Assessment and Psychological Treatment of Sexual Dysfunctions

Here's a step-by-step guideline of how to diagnose and treat sexual dysfunctions.

Assessment of Sexual Dysfunctions

Often requires medical evaluation

• By competent, sensitive physician

Psychosocial evaluations

• Can be complex
• Multiple etiologies
• Distinguishing cause, effect, & their interaction
• Frequently identify co-morbidities
• Sexual and non-sexual
• Medical and psychological
• Within and between partners

Ideally, both partners get interviewed

• Together and separately
• Not always possible
• Could itself be diagnostic
• Identified patient is sent in to be "fixed"
• Stories often differ
• Even about objective data
• Often about conceptions of the problem
• Or even if there is a problem

"There are no unaffected partners in sexual dysfunctions" (Bill Masters)

• Resentment
• Anger
• Doubts
• Does she still love me?
• Does he still find me attractive, sexy, appealing?
• Diminished Quality of Life

Sexual dysfunctions vary across several dimensions

• Nature of presenting complaint
• Is this really a sexual problem?
• Length of dysfunction
• Primary vs. Secondary
• Has the person always had the dysfunction or was there ever a period of good functioning?

Sexual dysfunctions vary across several dimensions

• Medical vs. Psychological Etiology
• Frequently difficult to determine
• Particularly if the problem is of long duration
• Locus of the problem?
• One partner, the other, or both?
• Do both partners see this the same?
• Single or multiple dysfunction(s)
• In one partner or both?
• Relationship, if any, of multiple dysfunctions?

Important to explore

• How each partner understands the problem
• What has the couple has tried to deal with the problem?
• With what success?
• Anything make it better/worse?
• What is the non-sexual relationship like?
• Non-sexual sources of stress
• Health problems?
• Medications?
• Why are they in treatment now?
• What does each hope to get from treatment?
• How willing is each to participate in treatment?
• Strengths, as well as problems
• What competes with sex?
• Time, work, kids
• A detailed description of what the couple typically does sexually
• Maladaptive attitudes, beliefs, behaviors, and expectations
• Each partner's outside sexual experiences
• Before or during this relationship
• What's at stake if the problem isn't resolved?
• Is the problem also a solution?
• Secrets
• Fantasies

---

Sexual History

• Critical for understanding the problem
• Always done for symptomatic partner
• Best when done for both partners
• Time and detail are variable
• How far back do you go?
• How much detail do you need?
• Certainly, need a detailed history of the problem
• As far back as it goes
• Precipitating events?

Sexual history includes

• Sexual messages received growing up
• Earliest sexual experience
• How did it go?
• Significant sexual experiences
• Both positive and negative
• Particularly any abuse (psychological, physical, sexual)
• History of sexual relationship with current partner

Treatments

Psychological

• Individual
• Couple
• Combination

Medical

• Rarely includes the partner in assessment or treatment

Combinations

Psychological Treatment

• Primary goals
• Support
• Normalization
• Permission giving
• Sex education
• Stress reduction
• Symptom removal
• Improved communication (sexual & other)
• Attitude change
• Helping to make sex fun

Most common approaches are cognitive-behavioral, also the most researched and supported

Cognitive: Identifying and challenging irrational or unreasonable beliefs, attitudes, expectations

Behavioral: Sensate focus exercises

Most involve sex education

• Learning what's "normal"

Improve communication

• Learn and communicate about each other's desires and fears s

Important to work within the individual's or couple's value system

• Important to be non-judgmental
• You must be comfortable talking about sex
• Any sign of your discomfort will make it more difficult for them to talk
• How comfortable are you?
• How do you know?

It will be difficult for many clients to talk about their sexual problems

• Where were they supposed to learn to be comfortable discussing sex?
• At home, school, with friends or family?
• Where did you learn to be comfortable?
• Admitting to sexual problems is even more difficult
• Especially for men
• Gets more difficult the longer the problem has existed

---

Few seek help for sexual problems

• 20% of women 10% of men (NHSLS)

Need to identify individual or relationship issues that may cause, maintain, or exacerbate the sexual problem

Individual

• Anxiety
• 36% of men and 50% of women with panic disorder had sexual aversion disorder
• Depression
• Substance abuse
• Low self-esteem

Relationship Issues

• Can be the cause, effect, or both of sexual problems
• Sexual boredom
• Dislike of partner
• Anger, Fear
• Power differences, control issues
• Fallen out of love
• Lack of sexual attraction
• Infidelity
• Disappointment
• Perceived selfishness
• Money, kids, in-laws
• Different values or interests
• Abuse
• Partner's psychological disturbance

Sensate Focus

• Developed by Masters and Johnson
• Guided couple's exercises
• Both diagnostic and therapeutic
• In vivo systematic desensitization
• Early exercises designed to be more sensual than sexual

Designed to

• Reduce stress, expectations, and spectatoring
• Increase sexual pleasure

Designed to help couples

• Identify what pleases them and their partner by focusing on their own and their partner's bodily sensations
• Improve sexual communication
• Take time for their sensual pleasure
• Go back to a place when sex was fun and satisfying

Sensate Focus

• Done in private
• Includes prescriptions and proscriptions
• Is gradual, beginning with non-genital touching
• Usually precedes more disorder-specific exercises
• Is individualized to the couples
  • Where they are starting from
  • The nature of their problem(s)
  • Their response to each exercise

Desire Disorder

• Difficult to treat
• Prognosis is better when etiology is apparent
• No empirically validated treatments
• Approach usually depends on assumed etiology
  • Primary vs. secondary
  • Generalized or partner specific
  • Individual vs. couples' therapy
  • Medical (e.g., estrogen) vs. psychological
• Often requires lengthy individual and/or couples' therapy

---

Sexual Aversion

More common in women

• Prevalence unknown

More serious than desire disorder

• More often associated with significant individual psychopathology
• History of abuse, rape or other trauma
• More often associated with significant relationship problems
• Severe anger, distrust, infidelity

Difficult to treat

• Symptomatic partner may have little motivation
• Almost always requires lengthy individual and/or couples' therapy

Arousal Disorder

• Medication sometimes helpful
• Psychological interventions
  • Individual psychotherapy
  • Treat historical issues or Axis I disorders that are etiologically significant
  • Couples' counseling
  • Sensate focus
  • Treat communication and other relationship issues believed to cause or maintain the disorder

Female Sexual Dysfunctions

Vaginismus

• Good prognosis
• Dilation
• Relaxation
• Kegel exercises
• Partner involvement

Primary Anorgasmia

• Good prognosis
• Directed Masturbation
• Sensate focus
• Systematic Desensitization (~)

Secondary Anorgasmia

• Guarded prognosis
• Sex education
• Sexual skills training
• Communication training
• Directed masturbation (~)

Dyspareunia/Vaginismus

Treatment:

• Multidisciplinary
• Need a physician who understands and treats these problems
• Cognitive-behavioral therapy:
• Vaginal dilation (Vaginismus)
• systematic desensitization
• couples counseling

Erectile Dysfunction

• Oral medications
  • PDE-5 Inhibitors
  •  
• Prostheses
  • Rigid, Semi-rigid, Inflatable
• Psychological
  • Sensate focus
  • Systematic desensitization
  • Sex education
  • Communication training

Premature Ejaculation

• Medication
  • E.g., Clomipramine
• Psychological
  • Sex education
  • Normalizing PE
  • Blueprint alternatives
  • Cognitive-behavioral
  • Squeeze
  • Stop-start
  • Do better in short-term than long-term