Overview: Sexual dysfunction; sexual response cycle; types of sexual dysfunction - male: erectile dysfunction, pre-mature ejaculation, ejaculatory incompetence and female: vaginismus, dyspareunia, anorgasmia; causes- organic and psychosocial factors and management: sensate focus and management of specific dysfunction.

1. Sexual Dysfunction
and Management
- PRAGYA
(Clinical Psychologist)

2. Sexual dysfunction
• Refers to problem occurring during any phase of the “sexual
response cycle”
• Prevent an individual or couple from experiencing satisfaction
from sexual activity
• Treatment options are available
2

3. “Sexual response cycle
3
Desire
Arousal
PlateauOrgasm
Resolution

4. 4
Time
Sexual
Arousal
Desire
Excitement
Plateau
Orgasm
Resolution
SEXUAL RESPONSE CYCLE

5. Types of sexual dysfunction
• Desire disorder: lack of sexual desire or interest in sex
• Arousal disorder: inability to become physically aroused or
excited during sexual activity
• Orgasm disorder: delay or absence or orgasm
• Pain disorder: pain during intercourse
5

6. Causes of sexual dysfunction
6
Organic
• Physical/medical factors
such as illness, injury or
drug effect
Psychosocial
• Psychological, IPR,
environmental and
cultural

7. Causes contd…
• Either one or sometimes, combination of several different
factors
• For a person seeking treatment to have thorough physical
examination as well as appropriate laboratory testing of
blood and urine sample
7

8. Male Sexual
Dysfunction
8

9. Erectile dysfunction (ED)
• Inability to have or maintain erection that is firm enough for coitus
• Total absence of erection is infrequent except in certain medical
conditions
• Mostly, male has partial erection, too weak for vaginal insertion
• Sometimes, firm erection that quickly disappear if intercourse is
attempted
9

10. ED contd…
• Isolated episode do not mean that man has sexual dysfunction
• This reflect a temporary form of physical stress
• On long-term basis, performance fears may lead to:
1. Lowered interest in sex (avoidance)
2. Loss of self-esteem
3. Attempts to control anxiety by working hard to overcome it
10

11. ED contd…
• Fear of performance often cause one/both partners to become
spectators during intercourse
• They observe and evaluate their own or partner’s sexual
response
• Thus, become less involved as they are distracted
11

12. “Fear-spectator-failure-fear cycle
12
Erectile
failure
Performance
failure
Self/partner
take
spectator
role
Distraction
Loss of
erection

13. Types of ED
13
Primary ED
• Never been able to have
intercourse
Secondary ED
• Succeeded in having
intercourse before his
dysfunction began

14. Pre-mature Ejaculation (PME)
• Person is able to participate in variety of sexual activities and
only loses his ejaculatory control soon after intercourse begin
• Fear of performance often seem to heighten lack of
ejaculatory control
• Occasionally leads to ED by fear-spectator-failure-fear cycle
• Sexual inadequacy related with both partner not male alone
14

15. Ejaculatory incompetence
• Inability to ejaculate within vagina despite firm erection and
relatively high level of arousal
• RETROGRADE EJACULATION: bladder neck does not close
off properly during orgasm so semen spurts backward into
bladder, where it is mix with urine
• RETARDED EJACULAION: intra-vaginal ejaculation requires
long time & strenuous efforts at coital stimulation and sexual
arousal may be sluggish (opposite of PME)
15

16. Ejaculatory incompetence contd…
• Men had never experienced ejaculation (except nocturnal
emissions)
• When reproduction is goal of sexual partners, this can be
even more frustrating
• Occasional difficulty with ejaculation is not sign of sexual
disturbance which is related with fatigue, tension, illness,
or effect of alcohol/ any other drug
16

17. Female Sexual
Dysfunction
17

18. Vaginismus
• Muscle around outer third area of vagina have
involuntary spasms in response to vaginal
penetration
• Vaginal opening is tightly clamped shut preventing
intercourse as well as insertion of finger
• It may allow a woman to have intercourse with some
difficulty or cause pelvic pain while coitus
18

19. Vaginismus contd…
• Vaginal lubrication occurs normally as well as have
normal sexual desire
• non-coital sexual play may be pleasurable and satisfying
• Orgasm is often unaffected
• Male partner may be completely baffled (he either thinks
he is responsible for pain or thinks female partner is
deliberately avoiding intercourse)
19

20. Vaginismus contd…
• If male partner thinks he is responsible & blame himself,
he may become more passive or may develop ED
• If male partner thinks she is deliberately avoiding, then he
may lose patience, become resentful or openly hostile. He
may seek other sexual partner
• These are further distressing for female partner/ patient
• Mostly have psycho-social causes
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21. Orgasmic dysfunction / Anorgasmia
21
Primary
anorgasmia
• Refers to
women who
have never
had an
orgasm
Secondary
anorgasmia
• Refers to
women who
were
regularly
orgasmic at
one time but
no longer are
Situational
anorgasmia
• Refers to
women who
have had
orgasms on
one or more
occasions but
only under
certain
circumstances
Coital
anorgasmia
• Refers to
women who
are orgasmic
by variety of
means but do
not have
orgasm
during
intercourse
Random
anorgasmia
• Refers to
women who
have
experienced
orgasm in
different
types of
sexual activity
but only on
infrequent
basis

22. Anorgasmia contd…
• Lack of orgasm must be viewed in terms of:
• Individual desires
• skill and sensitivity of her partner
• circumstances of sexual activity (privacy, timing,
comfort, etc.)
• Women who sometimes has orgasms should be classified as
having orgasmic dysfunction only if frequency is so low that
cause distress/dissatisfaction
22

23. Dyspareunia
• Painful intercourse
• Pain can appear at:
• start of intercourse
• midway through coital activities
• time of orgasm
• after intercourse
• Pain can be felt as burning, sharp or cramping
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24. Dyspareunia contd…
• Pain can be external, within vagina or deep in pelvic
region or abdomen
• It detracts from sexual enjoyment & can interfere with
sexual arousal and orgasm
• Fear of pain may make woman tense and decrease sexual
pleasure
• Woman may avoid coital activity or abstain from all sexual
contacts
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25. Organic causes
25

26. ED
1. Diabetes
2. Alcoholism
3. Spinal cord injury
4. multiple sclerosis
5. Other neurological
condition
6. Infection/injury of penis,
testes, urethra or prostate
7. Hormone deficiencies
8. Circulatory problem
9. Street drugs (uppers,
downers and narcotics)
26

27. PME
1. Abnormal hormone levels
2. Abnormal level of brain chemicals
(Neurotransmitter)
3. Inflammation or infection of prostate gland or
urethra
4. Inherited traits
27

28. Ejaculatory incompetence
1. Blockage of ducts that semen passes through
2. Use of certain drugs
3. Nervous system disease such as stroke, nerve
damage to spinal cord or back
4. Nerve damage during surgery in pelvis
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29. Anorgasmia
1. Diabetes
2. Alcoholism
3. neurological disturbances
4. hormone disturbances/ deficiency and pelvic
disorders (infection, trauma or scarring from
surgery)
5. Drugs (tranquilizers, narcotics, BP medicine)
29

30. Dyspareunia
1. Any condition that results in poor vaginal lubrication
can produce discomfort during intercourse
2. Drugs that have drying effect (anti-histamine,
tranquilizer, marijuana)
3. Illness (diabetes, vaginal infection)
4. Estrogen deficiency
30

31. Psychosocial
Causes
31

32. Personal factors
1. Developmental trauma
2. Psychological traits
3. Behavioral pattern
4. Relationship difficulty
5. Troubled parent-child
relationship
6. Negative family attitude
7. Traumatic childhood
8. Adolescent sexual
experiences
9. Gender identity conflicts
10.Lack of sexual knowledge
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33. Societal factors
1. Human sexual inadequacy
2. Rigid religious background (in some religious view,
sex was regarded as evil) these factors are common
in Vaginismus, primary anorgasmia in female and
ejaculatory incompetence in male
3. Blind acceptance of cultural myths
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34. Psychological factors
1. Anxiety
2. Depression
3. Fear of pregnancy, STDs, pain
4. Fear of rejection, losing control, intimacy
5. Guilt
6. Poor self esteem
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35. Interpersonal factors
1. Communication (sexual &
non-sexual)
2. Power struggles
3. Hostility toward partner
4. Preference for another
partner
5. Distrust or deceit
6. Lack of attraction
7. Gender ole conflict
8. Conflicts in sex value
system
9. Sexual preference in terms
of timing, frequency, type of
activity)
35

36. Psychodynamic view
• Ejaculatory incompetence, ED and PME result from castration
anxiety and unresolved oedipal wishes present at
unconscious level
• Vaginismus and anorgasmia reflect unresolved Electra
conflicts as well as unconscious hostility toward men because
of penis envy and old fears of being punished for sexual play,
learned in early childhood
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37. Behaviorist view
• Learning theory sees sexual dysfunction as
conditioned or learned response
• ED may developed if a man feels guilty after every
sexual encounters
• Anorgasmia may developed as she was conditioned
to believe that sex was wrong/shameful or she might
be taught that “nice girls do not enjoy sex”
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38. Management
38

39. Sensate focus / Masters & Johnson Model
• Therapeutic focus is “relationship”
• Provide more effective way of identifying full dimensions of
problem
• Gain cooperation & understanding of both partner in
overcoming distress
• Integration of physiological & psychological data
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40. SF contd…
• Explaining anatomy & physiology of sexual response to
patient often had therapeutic benefits
• Identifying obstacle that block effective sexual function &
help people remove or overcome these obstacle
• Pressure to perform are removed and rediscover sensual
pleasure of touching or being touched
40

41. SF contd…
• Also relabel their expectations
• SF help couple achieve balanced perspective toward sex
in which sex is neither totality nor neglected part of
relationship
• Majority of time of therapy is usually spent on non-sexual
issues
41

42. Stage 1 : taking turn
• Couple is asked to refrain from direct sexual interaction
involving genital contact
• This approach helps to remove performance pressure (break
fear-spectator-failure-fear cycle)
• Each have turn touching their partner’s body except breast &
genitals
• Purpose is to establish awareness of touch sensations by
noticing textures, contours, temp and contrast
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43. Stage 1 contd…
• Touching should not be massage or attempt to sexually arouse
the other partner
• Periods should be as silent as possible
• Person being touched must let know (verbally/ non-verbally), if
any touch is uncomfortable
• Allows to find out how couple interacts & provides means for
reducing anxiety and teaching non-verbal communication
43

44. Stage 2 : hand riding
• Touching is expanded to included breast & genitals
• Begins with general body touching (not dive for genitals)
• Includes “HAND RIDING” (placing one hand on top of
partner’s hand while he touches her, one can indicate if
they would like more pressure, lighter touch, faster or
slower stroking, change of different spot, etc.)
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45. Stage 3 : mutual touching
• Couple is asked to try mutual touching
• Provide natural form of physical interaction.
• It doubles potential sources of sensual input
• Couples are reminded-no matter how sexually
aroused they get ,intercourse is still off limit
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46. Stage 4 : genital intercourse
• Continue the same when comfortable woman shift on top
position without attempting insertion
• Woman can play with penis, rubbing it against clitoris, vulva,
and vaginal opening
• If there is erection, she can simply slip tip of penis inside the
vagina
46

47. Stage 4 contd…
• If the partner feel anxious, focusing on sensation and
stopping action moving back to simple non-genital
touching
• When comfortable, full intercourse can occur.
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48. Management for ED
• Woman is advised to insert penis (reduces pressure on
the man to decide time to insert and remove potential
distraction of fumbling to find vagina)
• Man can set his natural reflexes to take over by not
trying to have erection and removing performance fear
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49. Contd…
• Man often find himself having firm erection during
early stage of sensate
• Important to understand, losing an erection is not
sign of failure (erection can come and go naturally)
49

50. Management for PME
SQUEEZE TECHNIQUE
• Woman puts her thumb on frenulum of penis and place first and
second finger just above & below coronal ridge on opposite
side of penis
• Firm, grasping pressure is applied for about 4 seconds and
then abruptly released
• This reduces urgency to ejaculate
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51. Contd…
• Must begin at early stage of genital play & continue
periodically every few minute
• Squeeze can be used whether penis is erect or flaccid
• pressure should be proportionate to degree of erection
• When couple begins having intercourse, woman is asked
to use squeeze 3-6 times before insertion
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52. Contd…
• Once penis is fully inside her, she should hold still for 15-30
second with neither partner thrusting and then move off
penis
• Apply squeeze again and reinsert
• Now slow thrusting can begin
• Once man improves his ejaculatory control both partners are
taught basilar squeeze
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53. Squeeze technique
53

54. Management for ejaculatory incompetence
• Treated by in-depth attention to underlying psychological
components combined with sensate focus experiences that seek
to lead man through sequence
• Ejaculation by masturbating alone
• Ejaculation by masturbating in presence of partner
• Ejaculation by manual stimulation from partner
• Partner stimulate penis vigorously to point of ejaculatory
inevitability and quickly insert in vagina
54

55. Management for Vaginismus
• First, teach techniques (Kegel exercise) for relaxing muscle
around vagina
• KEGEL EXERCISE:
 Deliberately tighten muscles for 3-5 seconds and then
simply let go for 5-10 seconds
 Relax completely between each contraction
 Relax pelvic muscle as well as improve blood circulation
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56. Contd…
• Next, woman is given various set of dilators to insert in vagina by
using plenty of sterile lubricating jelly & asked to practice at
home
• Starting with smallest size (slightly thinner than finger)
• Keeping dilator in place for 10-15 minutes at time
• Most woman with Vaginismus find that within 5-6 days they are
able to use largest dilators
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57. Management for anorgasmia
• Encouraging woman to explore her own body, especially
focusing on genital exploration & stimulation in relaxed and
undemanding manner
• Dealing with performance anxiety
• Fostering sexual communication so that woman is able to let
partner know preference of touch or stimulation at given time
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58. Contd…
• Reducing inhibitions that limit woman’s capacity for arousal
or block orgasm
• BRIDGING TECHNIQUE:
To make transition to have orgasms during intercourse,
either partner stimulate clitoris manually during coitus with
active thrusting
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59. Thank
you !
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