Treatment of Sexual Problems

RoseMary Beitia

Appalachian State University

Definition

“Sexual dysfunction is characterized by disturbance in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difficulty

This conceptualization of the “sexual response cycle” has evolved greatly over the past half century

Original William Masters & Virginia Johnson (model of the “sexual response cycle” consisted of: Excitement Plateau Orgasm Resolution

http://www.sexproblem.org/ News and Information On Sexual Problems. Symptoms, Causes ,risks, treatments and other Solution on Sexual Problems

Sexual Response Cycle

Hashmi (1929) consisted of the following: Desire Excitement Orgasm

Limited focus on physical arousal

According to systemic models the sexual response is the result of interaction between the following 3 domains:1. Biological2. Psychological3. Relational

http://www.sexproblem.org/1929)

Phases of the Sexual Response

As a function of “normal” sexual responding:

Desire: Defined by an interest in being sexual and in having sexual relations by oneself or with an appropriate partner

Arousal: Refers to the physiological, cognitive & affective changes that serve to prepare an individual for sexual activity (e.g., penile tumescence and erection, vaginal lubrication, expansion & swelling of vulva)

Orgasm: Refers to climatic phase with release of sexual tension and rhythmic contraction of the perineal muscles and reproductive organs: Sense of ejaculatory inevitability in males followed by ejaculation Contractions in the outer third of the vagina

Resolution: Refers to sense of muscular relaxation and general well-being; men are physiologically refractor while women may respond to further stimulation

(APA, 2000)

Male Sexual Response

http://www.sexproblem.org/

Female Sexual Response

Physiological indicators of arousal Vasocongestion in the pelvis Vaginal lubrication Labia minora may darken Clitoris hardens leading the

vaginal hood (prepuce of clit) to appear enlarged

Causing the vulva to lengthen and widen

Areola hardens & nipples become erect

Breast tumescence

http://www.sexproblem.org/

Female Sexual Response

Experts on female anatomy contend that there is an area in the outer third of the vagina, also responsible for orgasm, the Grafenberg or the G-spot Located in the front of the

body, 2” from entrance of the vagina

Clitoral vs. vaginal orgasm?? http://www.sexproblem.org/

Other Sexual Dysfunctions

Paraphilias Exhibitionism Fetishism Frotteurism Pedophilia Sexual Masochism Sexual Sadism Transvestic Fetishism Voyeurism

Gender Identity Disorders NOS Dysphoria

(APA, 2000)

Desire Disorders

Hypoactive Sexual Desire Disorder (HSDD) DSM-IV Criteria:

Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity

Not better accounted for by Axis I disorder (e.g., depression, anxiety) and not due to physiological effects of a substance (e.g., alcohol, prescription medications)

Sexual Aversion Disorder (SAD) DSM-IV Criteria :

Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.

Not better accounted for by Axis I (e.g., PTSD)

Arousal Disorders

General Understanding: Absence of or reduced arousal response Components:

Physiological (e.g., erectile dysfunction, vaginal dryness) Cognitive (e.g., attention to erotic stimuli, cues, fantasies) Affective (e.g., subjective sense of excitement, novelty, romance)

Anxiety negatively correlated with affective & cognitive components; although physiological (genital) responses may be observed

Differential diagnosis between diminished subjective arousal (affective & cognitive) and low sexual desire

(Wincze,& Carey, 2001)

Arousal DisordersClinical Presentation: Factors influencing Male Erectile Disorder Physiological: partial or complete inability to attain, or maintain

an erection sufficient for intromission and sexual activity Some men report full erection potential during non-coital

stimulation (e.g., masturbation, nocturnally during REM sleep) Psychosocial:

Performance anxiety Embarrassment Depression, increased suicidality Negative affect in presence of erotic stimulation Sensitive to feelings of demand Underestimate erectile response Result of chronic & acute stress

(Wincze,& Carey, 2001)

Arousal DisordersClinical Presentation: Factors influencing Female Sexual Arousal Disorder (FSAD) Physiological:

lack of responsiveness to sexual stimulation (e.g., vaginal lubrication, swelling of vulva)

Psychosocial: Anxiety, worry, fear Depression Low self esteem Performance anxiety Shame Sexual abuse Marital difficulties Poor communication with partner

Negative affect toward sex during adolescence Inaccurate subjective appraisal of arousal Reaction milder than males with ED (Wincze,& Carey, 2001)

Orgasmic Disorders in Men

Orgasmic Disorder (Inhibited Male Orgasm) DSM-IV Criteria:

Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration

Not better explained by Axis I, substance, GMCPremature Ejaculation DSM-IV Criteria:

Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician must take into account factors affecting duration of excitement phase, such as age, novelty of new partner and sexual situation and recent frequency of sexual activity

Not due exclusively to direct effects of substance (e.g., opioid withdrawal)

Orgasmic Disorders in MenMale Orgasmic Disorder Also referred to as “retarded ejaculation” Refers to physiological inability to achieve orgasm despite desire,

arousal & stimulation Ejaculation has 3 stages:

Emission Bladder neck closure Ejaculation proper

Not “retrograde ejaculation”Premature Ejaculation (PE) Three core components:

1. Short ejaculatory latency2. Lack of control over ejaculation3. Lack of sexual satisfaction

Perception of how long it takes for the “average” man to ejaculate varies between 7-14 minutes

Vary across countries, Germans, 7 mins; Americans, 14 mins Most commonly used index of PE is intravaginal ejaculatory latency

time (IELT) from 1-5 minutes(Wincze,& Carey, 2001; DeRogatis, & Burnett, 2007)

Orgasmic Disorder in Women

Female Orgasmic Disorder DSM-IV Criteria:

Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in type of stimulation that triggers orgasm.

Diagnosis based on clinician judgment that orgasmic capacity is less than reasonable given age, sexual experience, adequacy of sexual stimulation

Not better accounted for by Axis I, substance, GMC

Orgasmic DisordersClinical Presentation: Factors Influencing Female Orgasmic Disorder Physiological:

Inability to achieve orgasm Psychosocial:

Sexual knowledge Levels of sexual desire Sexual fantasizing Sexual attitude; confidence Religious/cultural beliefs Body image Self-esteem

Social norms can heavily influence orgasmic function Morokoff (1978) found that birth during the 20th century was related to

higher frequency of orgasm Lifelong or acquired

(Wincze,& Carey, 2001)

Prevalence & Comorbidity High rates of comorbidity with anxiety & depression

Loss of libido or decreased sexual desire has been reported in up to 72% of patients with unipolar depression; 77% with bipolar

General medical conditions associated with SD Men: diabetes, cardiovascular disorder, hypertension,

dyslipidemia, obesity, smoking, prostate disorders Women: chronic illness, poor general health status, such

as diabetes, breast cancer, lower urinary tract infection, surgical removal of ovaries, multiple sclerosis

Risk of SD is increased by smoking and excessive alcohol use; GMC may further increase risk

SD consistently reported in patients taking SSRIs Estimates range from 10%-65%

(DeRogatis, et al., 2007)

Specific Etiologies Common factors of low sexual desire in men & women:

Boredom Lack of physical attraction to partner Negative or faulty attitudes Dissatisfaction with partner sexual activity History of sexual abuse

Common factors of arousal disorders in men & women: Health status Performance anxiety Negative affect:

Suppression and expression of anger correlated with higher rates of ED Organic theories of PE

Penile hypersensitivity - lower ejaculatory threshold, reached more rapidly Hyperexcitability ejaculatory reflex – faster emission phase Genetic predisposition Central 5-HT receptor sensitivity – lower 5-HT transmission, receptor

hyposensitivity Religion & culture may influence sexual functioning, all three stages

(Metz, & Pryor, 2000; Wincze, Bach, & Blume, 2008; Wincze,& Carey, 2001)

Etiology as a Function of Risk Factors Causes are multiply determined Risk factors

Age Overall, SDs increase with age PE decreases with age Inverse relationship between age & distress brought on by SD

65% American women (20-29 yrs) LSD w/ distress; 22% (60-70yrs) w/o distress 67% European women (20-29yrs) LSD w/ distress; 37% (60-70yrs) w/o distress

Health status Genetic inheritance (Type 1 diabetes) Hormone deficiency Lifestyle (poor diet, low activity level)

Excessive substance use Dyadic adjustment Decreased sexual knowledge CSA

Predisposing factors (genetics) X Precipitating factors (coping w/ stressful life events) X Maintaining Factors (poor dyadic adjustment) = Diathesis Stress (DeRogatis, et al., 2007; Wincze,& Carey, 2001)

Psycho-“sex”-education

Topics to be addressed:1. Anatomy (diagrams, models)2. Physiology3. Unrealistic expectations of self & sexual

encounter4. Address myths of sexuality

Level of detail necessary for education may vary based on client

Continual throughout course of therapy

(Wincze, & Carey; Wincze, Bach, & Blume, 2008)

Myths of Sexuality Myths of male sexuality1. A real man is not into sissy stuff like

feelings and communicating.2. A real man performs in sex.3. Sex is centered around a hard penis and

what is done with it.4. Real men do not have sexual problems5. Focusing more intensely on one’s erection

is the best way to get an erection

Myths of female sexuality 1. Sex is only for women under 30.2. All women have multiple orgasms.3. Pregnancy and delivery reduces women’s

responsiveness.4. If a woman cannot have an orgasm quickly and

easily, there is something wrong with her5. Feminine women do not initiate sex or become wild

and unrestrained during sex.

Sex Therapy

Orgasmic disordersMale & Female Orgasmic Disorder

Education Encourage client to adopt realistic expectations

Encourage comfort with body and sexual desires Cognitive & Behavioral Techniques

Construct lists of good and bad sexual activity interests Encourage client to read magazines, sexual explicit

videos, art, etc; material utilized to create fantasies Assign self-stimulation exercises, gradually progress in

terms of commitment, sensitivity Daily, approx. 10-20 minutes depending on exercise