Section 9: Aytpical Sexual Behaviors, Clinical Cases and Therapists’ Responses

There are many types of atypical sexual behaviors, defined as sexual activities that do not commonly occur in society. These behaviors are motivated by paraphilias, defined as recurrent sexual fantasies and urges to engage in unusual sexual activities.

There does not at present appear to be generally accepted agreement among mental health professionals as to the etiology for each of the many different kinds of paraphilias. There may be clusters of personality traits that correlate with the presence of paraphilias, as well as a history of life events that interact with these personality traits in ways that contribute to the development of paraphilias. However, the exact mechanisms through which the paraphilias develop currently remain to some degree a mystery.

For clinicians who specialize in the treatment of sexual issues, this is an important – and difficult – understanding. Without clear information about the causes of a set of urges and behaviors, it can be more difficult to devise change strategies for those behaviors.

Treatment for paraphilias should probably only be attempted by mental health professionals who possess adequate education and training in this specialty area. The details of what would be involved in such treatment is outside the purview of this course. However, it is important for clinicians to possess at least a basic knowledge of paraphilias, as clients with paraphilias may appear from time to time in your practice.

In the DSM-5, there has been a significant change to how paraphilias have been conceptualized. In the DSM-5, certain paraphilias are not automatically considered mental disorders and are not automatically considered to warrant clinical intervention. In order for a paraphilia to be considered a mental disorder under DSM-5, the paraphilia must 1) be causing distress or impairment to the person exhibiting the paraphilia, and/or 2) the paraphilia must be presenting itself in a way that can create personal harm or the risk of harm to others.
 
Paraphilias are diagnosed by the presence of two criteria. Criterion A specifies the nature of the paraphilia, and Criterion B specifies whether the paraphilia causes distress or impairment to the person with the paraphilia, and/or creates harm or the risk of harm to others. Only those individuals who meet both Criterion A and Criterion B would now be diagnosed with a Paraphilic Disorder.

People whose sexual behaviors include paraphilias in the absence of these two criteria will no longer be automatically labeled as sexually deviant. While their sexual preferences are non-normative and different than socially mainstream behaviors, alternative or different sexual behaviors will no longer automatically demand a diagnosis.

Paraphilias are divided into two general types: non-coercive paraphilias (partners are willing participants) and coercive paraphilias (individuals are sexually aroused by fantasies or urges to inflict pain, either physical or emotional, on other people). Therapists may have varying degrees of willingness and expertise in working with all or certain of these, particularly if they involve coercion.

Generally, non-coercive paraphilias are harmful only if they bother the person’s partner, serve as a substitute for human contact, are dangerous, or become the only method a person has for achieving sexual pleasure. Coercive paraphilias can certainly be dangerous if a person acts out a violent fantasy on someone who is not a willing participant (University of California at Santa Barbara, 2008b).

For an accurate diagnosis to be made concerning whether a paraphilia is considered a disorder or simply sexual difference, the clinician must determine that distress or impairment is occurring to the client or harm is occurring to others from the presence of the paraphilia.

As noted very early in this course, one of the most important considerations in handling the sexual concerns of our clients is an ability to examine the material presented in a secure, confident and non-judgmental manner. For clinicians who have not had much experience with paraphilias, this can represent a difficult challenge.

The decision by the committee responsible for the DSM-5 to remove the label of sexual deviancy from the non-traditional sexual practices represented by the paraphilias does not mean that our culture as a whole is comfortable in viewing paraphilias as falling within the range of normal and accepted sexual practices.

To the degree that we clinicians have been raised within the larger culture, we are likely to have absorbed a significant degree of negative bias with regard to non-traditional sexual practices. Our initial reaction when a client discusses their sexual life and the existence of a paraphilia may reveal our own level of discomfort – unless there has been some preparation on the part of the clinician to address this discomfort.

This can be viewed as just another area in which clinicians must learn to become aware, knowledgeable, and, ultimately, skilled in handling issues of cultural diversity in order to “meet the client where he/she is at”. However, because sex and sexuality are so emotionally loaded within our culture, this can be a more difficult emotional challenge for clinicians that confronting many other areas dealing with cultural diversity.

Being confronted with a paraphilia for the first time as a clinician can be a jarring experience. It can push us to the limit in terms of maintaining control over our initial emotional response. However, the capacity to exercise emotional control is one of our most important core skills as a clinician. We must prepare a context in which the client feels safe, not judged. Without that capacity, we cannot invite the client into a relationship in which we can explore with him/her the problems – sexual or otherwise – that are creating the need for treatment.

Towards this end, it is helpful to increase our own awareness and knowledge about paraphilias. In addition to the material in this course, the University of California at Santa Barbara (2008) has an excellent website that gives information on each of the following paraphilias. See http://www.soc.ucsb.edu/sexinfo

NON-COERCIVE PARAPHILIAS

Fetishism

Fetishism is a paraphilia that involves a person’s becoming sexually aroused by inanimate objects. Common objects are shoes and underwear. Without these specific objects, present in either reality or fantasy, the person is often unable to become aroused. Males are far more likely than females to develop fetishes.

There are two different types of fetishes. In a form fetish, the object itself (e.g. shoes, underwear, diapers) is important. In a media fetish, the arousing factor is the material from which the object is made (e.g. rubber or leather (UCSB, 2008c).

Sadomasochism

Sadomasochism can actually be divided into two different paraphilias, sadism and masochism. Sadists experience sexual pleasure and arousal from inflicting some degree of pain (or mock pain), suffering, or humiliation on others. The majority of the time, this activity occurs with a willing partner.

The counterpart to the sadist is the masochist. A masochist experiences sexual pleasure and arousal from being the recipient of the pain, suffering, or humiliation. Sadomasochism, or S&M, is fairly common in its less extreme forms.


Sexuality Factoid

14% of men and 11% of women have had some sexual experience with sadomasochism

Source: Janus, S., and Janus, C. The Janus Report on Sexual Behavior. 1993. New York: John Wiley & Sons


Bondage and discipline, or B&D, is a type of S&M where one partner ties or restrains the other and then pretends to "punish" or "discipline" the person who is in bondage. This activity often does not involve any physical pain. Another type of activity that typically does not involve actual violence is Dominance and Submission. In this activity, participants act out roles such as the teacher and naughty student or the master and slave (UCSB, 2008d).

There is some very preliminary research that has found some degree of correlation between a history of being spanked as a child and increased interest in masochistic sexual relationships (Straus, MA, 2001) However, additional research in this area must be conducted for a more definitive picture to emerge concerning this relationship.


Coprophilia and Urophilia

Coprophilia is a paraphilia in which the individual derives sexual gratification from activities involving feces. Slang terms for this activity include hard sports, brown showers, scat fetishism, scat play, and scatophilia. Contact with feces should be kept to a minimum due to the many pathogens contained in feces (UCSB, 2008e).

Urophilia involves deriving sexual excitement from urine, as when doing "golden showers" or “watersports” (urinating on or in front of another person) (UCSB, 2008f). These two paraphilias are most often acted out with a willing participant, although they can take place without a person’s consent.

Transvestism and Crossdressing

Transvestism, most commonly referred today as crossdressing, involves dressing like a member of the opposite gender. This dressing may be an expression of transgender feelings or may involve experiencing sexual arousal and pleasure.

Today, the term crossdressing is generally used for the expression of transgender feelings, and the term transvestic fetishism refers to dressing for sexual arousal and pleasure. Males are more likely than females to sexualize crossdressing and do it for sexual arousal. Female crossdressers may be less obvious, since women are allowed to wear male clothing in our society.

Most crossdressers identify themselves as heterosexual (UCSB, 2008g). Interestingly, a male client who was a crossdresser requested to come to counseling sessions dressed as a female, because he said he felt more emotionally open when he was dressed as a woman.

Autoerotic Asphyxiophilia

Some people learn that they can heighten their sexual arousal and orgasmic pleasure by cutting off their oxygen supply via strangulation or suffocation. People who get "hooked" on this practice develop the paraphilia called autoerotic asphyxiophilia.

The practice can be done alone or with a partner. Either way, it is very dangerous, because people may accidentally kill themselves if they lose consciousness and are not able to release themselves from the strangulation device they have created (UCSB, 2008h).

The practice sometimes occurs in an escalating domino pattern among adolescents. A young person may be found hanging and his parents are left having to wonder if he committed suicide OR if he accidentally killed himself while masturbating.

COERCIVE PARAPHILIAS

Exhibitionism

Exhibitionism is a paraphilia in which a person (usually a man) obtains sexual pleasure from exposing his or her genitals to strangers (usually women), generally in a public place. The exhibitionist derives pleasure from the expressions of shock or disgust on his victim’s face.

Many exhibitionists maintain their innocence in doing this behavior (“I was in my own apartment in front of a window with an open curtain—they didn’t have to look”), and they say their victims enjoy the experience. Exhibitionists often masturbate before or after exposing themselves, while recalling the event (UCSB, 2008i).


Frotteurism

A frotteur intentionally rubs up against people and derives sexual pleasure by touching them in sexual ways without their consent and sometimes without their knowledge. These types of activities commonly occur in crowded public places, such as elevators, where the victim might assume the touching was accidental (UCSB, 2008j).

Scatolophilia

Scatolophilia is the clinical term for obscene phone calls. People who make these types of calls (scatolophiles) typically make sexual suggestions and receive sexual pleasure from the shock and discomfort of the people they call.

Scatolophiles may attempt to keep their victim on the phone through the use of persuasive manipulation or frightening threats. The behavior has decreased in recent years due to the increasing use of phone technologies such as caller ID (UCSB, 2008k).

Zoophilia

Zoophilia is the paraphilia in which a person becomes sexually aroused by fantasies of or actual sexual contact with an animal. The practice of having sex with animals is commonly known as "bestiality."

Most males with zoophilia tend to direct their activities to farm animals, whereas most females engage in sexual behavior with household pets. Bestiality is considered a form of animal cruelty, and in many parts of the world it is illegal (UCSB, 2008l).

Necrophilia

Necrophilia is the paraphilia in which an individual (known as a necrophile or a necrophiliac) becomes sexually aroused by fantasies of having, or actually having, sexual contact with a dead person. This sexual contact could range from intercourse, to oral sex, or simply masturbation in the presence of a corpse. Necrophilia is relatively rare (UCSB, 2008m).

Voyeurism

A voyeur is a person who derives sexual pleasure from watching other people who are naked and who are not aware they are being viewed. Heightened excitement usually comes from the fact that the person is not aware she or he is being watched. Voyeurs, usually males, are commonly known as "Peeping Toms." An example of a voyeur could be someone who spies on girls showering or dressing in a locker room.

Although many average people derive some sexual arousal from accidentally seeing an attractive person naked, peeping and watching become atypical when a person repeatedly seeks or resorts to peeping and eroticizes these experiences by masturbating during the viewing or afterwards. Voyeurism is usually an illegal act (UCSB, 2008n).

A slight variation of voyeurism is scoptophilia. In this paraphilia, sexual pleasure is derived from watching other people engaged in sexual acts or viewing other people’s genitals without their knowledge.

A scoptophile’s urges for these activities would not be satisfied by a pornographic movie or going to a strip club, because these activities lack the exciting elements of risk and forbiddenness (UCSB, 2008n).

Pedophilia

A pedophile is a person who derives sexual pleasure from fantasizing or engaging in sexual behavior with prepubescent children. Pedophiles are usually men, and they can be attracted to male children, female children, or both. Pedophilic behavior is child molestation and is illegal in every state of the USA.

Many people equate pedophilia and homosexuality, but these are NOT the same. The distinction is age. For example, adult males who are attracted to other adult males are homosexual; adult males who are attracted to children are pedophiles.

The causes of pedophilia are unknown, and current treatment modalities have had limited success. Pharmaceutical treatments with anti-androgens (drugs that reduce male sex hormone levels) and medications that increase serotonin (e.g., Prozac) continue to be investigated, and cognitive-behavioral therapy models, frequently accompanied by aversive and positive conditioning approaches, have demonstrated effectiveness in some cases (Psychology Today, 2006; WebMD, 2002).

Child Sexual Abuse/Molestation

Childhood sexual abuse refers to sexual relations that occur between a child and an immediate family member, any other adult, or an older child. This type of abuse is a problem all over the world. Females are most commonly the victims of child molestation, although males can also be victimized.

Estimates are that one in three girls and one in four to six boys are sexually abused before the age of 18. Abuse behaviors can include verbal abuse, exposure to sexual acts or pornography, genital touching, and vaginal or anal penetration. The vast majority of abusers (80%) are men, and usually these men are relatives or family friends of the victim (Parents United International, 2008).

Sexuality Factoid

There is evidence emerging that as many as one in three incidents of child sexual abuse are not remembered by adults who experienced them, and that the younger the child was at the time of the abuse, and the closer the relationship to the abuser, the more likely one is not to remember.

Source: Jim Hopper, Ph.D., Child Abuse Statistics, Research and Resources. www.jimhopper.com, 2004


Incest

Incest refers to sexual activity between close family members, specifically those family members who are not allowed to marry, e.g. parents and children, brothers and sisters, grandparents and grandchildren, aunts and nephews, uncles and nieces, and half brothers and half sisters. Incest is forbidden in a majority of cultures, and in most Western societies is illegal and punishable by law.

Authorities believe that because many cases of incest are unreported, the incidence of incest is more common than current statistics indicate (UCSB, 2008o).

Sex Offenders

A sex offender is a person who has been convicted of a sex crime, i.e. a sexual act which is prohibited by law (e.g. rape, molestation, sexual harassment, pornography production or distribution, downloading child pornography from the internet, etc.). Convicted sex offenders are often incarcerated for varying lengths of time and are required to register on the local sex offender registry, a database open to the public. Many do not.

In the past, treatment of sex offenders consisted largely of pharmacologic therapies, typically with anti-androgens and SSRIs. In recent years, new types of treatment programs have shown effectiveness in reducing recidivism rates for sex offenders. These programs offer psychological treatments with individual and group therapy, using a variety of modalities aimed at relapse prevention (Kersting, 2003). Ideally the treatment of sex offenders should be conducted by persons with specialized training in this area.

Gender Dysphoria

The DSM-5 has changed the previous diagnosis of Gender Identity Disorder in the DSM-IV-TR (302.6 and 302.85) and the focus now is on the dysphoria as the clinical problem and not gender identity as the problem. This may be, in large part, a result of a shift to remove stigmas that may have been associated previously with an individual’s expression of gender as differentiated from their natal (birth) gender and their gender identity.


Gender Dysphoria Summary Page

DSM-5 Code: F64.2 Gender Dysphoria in Children
Specify if: With a disorder of sex development (e.g. a congenital adrenogenital disorder) congenital adrenal hyperplasia (E25.0) or androgen insensitivity syndrome (E34.50)
Coding note: Code the disorder of sex development as well as gender dysphoria.

DSM-5 Code: F64.1 Gender Dysphoria in Adolescents and Adults
Specify if: With a disorder of sex development (e.g. a congenital adrenogenital disorder)
Congenital adrenal hyperplasia (E25.0) or androgen insensitivity syndrome (E34.50)
Coding note: Code the disorder of sex development as well as gender dysphoria.
Specify if: Postransition: The individual has transitioned to full-time living in the desired gender treatment regimen.

Etiology of Gender Dysphoria: The exact cause of this disorder is not fully understood. Individuals with a somatic disorder of sex development show some correlation of final gender identity outcome with the degree of prenatal androgen production. Further, in the Annual Review of Neuroscience 2011 34:69-88, Gender Development and the Human Brain, Melissa Hines writes that there is “growing evidence showing that (prenatal) testosterone exposure contributes similarly to the development of other human behaviors that show sex differences, including sexual orientation, core gender identity and some, though not all, sex-related cognitive and personality characteristics.” Gender dysphoria without a disorder of sex development is found in both natal females and natal males with signs of early onset manifesting somewhere between 2 and 4 years of age. In both adolescent and adult natal males, there are two broad trajectories for the development of gender dysphoria: early onset and late onset. Early onset starts in childhood and continues into adolescence and adulthood or there is an intermittent period where the gender dysphoria desists and the individuals self identify as gay or homosexual followed by recurrence of gender dysphoria. Late onset gender dysphoria occurs around puberty or much later in life. In adolescent and adult natal females, the most common course is the early-onset form of gender dysphoria. Late onset is less common in natal females compared with natal males. In gender dysphoria in association with a disorder of sex development, individuals with this disorder who develop gender dysphoria have already received medical attention at an early age because, for many, starting at birth, there were issues of gender assignment.
Prevalence: There were no reported statistics on the prevalence of gender dysphoria in children; however, sex ratios of natal boys to girls range from 2:1 to 4.5:1. For natal adult males, prevalence ranges from 0.005% to 0.014% and for natal adult females, from 0.002% to 0.003%.
Clinical Manifestations: Gender dysphoria is manifested differently in different age groups. Prepubertal natal girls may express the wish to be a boy, assert that they are a boy or assert that they will grow up to be a man. They prefer boy’s clothing and hairstyles are perceived by strangers as boys and may ask to be called a boy’s name. These girls may demonstrate marked cross-gender identification in role-playing, dreams and fantasies. Contact sports, rough and tumble play, traditional boyhood games and boys as playmates are often preferred. They show little interest in stereotypical female interests such as playing with dolls or feminine dress up or role play. Some natal girls may claim to have a penis or that they will grow one when older. They also may state that they do not want to develop breasts or menstruate. Prebuteral natal boys with gender dysphoria may express that they wish to be a girl or assert that they are a girl. They have a preference for dressing in girls’ or women’s clothing. They may role-play female figures (e.g., playing “mother”) and are often intensely interested in female fantasy figures. They may avoid rough and tumble play and competitive sports and have no interest in stereotypically masculine toys (e.g., cars, trucks). Some pretend not to have a penis and insist that they sit to urinate. They may state that their penis is disgusting and that they wish they didn’t have one. Natal adolescent males may begin shaving their legs at first sign of hair growth. They may also bind their genitals to make erections less visible. Girls may bind their breasts to make them less visible. Young adolescents with gender dysphoria may have clinical features that resemble those of children or adults with this condition depending upon developmental level. There is increasing research regarding the impact hormones (testosterone and estrogen) have on developing gender identity during adolescence although current research has not definitively defined the impact. Many young adolescents with gender dysphoria are concerned about imminent development of secondary physical changes such as the development of breasts for natal girls. In adults with gender dysphoria, the discrepancy between experienced gender and physical characteristics is often accompanied by the desire to be rid of the primary and secondary sex characteristics of their natal gender accompanied by a strong desire to acquire the primary and secondary sex characteristics of the other gender. Adults with gender dysphoria may adopt the behavior, clothing and mannerisms of the experienced gender. Adults with gender dysphoria may seek medical treatment to alter body characteristics or they may find other ways to resolve the incongruence between experienced/expressed and assigned gender by living in their desired role or by adopting a gender role that is neither conventionally male nor female. Adolescents and adults with gender dysphoria before gender reassignment are at increased risk for suicidal ideation, suicide attempts and suicides; however, after gender reassignments, the adjustment period varies and the suicide risk may persist.
Best Practices Diagnostic Approaches: An accurate diagnosis of Gender Dyphoria will generally include a careful diagnostic interview that performs a comprehensive mental status screening and gathers a thorough history of the client, including a detailed history of psychosexual development and disturbances thereof, and a history of perceived dysphoria between biological gender and experienced gender. A family history of emotional, physical, and/or sexual abuse, violence, and other kinds of family disruptions and dysfunction should be explored as a way to determine if the dysphoria may be more attributable to a history of trauma or socialized discomfort with the client’s biological gender. Further, the clinician will need to distinguish between gender dysphoria without a disorder of sex development and gender dysphoria with a disorder of sex development. Referral to a specialist in sexual and paraphilic disorders is also recommended, as this condition may be difficult to assess, diagnose and treat. Criteria for children are defined in a more concrete behavioral manner than those for adolescents and adults. Many of the core criteria come from well-documented behavioral gender differences between typically developing boys and girls. Young children are less likely than older children, adolescents and adults to express extreme and persistent anatomic dysphoria. In adolescents and adults, the incongruence between experienced gender and somatic sex is a central feature of the diagnosis. Factors related to distress and impairment can also vary with age. For children, there must be a marked incongruence between one’s experienced/expressed gender and assigned gender for at least 6 months. At least 6 of 8 criterion must be met for that duration. The criterion was described in the previous clinical manifestations section. In addition, the condition is associated with clinically significant distress or impairment in social, school or other important areas of functioning. For adolescents and adults there must be a marked incongruence between one’s experienced/expressed gender and assigned gender of at least 6 months in duration. There must be at least 2 of 6 criterion met to meet the criterion for gender dysphoria. In addition, the condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning. Rates of persistence of gender dysphoria from childhood into adolescence or adulthood vary from 2.2%-30% in natal males and 12%-50% in natal females.
Best Practices Treatment Approaches: Individuals with gender dysphoria disorder often have preoccupation with cross-gender wishes that interfere with daily activities. There may be a failure to develop peer relationships resulting in isolation from peer groups. Many individuals with gender dysphoria have a negative self-concept, increased rates of mental disorders, increased unemployment. Further, individuals’ access to health services and mental health services may be impeded as a result of institutional discomfort or inexperience in working with this patient population. It is critical that the clinician develop a trusting, supportive and non-judgmental relationship with the client in order to facilitate treatment. Cognitive behavioral therapy, family therapy and assisting client in developing and/or increasing social supports will be essential. The therapist will be in a crucial role of educating family members about gender dysphoria and the needs of the client. Medication management for symptoms of anxiety and depression may be necessary as well.
Other Conditions to Rule Out: Strong incongruence between natal gender and experienced gender can increase the risk of the development of depression, anxiety and substance abuse. It is important to limit the diagnosis of gender dysphoria to individuals whose distress and impairment regarding gender identity have met specific criteria. A differential diagnosis should be made between body dysmorphic disorder and gender dysphoria. Further, schizophrenia or other psychotic disorders and gender dysphoria may co-occur; however, in the absence of psychotic symptoms, an individual’s insistence that he or she is of another gender is not considered a delusion.
Comments: There is an increasing body of neurological research which is exploring the impact hormones – estrogen and testosterone – have in utero on the development of gender dysmorphia.


Other Specified Gender Dysphoria

DSM-5 Code: F64.8

This category applies to presentations in which symptoms characteristic of gender dysmorphia that cause clinically significant distress or impairment in social, occupational and other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The diagnosis would be:

F64.8 Other Specified Gender Dysphoria; the current disturbance meets symptom criteria for gender dysphoria, but the duration is less than 6 months.

Clinical Cases

In order to bring the information from this training closer to the experience of a mental health clinician, it may be helpful to see a number of different scenarios in which sexual problems were identified. These cases will help to illustrate the importance of conducting an assessment that addresses all aspects of the client’s sexual life: medical and physical, cultural, intrapsychic, and relational.

For the first case, we will demonstrate the use of the PLISSIT Model to establish an overview of the treatment approach. This will help clarify how best to use this model in actual clinical situations.

For some of these cases, there will also be information concerning different viewpoints taken by a group of sex therapists. This will help to demonstrate how different points of view can help to maintain flexible thinking on complex problems.

Case Concerning Delayed Orgasm

A 37 year-old woman in a lesbian marriage relationship came to a therapist telling of a lifelong history of difficulty with orgasm. She had her first orgasm at age 22 with oral sex, and she is able to orgasm now with a vibrator and with oral sex, but not with manual stimulation. Her concern is that orgasm is taking 30 minutes, she believes this is too long, and she gets concerned that her spouse (a woman she married in Canada last year) is getting tired.

The spouse states that she is not getting tired and her major concern is that her partner (the client) is upset about it. Recently the client saw a television program on Lifetime, Secrets of the Sexually Satisfied Woman (Berman & Berman) that showed a test to determine the sensitivity of the clitoris. Because the test indicated the woman on the program was not suffering from lack of sensitivity, the show did not focus on the potential treatment for lack of sensitivity.

The client would like to know what treatments are available if sensitivity in the clitoris is the problem. The client was on tricyclic antidepressants beginning at age 17, and for the past 5 years has been taking Zoloft. She realizes the Zoloft could be playing a role in lengthening the time to orgasm, but she states that she has always had the problem. Also, the Zoloft has had no impact on her sexual desire - she continues to have much desire and would like to be sexual with her spouse 2-3 times a week.


USING THE PLISSIT MODEL OF COUNSELING

P = PERMISSION
1. Bring up the topic of sex.
“How has___________ affected your sexuality?”
“Many people who come to the clinic have concerns about sexuality. What concerns do you have?”
2. Use words the patient understands.
3. Determine if the problems with reaching orgasm are primary, secondary, or situational.
4. Ask for a word picture of her experience--”Tell me what happens when _______”
5. Validate with the patient your understanding of what she is telling you
6. Explore self-concept, body image, values, knowledge, beliefs, cultural influences, family messages, current practices, feelings about touching body, past experiences, expectations of what is supposed to happen, fears involved, reactions of and to partner, nature of the relationship, fantasies, religious background.
7. Ask questions in a way that normalizes the experience.
8. Ascertain the meaning of her experience to her, to her partner.
9. Determine her expectations of treatment and the impact she believes the anticipated outcome will have in her life.

LI = LIMITED INFORMATION
1. Give general information related to orgasmic experiences – normative information of and beliefs about orgasms, societal and cultural influences on women’s sexuality, the effects of thinking vs. feeling during a sexual experience, common medication side effects
2. Address myths, misconceptions, and fears
3. Discuss anatomy and physiology
4. Give information about medical considerations that may affect orgasmic delay

SS = SPECIFIC SUGGESTIONS
1. Complete the Sexual Problem History
a. Description of current problem
b. Onset and course
c. Patient’s concept of cause and maintenance of problem
d. Past treatments and outcome
e. Medications, medical conditions, surgeries
f. Current expectations and goals of treatment
2. Recommend books and videotapes
3. Teach about the pubococcygeus muscle and Kegel exercises
4. Discuss client’s use of a vibrator - advantages and possible drawbacks
5. Suggest increasing awareness of turn-ons and time for self-exploration

IT = INTENSIVE THERAPY
Intensive therapy involves referral to a therapist who deals with sexual and other relationship issues. If this person is you, you will deal with the more chronic deep-seated personal and relational concerns such as past traumatic experiences; fears of loss of control and/or abandonment; unresolved anger; lack of communication skills; the relationship of sexuality and intimacy; the effects of medications and medical, surgical, & disabling conditions; cultural issues; and the meaning and value the symptom may hold for the patient.

Therapists’ Discussion of Case

Therapist 1
a) When I heard the description of the client's situation, my first response was, "What's the problem? She's totally normal!" My understanding is that it takes the average woman 20 minutes of stimulation to reach orgasm -- but that's an average, so it means that it takes half of women MORE than 20 minutes. So she's on the slightly longer than average side, but given the huge continuum of normal human sexual diversity, 30 minutes seems not uncommon.
b) She's worried her spouse is getting tired, but the spouse says she is not getting tired--so no problem there.
c) The main reason they came is to find out if there is indeed some type of pill or device that will facilitate orgasm. There is a device -- it's called a vibrator, and it works for her!
d) She can orgasm now with a vibrator and with oral sex, but not with manual stimulation. Isn't that also incredibly common? When I hear women talk about their orgasms, many say, "I can come from oral sex but not intercourse," or "with my vibrator but not with my hand," or "from intercourse but not oral sex," etc. Again, it seems to be to be very much in the normal range of the continuum of human sexual diversity. If anything, she can be celebrating that she has two different "methods" that work for her to be able to have an orgasm. Some women would be jealous!
e) From my perspective the problem may not be with the woman's body, but with a culture that is constantly sending women the message that their bodies may be defective. The client could seek out all kinds of tests and devices and pills. But I wonder if what she needs more is just loads of reassurance from the therapist, whom she has sought out as an expert, that her body is normal and that LOTS of women have very similar experiences related to orgasm. I guess this is basically one more message in agreement with those who have said that she seems to have very high standards for herself.

Therapist 2
Has the patient had her estradiol and free testosterone levels measured?

Therapist 3
My first thought certainly would be to de-emphasize the method of orgasm....make sex less 'goal-oriented'....I’d wonder about the variety of sexual technique in this couple...... wonder how arousing sex ever is, really, or if she/they are just doing it to 'get to the orgasm.' Second....I wouldn't rule out the role of the antidepressants, but....if she needs SSRI's, she might not do much differently than she's doing now with Zoloft, no matter what she tries (my psychiatrist friend tells me that although Lexapro has fewer sexual side effects than other SSRI's, the difference is like 30-50% instead of 50-70%. Third, oral sex and vibrator...not bad....her standards surely sound high.

Therapist 4
Bupropion (Wellbutrin) could be introduced with gradual weaning of the SSRI. Also consider a trial of decreased use of the vibrator; many women develop clitoral desensitization from chronic vibrator usage.

Therapist 5
You could suggest the Eros:
http://www.eros-therapy.com/index.cfm?optionid=523
You need a prescription to get it. It's a medical device - though I am told there is a similar device over the counter (OTC) for $50! However, one needs to rule out circulatory problems first, so suggest the OTC model with caution. What it does is give suction to the clitoris & surrounding tissues & so there is greater blood flow - it’s like a little vacuum for the clitoris. I just read an article that women who received radiation treatment used it with great success, and I saw an article saying it MIGHT be helpful for women who take SSRI's. However, I've got to tell you that it is such a weird little device that I've had virtually no takers.

Therapist 6
Regarding the Eros: It’s the cost (around $395) and the embarrassment of having to ask insurance about it. And frankly, some women just accept that for them, being on psychotropic medication is more important than an orgasm. If you have postpartum depression managed by meds, an orgasm is often at the bottom of the list of things to do.

Therapist 7
Regarding the Eros: We have heard from women who have had success with the Eros; in particular those who have had nerve damage or those who have received radiation treatment in the pelvic area. It is worth considering for the right population of women. Also, for those who seem squeamish about using a device, education is key.

Three Clinical Cases for Vaginismus

Case 1

A young woman aged 20 and her 22 year old husband presented for therapy for vaginismus. The couple had been married for two years and had not been able to have intercourse. History revealed that the couple had been together as a couple since junior high school and had made a decision to wait until marriage to have intercourse.

After marriage, they were unable to have intercourse due to the wife’s vaginismus. Therapy lapsed for a time, and several months later the wife returned alone and admitted that she had become involved in an ongoing extramarital affair. She also admitted that she no longer had vaginismus—her first experience of intercourse had occurred in the affair and happened on her 21st birthday.

At the time of her return to therapy, she was considering leaving her husband and marrying the other man. Once again, the client dropped from therapy, and several months later she returned, saying that she had stopped the affair, she and her husband were back together and doing well, and they were considering having a baby. When the therapist asked her what had happened, her response was, “I grew up.” Interestingly, the husband credited the therapist with the successful treatment of the vaginismus.

Case 2

Cultural influences can also play a role in vaginismus. An Indian couple presented complaining of inability to consummate their marriage of two years. Their primary objective for attempting to resolve the problem at the time they came for therapy was their desire to become pregnant.

The couple was in an arranged marriage, and had had very little contact with one another prior to marriage. When the therapist asked if difficulty with intercourse was a common problem in these types of Indian marriages, the husband responded, “Yes, but it usually gets better in six months. And you can tell from all the little Indian children running around that the problem does go away.”

In terms of solutions the couple had thought of prior to coming to therapy, the husband had considered possibilities such as getting his wife drunk and then attempting intercourse when she had passed out. The wife was not enamored with this idea. This case resolved quickly with education and exploration of concerns and some sex therapy exercises, and the couple was successful in having intercourse. Interestingly their first or second intercourse experience resulted in a pregnancy.

Case 3

Not all cases of vaginismus resolve as quickly. One young woman, age 31, has been coming to therapy every two-four weeks for a period of four years. Her presenting complaint was vaginismus, and she was referred by a nurse practitioner who was unable to perform a routine pelvic exam on the woman. This young woman had formerly been engaged, for a two year period, to be married, and was unaware she had vaginismus until her pelvic exam.

Earlier attempts in her life to use tampons had been unsuccessful, so she had stopped trying. History and ensuing sessions uncovered no history of trauma, but revealed a woman acutely fearful of any invasive procedures done to her body. In the past she had fainted when she took her cat to the veterinarian and when she herself received injections. Attempts to draw blood resulted in severe anxiety and the necessity of her having to lie down on a table.

The young woman, then age 26, was still living at home with her parents, and although she was a college graduate, she had been working for five years at a job requiring much commitment and responsibility that paid her $21,000 a year and gave her a one week vacation annually. She rarely took sick leave and was largely content, because she “really likes the job.” In the past four years she has asked for a raise (she’s now up to $26,000) and another week’s vacation (she now has two weeks per year), and she has moved out of her parents’ home and into her own apartment. She can receive injections and give blood samples while sitting in a chair.

Her vaginismus continues to be unresolved, and there seems to be no sense of urgency on her part to address the issue directly. She avoids pelvic exams, and a recent highly-valued romantic relationship ended with the boyfriend’s statement that he isn’t ready for a committed relationship. It is unclear how much of a role the vaginismus played in the breakup; earlier he told her that it wasn’t so important and that he would work with her on resolving it. No actual attempts at any type of insertive activities were made by the couple.

This completes the course on sexuality assessment and intervention. Following presentation of references, you may continue to the test section.

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