Supporting Sexual Health Throughout the Lifespan

Supporting Sexual Health Throughout
the Lifespan
Patty Cason MS, FNP-BC
UCLA School of Nursing
Disclosures-Cason
• Merck: Expert Forum; HPV Vaccine, Speaker;
Gardasil, NuvaRing, Nexplanon
• Teva: Advisory board; ParaGard, Speaker;
ParaGard
Objectives
• Demonstrate incorporation of reproductive life
planning into motivational interviewing
contraceptive counseling
Learning Objectives
• Explain the health benefits of addressing
sexual function with reproductive age women
• Identify factors that may affect sexual function
postpartum
• List 4 cornerstones to sexual health
• Discuss 2 methods for strengthening the
pelvic muscle
Gender and Sexual Preference Neutrality
This presentation is intended for use with any
type of pairing and variation of partnerships
Best Site
http://www.the-clitoris.com
A Gentle Shift in Paradigm
We are passionate about:
• Safer Sex
• Protecting our patients from STIs,
unplanned pregnancy, IPV, cervical cancer
• Condoms
• Condoms
• And then just
one more
A Gentle Shift in Paradigm
We are passionate about:
• Safer Sex
• Protecting our patients from STIs,
unplanned pregnancy, IPV, cervical cancer
• Condoms
• Condoms
• And then just
• one more
A Gentle Shift in Paradigm
• Every day we see all the bad effects from
having sex
• Considering what we see every day
sometimes we may start to feel like…
Maybe sex is really bad!
Condoms are great but so is semen
• Females having sex without condoms were less
depressed & depression scores went up as the
amount of time since their last sexual encounter
increased.
• Semen may antagonize depressive symptoms.
• Even a short period of exposure to sperm seems to
offer protection against development of
preeclampsia
Einarsson JI, Sangi-Haghpeykar H, Gardner MO. Sperm exposure and development of preeclampsia. Am J Ostet
Gynecol. 2003; 188(5): 1241-1243.
Gallup GG, Burch RL, Platek SM. Does Semen Have Antidepressant Properties? Arch Sex Behav. 2002; 31(3): 289-293.
Let’s take a moment to re-focus the lens
The data say that having orgasmic sex:
• Extends lifespan
• Is excellent for cardiovascular health
• Makes you look 7-10 years younger
Seldin DR, Friedman HS, Martin LR. Sexual activity as a predictor of life-span mortality risk.
Pers Ind Dif. 2002; 33(3): 409-425.
Davey Smith G, Frankel S, Yarnell J. Sex and death: are they related?
Findings from the Caerphilly Cohort Study. BMJ. 1997; 315(7123): 1641-1644.
Palmore EB. Predictors of the longevity difference: a 25-year follow-up. Gerontologist. 1982; 22: 513–8.
Davey Smith G. Pearls of wisdom: eat, drink, have sex (using condoms), abstain from smoking and be merry.
Int J Epidemiol. 2010; 39(4): 941-947.
Bassett R, Bourbonnais V, McDowell I. Living long and keeping well: elderly canadians account for success in aging.
Can J Aging. 2007; 26(2): 113-126.
Gavrilova N, Tessler Lindau S. Sex, health and years of sexually active life gained due to good health:
evidence from two US population based cross sections surveys of ageing. BMJ 2010; 340: c810.
Drory Y. Sexual activity and cardiovascular risk. Eur Heart J Supp 2002; 4: H13-H18
Buettner D. The Blue Zones: 9 Lessons Living Longer from the people who have lived the longest. Washington, D.C.:National Geographic Society,
2008
CVD
• Frequent sexual intercourse = no increase in
risk of strokes.
• Frequent sexual intercourse = protection from
fatal coronary events.
• Frequency of orgasm for females protective
against mortality.
Seldin DR, Friedman HS, Martin LR. Sexual activity as a predictor of life-span mortality risk. Pers Ind Dif.
2002; 33(3): 409-425.
Ebrahim S et al. Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the
Caerphilly study J Epidemiol Community Health 2002;56:99–102
Oxytocin
• A hormone released during physical intimacy
(from warm touch to sexual arousal and
intercourse.)
• Related to lower stress reactivity.
• Lower pain sensitivity.
• Faster wound healing.
• Relaxation.
Let’s take a moment to re-focus the lens
Having satisfying sex:
• Keeps your vagina plush*
• Is terrific for your relationship*
• Makes you a happier person
*if you have one
Sprecher S, Cate RM. Sexual
satisfaction and sexual
expression as predictors of
relationship satisfaction and
stability. In: Harvey JH,Wenzel
A,Sprecher S, editors. The
Handbook of Sexuality in Close
Relationships. Mahwah, NJ:
Erlbaum; 2004
Leiblum S, Bachmann G,
Kemmann E, Colburn D.
Swatzman L. Vaginal Atrophy in
the Postmenopausal Woman:
The Importance of Sexual
Activity and Hormones. JAMA.
1983; 249:2195-2198.
And best of all
Sex:
Promotes world peace
Tantric Wisdom
How often?
How often do you eat, sleep or exercise?
Having more sex
increases libido
Whatever your baseline,
increasing to more
frequent orgasmic sex is
likely to be beneficial
Cornerstones to sexual health
• Prioritization of daily (or consistent) sexual
practice
• “sex positive” attitude
• Appreciation that sex is a healthy activity
• Good sex begets more sex
Cornerstones to sexual health
• Awareness of, control over, and strength in
pelvic muscles
– AKA “core,” PC muscles, pelvic floor
• Daily exercise or healthful physical activity
Aschkenazi SO, Goldberg R P. Female sexual function and the pelvic floor.
Expert Rev Obstet Gynecol. 2009; 4(2): 165-179.
Bortz WM, Wallace DH. Physical fitness, aging, and sexuality. West J Med. 1999; 170(3): 167-169
Cornerstones to sexual health
• Self knowledge and awareness of
subjective erotic and sexual sensations
• Communication with partner(s)
Cornerstones to sexual health
“Sexual agency”
The ability to say:
– “yes”
– “no”
The ability to:
– Initiate sexual interaction
– Explain what you like (or show)
• and ask for it… nicely
Patients Think We Won’t/Can’t Help
76%
71%
68%
Provide no
treatment
Dismiss Uncomfortable
problem
Marwick C. Survey says patients expect little physician help on sex. JAMA. 1999 June
16;281(23)2173-4.
Lubricants
“Any sexual problem
on earth can be
resolved with some
combination of
communication and
lubrication”*
*Common wisdom
For Sex – Water Soluble
Sexual Lubricants
For Sex – Not Water Soluble
Medicalization of FSF/FSD
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
Kaschak E, Tiefer L. A New View of Women's Sexual
Problems. Binghampton, NY: The Haworth Press,
Inc., 2001.
Sexual problems due to socio-cultural,
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 socio-cultural,
political or economic factors
B. Sexual avoidance or distress due to perceived
inability to meet cultural norms regarding
correct or ideal sexuality, including:
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.
Sexual problems due to socio-cultural, political
or economic factors
C. Inhibitions due to conflict between the sexual
norms of one’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
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
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
A. Sexual aversion, mistrust, or inhibition of
sexual pleasure due to:
1. Past experiences of physical. Sexual or emotional
abuse
2. General personality problems with attachment,
rejection, co-operation, or entitlement
3. Depression or anxiety
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, STD, loss of partner, loss
of reputation
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.
Uterus
Urethral
Sponge
Shaft of
Clitoris
(G-Spot)
(Body or Corpus)
Bladder
Head of
Clitoris
Vaginal
Canal
Legs of
Clitoris
(Crus/Crura)
Vestibular
Bulbs
Anal Canal
Perineal
Sponge
Pudendal Nerve
External Genitalia
Clitoris
Vestibular Bulbs
Outer Aspect Urethral Sponge
Top Layers of Muscle
© Center for the Intimate Arts 2010
Deeper Muscles
Vagina
Anus
Deeper Aspect of
Urethral Sponge
Perineal Sponge
Bladder
Pelvic Nerve
© Center for the Intimate Arts 2010
Times When Sexuality Needs Extra Support
ASK--Offer Help
Perimenopause
Postpartum
Post op; particularly breast or gyn surgery
Medical issues
Infertility
Major life events; financial, death,
relationship
• Adolescence
• Menopause
•
•
•
•
•
•
Have Referrals Available
•
•
•
•
For individual therapy
For couples or sex therapy
Particular books or videos
For IPV
Intimate Partner Violence (IPV)
Reproductive Health Safety cards can be
ordered from:
http://fvpfstore.stores.yahoo.net/reproductive-health-safetycards.html
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
43
©2011 Futures Without Violence
Formerly Family Violence Prevention Fund
Pregnancy
Pregnancy
Discuss
• Anatomic, physiologic, and sexual changes
common in pregnancy.
• Likelihood that it is safe to continue sexual
activity through pregnancy.
• Perineal massage to minimize perineal
trauma.
• Evaluate for depression.
Postpartum
“Since the baby was born our sex
life is non-existent”
• Chronic loss of sleep
• Abundant close physical contact from
newborn
• 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.
Breastfeeding
• Arousal feelings may make some women
uncomfortable.
• Uterine contractions with orgasm → “milk
eject”/”letdown” reflex.
– Nurse before sex
• Discussion to normalize these responses.
Encourage
•
•
•
•
Communication.
Making time for intimacy.
Adding lubricant.
Increase sexual activity as tolerated.
– Without breast play
• More partner involvement.
– getting up to bring the newborn into the bed for
feedings
• Rest is very sexy.
How does strengthening the pelvic floor
help?
“Sometimes it hurts when my partner thrusts
too deep inside of me”
“I can’t feel very much sensation since the baby
was born”
“It always hurts when he first goes inside, then I
get used to it”
“My husband says it doesn’t feel as good as it
used to”
© Center for the Intimate Arts 2010
How does control of the pelvic floor help?
• Control over the PC muscle means a woman can
relax it when she chooses to in order facilitate
initial penetration.
• With PC muscle control a woman can tighten to
minimize the “pounding” sensation from deep
thrusting.
• The erectile tissue is able to be more stimulated
as the PC muscles contract around it.
Franklin E. Pelvic Power: Mind/Body Exercises for Strength, Flexibility, Posture, and Balance for Men and Women.
Hightstown, NJ: Princeton Book Company, 2002.
Biofeedback
& PELVIC FLOOR MUSCLES
• Biofeedback training is effective in training voluntary
pelvic floor muscle contraction
• Biofeedback:
– A clinician, nurse, therapist, or the patient inserts a
monitoring probe into the vagina or places adhesive
electrodes on the skin outside the vagina or rectal area
– As the patient contracts the correct pelvic floor muscles, it
is demonstrated on a monitor
Herderschee, R, Hay-Smith, E J, Herbison, G P, et al. (2011). Feedback or biofeedback to augment pelvic floor muscle training
for urinary incontinence in women. Cochrane database of systematic reviews, (7), CD009252-.
In the Office
“Feedback” Clinician Exam
• Can she contract? (find the muscles)
– Can chart this as “contractility”
• Is she also tensing her thighs, buttocks or
abdominal muscles? Touch them
• How strong is the contraction?
• How long can she hold it?
– This tells you where to advise her to start in her home
exercises
• Have her return in prn or in 5-6 weeks to re-check
Herderschee, R, Hay-Smith, E J, Herbison, G P, et al. (2011). Feedback or biofeedback to augment pelvic floor muscle training
for urinary incontinence in women. Cochrane database of systematic reviews, (7), CD009252-.
Home Exercises
Holding contractions
• The muscles are slowly tightened, and held to
a count of 5-10 sec
• At first, the patient may only be able to hold
the contraction for 1-2 sec
• Progress slowly over a period of weeks to a
goal of 10 second holds, 20 second rests
between holds
Vaginal Weights; Graduated
• Weighted vaginal cones can be used to help
strengthen the pelvic muscle.
• The cones come in sets that vary in weight.
• The tapered end is inserted into the vagina
• As the muscles get stronger, progress to a
heavier cone.
Vaginal Weights for PC strengthening
Vaginal Weights
Late adolecence:
Development of Female Sexuality
• Ask directly if they have had an orgasm yet
• Open ended questions about their sexual
adventures so far
• Let them know that most women learn how to
have an orgasm at first by themselves, then
with a partner’s hands or mouth (or both)
Facts on American Teens’ Sexual and Reproductive Health Guttmacher Institute January 2010
Reyna VF, Farley F. Is the teen brain too rational? Scientific American Mind. 2006–2007;59-65.
Powell K. How does the teenage brain work?. Nature. 2006;442(24):865-7
“I don't know if I've ever had an orgasm”
• Start with the basics
• Explain or show her where her pleasurable
anatomy is
• Outline a plan together
• If she has a partner, help her or them
determine a strategy for their intimacy during
her “program”
Shaft of
Clitoris
(Body or Corpus)
Head of
Clitoris
(Glans)
Urethral
Sponge
(G-Spot)
Vestibular
Bulbs
Legs of
Clitoris
(Clitoral Bulbs)
(Crus/Crura)
Vaginal
Opening
Perineal
Sponge
© Center for the Intimate Arts 2010
Pre-orgasmic
• Privacy!
• Start with self exploration; looking in the
mirror (if she’s comfortable) touching to learn
where things are.
• Progress to self touch for pleasure.
• Add any erotic tools; toys, Eros device, clitoral
stimulants, books, videos.
• Women respond to “aural” arousal.
Most Intriguing 21st Century Vibrator
Will using a vibrator make it impossible for
me to have sex with a partner?
• It will teach your nerve pathways how to go
from A-Z.
• You can use a vibrator with your partner.
Clitoral Stimulants
EROS
Clitoral
Therapy
Device
Pre-orgasmic→Orgasmic
• Let her know that the “self critic” or the
”observer” is always hovering around
• It’s worse with a partner
• But it does a good job of keeping orgasms
away even when we’re all alone
Pre-orgasmic→Orgasmic
• Let her know that the “self critic” or the
”observer” is always hovering around
• It’s worse with a partner
• But it does a good job of keeping orgasms
away even when we’re all alone
Pre-orgasmic→Orgasmic
• Explain that once she finds what feels good
she should continue doing whatever it is
– Then do it harder
– Or maybe faster
– She can try:
• Contracting the PC muscle
• Bearing down
• Moving her head or feet
© Center for the Intimate Arts 2010
Orgasmic
• Once she can have an orgasm by herself
→ practice non-penetrative play with her
partner
(or penetrative play if she is has liked penetration
for orgasm already)
• Show and tell her partner how
Orgasmic→ Penetration
• Once she can have an orgasm with a partner,
she can transition to using the same kind of
stimulation technique to include penetration
if she wants to
• Penetration in addition to external stimulation
as needed
• Coital alignment
Coital Alignment
• To make clitoral contact possible during coitus.
• Basic physiological alignment that provides
consistent and effective stimulation for female
coital orgasm
Aaron PP. The Coital Alignment Technique (CAT): An Overview of Studies, Journal of Sex &
Marital Therapy, 2000:(26):3, 257-268
Eichel EW. The technique of coital alignment and its relation to female orgasmic response
and simultaneous orgasm. Journal of Sex & Marital Therapy 1988:(14):2;129-141
The Position
Combines the:
a. “Riding high” variation of the missionary posture
b. With genitally focused pressure-counterpressure
stimulus applied in the coordination of sexual
movement
© Center for the Intimate Arts 2010
© Center for the Intimate Arts 2010
“With permission, from A New View of A Woman’s Body by the Federation of Feminist Women’s Health Centers.”
Illustrations by Suzann Gage.
Care of the vulva/perineum
No Products
• Wash with water after urinating or defecating
• Non-alcohol hypo-allergenic baby 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
•pH of 4.5
•500 IU of Vitamin E
•No soap or detergent
•Made by Nature’s Plus
Dysparunia: 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
Dysparunia: 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?
Introital or Vaginal
Problem:
Solution:
Fissure– look closely
No penetration until healed
Lubrication; consider albolene
If chronic evaluate further
Anatomic: endometriosis implant, vaginal
septum, hymenal restriction, vaginal
stricture
Repair, surgery, tx endometriosis
s/p episiotomy or laceration scar
+/- granulation tissue/polyp
Ablation/silver nitrate, massage
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.
Introital or Vaginal
Problem:
Solution:
Atrophic changes
Lubricant, Luvena, Topical estrogen
Vulvar pain syndrome: vestibulodynia,
vulvodynia, pudendal neuralgia
Complex solutions: rx, refer to a specialist,
physical therapy, biofeedback, consider
myofacial origin
Lichen sclerosis, lichen planus,
Biopsy; evaluate, topical steroid rx
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
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.
Vital Vulva
• Lubricant for daily use or “as needed”
• Not just for sex…makes a dry vulva
happy
MoonMaid Botanical Skin Care
“I used to want sex all the time but
now I have no sex drive. Is there a
pill that will help?”
Ask for more information:
• Any pain?
• Relationship issues?
• Life stressors?
• Does she get aroused when she has sex?
• Does she have an orgasm?
PDE-5 inhibitors
for women?
• Can they increase desire or arousal in women by
improving blood flow to the female genitalia?
• Studies found PDE-5 inhibitors did increase
genital blood flow in women
• Did not result in any real increase in desire or
arousal >placebo
• PDE-5 inhibitors did improve sexual function
>placebo in women who had satisfactory sex
lives before developing sexual problems after
starting an SSRI antidepressant
Nurnberg HG, Hensley PL, Heiman JR, et al. Sildenafil treatment of women
with antidepressant-associated sexual dysfunction: a randomized controlled
trial. JAMA 2008; 300:395-404.
Bupropion
• SSRI antidepressants can ↓ desire/orgasm
• Bupropion works differently than SSRIs
• May be a good antidepressant option for women with
depression who are concerned about or have sexual
side effects on SSRIs
MR Safarinejad et al. A randomized, double‐blind, placebo controlled study of the efficacy and safety of bupropion for
treating hypoactive sexual desire disorder in ovulating women. BJU Int 2010; 106:832.
Drugs for Female Sexual Dysfunction. The Medical Letter. Vol 52 (Issues 1353/1354). December 13/27, 2010
Clayton AH, Warnock JK, Kornstein SG, et al. A placebo-controlled trial of bupropion SR as an antidote for selective
serotonin reuptake inhibitor-induced sexual dysfunction. J Clin Psychiatry 2004;65:62–67.
Moll JL, The Use of Monoamine Pharmacological Agents in the Treatment
of Sexual Dysfunction: Evidence in the Literature J Sex Med 2011;8:956–970
Bupropion
• Nondepressed pts with desire and arousal difficulties
have improved sexual functioning bupropion > placebo
• More study needed
MR Safarinejad et al. A randomized, double‐blind, placebo controlled study of the efficacy and safety of bupropion for
treating hypoactive sexual desire disorder in ovulating women. BJU Int 2010; 106:832.
Drugs for Female Sexual Dysfunction. The Medical Letter. Vol 52 (Issues 1353/1354). December 13/27, 2010
Clayton AH, Warnock JK, Kornstein SG, et al. A placebo-controlled trial of bupropion SR as an antidote for selective
serotonin reuptake inhibitor-induced sexual dysfunction. J Clin Psychiatry 2004;65:62–67.
Moll JL, The Use of Monoamine Pharmacological Agents in the Treatment
of Sexual Dysfunction: Evidence in the Literature J Sex Med 2011;8:956–970
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.
• It doesn’t mean that they will always have sex, or even 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
Fun Video
• http://www.ted.com/talks/mary_roach_10_th
ings_you_didn_t_know_about_orgasm.html
What ever happened to pubic hair
• A brazilian as a rite of passage?
• Increase sensation or feel more numb by exposure?
• The endangered species
REPRODUCTIVE LIFE PLAN
(RLP)
RLP: What is it?
• A self-assessment of her life goals
• Goals in several broad categories
– Education
– Work/Career
– Family Planning
• We assist or guide as needed
RLP: Purpose
• To reveal our clients genuine intentions
regarding reproduction
• So she absorbs what is most important to her
• So that she can:
– obtain necessary information
– make choices
– adhere to her plan
– fulfill her own goals.
• Ambivalence is expected
RLP: How does it help?
• It shows how motivated she is to become
pregnant or prevent pregnancy
• Once this is clarified we can begin the
process of offering appropriate interventions
• Contraception or not
• Highly effective or not
• Preconception Care
• Life goals prior to planned pregnancy
Sample RLP questions:
Do you want to have (more) children? (Someday?)
If so:
When? (Or how old would you like to be?)
How many children would you like to have?
How long do you want to wait between pregnancies?
How would you feel if you were to become pregnant
over the next few months?
• What are you hoping to accomplish before then?
•
•
•
•
Discovering clients true motivations
• The point of a RLP is to get substantive
information from our clients about what is
motivating them so we can help them make
better choices
• The client is the one who will make the choices
MOTIVATIONAL
INTERVIEWING
(MI)
Motivational Interviewing with
contraception counseling
• Saves time
• Effective
• Client centered
When is MI not needed?
A patient says: “Give me the most effective
method you’ve got!”
MI has been used for
•
•
•
•
•
•
Addiction counseling and treatment
Contraception counseling
Behavior change
Diabetes self management
Weight loss
Medication adherence
MI: the approach
Start from a place of respect
Guiding not directing
Not “me vs. you” rather…“us together on the same side”
Help patients feel motivated by having them verbalize
their own reproductive and life goals
• Identify what is personally meaningful or of value to the
patient rather than those things that we as the HCP think
are most important
•
•
•
•
MI: the benefit
• Reduces frustration with the patient and
subsequently ourselves
• Removes our ego…
– “I need to make this patient do what’s good for her.”
– “I want to protect her from an unnecessary
unplanned pregnancy!”
– “If can’t get through to my patient, I fail.”
• Our morale as HCPs will be exhausted without
success
Ineffective strategies
Taking sides in the patients ambivalence
• Threatening bad outcomes;
– “You’ll get pregnant if you don’t ...”
– This gets their attention but doesn’t work for
behavior change
• Giving advice assumes this person simply
doesn’t know enough.
• To offer one idea after another = exhaustion
Accept ambivalence
• MI elicits behavior change by helping clients
explore and resolve ambivalence.
• Expect, find, accept and show ambivalence
• Also called developing discrepancy
• Just showing the discrepancy is a powerful
way to help patients make better choices
Ambivalence
On one hand we want to accomplish our goals
Rewards
Obstacles
On the other are many obstacles
Motivation for contraceptive use
• With perfect use of contraception
– 1 year,
– 3 years,
– 5-10 years,
– 20+ years…what will happen??
• The best case scenario...
Nothing!
Obstacles
• All contraceptive methods have potential side
effects
• Fear of negative health effects
• Risk for unplanned pregnancy is theoretical
• Perception of risk is not fully rational and is
based on past life experience---ask
Obstacles
• Contraceptive sabotage by a partner
• Logistical constraints
– Cost
– Wait times
– Work schedule
– Transportation
– Childcare
Obstacles
Intermittent/inconsistent sexual partnering
• Believes she doesn’t need contraception (today)
• Ask specific details of what she did and when
• Ask if she intends or would like to be sexual with
someone in the next month, year… two years
CASE STUDIES
Sandy
16 yr old G1 P0 TAB 1
RLP:
• Wants to get pregnant now
• Ask about her life goals
• Find something about her behavior that is
“mature” and refer to it
• Review PCC (insert reality)
• Demonstrate that you believe she is in charge of
her own life
Rather than tell her she’s too young:
• “You will be a wonderful mother some
day…and to be an even better mother,
what would you like to accomplish before
you have a baby? (or in addition) ”
• “Sounds like you’ve given this some
thought (or “you are obviously smart”),
what are some ways you see yourself
handling this?”
Maria BMI 31
22 year old G2 P0 TAB 2 student
RLP:
• Wants children one day. At least 3 years from
now. Wants to be married, finish school.
She’s clear that she is not willing to have
another abortion
• Prior DMPA (gained weight), very concerned
that hormones cause weight gain. Mostly has
used withdrawal and doesn’t believe she has
ever gotten pregnant that way
Maria
• “You said that you are using the pull out
method now. And on the one hand you
feel that if you get pregnant you would
continue the pregnancy, yet you also are
pretty sure you don’t want to have a baby
right now. Do I have that right?”
• “What would you like to accomplish
before you have a baby? And what
else?” (Refer to RLP life goals)
Maria
• “If delaying pregnancy until you finish school
is very important to you, would you be
interested in using one of the top tier
methods?”
• “Since a lot of women who rely on their
partner to “pull out” get pregnant, would you
like to talk about pre-natal vitamins and other
things that are important to do to prepare for
pregnancy?”
Understanding objections
• If we listen well enough to where the
resistance has come from we can develop
discrepancy (describe the ambivalence)
Confidence Ruler
Melanie Gold DO
0
Least
2
4
6
8
10
Most
Quantitative: “A ruler”
“Think of how you feel about getting pregnant right now
and then see if you can tell me where you fall on a scale
of 1-10. 1 being that it would be the worst thing you can
imagine, and 10 being that it would make you the
happiest you could possibly be.”
Demonstrate Ambivalence in Maria
• “a 2”
• “Why would you say you aren’t you a lower #?”
• “I’m not ready for a baby but I know that I won’t
have another abortion because I am an adult and
having a baby wouldn’t be the absolute worst
thing in the world”
• “Why do you think the # might not be higher?”
• “I really want to wait a few more years!”
Or qualitative questions:
• “How would you feel if you got pregnant
now?” “How ready are you?” “How important
is it to you to avoid pregnancy?”
Repeat or rephrase examples
“Let me make sure I understand you.”?
• “So on one hand you don’t want to get
pregnant…do I have this right? Yet, you are
not using birth control. How does this fit in
with your not wanting to get pregnant?”…Her
reply uncovers the ambivalence
Make it real
• “On one hand you really want to get pregnant
in the future, but not right now, and on the
other hand, it sounds like a part of you would
like to have a baby now? Do I have that
right?”
• “Have you discussed this with your partner?
Do you plan to tell him? How do you think he
would react?”
Information sandwich
Illicit/provide/illicit model
Sandwich the statement that gives the information
you want Maria to have between two questions
that are relevant to her:
• I: “How have you been feeling with your IUD?”
• P: “Even though you don’t feel different, we
know that your IUD is working to keep you from
getting pregnant before you are ready”
• I: “What do you think of that?”
What now? Open ended…
• What do you think you will do?
• What birth control are you thinking can help you...
(fill in with her stated goal)?
• What do you see as your options?
• Where do we go from here?
• What happens next?
Rather than:
• Do you have any questions?
• Do you understand?
Final steps
• Plan for obstacles; they have great
intentions but they return to their
lives once they leave the office
• Close the deal
–Operationalize same day IUD
placement
–Ask “How do you feel about this”
–Plan concrete next steps
QUESTIONS
References for MI
• ACOG Committee Opinion: Motivational Interviewing: A Tool for behavior
Change; 423; Jan 2009.
• Barnet B et al. Cost-effectiveness of a Motivational Intervention to Reduce
Rapid Repeated Childbearing in High-Risk Adolescent Mothers Arch Pediatr
Adolesc Med. 2010;164(4):370-376
• Barnet B et al. Motivational Intervention to Reduce Rapid Subsequent Births
to Adolescent Mothers: A Community-Based Randomized Trial Ann Fam Med
2009;7:436-445.
• Gold Melanie et al. Motivational Interviewing Strategies to facilitate
Adolescent Behavior Change. Adoles Health Update; 20(1):1-7, Oct 2007.
• Hecht J et al. Motivational Interviewing in Community-Based Research:
Experiences From the Field. Annu Behav Med. 2005.
• Hettema, Steele, Miller. Motivational Interviewing. Annu Rev. Clin Pychol.
2005. 1:91-111.
References for MI
• Julius et al. Medication adherence: a review of the literature and implications
for clinical practice. J Psychiatr Pract. 2009 Jan;15(1):34-44
• Lopez et al. Theory-based interventions for contraception. 2009 Jan, Cochrane
Database.
• Petersen et al. Applying motivational interviewing to contraceptive counseling:
ESP for clinicians. Contraception; 69(3):213-17. Mar 2004.
• Rollnick S, et al. Motivational Interviewing in Health Care. New York: Guilford
Press; 2008
• Rubak et al. Motivational interviewing: a systematic review and meta-analysis.
Br J Gen Pract. 2005 Apr;55(513):305-12.
• Schillinger, “Closing the Loop” Teach-back is supported by research. Arch Intern
Med/Vol 163, Jan 13, 2003
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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, poonanie, cooch, tunnel of love, vertical bacon
sandwich, bearded clam, cookie, cooleyhopper, nookie, the
pink, honey pot, cunny, vag, meat curtains, putz, fur burger,
box, front bottom, kebab, kitty, minge, snapper, catfish,
vertical smile, lovebox,
Name that female anatomy
carpet, deep socket, slice of heaven, flesh cavern, the great
divide, cherry, clit slit,laps, fuzz box, fuzzy wuzzy, glory hole,
grumble, man in the boat, mud flaps, mound, peach, the
furry cup, wizard's sleeve, DNA dumpster, bikini bizkit,
snooch, kitty kat, poody tat, grassy knoll, Jewel box,
rosebud, curly curtains, furry furnace, velcro love triangle,
nether lips, where Uncle's doodle goes, altar of love,
cupid's cupboard, bird's nest, bucket, love glove, serpent
socket, spunk-pot,
sugar basin, sweet briar, breakfast of champions,
wookie, pink circle, silk igloo, juice box, Golden Palace,
fetus flaps, skins, sugar hole, home plate, Deer Hoof,
Golden Arches, Cats Paw, Mule Nose, Yo Yo Smuggler,
Mumbler, Dinner Roll, Crotch Waffle, Piss Fenders,
Melvin, Dove Breast, Vedgie, Slurpy, Pastrami Flaps,
Wagon Ruts, Mumble Pants, Ninja Boot, Marcia, Skin
Canoe, Fatty, Mossy Jaw, The Big W, Chia Hole, Lip
Jeans, Beetle Hood, Hungry Minge, Welly Top, Frum,
Pancake Fold, Tongue Roll, Bologna Flap-Over, Furrogi
(Poland), love canal, nana, flower, chocha, whisker
biscuit, meat locker,
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,
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, flapped
bap, bonefish, bush tucker, 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,
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,
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, clam canal,
coose 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.,
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 turtleneck,
bread-box, little debbie, pole 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)