Between 20 and 40% of new patients attending clinics for contraception or STI advice have high levels of anxiety. It is important to recognize and manage this during the consultation to help explore their presenting problem, as well as encourage further clinic attendances. The origins of this anxiety are multifactorial, but talking about sex and any associated problems can be embarrassing. Those worried about their sexuality or having contracted a potential STI, may feel stigma and shame. New diagnoses of HIV infection, anogenital herpes, or syphilis, together with discussions related to an unplanned pregnancy, generate the greatest anxiety.
The greatest psychological reaction usually arises from a diagnosis of HIV infection. It does not necessarily relate to the stage of the disease and may exhibit a ‘bereavement’-type reaction—disbelief, denial, anxiety, and depression. There may also be suicidal tendencies. In addition, such feelings may be complicated by guilt, resentment, and stigmatization. Support is important, ensuring that information is given at and over a time best suited to the individual. Referral for specialist advice/counselling may also be required.
Certain procedures, e.g. colposcopy for abnormal cervical cytology, are associated with very high levels of anxiety. Stress and depression are common features of chronic conditions, e.g. HIV infection, provoked vestibulodynia, chronic pelvic/perineal pain, prostatitis, and persistent anogenital warts. Mental ill-health is also reported with conditions that persist or recur, such as anogenital herpes, genital warts, and vaginal candidiasis.
Asking open questions and giving patients sufficient time to express their concerns are important. Listening and empathizing are key communication skills to master. Remember that people disclosing sexual issues have chosen to talk to you, especially if you have asked ‘do you have any sexual problems?’ In a consultation, use your ears, eyes, and mouth, in that order.
Talking about sexual health concerns may help patients to reveal their innermost worries about their sexual performance. A careful discussion of the problem (with written information) may be all that is needed. Other may require appropriate signposting to other services, e.g. abortion clinics and psychosexual counselling.
Although therapeutic interventions, e.g. antiretroviral treatment for HIV, suppressive treatment for recurrent herpes, phosphodiesterase type 5 inhibitors (PDE5 inhibitors) for erectile dysfunction, may reduce psychological morbidity, patients may still find it difficult to disclose their diagnoses or condition to their sexual partners.
Examples include:
• Inappropriate reaction to the diagnosed condition.
• Undue vigorous penile squeezing to produce a urethral discharge.
• Obsessional attention to genital marks and irregularities.
• Repeated masturbation to confirm potency in those with erectile dysfunction.
• Repeated re-attendance for emergency contraception when an effective contraception method is used.
• Repeated attendance for PEPSE for low risk sexual exposure.
May be a symptom of some other underlying problem (e.g. rumours about a sexual partner). Manage by exploring the patient’s anxieties and correcting misinformation.
Excessive and inappropriate anxiety reactions, triggered by specific situations or objects, despite having an insight into the lack of reason or appropriateness.
Often triggered by stress and media publicity. Likely to be prompted by underlying guilt or a sexual concern, which should be addressed when formulating management strategies.
Attending sexual health clinics with an imagined HIV +ve test result. Presenting with symptoms and abdominal distention, suggesting pregnancy in pseudocyesis. Reasons and motivation are often unclear, but may be used to gain sympathy, hospital care, or social benefits. Psychiatric referral is often required.
In the most recent NATSAL survey 42% of men and 51% of women reported having one or more sexual problems in the previous year. Over 70% never seek help and of those that decide to talk to a HCP, less than 50% will follow-up a referral to a psychosexual counsellor. HCPs interested in this work can train and become a member of the College of Sexual and Relationship Therapists (COSRT) or diplomate/member of the Institute of Psychosexual Medicine.
Different therapies are used to explore the sexual problem and the HCP will assess whether the sexual problem is psychological, physical, or a combination of the two. By discussing and using active listening techniques, the HCP will help patients gain a better understanding of their sexual problem and any potential underlying cause. The HCP may advise exercises or tasks for patients to undertake in their own time.
Patients can decide whether they would like to be seen individually and/or with their partner. The sessions last 30–50 minutes with most psychosexual counsellors working in community sexual health clinics undertaking short interventional work, seeing patients between 4 and 6 times.
After organic problems have been identified and treated, the management of sexual problems requires motivation and cooperation of the patient, together with the support of their partner. Depending on the sexual issue, couple therapy may be indicated. Emotional issues that may underlie or complicate the presenting problem should be explored and addressed through counselling.
Simple, brief counselling can be undertaken by all HCPs with individuals or couples, and should include:
• basic information and correction of false ideas
• feeding back on transference and countertransference in the consultation
• using the genital examination as part of the therapy, e.g. addressing patient’s concerns on the size of his penis or her labia
• making suggestions, e.g. positions during intercourse
• providing permission and reassurances: often linked with a new suggestion, e.g. the use of vibrators and other sex aids
• facilitating communication between partners, in particular to develop self-esteem, self-assertiveness, and self-protection.
This may lead to behavioural psychotherapy for individuals, couples, or sometimes groups. The framework consists of the following:
• setting behavioural tasks, i.e. ‘homework’
• analysis of the patient’s or couple’s success, identifying obstacles, or difficulties
• provision of help, support, and advice to address the obstacles and problems
• review of the new situation with new tasks set or revised.
Causal factors include:
• Partner conflict and disharmony.
• Psychological causes, e.g. anxiety, depression, body dysmorphism.
• Physical causes: local (e.g. provoked vestibulodynia, endometriosis, cystitis), systemic (e.g. diabetes mellitus, multiple sclerosis), drugs (e.g. antihypertensives, antidepressants), surgery affecting body image (e.g. hysterectomy, mastectomy).
• Post-menopause: low androgen levels after removal of both ovaries or in women in their 60s, vaginal atrophy.
• Defining and managing any underlying problems: in post-menopausal women, local vaginal oestrogen and/or HRT, with androgenic activity may be beneficial (e.g. tibolone)
• Testosterone gel (Testim® or Testogel®): off-licensed use for female hypoactive sexual desire disorder, where both ovaries have been removed. Contents of one tube or sachet (50 mg/5 g) to be applied over a 10-day period, therefore 3 tubes/sachets a month. Women should receive concomitant HRT. Adverse effects include hirsutism and acne.
• Sensate focus: a 3-stage programme in which the couple progresses stepwise from non-genital pleasuring through genital pleasuring to non-demanding coitus under the control of the woman.
• Insufficient data on drugs: flibanserin licensed in the US provides a modest improvement in sexual satisfaction for pre-menopausal women. Phosphodiesterase-5 inhibitors appear to be disappointing.
Genital pain just before, during, or after sexual intercourse. Worsened by vaginismus (involuntary bulbocavernosus muscle spasm) and exacerbated by psychological factors, especially anxiety and partner disharmony.
• Congenital: e.g. vaginal septum.
• Physiological: inadequate lubrication (e.g. oestrogen deficiency, breast feeding).
• Traumatic: e.g. episiotomy, radiation therapy.
• infective—e.g. candidiasis, trichomoniasis
• ulcerative—e.g. genital herpes, syphilis, aphthosis, Behçet’s disease
• dermatological—e.g. irritant dermatitis, lichen sclerosis or planus
• degenerative—atrophic vaginitis
• Neoplastic: e.g. squamous cell carcinoma.
• Bartholin gland: abscess, cyst.
Retroverted uterus, pelvic congestion, cervicitis, endometritis, PID, pelvic adhesions, endometriosis, fibroids, adnexal pathology (e.g. ovarian cysts, tumours).
Anal fissure/fistula, irritable bowel syndrome, inflammatory bowel disease.
Urethritis, urethral caruncle, cystitis, painful bladder syndrome.
A learned response, often 2° to dyspareunia (e.g. from provoked vestibulodynia, atrophic vaginitis, trauma), leading to recurrent or persistent involuntary contraction of the musculature of the outer third of the vagina, interfering with coitus, and causing distress. Other causes/factors include fear of pregnancy, loss of control, association of intercourse with violence, previous sexual abuse, relationship difficulties, and religious/cultural taboos. Tampons are usually avoided and sanitary towels are used for menstruation. Involuntary perineal spasms may occur while preparing for/conducting a pelvic examination, which is often evaded.
Management is in stages—problem-orientated therapy with behavioural and desensitization exercises:
• Exclude or manage physical causes and psychological factors. Discuss and explore any misconceptions related to sexual functioning, with the partner’s involvement if agreeable.
• Encourage the woman to become comfortable touching her genitalia and inserting a finger into the vagina.
• Encourage her to firmly massage the vulval vestibule and posterior fourchette.
• Proceed to more fingers and/or the use of lubricated, graded vaginal dilators.
• Advise Kegel’s exercise: perineal contraction [against inserted finger(s) or dilators] followed by relaxation (as when passing urine), to help muscle control.
• Suggest partner involvement: gentle introduction of a finger into the vagina, slowly escalating to more fingers or dilators.
• When comfortable, proceed to penetrative sexual intercourse with the woman adopting a position (e.g. superior) to maintain control.
See Table 35.1.
Common, affecting 8% of men in their 40s, increasing to 40% in their 60s reporting ED: 60% organic, 15% psychogenic, 25% mixed.
• Lifestyle factors: obesity, smoking, alcohol, recreational drugs (e.g. amphetamines, barbiturates, cocaine, marijuana, heroin).
• Trauma and iatrogenic: e.g. prolonged bicycle riding, prostatic/pelvic surgery, pelvic fracture, and local radiation treatment.
• Drugs: e.g. antidepressants [most with bupropion, mirtazapine have the least effects), antipsychotics (many), antihypertensives (most), androgen inhibitors (e.g. finasteride for benign prostatic hypertrophy with alpha blockers having a lower risk of ED)].
• Vascular: responsible for nearly 50% of cases in those aged >50 years, e.g. ischaemic heart disease (IHD), hypertension, peripheral vascular disease. Coexisting IHD (up to 40%) manifests a mean of 38 months after ED (penile arteries 1–2 mm, coronary 3–4 mm).
• Endocrine: diabetes mellitus (>50% over 55 years have ED), neurogenic and vascular factors; hyper/hypothyroidism; hypogonadism, both physiological and pathological; hyperprolactinaemia.
• Neurological: multiple sclerosis; Parkinson’s disease.
• Psychogenic (depression, anxiety): increase in sympathetic tone. Performance anxiety may become self-perpetuating.
• History: for risk factors; libido (presence of morning erections, use of pornography, masturbation issues), shaving (need and frequency).
• Examination: genital abnormalities, including hypogonadism, facial/body hair, neurological (S2–S4 dermatomes), BP/peripheral pulses.
• Investigations: exclude diabetes (urinalysis/blood glucose); consider serum testosterone, prolactin + other endocrine tests (thyroid, pituitary function), lipid profile, etc. Ultrasonography and angiography rarely required.
• Psychosexual therapy (alone or in combination).
• Sildenafil—recommended dose 50 mg (range 25–100 mg) 1 hour before intercourse. Advise 1 dose in 24 hours (100 mg maximum). 29% fall in plasma concentration if taken with food. Half-life, 4–5 hours.
• Vardenafil—recommended dose 10 mg (range 2.5–20 mg) 25–60 minutes before intercourse. Advise 1 dose in 24 hours (20 mg maximum). 20% fall in plasma concentration with food. Half-life, 4.8–6 hours.
• Tadalafil—recommended dose 10 mg (range 10–20 mg) 30 minutes–12 hours before intercourse. Maximum dose over 24 hours, 20 mg. No decline in plasma concentration with food. Half-life, 17.5–21 hours. Can be taken daily when anticipated sexual activity is at least twice weekly – dose 5 mg a day. Adjust dose according to response.
• Avanafil—recommended dose 100 mg (range 50–200 mg) 15–30 minutes before intercourse. Advise 1 dose in 24 hours (200 mg maximum). 39% lower in plasma concentration following a fatty meal. Half-life, 6-17 hours.
• Success rates (erection suitable for intercourse) of PDE 5 inhibitors up to 75%, but high placebo rates (22–38%).
• Contraindicated in patients taking nitrates (both therapeutic and recreational), and those with hypotension, unstable angina, recent cerebrovascular accident, or myocardial infarction.
• Avoid alpha-blockers for 4 hours after taking sildenafil, use minimum dose for avanafil, lowest dose and 6 hours after vardenafil
Table 35.1 International index of erectile function-5 (IIEF-5) scoring system
| Over the past 6 months | Score | ||||
| 1 | 2 | 3 | 4 | 5 | |
| Confidence in getting and keeping an erection | Very low | Low | Moderate | High | Very high |
| Erections on sexual stimulation hard enough for penetration | Never/almost never | <50% of the time | 750% of the time | >50% of the time | Always/almost always |
| Maintaining erection after penetration | Never/almost never | <50% of the time | 750% of the time | >50% of the time | Always/almost always |
| Maintaining erection to completion of intercourse | Extremely difficult | Very difficult | Difficult | Slightly difficult | Not difficult |
| Satisfactory intercourse | Never/almost never | <50% of the time | 750% of the time | >50% of the time | Always/almost always |
IIEF-5: severe (5–7); moderate (8–11); mild to moderate (12–16); mild (17–21); and no ED (22–25).
Reprinted from Rosen, Cappelleri, Smith et al. (2000) Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International Journal of Impotence Research 11(6): 319–26, with permission from Springer Nature.
• Synthetic prostaglandin E1 agent (e.g. alprostadil) available as:
• Intra-urethral pellets—usual starting dose 250 mcg up to 1 mg. Maximum 2 doses a day/7 doses a week.
• Urethral cream—3 mg per 1 g in applicator applied to tip of penis 5–30 minutes before sexual activity. Maximum 1 dose in 24 hours not more than 2–3 times per week.
• Intra-cavernosal injection—usual dose range 5–20 mcg. Not more than 2–3 times per week with at least 24 hours between injections. Reduce dose if erection lasts more than 2 hours
• Up to 90% response rate with alprostadil injection and 40–60% with pellets/cream.
• Testosterone (IM or transdermal): should only be considered when ED is related to hypogonadism, otherwise no evidence of benefit.
• Pelvic floor exercises with biofeedback (including perineal muscle electrical stimulation): only if ED related to venous leakage or occlusion (success rate ~50%).
• vacuum devices—suck venous blood into the penis, causing erection maintained by a firm constricting band. Lacks spontaneity, may cause bruising, and produces a venous (cold/blue) erection
• implants—e.g. inflatable devices, malleable rods inserted surgically into the penis. 90–95% produce erections suitable for intercourse with satisfaction rates of 80–90%.
Most common sexual dysfunction in men under 40 years, reported in about 30%. Difficult to define as dependent on sexual partner and may indicate delayed partner orgasm, but generally indicative of ejaculation with minimal penile stimulation resulting in reduced sexual satisfaction. Generally considered to be a psychological problem; rarely reported with chronic prostatitis.
• Primary—patient has always ejaculated prematurely. Often considered to be a conditioned response from teenage masturbatory practices, but may reflect sexual performance anxiety, deep sexual concerns from childhood traumatic experiences, including sexual assault and/or familial conflict. Current research also suggests genetic susceptibility and decreased central serotonin (5-hydroxy tryptamine - 5-HT) mediated neurotransmission.
• Secondary—previous ejaculatory control. Probably largely related to performance anxiety.
If associated with ED, treat ED first. Encourage communication between the couple to discuss anxieties and issues.
• Distraction techniques (concentrating on something not linked to sex, such as thinking of countries of the World beginning with A).
• Taking a deep breath just before ejaculation. This can delay ejaculation and reduce the stimulation.
• Concentrate on foreplay to provide greater partner satisfaction.
• Stop/start: manual stimulation (initially) by partner or patient until ejaculation is imminent. Then cease for 30 seconds before resuming. The sequence is repeated until ejaculation is required.
• Squeeze technique: similar approach but firm pressure is applied across the penis at the frenulum, aborting imminent ejaculation. Over time these methods progress to vulval contact and then vaginal penetration, stopping for 30 seconds, or withdrawing and squeezing as ejaculation approaches. Success rate 65–90% with active participation of partner.
• Ejaculation 1–2 hours before coitus: results in longer latent period for coital ejaculation, especially if the partner is superior. Older men may have problems attaining a further erection.
• local anaesthetic gel/ointment, e.g. lidocaine (provided that there is no allergy)
• use of condoms containing local anaesthetic gel or thicker condoms.
• Drug treatment (licensed): dapoxetine initially 30 mg 1–3 hours before sex. Maximum dose 60 mg/day or 30 mg if taking certain drugs, including clarithromycin, erythromycin, fluconazole. Increase in intravaginal ejaculatory latency time from 0.9 minutes to 1.9, 3.1, and 3.6 minutes, respectively, for placebo, dapoxetine 30 mg and dapoxetine 60 mg.
• Drug treatment (not licensed): selective serotonin re-uptake inhibitors (SSRIs) and clomipramine delay ejaculation by their effect on central 5-HT receptors. SSRIs take at least 3 weeks to produce the effect, but clomipramine is effective after a single dose. Regimens shown to be effective:
• daily—clomipramine 10–40 mg or SSRI (paroxetine 20–40 mg, sertraline 50–100 mg, or fluoxetine 20 mg).
• ‘On-demand’—clomipramine 10–50 mg 5–6 hours before coitus.
• Pelvic floor (Kegel) exercises to improve ejaculatory control.
Difficulty, delay, or absence of orgasm following sufficient sexual stimulation, which causes personal distress.
• Physiological: decreased sensitivity, inadequate stimulation.
• Congenital: Wolffian and Mullerian duct malformations.
• Benign prostatic hypertrophy, prostatic carcinoma.
• Increasing age: neuronal degeneration, decreased sensitivity associated with falling levels of testosterone.
• Pelvic surgery: e.g. prostatectomy (transurethral/radical), bladder neck surgery, proctocolectomy.
• Neurological: e.g. multiple sclerosis, spinal cord damage.
• Endocrine: diabetes mellitus (neuropathy), hypogonadism.
• Drugs: e.g. alcohol, most anti-depressants and drugs for treating obsessive–compulsive disorders, alpha- and beta-blockers, anticholinergic agents.
• Psychological: e.g. fear of being seen, pregnancy, infection, from strict, religious background.
Treat underlying cause, when relevant. If associated ED, this should be managed first. If drug-related, consider altering medication or adding pharmacological adjuvants, such as amantadine (100–400 mg 2 days before sex or 75–100 mg 2–3 times daily), bupropion (75–150 mg as needed or 75 mg 2–3 times a day), buspirone (15–60 mg as needed or 5–15 mg bd), cyproheptadine (4–12 mg as needed).
• Psychological approach: more common in those with controlling personalities, which may be inward focused. Issues with showing emotions and letting go.
• Reduce masturbation as the penis may have become conditioned to a firmer stimulus of ‘hands’, rather than ‘vagina’.
• Explore and resolve any underlying anxieties or relationship issues.
• Establish extragenital ejaculation, with suitable stimulation (mechanical, such as a vibrator or visual as required), gradually introducing vaginal contact and insertion into the programme.
• Male superior position: facilitates ejaculation.
• Congenital/post-traumatic: e.g. phimosis, tight frenulum.
• Inflammatory: urethritis, genital herpes, syphilis, candidiasis, dermatological (e.g. lichen sclerosis), aphthosis, Behçet’s disease.
• Iatrogenic (e.g. intracorporeal and transurethral alprostadil; rarely priapism following PDE-5 inhibitor use).
• Testicular lesions: e.g. epididymitis, torsion.
• Seminal vesicle disorders: calculi, cystic malformations, metastatic cancer.
• Other pelvic causes: chronic prostatitis, benign prostatic hypertrophy and prostatic carcinoma, urethral stricture, pelvic arteriovenous malformation, hernia repair.
• Drugs: antidepressants, neuroleptics.
• Psychogenic: e.g. fear of being seen.
Anal dyspareunia during receptive anal intercourse may be due to psychogenic factors or intestinal tract diseases, including anal fissures, inflammatory disease, and irritable bowel disease.
Examine genitals to detect dermatological conditions, curvature of the penis/Peyronie’s plaques, phimosis, short frenulum, prostate tenderness. Investigations may include STI screen, urinary microscopy, cystoscopy, ultrasonography of lower abdomen, etc.
Treat underlying condition. Alpha-blockers or topiramate may be helpful in some with painful ejaculation and pain after hernia operations. Surgery may be an option in those with large Peyronie plaques, severe phimosis and pudendal nerve entrapment. Where no physical cause found, refer for psychotherapy.
Psychological problems are common amongst people living with HIV, and risk of HIV acquisition is higher amongst people with mental illness. Stigma, isolation, guilt, shame, disgust (self-stigma), pre-existing mental illness, post-traumatic stress, substance use, living with a chronic medical condition, neuropsychiatric side effects of antiretrovirals, all contribute.
Mental health and substance misuse not only impact upon quality of life, but can lead to disengagement with clinical care and non-adherence to ART.
Psychological screening should be a routine part of assessment and follow-up appointments.
Online forums, apps, one-to-one support, and peer support groups can help, as well as psychological therapies. Many HIV services will have access to dedicated clinical psychologists. Third sector and charitable organizations offer support in many areas. Signpost and/or refer as necessary.
Other issues that may arise include:
• Bereavement reaction with new HIV-positive result: extreme anxiety and phobia generated by HIV diagnosis and prospect of life-long ART. Psychological therapy and peer support may help
• HIV infection may be associated with reduced testosterone levels and its cause is multifactorial, leading to reduced libido and ED: ART, together with testosterone supplementation may help symptoms of androgen deficiency (reduced muscle mass, decreased strength, fatigue, depression, difficulty concentrating, decreased libido).
• Sexual dysfunction is common amongst both men and women living with HIV and contributes to reduced quality of life: physiological causes should be excluded by appropriate examination, medication review, and investigations. As the HIV cohort ages co-morbidities, poly-pharmacy contributes, as well as psychological factors.
• Recreational and ‘chemsex’ drugs used by some HIV-infected MSM may increase unsafe sex and contribute to poor therapeutic adherence.
• Cognitive disorders (memory, language, problems solving, attention) are frequently reported in people living with HIV despite effective ART. Establishing causation can be challenging, with interplay of mental health, substance use, medication side effects and effects of HIV itself. Screening for cognitive impairment is recommended with referral for further neuropsychological assessment if problems detected.