Hello, and welcome. I'm Dr. Amy Cohen, Program Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, SMI, Psychotropics, and Sexuality. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now, I'd like to introduce you to the faculty for today's webinar, Dr. Terry Dilks. Dr. Dilks is a Licensed Advanced Practice Registered Nurse in Louisiana, and is certified as both a psychiatric nurse practitioner and a family nurse practitioner. Additionally, she is licensed as a licensed professional counselor in the state of Louisiana. She is a professor and co-coordinator of graduate nursing at McNeese State University, and serves as the director of the Psychiatric Advanced Practice Nursing Track within the Intercollegiate Consortium, which is a consortium of four universities in southern Louisiana. She has been employed almost exclusively in the psychiatric mental health field since 1975 in various capacities. Dr. Dilks, thank you for leading today's webinar. Thank you, Amy. I appreciate it, and I'm very excited to share this information with you. This is my disclosure slide. I have been a paid speaker for OTSCA and Lundbeck. We will be discussing off-label uses of medications, and I will try to make sure that I point that out if it's not on the slide. And I need to give credit to some fellow clinicians, Dr. Helen Hurst, who's a certified nurse midwife at University of Louisiana, Lafayette, and Dr. Tracy Carlson, who is a sex therapist in the New Orleans area. So these are the learning objectives that we will be going over, and you will have them available. So I'd like to talk a little bit about the historical perspective. When we look back at sexuality, it's almost always exclusively defined in a male type of role. So ancient Greece and Rome, the manhood was related to vaginal penetration, and that was required for a good reputation. In psychoanalysis, Freud defined female sexuality problems, not so much male. He talked about a feminine transfer of erotic zones, which shifted from the clitoris to the vagina, and what he believed is that people or women who desired clitoral stimulation rather than vaginal intercourse were those who wanted to be more like men, who behaved more like men, and would deny their spouse their marital privileges. There are some other social and psychological ills that was linked to clitoral sexuality, including feminism and lesbianism. When we look at marital advice in the early 20th century, it emphasized sexual pleasure, and if a woman was not able to achieve an orgasm, that was seen as a technical issue, and we just needed to educate people about it and have them understand the difference between a male's responsiveness and a female's responsiveness. And at one point in time, they felt that women who couldn't achieve vaginal orgasm were put under nervous strain that was too excessive, so, you know, the hysteria type of description that came about during that time. When we look at various iterations of the DSM, it began with issues like frigidity, impotence, and that type of thing. The DSM-III, which is the first one I was really aware of, broke down psychosexual disorders into gender identity disorders when we looked at homosexuals as being a psychological problem, paraphilias, psychosexual dysfunction, and that particular iteration listed seven different kinds of sexual dysfunctions for women. It was in the 1970s when we began to change how we looked at sexuality, particularly as it related to women. Masters and Johnsons did some wonderful research and began to look at human sexuality problems as having a psychological component, and we could help achieve sexual satisfaction with behavioral-type conditioning. This took it away from blaming the woman or blaming the man for their inability to perform sexually and into, there are some therapy that we can do. There's some ways that we can make people a little more receptive. Currently, the DSM-V has some separate descriptions of sexual dysfunctions for men and women, and those are listed there, and there are some additional issues that are also listed. When Viagra and other medications like it came out on the market, it was seen as proof that erectile dysfunction did not have a psychological component to it, and it could be explained medically, so it began to medicalize sexuality again. It was just a mechanical issue. When we look at some of the literature that's out there, one of the things that really comes through for me is that when you're addressing sexual issues with a patient, you are addressing sexual issues with two patients, not just one, and that's sometimes difficult for us in psych to allow somebody else to come into a session because we are trying to protect confidentiality. However, the partner's responsiveness and the partner's feelings about their sexual relationship is integral to your patient being able to be responsive and figure out what's going on with them. Treatment tended to be only on the identified patient, and they weren't really looking at the whole breadth of the problem. We looked at relationships outweighing sexuality and looking at uncertainties about sexual capacity when we look at mental illness and sex. Communication is a huge issue, and communication is a huge issue not only for our patients and not only for their partners, but sometimes also for us and the biases that we bring into the therapeutic relationship. It's important, I think, when you are looking at dysfunctional sexuality that if there is a partner involved to find a way to get them involved in the treatment. When we looked at barriers for sexual and emotionally intimate relationships, financial stress was a huge one. You can imagine at this point in time with the COVID epidemic and people being out of work that you're going to see an increase in sexual dysfunction. There's also a stigma against people with a mental illness, and particularly those with severe and persistent mental illnesses with schizophrenia, bipolar disorder. There are these views that we have in our head of what people with those diagnoses look like. We hopefully have a better view than somebody in the general public, but they have Hollywood views on what somebody with schizophrenia looks like. Nobody would want to become sexually involved with somebody who looks like a street person who's not supporting their hygiene needs and that type of thing. One of the things that this particular study in 2016 showed was that we need to begin to address relational and intimate needs, not just medication needs or not just therapy needs for a particular patient. We need to be able to discuss intimacy and what that means. That is so much more than just sexuality. When you look at supportive dating in psych rehab centers, that might be something to bring into your program and bring into some of the educational pieces to it. Sex life showed the lowest quality of life ratings among patients with SMI. I think we would know that. The dissatisfaction for our men is greater than women's. A lot of times, they believe that their mental illness is going to get in the way of them being able to have a normal sexual relationship with them. We need to also be aware of the LGBTQ plus community and sexual needs that go on in there. There's a lot of issues we know with suicidality and also depression, anxiety, and sexual dysfunction tends to get left as sort of the last thing we discuss. DeJar and McCann and McMillan did some studies where they looked at contributing factors of mental illness, sleep disorders. I think many of us are well aware of that, low self-esteem, social isolation. Again, this particular period of time when we're looking at stay-at-home orders or people who have to quarantine, social isolation is huge. That's beyond just sexuality. That has to do with their ability to get into society and feel a part of society. When they looked at sexual dysfunctions itself, it seemed that more sexual dysfunction was associated with greater levels of psychopathology and presence of negative symptomology. We know, and we'll talk about it in a little bit, about anti-psychotic issues and adherence issues with negative sexual experiences. These are some of the studies, and I just wanted to go through some of them so that you can be aware. When we're looking at how do we as mental health professionals assess sexuality, there are some clinical concepts to consider. The first one is how often is the problem? Has it been present their entire life? Did they acquire it after they had some normal sexual functioning? Is it specific to a particular partner or a particular type of sexual activity, or is it with everybody? This part is sometimes difficult, I think, for clinicians as well as for our patients, is remembering that all sexual behaviors, part of our job is to help normalize their feelings about them. So if it's solitary or partnered, normal or dysfunctional, morally acceptable or socially disproved of, it is a sum of who the person is as a whole. There's a line there for some of us when we look at social disapproval between what is illegal and harmful to other humans and what is just reprehensible to us as a person. So keep in mind that sexuality is just one aspect of a person's life, but it's an aspect that we in psych, I think, really need to begin embracing. So you begin with a careful history focused on biological, what their interpersonal types of relationships are, what their... The psychological health, and this is kind of interesting to me. It's not just the patient, but the psychological health and biological health of their partners. Prevalence rates, we need to remember, are greater for our patient population or people with severe medical illnesses as compared to the general population. A lot of times folks, whether it's psychiatric patients or not, will not bring up sexuality issues and seek out help for their sexual problems. And part of that is how we talk about it. There's some embarrassment. I worked a lot with people who had histories of sexual abuse and molestation in early childhood, and their ability to discuss sexuality was sometimes impaired. And then right now, if you get somebody that's really motivated towards their job and they're wrapped up in everything, sex kind of gets down on the bottom of the list. If any of you are parents and you remember your sexual relationship with your significant other prior to children and after children, sex oftentimes got put down nearer the bottom because we had little people to take care of. Adults who seek help with sexual dysfunction are often in crisis. They don't come early into that. They come after something has happened. Whether there's infidelity, marital problems, they think their partner's going to go away. So the definition of sexual dysfunction is any decrease in desire, libido, sexual arousal, frequency of incourse, or delay or inability for orgasm. So it has a multidimensional aspect to it. In the United States, 40% of women, 30% of men in general, in the general public report some form of sexual dysfunction. And the most common is low desire in women and premature ejaculation in men. And also sexual dysfunction is one of the most common reasons that our patients stop their medications. There are other things that contribute to sexual dysfunction and dissatisfaction, including too much stress, too much alcohol. Again, if we look at what's going on right now, looking at alcohol and drug use as a way of coping with things, parenting, obesity, erectile dysfunction, changes in hormonal levels and the couple remembering what it is they like and love about each other outside of the bedroom. So their intimacy has to be more than just in sexuality. For the most common sexual issues or barriers, as far as looking at decreased desire, lack of interest, that type of thing, there's a lot of psychological and emotional factors that can enter into it. Hormonal levels, as I mentioned earlier, can also impact sexuality, particularly when a woman goes through menopause. Medications and there's a list of different kinds of medications. So it's not just the medicines we use, it's medicines that are used by the cardiologists and other folks as well. The inability to become aroused, psychological factors enter into that. Also surgery, if there has been some sort of A&P repair for women or some sort of surgery that impacts the sexual organs, then that can decrease somebody's ability to be aroused. So hopefully people are talking to folks about sexuality and it may take a while for that to come back. And again, medications. So you're seeing a theme here that medications are really one of the highest things that we get in terms of disruption of sexual functioning. So inability to reach orgasm, that can be related to sexual abuse, emotional abuse, things from childhood, hormonal issues, again, trauma, surgery, and medications. Painful issues are some of the easiest thing, I think, for us to deal with. We can look at lubrication issues. We can look at, is there an infection going on? Are they having frequent UTIs related to sexual functioning? And so there are things that we can do to help out with that. When we look at the biology of sexuality, we really still don't understand it fully. We know that these particular neuroanatomic areas are involved in sexual functioning. We're not really sure how we can impact them. So it's just, this is the neuro, the neurobiology of this particular presentation is to be aware that there are some brain areas that I think we're going to see some future research in. Neurotransmitters, when we look at neurotransmitters and hormones that affect desire, we have those that are positive, dopamine, melanocortin, testosterone, estrogen. They tend to help with desires. The one that does not are serotonin. And many of our antidepressants and now many of our atypical antipsychotics affect serotonin levels. So you're going to see some sexuality being impacted as a result of that. When we look at arousal, nitric oxide is important, norepinephrine, melanocortin, testosterone, estrogen, they help facilitate arousal. And those that negate arousal, again, 5-HT, so serotonin comes into it. Orgasmic issues can be facilitated with nitric oxide, the norepinephrine and dopamine. And again, serotonin has an inhibitory function on orgasmic response. And there are other neurotransmitters and hormones that are also implicated in sexual dysfunction. So if we look at medications, the SSRIs, one of the side effects to it was delayed ejaculation in the early 1990s when we began to look at it. And for many years, men who had premature ejaculation were prescribed SSRIs to assist with that because of the side effect. Again, when we get Viagra and other similar medications being brought to market, a wave of men rushed to get it. I remember I was working in family practice at that time, and we had a little 90-year-old guy who had just gotten married who wanted 30 pills a month because it was going to solve all of his problems. When plebanterin was approved for sexual interest arousal disorder in women, and I'm telling you, if we can find something that works well, it doesn't have a lot of side effects, again, you're going to have a bunch of people rushing to get that particular drug. The response was underwhelming, and it was underwhelming because it's a difficult drug to take. You have to agree to particular things. You have to abstain from alcohol. It can interact with some drugs, and it just really did not pack the punch that people were hoping that it would. When we look at the PDR and things like that, we don't see reports of female orgasmic delay until about the 1970s when MAOIs were found to cause that. The PDR, when it initially came out, it only talked about sexual difficulties for males. We looked at, or there was a thought that sexual problems were more common in men than women, and that, I think, is related to that it's really evident if somebody's able to obtain an erection or not, and it's less obvious in females, and it wasn't talked about a lot. Again, you have two patients when you're dealing with sexual issues, and the DSM has some specific different classifications these days. When we look at medications that are associated with sexual dysfunction, there's a wide variety of them, and most of them are medicines that we use, the antipsychotics, antidepressants, and benzodiazepines, but also beta blockers and diuretics are really implicated in sexual dysfunction. There's a wide variety of assessment tools, and I've provided you with links to them. I could not show them to you because they're proprietary, but you can get to them through these particular links. The ASEX, the Arizona Sexual Experience Scale, is a brief scale, and it's one that I see most often cited in the literature, although there are others. It depends on how much detail that you want. I would use the ASEX as a screening tool for you to begin having some discussions. Some of these others are a little bit better about fine-tuning what is the sexual dysfunction that's going on. Again, different tools that are out there. The Psychotropic-Related Sexual Dysfunction Questionnaire is one that would be interesting to us, particularly those of our patients who are on psychotropics, and helps us pinpoint where there are issues with it. The other one, the Sexuality Assessment Tool, is for residential aged-care facilities and their staff, because we know that STD rates are often highest in nursing homes and areas of that nature. Again, you can find these, but they're proprietary. Good Sexual History also includes an exploration of cultural and social factors into what's going on, because you can tell somebody that they need to masturbate, for example, to help learn to be more responsive. But if their culture or their religion says that you can't do that, then those are factors that you have to work around. The CDC has a really good site, I thought, for obtaining a sexual history. And looking, if you remember nothing, remember the five Ps, talking about partners, practices, protections from STDs, past history of STDs, and prevention of pregnancy. So one of the things when you're taking a sexual history is to ask permission for it. And to open up the communication. Many times, if we just begin the conversation, you would be surprised at how open people are willing to be. So communicate, communicate. It's important to be sensitive and nonjudgmental. And I know as psychiatric clinicians, that's one of the things that we're taught, is to be nonjudgmental. Sex is one of those areas where sometimes that's a little difficult. So the history is going to include family influences, the gender roles in your family of origin. Were you allowed to be a tomboy, or did you have to dress in a dress all of the time? And your idea was you were going to grow up, get married, have children, cook, and clean house. Religious influences enter into it, gender identity things, sexuality issues in adolescence. And this is an area too, that sometimes it's a little difficult to open the discussion with. And at what age do you begin to discuss with your adolescent patients about sexuality? And the literature is sort of vague on that, but generally around age 12 and sometimes younger, that's the time to at least open the door for it, that they can talk to you about it. If their parents are there, that makes it somewhat difficult and uncomfortable at times. So I usually ask the parents if they'll give me a minute and let me discuss some things with the child or the adolescent that's there. And do they have specific questions about it? So the short form is, are you currently sexually active with one or more partner, male, female, or both? And I find that that's a good way to phrase it rather than saying, are you homosexual, bisexual, gender identity, or gender dysphoric, or whatever their particular classification of themselves is these days. Is sex satisfying? If it's not, that's an area for you to approach. Is it satisfying for your partner? How has what's going on with you impacted your sexual functioning? Are you experiencing any pain? Do you have difficulty with orgasms? And do you have any questions or concerns about your sexual functioning? I was talking with Amy earlier, when you're having these kinds of conversations, it's important to remember the person that you're talking to. A teenager may not understand what the word orgasm means. So you have to be able to address things in things that are not socially acceptable terms because they may not understand what you're saying. So remember when you're talking about medications and side effects, it's important to have informed consent. The patient has the right to know what's going on. These are some specific medications that are the major offenders for erectile dysfunction. And again, you can see some of them are ours. Some of them belong to other areas of medicine. Recreational and commonly abused substances that can cause erectile dysfunction. I don't know that people understand that smoking cigarettes or nicotine itself can cause some problems. So that's one of the areas that, when you're doing education about smoking cessation, you might be able to use. Sexuality and schizophrenia and different types of psychoses. So the disturbances in sexuality could be related to the psychosis itself. It could be related to the negative symptomology. It can be depression, it can be medication, it can be life experience, it can be where they're living, who they're living with. And if we don't address their sexual needs, it can impact their recovery in a negative way. It can lead to difficulty with adherence with medications. It can lead to difficulty with them making appointments because as somebody gets better, oftentimes their interest in sex becomes more acute than what it might be when they're dealing with active hallucinations. So different studies of sexual dysfunction found rates in people with schizophrenia to range between 70% and 30%. It depends on the study you read and it's so widely variable. 13% of these folks were unable to maintain a sexual partner and only 20% were engaged in sexual activity, even though half of them believed that it was important. Again, cross-cultural factors lead to problems. It may lead to us not inquiring about it. We get very focused on dealing with their psychosis and the things that are going on in that, that sex often doesn't get mentioned. And again, there are time factors. These types of conversations require more than a five to 15 minute med check visit. The antipsychotics and sexuality, that should be antipsychotics and sexuality, not sexual, is largely neglected by researchers. It's not something that they actively look for. Again, you look at the impaired sexual functioning in folks with schizophrenia. These particular studies showed it as high as 80% in both men and women, and it can affect all the different phases of sexual responsiveness cycle. So this is the mechanism of action that we think impacts sexual function. The dopamine antagonistic action can decrease desire because it inhibits the motivation and reward. Increased prolactin in the tuber infundibular pathway, I love that word, has decreased desire, impaired issues with arousal and orgasm. So your ability to figure out exactly what mechanism of action is causing a particular type of sexual dysfunction may lead you in a way that we can deal with it either with a different agent or add-on types of medications. And again, the 5-HT issues with serotonin have impact sexual functioning. Haloperidol, paliperidone, and resperdone have the highest risk for hyperprolactinemia, and that can be with or without clinical symptoms. And again, this is decreased libido, arousal, that type of thing. The antipsychotics that show the lowest sexual side effects. Quetiapine has conflicting data. Some of the studies that I read said it had no sexual or very low sexual side effects. Others said, no, it was a little bit higher than that. Ciprazidone, olanzapine, profenazine, aripiprazole. The lowest risk in the long-acting injectables for prolactin elevation and sexual dysfunctioning is in the aripiprazole preparation versus paliperidone. It depends on the person's reaction to it. Doesn't mean that you cannot use these agents. It means that you need to have a greater awareness of opening up those particular discussions. When we look at management of antipsychotic-related sexual dysfunction, one of the first things for us to do, as we do many times when there are issues, is exclude the comorbid conditions, alcoholism and drug abuse in particular, where you may want to measure the prolactin levels when indicated. Sometimes the prolactin levels will go up and then after the patient is stabilized, they'll come back down. Other times they stay up. So modifying the different risk factors that are in there. And we know that we have difficulty in this patient population with smoking cessation and that type of thing. Sometimes if you wait, it gets better. Sometimes you need to reduce the medication, the dosage, or switch medications to something else. A couple of studies recommended switching to aripiprazole and felt that switching was superior to add-on medications. And that was one of the things that I feel pretty strongly about. The fewest medications we can use, the better. So switching is considered a first-line option. And again, quetiapine, subrazadone, as far as switching, tended to have some fairly decent results. There's some weak evidence for yohimbine and it's off-label, but I've had some patients have done very well with that, primarily male patients. If we look at mood stabilizers and anaxolytics and bipolar disorder, sexual disturbance is related to the phase of the illness. We know that people who are manic or hypomanic sometimes also become hypersexual, engage in risky behaviors. They may not take protection. They may engage in behaviors with multiple partners. So that piece to it, if we get the mania under control, oftentimes some of that risky behavior comes down. With the depressive episode, though, we get the decreased libido. People with bipolar disorder often have more stable relationships than people with schizophrenia or other psychotic disorders. And I think it's due to the nature of the disorder because there's not as much psychosis attached to it. Males tend to have more sexual relationships than females, although I've had a couple of women with bipolar disorder that the way we discovered that they're becoming manic is when they start engaging in extramarital sexual relationships. There is an impairment in desire, excitement, orgasmic capability associated with suicidal plans or lack of hope. So this, I think, brings home the point that we need to address these issues with our patients because if the sexual dysfunction continues and it's not discussed and it's not addressed, then you get a higher association with suicidal-type behaviors. The different mood stabilizers, mechanisms of action and sexual functioning, some of them we know things about, other things we don't. So part of the problem, I think, with treatment of bipolar disorder is we look at a wide range of mood stabilizers, including lithium in the anticonvulsants, use of the antipsychotics, and some folks use benzos with it as well. There's a reduction of free testosterone with some of the older anticonvulsants that we need to remember. Valproate increases the serum testosterone and other things that may have an impact on sexual functioning. There is an increased hepatic synthesis of the sex hormone binding globulin and metabolism of sex hormones. So with some of the medications, if you've got women who are taking contraception, I'm sure many of you know this, but you need to explore that and make sure they're taking other measures to prevent pregnancy. So these are some specific drugs and their specific effects on sexual functioning. And again, it's sort of all over the place. The ones that seem to have the least effect include lamotrigine and pregabulin, and they have virtually no hepatic metabolism. So there are some reports of issues with sexuality, some improvement. Lamotrigine is the one I tend to use the most. I don't really see an effect on sexuality with it. Many of the others I do. Lithium, again, we don't have a lot of data with it. Monotherapy seems to have limited effects. We know that in the treatment of bipolar disorder, we don't always have the luxury of having monotherapy with these patients. We have to utilize a variety of medications. We don't see a statistically significant effect on sexuality with alprazolam, but we do with some of the other benzos. The Z drugs have some mild decrease in libido and some impotence with it. So treatment strategies for folks with bipolar disorder. There aren't any. There are no specific treatment strategies that have been readily identified. Again, we look at lowest effective dose, switching or adding things on. It was a very small trial and not enough, I think, to affect practice, but I found it kind of interesting suggesting that 240 milligrams of aspirin might help erectile dysfunction in conjunction with the use of lithium. There's some evidence that switching from enzyme-inducing to non-enzyme-inducing anticonvulsants might help, and considering adding on lamotrigine to some of the others can help with male sexual dysfunction. So this particular chart, this is part of the off-label stuff. These different medications have been shown in anecdotal data to be useful, and some of them I've found useful, some of them not so much. Bupropion is the one that I tend to go to first, and I get mixed results with that. With men, I've used johimbine, and with women, I've used cyproheptadine, and those two have limited results. I've also used sildenafil with women with about a 50-50 chance of it improving sexuality. So it's not the greatest, and it's hard to get insurance to approve it for women and sexual dysfunction. So now we're gonna talk about stuff that is non-pharmacological, and most of these slides came from Tracy, who is the sex therapist, and that's her specialty with it. So she cited Berman and Berman that have identified these 10 key components to sexual satisfaction. And again, the communication in and out of the bedroom, it's important to have intimate relationships that are not just for sex and coital sex. Looking at the relationship health, the emotional and physical connectedness of the two people, strong emotional health and social support are important. Self-stimulation, so again, we're looking at issues that sometimes we don't talk about in terms of masturbatory enhancement of sexual functioning. Addressing the past, again, I did a lot of work with people who had been sexually abused as children, and many times, the difficulty that they have in sexual relationships is impacted by the past, and they can't get past that. They can't become orgasmic as a relationship to it. So what are the orgasm, arousal, lubrication issues, overcoming physical obstacles that may get into the way, and then sexual empowerment of both members or both partners in the relationship. To be able to ask and give things that the other partner wants, as long as they're both okay with it. So when we look at enhancement stimulation, there are toys all over the place, and Amazon has opened this up to where you don't have to go and hide your face in a store anymore. You can openly order it on Amazon or other places. It comes in a brown box, nobody knows about it. Looking at masturbatory exercises, different types of positions, oral sex, anal sex, kissing, touching, changes in sexual routines. In fact, masters and Johnsons used to prescribe no sex for their patients, where they would go in and give each other erotic massages, but they were absolutely not able to have sex, and that helped them focus more on the other person and their enjoyment. So again, there are lots of toys that are out there, lots of things that are available. Looking at distraction and fantasies as part of sexuality, and as mental health professionals, it's helpful if we're able to provide this type of guidance to our patients, to talk about what other things they might do. Like if your kids are up, that's gonna be a distraction, you gotta wait till they go to bed. But you can use things like music, videos, it can be pornography, but it doesn't have to be, it can just be things that help the couple get in the mood a little bit better, relaxation, attending to the environment, trying to make sure you're not trying to squeeze it in at the end of the day, cause you have to, that type of thing. So, us being able to talk to our patients about things that they might consider adding into their sexual relationships. Again, noncoital behaviors that can be physically stimulating, sensual massages that I talked about earlier, walking often, when we walk together and we walk side by side, that may open up conversation because you're not doing the direct eye contact and it's easier to talk about things that are uncomfortable, I think, when you're engaged in something else. Yoga is another thing that's been found to help with physical stimulation. Minimizing pain has to be addressed. Again, there are lots of lotions and potions out there, talk to them about positional changes, look at starting off a sexual activity with a bath together, bubble bath, candles, aromatherapy, that type of thing can be helpful as well. So, there are no well-established, well-validated treatments for women. With primary anorgasmia, the sex therapists use sensate focus, directed masturbation. With secondary anorgasmia, sex education and looking at sexual skills training, communicating with their partner on sex, and again, the directed masturbation exercises. With vaginal pain, vaginal dilators can be used, using relaxation, helping the woman understand that Kegel exercises may help in that area as well, as well as lubrication issues. There are no well-established, validated treatments for men either. With erectile dysfunction, systematic desensitization may play a role, you can do some behavioral stuff, sex education, communication, if Viagra and other types of medications don't help. With premature ejaculation, you can consider the SSRIs, but you can also utilize the pause and squeeze technique. With those folks with inhibited sexual desires or problems, painful sex, delayed orgasm, it can be very difficult to treat and very limited. Some of the medications that we use can cause some retrograde orgasm with men as well. So being able to talk to them about that. Psychotherapeutic options, there's a lot of really good books out there. When I first began giving this talk, there were 20,000 different titles on Amazon alone, and that was several years ago. When The Joy of Sex came out, and that was in the 70s, late 70s, early 80s, I think, or mid 70s, that really kind of opened up some conversations as well. It allowed folks to explore different sexual positions. If the Kama Sutra has been out for centuries, that also looks at different sexual positions as well. CBT can be helpful as far as therapy goes, and couples therapy can be very helpful. So the book that I like for women with orgasm is, oh gosh, I'm gonna blank on it. I'll remember it and I'll answer it in the question area. It talks about looking at multiple orgasms and helps with the communication within the couple. Almost any of the good couples books that are out there, couples workbooks can help with sexual dysfunction issues as well. So 45 minutes on the nose, folks. I scuba dive, and this little guy is maybe a quarter of an inch long, and I just thought he was cute, so I took a picture of him. And this leads us to the question area. These are some of the references that I used. There are other references within the slide deck. And so now it's the Q&A portion of this. Right.

serious mental illness

sexual dysfunction

psychotropics

treatment strategies

communication

medication management

schizophrenia

bipolar disorder