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Treatment of Sexual Disorders

The most common sexual problems seen by therapists are different for males and females. For males the most commonly complaints are premature ejaculation and impotence or erectile dysfunction.

Premature ejaculation is orgasm occurring early in sex, cutting sexual activity short by eliminating the male's desire and ability to maintain an erection. Impotence (IMP-a-tence) or erectile dysfunction is a male's inability to sustain an erection.

The most common sexual problem for females is anorgasmia, an inability to have orgasms. Both males and female can suffer from lack of desire, which is a common cause of sexual problems in relationships.

What are the most common sexual problems?

Some people are perfectly happy without sex. On the other hand, a sudden drop-off in sexual desire, within a relationship, may indicate a problem such as depression, hormonal imbalance, or dissatis­faction with the relationship.

Frost and Donovan (2015) write, "Given that low desire is present in as many as 55% of women, it is possible that variations in desire levels may be a normative response to life circum­stances." In other words, if a woman is widowed, abused, betrayed, or in distress over a relationship, reduced desire is normal.

One implication is that therapy should focus on reasons for distress associ­ated with low desire, rather than the low desire itself. This usually ends up bringing a person's past history and current relationship into discussion, within therapy.

Carvalheira and Costa (2015) did a web-based survey of 5,255 men from three European countries. The data showed that "relational factors, particularly couple intimacy were the strongest predictors of sexual satisfaction for both heterosexual and homosexual men."

There was no difference in overall sexual satisfaction between gay and heterosexual groups, consistent with previous research. In both groups, the happiness and intimacy of a relation­ship was the best predictor of satis­factory sex.

Sexual difficulties occur occasion­ally in otherwise-normal lives. If they are persistent and interfere with normal sex life, their treatment may require therapy.

The most common sexual problems respond to simple therapies that work for the majority of people. The exception is lack of desire, which typically relates to larger issues that take time and effort to sort out.

Treatment for erectile dysfunction depends on its underlying cause. Impo­tence can be caused by illness, disease, depression, drugs such as alcohol, or difficulties in the emotional side of a relationship.

The discovery of a specialized valve system in the penis revealed that many cases of impotence were biological in nature. Rather than being due to psychological factors, they were due to narrowed arteries.

What are some causes of impotence?

Whether an erectile dysfunction problem is psychological or biological can be diagnosed by monitoring a male during sleep. If erection fails to occur during REM sleep, the cause of impotence is probably damage to the valve system rather than a psychological problem.

The drug Viagra (sildenafil), released in 1998, revolutionized treatment of impotence in older men. It works by dilating blood vessels.

Sildenafil is almost 100% effective in men who have an undamaged valve system. If it restores normal function, most men consider them­selves cured.

What are non-biological causes of impotence?

If impotence is not due to narrowed blood vessels, it is usually the result of (1) not wanting to have sex, or (2) being anxious about performing well. To help re-direct attention to sensual inter­actions, a therapist is likely to suggest the same activities between partners recommended for treatment of lack of desire in females.

That approach was called sensate focusing by Masters and Johnson (1970). It is conducted in private by romantic partners. They give each other delicate, pleasurable sensations while stopping short of intercourse.

Sensate focusing may include mutual massage, very light touching of the skin on the face, arms, and body, or hair-brushing, or back-scratching. Sensate focusing re-awakens the body's response to pleasurable sensations. This opens the door to sexual activity later when the time is right.

What is sensate focusing?

Premature ejaculation occurs when a man comes to a sexual climax (and loses appetite for further activity) too soon during sexual activity. Premature ejaculation is commonly treated with the squeeze technique developed by Masters and Johnson.

In the squeeze technique, the woman brings the man close to orgasm then squeezes the tip of his penis. This does not hurt but makes the feeling of im­pending orgasm go away. Sometimes the man will partially lose his erection.

The squeeze technique is a variation of the older stop-start technique. A leading sex therapist, Helen Singer Kaplan, preferred the stop-start technique to the Masters and Johnson technique.

In the stop-start technique, the woman stimulates the man with her hand but stops before he has an orgasm and waits for him to begin losing his erection. Then she resumes stimulation, stopping again before orgasm. This continues until the man becomes familiar with, and able to control, the act of holding off orgasm.

How is premature ejaculation treated?

Anorgasmia is the inability of some women to have orgasm. The woman-on-top position is useful in treating this disorder, because it gives a woman better control of movement and sensations. After a woman becomes capable of having orgasms in this position, she may find orgasm becomes possible in other positions.

What are other possible causes of anorgasmia?

Sometimes anorgasmia is due to vaginismus: involuntary clenching of vaginal muscles due to tension and anticipated pain. Pain during inter­course may be caused by yeast infections or lack of lubrication. If sex is painful, then avoidance conditioning occurs. Stimuli associated with sex trigger anxiety.

A woman who is tense and anticipating pain is not likely to feel aroused. If she nevertheless tries to have sex, she is unlikely to have normal vaginal lubri­cation. That aggravates the problem of pain and irritation during intercourse.

Women with vaginismus were more likely to report a history of "inter­ference" in childhood sexuality, which could include everything from severely repressive parenting to episodes of abuse. They tend to have negative feelings about their own sexuality (Reissing, Binik, Khalif, Cohen, and Amsel, 2003).

To break the cycle of pain, fear, and lack of arousal, an understanding partner should be enlisted in gradual sensitiza­tion therapy, such as sensate focusing, described above. Medical conditions such as yeast infections are treated. Extra lubrication is provided with a product designed for the purpose.

What therapy for anorgasmia did LoPiccolo and Lobitz develop?

LoPiccolo and Lobitz (1972) developed a therapy for anorg­asmia. They sug­gested that the first step was for a woman to become comfortable with her own body and familiar with the sensa­tions of orgasm. They recommended self-exploration, then masturbation, moving on to intercourse.

Unfortunately, the recommendation for masturbation makes this treatment unacceptable in some cultures. However, the success rate for this treatment is good.

A couples-related approach is to use sensate focusing. This is commonly associated with a temporary ban on intercourse during sex therapy. The idea is to get couples focused on sensations, not on performance anxiety or other factors.

The possibility of sex is removed temporarily. This allows the couple to focus on subtle, pleasing sensations of light touch, massage, and whatever else feels unthreatening and good to both partners.

Fruhauf, Gerge, Schmidt, Munder, and Barth (2013) did a meta-analysis of 20 randomized, controlled studies between 1980 and 2009–all that were avail­able–to see whether psychological interventions in sexual dysfunction were effective. Effects varied, but the highest success rates were for treatment for low sexual desire ("hypoactive sexual desire disorder") and lack of orgasms ("orgasmic disorder").

Sex Therapy gets more Complicated

In the 1980s and 1990s, the profession of sex therapy became more difficult and complicated. Problems that were easily solved, like premature ejaculation, were no longer brought to the therapist's office.

Even before the internet, widespread interest in a happy sex life lead to many best-selling publications, so the solutions to common problems became widely known. People were able to treat themselves without paying for a therapist. Family doctors became more comfort­able dispensing advice about such techniques.

What sorts of problems started being brought to therapists more often?

Sex therapists began to see a new type of client: people with problems that resisted treatment. Patients with "easy" problems like premature ejaculation and failure to reach orgasm were replaced by patients with problems like loss of sexual desire or aversion to sex.

These problems tended to involve complex social factors. For example, they might involve the lasting effects of a strict upbringing, or rape, or childhood sexual abuse, or the fading of chemistry in a marriage.

"This type of integration calls for a new breed of sex therapist, therapists trained in individual, sex, marital, and family therapy," wrote Gerald Weeks in the book, Integrating Sex and Marital Therapy (1987). Sidney Jourard made a similar observation many years earlier:

...It is my experience that problems brought to me as supposedly purely sex problems turn out inevitably to be prob­lems that arise from fouled-up relationships. (Jourard, 1961)

Pam Henderson (2014), a psychosexual therapist in Cambridge, U.K., noticed how clients initially focus on specific problems. Those discussions can eventually transition to include a broad range of relationship issues. She wrote:

In my experience, clients do not arrive with a goal of "I'd like to explore sexual and erotic intimacy with my partner" or "I want to discover pleasure and optimal sexuality." They say things like, "I want firm, reliable erections," "I want pain-free sex," or "I have to start wanting sex or he'll leave me."

They have frequently made a diagnosis that makes sense to them before they come to see us. They (or someone else) may even have named it. Their goal is usually symptom reversal...

To ignore this client goal ("let's not bother with erections, let's focus on pleasure and erotic intimacy") would be unethical–we have a basic duty to respect the autonomy of clients and their right to self-determination...

Fortunately, sex therapy offers a potential resolution to this tension, namely, a process in which client goals can shift as their under­standing of themselves, their relationship(s) and the impact of their cultural contexts evolves. ...Sex therapy can be an invitation to explore a different meaning for sex. (Henderson, 2014)

Binik and Meana (2009) pointed out that sex therapy is somewhat unique in defining itself by the class of problems it treats. "There is no 'depression therapy' or 'anxiety therapy' or 'eating disorder therapy' or 'borderline personality disorder therapy' with its own regulating body and identity."

"Yet, sex therapy seems to function...as if it is a therapeutic approach unto itself." In reality, Binik and Meana wrote, there is no agreed upon definition or approach to sex therapy.

Sex therapists adopt theories from almost every school of psychotherapy. "There is nothing inherently amiss with that, but it fails to support sex therapy's claim to a unified and articulated approach." (Binik and Meana, 2009, p.1020)

Perhaps striving for a unified approach is not really necessary or in tune with larger trends in psychology. Back in Chapter 1, one of the modern trends described in psychology was toward a task-centered approach and away from identification with schools of thought.

Unified approaches were common when Freudians fought behaviorists and humanistic psychologists offered a third alternative. However, with cognition and neuroscience added to the mix of different approaches known to all, psychological scientists are more likely now to focus on particular issues, drawing from any relevant tradition in treatment.

Most psychologists are open to any approach that works, which would include all of those commonly referred to as "evidence-based". For both clinicians and experimental researchers, that may be the most scientific way to operate. Additionally, almost all sex therapists agree on the need for addressing the whole relationship.

In the meta-analysis by Fruhauf, Gerge, Schmidt, Munder, and Barth (2013), the most successful sex therapies were those for low sexual desire and lack of orgasms. Both typically address relationship issues to get good results.

Perhaps, as Henderson (2014) maintained, ordinary sex therapy has already become modernized. It has adopted a task-centered orientation, accepting a variety of theoretical contributions, and embraced complexity by treating sexual problems as part of personal relationships.

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References:

Binik, Y. M. & Meana, M. (2009). The future of sex therapy: Specialization or marginalization? Archives of Sexual Behavior, 38, 1016-1027. doi:10.1007/s10508-009-9475-9

Carvalheira, A. A. & Costa, P. A. (2015) The impact of relational factors on sexual satisfaction among heterosexual and homosexual men. Sexual And Relationship Therapy, 30, 314-324.

Frost, R. N. & Donovan, C.L. (2015) Low sexual desire in women: Amongst the confusion, could distress hold the key? Sexual and Relationship Therapy, 30, Issue 3. http://dx.doi.org/10.1080/14681994.2015.1020292

Frühauf, S., Gerger, H., Schmidt, H. M., Munder, T., & Barth, J. (2013) Efficacy of psychological interventions for sexual dysfunction: a systematic review and meta-analysis. Archives of Sexual Behavior, 42, 915-933. doi:10.1007/s10508-012-0062-0

Henderson, P. (2014) In praise of "ordinary" sex therapy. Sexual and Relationship Therapy, 29, 132-134. http://dx.doi.org/10.1080/14681994.2013.860436

Jourard, S. M. (1961). Sex in marriage. Journal of Humanistic Psychology, 1, 23-29.

LoPiccolo, J. & Lobitz, W. C. (1972) The role of masturbation in the treatment of orgasmic dysfunction. Archives of Sexual Behavior, 2, 163-171.

Masters, W. H. & Johnson, V. E. (1970) Human sexual inadequacy. Boston: Little, Brown.

Reissing, E. D., Binik, Y. M., Khalif, S., Cohen, D., & Amsel, R. (2003) Etiological correlates of vaninismus: Sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. Journal of Sex & Marital Therapy, 29, 47-59. http://dx.doi.org/10.1080/713847095

Weeks, G. R. (1987) Integrating Sex and Marital Therapy. New York: Brunner/Mazel.


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