1. Psychosexual Problems
Emma Mathews
Psychosexual therapist

2. Specialist treatments are provided for:
Erectile dysfunction
Premature or other ejaculatory disorders
Orgasmic difficulties
Vaginismus and dyspareunia (genito-pelvic pain/penetration disorder)
Problems of libido (reduced or excessive sex drive/interest)
Sexual arousal problems
Specific sexual fears or phobias

3. Liaison with other services
Urology
Dermatology
Reproductive Medicine
Endocrinology
Gynaecology
Sexual Health
Mental Health
Physiotherapy
Psychotherapy and Psychology

4. Pre-referral screening – female disorders

5. Pre-referral screening – male disorders

6. Treatment options Assessment and history-taking
Education and normalisation
Referral to specialist services if appropriate
Sensate focus programme
Specific behavioural tasks (self-exploration, vaginal trainers)
Working with cognitions

7. DSM

8. Revised Diagnostic Criteria Applicable to All Diagnoses
Unlike its predecessor, the DSM-5 includes the requirement of experiencing the disorder 75%-100% of the time to make any diagnosis of sexual disorder, with the notable exception of substance or medication-induced disorders.
There is now a required minimum duration of approximately 6 months.
The disorder must be deemed to have caused significant distress.

9. Revised Diagnostic Criteria Applicable to All Diagnoses
The disorder should not be better explained by a “nonsexual mental disorder, a consequence of severe relationship distress (e.g., partner violence) or other significant stressors”.
The disorder can be described as mild, moderate or severe.

10. Revised Diagnostic Criteria Applicable to All Diagnoses
A new group of criteria called “associated features” was also introduced:
partner factors (e.g., partner sexual problem; partner health status)
relationship factors (e.g., poor communication, discrepancies in desire for sexual activity)
individual vulnerability factors (e.g., poor body image; history of sexual or emotional abuse),psychiatric comorbidity (e.g., depression; anxiety), or stressors (e.g., job loss; bereavement)
cultural or religious factors (e.g., inhibitions related to prohibitions against sexual activity or pleasure; attitudes toward sexuality)
medical factors relevant to prognosis, course, or treatment

11. Erectile Dysfunction

12. DSM-V Definition
A recurrent inability to achieve or maintain an adequate erection during partnered sexual activities. It may occur in 7% - 18% of the male population at some point throughout their lifetime.

13. Primary erectile dysfunction
Areas explored:
Early family experiences
Fears about being taken over
Lack of comfort with personal sexuality
Check for adolescent fantasies
Investigate medical factors (e.g. tight foreskin, pain on ejaculation
Fears about penetration

14. Predisposing factors Male esteem invested in sexual performance
Latent homosexual orientation
Early family experience
Traumatic first experience
Religious taboos
Power – mother/father figures

15. Secondary erectile dysfunction
Areas explored with young people:
Recent loss (death, divorce, redundancy, etc)
Family conflicts
Boredom with the present relationship
Recent operations or illnesses
Failures or lost achievements

16. Precipitating factors
Recent loss
Ageing
Traumatic experience
Alcohol abuse
Failures
Infidelity
Depression
Premature ejaculation
Sexually compulsive/addictive behaviours

17. Maintaining factors Anxiety, worry, spectatoring Threatening partner
Cycle of anxiety – fear of failure
Poor communication
Loss of role
Depression
Guilt/shame

18. Erectile Dysfunction Maintenance Model

19. Treatment Treatment options include: Psychosexual education
Wax/wane, Male is asked to practice this first on his own with masturbation. Then joint tasks with his partner are incorporated.
There are pharmacological treatment options, PDE5 type inhibitors. Also injections, gel, penis pumps and penis implants.

20. Premature Ejaculation

21. DSM-V Definition
Consistently ejaculating within one minute or less of vaginal penetration.
Can begin with the onset of a male’s sexual experience, or later in life, after a period of normal sexual function

22. Premature Ejaculation
Specifiers:
Lifelong- has been experienced since the first intercourse attempt.
Acquired- has appeared after a period of sufficient orgasmic latency.
Generalized- occurs with different partners and situations.
Situational- only occurs with a specific partner and situation.

23. Premature Ejaculation
Severity :
Mild - occurs after vaginal penetration
Moderate - occurs seconds after vaginal penetrations.
Severe - occurs prior to penetration, upon penetration, or < 15 seconds after vaginal penetration.

24. Premature Ejaculation
Prevalence:
1% to 3% among men in the US.
However, there are cultural differences apparent, as another source indicates a much higher prevalence among Greek men at 20%-30%
Comorbidity:
May be comorbid with erectile dysfunction.

25. Premature Ejaculation
Risk Factors
Anxiety disorders, specifically social anxiety.
PTSD due to sexual trauma may also be a factor.
Discomfort with sex or ones body from trauma, can produce anxiety and a need to complete the sex act as quickly as possible.

26. Other Predisposing factors
Religious restrictions
Negative messages
Restrictive upbringing, dominating parent of either sex, rigid, disapproving, demanding impossible goals affecting confidence

27. Precipitating factors
High expectations regarding performance
First experience – significant, fear of discovery
Learned behaviour
Alcohol leading to one failure, leading to repeated alcohol consumption to cope with anxiety

28. Maintaining factors
Anxiety, guilt, inability to, difficulty in communicating
Lack of trust/lack of confidence
Impaired self-image/low self-esteem
Need to punish self/women
Partner fit – with a partner who does not enjoy sex, therefore invested in getting it over quickly
May be combined with female sexual interest/arousal disorder

29. Treatment Treatment options include: Psychosexual education
Stop/start, where thrusting is stopped when the man feels ejaculation is imminent, or the squeeze method, where pressure is applied behind the glans until the urge to ejaculate passes. Male is asked to practice this first on his own with masturbation.
There are pharmacological treatment options, such as SSRI’s which frequently have the side effect of delaying orgasm.
Topical anesthetic such as 7.5% benzocaine can reduce penile sensitivity and delay ejaculation

30. Delayed Ejaculation

31. DSM-V Definition
Sexual disorder in which a man is unable to ejaculate during sexual activity, specifically after 25 minutes to 30 minutes of continuous sexual stimulation.
This disorder is also known as delayed orgasm, retarded ejaculation, or inhibited ejaculation.

32. Symptoms of Delayed Ejaculation
An inability to climax during sex with a partner about % of the time, with either a delay in ejaculation or infrequent or absent ejaculation.
The ejaculatory delay is not considered pathological if it is due to a deliberate effort to prolong sexual activity.

33. Delayed Ejaculation
Lifelong - commencing at the onset of sexual activity
Acquired - starting after a period of normal sexual function
Generalized - ejaculation is delayed or not possible in either solitary or partnered sexual activity
Situational - a man can ejaculate while masturbating, but not with a partner, or during specific sex acts- e.g., oral sex but not vaginal intercourse
Degrees of severity - mild, moderate, or severe

34. Prevalence 75% of men report always reaching orgasm during sex
This is the least common male sexual complaint and most poorly understood male sexual dysfunction
Some sources believe the prevalence is higher than reported and it can be speculated that this is due to the perception that delaying orgasm is a desirable quality and a sign of sexual maturity, and self control.

35. Risk Factors (young men)
IMS (Ideosyncratic Masturbation Style) Men may masturbate with a speed and pressure which their partner may not be able to duplicate correctly.
Fear impregnating a woman
Excessive exposure to pornography - stimuli overexposure and desensitization process, increased amounts of stimulation is required for performance, which a partner may not be able to provide
Sexual trauma is another possible cause of delayed ejaculation
Cultural and religious prohibitions

36. Further considerations
Comorbidity with major depressive disorder.
SSRIs can cause delayed ejaculation, this typically resolves after several weeks on the medication.
A number of medical conditions can precipitate delayed ejaculation, such as traumatic surgical injury to the groin or genitals, multiple sclerosis, or diabetes

37. Treatment Objectives:
To sensitise the male to the pleasurable sensations he is suppressing
To maximise stimulation and minimise inhibition
To learn to enjoy pleasurable erections
To build trust and reduce guilt and shame
To reduce spectatoring
To reduce anxiety and build confidence

38. Male hypoactive sexual desire disorder

39. DSM-V Definition
The person has low desire for sex and absent sexual thoughts or fantasies.
The patient must experience the disorder from 75% to 100% of the time for six months or longer.
On most occasions the patient reports marked delay, infrequency, or absence of orgasm during sexual activity
Tendency to ejaculate within one minute

40. Causes – biological factors
Diseases of the vascular system
Diseases of the nervous system
Low levels of testosterone or oestrogen
Heavy alcohol consumption before sex
Depression
History of chronic alcoholism
Heavy cigarette smoking
Medications, anti-hypertensives and SSRIs

41. Causes – psychosocial factors
Rape
Early childhood sexual abuse
Relationship problems (anger, hostility, poor communication, underlying anxiety about relationship security)
Psychological disorders (Major depression, anxiety, or panic disorder)
Low physiological arousal
Stress and exhaustion

42. Treatment Education (lifestyle, relationships, sexual response)
Self focus
Sensate focus with partner
Mindfulness
Hormonal treatment if appropriate

43. Prone masturbation
Prone masturbation is the habit some males have of masturbating in a face-down (prone) position.
Some males who masturbate this way rub their penises against the mattress, pillow, or other bedding, or the floor.
Some males lie on their stomachs and thrust into their hands.
Around 90 percent of men masturbate by stroking up and down the penis with one hand.

44. What's wrong with masturbating prone?
Puts excessive pressure on the penis, and especially on the base of the penis.
These sensations are not easily replicated in conventional masturbation or in sexual intercourse.
A partner's body provides more resistance than the objects a male who masturbates prone uses to thrust into or against.
A vagina resists; a mattress doesn't.
Prone masturbation can reduce the ability of a male to have normal sexual relations.

45. What's wrong with masturbating prone?

46. What's wrong with masturbating prone?

47. Sexually compulsive and addictive behaviours
Behaviours are often:
Opportunity induced addiction
Attachment induced addiction
Trauma induced addiction
Problems getting an erection and ejaculating are both common consequences of sexually compulsive and addictive behaviours, especially porn addiction

49. Genito-pelvic pain/penetration disorder

50. DSM-V Definition
Pelvic floor muscles around the vagina contract or tighten whenever an attempt is made to penetrate
Includes one or more symptoms:
Tightening of the vaginal muscle resulting in the inability to penetrate
A feel of tension, pain or a burning sensation felt when penetration is attempted
A decrease in or no desire to have intercourse
Voluntary avoidance of sexual activity
An intense phobia or fear of pain

51. Causes Inflammation in the vaginal muscles or an injury in the vulva.
Traumatic past experience
That experience may well be intense pain during childbirth.
Victims of child abuse or women whose experience with intercourse has always been painful
Nerves becoming over-sensitive may trigger the disorder
Fear of getting pregnant or being told in childhood that “sexual desire is wrong or sex is painful”

52. Subtypes
Early-Onset - This is a case in which the pain in the pelvic muscles has persisted and continues to do so. The first attempt at penetration led to pain, and each time thereafter the pain continued to manifest
Late-Onset - The pain is experienced after vigorous physical activity of any sort. The pain may also be triggered after penetration is attempted with a penis, tampon or other objects
Situational - Intensity of pain varies by situation for instance, a woman may not able to feel the pain when inserting a tampon, but may experience an intense and shooting pain when attempting penetration during intercourse.
The pain may occur only during intercourse with one person and not another.

53. Treatment
If the person has had a physical injury or inflammation in the pelvic muscles, and that is causing the pain, it can be treated with appropriate medication
Depending on the intensity of the pain, surgery may be appropriate
Psychosexual therapy may help a person overcome fear of pain and penetration and help them to respond to anxiety in a more appropriate way
Psychosexual therapy may include use of vaginal dilators, sensate focus and self focus exercises
Referral to physiotherapy
Trauma focused interventions may be appropriate (TFCBT/EMDR) if a main precipitant for the problem is trauma (CSA, sexual assault, childbirth, traumatic gynaecological procedures)

54. e.g. around vulva/vagina
Use cognitive restructuring techniques, explore exactly what they think will happen, what that will mean for them, what it will say about them as a person, etc.
i.e. dig out the meaning…
e.g. “nothing that size could fit in there, it’s tiny, I’ll split open, there will be blood everywhere, I’ll be in agony, I’ll be out of control, I’ll be embarrassed, my partner will leave me, I’ll never be able to have sex, I’m not normal, etc.”
Explore positive beliefs held about their anxious thoughts, i.e. why they believe staying vigilant is helpful?
Attention training experiments and exercises
Vaginal muscles contract
Limit genital contact, various safety behaviours
Avoid any genital contact, cervical smears, tampon use, etc. various safety behaviours

55. Triggers PERCEIVED “DANGER” Adrenaline release FOCUS ON SELF
Anxiety symptoms (somatic & cognitive) rather than feelings of arousal & pleasure (somatic & cognitive)

56. Female sexual interest/arousal disorder

57. DSM-V Definition
A complete lack of or significant reduction in sexual interest or sexual arousal, including three or more of the following symptoms:
The absence of an interest in sexual activity
A decided reduction of interest in sexual activity
Absence of fantasizing or even thinking sexual or erotic thoughts
Disinclination to initiate sexual encounters with her partner
Exhibits no sense of pleasure during sexual acts
The problem may be lifelong or acquired
Severity may be mild, moderate or severe
The problem may be situational – occurring only in some instances or generalized – with no apparent limitations.

58. Considerations
Biological, social, psychological, environmental and hormonal factors
Comorbidity may present as mood and/or anxiety disorders; panic attacks, depression, phobias or bipolar disorder
Closeted memories or secrets can contribute to inhibited sexual enjoyment. For example, extramarital affairs or preoccupations

59. Masters, Johnson and Kaplan’s sexual response cycle

60. Female sexual response cycle (Basson, 2002)

61. The repercussions of GPPPD on a woman’s sexual response cycle (Basson, 2002)

62. Treatment
Patient education including information on normal anatomy and a discussion about the physiologic basis of sexual functioning
Individualized approach that may include a combination of cognitive-behavioural interventions
Therapy often includes education about how to optimize the body's sexual response, ways to enhance intimacy with their partner, and recommendations for reading materials or couples exercises

63. Enduring sexual dysfunction after treatment with antidepressants, 5α-reductase inhibitors and isotretinoin 300 cases
RxISK research - David Healy, Joanna Le Noury and Derelie Mangin
OBJECTIVE: To investigate clinical reports of post-SSRI sexual dysfunction (PSSD), post-finasteride syndrome (PFS) and enduring sexual dysfunction following isotretinoin
International Journal of Risk & Safety in Medicine xx (20xx) x–xx, DOI /JRS , IOS Press

66. Female student (with vaginismus) perspective…
Poor sex education – young people would benefit from frank, factual sex education
Women don’t know how to make themselves feel good sexually
Poor body image in many young people (women and men) can result in difficulty relaxing during sex
Gender issues – masculinity/femininity, confusion
Media portrayal of sex and gender

67. International student perspective (Bengali male with premature ejaculation)
No therapy available in Bangladesh, client knew of only one person who had ever accessed therapy in the capital
Mental health still a taboo in Bangladesh
Increased incidence of sexual trauma/rape for women, this is seen as “normal” and women are often blamed

68. Female student (with dyspareunia) and partner, both age 20
Partner also attended, on history taking he disclosed he had a problem with pornography use
He had been using pornography since age 12
No current sexual dysfunction identified with him but he did have some difficulty relating to his distorted ideas of how women should look and perform sexually due to his excessive exposure to “porn women” which impacted on his ability to become aroused

69. Case Studies

70. emmamathewstherapy@outlook.com emma.mathews@gmmh.nhs.uk
Contact details