Female Sexual Dysfunction Assessment and Counselling Case Presentations Jocelyn Verry Counsellor /Therapist Melbourne Sexual Health Centre

A Thought Ever since Queen Victoria died, men have been trying to tame the female orgasm. As long ago as 1913 Alfred Adler published his conclusion that 80 per cent of women were sexually non-responsive. In those days they would have been called frigid; these days we say they suffer from female sexual dysfunction (FSD). Germaine Greer Jan2003

What is Female Sexual dysfunction?? Disorder Descriptions Hypoactive sexual desire disorder †Persistent lack of desire for sexual activity and or lack of responsive desire This is beyond normative lessening with relationship duration or aging Sexual aversion disorder Persistent or recurrent phobic avoidance of sexual contact with a partner Female Sexual arousal disorder† Persistent or recurrent inability to attain or maintain sexual excitement Female Orgasmic disorder† Persistent or recurrent delay in, or absence of orgasm following a normal sexual excitement phase Dyspareunia Recurrent or persistent pain associated with vaginal penetration or attempted vaginal penetration Vaginismus Recurrent or persistent inability to allow vaginal entry in spite of expressed wish to have vaginal intercourse Noncoital sexual pain Genital pain following stimulation during foreplay† These must cause the woman distress in order to qualify as FSD .Source: Basson R, et al. “Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications,” Journal of Urology (March 2000), 163:888–895.

Causes of Diminished Sexual Passion Age Past Sexual Satisfaction Stress Children Power & Control Intimacy Trust Betrayal Conflict Resolution Communication Skills Commitment/Cohabitation (Sandra Lieblum 2006)

Biological risk factors Although psychological factors might account for much of the risk of dysfunction its possible that biological factors play a part The roles of oestrogen and testosterone in maintaining women’s sexual health are not clearly understood. Basson R International Journal of Impotence Research 2008

PLISSIT Model The American psychologist Jack Annon (1929-2005) developed a simple model illustrating the fact that most people with sexual problems do not need an intensive course of therapy. He used the acronym PLISSIT for four basic forms of sex therapy:

The PLISSIT Model of Sex Therapy P stands for Permission, since many sexual problems are caused by anxiety, guilt feelings, or inhibitions. It follows that a therapist who, using his professional authority, simply "gives permission" to do what the patient is already doing, can alleviate much unnecessary suffering. (Example: Guilt feelings and anxiety because of masturbation)The next step of therapeutic intervention is called LI or Limited Information. Often it is enough to give patients correct anatomical and physiological information to restore their sexual functioning. It is not at all uncommon that patients have erroneous notions about the functioning of their own body and thus fall victim to unrealistic expectations. In such cases little more than factual information and education is necessary.The next step – SS, Specific Suggestions, requires practical hints or exercises tailored to the individual case. Many of the exercises of mutual pleasuring recommended by Masters and Johnson belong in this category.Only the last step – IT or Intensive Therapy, requires a long-term intervention addressing complex underlying causes. Annon is convinced, however, that these cases are relatively rare.Thus, the whole PLISSIT model represents a graduated system of therapeutic sieves, in which the easy cases are caught and eliminated first, while the more difficult cases sink to the bottom in steadily diminishing numbers. Thus, Annon's pragmatic and practical model is a useful reminder for all therapists and their clients that not every sexual problem requires the whole therapeutic arsenal.

Jane 27 year old woman presented to the clinic with thrush. She was referred to counselling as has she had pain with sex and low sexual desire Jane has been to counselling but has never discussed this with the counsellor as never felt comfortable

Cycle of sexual dysfunction. Example showing how a client can enter the cycle of sexual dysfunction in one area (i.e., decreased orgasm) and proceed to another area (i.e., decreased desire) so that the presenting complaint may not represent the problem that actually requires evaluation and treatment. Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int. J Impotence Res 1998;10 (suppl 2):S117-20.

Jane Has seen many doctors (10 in total) re: her condition and also had a laparoscopy trying to seek a solution Jane stated she believed the thrush keeps him away and she does not have to have sex

Jane Jane’s Relationship History: First boyfriend at 16yrs (for 2 yrs) First sexual experience at 17yrs; she describes it as painful and scary At 19yrs she had a relationship with a man aged 44 (for 3yrs) as she thought elder man to be more knowledgeable but he was not sensitive to her needs

Jane Jane’s Relationship History cont… Then a few short term relationships (no casual relationships) Currently in a relationship with Mark (aged 22yrs) for the last two years “Mum told me growing up sex was only for the special person in your life and in marriage’

Jane When Jane was 10yrs she was at a playground with a friend. As she came down the slide she was groped all the way down by a teenage boy. She went home and did not tell anyone At the age of 14yrs kissed by her fathers friend in his office

Jane Jane has an elder brother that she described as not close. She was unaware of her sexuality until she was in her teens Mum and Dad’s relationship growing up: “Mum was the ‘Boss’ Dad was very shy and didn’t say much. There was not a great deal of affection shown towards each other.

Jane Jane and Bill have not had intercourse for a couple of months as every time they try it hurts Jane fears cuddling Bill as she always thinks he will want sexual penetration Bill initiates sex usually, as Jane rarely does

Jane Jane struggles with the belief that the male partner does not want intimacy with her he just wants to “fuck her” When having sexual intercourse with Bill she is distracted, thinking about what she has to get from the shops tomorrow

Jane Bill is very supportive of Jane and says he will do what ever he needs to do as he loves her a lot, but he does miss the connection achieved with intercourse Bill will attend for 1 session - as difficult with work commitments Aware they can have ‘couples work’ at an after hours practitioner

Jane Plan of Action: Plan to work with Jane for six weeks and then review Looking at; Jane’s fear of being objectified and used, her belief she is being seen as an object and her trepidation of giving herself over and opening up to the experience The more she hides the more likely she will be objectified

Jane Plan of Action cont… Unpack what she means regarding her belief that he is not interested in her Challenges with Bill, mistrust in self and to get on with what she wants

Ann and Mark Ann and Mark (both 32yrs) referred to counselling for sexual therapy as Ann had Hypoactive Sexual Desire Disorder and Female Sexual Orgasmic Disorder

Ann and Mark Ann had Mark had had couple counselling twice and had just recently stopped. They never discussed their sex life Ann had counselling for sexual abuse as a child

Ann and Mark Ann and Mark have been in a relationship for 12 yrs For both it’s their first long term relationship (previous relationships were casual) They have moved here from the country Queensland

Ann and Mark Sixteen months into the relationship Ann fell pregnant They both decided to terminate the pregnancy with one session of post termination counselling They remain using natural family planning methods which Ann feels works well

Ann and Mark Ann describes their sexual life as initially great “Couldn’t have enough of each other” but after the termination sexual desire became low Mark describes developing premature ejaculation after the termination. He believed their sexual life was ok but not ever great

Ann and Mark Recently whilst Mark was away working interstate Ann bought a little vibrator and for the first time had an Orgasm She was so excited and phoned Mark who initially reacted in a very dismissive way as he felt totally rejected and which in turn shut Ann down

Ann and Mark When Mark masturbated Ann would walk in on him and start talking, not respecting his space so he stopped feeling safe to do so Also occasionally when having sex Ann would make an insensitive comment and spoil the moment

Ann and Mark Ann and Mark have little contact with both families Ann's stepfather sexually abused her Mark had a very dominant mother Ann had a history of walking away from relationships and this time did not want to despite Mark having one incident of infidelity with her female friend

Ann and Mark Ann and Mark are committed to making changes around their sexual intimacy In the ‘Sexual Quality of Life Questionnaire’* Ann scored 16% (a higher score=higher sexual quality of life) * which is a self reported questionnaire developed to address the impact of a sexual dysfunction on quality of life

Ann and Mark Plan of Action: Plan to work for 6 weeks and review Initial interventions Explored individually; What do they want sexually? Who they are sexually? What they like? What they don’t like? What does sex represent ? What do they find attractive about each other?

Ann and Mark Plan of Action cont… Reporting back I asked them both what that they had heard, what stood out for them and what was it like to hear that. Helping them discover who are they together sexually Five months later both Ann and Mark have achieved the ability to masturbate individually, together and feel safe

Conclusion For women with desire and arousal disorders, such as the women in the case scenarios the evaluation involves taking a detailed history of sexual difficulties from both partners if possible Sessions should be focused on unreasonable expectations, maladaptive thoughts, misinformation on women's sexuality Any apparent relationship issues should be addressed before pursuing further sexual therapy