Sexual therapist Lorraine Grover offers hints on managing sexual problems in the surgery
1. It's helpful to know which problems sex therapy is useful for – and which it's not.
It's very useful for problems such as low desire, rapid ejaculation, vaginismus, arousal disorders, sexual compulsion and anorgasmia. Patients with psychogenic erectile dysfunction can find it beneficial. It's less effective for problems caused by major mental health issues, alcohol and drug abuse and recent major crises such as bereavement. It's not vital that both partners attend therapy, but outcomes are better if they do.
2. Sex therapy can be useful on its own or alongside pharmacotherapy.
Few health professionals know their patients better than their GP. This puts GPs in an ideal place to manage sexual difficulties. But lack of time – and of knowledge – may stop them doing so. Remember, sex therapy can be beneficial on its own or with other treatments – for example, PDE5 inhibitors require sexual stimulation to be effective. Patients may not have had sexual intimacy for a long time and providing support in how they can establish a satisfactory sex life is important.
3. Let patients know you are open to discussing sex.
You could say, for example: ‘In my experience, patients with diabetes may have sexual difficulties, so if that happens let me know. There are things that can be done.' Addressing sex as a standard part of history taking will normalise the consultation. Having leaflets and posters on display in the surgery can help.
Assessing erectile function is covered in 'Key questions' in this PulsePlus
4. Give the patient – and partner, if present – time to describe the problem.
It may be difficult for a busy GP not to interject in a 10-minute consultation. But a few minutes initially listening can give you significant insight and help you decide what to do next.
Using familiar language will allow patients to describe the problem accurately – but ask if there is a slang term you don't recognise.
Helpful questions include: ‘What was good about sex before?'; ‘When did it change?'; ‘Was the change gradual or sudden?'; and ‘Is it situational?'.
After taking a detailed history, you might well have an idea of why the problem has developed and be able to discuss treatment. If not, consider recommending therapy.
5. Discussing ‘normal sexual function' using simple anatomical pictures can be very useful.
These can be used to show what happens to genitalia before, during and after the arousal response and dispel myths and misconceptions.
6. If there is limited or no NHS access to psychosexual therapy for your patients locally, then try Relate.
Limited NHS access to a psychosexual service is available in most areas – either by direct referral or via GU medicine.
But GPs can refer – and patients self-refer – to Relate, which also offers training courses for health professionals (see below). The British Association of Sexual and Relationship Therapists provides lists of private therapists.
7. Tell patients relaxation and privacy are key.
Discuss with patients how they relax for sexual activity – particularly important when performance anxiety is the problem. You could recommend they try breathing exercises or listening to relaxing music.
Not worrying you'll be heard having sex is important too, especially with more adult children returning to the home.
It's a myth that sex is spontaneous – planning intimate time can ‘whet the appetite'. Learned behaviour can both trigger and maintain factors leading to sexual dysfunction and the history can identify them.
8. Feeling uncomfortable about being naked may be a problem for some.
Patients could try wearing a light covering such as a nightdress, sarong or silky boxers.
Altered body image after surgery may need to be discussed rather than avoided.
9. Encourage couples to explore.
Bathing or showering together allows intimate touch and the opportunity to experience different sensations. This may be particularly pleasurable on or around genitalia if increased stimulation is required. Flavoured lubricants and condoms can enhance oral sex.
Illness, especially when associated with stomas or dressings, may alter the smell of a partner and be off-putting. Ways around this include using toiletries that remind people of positive experiences.
Different sexual positions can help – for example, a patient who has had a cardiac event may prefer being a passive partner when they start having sex again to regain sexual confidence.
10. Good communication is vital.
What constitutes sexual activity varies so much; for some it may involve penetrative sex, for others it may be having a cuddle or holding hands on the sofa. There is no right or wrong. But there must also be effective communication of information and outcomes between patient and clinician.
Lorraine Grover is clinical nurse therapist in sexual wellbeing, practising at the BMI Shelburne Hospital in High Wycombe, The London Clinic Consulting Rooms and The Prostate Centre. Further details at www.lorrainegrover.com
Sex therapy can be useful on its own or alongside pharmacotherapy Psychosexual therapy session
