Adult To The Max is a sexual health store for adults. This website boutique features a full range of products that can enrich any relationship. Our goal is to provide a large variety of quality adult toys and videos, lingerie for special occasions, and personal lotions and fragrances to spice up your sex life.

In addition to providing adult products and exciting ideas to enhance your sexual health, this website provides important current information about sexual health issues. The issues that are presented include male and female sexual dysfunction: the signs and symptoms, the diagnosis, and the treatment options that are available for each. The discussion also outlines the underlying undiagnosed medical problems that may be causing the sexual dysfunctions.

We are rapidly learning that good sexual health is key to a healthy lifestyle. Adult To The Max is proud to provide this novel combination of current sexual health information and a vast inventory of adult products for you to explore with your special someone. Sexual Health Issues

Sexual Health Issues

SEXUAL HEALTH ISSUES

_{The information provided in this presentation was developed through the joint sponsorship of Boston University School of Medicine and the National Foundation for Sexual Health Medicine. It was originally developed as a continuing medical education activity for primary care physicians. Its purpose here is to promote human sexual health by providing information to individuals that may be experiencing sexual dysfunction and by encouraging these individuals to seek medical attention as these dysfunctions may be symptoms of underlying medical conditions. The information provided here is not medical advice nor is it meant to substitute for an evaluation by a licensed healthcare provider.}

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GOALS OF THIS PRESENTATION OF SEXUAL HEALTH ISSUES:

1. Improve information/education regarding sexual function and dysfunction

2. Improve open discussion on sexual health

3. Improve the diagnosis and management of male and female sexual dysfunctions by providing information to individuals and encouraging them to seek medical attention, as many of the problems that will be discussed have effective and safe medical treatment options.

Society’s view of the role of sexuality in one’s life is rapidly evolving. Since the so-called sexual revolution in the 1960’s, people have been discussing sexuality and sexual relationships more openly. In 1975 The World Health Organization (WHO) declared that sex is a fundamental human right. Sexual health provides many benefits. These are physical, emotional, and psychological. Primary care physicians and healthcare providers are in the “first line” medical position to identify and address these concerns.

Why the increased interest in sexual disorders? It can be outlined by the following:

• Advances in scientific understanding of sexual responses in men and women

• Changing attitudes from clinicians and patients

• Changing demographics: people are living longer

• Availability of safe and effective oral medications (eg. Viagra TM, Levitra TM)

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Before HIV and Hepatitis (Pre-1980)

• Primary care physicians seldom asked about their patient’s sexual behavior

• Patients rarely introduced the topic

• Evaluation and treatment were often provided by urologists or mental health professionals

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HIV/ Hepatitis Era (1980- 1998)

• Increased risks from “unsafe sex”

• Increased screening for sexually transmitted diseases

• Clinicians started to talk about sex

  • Asking, “With whom?” and “what do you do?”

  • But rarely asked, “Are you satisfied?”

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Viagra Era (Post-1998)

• Primary care physicians can effectively treat men with erectile dysfunction (ED)

• Physicians need to ask their patients specific questions about sexual functioning and satisfaction

  • “What do you do during sex, and with whom?”

  • “Are you satisfied?”

• Fact: More women than men experience sexual dysfunction

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OVERVIEW OF SEXUAL DYSFUNCTION

• Highly prevalent

  • Men: 31%

  • Women: 43%

• True dysfunction affects quality of life

• Affects both partners

• Effective treatments are available

• Most people can and should be treated in a primary care setting

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MALE SEXUAL DYSFUNCTION

• Disorders of libido/desire

• Disorders of arousal (ED)

• Disorders of ejaculation/orgasm

• Other

  • Sexual pain disorder (Peyronie’s disease :painful curvature of penis)

  • Deformity (congenital: born with deformity)

National Health and Social Life Survey (NHSLS)

• Study of sexual behavior in a demographically representative 1992 group of 3,432 US adults

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NHSLS RESULTS- MALE: Prevalence by age

• Premature ejaculation was the most prevalent (numerous) disorder

  • 30% of men across all age groups

• Prevalence of low sexual desire was positively associated with age

• Men 50 to 59 years old were about 3 times more likely to report low sexual desire compared to men 18 to 29 years old

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NHSLS RESULTS- MALE: Quality of Life

• ED and low sexual desire are most associated with diminished quality of life

  • Low levels of physical and emotional satisfaction and general happiness

• Premature ejaculation does not appear to affect quality of life, compared to control subjects

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FEMALE SEXUAL DYSFUNCTION

• Disorders of desire

  • Hypoactive (low) sexual desire disorder

  • Sexual aversion disorder

• Sexual arousal disorder

• Orgasmic disorder

• Sexual pain disorders

  • Dysparaunia (painful intercourse)

  • Vaginismus (vaginal spasm)

  • Noncoital (non intercourse) sexual pain

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NHSLS RESULTS- FEMALE: Prevalence by Age

• Sexual dysfunction tends to decline with age, unlike prevalence in me

  • Lubrication difficulties exhibited age-related increase in women

  • Study limitations:

    • Cross-sectional design

    • Women older than 60 y/o not included

    • No adjustment made for menopausal status or medical risk factors

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NHSLS RESULTS- FEMALE: Quality of Life

• Low sexual desire, arousal disorder, and sexual pain are all strongly associated with low feelings of physical and emotional satisfaction and diminished happiness

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PRESENTATION OF PARTICIPATING MEN AND WOMEN

• Men participatin

  • Most with one-dimensional problem: erectile dysfunction (ED)

  • Typically with vascular (circulatory) risk factors

  • Mostly older age: mid 50’s

• Women participating

  • Most with multidimensional complaints

  • Commonly with depression

  • Mostly younger age: early 40’s

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WHY IS SEXUAL HEALTH RELEVENT TO PRIMARY MEDICAL CARE?

• Sexual dysfunctions and concerns are common in men and women of all ages

• Sexual health is important to the overall health and quality of life

• Sexual dysfunction may signal the presence or progression of underlying disease

  • Sexual health medicine continues to move into the domain of the Primary Care Physician (PCP)

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WHY SHOULD PHYSICIANS ASK PATIENTS ABOUT SEXUAL ISSUES?

• Asking provides an opportunity to

  • Offer risk-behavior counseling

  • Screen for sexually transmitted disease and risk activity

  • Improve sexual satisfaction

• Most individuals with sexual issues have not been identified

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PATIENTS WANT TO TALK ABOUT SEXUAL ACTIVITY BUT HESITATE TO BEGIN DISCUSSION

In a survey of patients published in JAMA,1999

• 85% of adults would like to discuss sexual functioning with their doctors but…

• 71% believe their physician would not want or have the time to deal with sexual problems

• 68% of adults are concerned about embarrassing their doctor

• 76% thought no treatment was available for problems

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RECENT POPULAR PUBLICATIONS SUPPORT PREVALENCE OF SEXUAL DYSFUNCTION AND STRESS NEED FOR TREATMENT

• Newsweek feature article June 30, 2003 “No Sex, Please, We’re Married. Are Stress, Kids, and Work Killing Romance?”

• Harper’s Bazaar, November 2003 “Are You Too Stressed for Sex?”

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COMMON RISK FACTORS FOR SEXUAL DYSFUNCTION (SD): LIFESTYLE ISSUES

• Age over 40

• Smoking

• Excessive alcohol use

• Excess weight or obesity

• Substance abuse

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MEDICAL CONDITIONS COMMONLY ASSOCIATED WITH SD

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MEDICATION OFTEN CAUSES SEXUAL DYSFUNCTION

Some include:

• Anticonvulsants

• Antidepressants

• Antihypertensives (blood pressure)

• beta blockers, diuretics

• Anti-acid medication

• Anti-cholesterol medication

• Sedatives

• Progestin-dominant oral birth control pills

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DEPRESSION: A MAJOR CAUSE OF SEXUAL DYSFUNCTION

• Depression and its treatment is a major cause of sexual dysfunction

• Antidepressants such as tricyclics, MAOIs, and SSRIs

• Very few patients will report drug-induced dysfunction unless directly asked

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PHYSICAL DISABILITIES ASSOCIATED WITH SEXUAL DYSFUNCTION

• Alzheimer’s disease

• Epilepsy

• Multiple sclerosis

• Poststroke

• Traumatic brain injury

• Rheumatoid arthritis

• Spinal cord injury

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PSYCHOSOCIAL / INTERPERSONAL ISSUES RELATED TO SEXUAL DYSFUNCTION

• Stress and anxiety

• Recent changes in socioeconomic status

• Partner or relationship issues

  • Lack of communication or emotional closeness

  • Lack of sexual interest on part of partner

  • Abuse (domestic violence, childhood abuse, etc.)

• Gender identity and sexual orientation conflicts

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MALE SEXUAL DYSFUNCTION

Normal Male Sexual Response

• Excitement (libido and desire)

• Arousal (tumescence/erection)

• Plateau

• Orgasm and ejaculation

• Resolution (detumescence)

• Satisfaction

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Causes of Male Sexual Dysfunction (MSD)

• Disorders of libido/desire

• Disorders of arousal (erectile dysfunction, ED)

• Disorders of ejaculation/orgasm

• Other:

  • Sexual pain disorder (Peyronie’s disease)

  • Deformity

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Characteristics of Male Sexual Dysfunction (MSD)

• Age alone is a risk factor

  • Normal physiologic changes may affect libido, erectile response, and ejaculation

  • Testosterone levels decrease with age, and this may decrease libido

  • Refractory period before re-arousal lengthens

  • Direct tactile stimulation of penis may be needed

• Increase in average life expectancy leads to increased incidence of sexual dysfunction

• People often misunderstand normal changes that occur with age and should be educated

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Risk Factors Associated With MSD

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Medications Are Associated With MSD

• As many as 25% of cases of ED(erectile dysfunction) are related to medication side effects

• Antihypertensives

• Alcohol

• Antiandrogens

• Illicit drugs

• Psychiatric medications (antidepressants, antipsychotics)

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Importance of Detecting MSD

• Sexual dysfunction may signal underlying disease

  • Diabetes

  • Hypertension

  • Cardiovascular (heart) disease

  • Hyperlipidemia (high cholesterol)

  • Depression

• Sexual dysfunction is associated with significant morbidity (illness)

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Decreased Libido/Desire Disorders

Diagnosis and Treatment

What is Libido/Desire?

• Drive

• Libido/desire disorder is a common complaint that is difficult to define and to approach therapeutically

• Desire disorders usually coexist with other sexual dysfunctions like ED

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Causes of Low Desire

• Low testosterone levels (<300 ng/dL), elevated prolactin

• Age-related (>50) or drug-induced examples: SSRIs,

• Also associated with:

  • Medical conditions

  • Psychiatric disorders especially depression

  • Substance abuse

  • Interpersonal difficulties and relationship discord

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Decreased Libido: Diagnosis

• History and physical exam by physician to identify things like

  • low testosterone or sexual disorders (ED)

• Questions that need to be asked:

  • Duration of problem (lifelong vs situational)

  • Sexual thoughts, fantasies

  • Response to sexual stimuli

  • Depression, poor body image, stressful events

  • Relationship problems

  • Alcohol and drug abuse; prescription medication use

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Decreased Libido: Treatment

• If hypogonadal and testosterone replacement is indicated

  • Available in intramuscular injections, transdermal patches, and gel

• If loss of libido is caused by depression

  • Treat depression

• If caused by ED (erectile dysfunction)

  • Physician can evaluate and treat

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Erectile Dysfunction: Diagnosis and Treatment

Male Sexual Dysfunction: ED

• ED is defined as the inability to attain and or maintain penile erection sufficient for satisfactory sexual performance (NIH, 1993)

  • Age dependant

  • Main classifications: psychogenic, organic (medical), or mixed

• Up to 30 million men in the USA may be affected (NIH,1993) and over 600,000 new cases annually

• Can be successfully treated in virtually all cases

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Psychogenic and Organic ED

• ED has a primary organic (medical) cause in approximately 80% of men

• Most cases of ED have a mixed organic/psychogenic cause

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Psychogenic Causes of ED

• Performance anxiety

• Strained relationship

• Lack of sexual arousability

• Psychiatric disorders: depression, schizophrenia

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Signs of Psychogenic ED

• Young age with abrupt onset

• Partner-specific ED

• Dysfunctional situation

• Rigid nocturnal/morning erections

• Normal self induced erections

• Difficulty coping with stress

• Depression, psychosis, or anxiety

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Treatment Options for ED

• Medication and lifestyle changes

• Psychosocial counseling

• Hormone replacement

• Oral medication: Sildenafil (viagra TM), Vardenafil (levitra TM) Pending FDA approval Tadalafil (cialis TM)

• Vacuum constriction devices

• Injectable medication

• Penile implants

• Vascular surgery

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Please note both of these medications listed above are now available by prescription

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Please note this medication is now available by the registered name: Levitra

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Male Sexual Dysfunction

Ejaculatory Disorders: Diagnosis and Treatment

MSD: Ejaculatory Disorders

• Ejaculatory disorders: most common male sexual dysfunction

• Premature ejaculation: most common ejaculatory disorder (70%)

• Delayed ejaculation: unusual but not rare (~8%); may be drug-induced

• Inability to ejaculate/achieve orgasm: may be drug-induced

• Diminished ejaculate volume: commonly age-related

• Retrograde ejaculation

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Premature Ejaculation

• Persistent or repeated ejaculation with slight stimulation before, on, or shortly after vaginal penetration and before he wishes it

• Either life-long or acquired

• Primarily psychologically/behavior based

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Premature Ejaculation: Role of Psychosexual Counceling

• Masters and Johnson: Reassure couple that it can be successfully treated

• “Squeeze technique”

  • Wife/partner stimulates man to erection

  • Wife/partner/individual applies pressure to base of penis

  • Man loses urge to ejaculate and some loss of erection

  • Repeat cycle for 15-20 minutes

  • Masters and Johnson report >97% success rate

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Premature Ejaculation: Drug Treatment

• Medication with side effects that retard ejaculation

  • Most commonly SSRIs (fluoxetine, sertraline,paroxetine)

• Topical anesthetics (lidocaine, herbs, certain condoms)

  • Retard ejaculation

  • May cause vaginal numbness and anorgasmia

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Delayed Ejaculation: Causes

• Spinal injuries

• Side effect of some medicines

  • Antidepressants

  • Benzodiazepines (Xanax, Valium)

  • Antihypertensives

• Alcohol abuse

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Delayed Ejaculation: Diagnosis

• Determine cause

  • Psychological: fear of pregnancy, affection; religious orthodoxy; sexual orientation issues

  • Medical: neurological disorder (multiple sclerosis); alcoholism; medications

  • Unknown cause

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Delayed Ejaculation: Treatment

• Some men may benefit from information and reassurance alone

• If generalized and caused by medication

  • Wait for tolerance to develop

  • Decrease dosage with physician’s direction

  • Change medication with physician’s direction

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Special Concerns with Special Populations

Prostate Cancer and MSD

• Prostate cancer is the most commonly diagnosed cancer in men

  • A common side effect of cancer treatment is sexual dysfunction

• Early treatment of ED post-treatment may decrease dysfunction

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Depression and MSD

• A bi-directional problem (one may cause the other)

• Significant numbers of untreated depressed men experience sexual dysfunction(40%- decreased interest in sex; 50%- arousal difficulties; 20%- erectile difficulties)

• Many commonly used antidepressants affect sexual function and desire

• Double-blind studies have established that buspirone 60 mg daily or sildenafil 50mg per day can reverse SSRI induced sexual dysfunction

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Sexual Functioning Post-Myocardial Infarction

• After myocardial infarction patients frequently have impaired sexual function

• Psychological distress is a primary factor often due to safety concerns

• Few patients have specific cardiac reasons for limiting sex

• In stable post-MI cases, most may resume sex after 6 weeks and after consulting with their doctor

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Evolving Concepts in Female Sexual Dysfunction

Female Sexual Response

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Female Sexual Dysfunction (FSD):INTRODUCTION

• FSD is characterized as a disturbance in, or pain during, the sexual response cycle

• Female sexual dysfunction is a widespread problem,affecting 25% to 63% of women in the US

• More difficult to diagnose and to treat in women than in men

• Until recently, a well-defined, accepted diagnostic framework for FSD did not exist

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Female Sexual Dysfunction (FSD): Classification (1)

• Hypoactive (underactive) sexual desire

  • Deficiency of sexual fantasies/thoughts and/or receptivity to sexual activity

  • Personal distress

  • Sexual aversion disorder: phobic aversion and avoidance

• Sexual arousal disorder

  • Persistent or recurrent inability to attain or maintain sufficient sexual excitement

  • Personal distress

  • Subjective or genital dysfunction (lubrication/swellingproblems)

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FSD: Classification (2)

• Orgasmic Disorder

  • Persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sexual arousal and stimulation

  • Causes personal distress

• Sexual pain disorders

  • Dysparaunia:persistent or recurrent genital pain associated with sexual intercourse

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FSD: Classification (3)

• Vaginismus

  • Involuntary spasm of the outer third of the vaginal

  • Interferes with penetration

  • Causes personal distress

• Noncoital (not involving intercourse) sexual pain disorders

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FSD: Subtypes

• Lifelong versus acquired

• Generalized versus situational

• Organic, psychogenic, and mixed

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NHSLS Results: Female Sexual Dysfunctional

Prevelence of FSD by Age

• Tends to decline with age, unlike prevalence of sexual dysfunction in men

• Lubrication difficulties exhibit age related increase in women

Study limitations:

• Cross-sectional design

• Women older than 60 y/o not included

• No adjustment or association made for menopausal status or medical risk factors

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NHSLS Results: FSD and Quality of Life

Quality of Life

• Low sexual desire, arousal disorder, and sexual pain are all strongly associated with low sexual feelings of physical and emotional satisfaction and low feelings of happiness

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NHSLS Results: FSD

Marital status

• Being married had a positive effect on interest in sex and the ability to achieve orgasm

• Lubrication was the only area in which married women reported more problems than unmarried women

• Response to pleasure in sex and pain during intercourse

  • The never married women had the fewest problems

  • Those who were divorced, widowed, or separated had the most problems

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Impact of FSD

• FSD has the potential for serious, lasting negative effects on a woman's lifelong

• Many women suffer in silence and do not realize treatments are available

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FEMALE SEXUAL DYSFUNCTION

CAUSAL FACTORS

Factors in the Female Sexual Response

• Vasoactive intestinal polypeptide (VIP) and nitric oxide (NO) may promote vaginal relaxation

• Hormonal influences

  • Estrogens, androgens, oxytocin, progesterone

  • Estrogens affect sensitivty, vasodilation, NO synthase (enzyme)

  • Testosterone affects libido

  • Hypothalamic-pituitary-adrenalgonadal axis

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FSD: Vascular Causes

• Iliohypogastric/pudendal arterial bed circulation problems

• Clitoral and vaginal insufficiency (dysfunction)

• Hypertension

• Coronary artery disease

• Previous myocardial infarction(heart attack)

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FSD: Neurogenic Causes

• Pudendal sensory and motor nerve problem/injury

• Autonomic (involuntary) nervous system dysfunction

• Spinal cord injury, central and peripheral nerve damage

• Multiple sclerosis

• Peripheral neurapathies (common in Diabetes)

• Stroke

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FSD: Endocrine Causes

• Endocrine disorders

  • Diabetes

  • Hyperprolactinemia

  • Thyroid disorders

  • Adrenal disorders

• Hormone disorders

  • Estrogen deficiency

  • Androgen (testosterone) insufficiency

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FSD:Gynecological Causes

• Recurrent cystitis(urinary tract infections)

• Sexually transmitted diseases

• Postpartum (after pregnancy/delivery) states and breastfeeding

• Hysterectomy and oophorectomy

• Perimenopausal and postmenopausal states

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FSD: Other Medical Causes

• Medications (especially antidepressants and birth control pills)

• Autoimmune disorders

• Arthritis

• Renal (kidney) diseases

• Bladder or bowel diseases

• Breast cancer

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FSD: Psychogenic Causes

• Intrapersonal conflicts

  • Religious taboos, social or cultural restrictions, guilt

  • Abandonment, trust, control,and safety issues

• Interpersonal conflicts

  • Relationship conflicts

  • Poor communication

• Sexual history

  • Past or current abuse, date rape,harassment

  • Sexual inexperience

• Stressors

  • Family illness, death, financial or job problems

  • Depression

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FSD: Role of Androgens

• Androgens (testosterone) appear to be important in female sexuality

• Decline in androgens parallels increasing age in late reproductive years (30+)

• Declining levels contribute to decline in sexual desire, arousal, and orgasm

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FSD: Role of Estrogens

• Estrogen deficiency leads to marked genital atrophy (degeneration)over time,while difficulty with lubrication occurs rapidly

• Genital atrophy and decreased lubrication lead to sexual dysfunction

• Estrogen replacement therapy (ERT) correlates positively with sexual activity and desire in postmenopausal women

• Early administration of ERT may prevent irreversible changes to the urogenital tract

• ERT must be discussed with a physician before starting to evaluate risks (increased occurance of breast cancer and possibly heart attack/stroke) versus benefits

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FEMALE SEXUAL DYSFUNCTION

ASSESSMENT

FSD Assessment: History

• Discuss any issues with a physician

  • Before woman enters menopause

• Issues that should be discussed

  • Any changes in monthly periods

  • Any changes in sexual activity or pleasure

  • Any difficulty with lubrication or arousal

  • Is orgasm achieved?

  • Is there any anxiety or depression?

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FSD Assessment: Physical Exam

• Medical exam by physician to assess general medical condition

• Gynecological exam

  • Includes bimanual, retrovaginal, and speculum exam

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FEMALE SEXUAL DYSFUNCTION

TREATMENT

Behavioral Therapy

• Sensation focus excersizes

• Masterbation training

• Use of dilators (“dildos”)

• Kegel excersizes

• Biofeedback

  • EMG sensors to evaluate for muscle spasm

  • Home trainers to promote relaxation techniques

• Direct pelvic floor massage (vibrators)

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Estrogen Replacement

• May be indicated for postmenopausal women

• Improves clitoral sensitivity, increases libido, decreases pain with intercourse

• Topical therapy relieves pain and dryness (postmenopausal)

• Estradiol ring

  • Low dose estrogen

  • May be option for women with breast cancer

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Androgen Replacement

• Androgen (testosterone) insufficiency characterized by

  • Low libido

• May be indicated in postmenopausal women and premature ovarian failure

• Conflicting reports with younger premenopausal women

• May improve desire, pleasur, well-being

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Androgen Replacement:Potential Side Effects

• Weight gain

• Clitoral enlargement

• Facial hair

• Hypercholesterolemia (high cholesterol)

• Liver damage

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Therapy with DHEA

• DHEA and DHEA-S: adrenal precursors to testosterone

• OTC DHEA 50-100mg

• May be useful in pre and postmenopausal women

• Positive response in small study

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Therapy with PDE Inhibitors( Viagra TM)

• Promotes clitoral and vaginal smooth muscle (involuntary) relaxation and vasodilation

• Genital not subjective , arousal

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Therapy with EROS-CTD (Vacuum Clitoral Stimulator)

• Vacuum therapy device by prescription

  • Hand-held, battery operated

  • Small, soft plastic cup over clitoris

  • Gentle vacuum creates increased genital blood flow

• Promotes engorgement and lubrication

• Improves orgasmic response and sexual satisfaction

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Prevalence of Sexual Dysfunction with SSRI'S (Antidepressants)

• 25% spontaneous report

• Fluoxetine 54%

• Sertraline 56%

• Fluvoxamine59%

• Paroxetine 65%

  • Highest incidence og orgasm delay

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SSRI-Induced Sexual Dysfunction: Management Options for Physicians

• Dose reduction

• Wait for tolerance to medications

• ”Drug Holidays”:skip doses on days sexual activity planned (Must be discussed with phyician before initiating this option)

• Sexual dysfunction-sparing medications

  • Buproprion

  • Nefazadone

  • Mirtazapine

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Orgasmic Disorder: Treatment Options

• Counseling to:

  • Minimize sexual inhibitions: consider Sex therapist

  • Maximize sexual stimulation: consider vibrators etc.

• Estrogen/androgen replacement in some patients

• If due to medication: consider changing therapy

• Consider referal to sex therapist

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Sexual Pain Disorders: Treatment Options

• Dysparaunia (painful intercourse)

  • Treat underlying problems if any

  • Consider lubricants

  • Topical estrogen in women with atrophy (degeneration)

    • Consider surgery for exploration if necessary

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• Vaginismus (vaginal spasm)

  • Progressive muscle relaxation and vaginal dilatation (using “dildos”)

    • Success rates approach 90%

  • Nonresponders should be referred to sex therapy

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The information provided in this presentation was developed through the joint sponsorship of Boston University School of Medicine and the National Foundation for Sexual Health Medicine. It was originally developed as a continuing medical education activity for primary care physicians. Its purpose here is to promote human sexual health by providing information to individuals that may be experiencing sexual dysfunction and by encouraging these individuals to seek medical attention as these dysfunctions may be symptoms of underlying medical conditions. The information provided here is not medical advice nor is it meant to substitute for an evaluation by a licensed healthcare provider.

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