Basic introduction to sexual dysfunction. Introduction to psycho sexual treatment approach.

1. Mr Upendra Singh
Lecturer, Dept. of Psychoatric Social Worker, Dr Ram
Manohar Lohia Hospital, New Delhi, India

2. Introduction
• Sexual activity is physical, however many factors influences
sexual response of an individual.
• Therefore, sexual dysfunction can be understood as problems
in any phase of sexual response cycle.

3. Introduction
• Primary sexual dysfunction is a condition, which is present
since the individual became capable of functioning sexually
(i.e. post-puberty).
• Secondary sexual dysfunction is a condition that begins in an
individual who previously experienced an acceptable level of
sexual functioning.

4. Masters and Johnson’s Model of
Human Sexual Response
1. Arousal / Excitement
2. Plateau
3. Orgasm
4. Resolution

5. Kaplan, 1974
1. Desire
2. Arousal / Excitement
3. Orgasm
4. Resolution

6. Definition
• Thus, you can understand Sexual dysfunction as a problems
that creates an inability to experience satisfaction from sexual
activities for any individual or for a couple.

7. Classification – ICD-10
• F52 Sexual dysfunction, not caused by organic disorder or disease
F52.0 Lack or loss of sexual desire
F52.1 Sexual aversion and lack of sexual enjoyment
.10 Sexual aversion
.11 Lack of sexual enjoyment
F52.2 Failure of genital response
F52.3 Orgasmic dysfunction
F52.4 Premature ejaculation
F52.5 Nonorganic vaginismus
F52.6 Nonorganic dyspareunia
F52.7 Excessive sexual drive
F52.8 Other sexual dysfunction, not caused by organic disorders or disease
F52.9 Unspecified sexual dysfunction, not caused by organic Disorder or
disease

8. Classification – DSM 5
• Sexual dysfunction
302.71 Male Hypoactive Sexual Desire Disorder
302.72 Erectile Disorder
302.72 Female Sexual Interest / Arousal Disorder
302.73 Female Orgasmic Disorder
302.74 Delayed Ejaculation
302.75 Premature (Early) Ejaculation
302.76 Genito-Pelvic Pain / Penetration Disorder
302.79 Other Specified Sexual Dysfunction
302.70 Unspecified Sexual Dysfunctionm

9. Lack or loss of sexual desire
• Lack of sexual desire does not rule out sexual enjoyment or
arousal, but makes the initiation of sexual activity less likely.
ICD-10

10. Sexual aversion and lack of sexual
enjoyment
• Sexual aversion
– The prospect of sexual interaction with a partner is associated with
strong negative feelings and produces sufficient fear or anxiety that
sexual activity is avoided.
ICD-10

11. Sexual aversion and lack of sexual
enjoyment
• Lack of sexual enjoyment
– Sexual responses occur normally and orgasm is experienced but there is
a lack of appropriate pleasure.
– Common in females
ICD-10

12. Failure of genital response
• In men, the principal problem is erectile dysfunction, i.e.
difficulty in developing or maintaining an erection suitable for
satisfactory intercourse.
• In women, the principal problem is vaginal dryness or failure
of lubrication.
ICD-10

13. Orgasmic dysfunction
• Orgasm either does not occur or is markedly delayed.
• Common in females
ICD-10

14. Premature ejaculation
• The inability to control ejaculation sufficiently for both
partners to enjoy sexual interaction.
• Ejaculation may occur before vaginal entry
• Ejaculation may also appear to be premature if erection
requires prolonged stimulation, causing the time interval
between satisfactory erection and ejaculation to be shortened;
the primary problem in such a case is delayed erection.
ICD-10

15. Nonorganic Vaginismus
• Spasm of the muscles that surround the vagina, causing
occlusion of the vaginal opening.
• Penile entry is either impossible or painful.
ICD-10

16. Nonorganic Dyspareunia
• Pain during sexual intercourse
• Occurs in both women and men
ICD-10

17. Etiology – Medical Model
• Infectious and Parasitic
diseases
– Elephantiasis
– Mumps
• Cardiovascular diseases
– Atherosclerotic disease
– Arotic aneurysm
– Leriche Syndrome
– Cardiac failure
• Renal and Urologic disorders
– Peyronie's disease
– Chronic renal failure
– Hydrocele or varicocele

18. Etiology – Psychological Model
• Psychoanalytic Perspective
– Sexual disturbance is related to an unconscious belief
– Inability to carry out the sexual act is conceptualized as a defense that
prevents an activity regarded as dangerous (Fenichel, 1945).
– The unresolved Oedipus complex is the underlying root of sexual
disturbance.

19. Etiology – Psychological Model
• Behavioral Perspective
– conditional anxiety or fear with sexuality
– inappropriate or negative reinforcement of positive sexual behavior; or
– faulty modeling of sexual responses, or a combination of any of these
factors
(Common predisposing factors to sexual dysfunctions are restrictive
upbringing, traumatic early sexual experience and misconceptions
about sexuality).

20. Psychosocial Perspective of Sexual
Dysfunction
• Gender Identity Development
• Problematic Attachment and Experience With Parents
• Exposure to Childhood Non-Sexual Abuse and Neglect
• Experience of Childhood Sexual Abuse
• Puberty, Adolescence, and Early Sexual Experiences
• Vulnerability and Risk Factors
• Cognitive Schemas
– Efficacy Expectations
• Sexual Beliefs
– Performance Anxiety and Demand

21. Life-Stage Stressors
• Infertility
• Postpartum Period
• Aging
• Menopause

22. Interpersonal & Relational Factors
• Intimacy
• Relationship Satisfaction
• Partner’s Sexual Dysfunction
• Partner’s Illness
• Partner’s Discrepancies
• Partner’s Responses
• Partner’s Abuses

23. Assessment of Sexual Dysfunction
• Self monitoring
• Clinical History
• Psychometric Assessment
• Physiological Assessment

24. Psychosocial Treatment Approach
• The PLISSIT model of sex therapy
• William Masters and Virginia Johnson (1970) Sex Therapy
• Behavior Therapies
– Progressive muscle relaxation
• Cognitive Restructuring
– Any cognitive psychotherapy can be used like Rational Behavior Emotive Therapy
of Ellis or Cognitive Behavior Therapy of Beck and Self-instructional Training of
Melchenbacum.
• Biofeedback
• Mindfulness

25. PLISSIT model
• Annon (1974) postulated a model called PUSSIT
• He has organized the existing techniques at 4 levels :
1. Permission
2. Limited information
3. Specific Suggestion
4. Intensive Therapy (Long term)

26. Master and Johnson Techniques
• Sensate Focus
– Step 1: Non-Genital Touching
– Step 2: Genital Touching
– Step 3: Adding Lotion
– Step 4: Mutual Touching
– Step 5: Sensual Intercourse
• Foreplay & After play

27. Cognitive Restructuring
• Identify interfering thoughts
• Impact of thoughts on sexual arousal
• Normalize sexual difficulties when negative thoughts or
images are present
• Ask patient to describe arousing thoughts he had before the
dysfunction began (body parts, physical sensation)
• Self-monitoring form after engaging in sexual activity

28. Squeeze Technique: Masters & Johnson
(1970)
Male client squeezes the ridge of his penis with two fingers and
his thumb below the head of his penis when he reaches
ejaculation.
• Hold for approximately 10 seconds
• Used before penetration or during withdrawal during
intercourse
• Squeeze technique is for multiple use during a single sexual
intercourse.

29. Reference
• World Health Organization. The ICD-10 classification of mental and behavioral disorders:
clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.
• American Psychiatric Association. (2013). Sexual Dysfunction. In Diagnostic and statistical
manual of mental disorders (5th ed.).
• Lori Brotto, Sandrine Atallah, Crista Johnson-Agbakwu, Talli Rosenbaum, Carmita Abdo, E.
Sandra Byers, et al, (2016). Psychological and Interpersonal Dimensions of Sexual Function
and Dysfunction. J Sex Med, 13:538-571.
• Avasthi A., Rao T. S. S., Grover S., Biswas P., Kumar S. Clinical Practice Guidelines For
Management Of Sexual Dysfunctions. Dept of Psychiatry, PGIMER, Chandigarh & J.S.S
Medical College, Mysore.

30. Thank You!!!