Clinical Success with Sexual Topics

Within the walls of the pelvic rehabilitation clinics, we often hear more intimate details than we ever imagined we would, could, or perhaps should. With increasing patient care experiences, most therapists demonstrate increased knowledge, awareness, and with some practice, increased skill at discussing sensitive issues such as sexuality. Every person and relationship is unique and we are sometimes asked questions by our patients such as "Should I be having more sex?" or "Am I normal?"

I have sometimes been surprised when a patient reports that he or she is "not having sex often enough" and for that patient it means that daily sexual activity is no longer happening. Other patients are quite satisfied with their sexual activity occurring 2-3x/month. We meet patients who have gone for years without engaging in sexual activity, perhaps because of pain, or lack of intimate partnership, or medical issues with a partner. It is very useful to avoid having expectations for what we as therapists think a patient should or should not be doing, whether that pertains to a particular sexual practice or to a level of involvement with a partner.

-Holly Tanner. Sexuality and the Older Patient. Tuesday, 13 September 2011.

Herman & Wallace offers several course options that deal with these sexual topics. Those courses that have upcoming course dates are: 

• • Sexual Interviewing for Pelvic Health Therapists with instructor Mia Fine, PhD, LMFT-S, CST-S, CSE
    • December 9-10, 2023
  • Sex and Religion with instructor Rivki Chudnoff, MSPT
    • January 7, 2024
  • Sexual Medicine in Pelvic Rehab with instructor Tara Sullivan, PT, DPT, PRPC, WCS, IF
    • January 20-21, 2024

Enjoy a 10% discount on these 3 courses if you register between now and midnight Wednesday, December 6th, 2023 with coupon code: SEXED10

Application Fee: $375.00                                                        Experience Level: Beginner                                                        Contact Hours: 12

Course Date: December 9-10, 2023

It is vital that providers working with pelvic floor concerns have the necessary education and training to work with patients on issues of sexual dysfunction. It is also important that providers be aware of their own biases and be introduced to the various sexual health resources available to providers and patients.

Sexuality is core to most human beings’ identity and daily experiences. When there are concerns relating to our sexual identity, sexual health, and capacity to access our full potential, it affects our quality of life as well as our holistic well-being. Working with folks on issues of sexual health and decreasing sexual dysfunction encourages awareness and encourages healing. Imagining a world where human beings don’t walk around holding shame or traumatic pain is imaging a world of health and happiness.

Often unwanted sexual pain goes unaddressed. Why? Because we are not taught about the interactions between feelings, relationships, and our body. We are not taught that sex should not be painful; that pain is (likely) our body giving us information that something is going on (Hello crappy sex education and the stigma of sexual health and body awareness!). It’s not uncommon that most people who experience sexual pain often feel they are broken.

How to heal from unwanted sexual pain? There’s a trifecta! Effective healing comes from working with a sex-positive medical provider, sex therapist, and pelvic floor therapist. We will all collaborate! 

Sex is not supposed to be painful. You are not broken.

Sexual Interviewing for Pelvic Health Therapists is two day course, written and instructed by a Licensed Marriage and Family Therapist and AASECT Certified Sex Therapist and is intended for pelvic rehab therapists who want to learn tools and strategies from a sex therapist’s toolkit. Lecture topics include bio-psycho-social-spiritual interviewing skills, maintaining a patient-centered approach to taking a sexual history, and awareness of potential provider biases that could compromise treatment. Labs take the form of experiential practice with Bio-Psycho-Social-Spiritual-Sexual Interviewing Skills, case studies and role playing.

Upon completion of this course, participants will be able to provide a Comprehensive Sexual Health Interview, recognize potential biases when working with patients, identify ethical considerations, and effectively collaborate with behavioral health providers upon referral. This course is intended for participants in the medical profession who work with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns.

-Mia Fine. Pain during sex? It might be Dyspareunia. Tuesday, 18 May 2021.

Application Fee: $275.00                                                        Experience Level: Beginner                                                        Contact Hours: 9.75

Course Date: January 7, 2024

CASE STUDY: Sarah is a 23-year-old woman who presents to your office for an evaluation. Upon scheduling, she did not wish to disclose to your office manager what kind of pelvic health issue she wants to be seen for.

Upon patient interview, Sarah reveals that she has been married for 8 months and all attempts at intercourse have been unbearably painful. She reports a 14/10 on a pain scale and that she has vocally cried out in pain with any attempts at penetration. She is feeling hopeless that this will ever get better, and is concerned that something is wrong with her and that her vagina is “too small” for intercourse. Sarah admits that she has never examined her own vaginal opening or seen it in a mirror because it “grosses her out”.

Sarah is otherwise in good health but has never had a gynecological exam. She and her husband are both from a conservative religious background and were educated in religious schools with limited sex education, and were provided with little information about sex prior to marriage. Neither of them had been sexually active prior to marriage. Sarah currently ascribes to her religious beliefs and practice which prohibits any conversations about sex with anyone other than her partner. She expresses an aversion to sexual activity and to her husband’s genitalia and semen. Sarah confides that she feels guilty that she is not able to have intercourse and “make her husband happy”.

Although she denies any discomfort with sitting or wearing tight-fitted garments and has no other pain in her body, recently she has started to have pain in her vulvar area that starts before attempting intercourse. After attempts at penetration, she has difficulty falling asleep due to her pain.

She has a self-diagnosed “tiny bladder” and frequently has to urinate every hour. Sarah reports a long history of constipation, with bowel movements about once a week with straining (type 1-2 on the Bristol stool scale)

She reports regular periods, but excruciating pain the first 2-3 days that can be debilitating at times. She has never successfully inserted a tampon.  

Sarah’s personal goals for treatment are:

1. To have intercourse without pain
2. To become pregnant as soon as possible, as is expected in her social circles and close-knit community

• What is your next move?
• What other questions would you like to ask this patient?
• What would your treatment plan look like for this patient?
• What other healthcare providers might you refer her to?

 Sex and Religion has the following goals:

• Demonstrate a foundational understanding of the traditions, customs, laws, and values associated with different faiths.
• Identify potential challenges and barriers to care unique to pelvic health patients from conservative religious backgrounds.
• Describe five strategies for increasing comfort and confidence in interfacing with patients from different religious backgrounds.
• Patient interview and education techniques.
• Discuss collaborative approaches to evaluation and treatment that are compliant with the patient’s religious and cultural norms.
• Evaluate culturally sensitive intervention in a case study format with your peers.

As pelvic health providers, we go into this special field with the desire to provide the best care for our patients in the most sensitive way possible. It can be particularly daunting when we encounter patients from religious backgrounds and cultures that are unfamiliar to us. In our attempts to be sensitive, we may be tempted to shy away from asking patients the questions that really need to be asked. We may avoid providing patient education we may have otherwise provided because we don’t want to offend, or may tiptoe around a treatment session where we may have otherwise taken a more confident approach. My hope is that practitioners will leave my course Sex and Religion confident in their abilities to provide the highest level of care with confidence, sensitivity, and compassion for all of their patients.

-Rivki Chudnoff. A Case Study in Cultural Sensitivity. Friday, 14 April 2023

Application Fee: $450.00                                                        Experience Level: Beginner                                                        Contact Hours: 15

Course Date: January 20-21, 2024, June 15-16, 2024, and October 19-20, 2024

Anatomical information centralized around the medical field has been historically male-dominated, affecting how the world discusses and understands anatomy and their bodies even in the current day. In 2005 Wade, Kremer and Brown ran a study on college students and found that 29% of women and 25% of men could not identify the clitoris on a diagram of the vulva. We need to revolutionize female sexuality in general, change the focus from the linear model where penetrative sex and orgasm are the focus as it’s been traditionally taught. 

The full clitoris goes far beyond the crown which is the external tip. The clitoris actually extends several inches into the body where it branches into a shape similar to a wishbone. I want to share a description that I love from Latham Thomas, “It’s all this amazing erectile tissue that wraps around, and it all engorges when it’s stimulated. Pound for pound, if you have a vulva, you actually have the same amount of erectile tissue that people with penises have, but it’s just internal.” These clitoral legs are responsible for the sensations where the front wall of the vagina connects to the paraurethral glands (the G-spot) and for female ejaculation.

I authored the Herman & Wallace Sexual Medicine in Pelvic Rehab course for practitioners to have a platform to learn proper anatomy, identify misconceptions, and understand that sexuality is circular with satisfaction as the focus. With the understanding of ‘normal’ anatomy and function, we can help our patients with sexual dysfunctions return to a healthy sexual lifestyle.

Sexual Medicine in Pelvic Rehab is a two-day, remote continuing education course designed for pelvic rehab specialists who want to expand their knowledge, experience and treatment in sexual health and dysfunction. This course provides a thorough introduction to pelvic floor sexual function, dysfunction, and treatment interventions for the gender and sexual spectrum, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, and multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Lecture topics include hymen myths, female squirting, G-spot, prostate gland, female and male sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm. Other topics include the function (and specific dysfunction) treated by physical therapy in detail including: vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post-prostatectomy; as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus. Upon completion of the course, participants will be able to confidently treat sexual dysfunction related to the pelvic floor as well as refer to medical providers as needed and instruct patients in the proper application of self-treatment and diet/lifestyle modifications.