Sexual Dysfunctions: Etiology and Treatment

Sheila Garos. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.

Studies indicate that problems in sexual functioning may be quite common (Spector & Carey, 1990). As early as 1970, Masters and Johnson estimated that 50% of couples in the United States suffered from a sexual dysfunction (Masters & Johnson, 1970). Other estimates suggest that up to 24% of the U.S. population will experience a sexual dysfunction at some point in their lives (Robins et al., 1984). In 1992, Laumann and colleagues conducted a study to assess the prevalence and risk of experiencing sexual dysfunction across social groups (Laumann, Gagnon, Michael, & Michaels, 1995). They found that sexual dysfunction was more prevalent in women (43%) than in men (31%) and was associated with characteristics such as age, educational attainment, poor physical and emotional health, experiences in sexual relationships, and overall well-being. Having a sexual problem or dysfunction can invoke embarrassment, fear, shame, and feelings of inadequacy. For these reasons, the number of individuals who suffer with a sexual dysfunction is often greater than what reported statistics reflect.

Table 18.1 outlines the current classification scheme of sexual disorders found in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition [American Psychiatric Association, 1994]). Sexual dysfunctions are further classified into three subtypes: pain disorders, arousal disorders, and orgasmic disorders. To understand the etiology and treatment of sexual disorders, it is necessary to have some knowledge of the psychobiology of the human sexual response.

Background and Etiology

The Human Sexual Response

Biomedical advances and clinical studies suggest that for most people, human sexual functioning proceeds sequentially and rudimen-tarily involves a biphasic response that is composed of (a) tumescence, or the engorgement of the genitals with blood that leads to erection in men and vaginal lubrication and swelling in women, and (b) detumescence, or the outflow of blood from the genitals following orgasm (Bancroft, 1995; Herbert, 1996; Schiavi & Segraves, 1995; Wincze & Carey, 1991). However, the psychobiological mechanisms that underlie the sexual response are far more complex and warrant further investigation (Davis, 2001; Gaither & Plaud, 1997; Jupp & McCabe, 1989; Meston & Frohlich, 2000; Pfaus, 1999; Regan, 1996; Stoleru et al., 1999).

Table 18.1 DSM-IV Classifications of Sexual Dysfunctions

Pain Disorders Desire Disorders Arousal Disorders Orgasm Disorders Miscellaneous Classifications
Dyspareunia Hypoactive sexual desire disorder Female sexual arousal disorder Female orgasmic disorder Sexual dysfunction due to a medical condition
Vaginismus Sexual aversion disorder Male erectile disorder Male orgasmic disorder Substance-induced sexual dysfunction
Premature ejaculation Sexual dysfunction not otherwise specified

Masters and Johnson (1970) described a physiological model of the sexual response that included four physiological phases: excitement, plateau, orgasm, and resolution (Table 18.2). However, this model failed to address those patients who reported difficulty in becoming aroused or who expressed an aversion to sex (Kaplan, 1977). Subsequently, a “desire stage” was conceived that was believed to precede the “excitement” phase described by Masters and Johnson. Desire involves a patient’s “cognitive and affective readiness for, and interest in, sexual activity” (Wincze & Carey, 1991, p. 4).

Etiological Factors

Given the complexity of sexual performance, sexual desire, sexual satisfaction, and meaning of sexual behavior that is constructed from dominant culture and beliefs, one must not rely exclusively on physiological models to describe or assess sexual functioning (Laqueur, 1990; Tiefer, 1991). Diagnosis and assessment must include an evaluation of organic causes as well as psychogenic factors that contribute to, or occur secondarily to, a sexual dysfunction (Pollets, Ducharme, & Pauporte, 1999) such as conflict (Metz & Epstein, 2002), guilt (Walser & Kern, 1996), depression and other affective states (Seidman & Roose, 2001), trauma (van Berlo & Ensink, 2000), and anxiety (Shires & Miller, 1998). Likewise, principles of learning and conditioning in regard to the sexual response must be considered (Lalumiere & Quinsey, 1998), as should cognitive appraisals and expectancies about sexual arousal and desire (Palace, 1995; Weisberg, Brown, Wincze, & Barlow, 2001), relationship distress (Metz & Epstein, 2002), and developmental issues such as age and a person’s stage in life (Avina, O’Donohue, & Fisher, 2000; Bartlik & Goldstein, 2001; Dennerstein, Dudley, & Burger, 2001). Many patients develop sexual dysfunctions as the result of medical conditions such as spinal cord injuries (Sipski, Alexander, & Rosen, 2001), kidney disease (Malavaud, Rostaing, Rischmann, Sarramon, & Durand, 2000), diabetes (Bhugra, 2000), cancer (Merrick, Wallner, Butler, Lief, & Sutlief, 2001; Shifren et al., 2000), and other chronic illnesses (Schover, 1989). Finally, medications prescribed to treat a variety of medical and psychological conditions can often lead to reduced sexual desire or other interference with sexual performance (Gelenberg, Delgado, & Nurnberg, 2000; Waldinger et al., 2002).

Table 18.2 Sexual Response Phases and Associated Dysfunctions

Phase Characteristics Dysfunction
1. Desire Characterized by subjective feelings of sexual interest, desire, urges, and fantasy; no physiological correlates Hypoactive sexual desire disorder Sexual aversion disorder
2. Excitement Characterized by subjective and physiological concomitants of sexual arousal such as penile erection in men and vaginal engorgement and lubrication in women Female sexual arousal disorder Male erectile disorder
3. Orgasm Characterized by climax or peaking of sexual tension, with rhythmic contractions of the genital musculature and intense subjective involvement Female orgasmic disorder Male orgasmic disorder Premature ejaculation
4. Resolution Characterized by a release of tension and a sense of pleasure or well-being Dyspareunia Vaginismus

Source: Adapted from Weiner and Davis (1999, p. 411). In T. Millon, P. H. Blaney, & R. D. Davis (Eds.), Oxford Textbook of Psychopathology. Copyright © 1999 by Oxford University Press, Inc. Used by permission.

Assessment and Treatment

Basic Principles of Sex Therapy

Traditionally, sex therapy is a short-term therapy designed for the special treatment of sexual dysfunctions. Sex therapy is a behaviorally based, systematic protocol designed to move patients through a series of “graded experiences, from an avoided, partial, or plea-sureless response to a fully pleasurable response” (Birk, 1999, p. 525). Contemporary approaches to sex therapy often address issues in the patient as well as in his or her partnership more systemically. Emotional, spiritual, cultural, affective, cognitive, and social factors are addressed and evaluated. Thus, effective treatment of psychogenic sexual dysfunctions requires knowledge of family systems and family therapy as well as extensive experience in working with couples in general.

Overall Evaluation and Assessment

During an initial evaluation the clinician will typically seek demographic information, the nature and development of the dysfunction, a psychosexual history, a description of the patient’s current sex life, the partners’ perception of the quality of their relationship, the degree of psychopathology of one or both partners, physical health, and the patient’s motivation for and commitment to treatment (LoPiccolo & Heiman, 1978). The initial evaluation can seem quite invasive for the patient, and it is important to inform him or her why the type of information sought is necessary. Questions must be specific to ascertain the nature and degree of dysfunction and to help delineate between possible organic and psychogenic causes of the problem. Additional information that may be sought includes, but is not limited to, the patient’s personality, professional life, education, sexual development, sexual values, experiences with other partners, history of masturbatory behaviors, and attitudes about pleasure, family life, and religious background.

Overall Treatment Approach

Thoughts, attitudes, and feelings play a significant role in mediating physiological responses to sex. The goal of many techniques is to “replace antisexual anxiety with sexual pleasure” (Heiman, 1978, p. 123). Thus, facilitation and maintenance of arousal and associated thoughts, feelings, and attitudes are an important component in treating sexual dysfunctions. Psychophysiological measures such as nocturnal penile tumescence and daytime arousal evaluation can be used to assess subjective and objective measures of arousal. In addition, men being evaluated for erectile dysfunction (ED) may undergo a penile blood pressure examination.

A number of psychosocial interventions are available to help with sexual difficulties. Perhaps the most common is sensate focus, which involves teaching patients and their partners to engage in intimate physical and emotional closeness in a gradual nonthreatening manner. Homework is assigned in which couples engage in various stages of the protocol. Explicit instructions are given to couples as to how to approach each stage of treatment. “Rules” of engagement are outlined, with some of these rules prohibiting genital contact during the earlier phases of the exercise. Modifications can be made to best address the needs of the patient and the type of dysfunction being treated. Inclusion of steps and the duration of each is left to clinical judgment. An outline of sensate focus is presented in Table 18.3.

Female Sexual Dysfunctions

Hypoactive Sexual Desire Disorder. According to Laumann, Gagnon, Michael, and Michaels (1994), approximately 33% of women experience a lack of sexual interest at some point in their lives. From ages 18 to 24 years, about 32.0% of women report some difficulty with sexual desire; at ages 30 to 34 years, this number decreases to 29.5%. The largest group affected is women ages 35 to 39 years (37.6%). Among women ages 40 to 54 years, the number of women reporting desire disturbances declines, only to increase once again after that.

In the DSM-IV (American Psychiatric Association, 1994), sexual desire disorders fall into two categories: hypoactive sexual desire disorder (HSDD), defined as a “deficiency or absence of sexual fantasies and desire for sexual activity” (p. 496), and sexual aversion disorder (SAD). Diagnosis of HSDD generally involves clinical judgment as well as corroborating information from the patient’s partner (Rosen & Leiblum, 1989). It is important to keep in mind that often a partner with higher desire becomes the referent for the partner with lower desire, in which case it may be indicative of a desire discrepancy as opposed to a desire disorder. Clinical judgment must also take into account interpersonal determinants, frequency and chronicity of the symptom, subjective distress, effect on other areas of functioning, and the person’s current life situation. Some individuals have difficulty in initiating sexual activity; others are unresponsive to sexual advances from their partners (i.e., lack of receptivity). It is important to determine whether HSDD is global, with the patient lacking interest in any or all sexual activity, or situational, with the patient’s lack of desire occurring only with a specific partner or type of activity.

HSDD can occur as a secondary condition when other sexual dysfunctions are present (e.g., anorgasmia in women, ED in men). HSDD may also result from a number of physiological or psychological conditions, including other medical conditions (Phillips & Slaughter, 2000), stress, substance use, low self-esteem, anhedonia, hormonal changes, and negative self-evaluation (Heiman & Meston, 1997; Morokoff, 1985; Rosen & Leiblum, 1989). Medication side effects are another possible cause of reduced desire (Wincze & Carey, 1991). Finally, a history of sexual abuse or trauma, abuse, or assault can lead to decreased desire due to “chronic fears of vulnerability of loss of control, inability to establish intimate relationships, or a conditioned aversion to all forms of sexual contact” (Rosen & Leiblum, 1989, p. 27).

Table 18.3 Treatment Stages of Sensate Focus

  • Stage I: Nongenital pleasuring
  • At this stage, each partner will touch one another for at least 20 minutes. One partner will initiate and touch for the specified time, and then the two will switch roles and positions. The partner who is touching should be assertive by touching the other in ways and places (minus breasts, buttocks, and genitals) that are pleasing for the one doing the touching. Experimentation with touching each partner in new places and in new ways is encouraged. A partner can use his or her legs, hands, face, arms, and the like when touching the other partner. The partner being touched should concentrate on relaxing his or her whole body and the sensations that touch by the other partner is creating. If spectatoring or anxiety is a problem, the couple should stop for a few moments until relaxed and then start again. If either partner becomes aroused, it is permissible to masturbate to relieve tension so long as the person does it himself or herself. In some cases (e.g., a past history of trauma), the partners can begin this stage with their clothes on.
  • Stage II: Touching for One’s Own and One’s Partner’s Pleasure
  • This stage is similar to Stage I. Each stage has two parts, with one partner caressing and touching the other first and then the partners switching roles. What differs is that at Stage II, each partner indicates to the other what he or she would like the other to do. A hand can be placed over that of the partner to demonstrate how one would like the touch to feel (e.g., faster, harder, softer, slower, more to the right). It is still up to the person who is doing the caressing to decide what he or she will do. Partners are encouraged to discuss their experience after each stage.
  • Stage III: Sensate Focus With Genital Focus
  • The same basic principles apply to this and the remaining stages of treatment. A ban on intercourse remains; however, genital contact with the mouth and/or hands is now permitted. A will caress B, and then B will caress A. During this stage, change in the pressure, speed, or direction of touch can profoundly affect the sensation received. Thus, communication is of utmost importance. Couples are told not to focus on genital regions exclusively and to spend as much time as before on genital kissing and touching. At this stage, lubricants, oils, and lotions are permitted to enhance pleasure of both partners. The main objective is still to concentrate on and enjoy the bodily sensations being experienced. Should one of the partners become aroused or experience orgasm, the session can continue. It is important to remember that orgasm is not the “goal” of the session.
  • Stage IV: Sensate Focus With Genital Contact and Simultaneous Caressing
  • The focus of this stage is on simultaneous caressing that enables both partners to give and receive pleasure at the same time. Partners are encouraged to communicate to each other when one is doing something that feels particularly nice. Self-assertion and self-protection are also encouraged.
  • Stage V: Vaginal Containment
  • Once the sensate focus is established with consistency, some ejaculatory control is exercised, and erections can remain reasonably firm, the couple is ready for Stage V. This stage is designed to facilitate sensory focus and enjoyment without performance anxiety. Once the partner is ready and the patient is able to maintain a reasonably firm erection, the partner will guide the patient’s penis into her vagina. The most accommodating position for this is the “female superior” position, where the patient lies flat on his back with the partner kneeling above him with her knees on either side of his body, roughly at the level of his nipples. The woman will gently insert her partner’s penis into her vagina. This allows the partner to have greater control. The goal of this stage is for the partners to reorient themselves with the sensation of the penis and the vagina. The woman should tighten and relax her vaginal muscles on her partner’s penis. Genital caressing may resume. The patient is told to concentrate on sensations while the partner keeps control of what is happening. Couples are also to resist the desire to thrust.
  • Stage VI: Vaginal Containment With Movement
  • It is important to remind the partners at this stage that they are to employ the same principles concerning physical contact that they used at the beginning of treatment. Giving and receiving pleasure, and touching each other in a way that is pleasing to both partners, remains the aim of treatment. Mutual caressing continues and involves both genital and nongenital areas. Each partner should feel aroused and receptive before vaginal entry takes place.
  • After vaginal containment is tried for some time, limited thrusting can be tried to assess each partner’s sensations and feelings. Either partner is allowed to tell the other to stop at any time so as to set limits and boundaries without fearing that the partner will become angry. It is also important to remember that responsiveness will vary from stage to stage and from month to month. At this point, the clinician should reiterate that orgasm, particularly mutual orgasm, is not the goal that must be satisfied to meet the expectations of the patient or his partner.
  • Cognitive restructuring techniques, such as challenging negative attitudes and learning to reduce intrusive thoughts, are often incorporated into treatment. Communication training is often a vital element in the treatment of sexual dysfunctions because many couples lack effective communication skills in general and are particularly reluctant to communicate their sexual needs, likes, dislikes, and desires.
  • The use of erotic materials or “toys” is sometimes recommended to patients and should be approached as exposure to a sexual experience with attention paid to mood and setting. Of course, it is essential to assess the patient’s or couple’s views about the use of such materials to determine whether these approaches are viable and would not be considered offensive or objectionable. Masturbation training with fantasy should be approached with similar caution. It should not be assumed that all patients know how to masturbate or how to do so effectively. Masturbation training, when used successfully, can help to build sexual confidence and desire.
  • Other treatments for male sexual dysfunctions include vasoactive therapies, which involve the use of intracorporeal injections of papaverine or transurethral alprostadil suppositories. These agents act as vasodilators. Surgical approaches can be used to correct male erectile dysfunction and include the placement of an implantable penile prosthesis, penile arterial revascularization, and penile venous ligation. Vacuum devices can also be used to draw blood into the corpora cavernosa of the penis. Placing a band around the base of the penis then traps the blood. Among pharmacotherapeutic agents, the most recent, and perhaps most popular, is sildenafil (Viagra).

In the assessment of HSDD, frequency of activity should not be considered a reliable indicator of sexual desire. However, initiation is an important consideration because it serves as an indicator of female motivation to engage in sexual behavior (Wallen, 1990). Often, a patient will engage in frequent coitus or other sexual activities out of a sense of obligation, coercion, or an attempt to please or accommodate his or her partner’s wishes and preferences. Likewise, one must consider that symptoms of low desire may reflect problems of relationship intimacy, power differentials, or territoriality in the relationship (Verhulst & Heiman, 1988).

Masturbatory practices vary, as do cognitive correlates of desire such as fantasy (Schreiner-Engel & Schiavi, 1986). Moreover, gender differences must be taken into account in the evaluation of cognitive descriptors of desire (Denney, Field, & Quadagno, 1984; Jones & Barlow, 1990; McCauley & Swann, 1978, 1980; Person, Terestman, Myers, Goldberg, & Salvadori, 1989).

A number of treatment strategies are available to address problems associated with sexual desire disorder (for a review, see O’Donohue, Dopke, & Swingen, 1997). These approaches include (a) psychotherapy (Kaplan, 1977; Scharff, 1988), (b) cognitive-behavioral approaches (Rosen & Leiblum, 1989), (c) cognitive restructuring (LoPiccolo & Friedman, 1988), (d) analysis of interactional and communication patterns (Schwartz & Masters, 1988), (e) “territorial interactions” (e.g., “When you touch my body, I feel like you are invading my space”), (f) “rank-order” communication (e.g., “I always feel like the underdog in sexual relationships”), and (g) “attachment interactions” (e.g., “I find it hard to trust you after my feelings have been hurt”) (Verhulst & Heiman, 1979, 1988). Other strategies include the use of pharmacological agents, hormonal treatments, and the “coital alignment technique” that can help to increase effective stimulation for women during intercourse (Pierce, 2000). In some cases, the use of sex toys and other stimuli (e.g., fantasy, erotic material) and “orgasm consistency” training (Hurlbert, White, Powell, & Apt, 1993) may be helpful.

Sexual Aversion Disorder. SAD is a more severe disruption in desire. SAD is characterized by a “marked aversion to, and active avoidance of, all genital contact with a sexual partner” (American Psychiatric Association, 1994, p. 499). The aversion to genital contact “may be focused on a particular aspect of sexual experience (e.g., genital secretions, vaginal penetration)… [or] revulsion to all sexual stimuli, including kissing and touching” (p. 499). This disorder is often accompanied by poor body image and avoidance of nudity (Katz, Gipson, & Turner, 1992; Ponticas, 1992). Women with SAD may experience reactions such as terror, panic, and nausea. Efforts to cope with the disorder may include avoidance of sexual contact, substance use, and neglect of one’s personal appearance. Although SAD and HSDD are distinct, the two conditions are often related and have similar causes such as endocrine alterations, medical conditions, psychological distress, relationship factors, prior sexual trauma, and negative learning experiences (Halvorsen & Metz, 1992).

In treating SAD, it is important to understand the “approach-avoidance” conflict that exists in many of these patients (Ponticas, 1992). Given that most causes of SAD are not physiological, addressing psychological issues that underlie the disorder is of particular importance in treatment. In addition to psychotherapy, systematic desensitization and vicarious extinction techniques can be used to reduce or minimize the patient’s anxiety and fear response (Wincze, 1971).

Female Orgasmic Disorder. Anorgasmia is regarded as the most common sexual dysfunction in women (Heiman & Grafton-Becker, 1989; Spector & Carey, 1990). Moreover, approximately 85% to 90% of women report having orgasms without difficulty; however, only one third have had an orgasm during intercourse (Seeber & Gorrell, 2001). In addition, the incidence of orgasmic difficulty tends to be higher in single women (Laumann et al., 1994).

Female orgasmic disorder is characterized by “a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase” (American Psychiatric Association, 1994, p. 505). Clinical judgment is an important factor in diagnosing this condition given that a woman’s orgasmic capacity must be determined to be less than would be “reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives” (p. 505). Many women express concern that something is “wrong with them” if they do not experience orgasm during intercourse or if they have multiple or simultaneous orgasms. Patients need to know that many women do not reach orgasm during coitus because penile stimulation is often not intense or direct enough to produce orgasm.

Women’s orgasmic potential and type of orgasm are variable. Orgasmic capacity has been associated with sexual assertiveness (Hurlbert, 1991), comfort with masturbation (Kelly, Strassberg, & Kircher, 1990), and relationship and psychological distress (Kaplan, 1992; McGovern, Stewart, & LoPiccolo, 1975). Most women have clitoral orgasms that result from stimulus to the clitoris and surrounding tissues. Fewer women have pelvic floor or vaginal orgasms, and for some women orgasm involves a combination of the two. It is important to discern whether the patient’s orgasmic disorder is situational (i.e., the patient is able to reach orgasm via masturbation but not by manual stimulation or intercourse) or generalized (i.e., occurring across all situations and partners). Female orgasmic disorder typically does not arise from a physiological condition and is generally not correlated with vaginal size or pelvic muscle strength. However, some conditions (e.g., spinal cord injuries, vaginal excision and reconstruction) have been associated with orgasmic difficulty. Medications such as benzodiazepines, antihypertensives, neuroleptics, and antidepressants may contribute to orgasmic difficulty, as can substance use and abuse.

Often, the source of orgasmic difficulty in women is their own or their partners’ lack of knowledge about the female sexual response and female genitalia. The problem is often resolved by helping clients and their partners learn to extend stimulation and lovemaking beyond genitally focused sex. Greater sensate exchange between partners, expanding women’s arousal pattern, directed masturbation, and anxiety management also can be helpful.

Dyspareunia and Vulvodynia. Estimates of the prevalence of dyspareunia range from 8.0% (Osborn, Hawton, & Gath, 1988) to 33.5% (Glatt, Zinner, & McCormack, 1990). Although accurate prevalence rates are difficult to determine, studies have shown that causal attributions of pain are related to levels of adjustment. For example, women who cited psychosocial attributions indicated greater psychosocial distress, more problems with sexual function, and more frequent reports of sexual assault as well as lower levels of marital adjustment (Meana, Binik, Khalife, & Cohen, 1999).

Pain is a subjective experience. In dyspareunia, the phenomenology of pain is genital and associated with intercourse. In some cases, pain occurs before or after intercourse as well. In women, “the pain may be described as superficial during intromission or as deep during penile thrusting…, [with] symptoms rang[ing] from mild discomfort to sharp pain” (American Psychiatric Association, 1994, p. 511). Vulvodynia refers to pain located specifically in the vulva. Dyspareunia can be lifelong or acquired as well as generalized or situational. Abarbanel (1978) suggested four phenomenological categories of pain associated with dyspareunia: (a) perception of a sharp but momentary pain that varies in intensity, (b) repeated and intense discomfort, (c) aching, and (d) intermittent painful pangs or twinges. A thorough medical examination must be conducted to rule out physical factors such as pelvic tumors, hymeneal remnants, prolapsed ovaries, and scarring that occurs as a result of either an episiotomy or vaginal repair (Bancroft, 1995). Hormonal changes that result from contraceptive use or menopausal changes can lessen vaginal lubrication and subsequently cause soreness and irritation during intercourse or penetration. Once organic causes of pain are ruled out, psychological factors such as anxiety, poor body image, religiosity, anger, and distrust toward the patient’s partner should be investigated.

Psychotherapy is an important element in the treatment of dyspareunia and should be approached in a multimodal framework to examine the patient’s (a) behavior (e.g., deficits and shortcomings in sexual techniques), (b) affect (e.g., feelings of guilt, shame, and anger), (c) sensation (e.g., assessment of the location, type, frequency, and intensity of pain), (d) imagery (e.g., body image, negative memories), (e) cognition (e.g., negative self-statements, dysfunctional beliefs), (f) interpersonal functioning (e.g., communication, climate between partners), and (g) biological factors (e.g., improper hygiene, medications) (Leiblum & Rosen, 1989).

Vaginismus. Vaginismus is a relatively rare disorder characterized by “recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted” (American Psychiatric Association, 1994, p. 513). In some women, thoughts of penetration alone can create spasms. Contractions can be mild, creating tightening and discomfort, or severe, preventing any penetration. Sexual desire, pleasure, and orgasmic capacity can be impaired as a result of the disorder. The patient should be screened for potential organic factors that can contribute to formation of the disorder such as vaginal hysterectomies or other surgeries, atrophic vaginitis, endometriosis, painful hymenal tags, and urethral caruncle (Lamont, 1978; Tollison & Adams, 1979). Although many of these conditions are not directly responsible for vaginismus, they may be associated with the disorder indirectly through classical conditioning.

The main objective is to eliminate the “spasmodic reflexive contraction of the muscles controlling the vaginal entrance typically through a series of gradual approximations with the insertion of increasingly larger dilators” (Leiblum, Pervin, & Campbell, 1989, p. 113). Use of graduated rubber or plastic catheters helps to extinguish the conditioned spasmodic response via systematic desensitization. The patient or her partner’s fingers can also do insertion. In addition, it is important that the patient feel in control of what is happening, and this extends to her guiding penile entry during coitus. Use of the female superior position during intercourse should be suggested because this can help the patient to maintain control of entry and movement. Cognitive-behavioral approaches are also used to challenge underlying thoughts and beliefs that drive the conditioned fear response. Psychotherapy can be used to explore unconscious fears and conflicts that may underlie the disorder. Therapy should include progressive relaxation techniques and fantasy exercises to help alleviate fears of gynecological exams as well as intercourse.

Male Sexual Dysfunctions

Male Erectile Disorder. An estimated 30 million men suffer from ED in the United States. ED prevalence rates increase to more than 50% in men ages 50 to 70 years, and ED occurs in approximately 40% of men with diabetes (Feldman, Goldstein, McKinlay, Hatzichristou, & Krane, 1994). In men under age 35 years, approximately 70% suffer from psychogenic ED, whereas 85% of men over age 50 years have organic ED (Weiss & Mellinger, 1990).

ED has been defined as an inability to achieve or sustain an erection of sufficient rigidity or duration to enable satisfactory sexual performance (American Psychiatric Association, 1994). Often, ED is associated with older age (Marumo, Nakashima, & Murai, 2001). There are different patterns to ED, with some patients reporting an inability to obtain an erection from the onset of sexual activity and others reporting having a satisfactory erection at the onset of sex but then losing the erection when attempting penetration or once penetration is complete. Particularly when ED is psychogenic, patients will frequently report having an erection on awakening or during self-masturbation. Subtypes include lifelong versus acquired and generalized versus situational.

To obtain a diagnosis of ED and an accurate understanding of the etiology of the disorder, assessment should include a detailed sexual and medical history, physical examination, and psychological interview. A medical history and a physical examination are particularly important because a number of physiological factors contribute to the pathophysiology of ED. These conditions include, but are not limited to, (a) cardiovascular disease and hypertension (Burchardt et al., 2001), (b) other vascular disorders and neuropathy associated with diabetes (Dey & Shepherd, 2002; Hecht, Neundorfer, Kiesewetter, & Hiltz, 2001), (c) prostate cancer or prostate cancer treatments (Incrocci, Slob, & Levendag, 2002; McCullough, 2001; Potters, Torre, Fearn, Leibel, & Kattan, 2001), (d) spinal cord lesions (Biering-Sorensen & Sonksen, 2001), and (e) hyperparathyroidism (Chou et al., 2001). Depression (Seidman & Roose, 2000), cigarette smoking (McVary, Carrier, & Wessells, 2001; Spangler, Summerson, Bell, & Konan, 2002), and medications (Gelenberg et al., 2000; Rizvi, Hampson, & Harvey, 2002) can also affect erectile function.

Other assessment techniques include measurement of voluntary contractile activity of the ischiocavernosus muscle (Kawanishi et al., 2001), penile pharmacotesting with alprostadil (Aversa et al., 2002), sexual stimulation penograms (Choi et al., 2002), and measures of nocturnal penile tumescence (Basar, Atan, & Tekdogan, 2001).

Several treatment options are available for organic causes of ED. There are pharmacological agents such as apomorphine (Altwein & Keuler, 2001; Mulhall, Bukofzer, Edmonds, & George, 2001), yohimbine (an alpha-adrenore-ceptor blocker) (Tam, Worcel, & Wyllie, 2001), hormonal treatments, and (most recently) sildenafil citrate (Viagra). Sildenafil has been shown to be efficacious in treating ED in men who suffer from mild to moderate depressive illness (Muller & Benkert, 2001; Seidman, Roose, Menza, Shabsigh, & Rosen, 2001) and spinal cord injury (Sanchez et al., 2001). Sildenafil has also been shown to be a safe and effective treatment of ED in both long- and short-term treatment (Burls, Gold, & Clark, 2001; Fagelman, Fagelman, & Shabsigh, 2001; Steers et al., 2001) and has been found to improve the quality of life in those patients who use sildenafil (Giuliano, Pena, & Mishra, 2002). Studies suggest that sildenafil is particularly effective in cases of arterial insufficiency and psychogenic causes of ED (Basar, Tekdogan, et al., 2001) and that the drug is well tolerated in men over age 65 years (Tsujimura et al., 2002). However, even when the patient is treated effectively with sildenafil, it is important to address the psychosocial factors that either preceded or developed as a result of ED (Dunn, Croft, & Hackett, 1999; McDowell, Snellgrove, & Bond, 2001), given that sexual satisfaction (Shirai, Takimoto, Ishii, & Iwamoto, 2001), quality of partnership (Muller, Ruof, Graf-Morgenstern, Porst, & Benkert, 2001; Paige, Hays, Litwin, Rajfer, & Shapiro, 2001), and attitudes toward interventions have important consequences for the planning and treatment of sexual problems and partner satisfaction.

Intracavernosal injections are another treatment option (Richter, Vardi, Ringel, Shalev, & Nissenkorn, 2001). Intracavernosal injection of alprostadil (Caverject) has resulted in reported success rates of 67% to 85% (Engelhardt, Plas, Hübner, & Pflüger, 1998). When injected directly into the corpus caver-nosum, alprostadil causes the arteriolar smooth muscle cells to relax. No more than three injections per week, with a period of 24 hours between administrations, is recommended. Another option is transurethral alprostadil. Once the suppository is inserted, it will first diffuse into the corpus spongiosum and then into the corpus cavernosum, whereby the arteriolar smooth muscle relaxes, resulting in an erection (Viera, Clenney, Shenenberger, & Green, 1999).

A third option in the treatment of organic ED is a vacuum erection device. Most devices work by creating a vacuum in a cylinder placed over the penis. The vacuum draws blood into the corpora cavernosa and is trapped by placing a constricting band at the base of the penis. Another option is the penile prosthetic implant. Two types of implants exist: a semi-rigid silicone implant (Small, Carrion, & Gordon, 1975) and a hydrolic inflatable device (Scott, Bradley, & Timm, 1973). However, factors such as poor marital adjustment and poor coping ability have been associated with poor postsurgical results (Meisler, Carey, & Krauss, 1988; Schover, 1989).

In cases of psychogenic ED, the patient should be referred for sex therapy, the goal of which is to restore the patient’s potency to the best level possible. The meaning of impotence must be explored and transformed into cognitive and emotional experience because “attentional processes are highly salient in creating disruption of genital responsivity” (Beck, 1986, p. 218). Men with psychogenic impotence often express feelings of inadequacy, confusion, fear, anger, and shame. Performance anxiety becomes central in their sexual experience as they take on a “spectator” role, watching to see whether their penises will “perform” at will as expected. Once an erectile “failure” occurs, the cycle of anxiety, fear, and shame repeats itself. Self-generated distraction techniques that use cognitive interference have been used successfully to help manage anxiety in patients with ED (Beck, 1986; Beck & Barlow, 1986a, 1986b).

Partners of men with psychogenic impotence experience their own fears and frustrations. It is common for a partner to think that she is somehow responsible for the patient’s difficulties. For example, the partner may think that she is no longer attractive to the patient or that the patient is having an affair. Thus, it is important to include the partner in treatment so that the relationship can be treated as well (Leiblum, 2002). Men with psychogenic ED can overcome the disorder “by understanding their responses to their dilemmas, integrating previously unacknowledged feelings, seeking new solutions to old problems, increasing communication, surmounting the barriers to intimacy, and restoring sexual confidence” (Althof, 1989, p. 239).

Various interventions can be used in the treatment of psychogenic ED. Behavioral exercises and cognitive-behavioral therapy can be used to confront performance anxiety, dispute irrational beliefs, counteract negative body image issues, and heighten sensuality. Sensate focus is a central aspect of treatment (Table 18.3). In addition to using these behavioral approaches, the couple needs to be educated about sexual function and anatomy. Therapy can also address the destructive sexual system and dysfunctional relationship dynamics that inevitably develop in these cases.

Male Orgasmic Disorder. Male orgasmic disorder is characterized by “persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase” (American Psychiatric Association, 1994, p. 507). Consideration of this diagnosis must take into account the patient’s age and whether the amount of stimulation the patient receives is adequate in duration and intensity. Delayed ejaculation can occur during lovemaking and/or during masturbation. Most men with orgasmic disorder report feeling sufficiently aroused at the onset of sex. However, coital thrusting soon feels like a chore rather than a source of pleasure. Maintaining an erection is not a problem. Soreness and discomfort due to prolonged rubbing can aggravate matters and often makes for greater frustration for both the patient and his partner. Certain medical conditions (e.g., spinal injuries, nerve damage, diabetes), substance abuse, and medications (e.g., beta blockers, antidepressants) can cause the disorder. In fact, drug therapies are the most common cause of the dysfunction. A thorough examination by a physician is warranted. Psychological problems, such as traumatic childhood experiences, extreme anxiety or guilt, ridicule from a past partner, and feelings of anger, can also contribute to the disorder.

A distinction must be made between male orgasmic disorder and “retrograde ejaculation.” Normally, ejaculation is caused by contraction of the pelvic muscles, which are behind the penis and expel semen out of the penis through the urethra. Retrograde ejaculation is a condition in which semen travels back into the bladder instead of forward through the urethra (Wolf, 2001). Although semen is absent, the sensation of orgasm is still usually pleasant.

A third type of orgasmic disorder is called anejaculation. In this condition, the patient is unable to ejaculate at all. Anejaculation can be caused by spinal injury or duct abnormalities (Cole, 2002; Goldstone, 2000) or by psychological factors. A thorough medical examination is necessary to rule out any physiological causes, at which point referral to a sex therapist or psychologist is warranted.

If an orgasmic disorder is caused by medication, symptoms should remit once the medication is discontinued or the dose is adjusted. In the case of retrograde ejaculation, oral medications are available that can help to contract bladder neck muscles. Psychotherapy can help by giving the patient “permission” to concentrate on his own pleasure as well as by examining underlying psychological factors that may be contributing to the problem.

Early or Premature Ejaculation. Despite its common occurrence, it is difficult to estimate the frequency of premature ejaculation (PE). Estimates have ranged from as low as 4% (Metz, Pryor, Abuzzahab, Nesvacil, & Koznar, 1997) to as high as 36% (Nettelbladt & Uddenberg, 1979). It is estimated that approximately 25% of men report having an unsuccessful first intercourse experience, with the most common reason being that ejaculation occurs before vaginal penetration (McCarthy, 1989). The DSM-IV (American Psychiatric Association, 1994) defines PE as the “persistent or recurrent onset of orgasm and ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it” (p. 509). Definitions of PE vary, and this is reflected in experimental and clinical research (Rowland, Cooper, & Schneider, 2001).

When considering a diagnosis of PE, it is important to take into account the patient’s age, novelty of the sexual experience or partner, and frequency of sexual activity. Relationship stress, anger at one’s partner, anxiety about intimacy, and low frequency of intercourse are other possible causes of PE. Assessment of PE should include an investigation of neurological conditions, acute physical illness, physical injury, and medication side effects (Metz & Pryor, 2000). It is also important to determine whether early ejaculation occurs during masturbation and whether it is partner specific.

It is helpful to understand the physiology of the male orgasm to better understand PE. Ejaculation occurs as a result of many different physiological events. Many young men think that orgasm and ejaculation are the same when in fact the two are related but separate processes. It is possible for men to have an orgasm without ejaculating (dry orgasm), just as it is possible to experience a partial ejaculation without the sensation of orgasm.

Early in sexual development, masturbation is often practiced in a rapid, intense, and goal-oriented fashion. As a result, the “adolescent male focuses only on penis stimulation and is intent on reaching orgasm and the associated few seconds of intense pleasure” (McCarthy, 1989, p. 145), and this is counter to the process of learning ejaculatory control. Feelings of guilt, anxiety, shame, and/or fear of being caught may contribute to the problem. Eventually, a combination of high anxiety and sexual excitement can create a pattern of early ejaculation, which is often made worse by the tendency of the patient to self-monitor his orgasmic response. Thus, an important component of treatment is teaching the patient to experience masturbation and intercourse as a more sensual, pleasure-focused, and “whole body” experience.

Orgasm in males is a two-phase process consisting of the emission phase and the ejaculatory phase. Emission is the movement of semen into the urethra. Expulsion is the propulsion of semen out of the urethra at orgasm. A reflex of pelvic floor muscles that rhythmically contract causes ejaculation. There is a point at which men are not able to voluntarily control ejaculation. This is called the point of “ejaculatory inevitability,” which is usually a few seconds before the start of ejaculation. A central intervention in the treatment of PE is to help the patient learn to identify and control the point of ejaculatory inevitability. One method used to accomplish this involves what is called the “stop-start” technique. The patient begins by instituting the “start-stop” technique during masturbation. Usually this begins without the use of lubrication. This allows the patient more privacy and control. The patient stops self-stimulation until he feels like he has regained control. At that time, he begins stimulating his penis again. This procedure is repeated over time until the patient is able to prolong his engagement in sexual stimulation while controlling his urge to ejaculate. Eventually, this procedure is transferred to stimulation with the partner. The couple can institute the technique by having the partner on top with the patient instructing the partner to stop movement when he senses he is losing control. Often, the couple can progress to simply slowing down when the patient begins to feel close to ejaculating.

Case Study

“Reggie,” age 30 years, and “Marsha,” age 27 years, sought therapy with a presenting complaint of marital discord. The partners stated that their marriage of 2 years was already in trouble and that therapy was their “last resort.” Both Reggie and Marsha said that they loved one another and did not want to separate or pursue a divorce. Neither was married before. The partners had no children but expressed that having children was something they would like to do in the future. Marsha was in the third year of her doctoral program in education. Reggie was currently working two part-time jobs while searching for employment as a data operations manager. Reggie had his B.S. degree but had “no desire to go back to graduate school.”

The partners agreed that over the past 8 months their relationship had become more and more strained. Marsha expressed aggravation with what she termed “Reggie’s lack of motivation in seeking stable employment.” Marsha was feeling extremely pressured with graduate school, and although she earned a small income by teaching, the couple was having to rely on school loans as its main source of support. Reggie disagreed with Marsha’s assessment of his job search efforts. He maintained that Marsha’s anger was due to her desire to start a family and that she interpreted his “lack of motivation” as an indicator that his desire for children was not as great as hers. As the assessment continued, more information was gained about the partners’ respective developmental histories, family lives, family compositions, and medical conditions. Neither had any past psychiatric history. Both were occasional “social” drinkers, with no history of substance abuse. Neither partner smoked.

When asked about previous relationships, Reggie stated that he had been engaged at age 22 years but that his fiancé had called off the wedding. Since that time, he dated and had sexual relationships with several women until he began dating Marsha 3 years ago. Marsha dated in high school. She had two long-term relationships; one lasting 2½ years and the other lasting 6 years. The 6-year relationship was with her “high school sweetheart” and began when Marsha was age 17 years. The other relationship took place with a man she met in college when Marsha was age 24 years. Reggie and Marsha had experience with sex prior to their marriage. Reggie claimed that he found sex pleasurable but that he recently had trouble maintaining an erection. He stated that he had less interest in sex. He denied any past erectile difficulties. In contrast, Marsha suffered pain with intercourse that worsened over time. She began having pain at age 23 years. Marsha described the pain as a “sharp stab high up inside me” that occurred after entry and during intercourse. Marsha was recently referred to a urologist, who told her that one reason for her pain was that her urethra was situated very close to her vagina, and this could create abdominal pain during intercourse, particularly during orgasm. She was given an antispasmodic medication. Marsha complained about using the medication because it had to be taken with a lot of water several hours prior to intercourse.

Marsha and Reggie were seen individually for one session. In the session with Marsha, she stated that she is able to lubricate without difficulty and can experience orgasm during oral sex and masturbation. She also reiterated her suspicion that Reggie might not want children after all. She expressed feeling angry and betrayed. Marsha also described herself as “focused and intense” and stated that Reggie tends to be much more passive in the relationship, causing Marsha to feel as though she has to be “the responsible one.” Marsha reported that another source of discord was Reggie’s avoidance of conflict. Marsha insisted that Reggie will “tell me what I want to hear” rather than what he really thinks.

In the session with Reggie, he disclosed that he was not ready to have children and felt great pressure from Marsha to “get his act together” so that the couple will be in a better financial position to start a family. Reggie expressed that he moved across the country and left a good-paying position so that Marsha could attend graduate school. He felt resentful that Marsha “seems to forget that.” Reggie stated that since his erectile difficulties began, he has been able to maintain an erection on some occasions during masturbation. He has also awakened with an erection periodically. Reggie stated that he rarely initiates sex. When Marsha initiates sex, he tells her that he is tired or not in the mood.

Reggie and Marsha had a number of relational issues that needed to be addressed in therapy before sex therapy would become the focus of treatment. During the first month of treatment, the couple’s relationship was the focus of therapy. Reggie and Marsha were asked not to engage in sexual activity during this time. They were encouraged to show affection and be close if and when they were comfortable with doing so. As the partners’ relationship began to improve, they began spending more time with each other, reported enjoying each other’s company more, and were expressing more affection toward one another. Working on their relationship in general helped to move them to greater nonsexual intimacy, and this is often an important step in sex therapy. Despite the request not to do so, the couple attempted intercourse twice before sex therapy began. Each time, Reggie was unable to maintain his erection. Marsha complained that she was still finding the experience painful. It is common for couples to “break the rules” during treatment and to engage in sexual intercourse or other forms of genital contact. Thus, it is important to let the couple know that unsuccessful attempts are a frequent and “normal” occurrence so as to avert further setbacks.

Reggie had expressed feeling upset with himself. Marsha admitted that she would become frustrated and angry when “sex didn’t work.” Reggie was experiencing interfering thoughts prior to and during sexual relations. He admitted feeling “like less of a man” since his problem began. He readily became worried about the quality and duration of his erection as well as images of Marsha’s displeasure, disappointment, and anger. These thoughts would lead to greater anxiety and depression.

It was important to work with Reggie to help him restructure his thoughts and focus on thoughts that would facilitate feeling pleasure rather than those that would inhibit his sexual function. Once Reggie was better able to establish a positive sexually facilitating thought process, he was ready to proceed with sensate focus. During this time, Marsha’s fear that she was somehow responsible for her husband’s lack of sexual interest, and the subsequent feelings of inadequacy and frustration, were explored. This was an important component in assessing Marsha’s cognitive process. Misunderstandings on the part of the partner can sabotage treatment. Educating the couple about ED helped to alleviate some of Marsha’s fears and resentment. The couple also had to be educated about sensate focus and why certain restrictions were warranted during the intervention.

Prior to beginning sensate focus, couples should be told to assert and protect themselves during each session. Self-assertion involves the expression of phrases such as “I would like you to …” and “Why don’t you …” Examples of self-protective phrases would include “I don’t find that pleasing” and “Please touch me somewhere else.” A gentle removal of a partner’s hand can also serve this purpose. One reason for this is that partners need to realize that likes and dislikes can be communicated without personalizing one another’s statements. A formal agreement is made between the partners to ban attempts at intercourse or other genital contact during early stages of the program. This agreement removes the pressure to “succeed” or perform. Goals of sensate focus include (a) learning to touch one’s partner for one’s ownpleasure, (b) relaxing when being caressed and using a protective statement or gesture when one finds the touch unpleasant, (c) learning to recognize when one  is “spectatoring,” (d) recognizing how nice it is to touch and be with one’s partner, (e) recognizing how nice it is to be touched, and (f) becoming more acutely aware of what one is feeling physically and emotionally during the session.

Reggie and Marsha began sensate focus treatment that, in their case, lasted approximately 3 months. Throughout the treatment process, it was necessary to monitor the partners’ communication with one another regarding both sexual and nonsexual matters. It was also important to check out the couple’s comfort levels during the duration of treatment and to attend to any interfering thoughts or compliance problems that surfaced during the intervention period. Reggie and Marsha also were instructed to conduct their “sessions” in an environment that was free of distractions and conducive to facilitating an erotic experience. This meant that they also needed to schedule their sessions when they had adequate time to be together. Relational issues and the general quality of the couple’s relationship continued to be an integral part of therapy.

Table 18.3 outlines the progressive stages of sensate focus therapy. The couple was to spend at least 30 minutes together, three times per week. As Marsha and Reggie approached the fifth stage of sensate focus, which involved vaginal containment without thrusting, certain modifications had to be made to try to alleviate Marsha’s pain and discomfort. During this stage, the receptive partner controls activity. In this way, the amount of movement and depth of penetration can be controlled by the partner. Having Marsha assume the “top” position further enhanced her control. By doing so, she was better able to angle her pelvis in such a way that she had less discomfort. In the supine position, Marsha was encouraged to place pillows under her hips and to experiment with the height and angle that is most comfortable. During the final stage of sensate focus treatment when intercourse resumed, it was suggested that Marsha use a certain lubricant to ensure adequate lubrication and to heighten arousal. Once Reggie’s ED resolved, the couple was given videotapes that demonstrated varied sexual positions and techniques. These tapes gave the couple additional information about positions that would be most comfortable for Marsha and satisfying to both partners.

Eventually, Reggie and Marsha were able to resolve their sexual difficulties. Treatment success was due in large part to the partners’ commitment to the therapeutic process, their resolve to work through their marital and relational issues, and their compliance with the sensate focus intervention. They were seen approximately 6 months after the termination of therapy for a follow-up visit. No problems were noted at that time.

A second method of intervention is the use of the “squeeze technique,” which involves stimulation to the penis until the patient is close to ejaculation. Just prior to ejaculation, the patient or his partner places his or her hand just below the head of the penis and squeezes hard enough to cause partial loss of the patient’s erection. This technique is meant to help the patient become aware of sensations that precede orgasm and to then control and delay orgasm on his own. This technique progresses from manual stimulation to motionless intercourse and eventually to intercourse with movement.

Drug therapy can also be effective. Low doses of antidepressant medications such as Zoloft, Anafronil, and Prozac are often used because of their sexual side effects that include the prolongation of orgasm. More recently, topical agents such as anesthetics and herbal medications have been investigated as a possible treatment option (Choi et al., 1999, 2002; Morales, 2000).


The field of sexual science has advanced considerably; however, the conceptual framework that guides the practice of sex therapy has traditionally been, and continues to be, rooted in biological science. A failure to broaden our understanding and integration of individual, relational, spiritual, and psychosocial factors that may contribute to the problem at hand compromises our effectiveness in helping those who struggle with issues pertaining to sex and sexuality. Treatments have continued to be more technologically or pharmacologically advanced. Granted, sex therapy can be credited for its ability to treat sexual problems quickly and effectively; however, the goal of most approaches is performance based. By shifting the traditional behavioral or cognitive-behavioral approaches “to one that moves beyond behavior and communication to personal growth in relationship, we discover new horizons in human sexual potential” (Kleinplatz, 2001, p. 190). An important factor in sex therapy is to help guide individuals in exercising greater personal agency over their relational needs as well as their erotic potential. Interventions should be geared toward treating the individual as a whole, not simply as a malfunction in biological equipment.