Couple Therapy and the Treatment of Sexual Dysfunction 2011
Background• Masters and Johnsons were founders of modern couple sex therapy• One of the most enduring and important aspects of their work has been the four stage model of sexual response, which they described as the human sexual response cycle.• They defined the four stages of this cycle as:1. Excitement phase (initial arousal)2. Plateau phase (at full arousal, but not yet at orgasm)3. Orgasm4. Resolution phase (after orgasm)
DSM-IV-TR Sexual Disorders1- Sexual Desire Disorders• – Hypoactive Sexual Desire (HSDD)• – Sexual Aversion2- Disorders of Sexual Arousal• – Female Sexual Arousal Disorder• – Male Erectile Disorder3- Disorders of Orgasm• – Female Orgasmic Disorder• – Male Orgasmic Disorder• – Premature Ejaculation4- Sexual Pain Disorders• – Dyspareunia• – Vaginismus
What is the term “Sexual function”?It is the ability to experience• “desire" positive anticipation and feel deserving of sexual pleasure,• “arousal” receptivity and responsively to erotic touch, resulting in subjective arousal and lubrication for woman and erection for man,• “orgasm" a voluntary response that is a natural culmination of high arousal and• “satisfaction” feeling emotionally and sexually fulfilled and bonded
What is “sexual dysfunction”?• Sexual dysfunction is broadly defined as the inability to fully enjoy sexual intercourse• sexual dysfunctions are disorders that interfere with a full sexual response cycle• These disorders make it difficult for a person to enjoy or to have sexual intercourse
Female Sexual DysfunctionHypoactive Sexual Desire Disorder (HSDD)• characterized as a lack/absence or low levels of sexual fantasies* and desire for sexual activity for some period of time though aroused and orgasmic once.• Primary desire problems can be caused by anti-sexual family learning, poor body mage, lack of experiences with self exploration/masturbation, childhood sexual trauma, fear of pregnancy, HIV, fear of sexual humiliation, conservative religious backgrounds,…etc• Secondary HSDD causes are disappointment, anger with partner and negative sexual experience (i.e. rape)*Not fantasizing is not considered a hypoactive desire disorder!
Orgasmic Dysfunction• Orgasmic disorder is lack of or delay in sexual climax (orgasm) even though sexual stimulation is sufficient and the woman is sexually aroused.• Usually men are more upset about this than woman. He wants her to function the way he function( having orgasm during intercourse without additional stimulation).• This has been traditionally considered the “right” way to be orgasmic.• In fact, many women who are regularly orgasmic with couple sex are not orgasmic during intercourse.• This is not dysfunction but a normal variation in female sexual response. Female sexual response is more variable and complex than male sexual response.• In truth, many women who are sexual orgasm during intercourse often use multiple stimulation.• A woman may be non orgasmic, single orgasmic or multiple orgasmic.
Female arousal Dysfunction• Absence of or markedly diminished feelings of sexual arousal, (sexual excitement and sexual pleasure), from any type of sexual stimulation• Genital Sexual Arousal Disorder: Complaints of absent or impaired genital sexual arousal. Self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia• The objective (physiological) measure of arousal are ease and amount of vaginal lubrication. The subjective measure is feeling “turned on”.** Combined Sexual Arousal Disorder: Absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure), from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication).
EROS CTD Female Vacuum Therapy• FDA approved to treat FSD (vasculogenic)• Requires prescription• Creates gentle suction over the clitoris to cause engorgement• Improves vaginal blood flow and lubrication• Urometrics
Painful Intercourse• Dyspareunia: Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse. Most common cause of dyspareunia:Vulvar Vestibulitis Syndrome (VVS)• Vaginismus: Persistent or recurrent difficulties to allow vaginal entry of a penis, finger, and/or any object, despite the woman’s expressed wish to do so. Often phobic avoidance and anticipation of pain.• The problem of painful intercourse is paradoxical! Where as some cases are easy to resolve, others need the coordinated efforts of a gynecologist, sex therapists, and a female physical therapist( to direct teach the control over pelvic floor musculature).
Male Sexual DysfunctionPremature Ejaculation:• 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 that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity.• Also known as Rapid Ejaculation• Most prevalent sexual dysfunction in men
Erectile Dysfunction• Persistent or recurrent inability to attain, or to maintain until the completion of sexual activity, an adequate erection.• With introduction of Viagra 1998, there has been a paradigm shift in ED. “the friendly-user” intervention. It is much easier to take a pill than use other interventions such as surgeon, external pump, penile injections,…etc. However, Viagra has resulted in the medicalization of male sexuality.• Unfortunately, many men who face ED avoid any affectionate or sexual contact, in fear to face “the embarrassment of erectile failure”.
Hypoactive Sexual Desire Disorder in men• For majority of men, HSDD is a secondary dysfunction. It affects 15% of men and increases by age.• Primary HSDD is rare (less than 10%), because of the culture link between masculinity and sexuality and adolescence experience with masturbation.• Male HSDD secondary usually is linked to a dysfunction and primary usually caused by a sexual secret (affair, history of sexual trauma, guilt or shame of sexuality or afraid of sexual failure).• Usually men with HSDD who attend couple therapy usually are forced by their partners. Their goal is to avoid self disclosure and therapy. They want to keep their sexual life secret away from partner and therapist.• HSDD does not necessary make couple therapy the treatment of choice. Severe relationship problems (partner abuse, lack of respect, ..etc) and severe individual problems (bipolar, alcoholism, panic disorder, …etc) can sabotage sex therapy.
Ejaculatory Inhibition• EI is the least common sexual dysfunction.• Usually the man can ejaculate with masturbation and some man can ejaculate with manual or oral stimulation but not during intercourse (or only rarely).