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Treatment of Sexual Dysfunction (SD) RoseMary Beitia Appalachian State University.

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1 Treatment of Sexual Dysfunction (SD) RoseMary Beitia Appalachian State University

2 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)

3 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)

4 A Brief History Psychoanalytic approach - sexual problems were linked to unresolved, unconscious conflicts during specific developmental periods Rise of behavioral techniques involving systematic desensitization pairing relaxation & exposure methods 1900-1950 1950-1970 Masters & Johnson initiated a more biopsychosocial model consisting of physical examinations, history of dysfunction, education, behavioral & cognitive tasks, interpersonal issues; proposed brief, problem focused solutions 1970 - 1974

5 A Brief History continued 1974-1980 1980 - current Neo-Masters & Johnson Era Helen Singer Kaplan’s The New Sex Therapy integrating M&J approach with psychodynamic methods Mid-1980’s dawned the medicalization era; including combined CBT & pharmaceutical treatments; but has not had as significant an impact on female sexual dysfunction

6 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)

7 Male Sexual Response

8 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

9 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??

10 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)

11 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)

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

13 Other Sexual Dysfunctions Paraphilias  Exhibitionism  Fetishism  Frotteurism  Pedophilia  Sexual Masochism  Sexual Sadism  Transvestic Fetishism  Voyeurism Gender Identity Disorders  NOS  Dysphoria (APA, 2000)

14 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)

15 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)

16 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

17 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)

18 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)

19 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)

20 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)

21 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)

22 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

23 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)

24 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 20 th century was related to higher frequency of orgasm Lifelong or acquired (Wincze,& Carey, 2001)

25 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)

26 Prevalence Data Set HSDD ED PE/ Anorgasm HSDDFSADAnorgasm NHSLS N=1,410 N=1,749 (age 18-59) 15%10%8%* orgasm 22%; 32% lack interest 14%29% achieve frequent orgasm GSSAB N=27,000 (age 40-80) --10%14%-30% * PE 24%- 43% lack interest -- Other data sets 3%- 55% 10%- 33% --10%- 64% 8%- 28% 39% pop. of Vietnamese 25% Dunn, 2004 Male SD Female SD Totals M: 31% W: 43%

27 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)

28 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)

29 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)

30 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

31 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)

32 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)

33 Treatment Approaches Sex Therapy (CBT + Master’s & Johnson) Pharmacotherapy & Medical Devices A Systemic Approach Bibliotherapy

34 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

35 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)

36 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

37 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

38 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)

39 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)

40 Wincze & Barlow Model (1997) MedicalEvaluation PsychosocialEvaluation Assessment & Integration of Information MedicalIndications Minimal Couple Distress One partner Sexualproblem Psychologicalproblem SubstanceAbuse Couple Sex ProblemsOnly SignificantCoupleDistress MedicalStabilization Individual Sex Therapy IndividualPsychotherapy CoupleTherapy Substance Abuse Tx Possible Couple Therapy Possible Possible Sex Therapy

41 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

42 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

43 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)

44 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.

45 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.

46 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

47 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

48 Sex Therapy Desire Disorders Primary Goals & Strategies: Communication Training Cognitive Restructuring Education Behavioral Intervention

49 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

50 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

51 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

52 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

53 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.

54 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

55 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

56 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

57 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

58 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

59 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

60 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

61 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?

62 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)

63 “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?

64 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

65 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

66 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

67 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

68 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)

69 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)

70 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. Back to slide

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