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Assessment and Psychological Treatment of Sexual Dysfunctions

Here's a step-by-step guideline of how to diagnose and treat sexual dysfunctions.

Assessment of Sexual Dysfunctions

Often requires medical evaluation

  • By competent, sensitive physician

Psychosocial evaluations

  • Can be complex
  • Multiple etiologies
  • Distinguishing cause, effect, & their interaction
  • Frequently identify co-morbidities
  • Sexual and non-sexual
  • Medical and psychological
  • Within and between partners

Ideally, both partners get interviewed

  • Together and separately
  • Not always possible
  • Could itself be diagnostic
  • Identified patient is sent in to be "fixed"
  • Stories often differ
  • Even about objective data
  • Often about conceptions of the problem
  • Or even if there is a problem

"There are no unaffected partners in sexual dysfunctions" (Bill Masters)

  • Resentment
  • Anger
  • Doubts
  • Does she still love me?
  • Does he still find me attractive, sexy, appealing?
  • Diminished Quality of Life

Sexual dysfunctions vary across several dimensions

  • Nature of presenting complaint
  • Is this really a sexual problem?
  • Length of dysfunction
  • Primary vs. Secondary
  • Has the person always had the dysfunction or was there ever a period of good functioning?

Sexual dysfunctions vary across several dimensions

  • Medical vs. Psychological Etiology
  • Frequently difficult to determine
  • Particularly if the problem is of long duration
  • Locus of the problem?
  • One partner, the other, or both?
  • Do both partners see this the same?
  • Single or multiple dysfunction(s)
  • In one partner or both?
  • Relationship, if any, of multiple dysfunctions?

Important to explore

  • How each partner understands the problem
  • What has the couple has tried to deal with the problem?
  • With what success?
  • Anything make it better/worse?
  • What is the non-sexual relationship like?
  • Non-sexual sources of stress
  • Health problems?
  • Medications?
  • Why are they in treatment now?
  • What does each hope to get from treatment?
  • How willing is each to participate in treatment?
  • Strengths, as well as problems
  • What competes with sex?
  • Time, work, kids
  • A detailed description of what the couple typically does sexually
  • Maladaptive attitudes, beliefs, behaviors, and expectations
  • Each partner's outside sexual experiences
  • Before or during this relationship
  • What's at stake if the problem isn't resolved?
  • Is the problem also a solution?
  • Secrets
  • Fantasies

Sexual History

  • Critical for understanding the problem
  • Always done for symptomatic partner
  • Best when done for both partners
  • Time and detail are variable
  • How far back do you go?
  • How much detail do you need?
  • Certainly, need a detailed history of the problem
  • As far back as it goes
  • Precipitating events?

Sexual history includes

  • Sexual messages received growing up
  • Earliest sexual experience
  • How did it go?
  • Significant sexual experiences
  • Both positive and negative
  • Particularly any abuse (psychological, physical, sexual)
  • History of sexual relationship with current partner

Treatments

Psychological

  • Individual
  • Couple
  • Combination

Medical

  • Rarely includes the partner in assessment or treatment

Combinations

Psychological Treatment

  • Primary goals
  • Support
  • Normalization
  • Permission giving
  • Sex education
  • Stress reduction
  • Symptom removal
  • Improved communication (sexual & other)
  • Attitude change
  • Helping to make sex fun

Most common approaches are cognitive-behavioral, also the most researched and supported

Cognitive: Identifying and challenging irrational or unreasonable beliefs, attitudes, expectations

Behavioral: Sensate focus exercises

Most involve sex education

  • Learning what's "normal"

Improve communication

  • Learn and communicate about each other's desires and fears s

Important to work within the individual's or couple's value system

  • Important to be non-judgmental
  • You must be comfortable talking about sex
  • Any sign of your discomfort will make it more difficult for them to talk
  • How comfortable are you?
  • How do you know?

It will be difficult for many clients to talk about their sexual problems

  • Where were they supposed to learn to be comfortable discussing sex?
  • At home, school, with friends or family?
  • Where did you learn to be comfortable?
  • Admitting to sexual problems is even more difficult
  • Especially for men
  • Gets more difficult the longer the problem has existed

Few seek help for sexual problems

  • 20% of women 10% of men (NHSLS)

Need to identify individual or relationship issues that may cause, maintain, or exacerbate the sexual problem

Individual

Relationship Issues

  • Can be the cause, effect, or both of sexual problems
  • Sexual boredom
  • Dislike of partner
  • Anger, Fear
  • Power differences, control issues
  • Fallen out of love
  • Lack of sexual attraction
  • Infidelity
  • Disappointment
  • Perceived selfishness
  • Money, kids, in-laws
  • Different values or interests
  • Abuse
  • Partner's psychological disturbance

Sensate Focus

  • Developed by Masters and Johnson
  • Guided couple's exercises
  • Both diagnostic and therapeutic
  • In vivo systematic desensitization
  • Early exercises designed to be more sensual than sexual

Designed to

  • Reduce stress, expectations, and spectatoring
  • Increase sexual pleasure

Designed to help couples

  • Identify what pleases them and their partner by focusing on their own and their partner's bodily sensations
  • Improve sexual communication
  • Take time for their sensual pleasure
  • Go back to a place when sex was fun and satisfying

Sensate Focus

  • Done in private
  • Includes prescriptions and proscriptions
  • Is gradual, beginning with non-genital touching
  • Usually precedes more disorder-specific exercises
  • Is individualized to the couples
    • Where they are starting from
    • The nature of their problem(s)
    • Their response to each exercise

Desire Disorder

  • Difficult to treat
  • Prognosis is better when etiology is apparent
  • No empirically validated treatments
  • Approach usually depends on assumed etiology
    • Primary vs. secondary
    • Generalized or partner specific
    • Individual vs. couples' therapy
    • Medical (e.g., estrogen) vs. psychological
  • Often requires lengthy individual and/or couples' therapy

Sexual Aversion

More common in women

  • Prevalence unknown

More serious than desire disorder

  • More often associated with significant individual psychopathology
  • History of abuse, rape or other trauma
  • More often associated with significant relationship problems
  • Severe anger, distrust, infidelity

Difficult to treat

  • Symptomatic partner may have little motivation
  • Almost always requires lengthy individual and/or couples' therapy

Arousal Disorder

  • Medication sometimes helpful
  • Psychological interventions
    • Individual psychotherapy
    • Treat historical issues or Axis I disorders that are etiologically significant
    • Couples' counseling
    • Sensate focus
    • Treat communication and other relationship issues believed to cause or maintain the disorder

Female Sexual Dysfunctions

Vaginismus

  • Good prognosis
  • Dilation
  • Relaxation
  • Kegel exercises
  • Partner involvement

Primary Anorgasmia

  • Good prognosis
  • Directed Masturbation
  • Sensate focus
  • Systematic Desensitization (~)

Secondary Anorgasmia

  • Guarded prognosis
  • Sex education
  • Sexual skills training
  • Communication training
  • Directed masturbation (~)

Dyspareunia/Vaginismus

Treatment:

  • Multidisciplinary
  • Need a physician who understands and treats these problems
  • Cognitive-behavioral therapy:
  • Vaginal dilation (Vaginismus)
  • systematic desensitization
  • couples counseling

Erectile Dysfunction

  • Oral medications
    • PDE-5 Inhibitors
    •  
  • Prostheses
    • Rigid, Semi-rigid, Inflatable
  • Psychological
    • Sensate focus
    • Systematic desensitization
    • Sex education
    • Communication training

Premature Ejaculation

  • Medication
    • E.g., Clomipramine
  • Psychological
    • Sex education
    • Normalizing PE
    • Blueprint alternatives
    • Cognitive-behavioral
    • Squeeze
    • Stop-start
    • Do better in short-term than long-term

APA Reference
Writer, H. (2008, December 27). Assessment and Psychological Treatment of Sexual Dysfunctions, HealthyPlace. Retrieved on 2019, September 23 from https://www.healthyplace.com/sex/main/assessment-and-psychological-treatment-of-sexual-dysfunctions

Last Updated: June 25, 2019

Medically reviewed by Harry Croft, MD

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