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Finding a Therapist
Q
What is the difference between a psychologist and a psychiatrist?
A
psychiatrist has attended medical school and completed a
residency in psychiatry. A psychologist, on the other hand,
has usually completed 4 years of graduate school and an
internship in psychology. Although both are experts in emotional
and behavioral issues, they approach problems from different
viewpoints. The psychiatrist, being a medical doctor, often
sees emotional difficulties from a physiological perspective
and typically prescribes medications for problems such as
depression and anxiety. The psychologist, as a behavioral
scientist, understands the problem from an emotional/family
background and uses approaches such as therapy, counseling
or hypnosis. For certain problems, the two individuals may
work together using both counseling and medications.
Q
How do I find a counselor or therapist to work with?
Word
of mouth or a referral from a friend are often the best
places to start. If you have an HMO or insurance that will
pay for therapy, you can obtain a list of therapists who
are covered under your plan. Other ways to find a therapist
include calling a local hospital or mental health center,
contacting your state psychological association, using the
yellow pages or the internet. Be a cautious consumer! Ask
about credentials, experience, specialties and professional
activities. If you feel uncomfortable with the therapist,
continue looking elsewhere until you find someone that you
feel comfortable with.
Q
How do I find a sex therapist?
Some
psychologists and other therapists may specialize in sex
therapy or couples counseling. Sex therapists in the United
States are credentialed by The American Association of Sex
Educators, Counselors and Therapists, (AASECT). This association
provides a referral service by calling 1 (804) 644-3288
or by connecting to their web site at www.aasect.org.
You might also get information and a referral from your
primary care doctor, urologist or gynecologist.
Q
How do I know where is the best place to get help?
Often,
finding the right professional for you or a partner is a
trial and error process. As a rule of thumb, consider finding
a professional who is “plugged” into a larger
network. A professional who works in isolation from other
colleagues can ultimately be a disadvantage for the patient.
Today, sexual concerns are often seen as multi-faceted and
require an expertise beyond that of a single individual.
For example, before undergoing extensive sex therapy, insist
on a medical evaluation. At other times, even though there
may be a medical problem, don’t neglect attending to
your relationship. Insist on getting the best help possible
and don’t settle for second best!
Q
Is there a charge for the first consultation with a psychologist
or therapist?
Most
often psychologists and other mental health professionals
do charge for the initial meeting. There are exceptions
to this practice in different countries, different states
and among various practitioners. If money is a concern,
ask about this courtesy when calling to set up the first
appointment. A clinical practice is a small business however,
and economics usually dictate that it is necessary to charge
for professional time.
Q
How do I know that information discussed with my therapist
will be kept confidential?
There
are very strict laws in all states that regulate what information
can be released to other people or to insurance companies
and attorneys. In general, a signed release of information
is necessary before any information can be shared with other
people. The exceptions to this law include the reported
abuse of a minor or when there is sufficient concern about
the safety of the patient or another person. Your state
psychological association can provide you with specific
information for your state. It is always recommended to
discuss this issue with your psychologist at the beginning
of treatment.
Top
Sexual
Addictions
Q
Do sexual addictions really exist?
Yes,
sexual addictions do exist and can create chaos in the lives
of an individual and their family. Moreover, sexual addictions
can also put the individual in danger of legal action, potential
violence or sexually transmitted disease. Whether specific
behaviors can be considered sexual addictions may vary from
person to person. However, an addiction may exist if an
individual is unable to control certain sexual behaviors;
the sexual behavior is self-destructive and it interferes
with the normal daily functioning of the individual.
Q
What type of sexual addictions are seen by psychologists?
There
is a tremendous range of sexual addictions that people experience
and seek treatment for. Over the last several years, addictions
to internet pornography are very common. This type of addiction
may be accompanied by excessive masturbation lasting long
periods of time or by the use of prostitution. Other forms
of sexual addiction may involve exhibitionism, public masturbation,
uncontrolled sexual contact with strangers and a wide variation
of activity designed to elicit sexual pleasure.
Q
What types of treatments are available for a person with
a sexual addiction?
There
is no one form of treatment that has been proven most effective.
Often, a combination of treatments are used in working with
the person who has a sexual addiction. For example, some
of the psychiatric medications can be helpful in reducing
sexual drive or in decreasing sexually intrusive thoughts.
These medications may also allow an individual to consider
consequences before acting on a sexual urge or impulse.
In addition to medications, treatment almost always involves
therapy or counseling on a regular basis. In the United
States there are also self-help programs for people with
sexual addictions. These are modeled after the AA 12 step
programs and are found in most major cities in the US.
Q
What can I do if I think my partner has a sexual addiction?
Clearly,
the first step is to speak with your partner and discuss
your observations and concerns. Like all addictions, denial
is common. In some cases, the individual may not realize
that a problem exist or that certain behaviors have become
out of control. Encouraging psychological treatment and
providing strong emotional support are critical if changes
are expected. Expressing emotional support is often difficult
at this time because of personal distress and feelings of
anger.
Q
How can someone I love do this to our relationship?
In
trying to grasp a situation such as this, it is important
to remember that the sexual behavior is an addiction. Like
all addictions, they serve a purpose. Often, the behavior
is an attempt to cope with feelings such as depression,
stress or other emotionally painful material. In other cases,
there may be a void in the individual’s life or in
their primary relationship. Typically, the reasons behind
addictive behavior are complex and multi-faceted. For this
reason, marital or couple’s counseling may be an adjunct
to treatment
Q
Can a sexual addiction really be eliminated?
Like
any addiction, maintaining control and avoiding future problems
is a difficult, life long process. Maintaining sobriety
over sexual addictions requires strong motivation and a
constant vigilance over times of potential danger. With
good emotional support however, it is possible to make the
necessary changes. For most people, a sense of over-confidence
and a premature termination of psychological treatment and
support are the biggest mistakes that can lead to future
problems.
Top
Sex
Therapy
Q
How do I know if my sexual difficulty is from a psychological
or physical problem?
The
answer to this question may depend on whom you ask. A mental
health professional may believe that your problem comes
from a psychological issue and a medical doctor may feel
that there are physical concerns. The reality is that most
sexual difficulties have both psychological and physical
components that can contribute to the problem. Today, because
of recent medical advances, physical causes are often discovered
in the majority of cases. The psychological or emotional
component thus may be a result of the sexual problem rather
than causing the sexual difficulty. Also, relationship issues
often emerge after any form of sexual difficulty. Because
there is no simple answer to this question, a good sex therapist
should refer you to a medical doctor for an evaluation while
a medical doctor may also suggest that you address the emotional
issues with a therapist.
Q
If my sexual difficulty is because of psychological causes
what can I do?
There
are new effective treatments for people who have sexual
problems due to either physical or psychological reasons.
Almost everyone who has a sexual difficulty hopes that a
physical reason can be discovered. We all want a quick fix
and hope that a pill can solve our problem. (This is why
Viagra has become so popular.) Psychological causes for
a problem are much more vague, difficult to understand and
sometimes more difficult to treat. If there are psychological
difficulties, we tend to blame ourselves and self-esteem
is affected. Unfortunately, even in this age, many people
feel a sense of shame and inadequacy about psychological
problems. We all believe we should be able to fix the problem
ourselves without seeing a professional!
Q
Shouldn’t I wait to see if a sexual problem goes away
on its own before I see a professional?
With
sex being such a personal matter, most people do wait considerable
time before seeking professional assistance. The embarrassment
surrounding sexual difficulties often prevents people from
getting early help. Some problems do clear up on their own
especially if they are related to factors such as excessive
alcohol consumption or stress. However, if a problem persist
over a period of weeks or months there is a good chance
that the situation will not improve without some professional
intervention. Once a sexual problem has occurred, even once,
we tend to anticipate difficulties every time in the future.
This loss of sexual confidence and fear of failure can easily
intensify an already existing sexual difficulty.
Q
I am unable to ejaculate during intercourse although I have
no difficulty during masturbation. What should I do?
This
problem is often seen in clinics and can be either from
medical or psychological issues. For example, a decrease
in the sensitivity of the penis may be caused by a nerve
injury thus making ejaculation difficult with the friction
of intercourse. On the other hand, anxiety about reaching
orgasm may be another factor. A good medical evaluation
is an essential first step and would be recommended by most
therapists.
Q
What causes pre-mature ejaculation?
No
one is quite sure how men develop problems with rapid ejaculation.
However, many professionals believe that the ability to
control one’s ejaculation is a skill that is learned
during adolescence and early adulthood. Often, masturbation
is considered a method in which this response is learned
and mastered. Although the problem is more common among
young men it can persist throughout the life span of an
individual. Today, in addition to the standard sex therapy
treatments available, medications (such as anti-depressant
medications) are often used to delay ejaculation. Unfortunately,
some of these medications can also have a negative effect
on sexual interest and the quality of a erection.
Q
Is it common for women to loose interest in sex after the
birth of a child?
Men
and women may lose interest in sex at any time throughout
their lives. Often, this lack of interest may extend for
years. For women, the loss of sexual desire after the birth
of a child is very common and is poorly understood. Newer
research is beginning to suggest that a decrease in hormone
levels may play a major factor in this condition. In spite
of its frequency, good treatment is also difficult to find.
Most ob/gyn doctors have little to suggest that will improve
sexual desire. Naturally, such a situation can create extreme
tension in a marriage and often leads to frustration, anger
and marital conflict. Some Urology departments at major
medical centers are beginning to take an interest in this
condition and offer treatment to the woman and her partner.
Q
Is it normal for sexual intercourse to be painful for women?
Female
sexual dysfunction is a new area of scientific study and
at this time little is known about its causes. It is not
normal for women to experience discomfort during sexual
activity or intercourse. However, there can be numerous
reasons why intercourse may be painful for women and it
is a common complaint. Physical reasons may include low
androgen levels, lack of arousal and lubrication or internal
structures such as cysts on the walls of the vagina. Doctors
are just beginning to understand the many variables involved
in causing women to experience sexual discomfort. Psychological
issues such as anxiety, past sexual trauma, rape, abuse
or relationship difficulties may also be factors related
to discomfort during sexual intercourse. Like many female
sexual problems, evaluation and treatment for these problems
may be difficult to find. As more women become vocal about
sexual dysfunction however, doctors are being forced to
address their concerns. It is important to be a strong advocate
for yourself in seeking treatment.
Q
Why do men have such a difficult time facing a sexual difficulty?
Most
men will develop some form of sexual dysfunction at various
times throughout life. Often, this will be a crisis in the
man’s life. For many men, these difficulties are temporary
and can be attributed to stress, fatigue, medical issues
or a pre-occupation with work or some other aspect of their
lives. Because sex is such a vulnerable area for many men,
issues of masculinity often come into question when a sexual
difficulty arises. Self doubt can intensify almost any sexual
difficulty and feelings of inadequacy are usually very prevalent.
A man’s masculinity and his sexual attraction to others
are not related to the quality of erections, sexual desire
or ability to delay ejaculation. Having a sexual difficulty
need not be a serious, anxiety-provoking situation.
Q
Isn’t it normal to have sexual problems as you get
older?
Most
men and women do develop some form of sexual dysfunction
as they age. Often, this may be a result of some medical
issue such as a circulation, hormone or neurological problem.
Also life style factors such as alcohol use, smoking, weight
and cholesterol levels have been associated with sexual
difficulties. Even depression and many medications have
sexual side effects. Nevertheless, many people stay sexually
active throughout their lives and have a strong sexual desire
even into their 70s and 80s. Although it may be common to
develop sexual problems as you age, you should expect to
be sexually active throughout life. If not, treatments are
available at any age.
Q
Will Viagra solve my sexual difficulties?
In
spite of Viagra being the most popular medication ever developed,
it will not solve all sexual problems. It was originally
developed for the treatment of erectile difficulties and
has been proven to be very effective in many cases. Although
not intended for other problems, it is sometimes used to
help with low sexual desire and ejaculation problems. Its
effectiveness in these types of cases has not been proven
and is often used in conjunction with sex therapy. Currently,
Viagra is also being studied in the treatment of women’s
sexual problems. Viagra has opened the door for research
on new medications for the treatment of sexual dysfunction.
If you have a sexual problem, it is wise to stay in touch
with medical professionals as new oral medications and treatments
are constantly being developed. We are in a time of tremendous
revolution in the treatment of these problems.
Top
Transgender
Q
Is there a transgender program in the Boston area?
Boston
Medical Center has established itself as an important resource
for the New England transgender community. This program
is made up of a multidisciplinary team consisting of psychologist,
endocrinologist, primary care doctors and surgeons. In addition,
weekly support groups, conducted by members of the community,
are held at the medical center.. A number of people also
receive psychological or medical services at this facility
while obtaining additional services at other facilities
in Boston or throughout the country. Other services are
available at local health centers, community agencies or
through individual private practices.
Q
Will insurance pay for a sex change?
Most
insurance plans generally do not pay for the psychological
and medical expenses relating to a sex change. Unfortunately,
these services are not considered medically necessary by
most states or by the insurance industry. Moreover, the
expenses can be considerable given the cost of psychological
treatment, hormones and possible surgery. Because this is
typically an extended process, costs are often spread over
several years and many practitioners use a sliding scale
for payment of services. Every case is individual however
and it is best to speak with your therapist or doctor about
the financial obligations involved in this undertaking.
Q
Why is psychotherapy necessary before staring hormone therapy
or undergoing surgery?
In
order for an endocrinologist to consider hormone therapy
or for a surgeon to perform sex re-assignment surgery, the
individual must meet the DSM-4 psychiatric diagnostic criteria
of gender identity disorder. This is determined and documented
through a psychological evaluation. The results of this
evaluation are communicated via a letter to the physician
prior to initiating treatment. Prior to surgery, supporting
letters from two separate therapists may be required by
some surgeons.
Q
How long do I need to be in psychotherapy before I can start
hormones?
The
Standards of Care provide considerable flexibility in this
area and length of psychological treatment depends on a
variety of factors. These include real life experiences,
age and past treatment. Although there is considerable latitude
regarding therapy requirements, a few months of therapy
provides a good opportunity for the therapist and patient
to know each other and to identify potential difficulties.
Ideally, therapy should help to facilitate a smooth adjustment
to hormone treatment. This gradual process of changing genders
with therapy, hormones and surgery is called transitioning.
Some therapists, including myself, consider it important
to stay involved throughout this process.
Q
Is a sex change permanent?
The
psychological services relating to sex re-assignment are
obviously designed to explore one’s options. Since
beginning a treatment of hormone therapy alters body structure
and mass, this should be considered permanent and done only
after careful thought and discussion. Surgical changes,
which are the final step in a sex re-assignment, are naturally
permanent.
Q
How do I get more information about transitioning?
The
process of changing one’s gender or sex is called transitioning
and is undergone only after very serious consideration,
intensive psychotherapy and professional medical consultation.
Most individuals that would consider such a process have
been extremely unhappy with their biological gender since
early childhood. Often, they have experienced serious emotional
difficulties and profound depression. As a result of their
experience, they see no option other than sex-re-assignment.
It is a process that requires a commitment of many years
and requires considerable emotional, financial and physical
hardships. There are professional standards of treatment
(The Harry Benjamin Standards) that are closely followed
in most cases. Reviewing these standards (www.hbigda.org)
and joining a transgender support group is a good place
to start.
Top
Disability
Q
How long does it take to adjust to a disability?
Psychological
adjustment to a disability is a life long process that is
different for every individual. There is no correct way
to adjust or normal process of adjustment. In fact, some
people may never feel a sense of adjustment or acceptance.
The important point is that at some time after an injury
or illness, life must go on. If emotional difficulties are
preventing you from living a ‘healthy functioning”
life, it may be helpful to consider talking to a professional
about your feelings and thoughts. Only the person with the
disability and their loved ones can determine whether they
have adjusted to their new situation.
Q
Is it normal to be concerned about sexuality after a disability
or when major medical problems have occurred?
Almost
everyone has questions, anxieties and concerns about relationships
and sexuality after a disability. Such concerns are completely
normal. Unfortunately, it can be difficult to get information
on these topics while in the hospital or after discharge.
Because sexuality is such a private and personal matter,
many people don’t feel comfortable in asking questions
or seeking information about these areas. If you have questions
at any time regarding your sexual functioning, be persistent
in finding a professional who can provide you with the information
you need. You have a right to be fully informed as to how
your medical condition will affect your sexual expression.
Q
Why wasn’t sex talked about when I was in the hospital
or during any of my doctor appointments?
Medical
professionals, including doctors, may feel uncomfortable
talking about issues relating to sexuality. Family values,
moral or religious beliefs and cultural considerations may
play a factor in whether any professional will approach
the topic of sex. Also, most professionals have received
very little training, if any, on the topic of sexuality.
Often, professionals will wait for the patient to ask the
first question or to give an indication that sexuality is
a concern. If your doctor does not feel comfortable with
the topic, ask for a referral or seek help from someone
who feels more comfortable with sexual functioning. You
may need to be assertive in getting accurate information.
Q
Which medical conditions can have sexual implications for
me and my partner?
Virtually
all serious medical conditions and disabilities can have
an impact on how sexual feelings are expressed. For example,
sexual changes may result from any illness that affects
the genital region, breasts, pain levels, mobility, urination,
bowel movements, balance, sensation, communication, mood,
breathing, hearing or eyesight. If you have concerns regarding
your sexual functioning always ask your doctor. Never expect
that your doctor will raise these issues without your prompting.
Q
What is so different about the sexuality of a person with
a disability?
In
reality, sexuality for people with disabilities is not so
different than it is for any person. The person with a disability
however has greater obstacles to overcome in becoming sexually
active. These include both medical issues and cultural prejudices.
Medical problems and physical disabilities often affect
sexual abilities and require significant physical and psychological
adjustments. Also, people in society typically regard people
with a disability as non-sexual. These negative attitudes
can make it difficult to meet people and to have a successful
relationship.
Q.
Since my spinal cord injury, I can never quite reach an
orgasm. Is there anything I can do that would get me closer
to an orgasm?
A. The ability to ejaculate and have an orgasm is a complex
neuromuscular process that is adversely affected by a spinal
cord injury. Following injury, it is not unusual for individuals
to have significant difficulties in reaching orgasm. In
most cases, loss of sensation and inadequate stimulation
contribute to the problem. Thus increasing stimulation,
especially in areas where sensation may be spared, is a
worthwhile pursuit. Many individuals find that using a vibrator
with adjustable amplitude can provide the level of stimulation
necessary for ejaculation and orgasm. Increasing visual
and auditory stimulation may also be helpful in enhancing
the level of arousal. In addition, some experts believe
that regular and frequent sexual activity may also increase
the likelihood of restored ejaculatory functioning. Ongoing
sexual activity maintains the integrity of the various chambers
and arteries of the penis. Remember when using a vibrator;
be especially careful of autonomic dysreflexia.
Q. Can women with complete spinal cord injuries have
an orgasm?
A. Up until the last few years, there was the common belief
that men and women with complete injuries were not capable
of achieving a physiological orgasm. Instead, memories of
the past, feelings of closeness and a sense of well-being
were described as an “emotional orgasm” and
were offered as a substitute to a physical orgasm. The research
done by Marca Sipski, M.D. at Kessler Rehabilitation Center
and at the University of Miami has clearly demonstrated
otherwise. This has been ground breaking research and worth
reviewing by women who see this as important. Although the
physical reasons for this are still unclear, many women
of all levels and with complete injuries can be orgasmic
under the right conditions. Some of the factors that have
been found to correlate with the ability to have an orgasm
are: comfort with one’s body, persistence, knowledge
about one’s sexuality and intensity of stimulation.
To date, no studies have demonstrated similar results for
men with spinal cord injuries.
Q. Viagra doesn’t seem to help me with my erections?
What’s the next step?
A. Although studies have demonstrated that Viagra is effective
with about 80% of men with spinal cord injuries, there are
many individuals who continue to have difficulty achieving
or sustaining an erection after such an injury. If the situation
is not urgent, I would suggest speaking to your doctor about
the new medication Vardenafil (LaVetra) which is scheduled
for release in 2003. This medication, which did not get
FDA approval in 2002 as expected, is said to be three times
as strong as Viagra. In general, if oral medications are
not effective, injections are the next logical step. Penile
injections continue to be very effective for many men and
satisfaction rates are high. Most people prefer them to
using a more artificial option such as a vacuum constriction
devise. Try to avoid a penile implant since these are always
permanent and will make you a very poor candidate for any
new treatments or medications that may be developed in the
future.
Q. Does Viagra improve sexual functioning for women with
spinal cord injury?
A. Research is still trying to answer this question and
a multi center SCI study is currently underway. Early studies
with women did show that Viagra was no better than a placebo
for women who had low desire and poor lubrication. Currently,
the new studies with women have been redesigned to exclude
women with poor desire. Thus, in addition to the spinal
cord injury studies now underway, Pfizer is exploring the
impact of Viagra on women with poor lubrication who have
normal desire. It is just a matter of time before oral medications
to improve women’s sexual functioning make their debut.
Today however, we just don’t have the answers.
Q. Does sexual functioning improve over time since injury?
A. There is no precise answer to this question although
many people do report positive changes over a period of
years since injury. For example, it is not unusual for some
men to report having an ejaculation or an orgasm for the
first time several years after injury. Other men notice
gradual improvements in the quality of their erections.
Being sexually active on a frequent basis may be the most
helpful tool in improving your sexual functioning over time.
Frequent sexual activity tends to maintain good blood flow
to the genitals and contributes to the integrity of penile
tissue. Many of the early studies with Viagra demonstrated
the long-term benefits of frequent engorgement of the cavernosal
arteries and corporal chambers. There is truth to the old
saying, “use it or lose it!”
Q. So much has changed after my injury. Can guys with
spinal cord injury really enjoy sex?
A. Early after injury the idea of resuming a positive sexual
life can be overwhelming. Some men tend to avoid sexual
activity because of embarrassment, poor self-esteem or the
fear of failure. On the other hand, some men see this as
a challenge to be conquered. These men learn as much as
they can and take advantage of every opportunity to be intimate.
Over time and with confidence about their sexual abilities,
they enjoy long lasting relationships and frequent sexual
intimacy. It is possible to have a great sex life after
an injury but it doesn’t develop without a personal
commitment to make it happen. Having an enjoyable sex life
requires time, practice, and the knowledge that sex is an
important part of life not to be missed.
Top
Asking
a Question
Q
How can I get an answer to a personal question?
Most
professionals will be pleased to provide answers to personal
questions and you should never hesitate to ask questions
regarding sexual concerns or other matters. If you have
a question that was not answered in the above list, you
are welcome to click here
in order to send me a confidential e-mail.
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