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Sex Therapy and Sexual Dysfunction

The Sexual Dysfunctions

Large numbers (Recent survey indicates 40%)

People often believe that they are the only failures

Enter a conspiracy of silence, sexual dysfunction, unable to have orgasm, inability to orgasm, sex therapy, premature ejaculation, impotence

Sense of shame/blame/inadequacy

(The relief in the therapist clarifying it )

Arousal disorders [10%]


Erectile difficulties in men

Cycle of performance anxiety

Increased awareness of physical components


Inability to maintain adequate vaginal lubrication

Intercourse painful or uncomfortable

May choose to keep problem hidden from partner

Performance anxiety often not considered in women





Vascular disease



Orgasm disorders


25% of men struggle with premature ejaculation 

Medication may be helpful (SSRIs/Clomipramine) 

Squeeze technique


5% of women do not have orgasms under any circumstances

40% of women do not have orgasm with intercourse

Increased awareness that intercourse may provide insufficient stimulation for orgasm

SSRIs may inhibit orgasm and sexual desire (80%)

Using Bupropion (Wellbutrin) may counteract SSRI

Desire phase problems [30- 50% of couples]

The most prevalent

Not amenable to the directed approach

No unified hypothesis about it

High expectations from the media - magazines etc,

Pose a dilemma for the therapist

People often do not get better

"Affairs'" may confuse this picture


Intimacy/closeness conflict



Medical - Chronic illness/hormonal

Paraphilic preoccupations

Does the individual have sexual fantasies about someone else and does he/she masturbate ?

Mixed patterns (Reciprocal patterns - eg, vaginismus/premature ejaculation)




Deep dyspareunia

Paraphilias [5%]

DSM IV "A group of disorders whose essential features are recurrent, intense sexual urges and sexually arousing fantasies generally involving non human objects, suffering, humiliation of one's self or partner, or children or other non-consenting adults."

Sexual compulsions 







Compulsive involvement with pornography (Internet)

Evaluation of Sexual Dysfunctions

Need to assess




Asking about Sex

We have had no models for talking about it

No training - medical schools and residencies still ignore it

Mixed messages on the media -- open, explicit shame - censored

Cross generational awkwardness

Often the sexual interaction provides enormous information about the couples dynamics and vulnerabilities. 

Power struggles

Issues around being given to -- receiving

Being able to identify what they want

Tell me about your sexual relationship

Are you Satisfied

Would you want anything to be different

How long has this been an issue

Does anything make it better/worse

What is your "formulation" about the cause

What has sex been like with other partners

Frame it - "There are some specific questions I would like to ask..." Patterns of initiation Fantasies

Experimentation -- reading erotic material/porno movies, sexual toys, aids Etc/Internet

Do you talk with each other about what you like/dislike Comfort with asking for things/Reciprocity Masturbation

Being clear that you understand what they might be talking about Have to be "stupid" in the listening --ie, not assume or be complex but to ask details -- When someone talks about "losing erection" on the face of it -- erectile difficulty - but it may be premature ejaculation.

A woman who says she does not have an orgasm during intercourse

Do you feel excited

Do you get moist

Does your partner touch your clitoris

Would you like him to do that

A man who has trouble getting erection 

Do you feel excited 

Are you feeling scared 

Does your partner touch your penis 

Would you like her to do that

Medical Factors in Evaluation

The Urological evaluation

Vascular - Nocturnal penile tumescence/postage stamp test 


Hormonal - Testosterone/FSH/LH/Thyroid


Physical examination - Muscle spasm/pain/

Menopausal issues - Hormone assessment/Testosterone levels

Treatment Approach

Joint and individual meetings

Family and sexual history

Sharing the ideas -- the point of "collaboration"

Integrating Approach


Creating a safe climate Providing a model for discussion Being a resource for information Suggesting books

Specific assignments -- the Sensate Focus model looking at what happens with that

What's New?


Physiology of erection and difficulties

Intrapenile injections

Oral medications (Viagra)

Greater recognition of physical issues - increases with age

Orgasm -- behavioral/medications


Impact of childhood sexual abuse and aftermath

The work with testosterone on desire

Painful Intercourse - more prevalent than we knew

Continuing development of changes related to women's movement

Women taking control of sexuality - not a function of being responsive to male

Resultant issue for men that get flushed out

Men are confused -- see more who are taking the proverbial aspirin


Myth that old people have no interest

More Open

Books/media/self help videos etc.




Aids - implants, pumps vibrators, dildos etc.


More people are waiting longer

More are choosing not to have intercourse b/4 mart.

May shift things -- have to talk more first -- silver lining

Ongoing Conflict in the Culture


Sex education or lack thereof