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Two. Mhm. Do you want me to just introduce myself? No, you're gonna stop. Hello everyone. Sorry for the delay. We had some technical issues. Uh But welcome to this monthly webinar webinar. Um My name is Mary. I'm an I MT three and specialty ambassador for east of England and a be sharing with Lakshmi who's an ST five in general medicine in East Midlands. So today's talk is by Doctor Laura Jarvis and she's a specialty doctor in sexual and reproductive health in Scotland. And her job involves uh providing contraception as well as diagnosing and treating sexually transmitted infections. She has a special interest in menopause and psychosocial psychosexual medicine, which is what she's going to tell us about today. Outside of work, she enjoys hill walking, gardening and lots of outside activities. So, welcome again, Doctor Davis and over to you. Thank you very much. Thanks so much for inviting me this evening. Many apologies for the technical hitches. Um I think we're up up and running now though. So um I just want to say that um obviously I've been working in sexually productive health for a long time over 20 years actually. And I wanna tell you a little bit about my story about how I came to become interested in this particular area, which is psychosexual medicine. So um here's me back in 2002. So 100 years ago when I was working just newly started working in sexual health and encountered a very difficult um clinical case that completely stumped me. So here I am saying, look and to my colleagues, I saw a young woman today who was complaining of pain with penetration. I was unable to insert a speculum and this case completely stumped me. And thankfully, my wonderful male colleague, um sort of stepped in and said, um Laura, I think this patient might have vaginismus and um this completely blew my mind cos I didn't know what vaginismus was. I've never heard of it. And um he said to me, look, I think um she could have this thing. It's, it's basically involuntary tightening of the pelvic floor muscles. And I think at that point, um it was a, a real moment for me because I realized that there was a huge amount that I still didn't know. And I and I sort of embarked on a, on a learning journey myself. So here's me um on my career route, I did my training with the faculty of sexually productive health and did the coil training in plants and began fitting contraception and providing sexually transmitted infection, um support, et cetera, et cetera. And then I did my training with the British Menopause Society. And then probably most interestingly was the work that I started. Then the training that I did through the Institute of Psychosexual Medicine. So what I'm gonna talk about this evening? First of all, I'm going to talk a little bit about what psychosexual medicine even is. I'm gonna present a few cases just to illustrate the work that we do. Um These are cases that are amalgamations of, of patients that I've seen for confidentiality reasons when you might consider um a psychosexual problem, when you might refer somebody for help and how you might train in psychosexual medicine yourselves if you're interested in this area. So what is a psychosexual problem? Would anybody like to, to hazard a guess? Um I've, I've got a, a definition here that I will give you. So a psychosexual problem is a problem that's predominantly psychological rather than physiological in origin. So an example, a good example of that might be um somebody who is struggling with erectile dysfunction. But actually, when you ask them about this, they're able to get morning erections, they're able to masturbate. So there's clearly nothing wrong with their penis. It's really just when they're in situations when they're with a partner that they struggle there with their sexual performance if you like. So, I mean, I'm talking to a group of people here who are talking about sex every day. So I would hope that if I was asking you how confident you are asking patients about their sexual lives that you would be quite, maybe high up on this little scale. So, where would you put yourselves? One being? Oh, not very comfortable. Five being very, very comfortable. Just have a wee think about where you would be on that, on that scale if you like. And have you seen a patient with a psychosexual problem when you've been working in your clinics? Um or even the wards, all the work you've been doing up until now. If you have, I'd love to hear about him at the end though, there'll be time, time at the end for comments and questions and things. So there are different approaches to helping somebody who has a sexual problem so we can use a behavioral approach. And what that might look like is, is literally suggesting that somebody changes their behavior. So that might be, you know, suggesting to a couple that they don't have penetrative sex for a while, um may and maybe just focus instead on the, on, on touching and, and avoiding the genital area if they're feeling under huge pressure in their sexual lives. Um then there's a pharmaceutical approach. So that might be something like trying something like, I guess Sildenafil Viagra. And that can really help even if the, if the patient's problem is, is, is largely psychological, it can be a huge emotional psychological crutch to know that you've got a wee tablet that you can use. But I'm not gonna focus on any of those things tonight. I'm gonna focus mainly on the psychosexual approach. OK. So, um it's not to say that I don't use some of these other approaches, but it's, it's beyond the scope of tonight's talk. So, let me tell you about Sophie. So, Sophie is a patient that I saw um some time ago. Um she's a 24 year old student and she came to see me because she was really struggling. She and her partner had been together for a year, but they never managed to have penetration. And when Sophie walked in the room, I could feel this real sense of her, of desperation and shame and embarrassment really, um, it's completely overwhelming and she told me that her partner's understanding but that she feels so abnormal and she really wants to have this problem sorted. And I felt a real sense of pressure to, to help, to help Sophie. So I asked her if I could examine her and she went behind the curtain. And the first thing I noticed when I pulled back the curtain to, to go and examine Sophie was she looked, um, kind of, I suppose detached, really, her eyes were, were sort of fixed elsewhere and she looked like she, she was trying to wish herself away somewhere else. And I, and I reflected this through her. I said, you, you seem quite sort of distant and detached. And she said, with a big sigh, she said, I've, I've just been here so many times and then I saw this just single tear just sadly, just dropping down her cheek. And I, and I asked her what, what she meant by that term. And she said, um, she was, was diagnosed with Crohn's disease when she was just a teenager just th 13 or 14. And she then had to sort of, um undertake a whole number of, of um, investigations examinations. And really a whole of our teenage years were spent in and out of hospital with people, clinicians, doctors, nurses, um examining her genital area. And, you know, it was just this real sense with her that um this part of her body had become, you know, very public and, and, and, and for everybody to, to have a look at and, and, and I reflected this back to and when I, when I tried to examine her, um, to, to, to, to put a finger inside the vagina, I could feel this tense band of muscles and um, this, I was really unable to get a finger anywhere near the inside the vagina. And I reflected to Sophie that the muscles in the vagina are, are tensing up protecting this part of her body. And we would call this condition vaginismus. And um, she, she, she then got dressed and she came and sat down next to me and I could sense somehow this a bit of relief really and maybe finally understanding um why they were having so much difficulties with penetration. And um over the next few sessions, we were able to work together, she was able to understand that the reaction, this subconscious reaction that she was having um to sex when so much of her life and her teenage years have been spent, you know, having to be very um public about, about this area of her body and she worked away with, with self massaging and she bought a little vibrator as well to use. And eventually after two or three sessions, she came in one day with a big beaming smile and she and her partner managed to have penetration. She was absolutely delighted. So, what is psychosexual medicine? Well, it's based on psychodynamic psychotherapy. So that's a big posh fancy term. But really all that means is that, that um we have a lot of time to listen. So predominantly, er, we're listening to what people say and we have long appointments. So I have an hour long appointment with patients, which is a wonderful luxury and we also observe everything about the patient from the minute they come in the door, how they stand their body language, their posture, the clothes they're wearing. And, you know, um all of these things give such an insight into the patient's subconscious and then we pick up on the feelings that are in the room. So with, with Sophie I could, even the minute she arrived in the room, I could feel this real sense from her, of, of, of sadness and desperation and, and then what you do is you sort of parcel this up into a hypothesis and you sort of reflect it back. So you say, look, I'm just wondering if the fact that so much of your teenage years were spent, you know, in and out of hospital with people gud about in your nether regions. Um is because of that. Now, you struggled then to explore your own sexuality when a lot of teenagers would be doing that. And it's as if that's, you've not been able to do that. And here you are really struggling to, to start your sexual life with your partner, put it back to them. So it's a bit like uh the way I see, it's a bit like being presented with an onion and you're gradually peeling off the layers. And so you and the patient are working away together that the clinician doesn't have the answer. And it's that for me is one of the biggest things about psychosexual medicine is that um whereas in other areas, I need to have the answer, I need to know which antibiotic we treat this infection for which would be the best um contraceptive to use on this occasion. Um So for me, this is quite refreshing because actually, I don't have the answers, the patient has the answers. And we're gradually peeling off the layers together until we get to the real core of what the problem is. So, can I, let's just talk a little bit about psychology and, and I'm not really an expert in this at all, but I've come to learn a little bit about the mind, which is so fascinating and it gets really interesting. Um So let's just think about uh we've got our conscious mind and that's what we're obviously conscious of. We know what's going on, how we feel about ourselves. People, we know our friends, our partners, but then we've got this whole chunk underneath which is the subconscious mind. And um there could be all sorts of things in there. Um Mainly I suppose it's about the relationships with our, in our early years that we had with our primary caregivers. Um And um we've developed psychological defense mechanisms because some of the stuff in our subconscious is, is quite anxiety provoking, quite unpleasant. So some, not all of it. OK. So if you, if you think about this, this photograph here, what does it conjure up for you? Um Certainly, for me, it conjures up a sense of pretty miserable, lonely little girl on, on a, on a swing. Um Looks like quite a bleak place to live. Um She's quite lonely. And if, if you, if you grow up whereby you don't feel, um you don't feel safe, I suppose and you don't feel unconditionally loved, it's quite difficult to then move on with your sexual life, which is which and, and connect intimately with a partner. So, quite often, um we, we find ourselves exploring some, some things that happen to people when they were growing up in their childhood or in their teenage years and these can impact on their sexual lives still. So let's talk a little bit about psychological defense mechanisms. Cos these are really fascinating as well. These are strategies that prevent you from anxiety usually developed in childhood. But they become very unhelpful if they persist into adult life and they protect you against feelings of loss, shame, disappointment, grief, all sorts of, you know, harsh emotions like that. And this is just AAA few examples really of, of psychological defense mechanisms. And we, we see a lot of these, if we look out for them, we can really see them in our patients when they're in clinic. So we see denial, don't we? We see people. Um So, you know, um hold on a minute here, you're drinking quite a lot. I wonder whether you might be an alcoholic? Oh, I'm not an alcoholic. I could give up tomorrow. No problem. You know, there's a, there's a sense of a denial, there isn't there. Um Humor. So we, I see that quite a lot in our clinic and you, you might see it too with your patients and suddenly inappropriately bursting into laughter. And it's, it's like an at the most inopportune moment. You think that's a bit strange, but I think it's usually a sign of anxiety or discomfort that, you know, humor, humor is their, their, their way of defending displacement. That's always an interesting one whereby, you know, you, you might have had a terrible day at work and you, um, your boss has been a bit unreasonable but rather than, you know, sitting down with your boss and, and saying how you feel, instead you take that all home with you and you end up, you know, punching a wall or kicking the cat or something or, you know, um it, it's not really the right place for you to be processing the emotions. You've, you've taken them somewhere else. Compensation. So we where if something's going kind of bad in one area of our lives, um we, we throw ourselves, throw ourselves into another area. So for example, I had a patient, she sadly split up from her husband and um the Children went to live with him and she was so grief struck and, and, and lonely that she just threw herself into work. She was working 18 hours a day, you know, regression. That's when we, when we kind of regress into childhood. And I saw a patient not so long ago and she came for a coil fit and she came, and she brought a kind of um soft toy with her like a teddy. And I thought this was interesting. I definitely thought that was something um the patient was, was there was something childlike regressive behavior there. And sure enough, there was, she'd had some very unpleasant experiences in her early years, sexual assault, sexual abuse. Um What I haven't talked about yet, projections. So when we unpleasant feelings that we might have to somebody, we instead we turn them around and, and, and they, we project them the other way. So we might say, I don't think, you know, that lady likes me very much. Um But actually, it's, it's about you having feelings towards her and finally passive aggression. So I think we, we hear that term battered around quite a lot, don't we? But really what that means is whereby you don't really express how you feel. So listen, I was a bit cross when I came home today and discovered that you haven't put the washing out. I asked you to do that earlier on rather than that you sort of stomp around the house and it's, it's a very passive way of showing that you're unhappy about something. So these are all things that we look out for with patients, these little defense mechanisms because the likelihood is that behind there is something very painful and um troubling them. So, but this is this the psychological defense mechanism that I'm most interested in, in psychosexual medicine. Um We see this quite a lot um somatization. So this is um when a painful emotion may be too difficult to face and may present as a physical symptom in the body. So, I think, ii mean, I'd be curious to hear what you guys think, but I certainly see this quite a lot in the, in the sexual health clinic. Generally, I saw a patient just recently who had a, was fixated on a wart that he had just on his pubic area and it actually, it mainly gone, it was just all left was this tiny red mark. Um And it was, it totally fixated and kept coming back, kept coming back. And actually, when we, when we looked into it a little bit deeper for him, this, this was signified a sense of um, he, he felt, he picked up this infection um when he'd been unfaithful to his wife and that, that there was a, a sense of guilt and shame really about having this, this wart. So I think that was definitely some somat going on there quite like this, this quote, this Gabor Mattis, one of my heroes, he's a psychotherapist and a um psychiatrist. And he, his family suffered sadly in, at the hands of the um the holocaust and they were Hungarian Jews. So he has got first hand experience, I guess of how we, we, we have traumas and uh can impact on us. So he says here, if you don't know how to say no, your body will say it for you through physical illness, which is so true. So, with psychosexual medicine, we, we're very different, I guess to other counseling modalities in that we, um, we would do AAA genital examination. So anybody training in psychosexual medicine has to be a clinician because they've got to be able to do a, an examination. And so nurses, pelvic physios, um, er, doctors, we've got all sorts of people who train in psychosexual medicine but the genital examination is so crucial because, and you'll, you'll see this well as well with your patients, I'm sure that when, when you put them in on the couch and you put them, um you know, ready for an examination, um sometimes they start telling you things so you know what I hear is things like, you know, oh doctor, I haven't shaved today or, oh, I don't know how you can do this job. It's so dirty or, and this is, this is their subconscious starting to, to open up and tell you because they're in quite a vulnerable position and you've sort of peeled off a layer of that onion and you're starting to hear the subconscious and I'm sure you'll hear all sorts of comments like that when you, when, if you just listen out for them, when you see patients on the, on the couch. So let me tell you back, James. So he, he's a 21 year old student and he came to see me in my clinic and um he, he was dressed like this he's had his hoodie. You want it, it, it's kind of covered over you want. He says if he wanted to kind of just disappear. So, so, so embarrassed, so ashamed about his having this problem and what he explained to me that, um, he's been really struggling to maintain his erection for the last, um, six months or so. Um, he's been with his partner for six months, but actually even with his previous partner, he was struggling as well. And, uh, it was, it was absolute torture for him to tell me this. It was really hard, sort of for him to get the words out. And, um, he told me interestingly that he could get morning erections and he could masturbate, which is, which is fascinating, isn't it? So, he, he knew he actually had some quite good insight. He knew that the, he said, I think it must be in my head. So I asked him if I could examine him and he agreed readily and he went round behind the curtain. And when I pulled back the curtain, what struck me first of all about this, this person was that he, he, he'd, he'd almost regressed. He looked like he was, there was something quite childlike about him lying on the bed, he'd kind of curled himself up almost into sort of fetal position and it, it sort of, it tugged a little bit at my maternal feelings. Cos I've, I've got AAA younger a teenage son about this age. There's definitely something tugging in my maternal inst stick there. And I asked him if I could, if I could examine him and, and, and he, he pulled back the little sheet that he had there and, and it was really hard for him to look at his genital area. And I, and I reflected this back to him said, you, you don't seem to be able to look at this part of your body. And he said, look, I just feel so let down by it. It's really let me down. And II, II don't know what to do. I'm, I'm at the my wit's end. And then there was a bit of a pause and out of nowhere, he said, um my mum really let me down and I was a bit taken aback. Suddenly there was very much this mum was in the room with us. Um She said she just, she just, she just wasn't there for us at all. Um She really struggled with her, with her own mental health. She was an alcoholic and, and, and he and his brother, his younger brother really had to sort of bring themselves up and, and at this point, he, he could see the tears welling up in his, in his eyes. And I felt this real sense of sadness for this young guy. And he told me that when they went to school, they were teased because their clothes weren't clean they didn't have the right kind of stuff in their pack lunches. Um, it was really on, on, on kind and a really sad childhood really. It sort of reminded me if anybody's read the book, um, S Bain. Um, you know, it, for me it was like, it was a su bain type type childhood. And, um, it was interesting that this was all coming out now. So I asked him to put his clothes back on and we sat back down again and there was a bit of a silence and he said, well, II, II didn't realize that, that, that, that the, the, the childhood I had and that the difficulties I had growing up could, could be related to this problem. He said, I've never before considered that. And so he was able to get some counseling to try and process some of the things that happened in his childhood and um move on with his sexual life as a result. So, what do we see at the sexual problem clinic? Well, we see erectile dysfunction. We see dysuria, vaginismus, loss of libido and orgasm, emotional effect of having an s ti sexual problems, post childbirth, of course, sexual problems resulting from infertility or menopause. I find it very useful when I'm doing the menopause clinic to also have my psychosexual hat on as well, sexual problems after surgery or termination or sexual problems after sexual abuse. Now, we, what I will say here is that um, the, um, we're not sexual abuse counselors, but if somebody has, you know, been through our sexual abuse counseling service and they're still having a sexual problem, then we would see them after that. But the, these are some of the more interesting um, presentations really and the, when you might consider a more covert psychosexual problem. So somebody who's coming in with, with chronic pelvic pain, genital pain and we certainly see quite a bit of that in the, in the sexual health clinic, recurrent vaginal discharge or penile discharge. So somebody who's, you've done all the swabs five times over, you can't find anything, everything's come back negative, they don't have a big risk, but still they're coming back and asking repeatedly, you know, about a discharge. They have the, the likelihood is that there's something else underneath there isn't there? I had a patient, a lady quite recently and this is, this is the scenario for her. He kept coming back vaginal discharge. And eventually she was able to um you know, reveal if you like that. Her ex partner had been very abusive and he used to say things to her, used to make horrible comments to her about her vagina and say it was like a big floppy tunnel and a wizard sleeve and all these horrible things. So, um she had been left with these very um uh I suppose self conscious really about her genitals. And finally, people who can't find a suitable contraceptive method. You know, you've, you've every pill in the cupboard you've had out, you've had every coil out, but still. No, no, no. And you start to wonder, wait a minute here. Is this something else? Is, is there something else that's really troubling them that we're missing? So, um, when we do our psychosexual clinic, um, most patients, that's the big purple chunk. Most patients are only seen on one occasion. Um, some are seen twice or three times and only a small percentage is seen more than that. So it's, it's designed as a very brief therapy and um to give patients the tools that they need to go away and fix their own problem. So let me tell you about Sarah. So Sarah came to see me, she wasn't actually in the psychosexual clinic at all. This was in a normal, just my normal um sexual health clinic dropping clinic. And she told me that um, she, her wee baby now was eight months old and that she'd had a quite a difficult delivery uh with the forceps and a tear and that she and her husband have not been able to have sex since the delivery. And you felt as if with this lady, there's a real sense of like, um, er, she was a very efficient lady. She, she had a list of jobs to do and this is one of her jobs today was to sort this problem out. So I had this real sense of like, oh gosh, I better hurry up and get on with it. So I asked her to, to step up onto the bed and she was very happy. And when I pulled the curtain round, um, she was sort of lying there and I asked her how she felt about her genital area, which is often something that I do ask. Actually, it's quite often quite revealing what people say. And she said, oh, she pulled her face, she sort of screwed her face up. Oh, gosh. She said, oh, it II can't even look at it. Which is interesting. And I said, oh, why, why is that? She said, oh, I've never really liked the look of it. Um, so that was interesting. So II had a look myself and I was able to see where the little scar was where she'd had the Piot toy, but it actually, it healed up really nicely. And I put a finger inside her vagina and there was no pain, there was no vaginismus. So I fed this all back to Sarah. I said, look, you know, it sounds like you had a pretty traumatic delivery. But actually the genital area here seems to have healed up. Um, and she was, she was quite, um, I think she was quite sort of pleased to be honest and she sort of put her clothes back on and she came back and sat down next to me and I once again, I sort of reiterated that II felt that despite this a traumatic delivery things, are we now healing? And she said, you know, yeah, she said, I think where this has all come from is she said she attended a Antenatal class and the people there, um, were sharing some of their experiences of past deliveries that they'd had and some of them were very graphic. And, um, she said, and I was gonna show you this picture here that by the time they're finish with you, your, you'll look, your vagina is gonna look like a dog's dinner or a car crash. And these are such awful, violent, horrible images, aren't they? Um This poor woman was left really with these with these violent sort of images inside her head. And of course, she'd never looked at her vulval or vaginal area. And um so we would describe these as songs like fantasies that she's got inside her head. So this is, you know, instead of actually having a look and kind of saying actually it looks ok here she's left instead with these with these awful horrible fantasies. So we explored that and um she agreed that she was going to go home and, and, and just have a look herself at the genital area and maybe try and put aside some of these horrible um images. So how do you train in psychosexual medicine? Well, I trained with the Institute of Psychosexual Medicine and as I said to you before, it's, it's for all healthcare professionals, you don't have to be a doctor. You can be a nurse, you can be a physio. Um Anybody really who's involved with patients presenting sexual problems to them. GPS, the teaching is primarily in little seminar groups, so small groups, maybe 6 to 8 people and you take it in turns to present a case. So there's no, there's no great chunks of theory that you have to learn, which actually was also very nice. And it gradually you the the group sort of looks at the case in some detail, looking at the feelings in the room, looking at the practitioner, patient relationship, looking at the patient's defenses, the practitioner's defenses, so that you're understanding what went on in that consultation. It's very interesting. Well, I think so, um a good place to start your learning is to do one of these brief introductory terms. They're 12 hours long and they are take, take place either virtually online or face to face, sometimes depending on. And you can have a look at the Institute of Psychosexual Medicines website to see when these seminars, the next seminars running. And we're running our um autumn clinical meeting coming up soon. And it's, it's the the theme this um time is going to be all about male sexual difficulties and we're offering a special range of just 10 lbs for students. So that'll be a whole morning of, of talks there some very interesting talks. We've got a chap talking about what it's like to recover from after prostate cancer. And we've got an andrologist talking about, um, he, he works as an andrologist and also sees patients with psychosexual problems. It's really interesting. So, have a look at our website if you're interested in that. Um, finally, you can have a wee read if you want to have, learn more, you can look at our textbook which every chapter is written by a different clinician. So it's got a slightly different topic. And of course, there are some websites that you can turn to for advice. Um The Jo Devine website is a, it is um describes itself as a luxury sex toy shop. You might have come across it already, but we do sign posts there sometimes. Yeah. And, and the vagin network is quite good. It's a, it's a patient support group. And um that is I sometimes signpost people there if they want to, I suppose, connect with a community of people who are also having issues in that area. So I'm nearly coming to an end. So just to summarize, we've talked a little bit tonight about what psychosexual medicine is. I've illustrated this with some cases and we've talked about when you might refer somebody or to consider a psychosexual problem and how to train a psychosexual medicine yourselves. You can follow me on Twitter if you want. Um I'm always tweeting about stuff sexual stuff. Um But more importantly, please follow the Institute of Psychosexual Medicine on their social media platforms. Um Facebook X or Twitter and Instagram, that's what they're on. And finally thank you very much for listening. Um Sorry if there was a few glitches at the beginning with people and I noticed from the chat, some people have maybe not been able to log on. So hopefully you'll get a chance to, to follow what, watch the recording instead. And that's me. So shall I just stop? I can stop presenting and then open up the floor to some questions. Thank you very much, Doctor Daves for such an enlightening talk. Um I think my eyes have just been opened to this world of psychosocial medicines, psychosexual medicine. Um, so we have a few questions already, but I guess my, my first question would be. What age range of patients do you see in psychosexual medicine? Oh, that's a really good question. Um, we see, we see everybody from age sort of, I suppose, you know, 18, up to 75. I mean, I'm trying to think my oldest patient is, I think in their seventies, you know. So, so anybody really, I would, I would say the average age is probably, I think I, um the average age is probably 30 40 you know, I would say. But yeah, anybody, anybody can have a sexual problem, can't they? Yeah, that's right. Thank you. And so we have a question from Jess Stuart. So she writes, I'm a current fin final year medical student and I'm interested in pursuing a career in sexual health. But I can't seem to find any clear information on the training pathways after I two. Could you explain this if possible, please? Oh, I, so I'm so delighted to hear that. I love it when medical students are interested. I wish I'd got interest in this when I was a medical student. Um So we, we try through the Institute of Psychosexual Medicine, we try and deliver um talks to, to universities and I'm, I'm really trying hard to get it into the undergraduate curriculum. So it, I'm, I'm, I do some teaching through in Dundee University. That's my local. And um I've kind of like managed to shoehorn a little talk about psychosexual medicine into their undergraduate curriculum there just to kind of wet people's appetites and make them realize that this is out there. So probably the best thing to do in, it's probably not an ideal thing to do in your fy years. It's probably better when you're in a job where you're actually going to be seeing um patients, you know, and examining patients. So, um so probably af after that consider doing one of the introductions courses, which are just 12 hours and then joining at one of the seminar groups. So I run a seminar group, we train um online mainly, but I do one face to face every term. And so that, that's how you can. So have a look at the Institute of Psychosexual Medicines website if you're interested. And, but yeah, absolutely delighted to hear that you're, you're interested. Ok, thank you. Um The next question is from doctor a ad. Uh OK. So he says he, she says there isn't anything pathological about a congenital lack of libido, especially staying as an, as sexual virgin safely reduces one's infection risk. I'm not sure. II get that question. Um mm No, I'm not sure. Yeah, maybe I can, maybe I can reflect on that and, and write a reply. Yeah, that's fine. Or maybe they can clarify in the message. And um next question from t Riley chronic pelvic pain associated with conditions like adenomyosis, endometriosis etc is quite under diagnosed with. It's taking women 8 to 10 years to be diagnosed. At what point do these patients get referred to psychosexual clinic? Oh, that's a very good point. Yeah. Yeah. Yeah. No, that's, I think you're right. I think, and there's been a lot, hasn't there recently in the medical press about this that it's um women are really struggling to get a diagnosis. So I guess, I guess the thing is that what, what that some of our patients, um it, it, you can have, you can have a physical problem and a psychological problem together. Can't you? It's not saying that there's one other, I mean, if you have, if these poor women if they have chronic endometriosis, they often have pelvic pain and they have pain with sex. You know. So, but some of that also might be, it can be enhanced sometimes by worry about fear with pain with sex. So there's always a place to explore both the mind and the body connection. Um, but you're absolutely right. I mean, at what point do you, I guess if, if all the investigations have come back negative that people have had a laparoscopy, they've had ultrasound, um, you know, and lots of examinations and they actually, they can't find anything. I guess it is worth exploring whether this could be a psychological problem. But I agree. We don't want to, we don't want to label everybody with. Oh, it's just a, it's just psychological at all and I'm, I'm, you know, we have to be so careful, don't we making sure that we're, that we're, that we're exploring the physical and the psychological? Ok. Thank you. And, uh, next question from Oliver Sergeant. Uh, thank you. Do you think there's a role for psychiatrists in psychosexual medicine? Oh, yeah. For psych trainees to do their course as well? Yeah. Yeah. We've had a, we've had quite a few psychiatrists, um, training in psychosexual medicine originally. It used to be based mainly psychiatrists that did it actually. But, um, what this thing about it is psychiatrists sometimes feel a little bit rusty with doing a genital examination and that's kind of crucial to this, to this work. Some, some, some are comfortable doing a, a genital examination. But if they've never done any, um, obstetrics gynecology or genital urine medicine, it might be something that they don't feel, um, quite so comfortable with. Um, but yeah, I mean, absolutely. So, so, yeah, we do. They're wonderful because they've got all of their knowledge about the, the, the, the mind and the human mind as well, you know. Yeah, it's great. Anybody. So that's one like to practice in psychosexual medicine. You should be com comfortable with doing, um, vagina examinations, pelvic examinations. Is that right? Yeah. Yeah, because it's because we're very much into, into the mind and body. So we need to, if somebody's describing pain in their vagina, it's good to have a look, isn't it? And see where the pain is and see if it's explore the physical and the psychological simultaneously. Yeah. Ok. Um Next question from V Vijay Kumar. I was interested in the above question about timing of diagnosis slash referral to services as well. How long does it typically take for patients to get refer? And how often do GPS have psychosexual training? Oh, yeah. That's a good question. So we've currently got a wait in Tayside up in Scotland here. We've got a waiting list of about three or four months. But we, we're doing quite well. I would say a lot of areas. It's a much longer waiting time, maybe a year and of course, in some areas in England, um, there are no, no psychosexual provision at all. So, it's, it's like a post go lottery really. Whether you, what you get, um, depending on where you live. Sadly. Um, sorry, I've forgotten the other part of that question. So, how long do people wait g, do psychosexual training as well? Yeah. So, yeah. GPS. I've got quite, I've trained a few gps in psychosexual medicine. Yeah. Yeah. Um, they have an issue with time for them. It's time, isn't it? And they have very short appointments. Um, you can't do, you can't do a psychosexual appointment in seven minutes, which is what A GP gets, you know, you just can't do it. So, so, yeah, a lot of them are very interested in it. Yeah, I do a lot of training with, with GPS. All right. Uh, next question, Maggie WD. Um, are there any medication or drugs available to deal with psychosexual problems? I think you've touched on that a bit. That's a, that's an interesting question. I mean, there are, you know, when we're looking at the human mind, I guess we are, I think I explained at the beginning of your talk. There's, there's different ways of treating a sexual problem and yes, we can treat it in a pharmacological way, can't we? So, for example, we can treat something with Viagra or occasionally people get, if they've got a very painful vagina because a vaginal atrophy will give somebody vaginal estrogen. So that, so that would be when we would look at. Yeah. And, but also worth exploring that this psycho psychological as well because somebody with a very painful vagina that's very atrophic. They will also maybe sometimes have vaginismus because because the sex has been painful on so many occasions, they, they also might have a secondary vaginismus. So when you give them vaginal issues and they might get better, but then they, they, the, the vaginismus remains. So I definitely think there's a, I think there's a um a role for having all these, it's like, you know, having all these tools if you like in your toolbox. OK. Yeah. Um So just to go back to Dr A's question, so Ellie has just rephrased it um to say, for example, people presenting with lo lo libido or no Liz, how can you ensure your approach is inclusive of a sexuality? Oh, yeah. Yeah. Yeah. Well, I guess that's such, that's such an interesting question actually. And I suppose you have to explore about what they really mean by what's actually happening in their sexual life. Do they, do they feel sexual? Do they, do they want to have s solo sex? Do they feel like masturbating? Do they be, are they, can they become aroused on their own or with a partner? So just, it's just exploring all of that, isn't it? What is, what is their relationship if you like with their genitals. Um, and so, and that helps you to really work out where the issue is here. Is it that they, is it that they, that they have no sexual feelings at all, um, for anybody or is it that they struggle with, with, um, with sex with a partner or, or is that they can have sex on their own and they can, so it's really just about exploring everything, isn't it? And, and what they really mean by, by asexuality is, is, is just absolutely no sexual feelings at all for anybody or themselves. But, you know, I think we just explore all that, wouldn't we? Yeah. Ok. Um, I hope that answers the question. Um, next, next one. the quite a lot of good questions coming up by the way. So next is from Maxima. I hope I've pronounced the name correctly. Is there any funding support available to access the IPM online course? I'm really interested. But for students, the cost is not the most accessible. Yeah. Yeah. First of all come to our, come to our autumn clinical meeting. It's only 10 lbs and you get a whole morning of lectures and plus the afternoon of, of, of seminar work. So that's actually a real bargain. Um, and then probably what I would say is I would wait until you're actually, um, working as a, as a doctor to do the course because then you'll have cases to present because the, the course is very much about experiential learning. So, I think you get a lot more out of it. Once you're a, once you're a clinician and you're, and you're, and you're up and running with, with, with patients. Ok. Ok. Yeah, that's good. Um, next question from, as you read, where is psychosexual treatment or therapy offered? Is it usually in sexual health clinics? It depends actually. Yeah. I mean, in, in my, I think in, in all most places it is, it sits within the sexually productive health clinic. Um, but some people, um, do it in, um, some, some gi mean, I know a gynecologist who's trained in psychosexual medicine, they do it within their service. A GP would do it within their, within their service. So it depends who you are. We've trained up a whole load of pelvic physiotherapists and they do it within their service. Um So they incorporate it into their consultations, the skills that you learn because the skills are very generic essentially. It's just a communication skill that you, I mean, I use it in almost every consultation to be honest because in every consultation, you've got a mixture, haven't you? Of the mind? The psyche going on and the body, even if it's a straightforward repeat pill prescription, you've got, you've understanding some of the red flags that come up all these, you know. So, so yeah, patients will or, or somebody who's a ca somebody who's a cancer care nurse, they may use the skills in their clinic when they're dealing with patients post cancer. So use it wherever you want. Yeah. OK. All right. Thank you. And uh perhaps our last question from Felicity B. Thank you for the fascinating talk. I found the mention of epi episiotomy scars and the effect it has on psychosexual health may reflect on my previous F 20 ND job. Do you think there's a way we as doctors can change our language of practice to reduce the long term psychological effects patients have after events such as traumatic deliveries. Oh, yeah, I think uh I think you're absolutely bang on there. I look back at, you know, when I was a junior doctor and I cringe sometimes things that I might have said like a throw away comments like, oh, there's a lot of blood or oh, what a mess or you know, these are so harmful, aren't they imagine somebody describing your genitals like this? And I think you do hear people saying, oh, it looks like it's a blood bath or it's a dog's dinner or it's quite hard, isn't it to move back? Move on from that when you want to, you know, become a sexual being again. And you've got these, these um strong images and people will say things like I had so many stitches and you know, so, so I think you're right. I think we have to be really careful about how we, how we say things about, about people's genitals because you, you can't actually look inside your own vagina. Can you and see what it looks like? So you're left with these very strong images? Yeah. Oh, ok. Well, thank you very much and thank you everyone for the um amazing questions. It's been quite an enlightening talk. Um Now I'll just ha hand over to Lakshmi for um uh last remarks. We can't hear you very well, actually. Sorry. Hello. Can you hear me? Yeah, thank you so much. It's quite again, we hear you. Great. Can you hear me? That's better now? Yeah. Yeah. Yeah. Yeah. Thank. Thank you, Doctor Noa for this amazing evening, nice presentation. It's, it's a lot of learning in one hour. It's, it's really amazing and I am also looking forward to enroll for this autumn conference. Thank you so much for taking your value time and thank you for all the audience, apologies for the initial technicals and uh con uh she's an I MT three trainee uh who is interested in sexual health and volunteered to become a chair of the session. Thanks to you dear. And in this occasion, I would like to announce our next webinar, which is coming up on November 21st. This will be presented by Doctor Simon Yi. He's a geo medicine trainee currently working in Lesotho uh with a special interest in public health and he will be talking about life of geo medicine doctor abroad. So we will be advertising in the staff site regarding the same and lie has kindly conveyed our our stash regards to all the I MT applicants and um training applicants. Uh the applications are opening next month. Our best wishes to all of you and, but that I think we will close the seminar now. Thank you. Yes, and thank you everyone. And please don't forget to complete the feedback form so that you get your certificate, please, please, please. Yeah. So already the link is there. Yeah, thank you very much. Thank you, everyone. Thank you. Ok, that was a shame about the technical issues. But I think we never mind these things happen, manage and then yeah, but thank you very much for your time. No problem. No problem at all. Yeah, that's that, that's really good questions actually, better questions than I normally get. I think it's cos you guys are working in sexual health so you get all this stuff anyway. Yeah. Yeah. Yeah, brilliant. Well, um I'm gonna go and have a cup of tea. Thanks very much. Yeah, sorry about the about the technical issues, but I think not your fault. We couldn't get the live but then it's totally not your fault at all. It works on which is fine. Yeah, well done. Nerve. It's always very nerve um nerve wracking the whole thing, but it's all fine. Right. Well done. Thank you. Bye bye.