Chapter 14 Sexual Difficulties and Solutions
Sexual problems are quite common
Statistically, occur more frequently in:
Younger women, older men
People w/less education
Perception of sexual problems is subjective
Not everyone experiencing a sexual problem is necessarily distressed or sexually dissatisfied
Pfizer Study of Sexual Attitudes & Behaviors global survey of >26,000 people in 29 countries
Types of specific sexual difficulties
• In reality, these overlap considerably
- problems w/desire and arousal often
affect orgasm;
- problems w/orgasm easily affect desire
and arousal
Desire-phase difficulties
Excitement/arousal-phase difficulties
3) Orgasm-phase difficulties
4) Dyspareunia
Painful intercourse
Desire-phase difficulties
1) Hypoactive sexual desire disorder (HSDD)
lack of interest both prior to sexual activity as well as lack of desire during the sexual experience
If “sexual appetite” is low, but person can become aroused/desirous after sexual experience begins, then person does not have HSDD
Used to be defined as generally low sexual appetite
In these terms, very common sexual difficulty
Contributing factors:
Life stress
Relationship problems
Medical problems
History of sexual abuse or trauma
Desire-phase difficulties (cont.)
2) Dissatisfaction w/frequency of sexual activity
2005 Global Sex Survey: 41% of men and 29% of women want sex more frequently
Couples normally have some differences in preferences re: sexual frequency (may go back & forth)
When these differences are significant source of conflict or dissatisfaction in the relationship, couple can have major difficulties
3) Sexual Aversion disorder: extreme and irrational fear of sexual activity
Thought of sexual activity can induce intense anxiety and panic
Excitement-phase difficulties
1) Female Sexual Arousal Disorder: 2 types
Genital sexual arousal disorder: persistent inability to attain or maintain lubrication-swelling response
_ Subjective sexual arousal disorder: absent or diminished awareness of physical arousal
Physical signs are there, but feelings of excitement and pleasure are missing
2) Persistent Sexual Arousal Disorder
Spontaneous, intrusive, and unwanted genital arousal in the absence of sexual interest
Uncomfortable tingling, throbbing, pulsating; not relieved by orgasms--can last hours or days
Excitement-phase difficulties (cont.)
3) Male erectile disorder (ED)
Consistent or recurrent inability to have or maintain an erection sufficient for sexual activity for >3 months. Quite common
1 in 5 men over age of 20 experience ED
Incidence of ED increases with age (see graph)
Orgasm-phase difficulties
1) Female orgasmic disorder
Absence, marked delay, or diminished intensity of orgasm--despite appropriate stimulation (usually clitoral)
Lack of orgasm during intercourse is not a disorder
Approx. 5-10% of adult women in U.S.
More common among women who are younger, unmarried, and have less education
Can be a learned skill, or learned w/the right partner:
One survey found that 62% of women were 18 years or older before they first experienced orgasm
Among college students, 13% of women have not had an orgasm (compared w/6% of men)
Situational female orgasmic disorder:
Refers to woman who is orgasmic when masturbating but not when stimulated by a partner
Orgasm-phase difficulties
2) Male orgasmic disorder
Inability of a man to ejaculate during sexual activity
Approx. 8% of men experience this
3) Premature ejaculation
The most common male sexual difficulty
Pattern of ejaculations within 2 minutes and an inability to delay ejaculation, resulting in impairment of man’s or his partner’s pleasure
Approx. 20-30% of men worldwide age 18-59
Men w/P.E. experience rapid arousal and often ejaculate before reaching full sexual arousal; report less enjoyment of orgasm than men w/o P.E.
Suggests some physiological component
Orgasm-phase difficulties
4) Faking orgasms
Usually discussed in reference to women, though some men also fake orgasms
Reasons given:
avoid disappointing or hurting their partners
get sex over with
need for partner approval
Can lead to vicious cycle
Partner continues same method (presumably ineffective) of stimulation, which he/she believes to be effective
Creates emotional distance during physical intimacy
14-A: Discussion question
PART 1: Is faking an orgasm ever okay to do? Why or why not?
PART 2: What do you consider premature ejaculation? Is there a time limit? If sexual activity continues after ejaculation of a male partner, does it matter if it is “premature”? What is sexual activity does not continue?
Dyspareunia: Pain or discomfort during intercourse
Much more common in women (see next slide)
> 60% of women experience dyspareunia at some point
In men, dyspareunia is unusual but does occur
If foreskin is too tight (phimosis), erection can be painful
Poor hygiene of uncircumcised penis can cause infection that can irritate the glans during sexual activity
Infections in urethra, bladder, prostate gland, or seminal vesicles can cause pain w/ejaculation
Peyronie’s disease: fibrous tissue and calcium deposits develop in space above/btwn cavernous bodies of penis
Usually caused by traumatic bending of penis during intercourse
Results in pain and curvature of penis upon erection
Dyspareunia in women
Situational discomfort
Inadequate arousal or lubrication
Physiological, hormonal conditions can reduce lubrication (nursing, menopause)
Vaginal infections can cause inflammation of vaginal walls that makes intercourse painful
Contraceptive foam/jelly, latex condoms/diaphragms can irritate vaginas of some women
Vulvar vestibulitis syndrome
Small, reddened area at entrance of vagina that causes severe pain
Experienced by ~10% of women
Sometimes caused by neurological problem that can be “retrained” by myofascial release, biofeedback,
Dyspareunia in women (cont.)
Deep pelvic pain
During coital thrusting, may be due to jarring of the ovaries or stretching of uterine ligaments
May occur only in certain sexual positions or at certain times during a woman’s cycle (usu. ovulation or menstruation)
Endometriosis
Endometrial tissue that normally only grows on walls of uterus implants on various parts of abdominal cavity
Infections in uterus
e.g. gonorrhea
Gynecological surgeries for uterine and ovarian cancer
Torn uterine ligaments
Due to rape or problem during childbirth
Dyspareunia in women (cont.)
Vaginismus
Involuntary spasmodic contractions of the muscles of the outer third of the vagina
Result in extreme pain upon insertion of a penis, or even a finger, into the vagina
Caused by a number of different possible physiological, psychological, and situational factors
Women can learn to minimize or prevent the contractions with treatment
Origins of sexual difficulties: physiological factors
Vascular, hormonal, neurological problems
Poor general health, diet, and exercise
For example, body fat, especially around the abdomen, reduces testosterone levels in men, and men who are obese are 90% more likely to have ED
Drug use
See table
Physiological factors (cont.)
General chronic illness
Many different illnesses can impact sexual functioning, either due to direct impairment of nerves, hormones, or blood flow, or due to pain and fatigue suppressing desire
Diabetes:
Nerve damage and circulatory problems resulting from diabetes cause ~50% of diabetic men to have reduction or loss of capacity for erection
Women w/diabetes often have problems w/sexual desire, lubrication, and orgasm
Cancer
Chemotherapy & radiation can damage hormonal, vascular, and neurological functions necessary for sexual functioning
Nausea, fatigue, pain, negative body image after surgery
Cancers of the reproductive system usually have the worst impact on sexual functioning
Physiological factors (cont.)
Multiple sclerosis (MS)
Neurological disease of the brain and spinal cord due to damage to the myelin sheath covering nerve fibers
Most MS patients experience problems w/sexual functioning, ranging from loss of sexual interest or genital sensation, reduced arousal or orgasm, or hypersensitivity to genital stimulation
Strokes:
Occur when brain tissue is destroyed as a result of blockage of blood to the brain or internal bleeding in the brain
Often result in limited mobility, altered/lost sensation, impaired verbal communication
Stroke survivors frequently report reduced sexual interest, arousal, and activity
Effects of medications
Over 200 prescription and OTC medications have negative effects on sexuality
Health care practitioners don’t always discuss potential sexual side effects -- ask or do your own research
Psychiatric medications
Antidepressants: reduced sexual interest, arousal, delayed or absent orgasm in up to 60% of users
Antipsychotics: frequent loss of arousal, orgasm
Tranquilizers (valium, xanax, etc.): interfere w/orgasm
Antihypertensive medications (treat high b.p.)
Can interfere w/desire, arousal, and orgasm
Other medications
Prescription and OTC gastrointestinal, antihistamine medications can interfere w/desire, arousal, erection
Methadone can reduce desire, arousal, orgasm
Disabilities
Have widely varying effects on sexual responsiveness
Cerebral palsy
Brain damage that occurs before/during birth or in early childhood
Results in mild to severe lack of muscular control
Genital sensation is unaffected, but some positions may be difficult, involuntary vaginal contractions can cause pain
Sexual adjustment depends on support from partner, social network as much as on physical possibilities
Spinal cord injury
May result in impaired physical ability for arousal and orgasm--varies considerably depending on the specific injury
Research: 86% of men and women w/SCI’s feel desire, over half experience arousal from stimulation, ~1/3 experience orgasm
Research in women has shown that the vagus nerve provides an alternate pathway from vagina/cervix to brain that bypasses the spinal cord
Disabilities
Effect of spinal cord injury on erection depends on location of injury along spinal cord
Disabilities (cont.)
Blindness and deafness
Can affect sexuality primarily when they interfere with learning social interaction skills, independence
Other senses can play an expanded role
Enhancement strategies for people with chronic illnesses and disabilities
Acceptance of limitations & development of remaining options
Pain control, either by minimization or treatment
Expand definition of sexuality beyond genital arousal and intercourse
Some people find that their illnesses/disabilities teach them fascinating new things about their sexuality, increase connection to partner
Cultural influences
Negative childhood learning
Parents’ attitudes toward sex, level of affectionate interaction with each other
Labeling sex as sinful or shameful can contribute to sexual difficulties later in life
Sexual double standard
Research: equality of gender roles is associated with greater sexual satisfaction in men & women
Opposing sexual expectations for women and men create problems
Men feel that they should want sex all the time, that asking for guidance from their partner isn’t ‘manly’
Women may learn to be sexually restrained for fear of being labeled a ‘slut,’ resulting in less exploration of their sexuality, not asking their partner for what they want
Cultural influences (cont.)
Narrow definition of sexuality
Idea that ‘real’ sex = penile-vaginal intercourse leads to inadequate clitoral stimulation for women, places unrealistic burden on intercourse
When problems occur, too much focus is often placed on issues of erection problems, when emotional or relationship problems are very often the root cause
Performance anxiety
Usually, anxiety about not being able to achieve erection or orgasm
One transitory problem with performance can cause a vicious cycle where anxiety about repeat problems causes problems next time
Individual factors
Sexual knowledge & attitudes
Awareness of our bodies and how we receive pleasure minimizes future sexual difficulties
Sexual abuse & assault
17% of women and 12% of men were sexually abused before adolescence
17.6% of women and 3% of men have been raped or were the victim of attempted rape
Increases likelihood of sexual difficulties later in life, affecting self-esteem, desire, arousal, and orgasm
Emotional problems
Anxiety, depression, and stress have a strong negative effect on sexuality
Individual factors (cont.)
Self-image
Individual factors (cont.)
Self-concept
Self-esteem, self-confidence correlate w/higher sexual satisfaction in women and men
Body image strongly affects sexuality
Affects women especially
Many women feel sexually inhibited b/c they are uncomfortable with their bodies
Media images of women have gotten further and further from the average size of women
Early 1980s: average model weighed 8% less than the average American woman; today, it’s 23% less
Men are increasingly affected as well
Male models/stars typically have no visible body hair and are getting ‘beefier’
Porn gives men unrealistic idea of normal penis size
Relationship factors
Unresolved resentments, trust issues, disrespect for partner
One partner feels pressured
Partners are too dependent on each other
Need balance of togetherness and separateness
Ineffective communication
Issues around pregnancy, STIs
Anxiety about unwanted, or desired pregnancy
Anxiety about contracting a STI
Problems accepting one’s sexual orientation
Homosexuals who fear societal or familial disapproval about being gay may attempt to live in heterosexual relationships despite their lack of desire for other sex
Sexual enhancement/Sex therapy
Cautionary statements
self-help/sex therapy techniques described in book are often effective
professional help may be needed in the form of sex therapy, couples’ therapy, or individual therapy
see an MD to assess physical causes
Sexual enhancement/Sex therapy
Self-awareness
Becoming well-acquainted with our sexual anatomy
Experimenting with masturbation to learn about sexual response
Communication
Using strategies described in Chp. 7 to improve communication about sexual activities
Learning how to tell or show partner what is desired, what type of stimulation is effective
Sexual enhancement/Sex therapy (cont.)
Sensate focus
Prescribed by therapists for a number of male and female sexual difficulties
Also helpful technique to increase intimacy in couples who aren’t experiencing sexual difficulty
Principles of the technique:
Non-goal-oriented physical intimacy
Takes the pressure off of “performance” and achieving orgasm
Focus on sensation of touching your partner
Exploring sensual touching beyond the genitals
Discovering whether aspects of intimacy bring up any feelings of discomfort
Specific suggestions for women
Becoming orgasmic: first alone
First: body exploration, genital self-exam, Kegels
Then: self-stimulation exercises (as described in Chp.
Vibrators can help women experience orgasm for the first time so she knows what it feels like
After a few vibrator-assisted orgasms, helpful to return to manual stimulation --easier for a partner to replicate
Specific suggestions for women (cont.)
Then, w/a partner
Masturbation w/partner present
Mutual body/genital exploration, then experiment w/touch, communicating their responses
Specific suggestions for women (cont.)
Facilitating orgasm during intercourse w/a partner
Woman can initiate movements & pressure that feel most stimulating
Woman (or partner) can also stimulate her clitoris manually or w/a vibrator during intercourse
Specific suggestions for men: Strategies for delaying ejaculation
More frequent ejaculation
“Come again”
Change positions
woman-on-top, no male thrusting, to decrease muscle tension, delay ejaculation
Communication
man tells partner when to reduce or stop stimulation, then resume after a few moments
Alternative activities
intercourse is just one option
Medical treatment
Low doses of antidepressants--considerable side effects
Specific suggestions for men: Strategies for delaying ejaculation (cont.)
Stop-start technique
Developed in the 1950s
Technique involves stimulation to brink of orgasm; stop, wait for sensations to decrease, start again
Man begins by working alone using masturbation
Eventually, work on technique with partner
Discussion question
Read the two handouts describing the sensate focus exercises and the stop-start techniques to help men delay ejaculation.
What are your reactions to these exercises?
Do they seem beneficial? Are there any aspects of these exercises that seem uncomfortable if you were to imagine practicing them with a partner?
Specific suggestions for men: Erectile dysfunction
Reduce performance anxiety (most common cause)
Sensate focus exercises take the pressure off “goal-oriented” intercourse
Then, genital stimulation other than intercourse
After man experiences full erection, partner stops stimulation, allows erection to subside
Resume genital stimulation to allow erection to return
Restores man’s confidence that erection will return
Final phase of treatment is intercourse
If man loses erection after penetration, return to oral or manual stimulation; if response is still blocked, return to nongenital sensate focus before moving forward again
Erectile dysfunction (cont.)
Medical treatments
Viagra (1998); newer drugs: Levitra and Cialis
Mechanism: smooth muscle relaxation in spongy bodies of penis, increasing blood flow, resulting in erection
Similar side effects: flushing, headaches, nasal congestion
Can cause priapism (erection doesn’t subside--can cause damage to penile tissue w/o treatment): takes effect < 3 hours, requires physical stimulation, effect may depend on quality of relationship
Have increased awareness of ED
Has led to some recreational use--has led to some increase in high-risk sexual behavior in combination w/drugs & casual sex
Vasoactive medication
Common ED treatment before Viagra-like drugs
Work by relaxing smooth muscle in spongy body of penis, increasing blood flow --> erection
Required injection into penis, or suppository inserted in urethra
Erectile dysfunction (cont.)
Mechanical devices
Suction blood into penis and hold it there during intercourse
External vacuum devices, with penile constriction bands
Rejoyn
Penile support sleeve made from soft rubber--fits over penis to provide support necessary for intercourse
Erectile dysfunction (cont.)
Surgical treatments
Penile implants--2 types
Semirigid rods inside a silicone covering placed inside cavernous bodies of the penis (disadvantage: penis always semierect)
Inflatable prosthesis that can be pumped as needed (see below)
Surgery cannot restore sensation or ability to ejaculate if it has been lost due to medical problems
Treating Hypoactive Sexual Desire
Some suggestions same as other dysfunctions
encourage erotic responses
Self-stimulation, fantasy
reduce anxiety
Sensate focus exercises
enhance sexual experiences through improved communication about which activities feel pleasurable and which do not
expand repertoire of activities
Less “goal-oriented” sexual activity
Moving beyond “genital-only” sensual/sexual activity
Therapy
Examine, resolve subconscious conflicts about pleasure
Examine whether there are unresolved relationship issues
Treating Hypoactive Sexual Desire Medical treatments
Men:
Testosterone supplementation to increase desire;
Viagra to help with arousal/response
Women:
Both estrogen and testosterone therapies can increase sexual desire and arousal in postmenopausal women
Testosterone can also increase desire in premenopausal women w/below-normal testosterone levels
Zestra: oil applied to clitoris and vulva to increase sexual response
ArginMax: nutritional supplement to increase clitoral sensation, desire, vaginal lubrication, orgasm frequency
Bremelanotide: inhalant that acts on neural pathways to increase desire and genital arousal--still in research phase
Creams containing alprostadil, prostaglandins, or L-arginine to inrease blood flow to genitals, enhance arousal and orgasm
Seeking Professional Assistance
What happens in therapy?
identify & clarify problems & goals
medical, sexual, relationship history
often given homework
NEVER includes sex with therapist
Selecting a therapist
referral from trusted source (some listed in text)
ask about credentials, training, & experience
interview: practicalities & "fit"
Sexual problems are quite common
Statistically, occur more frequently in:
Younger women, older men
People w/less education
Perception of sexual problems is subjective
Not everyone experiencing a sexual problem is necessarily distressed or sexually dissatisfied
Pfizer Study of Sexual Attitudes & Behaviors global survey of >26,000 people in 29 countries
Types of specific sexual difficulties
• In reality, these overlap considerably
- problems w/desire and arousal often
affect orgasm;
- problems w/orgasm easily affect desire
and arousal
Desire-phase difficulties
Excitement/arousal-phase difficulties
3) Orgasm-phase difficulties
4) Dyspareunia
Painful intercourse
Desire-phase difficulties
1) Hypoactive sexual desire disorder (HSDD)
lack of interest both prior to sexual activity as well as lack of desire during the sexual experience
If “sexual appetite” is low, but person can become aroused/desirous after sexual experience begins, then person does not have HSDD
Used to be defined as generally low sexual appetite
In these terms, very common sexual difficulty
Contributing factors:
Life stress
Relationship problems
Medical problems
History of sexual abuse or trauma
Desire-phase difficulties (cont.)
2) Dissatisfaction w/frequency of sexual activity
2005 Global Sex Survey: 41% of men and 29% of women want sex more frequently
Couples normally have some differences in preferences re: sexual frequency (may go back & forth)
When these differences are significant source of conflict or dissatisfaction in the relationship, couple can have major difficulties
3) Sexual Aversion disorder: extreme and irrational fear of sexual activity
Thought of sexual activity can induce intense anxiety and panic
Excitement-phase difficulties
1) Female Sexual Arousal Disorder: 2 types
Genital sexual arousal disorder: persistent inability to attain or maintain lubrication-swelling response
_ Subjective sexual arousal disorder: absent or diminished awareness of physical arousal
Physical signs are there, but feelings of excitement and pleasure are missing
2) Persistent Sexual Arousal Disorder
Spontaneous, intrusive, and unwanted genital arousal in the absence of sexual interest
Uncomfortable tingling, throbbing, pulsating; not relieved by orgasms--can last hours or days
Excitement-phase difficulties (cont.)
3) Male erectile disorder (ED)
Consistent or recurrent inability to have or maintain an erection sufficient for sexual activity for >3 months. Quite common
1 in 5 men over age of 20 experience ED
Incidence of ED increases with age (see graph)
Orgasm-phase difficulties
1) Female orgasmic disorder
Absence, marked delay, or diminished intensity of orgasm--despite appropriate stimulation (usually clitoral)
Lack of orgasm during intercourse is not a disorder
Approx. 5-10% of adult women in U.S.
More common among women who are younger, unmarried, and have less education
Can be a learned skill, or learned w/the right partner:
One survey found that 62% of women were 18 years or older before they first experienced orgasm
Among college students, 13% of women have not had an orgasm (compared w/6% of men)
Situational female orgasmic disorder:
Refers to woman who is orgasmic when masturbating but not when stimulated by a partner
Orgasm-phase difficulties
2) Male orgasmic disorder
Inability of a man to ejaculate during sexual activity
Approx. 8% of men experience this
3) Premature ejaculation
The most common male sexual difficulty
Pattern of ejaculations within 2 minutes and an inability to delay ejaculation, resulting in impairment of man’s or his partner’s pleasure
Approx. 20-30% of men worldwide age 18-59
Men w/P.E. experience rapid arousal and often ejaculate before reaching full sexual arousal; report less enjoyment of orgasm than men w/o P.E.
Suggests some physiological component
Orgasm-phase difficulties
4) Faking orgasms
Usually discussed in reference to women, though some men also fake orgasms
Reasons given:
avoid disappointing or hurting their partners
get sex over with
need for partner approval
Can lead to vicious cycle
Partner continues same method (presumably ineffective) of stimulation, which he/she believes to be effective
Creates emotional distance during physical intimacy
14-A: Discussion question
PART 1: Is faking an orgasm ever okay to do? Why or why not?
PART 2: What do you consider premature ejaculation? Is there a time limit? If sexual activity continues after ejaculation of a male partner, does it matter if it is “premature”? What is sexual activity does not continue?
Dyspareunia: Pain or discomfort during intercourse
Much more common in women (see next slide)
> 60% of women experience dyspareunia at some point
In men, dyspareunia is unusual but does occur
If foreskin is too tight (phimosis), erection can be painful
Poor hygiene of uncircumcised penis can cause infection that can irritate the glans during sexual activity
Infections in urethra, bladder, prostate gland, or seminal vesicles can cause pain w/ejaculation
Peyronie’s disease: fibrous tissue and calcium deposits develop in space above/btwn cavernous bodies of penis
Usually caused by traumatic bending of penis during intercourse
Results in pain and curvature of penis upon erection
Dyspareunia in women
Situational discomfort
Inadequate arousal or lubrication
Physiological, hormonal conditions can reduce lubrication (nursing, menopause)
Vaginal infections can cause inflammation of vaginal walls that makes intercourse painful
Contraceptive foam/jelly, latex condoms/diaphragms can irritate vaginas of some women
Vulvar vestibulitis syndrome
Small, reddened area at entrance of vagina that causes severe pain
Experienced by ~10% of women
Sometimes caused by neurological problem that can be “retrained” by myofascial release, biofeedback,
Dyspareunia in women (cont.)
Deep pelvic pain
During coital thrusting, may be due to jarring of the ovaries or stretching of uterine ligaments
May occur only in certain sexual positions or at certain times during a woman’s cycle (usu. ovulation or menstruation)
Endometriosis
Endometrial tissue that normally only grows on walls of uterus implants on various parts of abdominal cavity
Infections in uterus
e.g. gonorrhea
Gynecological surgeries for uterine and ovarian cancer
Torn uterine ligaments
Due to rape or problem during childbirth
Dyspareunia in women (cont.)
Vaginismus
Involuntary spasmodic contractions of the muscles of the outer third of the vagina
Result in extreme pain upon insertion of a penis, or even a finger, into the vagina
Caused by a number of different possible physiological, psychological, and situational factors
Women can learn to minimize or prevent the contractions with treatment
Origins of sexual difficulties: physiological factors
Vascular, hormonal, neurological problems
Poor general health, diet, and exercise
For example, body fat, especially around the abdomen, reduces testosterone levels in men, and men who are obese are 90% more likely to have ED
Drug use
See table
Physiological factors (cont.)
General chronic illness
Many different illnesses can impact sexual functioning, either due to direct impairment of nerves, hormones, or blood flow, or due to pain and fatigue suppressing desire
Diabetes:
Nerve damage and circulatory problems resulting from diabetes cause ~50% of diabetic men to have reduction or loss of capacity for erection
Women w/diabetes often have problems w/sexual desire, lubrication, and orgasm
Cancer
Chemotherapy & radiation can damage hormonal, vascular, and neurological functions necessary for sexual functioning
Nausea, fatigue, pain, negative body image after surgery
Cancers of the reproductive system usually have the worst impact on sexual functioning
Physiological factors (cont.)
Multiple sclerosis (MS)
Neurological disease of the brain and spinal cord due to damage to the myelin sheath covering nerve fibers
Most MS patients experience problems w/sexual functioning, ranging from loss of sexual interest or genital sensation, reduced arousal or orgasm, or hypersensitivity to genital stimulation
Strokes:
Occur when brain tissue is destroyed as a result of blockage of blood to the brain or internal bleeding in the brain
Often result in limited mobility, altered/lost sensation, impaired verbal communication
Stroke survivors frequently report reduced sexual interest, arousal, and activity
Effects of medications
Over 200 prescription and OTC medications have negative effects on sexuality
Health care practitioners don’t always discuss potential sexual side effects -- ask or do your own research
Psychiatric medications
Antidepressants: reduced sexual interest, arousal, delayed or absent orgasm in up to 60% of users
Antipsychotics: frequent loss of arousal, orgasm
Tranquilizers (valium, xanax, etc.): interfere w/orgasm
Antihypertensive medications (treat high b.p.)
Can interfere w/desire, arousal, and orgasm
Other medications
Prescription and OTC gastrointestinal, antihistamine medications can interfere w/desire, arousal, erection
Methadone can reduce desire, arousal, orgasm
Disabilities
Have widely varying effects on sexual responsiveness
Cerebral palsy
Brain damage that occurs before/during birth or in early childhood
Results in mild to severe lack of muscular control
Genital sensation is unaffected, but some positions may be difficult, involuntary vaginal contractions can cause pain
Sexual adjustment depends on support from partner, social network as much as on physical possibilities
Spinal cord injury
May result in impaired physical ability for arousal and orgasm--varies considerably depending on the specific injury
Research: 86% of men and women w/SCI’s feel desire, over half experience arousal from stimulation, ~1/3 experience orgasm
Research in women has shown that the vagus nerve provides an alternate pathway from vagina/cervix to brain that bypasses the spinal cord
Disabilities
Effect of spinal cord injury on erection depends on location of injury along spinal cord
Disabilities (cont.)
Blindness and deafness
Can affect sexuality primarily when they interfere with learning social interaction skills, independence
Other senses can play an expanded role
Enhancement strategies for people with chronic illnesses and disabilities
Acceptance of limitations & development of remaining options
Pain control, either by minimization or treatment
Expand definition of sexuality beyond genital arousal and intercourse
Some people find that their illnesses/disabilities teach them fascinating new things about their sexuality, increase connection to partner
Cultural influences
Negative childhood learning
Parents’ attitudes toward sex, level of affectionate interaction with each other
Labeling sex as sinful or shameful can contribute to sexual difficulties later in life
Sexual double standard
Research: equality of gender roles is associated with greater sexual satisfaction in men & women
Opposing sexual expectations for women and men create problems
Men feel that they should want sex all the time, that asking for guidance from their partner isn’t ‘manly’
Women may learn to be sexually restrained for fear of being labeled a ‘slut,’ resulting in less exploration of their sexuality, not asking their partner for what they want
Cultural influences (cont.)
Narrow definition of sexuality
Idea that ‘real’ sex = penile-vaginal intercourse leads to inadequate clitoral stimulation for women, places unrealistic burden on intercourse
When problems occur, too much focus is often placed on issues of erection problems, when emotional or relationship problems are very often the root cause
Performance anxiety
Usually, anxiety about not being able to achieve erection or orgasm
One transitory problem with performance can cause a vicious cycle where anxiety about repeat problems causes problems next time
Individual factors
Sexual knowledge & attitudes
Awareness of our bodies and how we receive pleasure minimizes future sexual difficulties
Sexual abuse & assault
17% of women and 12% of men were sexually abused before adolescence
17.6% of women and 3% of men have been raped or were the victim of attempted rape
Increases likelihood of sexual difficulties later in life, affecting self-esteem, desire, arousal, and orgasm
Emotional problems
Anxiety, depression, and stress have a strong negative effect on sexuality
Individual factors (cont.)
Self-image
Individual factors (cont.)
Self-concept
Self-esteem, self-confidence correlate w/higher sexual satisfaction in women and men
Body image strongly affects sexuality
Affects women especially
Many women feel sexually inhibited b/c they are uncomfortable with their bodies
Media images of women have gotten further and further from the average size of women
Early 1980s: average model weighed 8% less than the average American woman; today, it’s 23% less
Men are increasingly affected as well
Male models/stars typically have no visible body hair and are getting ‘beefier’
Porn gives men unrealistic idea of normal penis size
Relationship factors
Unresolved resentments, trust issues, disrespect for partner
One partner feels pressured
Partners are too dependent on each other
Need balance of togetherness and separateness
Ineffective communication
Issues around pregnancy, STIs
Anxiety about unwanted, or desired pregnancy
Anxiety about contracting a STI
Problems accepting one’s sexual orientation
Homosexuals who fear societal or familial disapproval about being gay may attempt to live in heterosexual relationships despite their lack of desire for other sex
Sexual enhancement/Sex therapy
Cautionary statements
self-help/sex therapy techniques described in book are often effective
professional help may be needed in the form of sex therapy, couples’ therapy, or individual therapy
see an MD to assess physical causes
Sexual enhancement/Sex therapy
Self-awareness
Becoming well-acquainted with our sexual anatomy
Experimenting with masturbation to learn about sexual response
Communication
Using strategies described in Chp. 7 to improve communication about sexual activities
Learning how to tell or show partner what is desired, what type of stimulation is effective
Sexual enhancement/Sex therapy (cont.)
Sensate focus
Prescribed by therapists for a number of male and female sexual difficulties
Also helpful technique to increase intimacy in couples who aren’t experiencing sexual difficulty
Principles of the technique:
Non-goal-oriented physical intimacy
Takes the pressure off of “performance” and achieving orgasm
Focus on sensation of touching your partner
Exploring sensual touching beyond the genitals
Discovering whether aspects of intimacy bring up any feelings of discomfort
Specific suggestions for women
Becoming orgasmic: first alone
First: body exploration, genital self-exam, Kegels
Then: self-stimulation exercises (as described in Chp.
Vibrators can help women experience orgasm for the first time so she knows what it feels like
After a few vibrator-assisted orgasms, helpful to return to manual stimulation --easier for a partner to replicate
Specific suggestions for women (cont.)
Then, w/a partner
Masturbation w/partner present
Mutual body/genital exploration, then experiment w/touch, communicating their responses
Specific suggestions for women (cont.)
Facilitating orgasm during intercourse w/a partner
Woman can initiate movements & pressure that feel most stimulating
Woman (or partner) can also stimulate her clitoris manually or w/a vibrator during intercourse
Specific suggestions for men: Strategies for delaying ejaculation
More frequent ejaculation
“Come again”
Change positions
woman-on-top, no male thrusting, to decrease muscle tension, delay ejaculation
Communication
man tells partner when to reduce or stop stimulation, then resume after a few moments
Alternative activities
intercourse is just one option
Medical treatment
Low doses of antidepressants--considerable side effects
Specific suggestions for men: Strategies for delaying ejaculation (cont.)
Stop-start technique
Developed in the 1950s
Technique involves stimulation to brink of orgasm; stop, wait for sensations to decrease, start again
Man begins by working alone using masturbation
Eventually, work on technique with partner
Discussion question
Read the two handouts describing the sensate focus exercises and the stop-start techniques to help men delay ejaculation.
What are your reactions to these exercises?
Do they seem beneficial? Are there any aspects of these exercises that seem uncomfortable if you were to imagine practicing them with a partner?
Specific suggestions for men: Erectile dysfunction
Reduce performance anxiety (most common cause)
Sensate focus exercises take the pressure off “goal-oriented” intercourse
Then, genital stimulation other than intercourse
After man experiences full erection, partner stops stimulation, allows erection to subside
Resume genital stimulation to allow erection to return
Restores man’s confidence that erection will return
Final phase of treatment is intercourse
If man loses erection after penetration, return to oral or manual stimulation; if response is still blocked, return to nongenital sensate focus before moving forward again
Erectile dysfunction (cont.)
Medical treatments
Viagra (1998); newer drugs: Levitra and Cialis
Mechanism: smooth muscle relaxation in spongy bodies of penis, increasing blood flow, resulting in erection
Similar side effects: flushing, headaches, nasal congestion
Can cause priapism (erection doesn’t subside--can cause damage to penile tissue w/o treatment): takes effect < 3 hours, requires physical stimulation, effect may depend on quality of relationship
Have increased awareness of ED
Has led to some recreational use--has led to some increase in high-risk sexual behavior in combination w/drugs & casual sex
Vasoactive medication
Common ED treatment before Viagra-like drugs
Work by relaxing smooth muscle in spongy body of penis, increasing blood flow --> erection
Required injection into penis, or suppository inserted in urethra
Erectile dysfunction (cont.)
Mechanical devices
Suction blood into penis and hold it there during intercourse
External vacuum devices, with penile constriction bands
Rejoyn
Penile support sleeve made from soft rubber--fits over penis to provide support necessary for intercourse
Erectile dysfunction (cont.)
Surgical treatments
Penile implants--2 types
Semirigid rods inside a silicone covering placed inside cavernous bodies of the penis (disadvantage: penis always semierect)
Inflatable prosthesis that can be pumped as needed (see below)
Surgery cannot restore sensation or ability to ejaculate if it has been lost due to medical problems
Treating Hypoactive Sexual Desire
Some suggestions same as other dysfunctions
encourage erotic responses
Self-stimulation, fantasy
reduce anxiety
Sensate focus exercises
enhance sexual experiences through improved communication about which activities feel pleasurable and which do not
expand repertoire of activities
Less “goal-oriented” sexual activity
Moving beyond “genital-only” sensual/sexual activity
Therapy
Examine, resolve subconscious conflicts about pleasure
Examine whether there are unresolved relationship issues
Treating Hypoactive Sexual Desire Medical treatments
Men:
Testosterone supplementation to increase desire;
Viagra to help with arousal/response
Women:
Both estrogen and testosterone therapies can increase sexual desire and arousal in postmenopausal women
Testosterone can also increase desire in premenopausal women w/below-normal testosterone levels
Zestra: oil applied to clitoris and vulva to increase sexual response
ArginMax: nutritional supplement to increase clitoral sensation, desire, vaginal lubrication, orgasm frequency
Bremelanotide: inhalant that acts on neural pathways to increase desire and genital arousal--still in research phase
Creams containing alprostadil, prostaglandins, or L-arginine to inrease blood flow to genitals, enhance arousal and orgasm
Seeking Professional Assistance
What happens in therapy?
identify & clarify problems & goals
medical, sexual, relationship history
often given homework
NEVER includes sex with therapist
Selecting a therapist
referral from trusted source (some listed in text)
ask about credentials, training, & experience
interview: practicalities & "fit"