Chapter 15 Sexual Problems and Therapy For use

Understanding sexual problems l Individual differences can create problems – – l 2 Different expectations Differences in desire Differences in preferred behaviors Relationship conflicts It is crucial that the couple view these problems as the couple having a problem rather than it being “your” problem or “my” problem; by working together these problems can be solved. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Sexual therapy l l 3 Psychoanalysis – long-term, intensive exploration of childhood causes for adult problems. Not commonly used today. Cognitive-behavioral therapy – short-term, focusing on attitudes, beliefs and how they affect our behaviors. Psychosexual therapy – insight into causes of the problems; successful with sexual aversion and low sexual desire. Medical model – looking for and treating organic causes for sexual problems. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

The PLISSIT model of sex therapy l l l 4 Each level represents a successively deeper level of therapy and is only explored if necessary. P = Permission (defining your own sexuality) LI = Limited information (a little education) SS = Specific suggestions (behavioral techniques) IT = Intensive therapy (psychotherapy; only 10% need this level) King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Sexual therapy techniques l l l Medical history – possible organic causes Sexual history – attitudes, behaviors, and partner reactions and involvement Specific suggestions – – 5 Systematic desensitization (reduce anxiety) Self-awareness and masturbation (know yourself) Sensate focus (non-demand mutual pleasuring) Techniques for specific problems King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Sensate focus The couple learns how to touch and be touched without worrying about

Defining sexual problems l l Subjective distress is a key element in the diagnosis of sexual disorders – part of defining one’s own sexuality includes deciding what conditions pose a problem. Four major categories: – – 7 Desire disorders Arousal (excitement phase) disorders Orgasmic disorders Sexual pain disorders King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Male sexual problems – Hypoactive sexual desire l Persistent or recurrent absence of sexual fantasies and sexual desire. – – – l 8 Primary – never having had normal level of desire Secondary or acquired – distress at a significantly lower level of desire than in the past Causes may be organic (e. g. , low testosterone) or psychological (e. g. , repressive upbringing, sexual trauma, negative self-schema) Sexual aversion – extreme hypoactive desire; anticipation of any kind of sexual interaction may cause great anxiety. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Male sexual problems – Erectile disorder (ED) l l l 9 Primary – he has always had problems Secondary – this is a new problem Global – the problem occurs in all situations Situational – normal functioning in some situations (e. g. , during masturbation) but not others (e. g. , attempting sex with a partner). Can be psychologically devastating to both partners. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Erectile Disorder – Causes l l l 10 Psychological – general stress and anxiety, depression, relationship problems, associating sex with guilt, traumatic experiences, performance anxiety and spectatoring. Organic – 80% of cases; use of alcohol, smoking, some medicines, circulatory problems (local or associated with other disease), injury, low testosterone, prostate disease. Occasional erectile failure is normal. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Erectile Disorder – Medical Treatments l l 11 Vacuum device – forces blood into the penis. A rubber ring worn at the base of the penis holds the erection. Penile implants – soft tubes that can be pumped up to create stiffness in the penis any time it is desired. An earlier type consisted of semi-rigid plastic rods. Injections – muscle relaxant injected into the penis allows for greater blood flow, with or without sexual stimulation. Pills – oral medication that works directly on the penis to create greater blood flow; the man only becomes erect when he experiences sexual stimulation. (Viagra, Levitra and Cialis) King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Erectile disorder – Psychological and behavioral treatments l l l 12 Medications or devices alone will not address the emotions associated with ED. Even when the cause of ED is organic, counseling is recommended. Anxiety can be addressed through counseling as well as behavior therapy techniques such as sensate focus and a teasing technique described in your textbook. Psychotherapy may be necessary in some cases. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

The “teasing” technique Learning that erection can come and go 13 King, Human Sexuality

Male sexual problems – Premature ejaculation l l 14 Absence of reasonable voluntary control of ejaculation. Psychological or organic causes (as listed previously). After therapeutic exercises such as sensate focus to teach the man not to hurry, the squeeze technique and/or woman-on-top coital position may be recommended. Other treatments are used, dependent upon the cause of the problem. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Male orgasmic disorder l l l 15 Male orgasmic disorder, also called ejaculatory incompetence refers to inability or difficulty reaching orgasm. Primary or secondary. Organic (drugs, alcohol, neurological disorder) Psychological (guilt/shame, fear of pregnancy, hostility toward partner, trauma) Often treated with the bridge maneuver. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Sexual pain disorders in males l l 16 Dyspareunia – most common causes are prostate, bladder or urethral infection. Also caused by phimosis and Peyronie’s disease. The anticipation of pain cause anxiety that leads to erectile problems. Priapism – painful erection lasting hours or days; causes include tumor, infection, drugs. Benign coital cephalalgia – severe headache at orgasm, usually in mildly obese, middle-aged men with elevated blood pressure. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Female sexual problems – Hypoactive sexual desire l l l 17 In addition to the causes listed for males, most hypoactive women are generally very unhappy with the quality of their relationship, particularly concerning the expression of affection. Although only 25% of cases can be traced to low levels of testosterone, treatment with testosterone has become quite common. Sexual aversion disorder – sexual trauma, repressive upbringing, negative self-schema. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Female sexual arousal disorder l l 18 Personal distress a persistent or recurrent inability to attain and maintain subjective and/or somatic sexual excitement (genital lubrication and swelling). FDA recently approved a vacuum pump device Viagra taken by young women with sexual arousal disorder increased vaginal lubrication but had no effect on subjective arousal. Most women do not separate desire from arousal. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Female orgasmic disorder l l The vast majority of women seek sexual therapy because of problems reaching orgasm. Primary or secondary; global or situational. Organic causes sometimes; but attitudes about sex and performance anxiety are common causes. First questions to ask: – – 19 Has there been enough foreplay? Is there sufficient clitoral stimulation? King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Learning to enjoy clitoral stimulation 20 King, Human Sexuality Today, 5/e © 2005 by

Treatments for female orgasmic disorder l l l Education and counseling regarding normal female sexual response. Sensate focus exercises to relieve anxiety. Techniques before and during intercourse that allow for more direct stimulation of the clitoris. – – 21 This isn’t “cheating” – would anyone expect a man to reach orgasm without stimulation of his penis? Woman-on-top coital position King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

With practice, a woman may be able to reach orgasm without manual stimulation, by

Female sexual pain disorders (1) l Dyspareunia – genital pain associated with sexual intercourse – – 23 First, is there sufficient vaginal lubrication? If only a certain position hurts, stop it! Inflammation of the vestibular bulbs (treated with surgery) is very common. Endometriosis, yeast infection, Bartholin’s gland infection, urinary tract infection, allergies to semen or spermicides can all cause sexual pain. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Female sexual pain disorders (2) l l 24 Vaginismus – involuntary contractions of the muscles surrounding the outer 1/3 of the vagina; occurs in about 2% of women. Psychological causes Learning to relax the muscles is attempted after dealing with the underlying causes. Sensate focus exercises are followed by systematic desensitization by gradual dilation of the vagina. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Hypersexuality (1) l l l 25 Most therapists object to the term “sexual addiction” because there is no evidence of any physical addiction. They prefer the term, “sexual compulsion. ” Sexual behavior is engaged in repeatedly and compulsively in order to provide escape from psychological discomfort. The behavior results in little or no emotional satisfaction. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall

Hypersexuality (2) l l 26 Hypersexuals may engage in either paraphilic (see chapter 16) or “normal” sexual behaviors. Likely cause – intimacy dysfunction during childhood, often due to neglect or abuse. Psychotherapy plus anti-depressant or antianxiety medications have been helpful. Internet sex addiction is very easy compared to other hypersexual behaviors. “Sex” is the most frequently searched topic on the internet. King, Human Sexuality Today, 5/e © 2005 by Prentice Hall