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Thank you everybody for being here with us tonight. We are just waiting uh uh for a few sec for a few seconds so that everybody can join uh our webinar. So let's just wait a few seconds. Uh And then we will start. So thank you very much for being here with us tonight. We have an excellent panel of speakers and we will soon start. Thank you so much. I will also write it in the chart but just remember that this webinar is being recorded. Um So it will be available on the yes system website uh usually in a few weeks at times. So if you're missing some parts, don't worry, you will find it in the recording. So me, do you want to start? Mhm. Um Hello everyone. Um Thank you to ES sm for this opportunity to hold a webinar that facilitates a gap in ong trainees and young specialists. And there I say as well, um specialists of knowledge as well. My name is May and I'm the Secretary General for the European Network of trainees in Obstetrics and Gynecology. A, a is a non-governmental independent and nonprofit association that was formed in 1997 with seven member countries and has since then grown to represent trainees and young specialists in 35 member countries in Europe. Only countries with National trainees Association can become members of a a and they collaborate very close with the European Bo and College of Obstetrics and Gynecology at India initiatives to improve training. So s core objectives is to foster international networking by integrating trainees and facilitating the exchange of ideas, knowledge and experience between the different member countries. We represent the training needs of trainees and young specialists, not just in a PCO but also in our collaboration with other organizations as well. By doing this, we aim to achieve the highest possible standards of training by harmonizing and improving training programs in Europe. The way we do this most visibly is through the an annual exchange and scientific meeting where each country hosts two member countries. Um two members from each member country to experience the healthcare training system for a few days. We also facilitate longer exchanges through our 1 to 1 exchange programs. Apart from conducting and publishing our surveys, members also can pursue their academic and research goals by applying to be a trainee editor for each job and F and vision. The journal of SD the collaboration with ES SM dated to back in 2018 when we were part of a multidisciplinary survey that addresses postgraduate training in sexual health and dysfunction. Thought forward to this year's ES SM Congress 2023 in Rotterdam where we still observed a gap in our knowledge and hemos dysfunctions on a round table session. There is still much work to do and to normalize the training insect dysfunction in our training curriculum. An and ES SM are collaborating to facilitate trainees and young specialists who are seeking to close this gap in training. We have an ongoing competition right now where you can win a preregistration to ES SM Congress 2024 in Bali Italy by following Anto and ES SM accounts like that social media post and make a simple 92nd video on a fact about female sexual dysfunction. The deadline is this week on the first of December 2023 and so you still have time for it and if let's say you didn't win the competition, thanks to SS MN. Top members can still avail of the early but registration rate until the end of this year. So follow our social media to keep yourself up to date on what other opportunities are out there between us and ES sm um to benefit yourself. Thank you. Thank you so much for this um great introduction. Uh Very clear. Now, I see that we have uh Alberto Silva who is the chair of the Yoma, which is the system sexual uh young sexual medicine section. So maybe Alberto, if you want to say a few words, then we can start with our speakers. Uh Thank you everyone to join this webinar. Uh This is our first webinar. We then talk the, the main cause of the YMA is to engage young health professional um interested in sexual health. So, creating a new networking education support and uh making the bridge be between the S SM the activities and some X SM uh committee to uh facilitate a little bit more than the the flow of the information of the new um the new information in sexual medicine in the Professor Jo Giovanni, they have already present a lot of activities and that s sm promote during this year and tried to, he is trying to join and bring more activities. And next year probably we have more, more information and more activities that uh will improve the, the presence of, of young uh medicines, uh uh medicines uh working in that in this area, it could be uh uh physicians but uh uh the already uh psychiatric uh physiatric uh and or others, others are trying to enlarge the the precipitation in sm for the, the next session, we'll the first speaker will be sober and thank you for, for joining us in the this webinar. Uh We have some, some information about you. So uh you have this experience to dance, uh dance, um movement therapy and um uh therapies in cert 56 therapies. So uh we hope this will our serve to, to evaluate research in your prof professional journey. Uh and the care of provide to our patient. So please, you have the words. Thank you very much. Uh Does everyone hear me? Yes, we can hear you very well. So feel free to share your screen and start your presentation. Thank you so much. Ok, let's do this. Uh Is it on a uh uh the right mode? Exactly. That's perfect. Ok, so good evening. Thank you very much. Thank you very much for the introduction. Uh As, as um Doctor Silva said, my name is Shit Sperber. I'm a dance movement therapist. Um And I'm a certified sex therapist. I work in rehabilitation uh clinic in a sexual rehabilitation clinic and in clinic in Tel Aviv, Israel. And tonight I'm here to talk to you about how we talk to our patients about sex. OK. Second, let's move this so I can see you guys better. Yes. So when you guys hear the word sexuality, what comes to your mind? You can write me here in the chat. Maybe I'll see uh what, what the words, what associations come up to mind to you when you hear the word sexuality. So usually what people will tell me is arousal, erection, a vagina, penis, vaginal lubrication, semen orgasm. Lots of words that have to do with sexual functioning. That's usually what people say when they hear the word sexuality and I want us to think a bit wider and bigger. So let's go on and see what the world Health Organization, how it defines sexuality. So World Health Organization defines sexuality as an inner energy, pushing us to find love, touch, warmth and intimacy. And let's think about this definition and see how much broader and wider and bigger it is than just sexual function. Ok. So when we're talking about sexuality, we're talking about attachment, we're talking about relationships, we're talking about intimacy. We're not only talking about body parts and uh physio uh physiological functioning. And here there is another um uh definition for sexuality. Sexuality is accomplished and multi fascinated broadly composed of psychological um a a sociological interpersonal identity and social political phenomena. OK. We're talking about something really broad that touches so many aspects of our life. We're talking about our psycho, our psychology. We're talking about sociology. We're talking about culture. When we talk sexuality, it's so much impacted by the culture we, we've been raised in and that we live in. So we're talking about something really very, very wide. Let's talk about sexual health. What is sexual health? So world a a health organization's definition for sexual health is a state of physical, emotional, mental and social we wellbeing in relation to sexuality. It's not merely absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, excuse me, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion discrimination and violence. So when we're talking about sexual health. Also, we're talking about something wide and broad that say that allows us quality of life and safe, happy, pleasurable sex in this context, it's very important to me as an Israeli sex therapist. Uh To mention that on the seventh of October, I don't know if you know Israel now is in war with Hamas. Uh and on the seventh of October, we had a mass terror attack by Hamas from Gaza and there was a use of sexual violence as a form of terror. So when we're talking about sexual health and sexual wellbeing, we're talking about also this, II, feel like obligated to mention what's happening in my country now. And I'm sorry for mentioning something so, so painful. Let's get back to our presentation and we're talking about um healthcare professionals. And I wanna ask is sex important. So this study was published in the journal and Family and Productive Health in 2009. And a global survey was um undertaken using the internet to assess 26,032 participants across 26 coun countries that completed a set of questions online. Three in five people agreed that sex was important to them. With nearly one in uh three, strongly agreeing with the statement, sex was important for both men and women and remains important as people grow older. 69% of respondents agree that sex is fun and that they enjoy sex. And two thirds agreed that a good sec life is vital part of life, of which a third, strongly agreed, strongly believe. In addition, 56 of non sexually active individuals agree with this statement. Ok. So people say sex is important to them. People say it's pleasurable. People say it's fun. Also, people that aren't sexually active say that they think sex is important. Ok. So according to this study, this a very big uh global uh survey sex is important to people. Let's talk about sex and wellbeing. So this study um uh that was published in 2013 is about positive sexuality and its impact on overall wellbeing. And let's see the conclusions, the evidence described in this uh review, illuminate it illuminates how positive aspects and experiences of sexuality are inter blind with a range of health outcomes. So good sex makes us healthier. OK? It makes us feel better, it makes us healthier. So yes, sex is important and this uh image was photographed by a photographer called Jade Bell. You can find her on Instagram and Facebook. I love her images. She has very beautiful sex, positive body, positive um work I like using things that she makes. OK. Now we're talking about you guys here in this lecture, are a gynecologist and urologist and in healthcare professionals. And this study shows patients expect gynecologists to approach the topic of sexuality because they don't bring it up, they don't bring it up themselves, the issues that relate to uh to sexual functioning. Ok. So patients are waiting and expecting for you guys to bring up this topic. This uh a study was published in women's reproductive uh health journal in 2020. So, and there's a mismatch because patients are waiting for gynecologists to talk about sex with them. And gy gynecologists don't do that what we don't talk about when we don't talk about sex. This is a study published in the journal of sexual medicine um in 2012. And it says as follows in a uh 2012 American study, gynecologists were surveyed about their practices inquiring about issues related to sexual function. A total of 1154 gynecologists were surveyed with 53 being men. The survey included several topics, one of which was the routine assessment of patient sexual activity. The findings revealed that only 40% of gynecologists asked about sexual problems, inquired about sexual satisfaction, only 28% sexual orientation or identity, only 27%. And this is shocking enjoyment of sexual activity. Only 13% of gynecologists ask. Ok. So we understand from the study before that our patients are waiting for us to ask them about sex. And we understand that most healthcare professionals don't ask. This study was published in the journal of sexual medicine in October uh 2016. And it's a uh um uh study, an American study involved a sending questionnaires to medical students to assess the frequency of inquiring about sexual function, their attitudes to towards the subject and factors influencing their willingness to discuss sexual problems with patients. The study found that medical students don't uh routinely ask patients about other sexual dysfunction despite believing it falls within the a preview of doctor's practice. Ok. So medical and students believe they're supposed to ask their patients about sex and still they don't do it. These results uncover the importance of including the topic of sexuality and methods of inquiry in medical school curricula. So what we've established till now is our sex is important. Sex is important to people. We have 26,000 people that answer that, you know, our patients are waiting for us to ask them about sex, you know, um that um that uh gynecologists don't ask about sex and that um um medicine uh students also believe they're supposed to ask about sex and they don't do it. Let's talk about when we're talking about sex, I wanna talk about the biopsychosocial perspective. It's very important because sex is like uh a junction of all these three aspects. So when we're talking about sexuality, we have the biological part which is influenced by hormones, physical health, illness, genetic predisposition disability, we have the social part, sex education, culture, peers, family circumstances, and we have a psychological interpersonal part, self esteem, body image, temperament, emotional regulation, coping skills, social skills and in the middle, all of this is sexuality. It's influenced and impacted by all these aspects. So tell me how we actually talk with our patients about sex and we're gonna take um a, we're gonna talk about the LICIT model. The pit model was a formed in 1976 by Jack Allen. It's pretty old, but it's still very practical and we apply it when we use a interventions and sexual issues with our patients. So pit stands for P permission L I limited information, specific suggestions and it intense therapy. And I want you to see that the model is like uh an upside down triangle. And what that means is that if you, when we see patients dealing with sexual issues, most patients, if we, if we uh give them permission to talk about sexuality and probably limited in information, which is psychoeducational. Uh um it, it sexual education that will be enough for them, fewer of our patients will need specific suggestions, which is basically sexual counseling and much less will need sex therapy. Most of our patients that we just educate them about said sex, given some counseling, it'll do enough for them. Some of us of them will need to um send to sex therapy. So in order to see how the uh pleaant model it works and how we apply it on a case study, we're gonna take a case study from the Netflix Series Sex Education. I hope everybody here has seen it uh because I think you can learn a lot through the series and it brings up, first of all, it um brought a lot of awareness to sexual i issues and in very wide media. And also I think it deals with not easy topics in a nice, a gentle full of humor way. So let's talk about Lily Lily from education. Li Lily deals with vaginismus. Vaginismus is AAA is described as an involuntary vaginal muscle spasm, interfering with sexual intercourse. So I don't know if you remember, but Lily is very sexual. She has lots of sexual fies. She writes of comics uh to erotic comics about uh her sexual family disease and what she wants more than everything is to lose her virginity. And she tries to find a partner that will agree to lose her uh to help her lose her virginity. She tries with Otis and they're getting into, they're trying to have touch and get her out. But Otis has a flashback from his father uh having a out of marital marital relationship and he, he can't do it. And Lily is very, she's, she's frustrated, she's looking for someone to lose her virginity with. And then Miss Patty, she meets this guy, octo guy uh and uh he's into it and she's role playing in costumes that she gets everything ready and they're in the bedroom and he's about to penetrate and he tries and she's in pain and she can't have intercourse, her vagina and her uh pelvic floor muscles contract there's no way to have intercourse. So Lily needs to, to seek some uh some uh counseling guidance. So the first layer of intervention when we're talking about speaking with patients about their sexual issues is permission, giving them permission to talk about sexuality. And I bought this uh image of Otis and Adams sitting in the sex clinic in the back bathroom of Om high school because what Otis basically does is first of all, gives the other students the permission to talk about sex to bring up sexual issues. Questions, thoughts. So when we're talking about permission, we're talking about creating safe space for our patients to talk about their sexuality. And how do we do that? We can ask them. First of all, we ask their permission to talk about sex. We say I'd like to ask you about your intimate life. Is that ok with you? And we're gonna see, they might say yes, they might say no, if they say yes, they're letting us in and then we can ask them, how's it going? And is everything ok? Are you dealing with pain and it, you, you just, we're talking about um a female lifespan, you've just had birth is everything thing. OK. How's it going? We're gonna allow them to talk about their sex life. That's permission. We ask them for permission, we talk about it and we show them we're a safe person to talk about sex life. Limited information. So really wants to have sex. But she can't, at least not sex that includes intercourse because she's in pain and because her vagina is contracting. So, first thing we, we wanna do when we're talking about limited information, it's psycho education, sexual psycho education. Many of our patients need to be sex, uh uh educated about sex. Most of us grew up in an environment that didn't talk about sex, not our parents, not our teachers, not our counselors. Most of us grew up and let's put it this way with a bad sex education and some of our patients just need to get limited information. So for example, the woman that's dealing with evaginate this or dys, first thing we'll tell her is sex isn't meant to hurt if we wanna talk about the biological. Remember the biopsychosocial perspective. So if we wanna give her limited information from the biological um uh aspect, we'll say the vagina is large enough to contain a male penis when you're sufficiently sexually aroused and wet. The penetration shouldn't be painful. Ok? We're telling her sex isn't supposed to hurt ever. If you wanna talk from um psychological uh um perceptive, we'll, we'll explain to her about the cycle of pain and avoidance. I'm not gonna get into talking about the cy cycle of pain of a woman and avoidance because the amazing doctor Laura led will be talking about it afterwards. We'll explain her about that and we will tell her usually women that are dealing with pain in, in, uh with this peria, they also lose, lose sexual desire. So we're gonna tell her it's very logical that you won't wanna have sex. Sex is painful. So we're educating her about sex and about pain. If you wanna talk from a social perspective, we're gonna tell you, you don't have to have sex when it doesn't suit you. You're allowed to say no. Most of us women still are raised in a misogynist Chavin uh environment and culture that expects women to be always sexually available for their partners. And we want to empower women to know they can say yes, they can say no, they can say whatever they want. OK? So this is all limited information about sex. First degree of intervention, second degree of intervention is specific suggestions. We're talking basically about sexual counseling. So if we wanna talk about it, oh And if these images you're gonna see Lily and Ala, Ala and Lily start dating. You see here, Lily holding a vaginal dilator that you can practice with on the pelvic floor muscles. I'll tell you a secret. She tries, she doesn't like it, she doesn't enjoy it. It becomes like something she doesn't want. In the end. The picture, the image you see in the bottom is Lily and Ala after they have both orgasm, they just decide that they're gonna masturbate one next to each other. And that's the way they have sex at some point. They start trying to have a penetrating sex and they go for something else. So if we're talking about specific suggestions from a, a biological uh perspective, we'll tell the, the uh patient, as long as there's pain, avoid intercourse that includes penetration. From a psychological perspective, we'll tell them penetration that causes pain can lead to increased vaginal tension, making the experience even more uncom uh comfortable. Therefore, it's advisable to address the pain before attempting penetration. If we're talking about um sexual uh counseling, we'll tell them they can use dilators and try to work on controlling the uh pelvic floor muscles. If we're talking from a social and cultural uh perspective, we'll tell uh our patient that sexual activity that doesn't involve penetration is considered sex because again, we grow and we all were raised in a uh a culture and a social environment that doesn't count any forms of sex that don't include penetration is sex. And we're gonna teach our patients a very about very erotic noninvasive sex, which is what Ala and Lily did in. Then you tell them, OK, until we treat the pain in many ways which Doctor Laura Zz will tell you about. We're not gonna have penetrative sex and you're gonna have a great time anyway. And intensive therapy. So, intensive therapy is the deepest form of uh intervention in sex therapy. And I brought here two images, one of Doctor Jean Milburn, the mother of Otis in sex education. And in a few of the uh scenes in the, in the, in the series, she does, you, you can, you can see how, how she does um de sex therapy. So depth sex therapy is psychodynamic therapy that aims to uncover the root causes of the sexual symptoms. So if we're talking about intense tense therapy, we're not, it's patients that we feel that just educating them or giving them some counseling or some tips, it's not enough. There's something underneath um maybe subconscious, maybe just a little bit more covered that's causing the sexual dysfunction. And I brought this image of Lily up the hill. I don't know whoever saw the uh series and Otis tries to give Lily intense therapy. He says you have to let go, you have to open up, you have to um uh let go of control that he wants her to drive down a hill. He thinks that will make her uh pelvic floor muscles, uh uh relax, it doesn't work. Of course, only professional um uh people that have got um psychotherapy training can do intense intense therapy. So sometimes medical doctors aren't um uh um qualified for that. Sometimes they, they are, but that's basically the, the last and deepest um form of intervention. So I'm gonna go back again. We're talking about the licit model. That's, this is how we talk about patients about their sexuality, permission, creating safe space and asking for permission from our patients to address sexuality, limited information. Um A sexual psycho education, specific suggestions is sexual counseling and intense therapy, is psychodynamic therapy trying to uncover the hidden more um or covered causes for the sexual dysfunction. Thank you very much for being with me. These are my contact. Uh My contact, my email is here. Any questions? Uh Feel free to write. Thanks a lot. Good evening. Enjoy the rest of the speeches. Thank you very much, uh MS Shea Weber. Um So our next speaker is Doctor Laura Robins. She is a uh an obstetrics and gynecology specialist with a background as a graduate of the training called uh Forex therapist. She also as the director of the Gynecol Sexology Clinic and provides sexual consultation services today. She will enlightens on the female sexual dysfunction in the reproductive years, the diagnosis and the management screen sharing her uh extensive clinical experience with us. Thank you. Now, you may want to turn on your m just unmute myself and now I'm going to share my screen. Hold on and, ok, so one second, just to remind everyone that you have any questions, please write them in the DNA box. Hold on. All right. So uh can you hear me? Yes, we can hear you very well. Now, go ahead. Ok. So um my name is uh doctor Laura Zell as they uh just uh previously introduced me. Um And they actually already gave a, a background. I studied sex therapy in a tela shower hospital in Israel and I have two gyneco uh sexology clinics in Jerusalem. Um So let me uh spoke a little bit about it at the beginning, the situation that we're in right now uh being in Israel. Um and I had to, I couldn't really speak about the, this lecture without giving a little bit of um what's been going on in Israel and how it relates to the whole situation. Um The fact that uh since that when I was first invited for the lecture, it was before the seventh of October, before we were at war. And there's been a tremendous amount of um sexual violence towards women, young girls um having to do during this war. And also, um of course, there's been um terrible murders and uh abdic and um uh kidnapping and even now there's almost 200 hostages in uh Gaza. And I couldn't uh start this lecture without talking about that. I think uh that it's at least as important about what I'm gonna be talking about. Um I was asked to speak about the topic of female sexual dysfunction in the reproductive years, uh diagnosis and management. And um I'm uh excited to speak to young uh trainees in this subject because just like we discussed in her lecture um that we don't otherwise often have a lot of information as obgyn S. So, what I'll talk about today is uh sexual dysfunction on a timeline. Um Why do medical professionals often uh avoid talk about sexual dysfunction. Uh according to the DSM classification about uh female sexual dysfunction, uh the biopsychosocial model. Um If you've ever studied anything with the ES SM, they told us that we have to, if they wake us up in the middle of the night, we should remember, biopsychosocial um practical recommendations about how to bring up the topic, a few case presentations and then uh some options about changes in sexual repertoire, practical recommendations for medical professionals and at the end of take home message and my contact information. So if we look at a scale on a timeline, um there might be starting from the left technical difficulties with uh intercourse or even infertility due to lack of education, there might be pain with intercourse otherwise known in dyspareunia. And that could be upon the penetration or friction or in the depth. And you might wanna think about things like endometriosis, uh anorgasmia or painful orgasm. And these can happen at any stage of life. But as OBGYN S typically, uh you might um be dealing mostly with the physiological changes around childbirth. There might be lots of myths like um a lot of patients have been told, oh, after you uh give birth, all of the pain will go away. But the truth is that after birth, there might be stitches, there might be breastfeeding and contraception and the baby might be sleeping in the same room, et cetera. And these can cause all sorts of dysfunctions. There can be changes after illness or like in oncological patients uh or in degenerative diseases or neurological diseases such as MS. And there can be changes uh after menopause or even surgical menopause, which is the topic of Sonia's last lecture, the last lecture. So why do medical staff often avoid talking about sexual dysfunction? Uh So let me mention some of these things. Uh lack of time or more urgent problems. Um Unfortunately, sexuality is treated as a luxury. Sex therapy is often not covered by insurance. The lack of knowledge or the embarrassment about to talk about sex, sexual uh function and thinking this is the main problem that if the problem bothers the patient, they'll raise the issue. So this happens to be a caricature. But it shows the doctor saying, oh, if there's a problem, I hope he brings it up. And at the same time, the patient is saying, I hope he asks me. So, what is this classification of the DSM? Uh This is from the DSM five from 2013. Um And it divides the into categories of female sexual interest or arousal disorder, which include high uh desire and arousal disorders, which are put together as one uh in the DSM five female orgasmic disorder and genital pa pelvic pain or penetration disorder. G PPD, uh which includes the dyspareunia, which is painful intercourse and vaginismus, which is the spasm of the outer third of the vagina that interferes with intercourse. And here you can see some of the muscles that are involved. So according to the biopsychosocial or also cultural models, what I explained to my patients is that I'm both a gynecologist and a sex therapist. And so I treat the problems as physical and emotional or psychological. And I explain that we often have to go back in order to move forward. We wanna get a good sexual background, history, the religious or conservative background, we wanna know if they have any myths about sexuality or about uh masturbation, for instance, and there's significant prognostic reference of sexual function before the disease, the birth or menopause. Um And so we wanna match expectations with the patient as well as with the partner and that as well. If it wasn't so good before the disease or before the birth, then maybe it, it's hard to expect it to be really good now. Um But also uh to, to know that there's no quick fixes and it takes time in patients. And I wanna try to attempt to recruit the partner. And I like to explain to my patients that the problem is a couple's one and even if it's painful, let's say for the female, the partner is also causing the pain and that's also a difficult position to be in. So I wanna ask the patient, what her, what their goals are from therapy. Um So this is uh actually uh taken from the No VC, which is uh a OBGYN um textbook. And it's about how to bring up sexual dysfunction by the medical team. So you can ask just an opening questions. Do you have any sexual concerns now, such as pain with intercourse, last lack of arousal or lack of enjoyment? And if they say yes, you can say I'll ask you some more detailed questions now or at a later visit. And if they say no, you say that's fine, sexual problems are common and most can be helped. And that as uh we were just discussing before and that's the permission. Um So here are a little bit more advanced questions about exactly when the pain is experienced, also taken from the nova. Um But even more important is exactly what from exactly when the pain is experienced is actually when the pain is not experienced. So, if it wasn't uh uh there were occasions where there was less pain, what was different? Was it a different um position for instance, or was it a different time of the cycle cause it's important also? All right. So I'm gonna talk just a little bit about a couple of case presentations. The first case is um 20 year old girl uh woman. She came in, she's Ultra Orthodox. She has been married for four months. She's on oral contraception because she's a carrier of a genetic disease and they need to do preimplantation. Genetic diagnosis of PGD before getting pregnant, she had low compliance with oral contraception, meaning she kept on forgetting the pill and she wanted to try NuvaRing, but it slipped out the gynecologist that a different gynecologist tried to examine her. And then he referred her to me and she described that she was having pleasure and that there was friction at the beginning and then she used lubricants, but now there's no need. So when I first examined her, what I saw was there were very enlarged labia Majora and it was technically difficult to examine her. So then I handed her a mirror. And what I found was that the friction from the quote unquote intercourse was actually her partner was just between the labia and he actually hadn't penetrated the vagina at all. Um So again, with the place model, um what we wanna do is we wanna normalize the situation and give the patient reassurance or permission. Uh We wanna try to avoid judgment as much as possible. Uh And then of course, give uh explanations of the anatomical structure and sexual education or limited information. So what I offer my patients often is a guided tour or a geographical tour and it depends on the patient's ability, but I offer for her to hold a mirror and then I showed the anatomy with AQ tip. Um she can uh point to the location of the pain, which can also might help with the diagnosis and you can use a clock, for reference, for instance, if we say six o'clock. So let's say over here that would be at the four she at the entrance of the vagina, which happens to be this pace place where it is the most common of pain. And the patient can give a pain score between zero and 10, how much it hurts. And that allows a follow up on the complaints and a referral to other consultants. And you can offer a patient before they get married or before the first sexual intercourse is preparation and guided tour. Um Sometimes I give Q tip exercises because there might be a misconception about the anatomy or the vaginal size. Um and she can put it in herself and see that it's not actually blocked. So it's good for patients with uh vaginismus as well and she can move it from side to side and see that there's actually room inside. So on sexual education or the limited information, we talk about the basic anatomy. And then I also wanna talk about pleasure. So we talk about the clitoris and the very what we see at the edge is the only very small amount of the clitoris. We talk about how the clitoris is actually the whole uh involves the whole area of the vagina. Um And so we wanna talk about touch for instance, and I like to compare the fact that the, the clitoris is actually um equivalent to the glands of the penis and just like a man might not enjoy direct touch on the glands, tapping even a lot of women, it's are too sensitive, direct touch on the clitoris. And so you wanna touch more like two fingers or a whole hand. Um And what's important to note is the fact that little boys are encouraged to touch. They know that it feels good because they have to hold their penis when they urinate. But little girls are told not to touch the area because it's dirty. Um And so it can cause a lot of problems of women that haven't actually looked at themselves ever almost. Um And I also wanna talk about a female orgasm and about the average time that it takes, the average time is seven minutes and it's seven minutes of total focus, which means that if you start thinking about the dishes at the same time, you have to start the count over again. And then I talked a little bit about sexual positions depending on the patient, how detailed the, the, the drawings I wanna show and um give them some uh options for that. Ok. So the second case is a 24 year old woman. Uh She was married plus one. She was referred because of dyspareunia as well as aenia aenia is pain with contact, that's not supposed to be painful for instance, wiping in the bathroom or sitting on her partner. And she came five months after giving birth she was breastfeeding and non progesterone only pills and she described primary dystonia meaning it always hurt. Uh but it's getting worse. So the first thing that we wanna do is stop the pain and prohibit the entrance of the vagina. What I explained is that it's closed for repairs. So that during the counseling process on initial exam, there were signs of vaginal atrophy. I'm just reminding the physio the physiology that means that there's an increased ph normally the ph of the vagina is, is a is acidic. Um But during breastfeeding because of prolactin and because of the progesterone only pills, um there's a decrease in estrogen and so there are signs of atrophy. Um There's a, I also saw an exam that there was increased pelvic floor tone. Um and she tried to close her legs when I was examining her. And um so the diagnosis was also vaginismus. And what was really interesting was that the allogen disappeared almost immediately after stopping the entrance to the vagina. And so I explained to her, the physiological and anatomical um reasons and the pain cycle which we'll just talk about. And then on the medical aspect, I changed the progesterone only pills to combined oral contraceptive, giving her some estrogen. And when she stopped breastfeeding, there was uh um endogenous uh estrogen that came in and as well, she worked on pelvic floor physical therapy and working with vaginal trainers. Um and another thing that we worked on was what's called sensate focus, which is an exercise, having a partner, couples touch exercise. Unfortunately, we don't have time to go into the details, but you can certainly read about it. So this is the cycle of pain. And I think this is a really important slide. Um There are a lot of different reasons for pain. It could be because of stress or lack of education. There might be because of physiological reasons, like in this case, after pregnancy or there could be trauma after some uh assault. For instance, for whatever reason, the body tightens the vaginal muscles and the tightening makes the sex painful and it might even not be possible to penetrate. And the problem is that each time the reflex of, of the muscles to, to contract is even worse. Meaning that each time it's more painful than the time before which of course causes the situation of trying to, of, of wanting to avoid intimacy and lack of desire. Um And it because why would you want it to, to have desire if it's painful? And unfortunately, what happens is the body comes to associate sex with pain. So what I did was try to explain to her that the body is functioning in her benefit. Then until the touch is adjusted or until she processes the negative experiences, there should be no entrance to the vagina. And the basic guideline in sex therapy is that sex is not supposed to be painful. And if the intercourse is painful, it should be avoided. And unfortunately, I still have colleagues that I've heard that say, oh, just continue if it hurts or overcome the fear, all this does is cause there to be a worse cycle of pain and a worsening of the problem. So what's important is that satisfactory? Sexuality doesn't require uh entrance to the vagina. It doesn't require intercourse, at least not at the beginning. And Gla boner who is my supervisor, according to her approach, she talks about it as a menu that there's a rich sexual menu and it's important to teach and support GERD outer course. So what's outer course, outer course is kissing uh role playing sex toys, bathing together. Everything else you can imagine except for penetrative sex. So what we want to encourage our patients is to make room for changes in the sexual repertoire. So, for instance, in a patient after breast uh surgery after mastectomy or et cetera, um you wanna use things such as a body map as you see here on the side, a body map is actually taken from trauma work, but it can easily be applied here. Uh red is areas that are off limits. Uh yellow is areas that sometimes you can touch and sometimes you shouldn't and green are areas that are ok to touch. And so in the case of a mastectomy, for instance, then maybe for that patient, the breast will be red. Um if there's a decrease in desire, we wanna match expectations. So you have a lot of patients that come home, they come uh to me and they expect to have uh come home from work and to jump on each other. But the truth is that most people, it doesn't work like that. Um You have to talk about timing. If you're trying to only have intercourse at 12 o'clock at night, uh after a work day, then maybe it's not gonna work. So you wanna try to plan when it's good for both partners and you also wanna talk about the setting, maybe change the sheets, maybe light a a fragrant candle, uh put in lingerie, maybe use some cologne, all sorts of things to try to get in the mood. But it's important also to consider taking turns. Not each partner wants to have the same thing always, especially if there's um disease or, or illness around that time. So maybe one partner, it's good for them to have or to receive oral sex and the other one just wants to cuddle or have a or have a massage and that's ok. Um And we also wanna be able to introduce vibrators if the strongest stimulation is needed, for instance, in neurodegenerative diseases. And when there's pain at the entrance of the vagina, there's different types of treatment. For instance, lubricants, the nonhormonal such as almond oil or Ky jelly moisturizers, most moisturizers such as Gyno or Vain uh occasionally numbing cream for the entrance, like lidocaine gel, azarine or other preparations including uh pain, uh reduction medications and, and um muscle relaxants. And of course, there's hormonal therapy when that's in, uh, when that's uh indicated and I'm sure that Sonia will discuss that in her lecture. So, some practical recommendations for the medical team. Uh, most women experience a gynecological exam exam is unpleasant. Um, but explain that it's not only for her, but it usually shouldn't hurt the normalization as we were talking about the permission from the pit model. Um Speaking of permission, always ask permission to examine the patient. Um, if part of the exam is gonna be painful, you should give a warning beforehand such as stripping, um and um, obstetrics. Um and you could, should offer an exam with a mirror, you can buy one and have just a handheld mirror in your clinic. You wanna offer the woman to insert the vaginal speculum or the transvaginal uh ultrasound transducer if she wants to. And most important is to explain that she has the right to stop the exam at any time if she wants to. And if a patient requests to have an exam under anesthesia because it's too difficult for her or with sedation, you can explain the pros and cons, but you shouldn't examine her without sedation if she insists. And so a final take home message that sexual problems are common in various periods of life. The problems may arise or get worse around medication or illness or trauma. And it's important to know that there are options and clinics for referral and hope for the future. Don't assume that if the problem bother the patient, she will raise the issue. Sometimes the medical team will uncover the problem that was not disclosed to the attending physician and open the door to conversation, which is the importance of a multidisciplinary staff and it it's OK not to treat the problem yourself but to know when to refer further. So thank you. Uh I like the sexes like math. You add the bed, subtract the clothes, divide the legs and pray you don't multiply or sometimes maybe pray you do and this is my contact information if you want to uh get in touch uh um any questions or comments about the lecture. Thank you. Thank you so much, Laura. This was very interesting. So maybe you can stop sharing. May. Mhm. Mhm. Hold on. Where is it? I'm still sharing it. I don't see myself sharing it like a black uh like a red tab on your uh stop share. Hold on, sorry. OK. Thank you. OK. Thank you. Thank you very much. And now we are going to the final speaker, Doctor Sonia a she's a senior specialist in URCO uh unit and Secretary of Clinical Sexology Working Group in on hospital Clinic of Barcelona. Uh He's she's already uh associate professor in University of Barcelona. Too, uh agree to research in gynecology, endocrinology and human Reproduction Group. So we are helped, we are uh enjoying that she can share her profound knowledge and experiencing female sexual dysfunction in here, diagnosing and management, offering a comprehensive view on critical topics. Thank you, please, doctor. So I want to share my presentation. No, that's perfect. OK. So first of all, I want to uh and thank you to S SM and talk and Sema especially May and Alberto to and uh give me the opportunity to talk about se female sexuality in the years. I will also uh thank the, the attendees for sharing your time uh with us and also able to thank to Laura and Suid because they make easier my presentation because you talk out the key points out of your, so your uh model and all uh the information that you give for female sexuality and, and how to attend. The women are also uh uh valuable for positive PPR but I will try to focus and be uh first. So what does mean for years for our women? No, maybe we have to think it's only menopause that is as you know, perfectly the end of the menstruation after 12 months of, of amenorrhea. And you know, it's a physiological phenomenon secondary to normal process of the loss of ovarian follicular function. Um but not only menopause has a, has a role in years. Maybe aging should be considered. Aging is a gradual accumulation of a wide variety of molecular and damage which involve a general decline in the capacity of the individual and that can affect the sexual sphere. And as a healthcare professionals, we should be aware of healthy aging, which is defined as developing and maintaining the functional ability that enables wellbeing. So let me um explain that uh a good sexual fashion, a positive sexuality, it's uh related with our best well being. So we have to focus with this healthy aging also in the sex and the sphere. But we also should consider frailty, frailty is another clinical condition characterized by an excessive vulnerability of the individual to endogenous and exogenous stressors. And this status generate a high risk of developing negative health related events. And obviously, it also can affect the sexual sphere, but this life stays for 50 years. And these three phenomenon, menopause aging and effect and frailty are not only a biological process. And in that, in that stage of the life also converts a critical period involving involving psychological and social phenomenon. The women will experience all changes, games and losses, coping strategies. So, as has been said, uh in the previous lecture, we have to be uh uh more open mind and, and take uh more broader broadly aspects of the sexuality, not only in the, in the biological aspects and all. And it's really important in, in this uh life stage because the women are experiencing a lot of changes and how they address all these changes may uh have an impact on this, on their sexuality. So, and we, we have to uh assess each women because each women can experience this uh life stages differently and try to understand if uh they are experienced or not any impact on their sexuality. And we have to know if the, if that impact is positive or is negative. And maybe we have to think not only in the uh sexual function, as have been saying in the, in the first uh lecture, not only in the, there is sexual dysfunction. How is the sexual response? Maybe we have to think about sexual activity and activity and sexual of kind, different kinds of sexual activity, different, different kinds of sexual behaviors. So I move on. Um I want to talk first about menopause and most of the large, the largest longitudinal studies suggest that advancing menopause status has a negative effect on sexual activity and sexual function. In that study from s uh as you know, um there is uh a clearly different um in between premenopause and early and late per postmenopause, the desire and arousal is decreasing. Contrary, the pain is increasing and when the authors uh perform the Multivariate analysis, this difference continue uh with the, with the transition to the menopause. Contrary, as you see in the, in that uh graphic the interest on sex and the masturbation first has a, a little increase in the early per perimenopause, but then decrease in the postmenopause. But when they uh perform the Multivariate age, not only by menopause and, and, and they consider the age and health and other uh psychological aspects. They didn't find um a statistical uh significant difference uh in the multigrade analysis. So maybe not only the menopause are related to interest of sex in that other um larger study from uh Nicolosi on 2004, uh performing more than 27,000 participants in 29 countries around the world, uh which include women and men from 40 to 80 years and analyze sexual behaviors and sexual dysfunction. If we focus on women, 66 65% of women reported to be sexually active in the last year. And if we focus on the elderly, the rate was 21%. So the authors conclude that sexual desire and activity are widespread among middle aged and elderly women worldwide and persisting to all age. And the in fact, 76% of the women uh reported that sexual activity is essential for self esteem and to maintain a relationship. So it's also important the sex, the positive sexuality is also important for uh women in the years. Contrary to that, only 23% of the participants of the woman uh agreed with the sentence older people no longer want sex. And 60% declared that they were in favor of the use of medical treatments to help older people enjoy sexual activity. So there is an interest of in sexuality also in older people. So we should uh be aware of that. As a healthcare professionals. If we focus on sexual function, the authors uh conclude that a lack of sexual interest is the most prevalent sexual dysfunction among all the including the elderly. But if you uh see them, the most sexual dysfunction affected by the age was lubri uh the lubrication, difficult difficulties but c this is um based on s on sexual symptoms, but it is not based on, on the stress about these sexual symptoms, as you know, and this uh um report previously by, by laura female sexual dysfunction definition require this stress. So maybe symptoms increase with age but probably the stress decreased, as was stated in the, in this other publication on menopause on 2006 where you can see uh low desire increase with age, but the stress of that symptom decrease with age. So it is important to uh ask not only about the present, the absence of any sexual symptom but also the distress that the the the women experienced by it. Um I want to al also to show uh uh this other cross sectional study based on 2000 participants, half of them women from 18 to 91 years, 91% were heterosexual. 3.6% homosexual, 2.8% bisexual, 0.8 asexual and 0.8 others. Uh based on a national survey in United States to analyze sexual behavior. I said previously that maybe it's important not only focus in t as in the sexual response, sexual dysfunctions, but also considered all sexual behaviors. Um Unfortunately, solo sex uh of that sample was not sorted by age. So we don't have information in the, in the productive uh women. But if we focus on partner sexual behaviors and in women, in women about fifties, we see we can see that the most frequent uh sexual behavior was vaginal intercourse. We have, we should consider that maybe here we have a v uh Yes, because the, the sample was mainly heos. But we have also, we can also learn that gave partner oral sex or receive oral sex have also really frequent uh us a va or injury for a partner or masturbated with someone else who are also um sexual behaviors in more than tw than than 50% of the, of the uh participants fifties and uh focusing in elderly uh women about seventies also read erotic stories, watch sexually explicit videos and the, and flirt with someone over a chat. So, um masturbation in front of a bar or use an anal sex toys or receive anal sex were less frequent but are also uh present in, in this, in this report years. And we should be ca caution because I tried to summarize the most frequent sexual behaviors reported by this sample but also the women uh about fifties uh span or women span during uh are interested in doing sexual activity. Want to role play with a partner, receive n or semi photos uh enhanced with pills or, or supplements, had sex with someone over face, facetime or Skype and had group sex. So it's important to ask each patient how experience their sexuality because these are only rates, but we don't know the women who enter in your um in your consultation, uh how experience their sexuality. Er If we don't ask considering frailty, most of the studies su suggest that frailty has a negative effect on sexual activity and sexual function. The challenge caused by disease may be more strongly associated with sexual problems than age itself. Frail females had 1.69 times higher odds of negative changes in sexual functioning and frailty was significantly related to a negative effect with sexual activity in this study. Um The authors also uh tried to analyze the effect not only um uh the effect of frailty in sexuality and try to change the direction and, and analyze the effect of sexuality in frailty and of no sexual activity and affective relations has a positive effect on quality of life and frailty. So the authors conclude that it's important to enhance and encourage frailty. People in sex in positive sexuality to uh had uh uh best uh health results and best in outcomes in health. I can go deeply, but it's also important in the years to consider people living in care, home or institutions, the right to express their sexuality, the need to protect vulnerable individuals, the ethical dilemmas in relation to dementia and so on. Um But in it's important also to, to be aware that not all women will experience uh negatively their sexuality in the pore years, qualitative study identify also a subgroup of, of women with positive effect on activity and sexual function. And this, this is because all women experience sexuality differently, please and experience are promote through friendships and between the couple and a previous with sex life. And some uh participants in the in that qualitative studies reported that is they, they experienced a stronger emotional connection, better ability to understand and communicate, communicate sexual needs, no fear of pregnancy, no menstruation related diseases, decreased family concerns more self-confidence. And also it is important to um uh to highlight that they refer um that they adapt their sexuality, the positive sexuality change in sexual behaviors, prioritizing different aspects of sexuality. But as we have seen, mm most of the, this is as a group with positive changes. But most of the of the women in that stage of life will experience an impairment in their sexual activity and their sexual function and how we can diagnose and manage that. So, as has been previously explained by, by my colleagues, the plic more, it's uh a really useful tool to assess and to manage uh uh sexual symptoms and in, in health for healthcare professionals. And I don't want to be really repetitive, but it's important to, to give permission for each women to, to express their concern related to their sexuality. It's really important in the poor years because there is a lot of fake myths and older people don't want sex. And I if we as a healthcare professional, uh give this, this uh permission, women can feel more comfortable to explain if she, if she, if her than has uh any problem, we can provide limited information. It is important to explain. And women uh should be aware what changes are possible after menopause after aging. Uh because we know that maybe sexual response change in times uh uh um especially in frailty, uh women with any disease because or, or you know, that diseases may have an impact on sexuality and also the treatments that we as a healthcare professional are refer to each disease may have an impact also in, in the, in the sex in female sexuality. So uh at least this limited information is uh is really mandatory. And then uh maybe there are women that with these two levels of intervention are happy and they, and, and they didn't need more. But so some women will be uh uh uh will be benefit from a specific suggestions or uh intensive therapy in some cases. And to take home message, II want to, to encourage you to avoid AJ A Js is, um, is referred to stereotypes, how we think, prejudice, how we feel and discrimination, how we act towards others on oneself based on age and in, uh related to sex. There are, and older, uh, women or women are really a lot of myths, uh, fake myths and we have to, uh share with all women, uh that sex. It's uh uh available in all age. And, uh, as you see, uh, women uh agreed with that statement, it's important to use adequate diagnostic tools, maybe um extended tools as female sexual function index that only measure sexual symptoms. And according to the, the score, you have a cut off uh without measuring uh the stress is not the best uh uh tool for that uh life stage because as we see, uh this stress in that stage may is not the same than in the in in reproductive years. Maybe we can discuss that uh later. But uh and another cut off, maybe it's useful in, in this for years and for diagnosis and management of the of the female sexual dysfunction, the port we should consider maybe of psychosocial approach and we should consider the sexual behavior diversity also or regardless of the age of the patient and a model center. And based on share decision making is also important to tailor the treatment as each woman will experience and and express their sexuality in different way and have different expectations. So, thank you and if you have any question. Thank you so much, Sonia. If you stopped sharing. Yes. Right. So we have the e assistant president here with us. He has just joined. So Giovanni Corona, maybe he wants to say a few words. Thank you, Danny. Uh Sorry for the problems, but I was involved in clinical activity till now. So just to uh thank uh Alberto and May Lee for organizing this fantastic webinar with a great success. The topic is great. I think I saw also several questions uh in the chart. Uh For sure. I hope that uh uh all of you will be in our next congress in Bari uh from February to eighth, from uh February 8th to 10th. For sure. We are uh Alberto is organizes a great uh um yo uh um uh uh session. So I'm sure that uh at least uh uh some of you would be there. Thank you again, Alberto. Thank you. Uh I think that this collaboration would be great in fu in the future and will give us uh a great opportunity to further collaboration. Uh Thanks again uh for uh stay with us uh and uh enjoy the discussion and the questions. Bye-bye. Thank you, professor. So, um thank you for all the questions to, to attend during the presentations and we'll begin the questions and answer sessions. We only have time to do one question for each speaker. Um Oh, so I will present the questions for uh both speakers and after that, you have two minutes more or less to, to have an answer if, if you can do it in that time. So for the doctor, so uh the first question is, what are the same effective strategies for initiating conversation with patients about their sexual health specialty in cultures where the topic is might uh might be considered taboo or Doctor Laura. Uh Can we discuss the role of the partner involvement in the treatment of sexual dysfunction? And the last question is uh for Doctor Sonia just reading here, sorry. Uh What the specifics challenge the menopausal change presents in management of sexual dysfunction. Do you have any, any kind of um uh pills or treatment in the future that will give some uh some um hope in this area? So you have the, you have the worms. So I'll start. Um And the question was, what are some of the effective strategies for initiating conversation with patients about their sexual health, especially in cultures where this topic might be considered to? So I think that the first and most important thing for us to remember is our patients are waiting for us to ask. OK, we have studies that confirm that they're looking for someone to, to inquire about it. They want someone to talk about it with them. And I can tell you I work a lot with faith based communities in Israel, either Arabs or ultra orthodox. Sometimes you have to be um a cultural uh sensitive to the language. There are all kinds of even words that you must, you, you need to know how to ask. But in general, people wanna be asked. I think if you want some suggestions uh using open ended questions instead of yes, no question asking open ended questions that encourage patients to share the con their concerned and, and experiences. For example, can you tell me about your sexual health or is there anything related to sexual health that you want like to discuss? Ok. So just opening, I think something important is normalizing the conversation, explaining it to patients. They discussing sexual health is a routine part of health care just like any other aspect of their wellbeing. OK. We're talking about with them about their um digesting A a um how do you say it system? Uh uh what, what's happening there? We can also talk about sex and I think uh something very important is to be respectful, to be respectful to patients comfort level. OK, always respect the patient's boundaries and a a comfort level will allow them to share as much or as little information as they feel comfortable. OK. This is something we need to be very attentive to our patients. So we're asking open questions, we're letting them know this is normal and medical and questioning and we're very attentive in seeing what's comfortable for them, what isn't and we're letting them take it from there. It's, yeah, that, that's a great suggestion. OK. This doctor Laura OK. I also just wanna add one more thing to what uh she let me uh answered about the question and I think it was very good for answer. I also wanna say that from experience and I've heard this, this is not my my saying but other people uh more experienced therapist than I am. Um that once you feel comfortable asking the question, uh the patient will, will, will usually answer. That's my general experience. Like if you're comfortable asking, uh they'll, they'll be comfortable with you. Typically, I mean, obviously there are cases that not, but in general that would, that would be like what I would say um about the question about how to involve the partner. So one of the things is, is to have the partner be present in the, in the sessions. Um because there, the things are lost in translation. Um Sometimes I uh I have patients say, oh, I'll pass on the information to my partner. Well, something is lost in between because certain things might be awkward and they won't talk about it, things like that. Um Oftentimes partners feel excluded from the conversation, um or even they do it themselves. Like I've had patients that come to me and they say my partner sent me to be fixed for this problem. And I say, OK, it doesn't really work like that. It's not a, a fixing problem. We have to work together to try to figure out how he can help he or she can help to make it better to, to, to help the situation. Um In addition, for instance, I'll give you an example. Uh let's say we're working with vaginal trainers. Let's say we have someone with uh uh vaginismus and she's not able to have penetrative uh vaginal sex. So we wanna help her by, by using trainers which are um uh raised in size from the size of a of, let's say a pinky to the size of the penis. Um And so what you wanna do, um oftentimes I have patients that what they do is they get the, the, the uh instruction, let's say from a, a pelvic floor physical therapist and they do the exercises on their own. But then the difference is that afterwards to the difference from doing that on their own that they're in total control to then having Penina sex with a partner that they don't get to control it. It's very, it's a very big difference. So I oftentimes encourage the couples to have to use the trainers, let's say together to have the partner insert it at a later stage once she's more comfortable with the trainer. So to try to get him also him or I'm saying him. But obviously it could be uh her that they could, that they could um help each other through the process. Um I say just in general also address the partner's concerns. Um, what's bothering the partner in the situation. It's not necessarily the same thing that bothers the, the, the client is the same thing that bothers the partner and it's important to hear all of these. Uh, it, it, it's important to hear what the, the concerns as well. I hope I answered the, the question. Thank you. Um, now, Doctor Sonia, yes, it's really difficult to talk in one minute. All the challenges, two minutes, couple changes. But um I think the, the, the key point is to know which is the main uh the, the main concern for the women. If it's uh something uh like this pain or it's not pleasure or uh uh the, the pleasure is uh move a lot less intense. There is a, a kind of uh loss of interest in sexual, in sexuality. So it, it's really different uh for uh from one woman to each other. And I think also it is important to, to understand how is the, the previous sexual life of, of that woman, which sexual behavior she considered is the the best or it's the, the more pleasure pleasure for, for them to, to try to focus their, their expectations and, and their, their uh future sexuality to, to try to, to be focused on that because sometimes, or it's really frequent in, in, in heterosexual uh women that they come uh because they have no interest. Uh And when you ask if the problem is, is not the interest in sexuality. The problem is that they have pain with the current sexuality because it maybe it's uh it's based in, in intercourse. And when you ask uh them, the intercourse never was so pleasurable. So maybe here we have to invest more time in sexual education, sexual sexual counseling, but maybe uh it's the same case, but the women has the best orga with penetration and you have to be very uh try to, to, to do a treatment, more focus in the biological aspect in that, in that other uh women also. And regarding if there is any pill or any treat medical treatment for in the future, I think uh I think it's not on, it's not the the key because the we have to be uh more open-minded and, and thinking the sexuality in more br in more broadly uh point of view and the bill maybe will uh have the solution for the bio biological aspect but maybe not for the, the positive sexuality and cultural um aspects of the sexuality. OK. So the final words will be with me. So, so II II wish we had more time because it it's really enjoyable to speak with uh people who are so comfortable talking about sex and so much to share as well. Unfortunately, we have to come to a close uh of this really, really exciting uh webinar. Um I suddenly came away learning even more uh about uh female function. And so I re really like to extend my thanks to our speakers for their contributions, sharing your experience and knowledge and to all of you for your active participation and your insightful questions. Um The discussion we've had just, is it just the beginning of an ongoing conversation in the view of female sexual health, female sexual dysfunctions? And I just wanna say as well as we reflect on today's discussions. It's important to acknowledge the unique challenges specifically play face by women in regions experiencing conflict like Israel, Palestine, Ukraine, Russia, and many other regions as well. Um Women are often the ones actually suffering the effects of this and in this area is affected by conflict where the incidence of sexual violence rise. It really highlights the urgent need for ong specialists to be more proficient in managing, you know, sexual dysfunction more than ever. The training is more important not just for providing essential medical care, but also provides some sort of beacon of hope uh and healing in the midst of um what happens as well. So to continue this important dialogue and further your knowledge and skills, I really really encourage all of you to consider participating in the activities of the European Society of Sexual Medicine um and join our congress in 2024 in Bari Italy. It's going to be an excellent opportunity for us to meet and really engage with all the leading experts in this field, share the research and gain you perspectives as well. Thank you again, very much for joining us today. Your commitment to advancing women's health is absolutely commendable and we look forward to meeting all of you soon next year. Thank you. Thank you, everyone. Thanks a lot. Thank you. Thank you for the moderate.