Treatment of Sexual Dysfunction (SD)

1. Treatment of Sexual Dysfunction (SD) RoseMary Beitia Appalachian State University

2. Definition • “Sexual dysfunction is characterized by disturbance in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difficulty” – APA 2000 • This conceptualization of the “sexual response cycle” has evolved greatly over the past half century • Original William Masters & Virginia Johnson (1966) model of the “sexual response cycle” consisted of: • Excitement • Plateau • Orgasm • Resolution • Limited to brief intervention, long-term efficacy not substantiated, more specialized approaches needed (APA, 2000; McAnulty, & Burnette, 2006; Segraves, & Althof, 1998)

3. Sexual Response Cycle • Kaplan (1974) consisted of the following: • Desire • Excitement • Orgasm • Limited focus on physical arousal • According to systemic models the sexual response is the result of interaction between the following 3 domains: • Biological • Psychological • Relational (Segraves, & Althof, 1998)

4. A Brief History Rise of behavioral techniques involving systematic desensitization pairing relaxation & exposure methods 1970 - 1974 1900-1950 1950-1970 Psychoanalytic approach -sexual problems were linked to unresolved, unconscious conflicts during specific developmental periods Masters & Johnson initiated a more biopsychosocial model consisting of physical examinations, history of dysfunction, education, behavioral & cognitive tasks, interpersonal issues; proposed brief, problem focused solutions

5. A Brief History continued Helen Singer Kaplan’s The New Sex Therapy integrating M&J approach with psychodynamic methods 1980 - current 1974-1980 Mid-1980’s dawned the medicalization era; including combined CBT & pharmaceutical treatments; but has not had as significant an impact on female sexual dysfunction Neo-Masters & Johnson Era

6. Phases of the Sexual Response As a function of “normal” sexual responding: • Desire: Defined by an interest in being sexual and in having sexual relations by oneself or with an appropriate partner • Arousal: Refers to the physiological, cognitive & affective changes that serve to prepare an individual for sexual activity (e.g., penile tumescence and erection, vaginal lubrication, expansion & swelling of vulva) • Orgasm: Refers to climatic phasewith release of sexual tension and rhythmic contraction of the perineal muscles and reproductive organs: • Sense of ejaculatory inevitability in males followed by ejaculation • Contractions in the outer third of the vagina • Resolution: Refers to sense of muscular relaxation and general well-being; men are physiologically refractor while women may respond to further stimulation (APA, 2000)

7. Male Sexual Response

8. Physiological indicators of arousal Vasocongestion in the pelvis Vaginal lubrication Labia minora may darken Clitoris hardens leading the vaginal hood (prepuce of clit) to appear enlarged Causing the vulva to lengthen and widen Areola hardens & nipples become erect Breast tumescence Female Sexual Response

9. Experts on female anatomy contend that there is an area in the outer third of the vagina, also responsible for orgasm, the Grafenberg or the G-spot Located in the front of the body, 2” from entrance of the vagina Clitoral vs. vaginal orgasm?? Female Sexual Response

10. DSM-TR Diagnoses *Focus of the presentation • Sexual desire disorders • Hypoactive Sexual Desire Disorder (HSDD); Male/Female • Sexual Aversion Disorder (SAD) • Sexual arousal disorders • Female Sexual Arousal Disorder (FSAD) • Male Erectile Disorder • Orgasmic disorders • Female Orgasmic Disorder (Inhibited Female Orgasm) • Male Orgasmic Disorder (Inhibited Male Orgasm) • Premature Ejaculation (APA, 2000)

11. DSM-TR Diagnoses cont’d • Sexual pain disorders • Dyspareunia (not due to GM condition) • Vaginismus (not due to GM condition) • Sexual Dysfunction Due to GM Condition • Substance-Induced Sexual Dysfunction • With impaired desire • With impaired arousal • With impaired orgasm • With sexual pain • With onset during intoxication • Sexual Dysfunction Not Otherwise Specified (NOS) (APA, 2000)

12. Subtypes • Indicate onset: • Lifelong Type • Acquired Types • Context: • Generalized Type • Situational Type • Etiological Factors: • Due to Psychological Factors • Due to Combined Factors (APA, 2000)

13. Other Sexual Dysfunctions • Paraphilias • Exhibitionism • Fetishism • Frotteurism • Pedophilia • Sexual Masochism • Sexual Sadism • Transvestic Fetishism • Voyeurism • Gender Identity Disorders • NOS • Dysphoria (APA, 2000)

14. Desire Disorders Hypoactive Sexual Desire Disorder (HSDD) • DSM-IV Criteria: • Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity • Not better accounted for by Axis I disorder (e.g., depression, anxiety) and not due to physiological effects of a substance (e.g., alcohol, prescription medications) Sexual Aversion Disorder (SAD) • DSM-IV Criteria : • Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner. • Not better accounted for by Axis I (e.g., PTSD)

15. Desire Disorders General Understanding: • Highly comorbid (e.g., depression, anxiety, GMCs) • Quantified in terms of sex interest, rather than actual sexual behavior Clinical Presentation: • Negative/ indifferent affect • Disparity in relationship member desire • Possess social expectations of “normal” sexual behavior • “Take it or leave it” attitude • Lack of attraction to partner • May be associated with trauma • Avoidance of sexual activity • When avoidance is accompanied by extreme aversion of genitals, SAD diagnoses may be more accurate • Onset • Disorder present in all situations (e.g., global vs. specific) • “Treatment resistent” (Wincze,& Carey, 2001)

16. Arousal Disorders Male Erectile Disorder • DSM-IV Criteria : • Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection • Not better accounted for by Axis I disorder, substances or GMC Female Sexual Arousal Disorder (FSAD) • DSM-IV Criteria: • Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate lubrication-swelling response of sexual excitement • Not better accounted for by Axis I, substances, or GMC

17. Arousal Disorders General Understanding: • Absence of or reduced arousal response • Components: • Physiological (e.g., erectile dysfunction, vaginal dryness) • Cognitive (e.g., attention to erotic stimuli, cues, fantasies) • Affective (e.g., subjective sense of excitement, novelty, romance) • Anxiety negatively correlated with affective & cognitive components; although physiological (genital) responses may be observed • Differential diagnosis between diminished subjective arousal (affective & cognitive) and low sexual desire (Wincze,& Carey, 2001)

18. Arousal Disorders Clinical Presentation: • Factors influencing Male Erectile Disorder • Physiological: partial or complete inability to attain, or maintain an erection sufficient for intromission and sexual activity • Some men report full erection potential during non-coital stimulation (e.g., masturbation, nocturnally during REM sleep) • Psychosocial: • Performance anxiety • Embarrassment • Depression, increased suicidality • Negative affect in presence of erotic stimulation • Sensitive to feelings of demand • Underestimate erectile response • Result of chronic & acute stress (Wincze,& Carey, 2001)

19. Arousal Disorders Clinical Presentation: • Factors influencing Female Sexual Arousal Disorder (FSAD) • Physiological: • lack of responsiveness to sexual stimulation (e.g., vaginal lubrication, swelling of vulva) • Psychosocial: • Anxiety, worry, fear • Depression • Low self esteem • Performance anxiety • Shame • Sexual abuse • Marital difficulties • Poor communication with partner • Negative affect toward sex during adolescence • Inaccurate subjective appraisal of arousal • Reaction milder than males with ED (Wincze,& Carey, 2001)

20. Orgasmic Disorders in Men Orgasmic Disorder (Inhibited Male Orgasm) • DSM-IV Criteria: • Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration • Not better explained by Axis I, substance, GMC Premature Ejaculation • DSM-IV Criteria: • 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 affecting duration of excitement phase, such as age, novelty of new partner and sexual situation and recent frequency of sexual activity • Not due exclusively to direct effects of substance (e.g., opioid withdrawal)

21. Orgasmic Disorders in Men Male Orgasmic Disorder • Also referred to as “retarded ejaculation” • Refers to physiological inability to achieve orgasm despite desire, arousal & stimulation • Ejaculation has 3 stages: • Emission • Bladder neck closure • Ejaculation proper • Not “retrograde ejaculation” Premature Ejaculation (PE) • Three core components: • Short ejaculatory latency • Lack of control over ejaculation • Lack of sexual satisfaction • Perception of how long it takes for the “average” man to ejaculate varies between 7-14 minutes • Vary across countries, Germans, 7 mins; Americans, 14 mins • Most commonly used index of PE is intravaginal ejaculatory latency time (IELT) from 1-5 minutes (Wincze,& Carey, 2001; DeRogatis, & Burnett, 2007)

22. Orgasmic Disorder in Women Female Orgasmic Disorder • DSM-IV Criteria: • Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in type of stimulation that triggers orgasm. • Diagnosis based on clinician judgment that orgasmic capacity is less than reasonable given age, sexual experience, adequacy of sexual stimulation • Not better accounted for by Axis I, substance, GMC

23. Orgasmic Disorders in Men & Women General Understanding: • Clients present with concerns about absence of coital, multiple or synchronous orgasms • Continuum model from mild to extreme • Clients tend to compare themselves to unrealistic ideals, creating anxiety and perpetuating dysfunction • “Maybe I’m just dead down there” • Media influence of patient perceptions emphasizing importance of psychoeducation (e.g., myths of sexual encounter, male & female sexuality) *Absence of orgasm during intercourse without direct clitoral stimulation is not uncommon in women (Wincze,& Carey, 2001)

24. Orgasmic Disorders Clinical Presentation: • Factors Influencing Female Orgasmic Disorder • Physiological: • Inability to achieve orgasm • Psychosocial: • Sexual knowledge • Levels of sexual desire • Sexual fantasizing • Sexual attitude; confidence • Religious/cultural beliefs • Body image • Self-esteem • Social norms can heavily influence orgasmic function • Morokoff (1978) found that birth during the 20th century was related to higher frequency of orgasm • Lifelong or acquired (Wincze,& Carey, 2001)

25. Prevalence • Many challenges to estimating the prevalence of sexual disorders • Methodological issues • Utilizing clinical verses non-clinical criteria • Vague diagnostic descriptions (e.g., definition of premature ejaculation, low sexual desire v interest) • Lack of universal/agreed upon diagnostic system • Sexual problem must be perceived as bad • Effects of social norms • Availability of regular sex partner • Selection bias in samples (formerly patients presented to hospitals, clinics, GPs) • Comorbidity (sexual problem may be secondary to primary psychological or medical issue)

26. Prevalence

27. Prevalence & Comorbidity HSDD • For men & women concurrence rates of HSDD with other SDs is an estimated 41% and 47% • *Poor dyadic adjustment most consistently associated with HSDD • WISoH&S data investigated menopause & SD in women • Low sexual desire (LSD) was 16% prevalent in premenopausal women • 29% in surgically menopausal 20-49 • 46% in surgically menopausal 50-70 • 42% natural menopause Arousal Disorders • Overall, prevalence range of ED is 10-20% • Presence of ED increases with age and poor medical status • IN HPFS survey data, ED increased from 33% to 61% in men above 70 Orgasmic Disorders • Prevalence of PE is approximately 30% across age groups (GSSAB) • Highest rates reported in Southeast Asia (30.5%) & lowest in Middle East (12.4%) • Found to be significantly correlated with Social Phobia Other disorders • Prevalence of pain disorders 1%-21% in women (DeRogatis, et al., 2007; Graziottin, 2007)

28. Prevalence & Comorbidity • High rates of comorbidity with anxiety & depression • Loss of libido or decreased sexual desire has been reported in up to 72% of patients with unipolar depression; 77% with bipolar • General medical conditions associated with SD • Men: diabetes, cardiovascular disorder, hypertension, dyslipidemia, obesity, smoking, prostate disorders • Women: chronic illness, poor general health status, such as diabetes, breast cancer, lower urinary tract infection, surgical removal of ovaries, multiple sclerosis • Risk of SD is increased by smoking and excessive alcohol use; GMC may further increase risk • SD consistently reported in patients taking SSRIs • Estimates range from 10%-65% (DeRogatis, et al., 2007)

29. Specific Etiologies • Common factors of low sexual desire in men & women: • Boredom • Lack of physical attraction to partner • Negative or faulty attitudes • Dissatisfaction with partner sexual activity • History of sexual abuse • Common factors of arousal disorders in men & women: • Health status • Performance anxiety • Negative affect: • Suppression and expression of anger correlated with higher rates of ED • Organic theories of PE • Penile hypersensitivity - lower ejaculatory threshold, reached more rapidly • Hyperexcitability ejaculatory reflex – faster emission phase • Genetic predisposition • Central 5-HT receptor sensitivity – lower 5-HT transmission, receptor hyposensitivity • Religion & culture may influence sexual functioning, all three stages (Metz, & Pryor, 2000; Wincze, Bach, & Blume, 2008; Wincze,& Carey, 2001)

30. Etiology A Systemic Perspective • According to the systemic and “biopsychosocial” model sexual response is the result of interaction between the following 3 domains: • Biological – physiological mechanism that prepare and enable genital response • Psychological – affective and cognitive predispositions and interpretations that sustain response • Relational – dyadic interactions which promote intimacy, meaning and mutually satisfying outcomes • *Multifactorial contribution of biological, psychological, psychophysiological and interpersonal factors are often difficult to distinguish

31. Etiology as a Function of Risk Factors • Causes are multiply determined • Risk factors • Age • Overall, SDs increase with age • PE decreases with age • Inverse relationship between age & distress brought on by SD • 65% American women (20-29 yrs) LSD w/ distress; 22% (60-70yrs) w/o distress • 67% European women (20-29yrs) LSD w/ distress; 37% (60-70yrs) w/o distress • Health status • Genetic inheritance (Type 1 diabetes) • Hormone deficiency • Lifestyle (poor diet, low activity level) • Excessive substance use • Dyadic adjustment • Decreased sexual knowledge • CSA Predisposing factors (genetics) X Precipitating factors (coping w/ stressful life events) X Maintaining Factors (poor dyadic adjustment) = Diathesis Stress (DeRogatis, et al., 2007; Wincze,& Carey, 2001)

32. Special Considerations Sexual Minorities Factors influencing impaired sexuality in homosexuals • Psychological issues accompanying choice to “pass” as straight • Gender identity issues • Identity & “coming out” problems • Sexual expression • Emerging sexual scene for lesbians influenced more by gay men than heterosexual females • Gay male community engaged in controversy over sex • Barebackers begun backlash against promotion of safe sex, labeling campaign members “condom nazis” • Nonmonogamy • High frequency of desire discrepancy/inhibited sexual desire in lesbians & sexual script issues • “Sex addiction” (Leiblum, & Rosen, 2000)

33. Treatment Approaches • Sex Therapy (CBT + Master’s & Johnson) • Pharmacotherapy & Medical Devices • A Systemic Approach • Bibliotherapy

34. Sex Therapy Treatment length • Traditional Master’s & Johnson • Daily sessions 2- or 3-week period (up to 15 sessions) • Current CBT therapy course may vary based on client/couple • Some clients benefit from only 3-4 sessions of psychoeducation • Otherwise, treatment is once a week for 10-12 weeks • Couples strongly encouraged to participate together

35. Assessment : Sessions 1-3 • Goals: • Establish rapport • Obtain a general description of sexual problem or problems • Discuss life concerns and current stressors • Determine nature & causal factors: • Lifelong vs. acquired • Generalized vs. situational • Due to psychological or combined factors • Obtain general psychosocial history • Determine whether sex therapy is appropriate • Therapist must remain aware of process concerns and how they affect relationship building • Are you comfortable addressing sexual issues? • Differences between client & therapist (e.g., age, gender) • Maintain firmly established boundaries • Important to maintain objectivity and remain sensitive with matters of religion or culture (e.g., devout Catholic with concerns about birth control)

36. Assessment : Sessions 1-3 • Sample structure: 1. **Begin with nonthreatening demographics (e.g., age, employment & marital status) • Set up safe and comfortable environment • Individual/couple format • Assess what partners are comfortable communicating with partner present 2. Continue with open-ended questions while keeping the client directed on presenting concern 3. Obtain a psychosocial & sexual history • Family structure, orientation • Assess for childhood abuse or trauma • Assess history and current peer relationship status, self esteem, dating experiences, body image • Current sexual functioning

37. Assessment : Sessions 1-3 4. Obtain a brief medical history (e.g., childhood diseases, surgery, medical care) • Current Health Status • Diet • Exercise • Maladaptive lifestyle habits (e.g., smoking, drinking) • General Medical Conditions associated with SDs • Hormonal disturbance (e.g., menopause) • Abnormally low testosterone levels (e.g., tx for prostate cancer) • Metabolic syndromes (e.g., diabetes, hypertension, hyperlipidemia, obesity) • Glaucoma • Vascular conditions (e.g., CHD, ischemic heart disease, angina) • Epilepsy • Assess exposure to STDs * In the event of a medical consult therapist may act as a liaison

38. Assessment : Sessions 1-3 5. Be sensitive to any potential covert issues 6. Provide client with a second opportunity to share concerns 7. When working with couples, at this point you would interview the second partner individually • Therapists commonly have each partner complete assessment measures while interviewing the other • Allows therapist to develop conceptualization of independent partner difficulties 8. Later the therapist will reunite the couple and review assessment measure outcome • *Important to address dyadic sexual adjustment 9. *Integration of information • Acquired vs. lifelong • Determine appropriateness of sex therapy 10. *Develop goals reasonable with client/couple • Avoid goals related to performance (e.g., firm erections)

39. Couple Distress • SD sometimes secondary to couple distress • Treatment may be postponed depending on severity • Accurate assessment of causal sequence of couple distress & SD • When couple distress is the cause of SD, resolution of these problems take precedent • Determine SD treatment appropriateness • Make referral to marriage counselor, individual therapist, physician, etc. (Wincze, Bach, & Blume, 2008)

40. Wincze & Barlow Model (1997) Medical Indications Medical Stabilization Sex Therapy Minimal Couple Distress Assessment & Integration of Information One partner Sexual problem Individual Sex Therapy Possible Couple Therapy Medical Evaluation One partner Psychological problem Individual Psychotherapy Possible Couple Therapy Psychosocial Evaluation Significant Couple Distress Couple Therapy Possible Couple Therapy Substance Abuse Substance Abuse Tx Couple Sex Problems Only

41. Assessment Measures • Indices of Sexuality & Sexual Functioning: • Men • International Index of Erectile Function (15 item) • Erection Hardness Scale (1 item) • RigiScan • Women • Brief Index of Sexual Functioning for Women (BISF-W) • Derogratis Sexual Functioning Inventory (DSFI) • Sexual Self-Efficacy Scale for Female Functioning (SSES-F) • Female Sexual Function Index (FSFI) • Profile of Female of Sexual Function (PFSF) • Structured Clinical Interview for Gynecologists Caring for Women With Sexual Dysfunction • Photoplethysmograph

42. Assessments Measures • Both Men & Women: • Sexual Desire Inventory • Cues for Sexual Desire Scale (CSDS) • Dyadic Adjustment Scale (DAS) • Inventory of Dyadic Heterosexual Preferences (IDHP) • Sexual Interaction Inventory • Golombok Rust Inventory of Sexual Satisfaction (GRISS) • Sexual Opinion Survey (SOS) • Sexual event logs • Indices of Psychosocial Functioning • BDI • BAI • Symptom Checklist 90; Brief Symptom Inventory (53-item abbreviated version) • Suicide risk assessment • Indices of Health Status • Medical History Form

43. Psycho-“sex”-education Topics to be addressed: • Anatomy (diagrams, models) • Physiology • Unrealistic expectations of self & sexual encounter • Address myths of sexuality • Level of detail necessary for education may vary based on client • Continual throughout course of therapy (Wincze, & Carey; Wincze, Bach, & Blume, 2008)

44. Myths of male sexuality A real man is not into sissy stuff like feelings and communicating. A real man performs in sex. Sex is centered around a hard penis and what is done with it. Real men do not have sexual problems Focusing more intensely on one’s erection is the best way to get an erection Myths of female sexuality Sex is only for women under 30. All women have multiple orgasms. Pregnancy and delivery reduces women’s responsiveness. If a woman cannot have an orgasm quickly and easily, there is something wrong with her Feminine women do not initiate sex or become wild and unrestrained during sex. Myths of Sexuality

45. Myths of Sexuality cont’d • Myths of Male & Female Sexuality • We are liberated and comfortable with sex. • All touching is sexual or should lead to sex. • Sex is intercourse. • Good sex requires orgasm. • People in love should automatically know what their partners desire. • Fantasizing about someone else means a person is not happy with what he/she has. **We are all susceptible to these false assumptions and seemingly silly generalizations about human sexuality.

46. Universal CBT Tools 1. Cognitive Restructuring • Goals: • Identify cognitions and beliefs about sexual encounter • Normalize feelings of anxiety, frustration, disappointment • Identify possible precipitating factor leading to acquired vs. life-long SD • Challenge negative thoughts • Strategies to challenging negative cognitions: • Provide education • Stick to the facts • Decatastrophize • Useful across various SDs & integrated throughout treatment course

47. Universal CBT Tools 2. Stimulus Control • Goals: • Method involves manipulation of environmental factors to facilitate a given behavior or outcome • Creating conditions conductive to healthy sexual functioning • Methods: • Generating lists of conditions or factors which positively & negatively affect arousal, such as: • Setting • Mood (self & partner) • Atmosphere • Performance concerns • Faulty beliefs • *Maximize positive factors & minimize negative factors

48. Sex Therapy Desire Disorders Primary Goals & Strategies: • Communication Training • Cognitive Restructuring • Education • Behavioral Intervention

49. Sex Therapy Desire Disorders Integration of Cognitive, Behavioral, Systemic Therapy • Stage 1: Affectual Awareness • Becoming aware of neg. attitudes/beliefs about sex and/or partner • Create a set of lists (at least 5 items per list) • Benefits for lower drive individual gaining a higher level of sexual desire • Benefits for relationship • Risks/costs of increasing sexual desire to self & relationship • Helps therapist & client gain understanding of: • Explore fears of gaining sexual desire • Influence of low desire on individual identity & within relationship • Therapist may also explore emotions related to “fear” lists • Role-play

50. Sex Therapy Desire Disorders • Stage 2: Insight and Understanding • Therapist explains multicausality of SD • Clients consider initiating and maintaining causes of low sexual desire • Asked to identify common individual factors • Consider power imbalance in relationship • Stage 3: Cognitive and Systemic Therapy • Therapist and clients consider how negative thoughts and beliefs mediate low sexual desire • Develop healthy coping mechanisms