Section 2: Sex Therapy Questions and Answers

Since clinicians are likely to be engaged in the assessment of sexual problems, it is important to have a good understanding of what are the most likely sexual disorders that are experienced by both men and women. Prevalence of these disorders will be included simply to help clinicians have an understanding of just how common each of these sexual problems can be.

What are the most common sexual disorders for men?

For men, the three most common sexual disorders that are likely to be encountered are:

1. Ejaculation disorders
2. Erectile disorders
3. Inhibited sexual desire

Ejaculation disorders include premature ejaculation (prevalence: over 30% of men) and an inability to achieve orgasm (prevalence: about 8% of men). (Rosen, 2000) Premature ejaculation is defined as: 1) Inability to control ejaculation before, during, or shortly after intromission; 2) Ejaculation before the individual desires it; and also 3) Rapid ejaculation that interferes with a relationship

About 10% of men report persistent trouble achieving or maintaining an erection, although by the age of 40 about 90% of men report at least one incidence of erectile dysfunction. For older men, erectile problems tend to be more driven by physical or medical problems, while for men under 35, over 75% of erectile problems have a psychological cause. (Rosen, 2000) Almost 18% of men also report significant performance anxiety related to sexuality. (Rosen, 2000) This may contribute to problems both with ejaculation and with erectile difficulty.

About 15% of men report a lack of interest in sex and another approximately 8% of men report that sex is not pleasurable. (Rosen, 2000) Diminished libido in men can be driven by many factors, including stress, lack of sleep, drugs and alcohol, and age related decreases in testosterone levels. As most clinicians know, a decrease in sex drive is also one of the more common side effects of SSRI medications.

There are also a number of psychological factors that can create a noticeable decline in sex drive, including depression, anxiety, and traumatic experiences. Relationship conflict and intimacy problems within relationships can also turn into a reduction in libido. A thorough assessment process is essential in determining the cause of the sexual problems and the proper role of the clinician in addressing those problems and/or making appropriate referrals to other providers.


What are the most common sexual disorders for women?

1. Low sex drive
2. Arousal Disorders
3. Difficulty with orgasm
4. Painful intercourse

According to epidemiological studies, as many as 30% of women report low sexual desire in the course of a year. (Rosen, 2000) As is the case for men, diminished libido can be driven by stress, lack of sleep, drug and alcohol use, and a number of different medications, including SSRI antidepressants and birth control pills.

Additionally, it is not uncommon for sexual desire to be decreased after childbirth for up to a year, with a small minority of women reporting a diminishment in sexual desire that lasts for many years, particularly after the birth of a second child. This may be the result of complex hormonal shifts that result from pregnancy and childbirth and that do not re-equilibrate after delivery. Breast feeding may also result in decreased libido for many women, due to an increase in the hormone prolactin. (Berman & Berman, 2001). Clients who are unaware of these hormonally driven drop-offs in libido may ascribe the problems to other factors, to the detriment of their relationship.

There also appears to be a very small number of women (and men, for that matter) who may possess a lifelong disinterest in engaging in sexual activity, due to a self-described lack of sexual feelings. It is difficult to find accurate statistics to know the prevalence of this group, but at the very minimum it is likely to be at least 1% of the population, based upon research established in the Kinsey report, and more recent research examining asexuality in the population. (Bogaert, 2004)

Arousal disorders are concerned with the inability of a woman to attain or sustain a state of physiological sexual arousal, or an inability to generate or sustain sexually induced vaginal lubrication to the completion of the sexual act. Prevalence estimates place the numbers of women with this difficulty at between 10-20% of the population. (Rosen, 2000)

Of particular interest to note for clinicians working in couples counseling, it appears there may be some considerable correlation between female arousal disorders and erectile dysfunction on the part of the partners of women with this disorder. (Goldstein & Davis, 2006)

Since sex is, most often, an interactive event between partners, it may be speculated that a drop off in desire on the part of one partner might have libido decreasing or anxiety producing effects in the other.

10-15% of women present with anorgasmia, or an inability to reach a sexual climax. About 12% of women never experience an orgasm.
(BBC Health)

Anorgasmia (also called nonorgasmia or inorgasmia) can be:

1) primary - never having experienced an orgasm by any means,
2) secondary - experienced an orgasm in the past, but is not able to do so at the present time, or
3) situational - is able to achieve orgasm in some situations, not others, with some partners, not others.

Primary anorgasmia is frequently the result of one or more of the following: 1) Lack of information and/or awareness about sex and self, 2) Communication problems within the sexual relationship, 3) Fears, guilt, or performance anxiety

Secondary anorgasmia can be the result of certain illnesses such as diabetes and multiple sclerosis, the side effects of medications, or certain types of injuries or surgeries. Relationship problems can also be a factor.

Situational anorgasmia may result from physical issues such as fatigue or medication side effects or may be connected to relationship issues (anger at partner, lack of attraction to partner, etc.).

Sexual pain disorders (SPD), are found in about 10-15% of women. (Rosen) Vulvodynia, dyspareunia and vaginismus, are the three major disorders found in this category. Even though one or more of these conditions can affect almost 10% of women at some point in their lives, most mental health clinicians do not have familiarity with them nor do they understand their causes and treatments.

What are Vulvodynia, Dyspareunia and Vaginismus?

Vulvodynia is defined as chronic vulvar discomfort, especially characterized by the patient’s complaints of burning, stinging, irritation, or rawness. An estimated 14 million women may have vulvodynia at some time in their lives, and for many the condition becomes a chronic problem.

It appears to affect primarily white women. Few women talk about it, and many health care providers are unaware of its existence. Hence, many cases of vulvodynia remain undiagnosed, and if diagnosed, they are frequently improperly treated. Vulvodynia can be a factor in the development of dyspareunia and vaginismus.

Vulvodynia most likely has multiple causes, including yeast, human papillomavirus, chemical irritants, allergic drug reactions, and previous treatments that actually worsen the condition. The pain may be neuropathic in origin, involving damage or malfunction of the central or peripheral nervous systems, often with no apparent cause. Also, there are subsets of vulvodynia that may overlap.

Histories of women who suffer from vulvodynia often reveal that they have been to numerous health care providers, often over a period of many years, yet frequently they have received few productive treatments, and they have continued to suffer. Often they have been told to 1) change your laundry detergent, 2) wear cotton underwear, 3) don’t wear tight fitting jeans, etc. When these have failed to provide relief, many women have been diagnosed with a psychological problem and told, “This is all in your head; there’s nothing wrong with you.”

Women who come to clinicians for counseling may feel helpless and hopeless that they will ever recover or they may think they have a very serious health problem that no one has been able to diagnose. Often the women are angry with the medical community for the lack of effective care and what may be perceived as health providers’ indifference.

At times treatments they have received, instead of improving the problem, have actually made the symptoms worse. The vulvodynia can include iatrogenic (made worse by treatment) factors in addition to the initial factors that precipitated the condition. Proper treatment requires that the correct cause be identified as early as possible.

The role and approach of a conscientious mental health clinician may create a safer and more patient-friendly environment for this condition to be discussed and uncovered. If a thorough sexuality assessment does uncover evidence of this condition, the clinician’s role will be to help prepare the client emotionally to have an honest open and ongoing discussion with a healthcare provider such as a primary care physician or OB/GYN so that the medical reason can be uncovered and treated.

In recent years, the specialty of Pelvic Floor Physical Therapy has emerged as an extremely helpful resource for patients with all types of sexual pain disorders as well as incontinence, prolapse, and muscle spasm. These therapists have received specialized training and are able to provide hands-on care to diagnose and treat these disorders very effectively in a non-threatening and supportive way.

Resources:
The Women’s Sexual Health Foundation www.TWSHf.org and the National Vulvodynia Association http://learn.nva.org are excellent sources of information and support.

Other Useful Resources:
http://www.nichd.nih.gov/new/releases/vulvodynia.cfm
http://www.aafp.org/afp/990315ap/1547.html
http://vulvodynia.com/

Book: Kaysen, S. (2002). The Camera My Mother Gave Me. This book is about a relationship between a man and a woman who suffers pain (vulvodynia and/or vaginismus) with sexual activity. The camera represents her vulva or vagina. Susannah Kaysen is the author of Girl, Interrupted.

Vaginismus, the involuntary contractions of the perivaginal muscles, is a condition that can prevent gynecologic exams and can also lead to unconsummated marriages of many years. In severe cases, even light touching of the outer vaginal opening can result in immediate contraction and pain. Symbolically it appears that the body is trying to protect itself from entry and some perceived danger.

At times the sexual history will reveal traumatic experiences that could account for an ongoing perception of danger. Also, recurrent painful sexual experiences such as those that occur with conditions involving chronic vulvar pain (e.g. vulvodynia - see preceding section, imperforate, microperforate, or septate hymen, etc.) can be factors in vaginismus.

At other times the history is much less clear, and indeed, some women will have a totally benign history. For some young women, vaginismus appears to be associated with deep-seated fears of other medical procedures that involve some type of entry into the body such as injections or having blood drawn.

For others, it seems to be associated with strongly held beliefs about the importance of protecting virginity, ostensibly until marriage. Once marriage occurs, the body does not automatically get the message that what was once strongly prohibited is now not only permissible, but expected. For other women, vaginismus seems to be connected to growing up, and opening of the vagina symbolizes a rite of passage into adulthood.

The role of the mental health clinician in addressing vaginismus will depend upon the origin of the problem as uncovered during a thorough assessment process. If a history of sexual abuse or trauma is uncovered, the clinician must make a determination of whether he/she has adequate knowledge, skills and experience to treat the underlying issues. If this falls outside of the clinician’s area of competence, a referral to a sexual trauma specialist would probably be indicated.

If the problem has more to do with anxiety related to sexuality or deeply held values based inhibitions about engaging in sexual activities, the clinician must make a determination of his/her comfort and experience level in tackling an anxiety disorder that expresses itself in this manner. Vaginismus was one of the conditions that Masters and Johnson addressed in their sex therapy program.

Their treatment protocol called for relaxation (not easy), dilatation under her control, biofeedback, and psychotherapy if needed. The key, throughout the program, is for the woman to always be in control of the process and of what is entering her vagina.

The procedure involves the woman’s performing vaginal dilatation using a series of graduated-size dilators while practicing progressive relaxation. Once she can successfully insert the largest dilator, she can then incorporate a partner in the process and can move from the dilator to penile penetration. This may be a time-consuming process and necessitates patience on the part of the woman and also of her partner.

If a mental health clinician surmises that a client may need to pursue this approach to treatment, referral to a sex therapy specialist is considered essential. A pelvic floor physical therapist may also be a very helpful resource. The combination of a sex therapy specialist coordinating treatment with a pelvic floor physical therapist can be very effective in promoting successful resolution of the vaginismus.

Resources:

Video:
The video “Treating Vaginismus,” although somewhat dated (1984), provides the best available audio-visual resource for the treatment process and use of the dilators. The film is produced by the Sinclair Intimacy Institute (see http://www.bettersex.com/).
Purchasing Dilators:
An excellent source for obtaining the dilators is Soul Source Enterprises at http://www.soulsourceenterprises.com/
Self-help Resources
http://www.vaginismus.com

www.HealthySex.com, Suggestions for Using Vaginal Dilators by Wendy Maltz, LCSW, LMFCC, Certified Sex Therapist, Author of The Sexual Healing Journey

Dyspareunia, or painful intercourse, can result from a number of causes. While the condition was viewed for several years as largely psychological in origin, today clinicians recognize that numerous physical factors can be involved in initiating and perpetuating the pain.

Current thinking about many types of pain suggests that there may be an initial activating factor followed by a pain cycle that becomes perpetuated by a variety of additional factors, both physical and psychological. Sorting through this process can be difficult.

There are numerous potential physical causes of dyspareunia, including physical changes from childbirth, fibroids, structural issues with the vagina, uterus or hymen, endometriosis, and many inflammatory conditions such as urinary tract infections or cervicitis. Dypareunia can also be caused by insufficient lubrication during intercourse, either from arousal difficulties or medications that affect vaginal lubrication.

Evaluating psychological versus physical causes of dyspareunia often presents a challenge to the clinician. Indeed, the causes are difficult to separate and the condition may involve a combination of both factors. Obtaining a history using the Sex Problem History instrument can be useful in determining whether the predominant cause is physical versus psychological, or whether there is a combination of both factors.

There are some hints that may be helpful to the clinician undertaking the assessment. If physical elements are primarily responsible, the woman may say that she liked sex until this pain began, she is comfortable with masturbation, she has sexual desire, the pain began at a specific time, the pain has a specific site and happens with a specific intercourse position, and/or the pain is cyclical (LoPiccolo and LoPiccolo, 1978).

If the cause has a largely psychological component, the woman may say that she has never liked sex, she doesn’t masturbate, she isn’t orgasmic, the location of the pain is "down there," penetration hurts every time, etc. Psychological factors include interpersonal as well as relationship issues. A person may feel uptight and have difficulty relaxing, be experiencing performance anxiety, be angry about engaging in sex, be turned off to a partner. (LoPiccolo and LoPiccolo, 1978).

Please note that if the patient has not had a recent physical exam, referral to an appropriate medical specialist for evaluation is essential in order to assess overall health status and determine the factors associated with the presenting pain.

Resource:
http://www.aafp.org/afp/20010415/1535.html


Are there other sexual conditions that are important to know?

A condition known as Persistent Genital Arousal Syndrome (PGAS), also known as Persistent Sexual Arousal Disorder (PSAD), is a complex and distressing problem that can occur in women. Sometimes used to describe women with high sexual desire - and at times equated with nymphomania - this condition is characterized by feelings of spontaneous and persistent physiological genital arousal that occur without any conscious awareness of sexual desire. (Goldmeier & Leiblum, 2006; Leiblum & Nathan, 2001).

The term nymphomania implies a strong interest and desire for sex, while in PGAS there is NO subjective wanting of sex - there is genital arousal without mental desire. If sexual behavior occurs, it is only in an attempt to quell the incessant sexual sensations, and orgasm often only makes it worse - it "feeds" the genital sensations rather than eliminates them. These feelings can persist for extended periods - days or weeks. Many women are embarrassed to report the problem to their health care provider and are relieved to learn that other women have similar complaints. (Leiblum & Nathan, 2002).

The etiology of the condition is mysterious and no single cause has been identified. In many women there may be a blend of soma and psyche. There is some thought that it may have some neurological similarities to Restless Leg Syndrome, as some research indicates a strong correlation between the presence of PGAS and Restless Leg Syndrome. (Waldinger and Schweitzer)

Prevalence of this disorder is unknown and at the present time no single treatment is recommended. Various pharmacological/physical and psychological approaches have been utilized, and research is underway to further the understanding of this difficult problem. (Leiblum, Brown, & Wan, 2005).


When Should a Non-specialist in Sexuality Refer a Case to a Specialist?

Non-specialists in sex therapy often wonder when they should refer or consider referring clients to a specialist in sex therapy. While there are no specific guidelines to determine this, the following areas should be considered in making a decision to refer.

1. The non-specialist’s knowledge base related to the client’s problem. For example, if a client is experiencing pain with sexual activity, how much does the therapist know about causes and treatments for a) anorgasmia, b) desire problems, c) erection problems, d) ejaculation problems, and e) specific pain disorders such as dyspareunia, vaginismus, and vulvodynia.
2. Therapists’ skill in dealing with sexuality issues.
3. Observation of clients’ progress - are they responding positively?
4. Therapists’ comfort with addressing sexuality issues and willingness to look at themselves in terms of what sexuality issues might evoke for them.
5. Are there parallels in a client’s life and the therapist’s life that may interfere with treatment, such as a husband who may be having an affair?
6. The therapist’s willingness to keep “secrets” if requested to do so.
7. The availability of resources for referral and treatment collaboration - OB/GYN physicians, Nurse Practitioners, Pelvic Floor Physical Therapists
9. Other resources the therapist has available for consultation - sexuality listserves made up of experts in the field, knowledgeable colleagues.
10. Personal boundaries - determining areas that may be better addressed by other specialists - for example, sex offenders, BDSM issues, survivors of child sexual abuse and other types of trauma.

Therapists interested in gaining more knowledge in working with sexuality issues can attend professional meetings, available throughout the year, put on by AASECT (American Association of Sexuality Educators, Counselors, and Therapists), SSTAR (The Society for Sex Therapy and Research), SSSS (The Society for the Scientific Study of Sexuality), and ISSWSH (International Society for the Study of Women’s Sexual Health).

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