Chapter 15
Sexual Problems and Therapy
For use with text,
Human Sexuality Today,
5th edition.
Bruce M. King
Slides by Callista Lee
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King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Understanding sexual problems
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Individual differences can create problems –
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Different expectations
Differences in desire
Differences in preferred behaviors
Relationship conflicts
It is crucial that the couple view these problems
as the couple having a problem rather than it
being “your” problem or “my” problem; by
working together these problems can be
solved.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Sexual therapy
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Psychoanalysis – long-term, intensive exploration
of childhood causes for adult problems. Not
commonly used today.
Cognitive-behavioral therapy – short-term,
focusing on attitudes, beliefs and how they affect
our behaviors.
Psychosexual therapy – insight into causes of the
problems; successful with sexual aversion and low
sexual desire.
Medical model – looking for and treating organic
causes for sexual problems.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
The PLISSIT model of sex therapy
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Each level represents a successively deeper
level of therapy and is only explored if
necessary.
P = Permission (defining your own sexuality)
LI = Limited information (a little education)
SS = Specific suggestions (behavioral
techniques)
IT = Intensive therapy (psychotherapy; only
10% need this level)
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Sexual therapy techniques
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Medical history – possible organic causes
Sexual history – attitudes, behaviors, and
partner reactions and involvement
Specific suggestions
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Systematic desensitization (reduce anxiety)
Self-awareness and masturbation (know yourself)
Sensate focus (non-demand mutual pleasuring)
Techniques for specific problems
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Sensate focus
The couple learns
how to touch and
be touched without
worrying about
performing or
reaching a goal
(such as orgasm).
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King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Defining sexual problems
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Subjective distress is a key element in the
diagnosis of sexual disorders – part of defining
one’s own sexuality includes deciding what
conditions pose a problem.
Four major categories:
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Desire disorders
Arousal (excitement phase) disorders
Orgasmic disorders
Sexual pain disorders
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Male sexual problems –
Hypoactive sexual desire
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Persistent or recurrent absence of sexual
fantasies and sexual desire.
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Primary – never having had normal level of desire
Secondary or acquired – distress at a significantly
lower level of desire than in the past
Causes may be organic (e.g., low testosterone) or
psychological (e.g., repressive upbringing, sexual
trauma, negative self-schema)
Sexual aversion – extreme hypoactive desire;
anticipation of any kind of sexual interaction may cause
great anxiety.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Male sexual problems –
Erectile disorder (ED)
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Primary – he has always had problems
Secondary – this is a new problem
Global – the problem occurs in all situations
Situational – normal functioning in some
situations (e.g., during masturbation) but not
others (e.g., attempting sex with a partner).
Can be psychologically devastating to both
partners.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Erectile Disorder – Causes
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Psychological – general stress and anxiety,
depression, relationship problems, associating
sex with guilt, traumatic experiences,
performance anxiety and spectatoring.
Organic – 80% of cases; use of alcohol,
smoking, some medicines, circulatory
problems (local or associated with other
disease), injury, low testosterone, prostate
disease.
Occasional erectile failure is normal.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Erectile Disorder –
Medical Treatments
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Vacuum device – forces blood into the penis. A rubber
ring worn at the base of the penis holds the erection.
Penile implants – soft tubes that can be pumped up to
create stiffness in the penis any time it is desired. An
earlier type consisted of semi-rigid plastic rods.
Injections – muscle relaxant injected into the penis
allows for greater blood flow, with or without sexual
stimulation.
Pills – oral medication that works directly on the penis
to create greater blood flow; the man only becomes
erect when he experiences sexual stimulation. (Viagra,
Levitra and Cialis)
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Erectile disorder – Psychological
and behavioral treatments
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Medications or devices alone will not address
the emotions associated with ED. Even when
the cause of ED is organic, counseling is
recommended.
Anxiety can be addressed through counseling
as well as behavior therapy techniques such as
sensate focus and a teasing technique
described in your textbook.
Psychotherapy may be necessary in some
cases.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
The “teasing” technique
Learning that erection can come and go
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King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Male sexual problems –
Premature ejaculation
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Absence of reasonable voluntary control of
ejaculation.
Psychological or organic causes (as listed
previously).
After therapeutic exercises such as sensate
focus to teach the man not to hurry, the
squeeze technique and/or woman-on-top coital
position may be recommended.
Other treatments are used, dependent upon
the cause of the problem.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Male orgasmic disorder
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Male orgasmic disorder, also called ejaculatory
incompetence refers to inability or difficulty
reaching orgasm.
Primary or secondary.
Organic (drugs, alcohol, neurological disorder)
Psychological (guilt/shame, fear of pregnancy,
hostility toward partner, trauma)
Often treated with the bridge maneuver.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Sexual pain disorders in males
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Dyspareunia – most common causes are
prostate, bladder or urethral infection. Also
caused by phimosis and Peyronie’s disease.
The anticipation of pain can cause anxiety that
leads to erectile problems.
Priapism – painful erection lasting hours or
days; causes include tumor, infection, drugs.
Benign coital cephalalgia – severe headache at
orgasm, usually in mildly obese, middle-aged
men with elevated blood pressure.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Female sexual problems –
Hypoactive sexual desire
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In addition to the causes listed for males, most
hypoactive women are generally very unhappy
with the quality of their relationship, particularly
concerning the expression of affection.
Although only 25% of cases can be traced to
low levels of testosterone, treatment with
testosterone has become quite common.
Sexual aversion disorder – sexual trauma,
repressive upbringing, negative self-schema.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Female sexual arousal disorder
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Personal distress a persistent or recurrent
inability to attain and maintain subjective
and/or somatic sexual excitement (genital
lubrication and swelling).
FDA recently approved a vacuum pump device
Viagra taken by young women with sexual
arousal disorder increased vaginal lubrication
but had no effect on subjective arousal.
Most women do not separate desire from
arousal.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Female orgasmic disorder
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The vast majority of women seek sexual
therapy because of problems reaching orgasm.
Primary or secondary; global or situational.
Organic causes sometimes; but attitudes about
sex and performance anxiety are common
causes.
First questions to ask:
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Has there been enough foreplay?
Is there sufficient clitoral stimulation?
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Learning to enjoy clitoral stimulation
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King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Treatments for
female orgasmic disorder
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Education and counseling regarding normal
female sexual response.
Sensate focus exercises to relieve anxiety.
Techniques before and during intercourse that
allow for more direct stimulation of the clitoris.
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This isn’t “cheating” – would anyone expect a man
to reach orgasm without stimulation of his penis?
Woman-on-top coital position
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
With practice, a woman may be able to reach orgasm
without manual stimulation, by rubbing her clitoris against
her partner’s pubic bone.
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King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Female sexual pain disorders (1)
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Dyspareunia – genital pain associated with
sexual intercourse
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First, is there sufficient vaginal lubrication?
If only a certain position hurts, stop it!
Inflammation of the vestibular bulbs (treated with
surgery) is very common.
Endometriosis, yeast infection, Bartholin’s gland
infection, urinary tract infection, allergies to semen
or spermicides can all cause sexual pain.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Female sexual pain disorders (2)
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Vaginismus – involuntary contractions of the
muscles surrounding the outer 1/3 of the
vagina; occurs in about 2% of women.
Psychological causes
Learning to relax the muscles is attempted
after dealing with the underlying causes.
Sensate focus exercises are followed by
systematic desensitization by gradual dilation
of the vagina.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Hypersexuality (1)
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Most therapists object to the term “sexual
addiction” because there is no evidence of any
physical addiction. They prefer the term,
“sexual compulsion.”
Sexual behavior is engaged in repeatedly and
compulsively in order to provide escape from
psychological discomfort.
The behavior results in little or no emotional
satisfaction.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall
Hypersexuality (2)
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Hypersexuals may engage in either paraphilic
(see chapter 16) or “normal” sexual behaviors.
Likely cause – intimacy dysfunction during
childhood, often due to neglect or abuse.
Psychotherapy plus anti-depressant or antianxiety medications have been helpful.
Internet sex addiction is very easy compared to
other hypersexual behaviors. “Sex” is the most
frequently searched topic on the internet.
King, Human Sexuality Today, 5/e © 2005 by Prentice Hall