Email them about trans lecture series – transgender patients and sexuality – move case to

there, how and what does sex mean to these patients

Ask about mirrors for pap

all sounds good to me. i think focusing on sexual health and pleasure/busting
myths/language/promoting autonomy can all be incorporated into a presentation on
"what's our role/what info do we need to know to begin?"

i don't think it should be full of "women men respond x way until they are menopausal and
then it's y", etc. instead developing some questions that offer patients the opportunity to
talk w us if they choose.

Josh—- i like all of this. Would love also to emphasize reframing “dysfunction.” And if useful
to bring in a bit of the history of thinking of it as dysfunction... I don’t know much about
this, but suspect that there’s a large pharmaceutical company slash medical industrial
complex push for medicalizing this.

I really like the idea about giving important tips about language. Including how to ask if
someone has a concern about sexual function or sexual pleasure. Because sometimes docs
just don’t know how to break that ice!

I think it might also be helpful to think about “problem posing” in this setting, Josh. How do
providers ask questions in a way that allows patients to explore which parts of their life
contribute (a) to lack of sexual pleasure, or to (b) the perception that they have a problem.

sexual pleasure among women/children (that is the population of the year) lecture.
So I'm taking suggestions.

I'm also thinking about including a case with a transpatient.

Oh, I'd include sensuality and alternatives to the sex response cycle in the case of the older patient

Maybe another about sex and a constellation of chronic illness - this can be about an older
body, maybe about depression, illnesses that impact sex
Or another on a younger person and anorgasmia - discussing self-exploration, toy safety,
identifying sexual pleasure goals

I feel like the goal should be around developing language and resources.
Sexual difficulties, sexual functioning, sexual health, sexual positivity, sexual pleasure

https://www.aafp.org/afp/2015/0815/p281.html#afp20150815p281-b1

Intro

The goals of this lecture is to

Practice using sex positive language

Identify tools to address common sexual concerns

Talk to patients about sex

2 minutes – Reflect and write on our own thoughts and comfort with sex

What are your feelings about masturbation, same-sex activity,

unmarried sexual expressions, etc.? Do you feel comfortable talking about these practices with

patients? Monogamy, polygamy, polyamory, one-night stands

Understand the medical communities reflex too is very much set in the 19th century context of
psychoanalysis, criminology,

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978945/

understanding female sexual pleasure, they also sought to contain it by emphasizing the role of
husbands in eliciting and managing it within social norms of gender, heterosexuality, and motherhood.

The salience of psychiatry in discussions of female sexual problems has its roots in the mutually
entangled development of psychiatry, sexology, and criminology in the last quarter of the 19th
century. A forensically minded sexology classified sexual behaviors, identities, and relationships,
with nomenclature (homosexuality, sadism, masochism, nymphomania, fetishism, and so on)
flourishing from the late 19th century well into the 20th [3–5,6••,7].
In the early

Men, wrote Huhner [17] (p. 400), will often have experienced sexual intercourse with prostitutes before
marriage; this could make them either unaware of how to elicit female pleasure, as prostitutes ‘from
long experience’ know ‘how to simulate passion’, or indifferent to it, mistakenly believing ‘women do
not have pronounced sexual feelings as they, men, do’ [17] (p. 394). Women’s lack of education in their
own sexual capacity meant that many ‘not knowing any better, suffer in silence’; never experiencing
sexual pleasure, some ‘never know the cause of their irritability or hysteria,

hile these texts underlined female sexual pleasure, they also sought to contain it by emphasizing the
role of husbands in eliciting and managing it within social norms of gender, heterosexuality, and
 motherhood. Female sexuality is to be elicited from women’s asexual innocence, but, if too assiduously
awakened, threatens to tip into voracious nymphomania [17,24] – a condition with often tragic
consequences such as incarceration in insane asylums. For the woman unable to reach coital orgasm,
sitting astride the man ‘is certainly better than titillation of the clitoris

Sexual dysfunction has it’s roots in DSM and psychology

British Medical Journal (BMJ) article on FSD entitled ‘The making of a disease’, arguing that Big Pharma
were significant in shaping the category, outraged responses flew in, accusing him of accusing women of
lying or inventing their distress.

And in a sense insurance companies

http://www.bmj.com/content/326/7379/45
Education And Debate

The making of a disease: female sexual

dysfunction
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7379.45(Published 04 January 2003)Cite
this as: BMJ 2003;326:45
 Article

 Metrics
 Responses
1. Ray Moynihan, journalist (raymond.moynihan@verizon.net)
Author affiliations
1. Correspondence to: R Moynihan, 4/1312 21st Street NW, Washington, DC, 20036, USA

Is a new disorder being identified to meet unmet needs or to build markets for
new medications?
The corporate sponsored creation of a disease is not a new phenomenon,1 but the making of
female sexual dysfunction is the freshest, clearest example we have. A cohort of researchers with
close ties to drug companies are working with colleagues in the pharmaceutical industry to
develop and define a new category of human illness at meetings heavily sponsored by companies
racing to develop new drugs. The most recent gathering, featured Pfizer as chief sponsor and
Pfizer-friendly researchers as chief speakers. The venue? The Pfizer Foundation Hall for
Humanism in Medicine at New York University Medical School.
Since the launch of sildenafil (Viagra) in 1998, more than 17 million men have had prescriptions
written for it as a treatment for erectile dysfunction, with Pfizer reporting sales in 2001 of
$1.5bn.2 The emerging competitors, Bayer's vardenafil and Lilly-ICOS's tadalafil, are likewise
expected to have annual markets in excess of $1bn each.
To build similar markets for drugs among women, companies first require a clearly defined
medical diagnosis with measurable characteristics to facilitate credible clinical trails. Over the
past six years the pharmaceutical industry has funded, and its representatives have in some cases
attended, a series of meetings to come up with just such a definition (table).

Summary points
Researchers with close ties to drug companies are defining and classifying a new medical
disorder at company sponsored meetings

Many critics have argued that the inclusion of FSD in the manual is inappropriate because the DSM is in
the business of pharmaceutical medicalization of sexuality.

Like we’re now starting to frame medicine from a health-first model, second-wave feminism tries to
frame female sexual experience away from pathology

Within the model of health as illness

Took steam in the mid-late 1800s during a period when prostitution was vital to the economy (it wasn’t
looked upon favorable but it was a recognized industry). Suffrage was beginning, women were
becoming more independent, going to school, socializing, working. Birth control methods were
developing. Electric lights were invented so it was safer to be out at night and more women participated
in nightlife. Psychology and medicine were exponentially developing theories on health, but these
experts were predominantly white, protestant, middle-upper class. And they developed false beliefs: It
was thought that sexual acts that could not lead to pregnancy were unnatural – this included oral sex
and masturbation. Great mental exertion is injurious to the reproductive power, and college produces
women with monstrous brains and puny bodies. Women were constitutionally weaker than men.
Women were free from the feelings of physical yearning or sexual desire. This was when “hysteria” was
highly researched and nymphomania became grounds for being sent to a lunatic asylum.

These experts saw the women in the brothels as harborers of diseases and saw infertility and
teratogenic effects of venereal diseases as a manifestation of evil.

Religious temperance was taking hold “fighting” the immorality of suffrage and Anthony Comstock
introduced harsh anti-obscenity laws in the 1870. Anything that could generate impure thoughts were
obscene even medical journals about birth control. It was illegal to give, write about, contraception or
abortion (women’s issues) and then he was appointed to chief postal inspector.

There were also increasing rates of divorce. And women were seen as “the assassins of the white,
middle-class family” “selfish women.” And American Medical journals in 1910s at one point
recommended that physicians should recommend marriage over careers.

Prohibition on alcohol and sex was then enforced, and women were targets of purity propaganda

So women’s sexuality then became a “husband’s privilege to arouse and maintain.” Men often
experienced sexual intercourse with prostitutes before marriage which made them unaware or
indifferent to eliciting female pleasure. Women on the other hand lacked education in their own sexual
capacity meant that many ‘not knowing any better, suffer in silence’; never experiencing sexual
pleasure, some ‘never know the cause of their irritability or hysteria, as it is often diagnosed. For the
woman unable to reach coital orgasm, sitting astride the man ‘is certainly better than titillation of the
clitoris.

Psychoanalysis posited that female erotic zones were vaginal, so that the focus of female sexuality and
femininity was vaginal orgasm.

And in this context, female sexual dysfunction was codified into the first DSM in 1950 as
psychophysiological genitourinary disease which included frigidity which was defined as the failure to
reach vaginal orgasm or absence of desire.

The DSM, changes slowly. And the human sexual response cycle was studied under the context of
dysfunction.

Pharma continues to create a negative culture for sexuality. The corporate sponsored creation of a
disease is not a new phenomenon, but the making of female sexual dysfunction is the freshest, clearest
example we have. A cohort of researchers with close ties to drug companies are working with colleagues
in the pharmaceutical industry to develop and define a new category of human illness at meetings
heavily sponsored by companies racing to develop new drugs.

To build similar markets for drugs among women, companies first require a clearly defined medical
diagnosis with measurable characteristics to facilitate credible clinical trails. Over the past six years the
pharmaceutical industry has funded, and its representatives have in some cases attended, a series of
meetings to come up with just such a definition

Why we are learning this

https://pdfs.semanticscholar.org/148d/01296542724100f8ede59d5bd49e9065493e.pdf

http://www.dbsalliance.org/site/DocServer/Restoring_Intimacy_CSFQ_Handout.pdf?docID=10141

How can we engage our patients in talking about sex? What are things we can say?

When can we integrate talking to our patients especially female patients about sex and sexuality?

Case 1

Goals of this case:

To practice engaging a patient in talking about their sex experience – ask what do you call your parts

Anorgasmia

Self-exploration

Toy safety
23yo female with one 4 year old daughter routine annual. She is single. She has no chief complaint, just
want routine visit including STI screening.

How would you ask this patient to open up about her sex life?

My favorite: Do you have any concerns about sex? – open ended – What concerns, if any, do you have
about sex?

How is your sex life? – can imply that someone needs to have a sex life to be normal

Caution about using STI screening as a jumping point to discuss sex. Do not want to imply that sex is
diseased.

You know, I have been thinking about this a lot. Why is it I only have orgasms with one guy? Sasha’s
father?

What more do you want to know?

I’ve had sex with several guys but he’s the only guy I’ve had an orgasm with. I’ve slept with him a couple
times since we broke up, but I don’t want to be with him like I don’t want to be in a relationship with
him.

I’ve tried to masturbate before, but it’s weird? So I usually stop after a few minutes. I dunno, it’s just
weird. I haven’t tried any sex toys but my friends keep telling me I should try.

It doesn’t hurt and sex doesn’t usually feel bad, and I’m in the mood, I just don’t have an orgasm.

Desire – presumably she’s asking you about it, so she has interest in having sex

Arousal – check

So is something wrong with me? I’d like to have orgasms with a future boyfriend.

Thank you for being so open about your experience. Nothing is wrong with you (say it directly,
immediate reassurance, use her words).

Explore what she has been told about orgasms. Can explore what was different with her and the ex vs
other partners

there is no “right” way to engage in sex and express your sexuality as long as everything
involves consent, empowerment, and respect.
Can talk to patients about their organs
What turns you on? Kissing
Stress and orgasms?
Why might she feel uncomfortable sharing that she hasn’t orgasmed yet with a partner
- Machissimo, too nice, may feel like it is something wrong with her, may feel like
they think it is something wrong with her, may feel like a failure, worry that they
think she’s not into them
2. How to talk to a partner about sex, how might you counsel her to talk to a new partner
Have orgasm before can help take pressure off of the woman to get herself off

How would it feel to masturbate together or in front of have them holding you, could be erotic,
can help partner understand how you like to be pleased
Normalizing, it may feel awkward for many people at first
Finding out what is good for you and communicating that
Do you talk during sex?
Some people only orgasm from masturbation
Make sure to ask why
Vulvodynia
Pg 771

Case 2

Interpartner communication

Chronic disease and sexuality

Sensuality

What are some things you might want to explore with the patient?

If there was vaginal dryness – safety of vaginal estrogen? Lube, THC

If there is pain, vaginismus – trainers, self-exploration, exploration with partner

There is a vaginismus community www.vaginismus.com

Ospomifene, is a SERM that acts as an estrogen on vaginal and vulvar tissue but as a blocker around the
rest of the body – side effects? FDA approved for dyspareunia and vaginal dryness

Kissing zones – folds, nipples

Where

Doing in mirror

What makes you feel sexy, powerful

- Mindfulness, dressing up, writing erotica – narrative med,

Massage
Creating environment

Asking for a date night to help with someone they trust

Using testosterone for desire in women – please don’t

How to talk to an existing partner

Use props - Getting a book or agazine, tv, movie, sex card game

Talk about it while playing a board game – enchanted evening, romantic rendezvous, cosmo’s steamy
sex games

Role playing and practicing language – can we talk about sex, how would you ask your partner to talk
with you about sex, tell me what setting, what you’ll be doing, how you would say it. Practice makes
easier

Get a group together, talk to a sexologist, make it a girls’ night

http://www.wocshn.org/membership-directory/

Go to a conference – lots of free ones in NYC

Babeland, unbound girls

I worry I smell, I worry I take too long

Reclaiming your sexual self wiley & sons 2004

Pg 767

Powerpoint module
https://sciontario.adobeconnect.com/_a1123264708/sexuality/
Safe toys – if cheap, can put condom to minimize toxins
Making sure they are water proof
A lot will say novelty, not regulated
If it’s broken or chipped or whatever, throw it out.
How to clean
vagina that’s been in your booty without thoroughly washing it or swapping condoms.

Lube – chapter 12 – lube for prone to itchiness or fungal infections – try one without glycerin

1800s birth of obscenity laws - Talk about obscenity laws and how they stem from a sex
negative culture and continue to reinforce sex negative culture or male dominant evil woman
sex culture – please fact check
Start with list – focus on those with implications for women

https://observationdeck.kinja.com/the-complete-list-of-weird-sex-laws-in-the-u-s-a-1485048155

https://mic.com/articles/131616/14-outdated-sex-laws-that-need-to-change-this-year-in-one-
map#.E7niyyXER

https://www.huffingtonpost.com/2014/03/14/state-laws-women_n_4937387.html

https://www.babble.com/mom/20-seriously-strange-us-sex-laws/

http://twentytwowords.com/the-most-ridiculous-sex-laws-in-every-state/

Page 956

Missouri – “the privilege of admiring the curvaceous unencumbered body of a young woan should not
be denied to the normal, red-blooded American male

Maine, condoms can only be sold at licensed locations

Nebraska, only physicians can sell condoms

Ohio, it’s illegal for a woman to strip off her clothes while standing in front of a man’s picture

Then talk about the most recent upheld in 2007

Alabama banned sale of devices that are designed or arketed primarily for stimulation of human genitals

William v Morgan

Other concern is language contributing to sex negative culture – chapter 66

Use of the word fuck as an explitive

Calling people by female genitalia

Using sex to argue – suck my balls, cock sucker, why is having sex a put down

Calling people slut or whore

Bitch, ho
Powerpoint 2?

Common myths

Douching - https://health.clevelandclinic.org/2015/03/feminine-odor-problems-what-you-should-know-
about-douching/

Vaginal steaming

Shaving chapter 52

Harm reduction

Women peak sexually in their 30s

g-spot

Kinks fetishes

Resources

http://www.soc.ucsb.edu/sexinfo/

https://www.guide2getting.com/

Talking about sex G2G ch 34