Malehealth's Sex Therapist

In Court Over Sex Claims

2006-09-20T15:06:00.000+01:00

Some newspapers have carried stories recently about an unchaperoned
male doctor who allegedly and inappropriately touched a female
patient. This made me think of the unique and unchaperoned position of
the sex therapist. We hear extremely intimate details of peoples sex
lives and form strong bonds with patients for the duration of therapy.
Therefore it is absolutely vital that the sex therapist is aware of
their own sexual feelings towards a patient, the sexual feelings
directed towards them by a patient, and the boundaries within which
they practice to produce a safe environment for both patient and
therapist. Cases of such abuse are rare but health professionals need
to be more aware that fancying some patients is a normal human
reaction and can be discussed with peers; it's the hiding of such
feelings that may cause a danger of enactment.

Viagra makes it harder?

2006-09-06T17:27:00.000+01:00

Pfizer are claiming their drug provides more rigid erections than
their competitors but this is difficult to assess from patient
reports. What are your impressions of Viagra, Cialis and Levitra? Have
you had to switch between drugs to achieve better rigidity? Have you
had to employ any other techniques to improve the rigidity? It would
also be interesting to hear from real patients on the use of Cialis
and it's duration of action; can it really be over 36 hours?

Ricky S's Premature Ejaculation (4)

2006-05-17T13:43:00.000+01:00

Ricky was more taken with the technique of 'stop-start' to gain better
control over when he ejaculated. This technique involves beginning
with self-masturbation, up to when you feel you are coming close to
ejaculating. You then stop masturbating and allow the erection to
subside. I recommend this is done a maximum of three times before
allowing ejaculation. The idea is to gain a better recognition of when
you are about to ejaculate, and confidence that you have better
control. Ricky will practice this at home and we will move on to
further techniques such as using an oiled hand and involving your
partner in future sessions.

Computer Woes!

2006-04-19T16:34:00.000+01:00

I only work one day per week in sexual problems and when I arrived today my computer had gone, vanished, apparently because someone else needed it more. Nice to be informed in advance! Annoyingly it's the small things I'll miss, like easy printing of patient leaflets (rather than relying on the treacle-like NHS flow). I'm taking my pens home with me tonight.

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Sex and the NHS

2006-03-29T19:38:00.000+01:00

Today I saw a 45 year old man who needed and wanted a drug like Viagra or Cialis, but who didn't qualify for an NHS prescription. Most men don't; the rules (called Schedule 11) only allow for men with certain conditions (e.g. diabetes, prostatectomy) to obtain these drugs on the NHS. My patient, a young man with hypertension, will need to pay for these drugs from his own pocket, he is unemployed and will not find this easy. Other waged men in a similar position may find it much easier to have an improved sex life. Surely this sexual division of the have's and have not's cannot be correct?

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The Male Contraceptive Pill

2006-03-03T10:28:00.000Z

Okay who would take it? Lads on a night out? Unlikely, stupid to have
unprotected sex. Men in a stable relationship? Probably, to share the burden
of contraception. Can you see yourself taking a pill every day? How about
having a small implant under your arm, like some women do? Maybe you don't
like the idea of your hormones being mucked about with. Hormonal male
contraception doesn't exist yet, although the technology is being tested.
Would you buy it?

Harry B's Penis Injections (4)

2006-02-17T11:23:00.000Z

We've covered that in some cases of erectile dysfunction (ED) the most
popular drugs, such as Viagra and Cialis, simply aren't effective enough to
produce an erection and patients need to try something stronger. Harry had
plumped for the easy and painless injection of a drug into the side of his
penis. After the initial injection (see previous posts) Harry reported there
hadn't been any side-effects but he hadn't developed an erection either. It
was now his turn to inject the drug and he did it very well. We increased
the dose and again I left Harry to allow the drug time to work. When I
returned the increased dose had developed the best erection Harry had
experienced in many years, certainly good enough for penetration. There were
no side-effects and Harry will now be able to use this drug in the comfort
of his own home.

Pat's Vaginismus 1

2006-02-08T18:23:00.000Z

Patricia was a 24 year old woman who presented with her husband, Norman,
complaining that attempted sexual intercourse was extremely painful, and in
fact she had never experienced full penetration due to this pain. She
described a normal lubrication but said she began to 'tense-up' when it
looked like penetration was close.She said the pain was located just inside
the entrance to her vagina and that it felt like there was a 'wall' there,
blocking entry of Norman's penis. This sounded very like a condition called
Vaginismus, where the muscles surrounding the vagina go into involuntary
contraction and can powerfully block penetration. It is a
psychophysiological reaction, probably to a fear or anxiety about past
painful events. In Patricia's case this was most likely an extremely painful
first experience with a tampon, and her anxieties and painful experiences
had worsened in the following years. The usual treatment for Vaginismus is
to relearn how the vagina accepts entry of objects, such as a finger at
first, and I will go through techniques for this in a later post.

Sex and Circumcision Controversy

2006-01-26T10:41:00.000Z

A number of men have complained to me of reduced erection and/or sensations following circumcision. This is a hugely controversial area as there are strong pro and anti lobbies for the procedure. The limited research done has produced mixed results; some suggesting a definite sexual role for the foreskin (prepuce)with it's high concentration of pressure receptors, some suggesting the foreskin is an appendage of skin with little or no sexual function. England has a neonatal circumcision rate of 6%, similar to the estimated worldwide rate of 10%. In the USA 65% of neonates are circumcised. Are we harming the adult sexuality of our children? Is it wise to opt for circumcision as an adult? These areas are not well understood and your views may be useful.

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Sexy Medical Students

2006-01-14T15:33:00.000Z

As a sex therapist I am also involved in the teaching of medical students. This began with symposiums for 4th year students and has been expanded to include some interested 3rd year’s too. I’m delighted to be doing this, it’s the ONLY time in their training they will consider psychosexual factors and already some very pertinent points have been raised. Why do so few diabetic clinics ask direct questions about sexual functioning? Why are sexual problems never covered in cardiology? Should Quality Of Life measures include sexual satisfaction? By informing tomorrows medics and getting them to become more comfortable talking about sex, we hope to facilitate better care for patients across the whole medical spectrum. The medical student who appreciates how disease affects sexuality and quality of life is hot!

Post-Holiday Sex

2006-01-09T08:30:00.000Z

Just back from a good Winter break and we're overrun with Erectile Dysfunction (ED) cases. Sometimes a patient’s medical history strongly suggests a physical reason for loss of erections, but only occasionally has that encouraged a GP to try the usual first line treatment (oral medication such as Viagra or Cialis) before referral to us. This is probably due to GP’s still being a bit uncomfortable in this area, but it would make a good deal of difference if they, in appropriate cases, tried this measure first.

Ricky S's Premature Ejaculation (3)

2005-12-06T14:57:00.000Z

The first step with Ricky was to make him a bit more comfortable with sex; he’d had a restricted sexual education so we talked about why and how men and women become aroused, the physical changes that can be expected, and the usual patterns of behaviour which develop. I’ve given him some exercises to try at home which should encourage exploration and relaxation.

He was keen to try a behavioural method of controlling ejaculation. This means gradually changing a behaviour step-by-step until the new behaviour is more natural then the old one. Ricky was ejaculating after about 20 seconds of masturbation and I wanted to change that behaviour and increase his time to ejaculation. The best way to do this is by practising with masturbation. Every man reaches a point at which ejaculation is inevitable, the trick with controlling premature/rapid ejaculation is to recognise when that point is near and then stop the pleasurable stimulation. With practice (the step-by-step changes), many men can increase their length of time before ejaculating. There are two main techniques:

The Stop-Start Method
The Squeeze Technique

Ricky was keener on the stop-start method and I’ll describe this in his next post.

Harry B's Penis Injections

2005-12-01T15:38:00.000Z

Harry and I discussed the pro’s and con’s of the physical treatments available to him for his erectile dysfunction and he was keen to try intracavernosal injection (ICI) of the drug alprostadil. ICI involves using a very fine needle to inject a drug into the shaft of the penis. I can see you all wincing! Don’t, 95% of my ICI patients find it almost completely painless and in fact I’ve tested it myself too, when I was watching the darts one night, so I could truthfully say it doesn’t hurt. The drug used allows the blood vessels in the penis to relax and widen so more blood can get pumped in and an erection can develop / get better. After the correct dose is found in the clinic then a man can start using it at home; he will need to inject himself each time he requires an erection.

I showed Harry how the drug was made up (very easy to do) and then gave him a test injection of a low dose to see how he would react. He developed a bit of an increase in the size of his penis over the next 10 minutes (I leave and encourage men to become aroused to get the best effects) but there wasn’t much rigidity, so we’ve arranged another appointment for him to demonstrate he can make up and inject the drug himself, and we’ll increase the dose if there is no further response.

You might be sitting there horrified at the thought of all this – but there’s no point being coy about it, if you need to use this method it’s not incredibly dignified but it is matter of fact and it probably will give you a hard enough penis to have sex with.

Andy and Sheila's erection problem (2)

2005-11-25T11:13:00.000Z

Sheila came along to our second appointment and we discussed her views of the couple's sexual problem. I said I thought it was as psychological problem because Andy could sometimes get good spontaneous erections - but Sheila corrected me and said that was only when Andy used Viagra! This wasn't what Andy had said to me first time, and shows the value of getting information from both partners. So suddenly there was the possibility that Andy's ED might again have a physical background, despite some other aspects of his history suggesting psychological. How do you sort this out? If there are both physical and psychological factors in erectile dysfunction, how do you decide which is the main cause? And you need to do this because that information will usually decide the treatment plan; very generally physical problems are best treated with drugs and psychological problems best with therapy.

One of the ways we use in our clinic is to test a man's erections when he is asleep! I know it sounds a bit weird. Men have erections in their sleep, usually three or four per night. Nobody really knows why they do but it’s thought it might be an exercise mechanism for the penis, get blood pumped into the tissues and keep them healthy. I give a man a small(ish) machine to take home and wear for two nights. It’s called a RigiScan (unfortunately) and it measures the rigidity of nocturnal erections. If the results show someone gets good firm erections in their sleep then that is a strong indicator the physical processes for erection are intact, and therefore the man’s erectile dysfunction is psychological. If there is no evidence of good nocturnal erections it doesn’t necessarily confirm a physical problem, but further investigations may be required.

I discussed this with Andy and Sheila (she thought the device was hilarious, Andy just looked scared) and I’ve given them the equipment to use at home. Hopefully it’ll give us a better insight into the main reason for their problem.

Do you masturbate too much?

2005-11-21T16:22:00.000Z

Masturbating. Wanking. Playing with yourself. Do you do it too much? Probably not; there’s a wide spectrum of normal frequency for this behaviour. Some people masturbate more than once a day, some once a month or less. Your frequency can depend on your mood; people who feel a bit stressed or ‘down’ usually masturbate more often than at other times. Both men and women masturbate but as long as you don’t think your masturbation is out of control (is having a long-term bad effect other areas of your life) then there’s absolutely nothing harmful about doing it as often as you feel like.

But what if you do feel you masturbate too often and it’s harmful, a compulsion or addiction? In that case you should talk to someone, and the best person to go to first is your GP. They will listen and be sympathetic to the way you feel, and will help you decide on the best treatment. What that treatment is depends on why you feel the way you do, but the GP will either treat you or refer you to the most appropriate place for help.

Masturbating is fine. Harming yourself is not. You know the difference.

Ricky S's Premature Ejaculation (2)

2005-11-10T14:13:00.000Z

Okay so we’ve established that 10 minutes of actual penetration makes you a marathon runner, not a sprinter...but Ricky said he was only lasting a couple of seconds before ejaculation. When he masturbated he could last longer, about 20 seconds. So how do you help someone who has premature/rapid ejaculation (PE)? The first step is to try to find out if the problem has a physical or psychological cause (aetiology). Most people think PE is a psychological problem and the most common treatments are to adjust the way men think and behave. It has also been suggested some men might have as yet poorly understood physical reasons (e.g. increased sensitivity of penile nerves) and their PE should be treated with drugs. We don’t really know much about physical causes or treatments, but we do know that both psychological and drug treatments can work. The dilemma is that I don’t ideally want to treat a psychological problem with drugs, and I certainly don’t want to treat a physical problem psychologically. I explain that a psychological treatment can give him the mental tools to ‘cure’ his PE but a drug treatment may be better and faster (but act like a ‘sticking plaster’ and not treat the root cause). If a man chooses the drug treatment route I always give him a psychological plan to follow too, as this helps enormously.

Ricky’s sexual education had been very restricted (age 36 at first sexual contact) and I though he would benefit from us going through some things that happen to men and women when they get sexually excited. I’d asked him to invite his wife, Linda, to this appointment but he said he hadn’t been able to speak to her about his problem. I said that I thought honest and open dialogue between Linda and he was very important but he flat refused to do this. He was open to trying a psychological treatment plan and we’ll go through techniques for this next time.

Most Common Presenting Problems

2005-11-09T18:48:00.000Z

In our clinic we treat male and female problems. With men the most common reasons (% of total clinic) are psychological erectile dysfunction (34%), organic erectile dysfunction (20%), premature/rapid ejaculation (8%), retarded ejaculation (4%) and loss of desire (4%). In women it’s loss of desire (15%), vaginismus (tightening of the vaginal muscles which makes intercourse difficult or impossible) (5%), and dyspareunia (painful intercourse) (5%). We also see a number of people who have changed or are in the process of changing their gender.

Harry B (2)

2005-11-08T15:24:00.000Z

Harry came back a much more relaxed man than last time. Nothing had changed with his treatment but I think he’d found out that coming here wasn’t as scary as he’d imagined and he’d enjoyed having some time to talk through his problems. With his medical background and history it was certainly a physical (sometimes called ‘organic’) erectile problem. He told me he’d tried Viagra 100mg and Cialis 20mg. These are the top doses of drugs which enhance the sexual response and allow more blood to get pumped into the penis to cause erection. He’d followed all the rules about giving the drug time to work, being sexually stimulated, trying the drug at least 12 times, and being relaxed (if appropriate, I encourage patients to have lots of foreplay but a brief ban on intercourse – this helps reduce the pressure on men to ‘perform’ and allows a better response), but these hadn’t worked at all. In fact there are a good number of people for whom these drugs just don’t work, but fortunately there are other, stronger, drugs available to boost erections. We discussed some of his other options; like using a vacuum erection device, MUSE (a pellet of drug inserted down the urethra), Intracavernosal Injection (ICI) of a drug (a small and painless needle jab in the side of the penis, and a combination of some of the above treatments. I’ve given Harry information leaflets on all these and he’s going to consider how he and his wife would like to tackle the problem next.

Andy and Sheila (1)

2005-11-04T16:53:00.000Z

Andy M came to our first appointment on his own. But problems with sex don’t just happen to one person, they have consequences for partners too; so the patient is really the sexual relationship rather than any individual. For example, if you are ejaculating (‘coming’) too quickly it will have effects on your partner’s sex life too, they will be concerned for you and want to help. They may be contributing to the problem. So, if you’re a couple, it helps to discuss things with both partners. However, Andy came alone and this isn’t unusual for a first appointment; men and women like to check things out first, see what the place is like, see what the therapist is like, dip a big toe in just to test.

His problem was that he was losing his erection sometimes when he was having sex. It began 2 years ago when he and Sheila were having very vigorous intercourse and he felt a sudden, sharp pain at the base of his penis. When he looked there was a large and painful bruise and it took a couple of weeks to heal properly, but when they tried to have sex again Andy lost his erection during penetration. He didn’t think too much about it the first time, it happens to us all, but the second time he got a bit worried, the third time more worried...and then he started to take Viagra. All this sounds very medical, maybe to do with an injury to the penis, but Andy then said that he began to get spontaneous and solid erections back again. In fact the couple had sex ten days ago and everything was fine. If he can still get good erections it’s almost certainly a psychological problem, but I see a lot of men who are very disappointed by this news, who actually want there to be something physically ‘wrong’ because they seem to be able to cope with that better. Perhaps it’s the word ‘psychological’ and the stigma attached to it, but there’s no doubt in my mind which type of problem I’d rather have.

How to get an appointment with a sex therapist

2005-11-03T09:32:00.000Z

The best way to get an appointment with a local NHS sex therapist is to go
to your GP and tell them what's bothering you. The GP may treat you but if
they (or you) think it suitable they will refer you to someone who treats
sexual problems. Who this is depends on the services in your area. In some
parts of the country there are medical (e.g. a hospital Urology department),
psychological (e.g. counselling) and psychosexual (e.g. sex therapist)
services. A sex therapist is able to assess and treat both physical and
psychological problems and, given that most sexual problems are a
combination of both, is in an ideal position to treat you.

If you absolutely do not want to approach your GP (your GP can provide us
with extremely useful information) then contact a local service and ask if
they accept self-referrals. If you are already attending another health
professional (e.g. a diabetic nurse or psychologist) you might ask them for
advice on how to get help.

Lots of people have problems with sex; one in ten men (that's about 3
million men in the UK alone) have problems getting or keeping an erection.
There is help available, go and demand it.

Week 1 - Harry and Ricky

2005-11-01T09:14:00.000Z

What does a sex therapist do? Or a sexual and relationship therapist, to give the full title. Listens to peoples concerns about their sex lives. Helps people with sexual problems, all sorts of sexual problems, some you might not have heard of. They can provide physical treatments (e.g. taking Viagra to boost erections) and psychological treatments (e.g. help with understanding why you don’t feel like having sex). They see men, women, couples, young people, older people, able-bodied or disabled; they see anybody who isn’t happy about sex. This blog is about the patients who come to see me and their journeys through sex therapy.

Harry B came in to see me in the clinic, it was his first appointment and he looked really terrified - trembling and his hands were sweaty. This isn't unusual and in fact it can take some people a couple of attempts before they manage to say the words to their GP, "I have a problem with sex", or force themselves to attend this clinic. So we just had a chat for a bit and gradually Harry became more relaxed and even managed a smile or two. He'd been referred by our Urology department with a seven year history of problems with his erections...as I was saying, it can take people a while to seek help for sexual problems. He had been diabetic (a known risk factor for erection problems) for eleven years and had already tried some drugs to boost his erections, but he was convinced that his problem was a psychological one, that if he just thought about sex in a different way then his erections would return. This first session was mainly about helping Harry become more relaxed though, so we arranged another appointment and he seemed happy to come back next week and tell me more.

Another interesting patient today was Ricky S, a 37 year old bus driver who had his first sexual experience when he got married last year to his 23 year old girlfriend. He'd masturbated in the past but this was his first penetrative sexual intercourse and, maybe unsurprisingly, he was ejaculating very quickly (although we have to be very careful about time-scales because some men think penetrating for 10 minutes is too quick!). Do you know what the North European average time is, from vaginal penetration to ejaculation? It's about 3 minutes. But it is a very difficult thing to measure, and I don't recommend you take a stopwatch to bed to find out!