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The Sexual Dysfunctions
Large numbers (Recent survey indicates 40%)
People often believe that they are the only failures
Enter a conspiracy of silence
Sense of shame/blame/inadequacy
(The relief in the therapist clarifying it )
Arousal disorders [10%]
Men
Erectile difficulties in men
Cycle of performance anxiety
Increased awareness of physical components
Women
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
Etiology
Psychogenic
Medications
Depression
Vascular disease
Hormonal
Neurologic
Orgasm disorders
Men
25% of men struggle with premature ejaculation
Medication may be helpful (SSRIs/Clomipramine)
Squeeze technique
Women
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
Etiology
Intimacy/closeness conflict
Depression
Medications
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)
Pain
Vulvovestibulitis
Vaginismus
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
Exhibitionism
Voyeurism
Fetishism
Pedophilia
Sadomasochism
Domination/Submission
Compulsive involvement with pornography (Internet)
Evaluation of Sexual Dysfunctions
Need to assess
Intrapsychic
Interpersonal
Medical/organic
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
Nervous
Hormonal - Testosterone/FSH/LH/Thyroid
Women
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
Behavioral/psychodynamic/cognitive
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?
Men
Physiology of erection and difficulties
Intrapenile injections
Oral medications (Viagra)
Greater recognition of physical issues - increases with age
Orgasm -- behavioral/medications
Women
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
Aging
Myth that old people have no interest
More Open
Books/media/self help videos etc.
Technology
Video
Pornography
Aids - implants, pumps vibrators, dildos etc.
Aids
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
Promoting/permissive
Sex education or lack thereof
Media
Prohibition