones to sexual health
• Discuss
Di
2 methods
th d for
f strengthening
t
th i
the pelvic muscle
Sexual Preference Neutral
This presentation is meant to apply to
any variation of partnership and pairing
– Teva;ParaGard
– Merck; Nexplanon, Gardasil,
NuvaRing, Contraception
– Bayer; Mirena, Skyla
Top Three
“Hand on the Doorknob”
Questions
• “I don't know if I've ever had an
orgasm
orgasm”
• “Will I become dependent on my
vibrator?”
• “I have no sex drive. Is there a pill
that will help?”
Best Site
http://www.the-clitoris.com
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Size
Uterus
Urethral
Sponge
Shaft of
Clitoris
(G-Spot)
(Body or Corpus)
Bladder
Head of
Clitoris
Vaginal
Canal
Anal Canal
Legs of
Clitoris
(Crus/Crura)
Vestibular
Bulbs
Perineal
Sponge
Erect Penis
Erect Clitoris
• Range: 4 to 26 cm •
(1.5 to 10.2 inches)
• Mean length:
– 14.15
14 15 cm (5.57
(5 57
inches)
• Mean
circumference:
– 12.23 cm (4.81
•
inches)
Herbenick D. J Sex Med 2014.
Pudendal Nerve
External Genitalia
Clitoris
Vestibular Bulbs
Outer Aspect Urethral Sponge
Top Layers of Muscle
Deeper Muscles
Vagina
Anus
Deeper Aspect of
Urethral Sponge
Perineal Sponge
Bladder
Range of total: 10-20
cm (4 to 7.9 inches)
– Length of body: 2 to 4
cm (0.8 to 1.6 inches)
– Length of crura: 5 to 9
cm (2 to 3.5 inches)
– Length: Bulbs: 3 to 7
cm (1.2 to 2.8 inches)
Width:1 to 2 cm (0.39 to
0.79 inches)
Pelvic Nerve
© Center for the Intimate Arts
2010
© Center for the Intimate Arts
2010
We Believe Passionately in:
We Believe Passionately in:
• Safer Sex
• Protecting our patients from:
– Sexually transmitted infections
– Unplanned
U l
d pregnancy
– Intimate partner violence
– Cervical cancer
• Condoms
• Condoms
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A Gentle Shift in Paradigm
• Every day, we see all the bad effects from
having sex
• It iis natural
t l tto start
t t tto thi
think…
k
…Sex is
reallyy bad!
“It’s better
just to avoid
having sex”
Condoms Are Great But So Is
Semen
• Females having sex without condoms were
less depressed
• Depression scores ↑ as the amount of time
since their last sexual encounter ↑.
↑
• Semen may antagonize depression
symptoms.
• Exposure to sperm may offer protection
against development of preeclampsia.
Oxytocin
• Released during physical intimacy -from warm touch to sexual arousal
and orgasm
• Related to lower stress reactivity
• Lower pain sensitivity
• Faster wound healing
• Relaxation
Einarsson JI. Am J Ostet Gynecol. 2003.
S.A. Robertson et al. Journal of Reproductive Immunology. 2003.
Gallup GG. Arch Sex Behav. 2002.
Having Satisfying Sex:
•
•
•
•
•
•
•
Keeps vaginas plush
Is good for relationships
Makes people happier
Supports immune function
Alleviates menstrual cramps
Decreases stress and insomnia
Improves headaches
Davison SL. J Sex Med 2009. Peleg-Sagy. J Sex Med 2013. NAMS.
Menopause. 2013. Atlantis E. J Sex Med 2012. Sprecher S, et al. The
Handbook of Sexuality in Close Relationships.2004. Leiblum S. JAMA. 1983.
Orgasmic Sex:
• Extends lifespan
• Is excellent for cardiovascular health
– no increase in risk of strokes
– protection from fatal coronary events
• Frequent orgasm is protective against
mortality for females
Ebrahim S et al. J Epidemiol Community Health 2002.Seldin DR. Pers Ind
Dif. 2002. Davey Smith G. BMJ. 1997. Palmore EB. Gerontologist. 1982.
Davey Smith G. Int J Epidemiol. 2010. Bassett R. Can J Aging. 2007.
Gavrilova N. BMJ 2010. Drory Y. Eur Heart J Supp 2002. Buettner D. The
Blue Zones:National Geographic Society, 2008
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Cornerstones to Sexual Health
Sex
Promotes
world
peace
Tantric Wisdom
Cornerstones to Sexual Health
Prioritization
Prioritization
Pelvic
muscles
Sexual
Health
Sexual
agency
Self
knowledge
“Sex Positive” Attitude
• Appreciation that sex is a healthy activity
• Good sex increases libido
• Prioritization of consistent sexual practice
Sexual
Health
Cornerstone to Sexual Health
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How often?
How often should you eat, sleep or exercise?
Whatever your baseline,
increasing to more
frequent
q
orgasmic
g
sex is
beneficial
Having more sex
increases libido
An orgasm
a day
keeps
p the
doctor
away
Cornerstones to Sexual Health
Sexual
Health
Self
knowledge
Self Knowledge
• Awareness of subjective erotic and sexual
sensations.
• Fluency in the language of one’s own
arousal.
Cornerstone to Sexual Health
Shaft of
Clitoris
(Body or Corpus)
Head of
Clitoris
(Glans)
Urethral
Sponge
(G-Spot)
Legs of
Clitoris
Vestibular
Bulbs
(Crus/Crura)
(Clitoral Bulbs)
Vaginal
Opening
Perineal
Sponge
© Center for the Intimate Arts
5
5/27/2014
Coherence
• Concordance between perception of
genital response and actual genital
sexual arousal
• The ability to accurately perceive
physiological changes
Chivers ML. Arch Sex Behav 2010
• Intentionally redirect attention to physical
sexual cues and genital sensations
• Audiovisual sexual stimuli engages a
greater number of sensory channels,
recruiting greater attention to different
sexual responses and cues
Prause N. J Sex Med 2013.
Cornerstones to Sexual Health
Sexual
Health
Coherence: To
Increase Sexual Response
Sexual
agency
“Sexual Agency”
The ability to say:
– “yes”
– “no”
The
e ab
ability
ty to
to:
– Initiate sexual interaction
– Explain (or show) what one likes
– and ask for it effectively (positive
positive
feedback
feedback)
Cornerstone to Sexual Health
Communicate Lubricate
“Any sexual problem
on earth can be
resolved with some
combination of
communication and
lubrication”
Herbenick D, et al. J Sex Med 2011.
Jozkowski KN, et al. J Sex Med 2013.
Kelly MP, et al. J Sex Marital Ther 2006.
Consider a Contract
“If you can get me aroused, I’m all for it!!”
• Both partners agree that if one of them
has the motivation and bravery to initiate
a sexual encounter, the other one will (at
least) give it a try
try.
• It doesn’t mean that they will always have
sex, or the kind of sex the initiator
intended
• But the initiator can expect their partner
will be open to the idea
• Fear of rejection is a huge turn-off
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Cornerstones to Sexual Health
Pelvic
muscles
Pelvic Muscles
Sexual
Health
Daily Exercise or Physical Activity
Cornerstone to Sexual Health
• Awareness of, control over, and strength in
pelvic muscles
– Pubococcygeal muscles
– Pelvic floor
Aschkenazi SO. Expert Rev Obstet Gynecol. 2009. Bortz WM. West J Med.
1999. Kim HN, et al. J Sex Med 2013.
Cornerstone to Sexual Health
• Aerobic
• Yoga
• Dance
Aschkenazi SO. Expert Rev Obstet Gynecol. 2009. Bortz WM. West J Med.
1999. Kim HN, et al. J Sex Med 2013.
Control Of Pelvic Muscles:
• Relax to facilitate initial penetration
• Contract around her erectile tissue to
increase stimulation
• Tighten
Ti ht
t control
to
t l the
th ““pounding”
di ”
sensation from deep thrusting (i.e.
deep dyspareunia with retroflexed
uterus)
– ICD 9: 625.0
© Center for the Intimate Arts
2010
ICD 10: F52.6
Franklin E. Pelvic Power: 2002. Herderschee, et al. Cochrane database of
systematic reviews. 2011.
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Train Voluntary Pelvic Muscle
Control
Biofeedback
• Trains voluntary pelvic muscle
control
• Uses external adhesive electrodes :
• Biofeedback
• Digital feedback from clinician
• Physical therapy
– On the vulvar/perineal
/p
skin
– On the abdomen, thighs, buttocks
– +/- a vaginal probe
• As a patient contracts the correct
muscles, it is displayed on a monitor.
Herderschee, et al. Cochrane database of systematic reviews. 2011.
Herderschee, et al. Cochrane database of systematic reviews. 2011.
In the Office “Feedback”
Clinician Exam
Kegals
• At first, the patient may only be able
to hold the contraction for 1-2 sec
• The muscles are slowly tightened,
and held for 5-10
5 10 sec
• Progress slowly over a period of
weeks to a goal of 10 second holds,
10-20 second rests between holds
• Can she contract?
• How strong is the contraction?
• How long can she hold it?
– This
Thi ttells
ll you where
h
tto advise
d i h
her tto
start in her home exercises
• Is she also tensing her thighs, buttocks
or abdominal muscles?
• Return prn or in 5-6 weeks to re-check
Times When Sexuality Needs Extra Support
Kaschak E, Tiefer L.
Binghampton, NY:
The Haworth Press,
Inc., 2001.
ASK--Offer Help
Adolescence
Postpartum
Post op; particularly breast or gyn surgery
Patients with medical issues; on medication,
cancer
• Infertility
• Major life events; financial, death, relationship
• Perimenopause/Menopause
•
•
•
•
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Standard Operating
Procedures
Have Referrals Available For:
•
•
•
•
•
•
•
Individual therapy
Couples therapy
Sex therapy
Nearby sex store
Books, instructional videos
On-line resources
Intimate partner violence
Evidence-based guidelines for
management of sexual issues.
•
•
•
•
Taking
T
ki
a sexuall hi
history
t
Desire
Arousal
Orgasm
January 2013
International Society for Sexual Medicine (ISSM) Journal of Sexual Medicine
Sexual Debut
• Ask directly if she has had an orgasm yet
• Open ended questions about sexual behaviors
• Let her know that most women learn how to
h
have
an orgasm by
b masturbating
t b ti or with
ith a
partner’s hand, mouth or both
Intimate Partner Violence
(IPV)
Reproductive Health Safety cards can
be ordered from:
www.futureswithoutviolence.org/onlinestore
URL link to short PSA video on You Tube:
http://www.youtube.com/watch?v=W6wqUuN8J0k&feature=player_embedded
©2011 Futures Without Violence
Formerly Family Violence Prevention Fund
Guttmacher Institute January 2010. Reyna VF. Scientific American Mind. 2007. Powell K.
Nature. 2006. Jannini EA et al. J Sex Med 2012.
©2011 Futures Without Violence
ICD 9: V61.11
ICD 10: Z69.11
52
“I don't know if I've ever had an orgasm”
ICD 9: 302.73 ICD 10: F52.31
• Outline a plan
• If she has a partner, help her or
th
them
determine
d t
i
a strategy
t t
ffor
intimacy during her “program”
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Tips
•
•
•
•
Contract her pelvic muscles
Move her pelvis
Bear down
Move her head or feet
Pre-orgasmic→Orgasmic
• Let her know that the “self critic” is
hovering around
• Distraction is worse with a partner
• But even when a woman is all alone
her distraction can prevent orgasm
M Cuntim, et al. Sexologies 2011.
Pre-orgasmic→Orgasmic
• Let her know that the “self critic” is
hovering around
• Distraction is worse with a partner
• But even when a woman is all alone
her distraction can prevent orgasm
M Cuntim, et al. Sexologies 2011.
© Center for the Intimate Arts
2010
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Will I Become Dependent on My
Vibrator?
Your “nerve
pathways”
will learn
how to go
from A-Z.
You can
use a
vibrator
with a
partner.
Orgasmic
• Once she can have an orgasm by
herself → “Show and tell” her partner
• If she
h elects
l t penetration→
t ti
add
dd
external stimulation as needed
Toxic toys
• The smell test; chemical or plastic
smell
• Non-porous
– 100% silicone
ili
– glass
– surgical steel
– sealed ceramics
– medical-grade plastics
Coital Alignment
Physiologic alignment to:
• Provide consistent and effective
stimulation for female coital orgasm
• Make
M k clitoral
lit
l contact
t t possible
ibl during
d i
coitus
• Coital alignment
Aaron PP. Sex & Marital Therapy, 2000.
Eichel EW. Journal of Sex & Marital Therapy 1988
The Position
“Riding high” variation of the missionary posture
Pressure-Counterpressure
The critical factor for female coital
orgasm is a woman’s pelvic mobility
• Stimulus applied in coordination
• Male
M l pubic
bi b
bone and
db
base off penis
i
rubs against the clitoral complex
• Female moves pelvis to control the
“upstroke”
• Male applies pressure on the
“downstroke”
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© Center for the Intimate Arts
2010
Care of the vulva/perineum
© Center for the Intimate Arts
2010
No Products
• Wash with water after urinating or
defecating
• Hand held shower sprayer
• Non-alcohol
N
l h lh
hypo-allergenic
ll
i b
baby
b
wipe if no access to water
• No soap, body wash, body creams
• No residue of detergent or fabric
softener on underwear
Natural Beauty Cleansing Bar
“I have no sex drive.
Is there a pill that will help?”
ICD 9: 302.71
•pH of 4.5
•No soap or detergent
•Made by Nature’s Plus
ICD 10: R68.82
Ask for more information:
• Any pain?
• Relationship issues?
• Life stressors?
• Does she get aroused when she has
sex?
• Does she have an orgasm?
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Good Sex Increases Libido
• No medication approved by FDA
• Bibliotherapy
LB Mintz AM, et al. J Couns Psychol 2012.
Placebo is Best
40% or more of women improved
significantly after a placebo
intervention
Bibliotherapy
• The intervention group read a self-help
book “A Tired Woman's Guide to
Passionate Sex” utilizing a cognitive
behavioral treatment program
• Significant increase in sexual desire
arousal domain and total scores of the
FSFI
LB Mintz AM, et al. J Couns Psychol 2012.
Flibanserin
• Hypothysis:
– Dopamine and norepinephrine are excitatory
factors
– Serotonin has inhibitory effects
• Flibanserin works on 5-HT receptors to
– regulate levels of dopamine and
norepinephrine
– induce transient decreases in serotonin
• Significant improvement in the number of
SSE and sexual desire vs. placebo
• FDA denied approval
Bradford A. Listening to placebo in clinical trials for female sexual
dysfunction. J Sex Med; 2013:10;451-459
INTIMATE Trials Testosterone Patch
Katz M, et al. J Sex Med 2013.
PDE-5 Inhibitors
For Women?
• PDE-5 inhibitors do increase genital
blood flow
• Did not increase desire or arousal
>placebo
• PDE-5 inhibitors may help sexual issues
with onset after starting an SSRI
Simon JA. Clin Endocrinol Metab 2005.
Buster JE. Obstet Gynecol 2005.
Davis SR. J Sex Med 2012.
Nurnberg HG. JAMA 2008.
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Bupropion
• Nondepressed pts: improved arousal* and
desire bupropion > placebo
• SSRI antidepressants can ↓ desire/orgasm
• Bupropion works differently than SSRIs
• May be a good option for women with
depression who are concerned about or
have sexual side effects on SSRIs
• More study needed
*ICD 9: 302.71
…Advanced Questions
• “What is the G spot?”
• “Is female ejaculation real?”
• “Does (male) circumcision decrease
sensation?”
ti ?”
• “Is there a difference between a
clitoral and a vaginal orgasm?”
ICD 10: F22.22
Safarinejad MR. BJU Int 2010. The Medical Letter. 2010. Clayton AH. J Clin
Psychiatry 2004. Moll JL. J Sex Med 2011. Basson R. N Engl J Med 2006.
Female Ejaculation
• Fluid expulsions are not typically a
part of female orgasm.
• The prevalence of FE is 10–54%.
• The
Th fluid
fl id may originate
i i t from
f
the
th
vagina, urinary bladder, female
prostate, or from a combination of
these sources.
“With permission, from A New View of A Woman’s Body by the Federation of Feminist Women’s Health Centers.”
Illustrations by Suzann Gage.
Fluid Expulsions
Pastor Z. Female ejaculation orgasm vs. coital incontinence: A
systematic review. J Sex Med 2013;10:1682–1691
Female Ejaculation Orgasm vs. Coital Incontinence: A Systematic Review
1 mL to 900 mL
Female Ejaculation
A smaller quantity of
whitish secretions from
the female prostate
Squirting
A larger amount of
diluted and changed
urine
Both phenomena may occur
simultaneously.
The Journal of Sexual Medicine
Volume 10, Issue 7, pages 1682-1691, 1 MAY 2013 DOI: 10.1111/jsm.12166
http://onlinelibrary.wiley.com/doi/10.1111/jsm.12166/full#jsm12166-fig-0001
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Coital Incontinence
Circumcision
• The prevalence of CI is 0.2–66%.
• Penetration incontinence occurs more
frequently and is usually caused by
stress urinary incontinence (SUI)
(SUI).
• Urodynamic diagnoses of detrusor
overactivity (DOA) and SUI are
observed in orgasmic incontinence.
The highest-quality studies suggest
that medical male circumcision has no
adverse effect on sexual function,
sensitivity sexual sensation,
sensitivity,
sensation or
satisfaction.
Pastor Z. Female ejaculation orgasm vs. coital incontinence: A
systematic review. J Sex Med 2013;10:1682–1691
Future?
Testosterone plus:
• PDE-5 inhibitors
• Medications affecting: dopamine,
norepinephrine
i
h i
&/
&/or serotonin
t i
Morris BJ. J Sex Med 2013
Fun Video
http://www.ted.com/talks/mary_roach
_10_things_you_didn_t_know_about_
orgasm.html
Poels S, et al. J Sex Med 2013.
van Rooij K, et al. J Sex Med 2013.
Bloemers J et al. J Sex Med 2013.
QUESTIONS
Expanded Content
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Dyspareunia: Whom to Ask
Any woman who is:
• Perimenopausal
• Postpartum
• On DMPA
• Post op for gyn surgery or breast CA
surgery
• Complaining of pelvic pain
• Postmenopausal
Dyspareunia: What to Ask
Arousal?
Orgasm?
Pain in vulvar or vaginal area—
examine when asking/showing
Is the pain with deep thrusting?
New or long standing?
Related to a certain partner?
What else is going on in her life?
Dyspareunia
Introital or Vaginal
Introital or Vaginal
Problem:
Solution:
Problem:
Solution:
Fissure– look closely
No penetration until healed
Lubrication; consider albolene
If chronic evaluate further
Atrophic changes
Lubricant, Luvena, Topical estrogen
Anatomic: endometriosis implant,
implant
vaginal septum, hymenal
restriction, vaginal stricture
Repair surgery
Repair,
surgery, tx endometriosis
Vulvar pain syndrome:
vestibulodynia,
tib l d i vulvodynia,
l d i
pudendal neuralgia
Complex solutions: rx, refer to a
specialist,
i li t physical
h i l th
therapy,
biofeedback, consider myofacial
origin
s/p episiotomy or laceration scar
+/- granulation tissue/polyp
Ablation/silver nitrate, massage
Lichen sclerosis, lichen planus,
Biopsy; evaluate, topical steroid rx
s/p vaginal surgery
check for mesh exposure, suture
material, granulation tissue, fistula,
adhesions
Withagen MI, Vierhout ME, Hendriks JC, Kluivers KB, Milani AL. Risk Factors for Exposure, Pain and Dyspareunia After
Tension-Free Vaginal Mesh Procedure. Obstet Gynecol. 2011; 118(3): 629-636
Edwards L. Vulvar fissures: causes and therapy. Dermatol Therapy. 2004;17(1):111–6.
Vaginitis
Tx as appropriate
Inadequate lubrication or arousal
Add lubrication +/or address arousal
issue
Deep
Problem:
Solution:
Endometriosis, adenomyosis
OCP, DMPA, LNG IUS, GnRH
agonist, androgen, aromatase
inhibitor
Retroverted/flexed uterus
Relaxed musculature
Patient education; Pelvic muscle
strengthening, select coital
position
S/P pelvic surgery
Assess orgasmic response, check
for complications
Pelvic or rectal mass; cyst, tumor,
fibroid, adhesions
Assessment and treatment
Interstitial cystitis, IBS, IBD,
diverticulitis, PID, UTI
Assessment and treatment
Inadequate lubrication or arousal
Add lubrication +/or address
arousal issue
Pregnancy
Falcone T, Lebovic DI. Clinical Management of Endometriosis. Obstet Gynecol. 2011; 118(3): 691-705
Basson R. Clinical Updates in Women’s Health Care: Sexuality and Sexual Disorders. ACOG 2003;11(2):22-32.
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Discuss
• Anatomic, physiologic, and sexual
changes common in pregnancy.
• Likelihood that it is safe to continue
sexual activity through pregnancy
pregnancy.
• Perineal massage to minimize
perineal trauma.
• Evaluate for depression.
Postpartum
Leeman L. Sex After Childbirth Postpartum Sexual Function. Obstet
Gynecol 2012;119:647–55.
“Since the baby was born our sex
life is non-existent”
• Chronic loss of sleep
• Abundant close physical contact from
newborn
• Overwhelmed,
Overwhelmed no time
• Postpartum depression
• Major shift in family dynamics
• 50% will be post op
Leeman L. Sex After Childbirth Postpartum Sexual Function. Obstet
Gynecol 2012;119:647–55.
Assess
• Symptoms of urinary
or anal incontinence.
– Pelvic floor
strengthening
• Mood changes.
• Perineal
lacerations/repair.
• Consider mode of
delivery.
Breastfeeding
•
•
•
•
•
Breastfeeding
↑ prolactin, ↑ oxytocin
↓ estrogens ↓ progesterone
Vagina can be like post-menopause
Often diminished drive
Can be arousing in up to ½ of women
Avery MD, Duckett L, Frantzich CR. The experience of sexuality during
breastfeeding among primiparous women. J Midwifery Womens Health
2000;45:227–37.
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Breastfeeding
• Arousal feelings may make some
women uncomfortable.
• Uterine contractions with orgasm →
“milk
milk eject”/”letdown”
eject / letdown reflex.
reflex
– Nurse before sex
• Discussion to normalize these
responses.
Encourage
•
•
•
•
Communication.
Making time for intimacy.
Adding lubricant.
Increase sexual activity as tolerated.
tolerated
– Without breast play
• More partner involvement.
– getting up to bring the newborn into the
bed for feedings
• Rest is very sexy.
Medicalization of Female
Sexual Function/FSD
Kaschak E, Tiefer L. A New View of Women's Sexual
Problems. Binghampton, NY: The Haworth Press,
Inc., 2001.
Does …
Kaschak E, Tiefer L. A New View of Women's Sexual Problems.
Binghampton, NY: The Haworth Press, Inc., 2001.
Bancroft J. The medicalization of female sexual dysfunction: the need for caution.
Arch Sex B e hav 2002;31(5):451-455
Sexual problems due to sociocultural, political or economic
factors
A. Ignorance and anxiety due to inadequate sex
education, lack of access to health services, or
other social constraints
1. Lack of vocabulary to describe subjective or
physical experience
2. Lack of information about human sexual biology
and life stage changes
3. Lack of information about how gender roles
influence men’s and women’s sexual expectations,
beliefs, and behaviors
4. Inadequate access to information and services for
contraception and abortion, STD prevention, and
treatment, sexual trauma, and IPV
Kaschak E, Tiefer L. A New View of Women's Sexual Problems. Binghampton, NY: The Haworth Press, Inc., 2001.
Sexual problems due to sociocultural, political or economic
factors
B. Sexual avoidance or distress due to
perceived inability to meet cultural
norms regarding correct or ideal
sexuality including:
sexuality,
1. Anxiety or shame about one’s body,
sexual attractiveness, or sexual responses
2. Confusion or shame about one’s sexual
orientation or identity , or about sexual
fantasies and desires.
Kaschak E, Tiefer L. A New View of Women's Sexual Problems. Binghampton, NY: The Haworth Press, Inc., 2001.
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Sexual problems due to sociocultural, political or economic
factors
C. Inhibitions due to conflict between
the sexual norms of one
one’s
s
subculture or culture of origin and
those of the dominant culture
D. Lack of interest, fatigue, or lack of
time due to family and work
obligations
Sexual problems relating to
partner and relationship
A. Inhibition, avoidance, or distrust arising
from betrayal, dislike or fear of partner,
partner’s abuse or couple’s unequal power,
or arising from partner’s negative pattern
of communication
B. Discrepancies in desire for sexual activity
or in preference for various sexual
activities
C. Ignorance or inhibition about
communicating preferences or initiating,
pacing, or shaping sexual activities
Kaschak E, Tiefer L. A New View of Women's Sexual Problems. Binghampton, NY: The Haworth Press, Inc., 2001.
Sexual problems relating to
partner and relationship
Sexual problems due to
psychological factors
D. Loss of sexual interest and reciprocity as
a result of conflicts over commonplace
issues such as money, schedules, or
relatives or resulting from traumatic
experiences such as infertility or the
death of a child
E. Inhibitions on arousal or spontaneity due
to partner’s health status or sexual
problems
A. Sexual aversion, mistrust, or
inhibition of sexual pleasure due to:
Kaschak E, Tiefer L. A New View of Women's Sexual Problems. Binghampton, NY: The Haworth Press, Inc., 2001.
Kaschak E, Tiefer L. A New View of Women's Sexual Problems. Binghampton, NY: The Haworth Press, Inc., 2001.
Sexual problems due to
psychological factors
B. Sexual inhibition due to fear of
sexual acts or of their possible
consequences, e.g., pain during
intercourse pregnancy
intercourse,
pregnancy, STD
STD, loss of
partner, loss of reputation
1. Past experiences of physical. Sexual or
emotional abuse
2. General personality problems with
attachment, rejection, co-operation, or
entitlement
3. Depression or anxiety
Sexual problems due to
medical factors
A. Pain or lack of physical response
during sexual
B. activity despite a supportive and
safe
C. interpersonal situation, adequate
sexual
D. knowledge, and positive sexual
attitudes.
Kaschak E, Tiefer L. A New View of Women's Sexual Problems. Binghampton, NY: The Haworth Press, Inc., 2001.
19
5/27/2014
Sexual decline post partum
• The highest-quality studies suggest
that medical male circumcision has
no adverse effect on sexual function,
sensitivity sexual sensation,
sensitivity,
sensation or
satisfaction.
• perinatal depression/anxiety
disorders
• mother's age and previous
miscarriages In relation to age,
miscarriages.
age the
older the mother the higher is the
risk for sexual decline.
Faisal-Cury A. The Relationship Between Depressive/Anxiety Symptoms
During Pregnancy/Postpartum and Sexual Life Decline after Delivery. J
Sex Med 2013;10(5):1343–1349
Morris BJ, Krieger JN. Does male circumcision affect sexual function,
sensitivity, or satisfaction?—A systematic review. J Sex Med
2013;10:2644–2657
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Name that female anatomy
Name that female anatomy
The Death of Adam, copher, cooter, beaver, fish
lips, taco, camel toe, muff, snatch, garage,
oven, love button, JJ, hoohah, bajingo, slit,
trim, quim, pooter, love rug, poontang,
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curtains, putz, fur burger, box, front bottom,
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smile, lovebox,
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cavern, the great divide, cherry, clit slit,laps,
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bizkit, snooch, kitty kat, poody tat, grassy
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23
5/27/2014
sugar basin, sweet briar, breakfast of
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Mumble Pants, Ninja Boot, Marcia, Skin
Canoe, Fatty, Mossy Jaw, The Big W, Chia
Hole, Lip Jeans, Beetle Hood, Hungry Minge,
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Bologna Flap-Over, Furrogi (Poland), love
canal, nana, flower, chocha, whisker biscuit,
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ground zero, bait, holy grail, pole hole, pork
pie, fuzz bucket, bubble gum by the bum,
saloon doors, pink truffle, burger bar,
temperamental ringpiece, python syphon, big
bud, the condo downstate, snake lake, pound
cake, beef tomato, tickled pink, launch pad,
horn of plenty, the indoor picnic, hamper of
goodies,
d
fl
flapped
d bap,
b
b
bonefish,
f h bush
b h tucker,
k
midnight dip, field of dreams, bean,
coozelucy, pish buffet, pooswaa, poonaner,
davey jones locker, pink panther, tinker bell,
south mouth, wonder bread, wolly bolly,
foxhole, hot pocket, head catcher, silk funnel,
ponchita, cherry pop tart,
mommy parts, nice slice, peter vise, peters
grove, penis purse,
grandest
canyon,
banana box, pink portal, red river gorge,
happy valle, baby zipper, richards house,
stop-n-pop, bone polisher, packin shack,
weiner wrap, clap trap, pearl hotel, sea food
six pack,
pack clam canal,
canal coose canal,
canal wand
waxer, vidgie, erie canal, candy kiss,
gauntlet, chin-chin, pachinko, cuntry pie, lip
tip, the big casino, amazon forest, cock cave,
fuck donut, hairy doughnut, fun hatch,
spasm chasm, red lane, belly entrance, fat
rabbit, scunt, pee jaws, mingus, The
Notorious V.A.G.,
Fortune Nookie, Bearded Taco, Slot Pocket,
Bluntfrunt, Pole Magnet, Pocket Pie, kitty
cage, Chicken's tongue, Conch shell, Crack of
heaven, Door of life, Fly catcher, Fruit cup,
Jelly roll, Lobster pot, bunny tuft, knish, lotus,
moneymaker, tackle box, bone hider, red sea,
pizzo, hairy heaven, furry 8 ball rack, crave
cave, toolshed, snake charmer, Furby,
Enchilada of love, Ham sandwich, Camarillo
brillo, Brazilian caterpillar, boy in the canoe,
flesh tuxedo, Mound of Venus, queef quarters,
Venus butterfly, cream canal, apple pie, pie,
wet mark, private area,
dugout, babyoven, penis parking, cooter
muffin, the promised land, cha cha, the
shrine, bitch ditch, fury pink mink, mammal
hole, the toothless blow job, happy flappy,
the code defier, the salt water taffy factory,
mommy's pie, the easy bake oven, the
deflower patch, the dea bone patch, the
vegitarian's temptation, the vegan store, the
blow hole, the pump protector, bag pipe,
pickle stinker, yoni, willys haven, scrumpter,
peach, sweat box, cucumber canal, egg drop
Box, sperm shack, dick dungeon, cock
curator, b.o.b.'s bungalow, thresher, punash,
slurpee machine, pink cookie,
coochie pop, babby, wet seal, bald biscuit,
the unmentionable, peeshie, panty hamster,
deep pink, jaws of life, gizmo, faith, cock
magnet, slippery slide, pink heaven, squid,
dick basket, hot spot, poochika, pudding,
bowl, love cave, squeeze-box, he bone
collector, goodie basket, depository, pink
t tl
turtleneck,
k bread-box,
b
d b
littl
little
d bbi
debbie,
pole
l
hole, pandora's box,snail tracker, homebase,
pud pocket, chanch, big montana, noochie,
choot, golden valley, nappy roots, dick
mitten, mystical fold, red bread, pushin
cushion,
Holiest
of
Holies,
twinkie,
Pizzuziwaz (Trinidad)
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