1. Sexual Dysfunctions and Therapy

2. Introduction Many people will have occasional sexual impairment (e.g., resulting from fatigue, headache, illness, etc.). Masters and Johnson estimate that 50% of all Americans have, or will experience, a sexual dysfunction: recurrent and persistent sexual impairment. The causes of sexual dysfunctions are typically classified as “organic” or “psychosocial,” although those factors can interact.

3. Organic Causes Any disease, trauma, or drug that affects the nervous system has the potential to cause sexual impairment. neurogenic disorders - injuries, strokes, etc. that affect the sex centers of the brain or spinal cord that serve genital reflexe vascular disorders - affect circulatory system (e.g., cardiac disease, leukemia, sickle-cell disease) Kaplan has described the following categories of organic causes of sexual impairment:

4. Organic Causes (con’t) endocrine disorders - affect hormonal balance (e.g., diabetes, kidney disease) debilitating diseases - advanced diseases that limit general health (e.g., lung cancer) and infections (e.g., herpes, genital warts) drugs - just about any

5. Non-organic (psychological) Factors There is a general consensus that most dysfunctions stem from non-organic (i.e., psychological) factors. Those factors may result from past experience or present circumstances. Past Experience Strict Upbringing –cultures that are restrictive regarding premarital, marital, and extramarital sex are also more likely to produce people with sexual dysfunctions –such restrictiveness will also vary according to religious upbringing (e.g., Catholics have a reproductive bias)

6. Non-organic (psychological) Factors Past Experience Childhood Trauma –experiences such as rape, incest, or parental discovery of sexual activity may manifest their affects in adulthood –may cause fear, anger, guilt, and anxiety to become associated with sexual activity Myths, Ignorance, and Misinformation –information from peers is often wrong or incomplete –the media presents and perpetuates myths of sexual prowess or desire –some people just don’t know much about sex –when an individual doesn’t meet those standards, he or she may feel inadequate, abnormal, or awkward in a sexual encounter, resulting in embarrassment or guilt

7. Non-organic (psychological) Factors Current Circumstances fear and anxiety(e.g., fear of impregnating a partner, painful intercourse, anxiety of performance evaluation and the fear of failure, etc.) guilt (e.g., from an extramarital affair, masturbating, etc.) major life changes (e.g., new job, recent divorce/separation, death in the family, etc.) negative feelings toward partner (e.g., anger or frustration) Perhaps the major cause of dysfunction is “stress” which is being currently experienced by an individual Depression also has the ability to impair sexual functioning.

8. Types of Dysfunctions Sexual Desire Disorders Hypoactive Sexual Desire Disorder - little or no interest in sexual activity with anyone –often associated with strict religious upbringing, habituation to sexual partner, sexual assault, depression, anxiety, marital conflict, fear of intimacy, or medication side effects Sexual Aversion Disorder - dislike and avoidance of genital sexual contact with a partner –often associated with childhood sexual abuse and adult rape The most difficult aspect regarding desire is that it is difficult to say how much is “normal.”

9. Types of Dysfunctions (con’t) Sexual Desire Disorders excessive sexual desire - sometimes called hyperactive sexual desire, sexual addiction or sexual compulsion –Nymphomania (female) and Satyriasis (male) –usually associated with obsessive-compulsive reaction –obsessive thoughts of sex cause anxiety and compulsive behavior that temporarily reduces anxiety

10. Types of Dysfunctions (con’t) Sexual arousal disorders: Formerly called frigidity or impotency –Erectile dysfunction -- used to refer to male sexual arousal disorder; no additional term used for females –may be “primary” (never been able to attain or maintain vasocongestion) or “secondary” (have previous history of ability to attain and maintain vasocongestion) are diagnosed when there is recurrent or persistent failure to attain or maintain vasocongestion not due to physical disorders or medication and given sufficient stimulation. Occasional nonresponsiveness is normal (e.g., too much alcohol, fatigue, headaches, etc.) and is not an indicator of this disorder.

11. Types of Dysfunctions (con’t) Orgasm Disorders Premature ejaculation - ejaculation that occurs before the person wishes it because of recurrent and persistent absence of reasonable control Inhibited Male Orgasm (retarded ejaculation or ejaculatory incompetence) - delayed ejaculation or total absence despite adequate periods of sexual stimulation –“primary” or “secondary;” primary form usually specific to intercourse (usually ejaculate with masturbation or oral sex) –May be caused by fear of impregnating partner, negative feelings toward partner, strict religious upbringing, or may masturbate “roughly” which is not possible during coitus There is considerable variation from person to person in the amount of stimulation necessary for orgasm, so diagnosis is difficult.

12. Types of Dysfunctions (con’t) Orgasm Disorders Inhibited female orgasm (female orgasmic dysfunction) - delayed orgasm or total absence despite adequate periods of sexual excitement –may be “absolute” (never) or “situational” (under some circumstances) masturbatory dysfunction - can’t while masturbating coital dysfunction - can’t while having intercourse (less than 50% of women, however, have orgasm during intercourse) –many therapists consider a woman dysfunctional only if it is of the absolute type

13. Types of Dysfunctions (con’t) Miscellaneous Dysfunctions Priapism (prolonged erection) - continuous erection not due to sexual arousal –can be caused by damage to the valves that control blood flow in the penis, infections (e.g., from Spanish Fly), or tumors, cocaine or heroin use, and some medications Functional dyspareunia (painful intercourse) - recurrent and persistent pain during sexual intercourse –typically biological in origin (e.g., diseases) –experienced as repeated, intense discomfort, sharp sensations, or intermittent twinges or aching sensations –pain can occur before, during, and after intercourse

14. Types of Dysfunctions (con’t) Miscellaneous Dysfunctions Vaginismus - involuntary constriction of pubococcygus (PC) muscles surrounding the outer third of the vagina, resulting in an interference with coitus –feels like hitting and obstruction 1in. inside the vagina –may be “absolute” (always) or “situational” (only during intercourse) –Vaginismus may be a source of dyspareunia or may be preceded by dyspareunia –may also be caused by rape, abortion, pelvic inflammatory disease, painful gynecological exam, or vaginal injury, or general fears of penetration

15. Sex Therapy Until the 1960s, psychoanalysis was the predominant approach to sexual dysfunctions. The idea was that unresolved childhood conflicts manifested themselves as dysfunctions in adult life. Behaviorists argued dysfunctions were learned so they could be unlearned. A cognitive-behavioral approach is most common today. They treat the sexual dysfunction symptoms by reducing stress and anxiety and attempt to change self-defeating thoughts and assumptions.

16. Techniques of Treatment education - instruction in communication skills, sexual techniques, anatomy and physiology of sexual functioning redirection of sexual behavior - focus attention away from self-monitoring (spectating) to giving pleasure to partner graded sexual exposure - reduce anxiety by gradual exposure to sexual situations Most behavioral programs include three components:

17. Techniques of Treatment (con’t) take turns in role of giver and receiver, touching, hugging, and kissing “giver” uses nondemand pleasuring - touch and explore partner’s body without sexually arousing the partner “receiver” focuses attention on the sensations produced by the giver and indicates what is uncomfortable or irritating gradually increase the kinds of activity allowed: breast and genital touching, simultaneous masturbation, penile insertion without movement, and finally intercourse these techniques work well with inhibited male orgasm, secondary inhibited female orgasm Nondemand pleasuring and sensate focus

18. Techniques of Treatment (con’t) create fear hierarchy and learn relaxation techniques may ask client to “imagine” the anxiety-provoking situations or use in vivo (real) situations Systematic Desensitization Masturbation Training Used primarily for women with primary inhibited orgasmic dysfunction. Learn about their bodies and relax to the point where they can have an orgasm.

19. Techniques of Treatment (con’t) Semans start-stop - stimulate penis until ejaculation feels close, then stop until urge passes and repeat Squeeze technique - stimulate penis until urge to ejaculate feels close, then squeeze around the corona of penis or base of penis until urge passes; wait 20-30 seconds and repeat Masturbation Training For premature ejaculation, the Semans start-stop technique or the Squeeze technique are effective. In both techniques, you gradually move to women-above, then side-by-side, and man-above.

20. Techniques of Treatment (con’t) Sometimes used in therapy when a client does not have an available partner. There is no research comparing the effectiveness of treatment of clients with and without the use of surrogates. The use of sexual surrogates is considered unethical by most psychologists and the practice has been generally abandoned. Sexual Surrogates

21. Other Treatment Approaches Most other approaches have been developed for male sexual problems. The following treatments should only be considered when other treatments have been found ineffective. Surgical Implants semirigid rod or inflatable devices (filled with liquid) have been used to treat erectile dysfunction potential side effects include infection and mechanical failure most men can experience orgasm provided there is no neurological damage men who have received the implants report general satisfaction; women prefer the inflatable device

22. Other Treatment Approaches (con’t) A vacuum pump (ala Austin Powers) is a nonsurgical alternative. The vacuum pump draws blood into the erectile tissue, causing the penis to become erect. A rubber band at the base of the penis holds the blood in place (up to 30 minutes).

23. Other Treatment Approaches (con’t) Hormones if erectile dysfunction is the result of low levels of testosterone, administration of that hormone may be helpful if hormonal levels are normal, administration of testosterone can increase “desire,” but not “performance” use of testosterone increases the risk of heart attack, atherosclerosis, and cancer of the prostate testosterone has also been used to treat females with low sexual desire and have low testosterone levels. High levels may masculinize women

24. Other Treatment Approaches (con’t) Drugs dysfunctions associated with anxiety may be treated with minor tranquilizers (e.g., Librium or Valium) the effectiveness of such treatment has not be overwhelmingly positive Viagra, Levitra, and Cialis have been used quite successfully to treat males with erectile dysfunction

25. Other Treatment Approaches (con’t) Drugs Cyclic guanosine monophosphate (cGMP) is produced when a male becomes sexually aroused. The cGMP causes smooth muscles which provide blood to the penis to relax. Consequently, blood flow increases resulting in an erection. Another enzyme called phosphodiesterase 5 (PDE5) breaks down the cGMP A common cause of erectile dysfunction is the amount of cGMP produced is not enough to maintain an erection. Drugs like “Viagra” (sildenafil citrate) block the action of PDE5 allowing a build up of cGMP.

26. Other Treatment Approaches (con’t) Drugs Like all medications, there are side effects. For example, there is some concern that some men, especially younger men who take Viagra recreationally, may end up with a dependency on the drug. You should consult with your physician to determine if such drugs are appropriate.