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Hi, everyone. Thanks so much for joining. Um, hopefully you can hear me. We'll just give five minutes for people to join and then we'll start. Thank you. Ok, everyone. Um, we will make a start. So my name is Millie. I am the education co lead at Stash. Um, and I have here who is going to be our co chair for the, um, evenings event. Um, at the end, there will be a feedback form. I'd really encourage you all to fill that in to give us ideas for future events and to give us feedback on this one. But for now I'll pass over to is to introduce our lovely speaker. Hi. Um, so I'd just like to introduce our speaker um, today. Um, so it's Doctor Solani Andrews. Um, so Solani, she's a consultant in gum and HIV medicine and the clinical director of the Central and Northwest London Sexual Health. Um, she's passionate about ensuring that addressing health inequalities is built into clinical care provision. Um She has a special interest in managing sexual problems, especially when associated with sexual infections and HIV. Um, she's the immediate past president of the British Society for Sexual me, sexual medicine and the chair of BS um Sexual Function and wellbeing special interest Group. Um She's a member of the exam committee committee for the Multidisciplinary Committee of Sexual Medicine um which sets the professional standards in sexual medicine in Europe. Um So doctor Shahani, it's great to have you here and we're looking forward to your chat and so over to you. Thank you Millie for inviting me in as you for that lovely introduction. So I can't seem to type anything in the chat box. If there are questions in the end, call them out and I'll answer them as we as we go along. Um So what my topic today is sexual function and wellbeing and I'm going to base it mainly around sort of what you would sort of need to think about as medical students and as uh early trainees, early carrier trainees. And I hope in respective of whatever specialty you choose to pick that this, this vets your appetite and you want to know a little bit more. You want to incorporate this within your practice no matter what you do. But of course, I do hope all of you plan to do g medicine as a specialty because as I was telling Milly earlier to earlier today, that's sort of the best specialty I can ever think of. I chose to do it and not a day of regret. It's um the varied aspects of what we see is it's absolutely fantastic. So I trained as a, you know, internal medicine doctor, then specialized in um GU HIV medicine. And then I got a bit more interested in this particular aspect of sexual functioning. So it's sort of my super, super specialty where I do a specialist clinic and for those with sexual problems in addition to my usual G and HIV clinics as well. So that's sort of my uh my declaration of uh interest or conflict or whatever. So particularly passionate about this. So what I'm going to do is first talk about sexual well-being, what does it mean? And then we'll go on to sexual functioning within the context of sexual well-being. So sexual well-being, we sort of think about how do we conceptualize it. And this is from Kirsten Mitchel who's a good friend and also a social scientist. Uh she's a professor in Glasgow and she's working at the moment with the NAT cell studies, which is the largest survey of um population, sexual behavior. And this is something they've conceptualized within her group and very useful. So when we think about sexual well-being, what does it mean for our patients, what does it be mean from a public health perspective? What does it mean for us as medics looking after people, she's conceptualized four pillars of sexual well-being. The first one is sexual health. We'll come to that sexual justice, sexual pleasure and finally, a pillar called sexual wellbeing of sexual functioning. And each of them sort of, uh, put in little boxes, what they might mean for people and have a look. It's all available. I'll send the slides later and I'll talk through each of them. You start with sexual health. You may have heard this before. So when they think about sexual health, nobody outside with the, you know, gum or HIV, you'll hear talking about sex very much. And if they need to talk about it, they ask very specific questions. They focus on it. When was your last period or you know how pregnant are you and the skirt around this whole thing of actually saying sex on or how people have sex and we who have about 100 euphemisms and medicine has another 100 just, just for good measure because we don't like saying it. And even within sexual health, we talk more about, you know, um what kind of sex do you have? Thinking about what diseases people could have or where to do the test from? We don't think about sex more holistically and, and then wh o so d recognized this and came up with this definition of what sexual health means. It's a bit more holistic, it's a state of physical, emotional, mental and social wellbeing, not just the absence of disease or dysfunction. So you, you know, you're talking to patients about sex doesn't mean have you got a disease or are you going to get pregnant or are you going to avoid a pregnancy. It has to be a bit more than that and it needs a positive, respectful approach to sexuality and sexual relationships and the possibility of pleasurable, safe sex, free of coercion discrimination and violence. So, sexual health is about recognizing that what sex means to the people we look after is more than the absence of disease. And this is not just in the realm of medicine. Also, when I talk about, you know, say sex education, we sit there in schools and tell them, you know, if you have sex, you'll catch these infections or you'll get pregnant. We forget why most young people choose to have sex. And if we turn the conversation around and say you may choose to have sex. But this is how you enjoy pleasure. This is how you keep yourself safe. This is how you negotiate sex. That's a much better way to have a conversation rather than focus on one particular thing. And that's what sexual health should be all about. The second concept. The second pillar of sexual health is um sexual wellbeing is sexual justice. And this is really important. And when we recognize this for our patients and for the people we look after and for ourselves, the way we view sex becomes very different. Sexual justice is having the sexual rights, the right to have pleasurable sex. He said between two consenting adults, but two consenting people without, without fear without being discriminated or judged and sexual citizenship. So, you know, in respect of how people choose to have sex, they are allowed to have sex and recognize their, their right to have sex and a sex positive practice. Um Just before I came today, we had a meeting about a uh about a sex worker service and how we look after them. And it came to a sort of a big safeguarding conversation and our sex worker lead said we within sexual health recognize that sex work is a profession. Uh But when you say that the same thing to other people, they don't recognize sex work as a profession. They immediately say, oh my God, why is she doing sex work? Is she being exploited? Is there coercion? Is there? Oh you know, is she really desperate or something else gone wrong? Never quite recognizing that somebody might just choose sex work as a profession as I've chosen to be a doctor. And that is ok and that is well within their sexual rights. So whether people choose to have one partner, multiple partners, who their partners are the same gender, different gender, different, whatever, all the diversity, we need to embrace it within the context that it's pleasurable. It's between consenting adults and there's no coercion or exploitation. And we need to open our mind when we start this conversation with our patients, then I come to sexual wellbeing. Sexual wellbeing is safety, respect, self esteem, resilience, comfort with sexuality forgiveness of past sexual experiences and self determination of one sex life. So they choose who to have sex with how we have sex with. And all of these come into it. And when people tell you about their sex life again, within my sexual problems, sometimes they come in and say, oh, I watched a lot of phone when I was 15 during COVID. Is that ok? As is my sexual functioning totally lost. And sometimes it's saying, look, you didn't have access to another human being and you were at the page where you're exploring P per E is not wrong. It's not going to cause an addiction or a problem. Embrace who you are because a young person seeking out to find out, discover their sexuality, find out the new answers of trying to find information. There's nothing wrong. There needs to be comfort with it and equally forgiveness. They sort of did something that I think. Oh well, you know, II don't know why I said yes to that person or said no to that person or people again, we need to sort of move on and say that's ok. And, and as professionals, we need to be able to do that as well when patients tell us their sexual history. And then finally, which is going to the main element of my talk, it's about sexual pleasure. And remember no matter what we say, how much we say, the reason people choose to have sex is for pleasure. They like it, they want to do it and, and we cannot remove that element of it. And somehow the idea behind having sex, it's, it's not about making babies. It, no, it's not about sex. Heterosexual sex. There are ways to make babies these days without, without sex. And actually, that's, that's very few acts of sex in a person's lifetime. Most of the time, the reason they choose sex is for pleasure and, and then we need to look at what could come in the way of pleasure for our patients. And that is going to be the main element of my talk today. I'm going to talk about how people have sex. What happens when somebody is having sex and what could go wrong when they're having sex? What could be the reasons, those things go wrong and what do we need to think about as doctors? And I'll, and then I'll finally leave with a few tips on what to do. II don't see any questions so far. I will carry on but do feel free to type in your questions in the chat box as we go along. So I'll start off with the sexual response cycle. Um I can't see a show of hands or faces here, but I wonder how many of you have heard of the sexual response cycle? And if, if you've heard of it, heard of it anywhere type away in the chat box. Yes. No, whatever just, just for a minute. So that I feel like, so you don't listening and haven't turn, turn the computer off. Haven, first time I've heard of it. Excellent. Well, thank you. So, hopefully, hopefully there's, yeah, there's something for me to talk about. Ns heard of it. Not in an official way. I haven't heard of it before. Thank you. Excellent. Thank you for that. That's useful to know. So, interestingly when I talk about sexual response cycle, no one had heard of it except people who do sort of my subspecialty within the specialty. So even if you speak to, to your medical medicine, physicians, many of them may say no having said that something shifted. It a few years ago, there was a channel for documentary about uh masters and Johnson and they talked about the sexual response cycle. This was in the sixties, uh Masters was a doctor Johnson, was his nurse. I think they ended up being a couple later on. And for the first time, he kind of sat there thinking, I don't know what happens when people have sex. W what is the medical idea behind sex? So what, what happens physiologically? And I don't think this is covered in your medical curriculum. Either we talk about so much physiology, how babies are made and how, you know, sperm is formed and all the rest. But actually, when we have sex, what happens physiologically within us as human beings and Masters and Johnsons were the first people to study it. And the way they did it is they took a young couple, put them in a classroom and uh they measured things. So they looked at how rigid the penis became. What happened during ejaculation, they put electrodes in the brain to see what the changes were, that were associated with it. What happens in a woman. And interestingly, it's easiest to study in a man with a penis. Because when somebody's got a penis, it's quite easy to sort of, you know, to describe what is going on. And they came up with the first three, the arousal, the orgasm and the relaxation. And this was because when there is a penis and it's getting excited, you can see the pen is getting rigid, that's arousal, but there's an orgasm in somebody with a penis there, ejaculation, you could see semen coming out that's orgasm and then they can't get it up again for a bit of time. There's a relaxation phase. They said, so they described the sexual response cycle as about the orgasm relaxation. And then they asked the partner, the female partner and said, you know, what did you feel? And you know, young person one off sort of said, actually, you know, I felt turned on. So I felt lubricated and then you did you have an orgasm? Yes. And after that, how did you feel now I felt quite good and they called it relaxation. So they said that extrapolated from a man to a woman and said, oh, it all seems to match up with something very similar. So this is how we feel response. So we get aroused, the orgasm, then we go into a relaxation phase. So first study um actually quite useful for us to formulate how people have sex. And then they realize that people can't just get around and have sex. Something else needs to happen before somebody wants to have some have sex with somebody else or by themselves that needs desire. You need to feel turned on. Your brain needs to feel turned on before the penis responds or the vagina responds or whatever happens next. Um So they added desire as another component to it and they said you feel desired and you feel around, you feel orgasm, then you relax. Great. It's a very good basic conceptualization and it's quite useful even today. And remember these steps because when patients come and say I can't have sex or I'm having difficulty having sex, you can ask them, what, where do you have difficulties? Is it difficulty desired? Is it difficulty getting turned or not having an erection? Is it difficulty orgasm or is there any pain or problems afterwards? And that is a very simple way to open a conversation about sex. And I hope everybody who's listening today, the 27 people, you will take that home. So when patients, as I have difficulties having sex you don't close the conversations. Oh my God. I don't know what to do with you. I don't know what the next question is. You'll, you'll go on and ask a few more questions next. And that is this. Now, what happened was Masters and Johnsons gave us this model which is really useful, wasn't tested very much for, for a while. And then there was Rosemary Basson, she was a gynecologist and she spoke to a lot of women and what she came up with, she realized, especially, you know, women as they got older, but they had lots of other things going on in life. They didn't start off like they did here. They didn't even have women, doesn't tell you wake up in the morning and said, I really feel lots of sexual desire today and then finds a partner and says, come on in. Now I'm going to get her out and then get an orgasm and relax. It didn't quite work like that more often than not. They felt sexually neutral that bit down there. Do you want to have sex or do you want to, you know, get on and go to work or what do you want to do? So, feeling sexually neutral seems to be the position. And then if there's emotional intimacy, if there's anything else or that the situation is right, the environment is right. They find that they're receptive to sexual stimulus, sometimes there can be the spontaneous desire or spontaneous hunger. But actually more often than not, it's responsive. They don't start off saying, oh, I really want to have sex. They see the right person and say, oh, he looks quite good. Maybe, maybe I will want to have sex and they're giving you the right cues and you think, ok, and getting turned on now and that influences the process in the limbic centers in the brain and it leads to arousal. So not starting off with desire, but actually starting off with arousal, feeling turned on feeling a bit, you know, lubricated feeling. Um I think, I think I'm gonna see an erection coming on that arousal. If the situation is right, if everything else is conducive, everything else is going all right can lead to desire. Now, when arousal and desire mix, they can lead to a satisfactory sexual experience, not necessarily orgasm, but a good experience that leads it leads to a positive enforcement. So the next time it happens, somebody may say, oh, I may II do feel like it. Now I feel like it this time. So that is called a responsive desire. So there's spontaneous desire and then there is responsive desire, responsive when, when other things go, right? And it happens again when you get a patient who says, I don't feel turned on at all. I've lost desire already. Don't immediately start writing the letter to your psychosexual service saying, oh my God, this patient feels no desire say what happens, you know, tell me a little more about it and whatever I've just explained to you, it's very, very human to ask the next question. Do you never ever feel desire or do you sometimes feel desire? Can you talk and turn you on and then do you feel like having sex? And they may say, oh, that's all right then, and you can say that's fine, that's completely fine. Desire can be spontaneous or responsive and both are normal. And the one thing we realized over the years, I've, I've been doing this for quite a few years now is as much as Rosemary Basson described the circular model in women. It applies to all genders. Men, men aren't machines, they don't start off with sort of men are simple. They have one button, women have 20 buttons. That's not true at all. Men are thinking, feeling human beings and men also feel responsive desires. If they had a bad experience with a partner, they just may not feel like sex again, equally when they have a good, good experience or everything else turns positive, they may want to have sex. And so do acknowledge that in all genders, it's not exclusive to one gender or the other. And there's no biological reason why this should be exclusive to one gender. What we recognize can be biologically different. As I said earlier, it's much more difficult um to find, say an erection and you know, you don't get an erection in women. So are you turned on or not? What if there are reasons why there's no lubrication? Um And so it's harder to explain these, you know, find these things or measure these things in women, but they're all there. The second concept is the genital arousal and the cerebral arousal. So you get turned on in your brain and if your brain and your genitals are talking to each other, they both get turned on. Sometimes one can get turned on and not the other. We talk about menopausal women because that's really easy. Menopausal women have all their, you know, the um testosterone, they lose it because the ovaries produce testosterone and the genitals do not get aroused just as quickly as not, not always, not in everybody but quite often. And so what they can do is they can see a partner, they can feel really turned on. The brain wants to have sex, the genitals might feel dry. That doesn't mean she doesn't have arousal. You, all you might need to do is give a bit of lubricant and that might sort it out. So that can be simple solutions to a problem. You just need to think very pragmatically. And so there's genital arousal and there is cerebral arousal or subjective arousal. And again, I important to find the and the final point is symptoms and distress, what we manage medically is distress, not symptoms. So if a patient comes and tells you, I do not feel like having sex. I don't get turned on by anybody. I feel absolutely fine. I'm really happy with the status quo. I have lots of friends. My life is fine. They may be an asexual person. They're not distressed by their situation and sometimes they may be distress because other people decide to make them distressed. It's not a spontaneous and I don't feel like it. I feel fine, but everyone else tells me that's really abnormal. So I need to do something about it. Not really, people are happy the way they are. That's absolutely fine. Um So what we manage medically, what we medicalize so called medicalization is the distress element like psychiatry. It's really, and you know, it, it really applies to sexual medicines. So remember that that's really key. So don't, don't give people a problem. They don't have um if they're telling you about it and they're distressed about it, it's a problem if they say I don't feel this or whatever, but everything else is fine. It's not a problem. So everyone's still with me. Ok, I'll take the next question because it's just interesting to take questions as we go along, the lack of teaching and medical physiology. Does it come from a place of what is culturally appropriate? Should we be taught in medical physiology? Absolutely. Paul, you're spot on it should be taught in medical physiology. And as we say, you know, physiology, books are written a long time ago. It keeps renewal and people don't get particularly interested in sexual physi uh across there is a move. It's a very small number of people who said this is important. This should be taught in medical school. So there's a Europe wide curriculum developed and this, the physiology of it has been included in medical school curriculum in Europe and in the UK, it's a bit more, we don't have a genetic curriculum. Each, each medical school decides on it. And I hope more of this will be included as we go along. It's convincing the medical um faculties that this is important. This is as important as, as all the other physiology that we teach people. And it comes from, yeah, it comes from what is culturally appropriate. And also remember, medicine is very, you know, very much. Um um there's a lot of bias in medicine. It's not long ago, the doctors said that masturbating is wrong and they called it or, and they said, oh, you lose bones and it's all terrible. And then we changed our mind completely about it. So, you know, that there is a lot of work to be done. And I think we kind of feel we look forward to handing it over to the next generation to, to take it forward. Eu teaching guidelines. I'll try and find the link at the end of the talk and I put it in the talk otherwise I'll circulate it in the end. So that's, it's uh yeah, there's a European faculty and they're putting it together and they've kind of put it together now. Great. So once you understand the concept of the four things, having this sort of a simple, you know, desire or also orgasm pain is quite easy, then it helps us conceptualize this is not the only, it's not the be all and end all of sex, but hopefully, simplifying it into four stages will give you the tools to ask more questions of your patients. So if it's desire is the desire high, is the desire low? If it's arousal, is it a problem in the brain? Is it the problem in your genitals? Again, you could easily ask your patients these questions if they're orgasm, is it, are they coming too soon? Are they coming too late or they or they can't come? What's going on there? And where is the pain? Is it in the vagina pelvis, ejaculatory pain? Is it after the orgasm? I wanna go into each of these problems. Specifically, it's really, really simple and hopefully, that'll help give you some confidence in opening the conversation. If not opening the conversation, when you take your histories and you're learning either as a medical student or as a, as a doctor, sort of learning on and going on and they tell you things, hopefully it will help you put these things somewhere in your mind. Because if you never ever ask these questions, never ever think about it, never talk about it, whichever specialty you do later, these conversations won't come easily. So, you know, get yourself thinking in that mode and then as you do in each of your specialties and if you choose to do medicine, you can, you can actually see where this might fit in. Uh Nico says from a nursing perspective, we are taught about sex as part of the activities of daily living and that should form of a holistic um assessment. But training about talking about sex is lacking. Thank you, Nico. And that is the problem. I think, you know, we say, oh yeah, we all recognize it and then we just, you know, bury our heads in the sand and say we don't give people the tools to talk and we don't normalize it the minute. You know, when I, when I, even when I started as a consultant and I said, I want to talk about sex if you said, oh, that's all good. But how much HIV do you know? And it, it took me a long time to convince my colleagues that I need to be able to talk about sex and I need to give them the tools to talk about sex from a sexual pleasure perspective. So, yeah, we still have a long way to go as a culture and particularly as healthcare professionals. The next way to conceptualize it is the biopsychosocial model is the problem biological? Is it something intrinsic, is it medical, is it psychological, is it something to do with, you know, how they, they are thinking about it? Is it social, cultural relationship related? And the reason I give you this too is because medics, if you're, if you're a nursing student, you're probably a little bit better. If you're a psychology student, you're really good. But medics particularly, I'm as guilty as anybody else. We d we are good at dealing with the biological. The minute it becomes psychological or social, we haven't a clue. And on a mile. And even as a, I give an example of when I was a junior doctor and the first patient who came in and told me they had a sexual problem and then cried and cried. I got them tissue and they ran, I ran out of the room and I found a health advisor who could talk to them and I left the patient with the health adviser because I didn't have a clue what to do. And hopefully I'm doing much better now, but I hope that doesn't happen to you. The minute we think it's psychological, we don't have to run out of the room. But actually, is it psychological? Do we just, are we just lumping everything into something psychological? So, think about the biopsychosocial model and, and then it helps you formulate what's going on. So I'm going to talk about the biological and the reason I'm going to focus on the biological not of the psychological or the social is for you as doctors, as nurses, as, as healthcare professionals to not form away. Every sexual problem is psychological or relational. There is a lot of medical components to it and we need to be aware of it for desire, arousal and orgasm. 11 important aspect of it physiologically is the neurotransmitters, two parts of the brain. This, this concept is again, really simple to understand. One bit excites us, makes us really happy, makes things go up. And that's the limbic system. And the neurotransmitters involved are norepinephrine, oxytocin, dopamine, melatonin melanocortin. These get us excited gets and gets as happy gets us wanting to have sex, puts up the desire makes us aroused equally. There is another bit of the brain, the frontal cortex which says, OK, so you're getting ready to have sex. But no, this is not the time, you know, you you have to go to work this morning, stop it, you know, get, get the dog balance that dog and that's the inhibitory prefrontal cortex, the prefrontal cortex which stops us from doing the things if it's inappropriate. And those are the serotonins, the opioids, the endocannabinoids. No, now that you know this, it's quite easy to understand why if someone's on an SSRI a serotonin reuptake inhibitors, they will have more serotonin neurotransmitter in the brain. So there's going to be more inhibition. So they may lose desire. They may find it difficult to get aroused or orgasm. And that's really easy because it's a simple neurotransmitter related problem. And this again is really useful to understand. So, take a medical history, find out what medication they're on. Could it be, could it be affecting how they're having sex? The second element is hormonal influence. Testosterone in g, improves all domains of sexual functioning in all genders. So it's not just testosterone is not an exclusively male hormone. It's, you know, women have testosterone in much smaller amounts, really important for their sexual functioning and all genders, irrespective testosterone affects their sexual functioning. Estrogen increases desire. But the problem with estrogen is when you have a large amount of circulating estrogen, you get a large amount of sexual hormone binding globulin in the blood S HPG. What S HPG does is it not only binds estrogen, it also binds testosterone. So what it does is it functionally lowers testosterone level and that in turn can cause, you know, a lowering of testosterone, therefore lowering of sexual functioning. So, estrogen is ok. But it's, it's a bit more complicated than just improving desire, progestogens, decreased desire, exa exact mechanism is not known thyroid can affect all pathways. It, it's quite a complicated mechanism that they can affect sexual functioning, hypo and hyperthyroidism. And finally, there's a peripheral mechanism, the simple plumbing and the new, new the nerve supply. And again. So the first two bits are physiological this one is sort of a more even more mechanical to get an erection. You need good arteries, taking the blood and good venous flow back up. If those are affected, if anything that affects the vasculature can affect your ability to get an erection, it can affect a woman's ability or anybody with a vulgar's ability um to get aroused. That happens in conditions like diabetes that happens in vascular conditions. So I find it ridiculous that somebody who could be treating diabetes and then the, and then the person says, oh, I can't get an erection, I can't get aroused. And they say, oh, let's, let's send you to a psychosexual counselor to see how they can talk you out of that. Of course not. If the artery is blocked, you're not gonna talk them out of it. So you're gonna give them some medication to treat it. You have to do a proper assessment. So again, really important to not to form things off as being psychological or social think medical first because that's the mainstay of what you do. And then the other things can come in. It's not ignoring the others. So if you have a medical problem that affects your sexual function, it's going to affect you psychologically. It's likely to affect relationships. It affects a wider domain. But don't forget the medical side of things. Any questions so far. Are you all with me? Good. So, translating the biological, we talked about the neurotransmitters, the primary neurotransmitters, cerebral. Um so what can affect the neurotransmitter pathways? So, if you have a brain tumor that could affect it. So the typical examples you get and sometimes in neurology, you actually see them if it's a frontal cortex tumor and it affects your functioning, there can be total disinhibition and you, you, you may see that again when we treat parkinsonism and we give dopamine those mechanisms again, they can have, they can be totally disinhibitory and and won't. And that can affect um the, you know, increase the desire medication like antidepressants. I talked about SSRI s antipsychotics that can affect sexual functioning, all domains of sexual functioning in all genders, the hormones. Again, that can be a primary hormonal problem. There can be other conditions which affect hormones. So if you have chronic liver disease, that can affect estrogen levels, it can cause a hyperestrogenic state, high levels of circulating SHBG can affect, can cause lowering of testosterone levels. A whole load of medication can affect these conditions. And finally, I talked about peripheral neurovascular and skin cardiovascular conditions, diabetes, peripheral neuropathy medication. So all these things affected and whichever specialty you do. There may be something you know, within, within your specialty where by sexual function, it could be affect, be affected. So I talked to my colleagues working, you know, um who give medications say for breast cancer, for instance, they give tamoxifen and that is a anti estrogen anti-androgen that can affect sexual functioning. And it's really important that whatev whatever you are posted, whatever specialty doing, think about, think about sex because that's what your patients are probably thinking. It's quite high on their topic. And we need to be able to open the conversation comfortably or listen when they open the conversation with us. I don't expect you to remember all of this, but that's just one example. You can look at the end of this ea website. There's a whole range of website. It's medication that can help that can affect it. So it's very simple for you sitting in there to Google and say, what are the medication can, that can cause low desire? What can cause ect dysfunction? What can cause it and you will find your answers. Yeah. Interesting. Under biological, we could have acute or chronic psychiatric conditions. Bipolar with manic episodes tend to be sexually disinhibited, elevated serotonin levels. Yes. Yes. For the psychiatric conditions is a bit more complicated than purely that. And as you know, you know, a l the neurotransmitter mechanism for many of these psychiatric conditions are, are very poorly understood. Um So it could be a purely neuropsychiatric thing. It could be the psychological thing. But equally when you give them uh antidepressants and antipsychotics, it, it causes um the reversal. One other thing to remember with depression and again is depression can cause increased sexual desire can cause neutral sexual desire or can cause lowering of sexual desire, all three can happen. So some depressed people may want to have more sex and that's normal then, and then you, you don't have to mustn't tell them you're not depressed because you're having a lot of sex. Because when they do have sex there's dopamine release, there's, there's good things going on in their brain, you feel good. So when you're depressed you may actually want to have more sex to try and feel better equally. Yeah, all the, all the others can happen as well. So it's not one day or the other. Now, the psychological I told you not to run a mile when you hear psychology or I don't know what to do and you immediately try and find a counselor or a psychologist or someone else. This is again a really simple model to tell you all that if you are a human being, if you lived some part of your life at some point, and I'm, I'm sure you're all sort of, you know, you have some life experience in nature. There are things we can do before we send our patients off for more, you know, deep psychotherapy with somebody else who needs it. And this is called the LICIT model and conceptualized in 1974 still, um it's, it still continues to be useful. The first bit is permission giving. When somebody tells you they have a problem just listening to them, giving them time to raise the issue and saying, could this be normal? Earlier, I talked about spontaneous desire and responsive desire. So the patient is talking to you and says I never initiate sex. But once my partner initiates, I can get going, I get, I get desire. I feel fine. Is it normal doctor? And for many of you, it's not just your, your patients will ask you, your friends will ask you when I went to medical school. All my friends assumed I knew everything about everything and the only thing they were interested in was sex. So most of my doctor, doctor questions that I got from my friends were about sex and actually I was taught so little in medical school. I think I made up quite a bit of it. When I was last question, I didn't quite confess to not knowing, but equally, they will ask you these questions and feel free to give permission if you know what, what permission you're giving. So things like spontaneous desire and responsive desire to explain to you. Easy to look up these things. I'm on Acessa for my depression and II seem to not get erections quite so well. Is it OK? Is it normal? And if you tell them? Yeah, it could be normal. But if the depressants are controlling it and you're managing to have sex, don't worry about it. But talk to your doctor that itself can go a long way for the person who's thinking, is it the medication or, or what's happening in my head. Um We prescribed loads of um hypertensive medication. A lot of them negatively affect erections. So you give a man in his forties, BP medication. Suddenly he realizes he can't have a lot of sex. He goes home and he tries to avoid sex with his partner. Partner wonders whether he's having an affair because he's avoiding sex with them. Um It can lead to a lot of complications if the problem is not explained to them and not loving them, telling them, you know, giving them information, it's ok to say medication can affect your sexual functioning. It's not as if, if you told them that it's not affecting it equally. It gives them permission to come back and talk to you about it if that happens. So permission giving really important. So if you listen to them carefully, there's a lot of places where you think you can give permission and about 90% of my work is permission giving. The second bit is limited information. So you can talk to them about the side effects of treatment. You can give them a little bit of information. I information that you have that they don't have, that's being a medical student, being a doctor, you know, a little bit more than them, you can tell them that. And then specific suggestions. If you had a bit more training, you know, I've had lots more training. I give specific suggestions on what they can do to improve their sex life. And then I work with a team of psychologists and my psychologists do the intensive therapy. I'm not a psychologist so I don't do intensive therapy. I am trained in psychosexual therapy but do a small amount of it. But the majority of it goes to my psychologist. So that's beyond my remit. And I pass it on. But if you look at it in the step care model, you can actually help quite a bit and you'll find yourself being that listening doctor that your patient needs. So that's my last slide. I've come to the end of my talk. So the things I want you to take home, the first one is the four pillars of sexual wellbeing, sexual health, sexual justice. Don't forget sexual wellbeing and sexual pleasure. And we do need to think about sex or sexual pleasure, not just the absence of illness, not just avoiding a pregnancy or any of those things. So don't medicalize sex. Sex is about the good stuff. Open the conversation about sex. If somebody says they have a problem with sex, you know, it's simple. Is it desire? Is it arousal? Is it orgasm? Is it pain? Four things really simple, really easy to remember. Is it biological? Is it psychological? Is it social relation or is something else going on simple? And if it is biological, again, I've given you three steps. Is it the neurotransmitters? Is it the hormones or something else going on. Think about medication. You don't have to think too much, but wherever you are, you could, you could start thinking these things and your brain can be more tuned to sex and which means you can help your patients better and finally be curious, don't fob them off. We cannot not be curious about sex. It's, it's, um, I've never done a talk about any aspects of sex. Be it? What treatment or sexual pleasure or about alternate sexuality or about swinging from the chandelier. I do talk about those as well and um I've never seen people looking bored because as human beings, we are curious, even if you're not personally curious about a co you know, a particular aspect of sex, you're curious about how those other people are doing it. And you know, and this gives us permission to do it. So give yourself permission, not just your patients. And being curious also means asking your patients. So I came from India, we didn't talk about in my medical curriculum. You know, we're talking about medical curriculum here about uh you know, the nursing perspective. They go and all about the medical curriculum. So little is talked about I'm the pre internet generation. So no one even told me about LGBTQ plus anybody other than a man and a woman outside the conflict in the context of marriage can have sex because that was frowned upon in my culture. And then I came, I was working in Central London and, and because I wanted to do HIV, and the majority of my pa patient population were gay men and they were telling me their stories, their histories. I didn't have a clue. What is this? Ok. Is it not? Ok? Is that what the first thing I needed to do is go and find a gay friend because you know, some questions you need to ask very quietly and not display your ignorance with your patients. So you sort of go to them and say, oh, they said this, is that ok? What should I be thinking about? So find your friends who can talk to you, you know, who can explain things to you. And then my next step was actually respectfully asking my patients, they'll tell me something or they use a jargon or they use a word I've never heard of. I'm from another country. You know, English is my fourth language. And I'll say, oh, excuse me, now, hold on a minute. You, you said that, what does that mean by the way you said brimming or you said, you know, fisting, what does that mean? And then they'll tell me patients take you under their wings if you're respectful. And even today in the last week's clinic, somebody taught me something I did. I've never heard of before about a particular sexual practice. And he said, oh, I just discovered this. Doctor Andrews and I said, oh, what's that? I've never heard of that. So, why did that happen? You know, what did you do? And, and then we have a, I have a joined up conversation. I tell them, you know, from a medical perspective, I wonder if that is risky and then they explain whether it's risky or not risky. And we think about it together and after years of medical practice, I am still learning and I cannot blame, I know everything about people's sexual lives or their complexities. But if you take a respectful approach, your patients will be your best teachers. And finally being non judgmental question yourself constantly. I told you about my conversation earlier today about sex work being work the first thing and everybody was, oh, she's a sex worker. What if she's not telling us this? And I said, what if she was a doctor if she was a doctor? And she told you this? Would you ask her whether she's a and she tells you she's a GP, would you suspect she could be secretly an anesthetist? And you wouldn't, you just take your doctor's word because you respect doctors whereas a sex worker, she says, II know I work as an escort. I'm really safe. These are the precautions I take you think, oh, what if she's not telling us when she's secretly a street sex worker? No. And, and we need to question our biases and when you ask a question, you may may not be wrong in asking those questions, but challenge yourself, ask yourself if you're being b biased, if you're being nonjudgmental. And that's what will take us a long way in our patient relationships. Um And making sure we get the right care for our patients and also making sure that our, that our, our advisor listen to. Um, on that note, I will finish and take any questions if you have some. Thank you so much. You really, um, that was really great. You really, you sort of broke down. What's quite a daunting topic, I guess for quite a lot of us, um, into those sort of step by step parts that's really helpful. Obviously, everyone can put any questions in the chat. I can just start off with one. while they're sort of typing, you spoke about, um, people coming in with sexual problems into the, into the clinic. What sort of part of the biopsychosocial model? Do you think most, um, problems come under or is it sort of difficult to say? Do they tend to be mixed, that sort of thing? You know, if they come to a doctor, I'll say think biological first because patients are really good judges of their own problems and we need to give them respect for that. So I have another, uh, another chart I haven't put it in here. There's, there's, um, someone did this lovely qualitative study about what happens in a journey of a patient before they come to you and tell you they have a sexual problem. So patients standing there, they feel something is happening like, ok, let's, let's pretend they can't get an erection, they can't get an erection. What do they do? They'll say I'll try again tomorrow night and see if it works. And then the, and then they're sort of feeling a bit disappointed. They'll say, let me try next month when I'm a bit relaxed. So many things are going on at work in life and whatever else. So it, maybe this and maybe I shouldn't argue. Maybe I've had too much wine to drink. Let's see if it goes away. So they wait and they usually give it a good few months, 3 to 6 months. And they say, oh, it hasn't gone away. Maybe this is the problem. And then what they do is they try and talk to a partner or a friend or somebody, they may say I'm having a problem or they might say, I wonder what someone does when they have problems with an erection to, to test the waters? Is this something I need or should I just let it be? Then it takes a few more months, more years and then they sort of get there and they get old, they gather all their co up when they come to a GP, you know, with, with psoriasis, let's say, and they say, oh, you know, do I tell them about my sexual problem or do I not? And they look at your face, is she going to listen to me? Does many look kind enough. Uh She's a woman. I'm a man, I'm older. Could I talk to her or maybe she won't challenge me. She doesn't look kind and looks like she will listen to me and then they might open the conversation equally me. If you put your sternest face and your, you know, big glasses like I do and look at them, they might say, let me just talk to her about psoriasis and leave the room quickly. And that's the next step. And then the doctor really might say, ok, tell me a little more about it. Oh, you've got a medical problem. So could, could this be, but, you know, could this be a medical problem doctor? Ok. You're 50. It could be, you know, you may not have any medical conditions, but actually, your arteries may not be pushing this blood out as quickly as before I need to think about it. Or you could say, ah, is there any psychological problem? How is your relationship with your wife or, you know, you need to go and find a counselor and you might close that conversation and then the patient may never come and open the conversation again with anybody else for a long time to come. And that's the steps it takes before people get somewhere. And so the first thing I'd say is if they come to you think, biological first, because I often say I can be forgiven for missing out a complex psychological formulation in somebody. But if I miss out a heart attack or a vascular problem, there is no excuse. I'm, I'm a trained internal physician. As I told me earlier, I've done cardiology for six months for heaven's sake. So, penile arteries, one third, the size of the coronary arteries and usually erectile dysfunction happens about three mo uh three years before they get their coronary symptoms. And so I won't be forgiven for that or I can't forgive myself for that. I know the medicine. So think biological first, think about what you need to do first before you move them up to, you know, all the others, they've already thought about the others and then they could look at it. Thank you. You're so right. The way you react to them in the first instance, will um go along with, with how, how they, how they feel about it after that. Thank you. Um Yes. So I can't see any questions in the chart. Um One thing that I found quite interesting was when you spoke about different medications that can contribute to um sexual um dysfunction. Um So, um particularly lack of desire or arousal, um in particular, the SSRI S. Um So how would we manage patients who are on SSRI S for um psychological problems such as um depress depression anxiety. Um but then they're also experiencing um lack of desire and arousal, which is also going to contribute to, could possibly contribute to um psychological distress. Um How would we deal with that? Yeah. So the first thing to know is do they need that prescription? And in another context where I see these prescriptions happening, you know, antidepressants being prescribed quite a lot is women who say they have sexual problems. So I can't get rest. I have a bit of pain down there while the pain immediately gets to give them some amitriptyline. What's amitriptyline going to do? It's gonna cause vaginal dryness. It's going to make it even more difficult to have sex. So think whether they need that at all for men, again, if they have lower urinary tract symptoms like prostate problems, the first thing they do is give an alpha blocker, alpha blockers, knock off the erections. Whereas if you give Tadalafil, it will treat directions and it will treat low urinary tract symptoms. So that is just examples. But within specialties, you know, the first thing you need to do is do they need this medication in the first place. It's possible they need it. It is possible the depression is really bad and it's, and it's, and being on the antidepressants has taken them to a much nicer place. There are different groups of antidepressants with different levels of sexual side effects. Uh nothing is completely safe, but on the whole um drugs like venlafaxine. Um Mirtazapine tends to affect sexual functioning much less, but Mirtazepine causes weight gain. So if a patient is prone to weight gain and then they're gonna put on masses of weight, Mirtazepine that can affect their uh body confidence. So you need to balance it out after the discussion with the patient. Thirdly, if they're, you know, as I said, being very depressed might put them off sex in the first place and actually putting them on the antidepressant might take, you know, may not give them that quick an erection, but actually on, on the whole might help their sexual functioning. So it's that balance. You sort of put that in and say, how much is this affecting you? How much can we put it down purely to this medication? Can we think about alternatives? And the full thing is gonna give other medication to treat the medication side effect, which we do um important to remember. Sildenafil, Tadalafil, these are really cheap drugs. Sildenafil is 14 pa tablet and GPS prescribed four tablets for a patient. Why are you telling them you can have four f four times until your next prescription, you can have sex. You know, it's 14 pa tablet. And I keep writing and saying, put 28 tablets in the prescription like you would with any other drug, let them choose how much sex they want to have. And so sometimes with the, with the psychotics antidepressant, I give them other medication to contract the side effects of the medication. Yeah, thank you. So it's definitely something to think about um in practice and just balancing and the need for these medications and thinking about what other alternatives we can give. Um I think there's another question in the box. So um it says is there evidence that intensive therapy is effective in resolving the majority of nonbiological sexual problems? It's very difficult because when you look at the evidence for sexual problems, II know I gave you a really simple conceptualization of each of these sexual problems and each of these problems could have multi multifactor reasons for why they're getting a sexual problem. Again, if you want to stick to something really simple because I kept talking about erectile function. I don't believe that's the only sexual problem people have. It's just easy to tell you with giving an example of a problem. So if you say um a young man, first time he has sex in a car, they're sneaking out very quickly, wants to have sex with a partner who's half dressed, they're rushing, then they hear, hear the whistle or something else happening nearby. They quickly get undressed. He gets performance anxiety and he loses his erection. Then it takes him about six months to get his confidence up again and try and go and gather the courage to go and find another partner and have sex. So that is, this is a purely known, biological sexual dysfunction, performance anxiety. And this can play in their mind once you know, somebody loses an erection, the minute they get anxious about it, they tend to lose erections. Now, how, what does intensive therapy have a role here? Yes, it does have a role. Depends on what else is contributing. Have they had other life stresses? Have they been going through posttraumatic thing that any, any stimulant just puts them off? So it depends on what, how much is formulated out there. Psychologically, then that intensive therapy is likely to work equally. A combination of medication and intensive therapy is likely to work as well. So we choose very few patients for intensive therapy. And if it's non biological, depends again on what is causing. So if it's trauma related, previous sexual trauma that's causing their sexual problem, uh there is a good chance that intensive therapy works equally. If they're in a really bad relationship, give all the intensive therapy you want, going to work. If they don't want to have sex with somebody, you can give again all the therapy you want. It's not going to change it. If, if your brain, you know, if your eyes see somebody and it doesn't feel attracted, you can't give intensive therapy to change that. And so that there is so many factors that come in. Uh intensive therapy do does have a role. It has a very good role and I've seen it resolve problems in many, many patients. Yeah, evidence for it depends on the condition and what you're looking at. But also the the people who say, 0 95% success rate really question them. That's not true because human beings are very complicated. Amazing. Thank you so much again for a really, really informative um talk. I've just put the feedback link into the um chat. So if all the attendees could fill that up, that would be really helpful for us. Um And yeah, thank you again. We really appreciate you coming to speak for us. Thank you. Good luck. Thank you. Bye for you.