Linda Weiner, MSW, LCSW

1. COUNSELING WOMEN WITHSEXUAL DYSFUNCTIONS:AN OVERVIEWSOCIETY OF UROLOGICAL NURSES AND ASSOCIATESANNUAL CONFERENCEFEBRUARY 25, 2012 Linda Weiner, MSW, LCSW Certified Diplomate in sex therapy, American Association of Sex Educators, Counselors & Therapists Diplomate in Sexology, American Board of Sexology Adjunct Professor, Brown School of Social Work, Washington University 7396 Pershing Avenue, St. Louis, MO 63130 314-588-8924 sextherapiststlouis@gmail.comwww.sextherapiststlouis.com

2. I. Categories: • DSMIV-TR Sexual Dysfunctions include: • Desire • Arousal • Orgasmic • Pain Disorders

3. II. Etiology: • Sexual Dysfunctions can arise from: • Psychological • Family of Origin • Early Negative Experiences • Personality • Trauma • Relational Concerns • Medical Issues • Drugs/Medications • or a combination

4. III. Subtypes: • Assessment includes a description of whether the condition has been: • Lifelong • Acquired (onset) • Generalized • Situational (context)

5. IV. Description of Disorders • 1. Sexual Desire Disorders • Hypoactive Sexual Desire Disorder: • Deficiency or absence of sexual fantasies and desire for sexual activity which causes distress or interpersonal difficulty, not due to a medical condition, another Axis I disorder, or drugs/meds. • Sexual Aversion: • Avoidance of and phobic reaction to anticipation of genital contact with a sexual partner causing distress not accounted for by another Axis I disorder.

6. 2. Sexual Arousal Disorders • Female Sexual Arousal Disorder: • Persistent or recurrent inability to attain or maintain to completion of the sexual activity adequate lubrication/swelling response of sexual excitement. • Distress; Not better accounted for by another diagnosis and/or lack of feelings of subjective pleasure. (check on this)

7. 3. Orgasmic Disorders • Female Orgasmic Disorder: • Persistent or recurrent delay or absence of orgasm following a normal sexual excitement phase. • Distress; No other Axis I cause.

8. 4. Sexual Pain Disorders • Dyspareunia • Recurrent or persistent genital pain associated with intercourse. • Distress; • Not caused by vaginismus • Lack of lubrication • Another Axis I disorder • Substance • Medical condition

9. Vulvodynia (a type of Dyspareunia) • Burning pain • Swelling • Redness at the vulvor vestibule inside the labia minora

10. Vestibulodynia (a type of Dyspareunia) • Pain with touch to the vestibule (where the outside of the skin meets the vagina)

11. Vaginismus • Recurrent/persistent involuntary spasm of the outer third of the vagina interfering with intercourse • Distress; • Not due to a general medical condition • No other Axis I cause

12. V. Intake Process in Counseling • Assessment of Sexual Dysfunctions • Medical • Psychological • Relational • Societal/Cultural • Generalized/Situational • Onset • Individual and Couple Strengths and Challenges

13. Treatment Strategies • Patient Education • Educating patients about what is “normal” • Education about normal anatomy • Physiologic basis of sexual functioning • Lifestyle changes such as stress management, exercise, relaxation and diet

14. Treatment Strategies • Medical and allied health practitioner coordination • Medications, hormones, hormone creams and phosphodiesterase inhibitors

15. Treatment Strategies • Relationship and communication skills counseling and sensate focus • Sex Therapy

16. Definition of Sensate Focus Sensate Focus is a hierarchy of structured touching and discovery suggestions.

17. Rationale for the use of Sensate Focus • Reduction of work, pressure, expectation, anxiety, negative conditioning • Reduces spectatoring or watching one’s experience, and teaches mindfulness • Reactivates the senses and builds sexual energy • Engenders feelings of closeness and intimacy • Builds feelings of closeness • Diagnostic and restorative

18. Difficulties with the Concept of • “pleasuring” in Sensate Focus Sensate Focus I: Developed to address sexual dysfunctions, not to increase sexual competency and explore eroticism. Sensate Focus II: Developed to encourage feedback about what feels good and what might be fun to explore. • To give and receive information and pleasure to one another • To take greater risks and indulge themselves in playful, spontaneous, eyes wide open and erotic interactions • To be their evolving sexual selves with one another with respect to their personalities, erotic interests and comfort zones Meshing of touching for self with erotic feedback from partner keeping you on track! If you are touching them for self and they turn on, you’ll keep it going because it’s erotic to you!

19. X. The Masters & Johnson Protocol for • Sensate Focus Sensate Focus Instructions Description – general • The “identified patient” initiates the touching 1-2x weekly for about 15-30 minutes. Clothing is optional at first. Clients are asked to non-verbally TOUCH FOR SELF, focusing on their sensations of temperature, texture and pressure, with no goal for arousal/response, using only hands and fingers. The partner being touched protects the touching partner by non-verbally communicating if something is physically or psychologically UNCOMFORTABLE. Both partners refocus on sensation when distracting thoughts impinge. Touch long enough to get over any discomfort (5-15 minutes), but not so long as to be tired or bored. Then switch. Begin in any comfortable position and change positions as you wish.

20. XI. The Modified Masters & Johnson • Protocol for Sensate Focus Instructions for Clients: Sensate Focus No intercourse, oral sex or mutual masturbation is suggested. If you choose to be sexual together – please take a “tea break” first. • Arrange for one hour of complete privacy when you are not exhausted. • Please limit alcohol/drug use unless discussed (sometimes Viagra, Cialis, Levitra suggested). • Set the mood for relaxation. • Clothing off, some lighting on.

21. XII. The Masters & Johnson Protocol for Sensate Focus The General Sequence of Sensate Focus Suggestions is: • Breasts and genitals off limits • Breasts and genitals on limits, subsequently with oil, powder or lotion • Mutual touching; with hand riding • Clinical look • Partner astride, playing outside • Insertion without movement • Insertion with movement • Fantasy, variation and play (Sensate Focus II)

22. References References, The Lost Art of Sensate Focus • Masters & Johnson Human Sexual Inadequacy • Thomas Maier, Masters of Sex • Staci Haines, The Survivor’s Guide to Sex • Linda de Villers & Heather Turgeon, The Uses and Benefits of “Sensate Focus” Exercises in Contemporary Sexuality, Vol 39, Nov 2005 • David Schnarch, Constructing the Sexual Crucible • Shmulsy Boteach, The Kosher Sutra • Barry McCarthy, Rekindling Desire • Helen Singer Kaplan. The Illustrated Manuel of Sex Therapy, Second Edition