Treatment of Sexual

Dysfunction (SD)

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” – APA 2000

 This conceptualization of the “sexual response cycle” has evolved

greatly over the past half century

 Original William Masters & Virginia Johnson (1966) model of the

“sexual response cycle” consisted of:
 Excitement
 Plateau
 Orgasm
 Resolution
 Limited to brief intervention, long-term efficacy not substantiated,
more specialized approaches needed

(APA, 2000; McAnulty, & Burnette, 2006; Segraves, & Althof, 1998)
Sexual Response Cycle
 Kaplan (1974) 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. Biological
2. Psychological
3. Relational

(Segraves, & Althof, 1998)

 A Brief History

Rise of behavioral
techniques involving
systematic desensitization
pairing relaxation &
exposure methods
1970 -
1900-1950 1974
1950-1970
Psychoanalytic approach - Masters & Johnson
sexual problems were initiated a more
linked to unresolved, biopsychosocial model
unconscious conflicts during consisting of physical
specific developmental examinations, history of
periods dysfunction, education,
behavioral & cognitive
tasks, interpersonal issues;
proposed brief, problem
focused solutions
 A Brief History continued
Helen Singer Kaplan’s
The New Sex Therapy
integrating M&J
approach with
psychodynamic
methods
1980 - current

1974-1980
Neo-Masters & Mid-1980’s dawned the
Johnson Era medicalization era; including
combined CBT &
pharmaceutical treatments; but
has not had as significant an
impact on female sexual
dysfunction
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
 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
 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??
DSM-TR Diagnoses
*Focus of the presentation
 Sexual desire disorders
 Hypoactive Sexual Desire Disorder (HSDD); Male/Female
 Sexual Aversion Disorder (SAD)
 Sexual arousal disorders
 Female Sexual Arousal Disorder (FSAD)
 Male Erectile Disorder
 Orgasmic disorders
 Female Orgasmic Disorder (Inhibited Female Orgasm)
 Male Orgasmic Disorder (Inhibited Male Orgasm)
 Premature Ejaculation

(APA, 2000)
DSM-TR Diagnoses cont’d
 Sexual pain disorders
 Dyspareunia (not due to GM condition)
 Vaginismus (not due to GM condition)
 Sexual Dysfunction Due to GM Condition
 Substance-Induced Sexual Dysfunction
 With impaired desire
 With impaired arousal
 With impaired orgasm
 With sexual pain
 With onset during intoxication
 Sexual Dysfunction Not Otherwise Specified (NOS)

(APA, 2000)
Subtypes
 Indicate onset:
 Lifelong Type
 Acquired Types
 Context:
 Generalized Type
 Situational Type
 Etiological Factors:
 Due to Psychological Factors
 Due to Combined Factors

(APA, 2000)
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)
 Desire Disorders
General Understanding:
 Highly comorbid (e.g., depression, anxiety, GMCs)
 Quantified in terms of sex interest, rather than actual sexual behavior

Clinical Presentation:
 Negative/ indifferent affect
 Disparity in relationship member desire
 Possess social expectations of “normal” sexual behavior
 “Take it or leave it” attitude
 Lack of attraction to partner
 May be associated with trauma
 Avoidance of sexual activity
 When avoidance is accompanied by extreme aversion of genitals, SAD diagnoses may
be more accurate
 Onset
 Disorder present in all situations (e.g., global vs. specific)
 “Treatment resistent”

(Wincze,& Carey, 2001)

Arousal Disorders
Male Erectile Disorder
 DSM-IV Criteria :
 Persistent or recurrent inability to attain, or to maintain
until completion of sexual activity, an adequate erection
 Not better accounted for by Axis I disorder, substances or
GMC
Female Sexual Arousal Disorder (FSAD)
 DSM-IV Criteria:
 Persistent or recurrent inability to attain, or to maintain
until completion of sexual activity, an adequate lubrication-
swelling response of sexual excitement
 Not better accounted for by Axis I, substances, or GMC
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 Disorders
Clinical 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 Disorders
Clinical 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, GMC
Premature 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 Men
Male 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 latency
2. Lack of control over ejaculation
3. 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 Disorders in Men &
Women
General Understanding:
 Clients present with concerns about absence of coital, multiple
or synchronous orgasms
 Continuum model from mild to extreme
 Clients tend to compare themselves to unrealistic ideals,
creating anxiety and perpetuating dysfunction
 “Maybe I’m just dead down there”
 Media influence of patient perceptions emphasizing importance
of psychoeducation (e.g., myths of sexual encounter, male &
female sexuality)

*Absence of orgasm during intercourse without direct clitoral

stimulation is not uncommon in women

(Wincze,& Carey, 2001)

Orgasmic Disorders
Clinical 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
 Many challenges to estimating the prevalence of
sexual disorders
 Methodological issues
 Utilizing clinical verses non-clinical criteria
 Vague diagnostic descriptions (e.g., definition of premature
ejaculation, low sexual desire v interest)
 Lack of universal/agreed upon diagnostic system
 Sexual problem must be perceived as bad
 Effects of social norms
 Availability of regular sex partner
 Selection bias in samples (formerly patients presented to
hospitals, clinics, GPs)
 Comorbidity (sexual problem may be secondary to primary
psychological or medical issue)
 Prevalence
Male SD Female SD
Data HSDD ED PE/ HSDD FSAD Anorgasm Totals
Set Anorgasm

NHSLS 15% 10% 8%* 22%; 14% 29% M: 31%

N=1,410 orgasm 32% achieve W: 43%
N=1,749 lack frequent
(age 18-59) interest orgasm
GSSAB -- 10% 14%-30% 24%- -- --
N=27,000 * PE 43%
(age 40-80) lack
interest

Other data 3%- 10%- -- 10%- 8%- 39% pop. of

sets 55% 33% 64% 28% Vietnamese
25% Dunn,
2004
Prevalence & Comorbidity
HSDD
 For men & women concurrence rates of HSDD with other SDs is an estimated
41% and 47%
 *Poor dyadic adjustment most consistently associated with HSDD
 WISoH&S data investigated menopause & SD in women
 Low sexual desire (LSD) was 16% prevalent in premenopausal women
 29% in surgically menopausal 20-49
 46% in surgically menopausal 50-70
 42% natural menopause
Arousal Disorders
 Overall, prevalence range of ED is 10-20%
 Presence of ED increases with age and poor medical status
 IN HPFS survey data, ED increased from 33% to 61% in men above 70
Orgasmic Disorders
 Prevalence of PE is approximately 30% across age groups (GSSAB)
 Highest rates reported in Southeast Asia (30.5%) & lowest in Middle East
(12.4%)
 Found to be significantly correlated with Social Phobia
Other disorders
 Prevalence of pain disorders 1%-21% in women
(DeRogatis, et al., 2007; Graziottin, 2007)
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
A Systemic Perspective
 According to the systemic and “biopsychosocial”
model sexual response is the result of interaction
between the following 3 domains:
1. Biological – physiological mechanism that prepare and
enable genital response
2. Psychological – affective and cognitive predispositions
and interpretations that sustain response
3. Relational – dyadic interactions which promote intimacy,
meaning and mutually satisfying outcomes

 *Multifactorial contribution of biological,

psychological, psychophysiological and
interpersonal factors are often difficult to distinguish
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)
 Special Considerations
Sexual Minorities
Factors influencing impaired sexuality in homosexuals
 Psychological issues accompanying choice to “pass” as straight
 Gender identity issues
 Identity & “coming out” problems
 Sexual expression
 Emerging sexual scene for lesbians influenced more by gay men
than heterosexual females
 Gay male community engaged in controversy over sex
 Barebackers begun backlash against promotion of safe sex, labeling
campaign members “condom nazis”
 Nonmonogamy
 High frequency of desire discrepancy/inhibited sexual desire in
lesbians & sexual script issues
 “Sex addiction”
(Leiblum, & Rosen, 2000)
Treatment Approaches

 Sex Therapy (CBT + Master’s &

Johnson)
 Pharmacotherapy & Medical Devices
 A Systemic Approach
 Bibliotherapy
Sex Therapy
Treatment length
 Traditional Master’s & Johnson
 Daily sessions 2- or 3-week period (up to 15 sessions)

 Current CBT therapy course may vary based on

client/couple
 Some clients benefit from only 3-4 sessions of
psychoeducation
 Otherwise, treatment is once a week for 10-12 weeks
 Couples strongly encouraged to participate together
Assessment : Sessions 1-3
 Goals:
 Establish rapport
 Obtain a general description of sexual problem or problems
 Discuss life concerns and current stressors
 Determine nature & causal factors:
 Lifelong vs. acquired
 Generalized vs. situational
 Due to psychological or combined factors
 Obtain general psychosocial history
 Determine whether sex therapy is appropriate
 Therapist must remain aware of process concerns and how they affect
relationship building
 Are you comfortable addressing sexual issues?
 Differences between client & therapist (e.g., age, gender)
 Maintain firmly established boundaries
 Important to maintain objectivity and remain sensitive with matters of
religion or culture (e.g., devout Catholic with concerns about birth control)
Assessment : Sessions 1-3
 Sample structure:
1. **Begin with nonthreatening demographics (e.g., age,
employment & marital status)
 Set up safe and comfortable environment
 Individual/couple format
 Assess what partners are comfortable communicating with
partner present
2. Continue with open-ended questions while keeping the
client directed on presenting concern
3. Obtain a psychosocial & sexual history
 Family structure, orientation
 Assess for childhood abuse or trauma
 Assess history and current peer relationship status, self
esteem, dating experiences, body image
 Current sexual functioning
 Assessment : Sessions 1-3
4. Obtain a brief medical history (e.g., childhood diseases, surgery,
medical care)
 Current Health Status
 Diet
 Exercise
 Maladaptive lifestyle habits (e.g., smoking, drinking)
 General Medical Conditions associated with SDs
 Hormonal disturbance (e.g., menopause)
 Abnormally low testosterone levels (e.g., tx for prostate cancer)
 Metabolic syndromes (e.g., diabetes, hypertension, hyperlipidemia,
obesity)
 Glaucoma
 Vascular conditions (e.g., CHD, ischemic heart disease, angina)
 Epilepsy
 Assess exposure to STDs

* In the event of a medical consult therapist may act as a liaison

Assessment : Sessions 1-3
5. Be sensitive to any potential covert issues
6. Provide client with a second opportunity to share concerns
7. When working with couples, at this point you would interview the
second partner individually
 Therapists commonly have each partner complete assessment
measures while interviewing the other
 Allows therapist to develop conceptualization of independent partner
difficulties
8. Later the therapist will reunite the couple and review assessment
measure outcome
 *Important to address dyadic sexual adjustment
9. *Integration of information
 Acquired vs. lifelong
 Determine appropriateness of sex therapy
10. *Develop goals reasonable with client/couple
 Avoid goals related to performance (e.g., firm erections)
Couple Distress
 SD sometimes secondary to couple distress
 Treatment may be postponed depending on
severity
 Accurate assessment of causal sequence of
couple distress & SD
 When couple distress is the cause of SD,
resolution of these problems take precedent
 Determine SD treatment appropriateness
 Make referral to marriage counselor,
individual therapist, physician, etc.

(Wincze, Bach, & Blume, 2008)

 Wincze & Barlow Model
(1997)
Medical Medical
Indications Stabilization

Minimal Couple
Distress
One partner
Sexual Individual Sex Possible
Medical Therapy Couple Therapy
problem
Evaluation
Assessment One partner Individual Possible
& Integration Psychological Psychotherapy Couple Therapy Sex Therapy
Psychosocial of Information problem
Evaluation
Significant Couple
Couple Therapy
Distress

Substance Substance Possible

Abuse Abuse Tx Couple Therapy
Couple Sex
Problems
Only
Assessment Measures
 Indices of Sexuality & Sexual Functioning:
 Men
 International Index of Erectile Function (15 item)
 Erection Hardness Scale (1 item)
 RigiScan
 Women
 Brief Index of Sexual Functioning for Women (BISF-W)
 Derogratis Sexual Functioning Inventory (DSFI)
 Sexual Self-Efficacy Scale for Female Functioning (SSES-F)
 Female Sexual Function Index (FSFI)
 Profile of Female of Sexual Function (PFSF)
 Structured Clinical Interview for Gynecologists Caring for
Women With Sexual Dysfunction
 Photoplethysmograph
Assessments Measures
 Both Men & Women:
 Sexual Desire Inventory
 Cues for Sexual Desire Scale (CSDS)
 Dyadic Adjustment Scale (DAS)
 Inventory of Dyadic Heterosexual Preferences (IDHP)
 Sexual Interaction Inventory
 Golombok Rust Inventory of Sexual Satisfaction (GRISS)
 Sexual Opinion Survey (SOS)
 Sexual event logs
 Indices of Psychosocial Functioning
 BDI
 BAI
 Symptom Checklist 90; Brief Symptom Inventory (53-item
abbreviated version)
 Suicide risk assessment
 Indices of Health Status
 Medical History Form
Psycho-“sex”-education
Topics to be addressed:
1. Anatomy (diagrams, models)

2. Physiology

3. Unrealistic expectations of self & sexual

encounter
4. 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 sexuality
1. 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 problems
5. 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 her
5. Feminine women do not initiate sex or become wild
and unrestrained during sex.
 Myths of Sexuality cont’d

 Myths of Male & Female Sexuality

1. We are liberated and comfortable with sex.
2. All touching is sexual or should lead to sex.
3. Sex is intercourse.
4. Good sex requires orgasm.
5. People in love should automatically know what their partners
desire.
6. Fantasizing about someone else means a person is not
happy with what he/she has.

**We are all susceptible to these false assumptions and

seemingly silly generalizations about human sexuality.
Universal CBT Tools
1. Cognitive Restructuring
 Goals:
 Identify cognitions and beliefs about sexual encounter
 Normalize feelings of anxiety, frustration, disappointment
 Identify possible precipitating factor leading to acquired vs. life-
long SD
 Challenge negative thoughts
 Strategies to challenging negative cognitions:
1. Provide education
2. Stick to the facts
3. Decatastrophize
 Useful across various SDs & integrated throughout treatment
course
Universal CBT Tools
2. Stimulus Control
 Goals:
 Method involves manipulation of environmental factors to
facilitate a given behavior or outcome
 Creating conditions conductive to healthy sexual functioning
 Methods:
1. Generating lists of conditions or factors which positively &
negatively affect arousal, such as:
 Setting
 Mood (self & partner)
 Atmosphere
 Performance concerns
 Faulty beliefs
2. *Maximize positive factors & minimize negative factors
 Sex Therapy
Desire Disorders
Primary Goals & Strategies:
 Communication Training

 Cognitive Restructuring

 Education

 Behavioral Intervention
 Sex Therapy
Desire Disorders
Integration of Cognitive, Behavioral, Systemic Therapy
 Stage 1: Affectual Awareness
 Becoming aware of neg. attitudes/beliefs about sex and/or
partner
 Create a set of lists (at least 5 items per list)
1. Benefits for lower drive individual gaining a higher level of sexual
desire
2. Benefits for relationship
3. Risks/costs of increasing sexual desire to self & relationship
 Helps therapist & client gain understanding of:
 Explore fears of gaining sexual desire
 Influence of low desire on individual identity & within relationship
 Therapist may also explore emotions related to “fear” lists
 Role-play
 Sex Therapy
Desire Disorders
 Stage 2: Insight and Understanding
 Therapist explains multicausality of SD

 Clients consider initiating and maintaining causes of

low sexual desire
 Asked to identify common individual factors

 Consider power imbalance in relationship

 Stage 3: Cognitive and Systemic Therapy

 Therapist and clients consider how negative thoughts
and beliefs mediate low sexual desire
 Develop healthy coping mechanisms
 Sex Therapy
Desire Disorders
 Stage 4: Behavioral Interventions
 Encourage engagement in more simply affectionate behavior
 “Baby steps”
 Removes pressure created by performance anxiety
 Mutually enjoyable activities (e.g., hugging, kissing, etc)
 Graduate to more sexually based activities (e.g., genital
stimulation, intercourse)
 Role-play how partner may enjoy love-making
 Systematic desensitization has shown effectiveness in treating sexual
aversion & pain disorders
 Client constructs fear hierarchy (10-15) activities
 Rate from most to least anxiety-provoking on a 0-8 scale (e.g.,
8=intercourse, 1=watching video of sexual activity clothed)
 Rate each item in terms of fear & avoidance
 Exposure
 Sex Therapy
Arousal Disorders
 Primary Strategies:
 Initial phase protocol, interviews and assessment
 *Medical examinations may be especially important for addressing
arousal & orgasmic disorders
 Education, assessment of beliefs about sex & sexual ability
 Cognitive Restructuring
 Behavioral intervention
 Behavioral Techniques:
 Sensate Focus: a behavioral technique useful in most SDs;
particularly useful with arousal disorders
 Therapist clearly explains goals and activities involved.
 Primary Objectives:
1. Lessen and remove performance anxiety
2. Draw attention to & augment pleasurable sensations (sexual/nonsexual)
3. Encourage couple to draw pleasure from various forms of stimulation
Sex Therapy
Arousal Disorders
Sensate Focus:
 Series of homework assignments
 practiced 1-3 times between therapy sessions
 15-30 minutes per exercise
 *Couple agrees not to engage in sexual intercourse
(unless instructed) throughout this course of therapy
 Sample series of assignments
 Assignment 1: Each partner gives the other a massage while
clothed. Clients are instructed only to enjoy each others
company, removing the pressure to become aroused or
perform for the other partner.
 Assignment 2: Each partner gives the other a massage while
nude with genital contact. Partners gently communicate likes
and dislikes yet the goal is still not to become aroused only
enjoy each other company.
 Sex Therapy
Arousal Disorders
Sensate Focus:
 Assignment 3: Repeat assignment 2.
 Assignment 4: Each partner gives the other a massage
while nude with genital contact. The partners continue to
practice giving and taking feedback. If at any time the
partners become aroused (such as in ED) the therapist
may instruct the female partner to allow the male’s penis to
become soft before resuming the exercise. Again, the
focus the exercises are not to become aroused.
 Assignment 5 & 6: Repeat Assignment 4
Sex Therapy
Arousal Disorders
Sensate Focus:
 Assignment 7: The couple engages in sexual activity
that includes penetration without thrusting and attend to
sensations
 Assignment 8: The couple engages in sexual activity
that includes mild thrusting and attend to sensations.
 Assignment 9: The therapist lifts the ban on sexual
intercourse
 Other Behavioral Interventions:
 Relaxation
 Systematic desensitization
 Sex Therapy
Orgasmic disorders
Male & 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
Sex Therapy
Orgasmic disorders
 Sample list of exercises:
1. Client views his/her body nude in the mirror
2. Client views his/her genitals nude in the mirror
3. Client rubs/stimulates non-genital areas
4. Client stimulates genitals
5. Client repeats previous exercises until comfortable
6. Self-stimulation fantasies
 Client shares discoveries with partner (e.g.,
mutual masturbation, fantasy role play)
 Relaxation exercises
 Sex Therapy
Orgasmic Disorders
Premature Ejaculation
 Behavioral Techniques:
1. Stop-and-start method (Semans,1957)
 Goal: Assist client to recognize pre-ejaculatory response and prevent it
 Involves stimulation of penis until sensation of “premonitory to ejaculation”
 Stimulation stopped, until sensation ceases, then reapplied
2. Masters & Johnson “Squeeze Technique” (1970)
 Goal: Prolong physiological ejaculatory response
 When man feels ejaculatory sensation, he/partner squeeze the ridge of the
penis with two fingers and his thumb below the head of his penis and holds
firmly (approx. 10 seconds or until partially loses erection)
 Used before penetration or during intercourse (withdrawal of penis)
 Technique can be used multiple times during a single sexual encounter
 Then graduates to intercourse without motion & full intercourse
 “Quiet Vagina”

*Pitfalls: Not successful in the long-term

Sex Therapy
Orgasmic Disorders
Premature Ejaculation
3. Vary coital position
 Female superior coital position & lateral coital position
4. Continue intercourse as long as possible after ejaculation
 Ejaculation does not signal end of intercourse
5. Continue sexual activity after coitus is no longer possible
 Ejaculation does not signal end of sexual activity

 Less emphasis placed on performance, reducing anxiety

and lengthening IELT
Pharmacological & Medical
Devices
 May be a helpful adjunct to psychotherapy or alone
 Desire & Arousal
 Men
 Viagra, Levitra, Cialis
 Topical vasodilators (aminophylline)
 Phosphodiesterase inhibitors (PDEI); udenafil, avanafil
 Vaccum and constriction devices
 Women:
 Hormone treatment (estrogen, androgens)
 Buspar
 Provestra
 Other herbal supplements with mild effects (e.g., yohimbine, ginkgo bilboa,
DHEA, ginseng)
 Ejaculatory Inhibition
 SSRIs (Dapoxetine)
 Clomipramine (Anavfil)
 PDEIs
 MAOIs, TCAs, SSRIs, antipsychotics and other dopaminergic
antagonists having been implicated as causes of SD
 Buspar is mildly effective in counteracting these effects
 Pharmacological Treatment

 Limitations:
 These interventions focus primarily
on restoring physiological sexual
responses
 Lingering concerns:
 Couple communication
 Negative attitudes toward sex
 Negative attitudes toward partner
 Inaccurate beliefs about sex
 Comorbidity
 What is the primary diagnosis?
Challenges of Therapy
 Many clients become discouraged or impatient due to:
 Self-critical nature
 Faulty attribute for SDs
 Devaluing actual sexual response
 Ignorance of process
 Time urgency
 Unrealistic expectations
 Religious or cultural opposition to therapy (e.g.,
masturbation)
 Compliance with HW assignments
 Preference for pharmacotherapy alone
 Noncompliance with medications (e.g., SSRIs for PE)
“Rolling with Resistance”
 Encourage realistic self-assessment, expectations
 Review accomplishments
 Encourage communication of specific concerns to partner or
therapist
 Encourage self-management:
 Give specific instructions
 Model or role-play techniques in session
 Discuss how and when HW should be undertaken
 Know the client’s medication schedule
 Revisit cognitive distortions based on myths or false beliefs
 Address resistance gently but directly
 Advocate for client
 *Stay aware of personal process issues in therapist
 Are you becoming frustrated with a client?
 Systemic Approach
David Schnarch, “Constructing the Sexual Crucible” (1997)
 Sexual-marital therapy
 Emphasize differentiation as the “central drive wheel” of
human relationships
 Therapeutic focus directed at maximizing each partner’s
individual level of differentiation and facilitating greater
intimacy through self-differentiation
 Goals:
 Self-confrontation
 Self-validation
 Self-soothing
 Emotional resilience through tolerance
Systemic Approach
Duration of treatment
 Intensive format, 4 daily 3-hr sessions
Structure of treatment
 Individualized content to each case (e.g., dependent on nature of
“gridlock”)
 May incorporates sensate focus exercises but emphasizes emotion
connection & tolerance of partner
 No bans on sex, physical stimulation and encouragement of fantasizing

Session 1:
 During initial interview assess cognitions, beliefs, emotions & relational
patterns regarding sex
 “Devil’s pact” – identify nature of high and low desire partner
discontentment
 Validating each client’s concerns; working from a differentiation standpoint
 Encourages high desire client to assume low desire client standpoint
 Low desire client becomes anxious, due to high desire client’s lessen reactivity
 Begin addressing issue at a deeper level setting stage for treatment
 Systemic Approach
Session 2:
 Refining the accuracy of the “lens”
 Reframe, client or therapist driven
 Into the crucible
 Continuing with differentiation technique
 Preface confrontation with validating statements “I am addressing the best in
you”
 Construction of the crucible
 Piecing together sexual history & individual histories of clients
Session 3:
 Establishing the elicitation window
 Involves tracking sexual patterns and meanings on current and historical
levels
 Setting the stage for client differentiation
 Focusing on emotional connections
 Continued cognitive restructuring like exercises (e.g., list writing)
 “hugging until relaxed” exercise
Systemic Approach
Session 4:
 Continued resolution of power dynamics between high and low desire client
 Both high & low level desire client differentiate with of self-confrontation and self-
soothing
 Seeing one-self through sex
 Clients exhibit tolerance of one another’s faults and inevitability of gridlock in marriage
 Therapist may continually confront clients with basis of presenting problem
 Observe level of differentiation
Termination
 Clients & therapists process benefits, likes & difficulties

*Most suitable for multiple sexual & nonsexual issues due to integration of sex
therapy, couple therapy, & individual therapy

 Also effective with well-functioning couples interested in increasing intimacy,

passion, desire
 Bibliotherapy
 Treatment for mental & physical health problems in
which written material plays a central role
 Applied within treatment formats with minimal or absent
therapist contact (e.g., self-help manuals, brief skills
training, education)
 Merits:
 Cost efficiency, may be performed without therapist facilitation
 May be a successful adjunct to behavioral sex therapies
 Meta-analyses suggest SD is amenable to bibliotherapy over
pharmacological approaches (e.g., yohimbine)
 Effect sizes .5-1.8
 van Lankveld (1998) average ES = .68
 Taking responsibility for self-improvement can enhance
mastery experiences & SE
 Primarily successful with orgasmic disorders
(van Lankveld, 1998)
Bibliotherapy
 Drawbacks:
 Bibliotherapies reflect direct-practice approach of M&J
not CBT formats
 Positive long-term outcomes not substantiated
 Research & materials available limited to orgasmic
dysfunctions
 Greater likelihood of non-compliance
 E.g., Lopiccolo, & Heiman (1976) Becoming
orgasmic: A sexual growth program for women,
Focus International
 23 hour video, workbook following exercises

(van Lankveld, 1998)

Rigiscan

The RigiScan, an instrument used to measure continuous

penile tumescence and rigidity. It has two loops, one to be
placed around the base of the penis and the other towards
the tip, which tighten every fifteen or thirty seconds. The
recording unit can be strapped around the waist or thigh.

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