Ch 12: Sexual Dysfunction and Sex Therapy

Introduction

• [Sexual health is] a state of physical, emotional, mental and social well-being in relation to sexuality;

  it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and

  respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable

  and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be

  attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.

  World Health Organization (2012)

• sexual health has biopsychosocial roots

• given the myriad factors that can generate sexual problems,

  there is not one simple or singular approach to solving them.

Causes of Sex Difficulties

• sexual dysfunction or sex difficulties—cases in

  which a specific sexual issue persistently emerges (i.e., it is not a one-time thing) and creates distress

  at either the level of the individual or of the relationship.

• For asexual

  individuals, their lack of desire is not personally distressing and they can go on to lead perfectly

  satisfying and normal lives without sex.

• subjective perceptions

  matter and our goal should not be to create problems where none exist.

• the absence of sexual dysfunction does not necessarily

  mean that someone is sexually healthy and satisfied. It is entirely possible to be free from

  sexual problems, but to have less than satisfying sexual experiences. Simply having functional genitalia is not a guarantee

  of great sex.

• biopsychosocial factors can contribute to sexual problems.

Biological

• There are numerous biological factors that can impair sexual function or cause pain during

  sex, including the natural aging process, chronic illnesses, physical disabilities, sexually

  transmitted infections (STIs), and drugs. As we get older, most of us will experience decreases in sexual functioning because our bodies and hormone levels change. In addition, the older

  we get, the more likely we are to develop chronic illnesses. These include diseases of the

  cardiovascular and nervous systems, which are especially likely to interfere with sexual functioning.

  For instance, diabetes (a disease that progressively damages blood vessels and inhibits

  effective blood circulation) is a major contributor to male erectile dysfunction. Diabetes can also contribute to female sexual difficulties by reducing blood flow

  to the clitoris and vagina. In addition, multiple sclerosis (a disease

  that damages nerve fibers throughout the central nervous system, thereby disrupting

  nerve impulses) often produces changes in genital sensitivity and may impact ability to reach orgasm.

• Various cancers are also linked to sexual problems, although it is sometimes the cancer

  treatment that is more damaging to one’s sexuality than the cancer itself. For instance, surgical

  treatment for cancers of the breast, penis, and testicles tend to change the body in

  very noticeable ways and often create body image issues. Likewise, surgery for prostate

  cancer often results in erectile and ejaculatory difficulties, a fact that is not

  surprising given the important role of the prostate in male sexual functioning.

• With respect to disabilities, spinal cord injuries are linked to erectile and ejaculatory difficulties

  in men and often impair the ability to orgasm in women. Contrary to popular

  belief, however, permanent sexual difficulties such as these do not necessarily diminish sexual

  desire or make it impossible to have a satisfying sex life. Redefining what sex is and/or creating

  secondary erogenous zones can help persons with physical disabilities develop and

  maintain sexual relationships.

• untreated STIs such as chlamydia and gonorrhea can turn into pelvic

  inflammatory disease in women, a condition that can lead to painful intercourse and impair ability

  to orgasm. In addition, a number of drugs and medications have negative sexual side effects. Antidepressants (namely SSRIs) tend to delay orgasm in men and

  women because they keep serotonin in the brain longer. Other psychiatric medications such as

  antipsychotics and tranquilizers also have neurological effects that can inhibit ability to reach

  orgasm. Some blood pressure and allergy medications have been reported to have negative sexual

  effects as well. Alcohol, tobacco, and other drugs can not only

  create episodic sexual problems, but long-term use of these substances can generate chronic sexual

  dysfunction. For instance, chronic alcoholism is linked to problems with sexual desire, arousal,

  and orgasm. Likewise, men who smoke for years are at increased risk of

  having erectile difficulties due to tobacco’s damaging effects on the body’s blood vessels. In addition,

  chronic use of cocaine, opiates, and other such drugs can inhibit sexual arousal and response.

Psychological

• Some of the most common psychological causes of sexual dysfunction include distraction, previous

  learning experiences, beliefs about sexual difficulties, body image, and mental illness. First, distraction

  often takes the form of spectatoring, which involves over-thinking

  or over-analyzing one’s own sexual performance while having sex. You can think of spectatoring

  as the act of becoming a spectator to your own sexual activity by mentally stepping out of the

  moment and evaluating how you are doing (e.g., Are you pleasing your partner? Could you be doing a better job?). Over-thinking your sexual performance may create anxiety that reduces

  arousal and likelihood of orgasm.

• Second, past learning experiences have important implications for our sexual functioning. For

  instance, people who grew up learning that sex is a shameful or sinful activity and women who

  have been taught to think that they should not enjoy sex may end up thinking about these things

  during the act, thereby dulling sexual response and pleasure. Likewise, people who have experienced

  traumatic sexual events in the past, such as rape, sexual assault, or childhood sexual abuse

  may feel an aversion to sex or have post-traumatic stress, which can make sex thoroughly unenjoyable

  and perhaps impossible. In fact, a history of sexual abuse is often uncovered during sex

  therapy for both women and men.

• Third, our beliefs about sexual dysfunction are linked to our experiences with sexual problems.

  For example, research has found that, at least among women, the more prevalent they believe

  sexual difficulties to be, the lower their own sexual functioning is. These beliefs about higher prevalence may lead to monitoring oneself for sexual problems

  or simply produce more anxiety and worry that one will develop a problem.

• Fourth, poor body image and a lack of knowledge regarding your own body can contribute to

  sexual problems. Many women and men are dissatisfied with the size

  and shape of their chest and genitals. This can create distress and anxiety that ultimately leads

  people with poor body image to avoid sexual activity altogether.

  Alternatively, they may only have sex under very limited circumstances (e.g., at night with all

  of the lights off or only while wearing a shirt). These restrictions have the added effect of reducing

  sexual spontaneity and frequency. Also, when such persons do have sex, they may be preoccupied

  with how they look or what their partner is thinking. With respect to sexual knowledge, a lack of

  familiarity with one’s own genital anatomy, particularly among women, is sometimes implicated

  in orgasmic difficulties.

• Finally, mental illness (irrespective of whether one is receiving pharmacological treatment) is

  linked to sexual dysfunction, but not always in the same way. For instance, affective disorders are

  sometimes associated with low libido (as in the case of major depression), and other times with

  hypersexuality (as in the case of bipolar disorder, at least when people are in the manic phase). Additionally, psychotic disorders such as schizophrenia are associated

  with several forms of sexual dysfunction. Certain mental disabilities are linked to sexual difficulties

  too; however, less is known about this because sexuality and sexual behavior are typically

  ignored for this population. Many societies deem the mentally disabled unable to provide sexual

  consent and, in some cases, these individuals may be institutionalized. Thus, sexual difficulties

  among the mentally disabled have gone unstudied and unaddressed because these individuals

  are often denied a sex life altogether.

• On a side note, sometimes it is difficult to separate out biological causes from psychological

  causes of sex difficulties because they frequently go hand-in-hand. For instance, coronary heart

  disease is linked to erectile dysfunction. Part of this linkage is a result of

  general cardiovascular problems, but it is also the case that having a heart attack makes people

  anxious about future sexual activity because they are afraid of getting “too worked up.” Thus, a

  given sexual dysfunction can have more than one cause, with biological and psychological factors

  often being intimately intertwined.

Social

• Last but not least, there are several social variables than can generate sexual difficulties. First,

  ineffective communication about sex both in and out of the bedroom is correlated with lower

  sexual satisfaction. This makes sense because if you fail to tell you partner what you like or what feels good, then you may not receive the stimulation you need in order

  to maintain arousal and to reach orgasm. Second, relationship problems such as unresolved

  conflict and anger often reduce desire for partnered sexual activity, which has a

  tendency to breed further relationship problems. Third, the way the partners in a relationship

  view sex can affect partners’ performance and satisfaction. For example,

  couples who are actively trying to have a baby sometimes put too much performance pressure

  on one another, which may create anxiety and arousal problems. Also, couples who turn sex

  into a chore or duty, or whose sex lives become very routine (e.g., a couple who only has sex

  on Tuesdays and only in the missionary position) may risk reducing their enjoyment. Lastly,

  cultural and religious factors are extremely important to take into account because they may

  dictate certain prohibitions when it comes to seeking out and experiencing pleasure from sex.

  For example, it is well known that East Asian cultures tend to have more conservative attitudes

  toward sex than European cultures. Research finds that persons of East Asian descent tend to

  report lower sexual desire and functioning than their European counterparts, at least partly

  because they report feeling more guilt about pursuing and enjoying sexual activity.

• sexual dysfunction is a biopsychosocial phenomenon. One theory that attempts to integrate all of these influences is the dual control

  model. The idea behind this model is that underlying

  sexual arousal and behavior are two important brain mechanisms: an excitatory system

  and an inhibitory system. Activation of the excitatory system promotes sexual arousal and

  activity, whereas activation of the inhibitory system suppresses it. Having two separate systems

  is thought to be adaptive. For instance, the excitatory system is important for ensuring

  that reproduction happens, whereas the inhibitory system may be useful for helping to maintain

  harmonious interpersonal relationships by suppressing the impulse to have sex with our friends’ romantic partners.

• It is theorized that both systems are influenced by biopsychosocial factors. For example, some

  people may be biologically “hardwired” to have one system be more active than the other. At the

  same time, however, activation of these systems is also affected by our previous learning experiences

  (e.g., have your previous sexual experiences been rewarding or punishing?) and by cultural

  factors (e.g., does your culture believe that sexual responses should be controlled and hidden away?).

• When one system becomes disproportionately active, no matter whether it is a result of biological,

  psychological, or social factors, sexual difficulties are more likely to occur. For example, higher

  excitatory activity may lead to compulsive and risky sexual behavior or premature orgasm, whereas

  higher inhibitory activity may lead to difficulties with sexual desire or with becoming and staying

  aroused. As you can see, the dual control model may be useful for understanding the origins of a

  wide range of sexual dysfunctions.

Types of Sexual Dysfunction

• Research on sexual difficulties

  has historically been heterosexist and made the assumption that everyone fits into the gender

  binary. As some evidence of this, many of the diagnostic criteria for sexual difficulties emphasize

  problems with penile–vaginal intercourse and there is typically little, if any coverage of sexual

  problems among individuals who are transgendered. However, anyone can experience sexual dysfunction,

  regardless of their sexual orientation, gender identity, or specific sexual practices.

• sexual dysfunction according to 4 distinct classes: problems with

  desire, arousal, orgasm, and painful intercourse. Please note that the problems identified can be

  issues people have had for their entire lives (a primary dysfunction), or issues that appeared out of

  the blue one day after a period of healthy sexual functioning (a secondary dysfunction). Also, it is

  important to recognize that these dysfunctions may only occur with one partner or during one

  type of sexual activity (a situational dysfunction), or they may occur with all partners and all sexual

  acts (a global dysfunction).

Desire Problems

• The most common difficulties pertaining to sexual desire are female sexual interest/arousal disorder (SIAD) and male hypoactive sexual desire disorder (HSDD), both of which are characterized

  by absent or reduced sexual fantasies and thoughts, a lack of desire for sexual activity,

  and personal distress resulting from these symptoms. The HSDD label used to apply to both

  men and women, but in the DSM-5, this label is technically now applicable only to men, and the

  new category of SIAD was created for women. SIAD is much broader than a lack of sexual

  desire and also includes reduced or absent excitement during sexual activity, reduced genital

  sensations during sex, as well as a lack of responsive desire (i.e., desire that sets in after sexual

  activity has started). Because female sexual desire and arousal difficulties are frequently

  comorbid (i.e., they co-occur) and can be difficult to distinguish, two previous diagnostic

  categories (female HSDD and female sexual arousal disorder) were combined into one in the

  latest version of the DSM.

• Low sexual desire is the most common form of female sexual dysfunction, and it tends to be

  more common among women than men. Of course, keep in mind

  that a lack of sexual desire is not necessarily pathological (e.g., as in the case of asexuals). Also, it

  is perfectly normal for sexually active people to experience fluctuations in desire throughout their

  lives (e.g., desire may temporarily decrease during times of significant stress). SIAD and HSDD are

  only considered disorders when they are both persistent and personally distressing. In cases where

  one partner has less sexual desire than the other and it generates relationship difficulties, this is

  known as a sexual desire discrepancy and is considered a couple-level problem, not the fault of

  one individual. Contrary to popular belief, sometimes men are the low-desire partners and sometimes

  women are the high-desire partners in different-sex relationships; however, it is important to

  note that desire discrepancies can also affect same-sex couples.

• Another desire difficulty is sexual aversion disorder, which refers to an aversion to any type of

  partnered sexual activity. The aversion can take many forms, ranging from fear to

  disgust. In severe cases, just the thought of sexual activity may be enough to generate a panic

  attack. We do not have good data on the prevalence of this disorder, but it is thought to be

  extremely rare. In fact, this diagnostic category was so infrequently used by clinicians that it was

  dropped from the DSM-5.

• What about the opposite of low sexual desire? Compulsive sexual behavior, also known as

  hypersexuality, refers to cases where people have “excessive” sexual desire and engage in very high

  amounts of sexual behavior. This can take the form of non-stop pornography use, a large number

  of anonymous sexual encounters, and/or an obsessive preoccupation with all things sex. The

  popular

  media often refers to this pattern of behavior as “sexual addiction”; however, despite all

  you have heard about this “addiction” and all of the celebrities who have entered “sex rehab,”

  compulsive sexual behavior was not recognized as a disorder in the DSM-5, at least partly because

  there is a lack of research on this topic and a lack of agreement about what constitutes “too much”

  when it comes to sexual behavior. That said, there is a listing for excessive sexual drive in the

  International Classification of Diseases (ICD) published by the World Health Organization. This

  diagnosis is subdivided into satyriasis (for men) and nymphomania (for women), with those names

  derived from the most sexually active creatures in Greek mythology (i.e., satyrs and nymphs).

  However, the notion of sexual “addiction” remains controversial.

Arousal Problems

• Sexual arousal difficulties fall into two categories: (1) problems becoming or staying aroused and

  (2) problems with persistent and uncontrollable arousal. In biological women, chronic difficulty

  becoming aroused is given the SIAD label, whereas uncontrollable arousal is

  known as persistent genital arousal disorder (sometimes called “restless genital syndrome”).

  SIAD may be diagnosed when effective stimulation reliably fails to produce vaginal lubrication and

  other physical signs of arousal and/or when such stimulation produces physical but not psychological

  arousal. In contrast, persistent genital arousal disorder, a relatively new

  and rare diagnosis, involves uncontrollable sexual arousal that occurs spontaneously, without

  being preceded by sexual desire or activity. In such

  cases, arousal can last for days at a time with orgasms providing only temporary relief. Some of

  you might be thinking to yourself, “What’s so bad about that?” Let me assure you it is not as pleasurable

  as you are imagining. People with this disorder report that constant arousal is physically

  uncomfortable and significantly impairs concentration, making it difficult to lead a normal life and

  to carry out very ordinary tasks. Physical causes have been implicated in both of these disorders,

  although research has suggested that psychological and relationship factors can sometimes play a

  role in SIAD.

• In biological men, difficulty becoming aroused is known as erectile disorder (ED), while uncontrollable

  arousal is known as priapism. ED, also commonly known as erectile dysfunction or impotence,

  refers to a persistent inability to develop or maintain an erection sufficient for sexual performance.

  This is one of the most common forms of sexual dysfunction in men, especially as they get older. ED can have physical or psychological causes and, depending upon the origin, the treatment

  is very different. In contrast, priapism (“permanent erection”) is defined as an erection that

  simply will not go away on its own. More specifically, it is an erection lasting longer than four hours.

  Such erections are painful and should be viewed as a medical emergency because, if left untreated, it

  can severely damage the penile tissues and eventually cause ED. Most cases of priapism are caused by

  medications or physical conditions and are not a result of having a high sex drive.

Orgasm Problems

• There are two types of orgasm problems: finishing too quickly or not at all. Although both problems

  can occur in men and women, men are more likely to have the problem of reaching orgasm too soon

  and women are more likely to have the problem of never reaching orgasm. Premature orgasm (also

  referred to as premature ejaculation or early ejaculation in men) occurs when an individual consistently

  reaches orgasm before it is desired. In such cases, orgasm occurs rapidly and sometimes prior to any

  sexual penetration. In men, it may even occur before a full erection is reached. However, pinpointing

  the exact moment when an orgasm becomes “premature” is dicey. Although the DSM-5 technically

  defines male premature ejaculation as occurring within one minute, I would argue that it is probably

  best not to define it in terms of seconds, minutes, or number of thrusts and instead focus on how the

  orgasm is subjectively perceived (i.e., Is the timing of it distressing? Does the individual avoid sexual

  intimacy because of it?). Although most people associate this problem with men, it has been documented

  among some women as well. Premature orgasm can have both physical

  and psychological roots, but some researchers have proposed that (at least among men) it may not

  be a dysfunction at all and instead may reflect an adaptive advantage. The idea is that because the male orgasm is essential to reproduction, having it occur faster will maximize the likelihood of

  conception by reducing the odds that the sexual act will be interrupted before completio). An alternative explanation is that some boys may condition themselves to ejaculate rapidly

  during adolescence to reduce the risk of being caught in the act. Given the prevalence of male

  premature orgasm, some have argued that adaptive and psychosocial explanations

  like these make sense and that perhaps we are unnecessarily pathologizing early ejaculation by classifying it as a disorder.

• In contrast, orgasmic disorder (also known as anorgasmia) is the term used to refer to women

  who have either an inability to achieve orgasm or a greatly delayed orgasm during sexual activity.

  Orgasmic disorder is common and involves delayed or absent orgasm, and/or

  reduced orgasmic intensity. In some cases, the inability to orgasm represents a lifelong pattern of

  behavior, whereas for others, it is situational (e.g., they may be able to reach orgasm through masturbation

  but not with a partner). Psychological factors are often at play, but female

  anorgasmia may also have physical roots (e.g., untreated STIs, spinal cord injury) and, in some cases,

  may result solely from insufficient stimulation. Please note that heterosexual women who cannot

  reach orgasm as a result of vaginal intercourse alone but can reach orgasm in other ways (e.g.,

  through clitoral stimulation) are not considered to have a dysfunction.

• In the DSM-5, orgasmic disorder is technically termed delayed ejaculation when it affects

  biological

  men, and it is far less common than both premature ejaculation and ED.

  In most cases, it involves a man whose ability to ejaculate is either significantly delayed or frequently

  absent during intercourse, but functions normally during masturbation and other activities. In this scenario, there is often a psychological explanation (e.g., such men

  may have a preference for other sexual activities over intercourse); however, in cases where a man’s

  ability to orgasm is lost completely, there are usually medical reasons (e.g., prostate cancer, spinal

  cord injury).

• orgasmic difficulties are also an issue faced by postoperative

  transsexuals,

  largely because sex reassignment surgery may disrupt the body’s original sensory

  pathways. However, male-to-female transsexuals usually face more

  difficulties

  after surgery than female-to-male transsexuals.

Pain Disorders

• The 2 main forms of sexual pain in men (both of which are relatively rare) are phimosis, a condition in which

  an uncircumcised man’s foreskin is too tight and makes erections painful, and Peyronie’s disease,

  a condition in which a build-up of scar tissue around the cavernous bodies results in a severe curvature

  of the penis and makes intercourse difficult and painful. STIs, smegma, and urinary infections

  can also lead men to experience physical pain during sex.

• In women, painful sex is far more common and has many possible causes. When women experience pain in anticipation of or during vaginal intercourse, or

  when vaginal penetration is difficult, it is known as genito-pelvic pain/penetration disorder (GPD). In the DSM-5, GPD represents the merging of two previous diagnostic categories:

  dyspareunia

  and vaginismus. These categories were merged because they frequently co-occurred

  and were hard for clinicians to distinguish.

• Dyspareunia referred to any type of pelvic or genital pain that occurred during sexual

  arousal or activity. STIs are one such reason, but other possible contributors

  include infections of the Bartholin’s glands, yeast infections, smegma accumulation

  under the clitoral hood, as well as vaginal scars and tears (from childbirth, an episiotomy, prior

  sexual assault, etc.). Other potential causes include inadequate lubrication, irritation from

  spermicides, and allergies to latex condoms. Psychological factors may also play a role in both

  developing and maintaining painful sex. For example, eye-tracking research has revealed that

  when women with dyspareunia are shown erotic imagery, they spend less time looking at the

  sexual aspects of the scene and more time looking at the background and contextual features

  compared to women with no sexual difficulties. This suggests

  that women with dyspareunia are either distracted from sexual stimuli, or they seek to

  avoid it. Of course, it is unclear to what extent distraction and avoidance may be a cause or a

  consequence of painful sex, but this pattern of responding to sexual stimuli could help painful

  sex persist once it starts.

• Vaginismus referred to a situation in which the lower third of the vagina exhibits sudden and

  severe contractions during any attempt at vaginal penetration, thereby making intercourse difficult

  and painful (Butcher, 1999). This may coincide with the very first attempt at vaginal penetration,

  or develop at some later point in life. Such contractions are completely involuntary and not

  only inhibit intercourse, but also gynecological exams and the insertion of tampons. Vaginismus

  usually represents a conditioned response, and often stems from a chronic history of painful sex.

  Vaginismus may also develop in response to chronic relationship problems, or past experiences

  with sexual coercion or assault.

Sex Therapy

• there is not just one way of

  approaching a given sexual problem.

Schools of Thought

• The Behavioral Approach

  • First is behavioral therapy, an approach pioneered by Masters and Johnson (1970). Their view was

    that sexual dysfunction can often be explained by basic principles of psychological learning theory,

    namely, punishment and reinforcement. If the behaviorism movement has taught us anything, it is

    that we can often learn new associations to replace those that are maladaptive. Thus, the goal of

    Masters and Johnson’s therapy was to change the way that people approach sex and to recondition

    the client to feel pleasure rather than stress in sexual situations.

  • In order to accomplish this, sex therapists must get their clients to stop perseverating on what

    they are “supposed” to achieve each time they have sex (i.e., orgasm) and, instead, relax. In other

    words, we need to remove the fear of failure in the bedroom that all too often becomes a selffulfilling

    prophecy. One way of achieving this is for couples to do something that sounds counterintuitive: temporarily stop having sex. Couples will then slowly work their way back into it

    through a series of sensate focus techniques. Sensate focus can be thought of as a gradual

    reconditioning process in which individuals ultimately come to associate sexual arousal and

    activity with relaxation and pleasure instead of anxiety. The way this works is that the partners

    will start out slow, with no demands placed upon each other, and progressively build up sexual

    intensity as they learn to let go of sexual fears and distractions. For instance, in the early stages

    of sensate focus, couple members may be instructed to take turns touching or massaging each

    other without focusing on the breasts or genitals and to simply enjoy the feeling of one another’s

    bodies. Next, partners may be instructed to guide the other person’s hand over their own

    body to demonstrate what they find pleasurable. In the days and weeks ahead, genital touch and

    the desired forms of sexual activity are reintroduced. During these later stages, couples

    are

    instructed to continue telling each other what feels good and not to view orgasm as the ultimate

    goal. These exercises are based on the notion that both touch and communication are vital

    aspects of healthy sexuality.

  • Sensate focus techniques are often combined with sex education because many cases of sexual

    dysfunction can be attributed to a lack of knowledge about the human body (your own and/or

    your partner’s). One such combined approach is the PLISSIT model of sex therapy, developed by

    psychologist Jack Annon (1976). PLISSIT is an acronym that stands for Permission, Limited

    Information, Specific Suggestions, and Intensive Therapy. The idea behind this model is that most people experiencing sexual dysfunction do not need major therapy; instead, most clients just need

    a little reassurance (permission), an anatomy lesson (limited information), or some new sexual

    strategies or advice such as sensate focus (specific suggestions). Most cases do not require the final

    step of intensive therapy.

  • How well does behavioral therapy work? Masters and Johnson (1970) reported a 20% failure

    rate overall, which many people interpreted as meaning that their methods were successful

    80% of the time. However, it appears that the 80% of non-failures represented a mix of partial

    and complete successes, so it cannot necessarily be inferred that 80% of the problems were

    completely resolved. As it turns out, it is more problematic than it

    might seem to define “success” in sex therapy. For example, consider a client with premature

    orgasm who was previously only able to last one minute, but was able to last an extra 30 seconds

    by the end of therapy. Is that a successful outcome? Some would say yes, but others might

    disagree. Despite significant variation in definitions and rates of success across disorders, there

    is no dispute that behavioral therapy can generate improvement for a variety of sexual dysfunctions.

  • On a side note, it is worth mentioning that while Masters and Johnson’s sex therapy research

    was originally validated on heterosexual clients, they found that administering the same type of

    sex therapy to same-sex couples was about equally effective.

• The Cognitive-Behavioral Approach

  • Cognitive-behavioral sex therapy (CBST) builds upon the behavioral approach by combining it

    with theories of cognition. Instead of simply instructing clients to alter their behaviors, CBST goes

    further by looking at the thoughts and feelings underlying our behaviors. Thus, in CBST, a client

    will be involved in some type of “talk therapy” in which a psychologist will attempt to identify the

    thoughts that generate anxiety that, in turn, create sexual problems. Ultimately, the goal is to

    reshape thought patterns to make them more positive. Such an approach would be most applicable

    to clients who have problems with spectatoring or who have distressing thoughts that pop into

    their minds during sexual activity. CBST is reasonably effective; again, however, success rates vary

    across disorders and with definitions of “success” (McCabe, 2001).

• Other Approaches

  • Beyond behavioral therapy and CBST, there are several other approaches to treating sexual dysfunction,

    including sex surrogacy and pharmacotherapy.

  • Sex surrogacy involves cases where a

    therapist provides clients with substitute or “practice” partners in order to reach desired therapeutic

    outcomes. As you might imagine, this is highly controversial.

  • Pharmacotherapy involves the treatment of sexual difficulties with medicinal drugs. Only

    psychiatrists (who are medical doctors by training) can practice the full range of pharmacotherapy

    because, even in the few locales that allow prescription privileges for psychologists,

    the types of drugs they are permitted to prescribe are limited in scope. The number of medications

    with a demonstrated therapeutic effect on sexual dysfunction is growing rapidly. This

    list includes hormonal therapy (testosterone supplementation for low desire in men and

    women, as well as estrogen replacement in post-menopausal women with arousal problems),

    Viagra (for treating erectile dysfunction), SSRIs (for premature orgasm), and Botox (for vaginismus). More and

    more people are receiving medication instead of working with a therapist to deal with their sexual difficulties.

  • The growth of pharmacotherapy has been controversial, with some arguing that drug manufacturers

    and physicians are increasingly ignoring the biopsychosocial nature of sexual dysfunction

    and valuing physical treatments over psychotherapy (e.g., Bancroft, 2002). The concern is that

    because drug treatments can be administered quickly, are highly profitable, and are preferred by

    some patients who seek convenience, they are on their way to becoming the first line of defense,

    even in cases where psychological treatments or couples therapy would be more appropriate. As a

    result, we may be fundamentally altering the nature of sex therapy away from an emphasis on the

    couple (as we saw in the Masters and Johnson approach) and toward the individual. Certainly,

    drugs have a place in sex therapy, and nobody is advocating that we get rid of them entirely – just that we do not overuse them and completely forget that the modern sex therapy movement was

    founded on the premise that many sexual problems can be alleviated simply by enhancing relationship

    intimacy and communication.

• Critiques and Controversies

  • there are some ongoing controversies in the field of sex therapy about

    how we should define therapeutic “success” and how large a role pharmacotherapy should

    play. In addition, there is a more general controversy about how we should define a sexual

    “disorder” or “dysfunction” in the first place, and when treatment is appropriate. For one

    thing, it is important to remember that what is “normal” and “abnormal” when it comes to sex

    is culturally relative. For instance, while people in the US may view a lack of sexual desire as

    problematic for a woman, some African and Middle-Eastern cultures may see this as normative

    and acceptable. In addition, some cultures may see sexual problems as having supernatural

    rather than organic or psychological causes, which means their approach to dealing with sexual

    difficulties will be quite different.

  • Related to this point, psychiatrist Thomas Szasz (1990) has argued that having diagnoses

    based upon patterns of behavior is completely arbitrary because what represents a sexual

    “problem” for one individual may be a desired outcome for another person. Thus, the whole

    notion of sexual “dysfunction” is a social creation in his view. To illustrate his point, why do we

    consider it problematic when someone has difficulties becoming aroused or typically reaches

    orgasm in under a minute, yet we do not call it dysfunctional when someone dislikes kissing or

    does not enjoy giving and/or receiving oral sex? Are we just selectively imposing sexual illnesses

    on certain people?

  • All of this is not to deny the existence of sexual difficulties; rather, it is to reiterate the point that we need to recognize the role of subjective perception

    when it comes to diagnosing and treating sexual problems. Specifically, we should be

    reserving the “dysfunction” label only for cases in which the behavior is causing personal

    distress or harming the individual’s ability to establish or maintain the intimate relationship desired.

Specific Treatments

• Treating Desire Problems

  • Desire dysfunctions tend to be the most difficult to treat and typically have the lowest success rates

    of all sexual disorders. However, there are multiple treatment options to consider, and it may take

    more than one attempt to achieve resolution. One possibility is behavioral therapy or CBST, because

    low desire and desire discrepancies sometimes stem from relationship problems.

    Thus, enhancing intimacy and communication through sensate focus or other techniques may help.

    Beyond this, pharmacotherapy is another possibility. Testosterone is a

    hormone that is linked to higher levels of sexual desire. Among both men and women, testosterone supplementation

    has increasingly been used to treat desire difficulties with some degree of success.

• Treating Arousal Problems

  • In women, difficulties becoming aroused can be treated with CBST if psychological or relationship

    factors are the root of the issue. If there are physical causes, hormone therapy is an option. In

    particular, estrogen replacement in post-menopausal women can enhance vaginal lubrication.

    Alternatively, artificial lubricants can be used with fewer side effects. Another option for increasing

    arousal is the EROS Clitoral Therapy Device, which you can think of as the female equivalent of the

    penis pump. EROS works by drawing more blood into the clitoris through a small, motorized suction

    device, thereby increasing genital sensation and sensitivity. Unfortunately, because persistent

    genital arousal disorder has only recently been identified and is relatively rare, research on possible

    treatments for this problem is very limited.

  • In men, persistent arousal (i.e., priapism) can be treated by drawing the blood out of the penile

    tissues. This can be accomplished with medications that constrict blood vessels in the penis,

    thereby forcing more blood out, or by manually removing blood with a needle. Ouch. In contrast,

    ED can be treated with CBST, drugs, pumps, or surgery. Before determining the appropriate treatment,

    a physician would need to assess whether the cause is biological or psychological. This can

    be determined by testing whether the patient is still getting erections during his sleep. Males naturally

    get four to five erections per night as they move in and out of different sleep cycles, which is

    why they often wake up with “morning wood” (on a side note, women get the same number of

    clitoral erections at night too, which means women technically get morning wood too). By encircling the base of the penis with a thin paper ring, men can easily see whether they

    are still getting sleep erections based upon whether that ring breaks during the night. If it does,

    psychotherapy would be the appropriate treatment. If not, some type of mechanical device (i.e., a

    penis pump, which draws blood in through a vacuum mechanism) or medical therapy would be warranted.

  • Of the medical options, drug treatment with Viagra (or its sister medications Cialis and

    Levitra) would be the least invasive. All of these drugs are chemically similar and work by creating

    the capacity for an erection. Specifically, these medications dilate the blood vessels leading

    to the penis, which allows more blood to flow in during sexual stimulation. Contrary to

    popular belief, these drugs do not produce automatic erections (erotic stimulation is required)

    and their effects are not immediate (they may take up to two hours to work). Most men with

    ED respond well to these drugs, but research suggests that their effectiveness is amplified when

    combined with couple’s sex therapy that focuses on improving communication and intimacy. However, it is important to be aware that one of the potential side effects

    of ED drugs is priapism.

  • The more involved option would be a penile implant, which is only considered if all other

    options have failed or are unsatisfactory because implants require destroying the cavernous bodies

    of the penis, thereby making it impossible to achieve a natural erection afterward. One type of

    implant involves placing inflatable tubes inside the cavernous bodies that are attached to a fluidfilled

    reservoir inside the abdomen and a pumping mechanism implanted in the scrotum. When

    an erection is desired, the scrotal pump is pressed until the penis is fully inflated by the fluid from

    the reservoir. A release valve is also implanted in the scrotum so that the erection can be deflated

    when it is not needed. Alternatively, rather than a pump, a pair of semi-rigid rods may be implanted

    inside the cavernous bodies. The penis can then be bent upward when an erection is desired, and bent back down afterward. Most men (85–86%) who receive an implant tend to be satisfied with

    the results; however, be aware that implants cannot restore lost

    sensation or orgasm capacity.

• Treating Orgasm Problems

  • premature orgasm is an issue that can affect both men and women; however,

    it is substantially more common among men. It is likely that many of these same techniques could be adapted to

    treat premature orgasm in women, although that has yet to be empirically studied.

  • Resolution of inhibited or delayed orgasm requires looking at whether the underlying cause is

    physical or psychological. Behavioral therapy and CBST may be useful if relationship conflict,

    anxiety, or distraction is the root of the problem. As part of a behavioral treatment program,

    clients

    may be instructed to get to know their own body better (e.g., getting comfortable with

    masturbation and exploring different stimulation techniques to determine what feels best) or to

    communicate more with their partner about what they enjoy. Kegel exercises may also be recommended because they tend to enhance genital sensitivity and may increase the likelihood of orgasm.

  • Of course, these techniques may not be effective if there is an underlying physiological cause.

    For instance, we know that SSRIs often cause delayed orgasm. Persons taking these drugs may need to work with their physician to reduce the dosage, switch to a non-SSRI antidepressant (e.g.,

    buproprion, which affects dopamine reuptake instead), or consider taking an additional drug to

    counteract the effect (case studies have suggested that Viagra can work for this purpose). Treatment courses would obviously be quite different if another physical factor (e.g.,

    chronic illness, injury, substance use) were contributing to orgasmic difficulties.

• Treating Pain Problems

  • treatment options for painful sex.

  • For phimosis, circumcision and superincision/

    dorsal slit can alleviate the tightness of the foreskin; however,

    recent research has found that application of topical steroids can expand the foreskin and are about

    as effective as surgery at resolving symptoms. For Peyronie’s disease, anti-inflammatory medication and physical therapy may be enough

    to manage the pain for some men, but in severe cases, surgery may be necessary to correct the penile curvature.

  • Treating GPD in women requires figuring out the source of the pain, with treatment courses

    differing widely depending upon whether it is the result of an infection, trauma, irritation, or vaginal

    dryness. When GPD represents vaginismus, there are at least two possible treatment courses.

    One involves the use of dilators, which are cylinders of varying sizes that can be inserted into the

    vagina. The goal with dilators is to gradually desensitize the vaginal muscles to different degrees

    of penetration, not to increase the size of the vaginal opening. A newer (and somewhat surprising)

    treatment possibility for vaginismus is Botox. Many of you are familiar with Botox as a drug

    injected into the face to prevent or reduce the appearance of wrinkles by temporarily paralyzing

    certain muscles. Physicians have discovered that by paralyzing the vaginal muscles with Botox, the

    involuntary contractions that characterize vaginismus no longer occur, which makes intercourse

    possible. By the time the Botox wears off and the muscles regain their ability to contract (a process that can take several months), the learned association that caused vaginismus usually disappears.

Tips For Avoiding Sexual Difficulties

• First and foremost, communicate with your partner both

  verbally and nonverbally during sex. Make it clear to your partner what you like, either by explicitly

  saying it, demonstrating it, or moaning with delight when it happens. Both verbal and nonverbal

  sexual communication are positively correlated with sexual satisfaction. Also, be

  specific in your communication and do not be afraid to use sexual terms. Research finds that men

  and women who use more sexual terms in their communication tend to be more satisfied and

  report feeling closer to their partners. The specific terms used appear to

  make a difference, though. For example, among women, there is no correlation between using

  clinical terminology (e.g., labia, fellatio, copulate) and relationship satisfaction; in contrast, using

  slang (e.g., pussy, blow job, screw) is positively correlated with satisfaction in women. Let me be

  clear: this does not mean that everyone should start talking dirty in order to improve their relationships.

  Rather, the important thing is to find the right set of terminology for you and your partner

  that feels comfortable and conveys the point.

• Second, follow the advice of Masters and Johnson and do not look at sex as an activity in which

  you are “supposed” to achieve something. Sex is an activity that should be relaxing and pleasurable,

  not a high-pressure job. Related to this, recognize that your body will not always function the

  way you want it to (e.g., sometimes men will not be able to “get it up” and sometimes women will

  not be able to reach orgasm); however, do not let this destroy your evening or your relationship.

  “Failure to launch” will happen to almost everyone at least once, but the key is not to perseverate

  on it because that can plant the seed for a future self-fulfilling prophecy

• Lastly, take care of yourself physically and psychologically. Sexual well-being is intimately intertwined with the health of both your brain and body.

  Alcohol use, smoking, obesity, stress, anxiety, and a multitude of other factors have the potential

  to impair sexual functioning. Thus, in order to have a healthy sex life, you need to be in good shape

  mentally and physically.

• In the event that you encounter a sex difficulty, do not be ashamed or embarrassed to seek help.

  Sexual problems are very common. To locate a sex therapist, check out the American Association

  of Sex Educators, Counselors, and Therapists website (aasect.org) to gather some leads. Be sure to

  check out the therapist’s credentials and training and make sure your desired therapist has a degree

  in psychiatry, psychology, counseling, or social work from an accredited university and is licensed

  to practice. When you visit the therapist, be sure to keep your expectations in check. Sex therapy

  is sometimes uncomfortable and the solutions are not necessarily immediate, but if you stick with

  it, the rewards can be immense.

Key Terms

• sexual dysfunction

• spectatoring

• dual control model

• female sexual interest/arousal disorder (SIAD)

• male hypoactive sexual desire disorder (HSDD)

• sexual desire discrepancy

• sexual aversion disorder

• compulsive sexual behavior

• persistent genital arousal disorder

• erectile disorder (ED)

• priapism

• premature orgasm

• orgasmic disorder

• delayed ejaculation

• phimosis

• Peyronie’s disease

• genito-pelvic pain/penetration disorder (GPD)

• dyspareunia

• vaginismus

• behavioral therapy

• sensate focus techniques

• PLISSIT model of sex therapy

• cognitive-behavioral sex therapy (CBST)

• sex surrogacy

• pharmacotherapy

• stop–start technique

• squeeze technique