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10 Articles in Volume 15, Issue #9
Differentiating Insomnia and Depression in Chronic Pain Therapy
Improving the Sex Lives of Patients With Chronic Pain
Incorporating Concierge Medicine into Pain Management
Interdisciplinary Rehabilitation: Information for Pain Practitioners
Latest Advances in the Diagnosis and Treatment of Polymyalgia Rheumatica
Letters to the Editors: Arachnoiditis, Pituitary Adenoma
Opioid Withdrawal: A New Look at Medication Options
Oral Opioids: Not for Everybody
Oxycodone Metabolism
Sexual Therapy for Patients with Chronic Pain

Sexual Therapy for Patients with Chronic Pain

Referring chronic pain patients to a sexual therapist can provide them with many benefits, including improved satisfaction with their sex lives, lower pain levels, and improved quality of life.

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.

Joseph Shurman: I order hormone levels or refer patients to an urologist or family practice physician to measure hormone levels and treat low hormone levels. If men are given testosterone replacement therapy, it is important to routinely measure their prostate-specific antigen level and perform a digital rectal exam to make sure that the patient does not develop prostate cancer. For those who have been on high-doses of opioids for a long period of time, slowly lowering the dose may actually lower their pain level and lessen the impact of opioids on their hormone levels. I will recommend cancer pain patients to take their pain medication before or even during sex, including the use of transmucosal immediate release fentanyl (TIRF) products (TIRF is indicated for breakthrough cancer pain). In one case, a patient with cancer, this was the first time the patient was able to be intimate with their spouse in a year—they went out on a dinner date. Prudent use of Viagra and Cialis may also be warrented in some cases.

Q Do you typically include the patient’s partner in therapy sessions?

Gloria Shurman: Unless the patient is single, including their partner in sessions is really important. Some patients with chronic pain have libido and orgasms but come to see me because their partner is afraid to hurt them during sex or they need help with sexual positions. I educate these patients and their partners on different options, sometimes using drawings that illustrate positions. What I recommend depends on what the pain process is and where the pain is in the body.

I think that a key part of the assessment is understanding the nature of the problem and not just assuming that the problem is intercourse, lack of interest, lack of ability to perform. Sometimes the root problem is fear of being close, because the partner is afraid of hurting the patient or because the problem has lasted so long that they don’t want to make the other person feel bad. It is a complicated problem, but it is not unsolvable.

Often my job is to help increase couple’s communication about sex by normalizing the process and treating sexuality as a fun part of human functioning. I try to make the conversations non-threatening, as if I were asking “What physical activities can you do?” or “ what are you doing for recreation?”

I still ask single patients about sex, because they can do self-stimulation and enjoy their bodies just the same. I make that seem like a normal part of their expression, because it is. For women I talk about vibrators, including what kinds are available. For men, I remind them that masturbation may lead to pain relief, because sometimes men in pain forget that they have that as an option.

Q How can physicians better partner with sexual therapists in the treatment of patients with chronic pain?

Gloria and Joseph Shurman: This area of treatment falls under the Share the Risk Model3 for treating patients with chronic pain. No physician—no matter how well educated, confident, compassionate, committed, or meticulous—can adequately meet all the needs of a patient with chronic and intractable pain. Instead, the model calls for a multidisciplinary team approach to treat the chronic pain patient, including a urologist or gynecologist to assess hormone levels and physical issues.

In addition, as part of the Share the Risk Model, we refer all of our patients on high-dose opioids to a psychologist and/or a psychiatrist/addictionologist with pain management expertise. Psychotherapists can identify problems that may be missed by the pain specialist, including sexual dysfunction as well as other comorbidities (eg, depression, anxiety disorders, and personality disorders) for which treatment is essential for proper pain management.

Importantly, it is not only opioids that may cause sexual dysfunction. Patients with chronic pain often also are taking blood pressure medications, antidepressants, and medications to treat high cholesterol, all of which may cause sexual dysfunction. Make sure there is communication with the physicians prescribing these medications.

—Reported by Kristin Della Volpe


Last updated on: November 7, 2018
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Improving the Sex Lives of Patients With Chronic Pain

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