Psychosexual Problems Emma Mathews Psychosexual therapist Specialist treatments

Psychosexual Problems Emma Mathews Psychosexual therapist

Specialist treatments are provided for: Erectile dysfunction Premature or other ejaculatory disorders Orgasmic difficulties Vaginismus and dyspareunia (genito-pelvic pain/penetration disorder) Problems of libido (reduced or excessive sex drive/interest) Sexual arousal problems Specific sexual fears or phobias

Liaison with other services Urology Dermatology Reproductive Medicine Endocrinology Gynaecology Sexual Health Mental Health Physiotherapy Psychotherapy and Psychology

Pre-referral screening – female disorders

Pre-referral screening – male disorders

Treatment options Assessment and history-taking Education and normalisation Referral to specialist services if appropriate Sensate focus programme Specific behavioural tasks (self-exploration, vaginal trainers) Working with cognitions

DSM

Revised Diagnostic Criteria Applicable to All Diagnoses Unlike its predecessor, the DSM-5 includes the requirement of experiencing the disorder 75%-100% of the time to make any diagnosis of sexual disorder, with the notable exception of substance or medication-induced disorders. There is now a required minimum duration of approximately 6 months. The disorder must be deemed to have caused significant distress.

Revised Diagnostic Criteria Applicable to All Diagnoses The disorder should not be better explained by a “nonsexual mental disorder, a consequence of severe relationship distress (e. g. , partner violence) or other significant stressors”. The disorder can be described as mild, moderate or severe.

Revised Diagnostic Criteria Applicable to All Diagnoses A new group of criteria called “associated features” was also introduced: 1) partner factors (e. g. , partner sexual problem; partner health status) 2) relationship factors (e. g. , poor communication, discrepancies in desire for sexual activity) 3) individual vulnerability factors (e. g. , poor body image; history of sexual or emotional abuse), psychiatric comorbidity (e. g. , depression; anxiety), or stressors (e. g. , job loss; bereavement) 4) cultural or religious factors (e. g. , inhibitions related to prohibitions against sexual activity or pleasure; attitudes toward sexuality) 5) medical factors relevant to prognosis, course, or treatment

Erectile Dysfunction

DSM-V Definition A recurrent inability to achieve or maintain an adequate erection during partnered sexual activities. It may occur in 7% - 18% of the male population at some point throughout their lifetime.

Primary erectile dysfunction Areas explored: Early family experiences Fears about being taken over Lack of comfort with personal sexuality Check for adolescent fantasies Investigate medical factors (e. g. tight foreskin, pain on ejaculation Fears about penetration

Predisposing factors Male esteem invested in sexual performance Latent homosexual orientation Early family experience Traumatic first experience Religious taboos Power – mother/father figures

Secondary erectile dysfunction Areas explored with young people: Recent loss (death, divorce, redundancy, etc) Family conflicts Boredom with the present relationship Recent operations or illnesses Failures or lost achievements

Precipitating factors Recent loss Ageing Traumatic experience Alcohol abuse Failures Infidelity Depression Premature ejaculation Sexually compulsive/addictive behaviours

Maintaining factors Anxiety, worry, spectatoring Threatening partner Cycle of anxiety – fear of failure Poor communication Loss of role Depression Guilt/shame

Erectile Dysfunction Maintenance Model

Treatment options include: Psychosexual education Wax/wane, Male is asked to practice this first on his own with masturbation. Then joint tasks with his partner are incorporated. There are pharmacological treatment options, PDE 5 type inhibitors. Also injections, gel, penis pumps and penis implants.

Premature Ejaculation

DSM-V Definition Consistently ejaculating within one minute or less of vaginal penetration. Can begin with the onset of a male’s sexual experience, or later in life, after a period of normal sexual function

Premature Ejaculation Specifiers: Lifelong- has been experienced since the first intercourse attempt. Acquired- has appeared after a period of sufficient orgasmic latency. Generalized- occurs with different partners and situations. Situational- only occurs with a specific partner and situation.

Premature Ejaculation Severity : Mild - occurs 30 -60 after vaginal penetration Moderate - occurs 15 -30 seconds after vaginal penetrations. Severe - occurs prior to penetration, upon penetration, or < 15 seconds after vaginal penetration.

Premature Ejaculation Prevalence: 1% to 3% among men in the US. However, there are cultural differences apparent, as another source indicates a much higher prevalence among Greek men at 20%-30% Comorbidity: May be comorbid with erectile dysfunction.

Premature Ejaculation Risk Factors Anxiety disorders, specifically social anxiety. PTSD due to sexual trauma may also be a factor. Discomfort with sex or ones body from trauma, can produce anxiety and a need to complete the sex act as quickly as possible.

Other Predisposing factors Religious restrictions Negative messages Restrictive upbringing, dominating parent of either sex, rigid, disapproving, demanding impossible goals affecting confidence

Precipitating factors High expectations regarding performance First experience – significant, fear of discovery Learned behaviour Alcohol leading to one failure, leading to repeated alcohol consumption to cope with anxiety

Maintaining factors Anxiety, guilt, inability to, difficulty in communicating Lack of trust/lack of confidence Impaired self-image/low self-esteem Need to punish self/women Partner fit – with a partner who does not enjoy sex, therefore invested in getting it over quickly May be combined with female sexual interest/arousal disorder

Treatment options include: Psychosexual education Stop/start, where thrusting is stopped when the man feels ejaculation is imminent, or the squeeze method, where pressure is applied behind the glans until the urge to ejaculate passes. Male is asked to practice this first on his own with masturbation. There are pharmacological treatment options, such as SSRI’s which frequently have the side effect of delaying orgasm. Topical anesthetic such as 7. 5% benzocaine can reduce penile sensitivity and delay ejaculation

Delayed Ejaculation

DSM-V Definition Sexual disorder in which a man is unable to ejaculate during sexual activity, specifically after 25 minutes to 30 minutes of continuous sexual stimulation. This disorder is also known as delayed orgasm, retarded ejaculation, or inhibited ejaculation.

Symptoms of Delayed Ejaculation An inability to climax during sex with a partner about 75 -100% of the time, with either a delay in ejaculation or infrequent or absent ejaculation. The ejaculatory delay is not considered pathological if it is due to a deliberate effort to prolong sexual activity.

Delayed Ejaculation 1. Lifelong - commencing at the onset of sexual activity 2. Acquired - starting after a period of normal sexual function 3. Generalized - ejaculation is delayed or not possible in either solitary or partnered sexual activity 4. Situational - a man can ejaculate while masturbating, but not with a partner, or during specific sex actse. g. , oral sex but not vaginal intercourse 5. Degrees of severity - mild, moderate, or severe

Prevalence 75% of men report always reaching orgasm during sex This is the least common male sexual complaint and most poorly understood male sexual dysfunction Some sources believe the prevalence is higher than reported and it can be speculated that this is due to the perception that delaying orgasm is a desirable quality and a sign of sexual maturity, and self control.

Risk Factors (young men) IMS (Ideosyncratic Masturbation Style) Men may masturbate with a speed and pressure which their partner may not be able to duplicate correctly. Fear impregnating a woman Excessive exposure to pornography - stimuli overexposure and desensitization process, increased amounts of stimulation is required for performance, which a partner may not be able to provide Sexual trauma is another possible cause of delayed ejaculation Cultural and religious prohibitions

Further considerations Comorbidity with major depressive disorder. SSRIs can cause delayed ejaculation, this typically resolves after several weeks on the medication. A number of medical conditions can precipitate delayed ejaculation, such as traumatic surgical injury to the groin or genitals, multiple sclerosis, or diabetes

Treatment Objectives: To sensitise the male to the pleasurable sensations he is suppressing To maximise stimulation and minimise inhibition To learn to enjoy pleasurable erections To build trust and reduce guilt and shame To reduce spectatoring To reduce anxiety and build confidence

Male hypoactive sexual desire disorder

DSM-V Definition The person has low desire for sex and absent sexual thoughts or fantasies. The patient must experience the disorder from 75% to 100% of the time for six months or longer. On most occasions the patient reports marked delay, infrequency, or absence of orgasm during sexual activity Tendency to ejaculate within one minute

Causes – biological factors Diseases of the vascular system Diseases of the nervous system Low levels of testosterone or oestrogen Heavy alcohol consumption before sex Depression History of chronic alcoholism Heavy cigarette smoking Medications, anti-hypertensives and SSRIs

Causes – psychosocial factors Rape Early childhood sexual abuse Relationship problems (anger, hostility, poor communication, underlying anxiety about relationship security) Psychological disorders (Major depression, anxiety, or panic disorder) Low physiological arousal Stress and exhaustion

Treatment Education (lifestyle, relationships, sexual response) Self focus Sensate focus with partner Mindfulness Hormonal treatment if appropriate

Prone masturbation is the habit some males have of masturbating in a face-down (prone) position. Some males who masturbate this way rub their penises against the mattress, pillow, or other bedding, or the floor. Some males lie on their stomachs and thrust into their hands. Around 90 percent of men masturbate by stroking up and down the penis with one hand.

What's wrong with masturbating prone? Puts excessive pressure on the penis, and especially on the base of the penis. These sensations are not easily replicated in conventional masturbation or in sexual intercourse. A partner's body provides more resistance than the objects a male who masturbates prone uses to thrust into or against. A vagina resists; a mattress doesn't. Prone masturbation can reduce the ability of a male to have normal sexual relations.

What's wrong with masturbating prone?

What's wrong with masturbating prone?

Sexually compulsive and addictive behaviours Behaviours are often: Opportunity induced addiction Attachment induced addiction Trauma induced addiction Problems getting an erection and ejaculating are both common consequences of sexually compulsive and addictive behaviours, especially porn addiction

Genito-pelvic pain/penetration disorder

DSM-V Definition Pelvic floor muscles around the vagina contract or tighten whenever an attempt is made to penetrate Includes one or more symptoms: Tightening of the vaginal muscle resulting in the inability to penetrate A feel of tension, pain or a burning sensation felt when penetration is attempted A decrease in or no desire to have intercourse Voluntary avoidance of sexual activity An intense phobia or fear of pain

Causes Inflammation in the vaginal muscles or an injury in the vulva. Traumatic past experience That experience may well be intense pain during childbirth. Victims of child abuse or women whose experience with intercourse has always been painful Nerves becoming over-sensitive may trigger the disorder Fear of getting pregnant or being told in childhood that “sexual desire is wrong or sex is painful”

Subtypes Early-Onset - This is a case in which the pain in the pelvic muscles has persisted and continues to do so. The first attempt at penetration led to pain, and each time thereafter the pain continued to manifest Late-Onset - The pain is experienced after vigorous physical activity of any sort. The pain may also be triggered after penetration is attempted with a penis, tampon or other objects Situational - Intensity of pain varies by situation for instance, a woman may not able to feel the pain when inserting a tampon, but may experience an intense and shooting pain when attempting penetration during intercourse. The pain may occur only during intercourse with one person and not another.

Treatment If the person has had a physical injury or inflammation in the pelvic muscles, and that is causing the pain, it can be treated with appropriate medication Depending on the intensity of the pain, surgery may be appropriate Psychosexual therapy may help a person overcome fear of pain and penetration and help them to respond to anxiety in a more appropriate way Psychosexual therapy may include use of vaginal dilators, sensate focus and self focus exercises Referral to physiotherapy Trauma focused interventions may be appropriate (TFCBT/EMDR) if a main precipitant for the problem is trauma (CSA, sexual assault, childbirth, traumatic gynaecological procedures)

e. g. around vulva/vagina Explore positive beliefs held about their anxious thoughts, i. e. why they believe staying vigilant is helpful? Attention training experiments and exercises Vaginal muscles contract Limit genital contact, various safety behaviours Avoid any genital contact, cervical smears, tampon use, etc. various safety behaviours Use cognitive restructuring techniques, explore exactly what they think will happen, what that will mean for them, what it will say about them as a person, etc. i. e. dig out the meaning… e. g. “nothing that size could fit in there, it’s tiny, I’ll split open, there will be blood everywhere, I’ll be in agony, I’ll be out of control, I’ll be embarrassed, my partner will leave me, I’ll never be able to have sex, I’m not normal, etc. ”

Triggers PERCEIVED “DANGER” Adrenaline release FOCUS ON SELF Anxiety symptoms (somatic & cognitive) rather than feelings of arousal & pleasure (somatic & cognitive)

Female sexual interest/arousal disorder

DSM-V Definition A complete lack of or significant reduction in sexual interest or sexual arousal, including three or more of the following symptoms: The absence of an interest in sexual activity A decided reduction of interest in sexual activity Absence of fantasizing or even thinking sexual or erotic thoughts Disinclination to initiate sexual encounters with her partner Exhibits no sense of pleasure during sexual acts The problem may be lifelong or acquired Severity may be mild, moderate or severe The problem may be situational – occurring only in some instances or generalized – with no apparent limitations.

Considerations Biological, social, psychological, environmental and hormonal factors Comorbidity may present as mood and/or anxiety disorders; panic attacks, depression, phobias or bipolar disorder Closeted memories or secrets can contribute to inhibited sexual enjoyment. For example, extramarital affairs or preoccupations

Masters, Johnson and Kaplan’s sexual response cycle

Female sexual response cycle (Basson, 2002)

The repercussions of GPPPD on a woman’s sexual response cycle (Basson, 2002)

Treatment Patient education including information on normal anatomy and a discussion about the physiologic basis of sexual functioning Individualized approach that may include a combination of cognitive-behavioural interventions Therapy often includes education about how to optimize the body's sexual response, ways to enhance intimacy with their partner, and recommendations for reading materials or couples exercises

Enduring sexual dysfunction after treatment with antidepressants, 5α-reductase inhibitors and isotretinoin 300 cases Rx. ISK research - David Healy, Joanna Le Noury and Derelie Mangin OBJECTIVE: To investigate clinical reports of post-SSRI sexual dysfunction (PSSD), post-finasteride syndrome (PFS) and enduring sexual dysfunction following isotretinoin International Journal of Risk & Safety in Medicine xx (20 xx) x–xx, DOI 10. 3233/JRS-180744, IOS Press https: //rxisk. org/enduring-sexual-dysfunction-300 cases/

Female student (with vaginismus) perspective… Poor sex education – young people would benefit from frank, factual sex education Women don’t know how to make themselves feel good sexually Poor body image in many young people (women and men) can result in difficulty relaxing during sex Gender issues – masculinity/femininity, confusion Media portrayal of sex and gender

International student perspective (Bengali male with premature ejaculation) No therapy available in Bangladesh, client knew of only one person who had ever accessed therapy in the capital Mental health still a taboo in Bangladesh Increased incidence of sexual trauma/rape for women, this is seen as “normal” and women are often blamed

Female student (with dyspareunia) and partner, both age 20 Partner also attended, on history taking he disclosed he had a problem with pornography use He had been using pornography since age 12 No current sexual dysfunction identified with him but he did have some difficulty relating to his distorted ideas of how women should look and perform sexually due to his excessive exposure to “porn women” which impacted on his ability to become aroused

Case Studies

Contact details emmamathewstherapy@outlook. com emma. mathews@gmmh. nhs. uk