Sexual Therapy for Patients with Chronic Pain
Q Why is discussing sexual function with patients who have chronic pain essential to care?
Joseph Shurman: Pain specialists and primary care doctors need to know about their patients’ sexual history for multiple reasons. First, you want to find out how frequently they are having sex; many of these patients—including young couples—are not having sex at all because they are in pain. Second, a lot of the medications that we are prescribing, particularly opioids, may suppress sex hormones. Third, if patients have a history of sexual abuse, their risk for chronic pain, aberrant behavior, drug abuse, and addiction, is much higher.
Gloria Shurman: Most physicians, even many gynecologists and urologists, don’t want to ask patients about sexual problems, partly because they are uncomfortable with the topic, and also because they fear it will lead to a time consuming discussion. This is unfortunate, because sexual activity is a great pain reliever and stress reducer. In my experience, sexual problems are almost universal among patients with chronic pain, yet most patients don’t discuss these issues with their doctors.
As Dr. Joseph Shurman noted, people who have been sexually abused have an increased risk for further abuse, chronic pain, drug abuse, and addiction. If you have a patient with a history of sexual abuse, it is imperative to carefully monitor their medication.
Q How can pain specialists and primary care providers better initiate conversations about sexual function among patients with chronic pain?
Gloria Shurman: Physicians should not be afraid of asking patients about sexual issues and should make it a mandatory part of their assessment. One way to do this is to include questions about sexual function at the end of standard assessment questionnaires (Table). For some patients, answering a questionnaire about sexual issues may be preferable to speaking directly with their doctor.
For people who do not report any sexual issues, physicians may want to revisit the questions at a future visit. Some patients don’t realize that there are options for helping people with chronic pain who have sexual issues. Intimacy is not just a function of sexual intercourse; it is also a way to communicate affection and a form of caressing.
An important question to include on the questionnaire is whether the patient has been abused. A self-reported history of abuse warrants a referral to a health care provider who specializes in working with abuse victims. Those victims are more likely to have severe pain and a longer duration of pain, and also are more likely to take higher levels of medication; thus, physicians would be wise to get assistance from a therapist in treating these patients.
The statistics are significant. Stud ies suggest that 40% to more than 50% of patients with a history of sexual abuse have chronic musculoskeletal pain.1,2 The intensity of the pain often is an indication of something beyond physical pain. It is especially important to look for a history of sexual abuse in patients with a greater number of chronic pain issues, especially conditions such as fibromyalgia, chronic fatigue syndrome, or nonorthopedic issues that are not obviously verifiable.
Q How can you tell if patients are being truthful when asked about a history of sexual abuse?
Gloria Shurman: The more vigorously patients deny a history of sexual abuse, the more one should be suspicious. The higher the intensity of their response, the higher the likelihood that there is something they are not telling you. Look for levels of discomfort with questions about abuse, including nonverbal cues (body language). Often, I can tell when patients are not being truthful about sexual abuse by watching their body language when I ask them questions. If they deny a history of sexual abuse or don’t answer my questions, I give them another session or two, and I come back to the topic. Generally, this helps me get to the truth.
Q If patients express concerns over their sexual function, what is the next step?
Gloria Shurman: Some physicians make sure to give patients specific options to improve sexual functioning, such as information about different sexual positions or advice on attachment/intimacy issues. However, many physicians don’t have the time or training to provide this level of care. Thus, as with any other condition that is outside of a physician’s specialty, patients should be referred to a sexual therapist or psychologist.
All physicians who work with chronic pain patients should have the ability to refer patients to psychologists, social workers, or even marriage/family therapists who are trained to assist with sexual problems. Physicians can find therapists with expertise in this area through state psychological associations.
Q What if there are no local psychologists who have experience with sexual therapy?
Gloria Shurman: Even psychologists without specific training in sexual therapy can research the information and help people by providing them with information about sexual positions and talking them through their frustration. I often get calls from therapists who are out of state and don’t have training in this area. Having a conference call with a specialist like me can help them to learn how to help their patients. I can walk them through a typical session—that is what they should be doing.
For physicians practicing in small towns, find an experienced therapist in the closest city who will consult remotely over the phone using Skype or FaceTime. This works well in my practice.
Q What should physicians do if they suspect patients have opioid-induced hormone suppression or general hormone deficiency that may be causing sexual dysfunction?
Gloria Shurman: I have treated men taking opioids who have decreased testosterone levels. Even relatively low doses of opioids may cause a drop in testosterone level. Because there might be a medical or physical intervention that will help these patients, I refer them to a urologist who is trained in sexual medicine as part of the exploration of what could be creating either a lack of interest or lack of ability to perform.
For women, I work with a gynecologist who specializes in hormone replacement therapy. I ask the gynecologist to assess the woman’s hormones to see if there are any medical options. There are still a lot of unknowns about hormone replacement therapy, and there is a lot of misinformation about it as well.