Human Sexuality: Diversity in Contemporary America 10e

14: Sexual Function Difficulties,

Dissatisfaction, Enhancement, and
Therapy

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 Main Topics

Sexual function difficulties: definitions, types, and prevalence.

Physical causes of sexual function difficulties and

dissatisfaction.

Psychological causes of sexual function difficulties and

dissatisfaction.

Sexual function enhancement.

Treating sexual function difficulties.

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 Sexual Function Difficulties: Definitions,
Types, and Prevalence
Sex problems are normal and typical.

As too little research has been done on the sexual function

difficulties of gay, lesbian, bisexual, or transgender
individuals and couples, most of this discussion reflects
heterosexual couples.

In general, however, heterosexual individuals, gay men, and

lesbian women seemingly experience similar kinds of sexual
function problems.

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 Defining Sexual Function Difficulties:
Different Perspectives
Standard medical diagnostic classification is found in the
American Psychological Association’s DSM-5, using the terms
sexual dysfunction and sexual disorders.

Sexual function dissatisfaction: an alternative term to sexual

dysfunction; a common outcome of a difficulty in sexual
functioning.
Acknowledges sexual scripts as individual.

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 The Diagnostic and Statistical Manual of
Mental Disorders
APA’s DSM-5 definition of sexual dysfunction:
a clinically significant disturbance in a person’s ability to respond
sexually or to experience sexual pleasure.
All dysfunctions require the symptoms to be present for at least 6
months, unless caused by substance or medication use, and cause
significant distress.
APA further notes that sexual response and function occur as an
interaction of biological sociocultural, and psychological factors.
DSM-5 largely reflects a psychiatric model, the heterosexual
context, and a linear sequence of desire, arousal, orgasm, and so
on.

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 Table 1 DSM-5 Sexual Dysfunctions/Disorders
Dysfunction/disorder
Female sexual interest/arousal disorder.
Male hypoactive sexual desire disorder.
Erectile disorders.
Female orgasmic disorders.
Premature (early) ejaculation.
Delayed ejaculation.
Genito-pelvic pain/penetration disorder.
Substance/medication-induced sexual
dysfunction.
Description
Absent/reduced sexual thoughts, fantasies, initiation,
and receptivity, and absent/reduced arousal and
pleasure during sexual activity.
Persistence or absence of sexual thoughts, fantasies,
and desire for sexual activity.
Difficulty with erections during partnered sexual
activity.
Difficulty in experiencing orgasms or reduced intensity
of orgasms during sexual activity.
Experiencing “early” ejaculation following vaginal
penetration.
Marked delay in or inability to ejaculate, usually
during partnered sexual activity.
Difficulties related to genital and pelvic pain and
vaginal penetration during intercourse.
A specific substance presumed to cause the sexual
dysfunction.

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@2019 McGraw Hill Education. source: American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Arlington, VA: 2013.
 A New View of Women’s Sexual Problems

Working Group for a New View of Women’s Sexual Problems (2001)

offers a different classification system.
Claims a physiological framework falsely assumes equivalency
between men and women and fails to acknowledge the role of
relationships and differences among women.
Describes sexual function problems “as discontent or dissatisfaction
with any emotional, physical, or relational aspect of sexual
experience,” in one or more categories:
• Sociocultural, political, or economic factors.
• Partner and relationship problems.
• Psychological problems.
• Medical factors.
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 Figure 1a Percentage of Sexually Active Men and
Women in Britain, Aged 16 to 74; Reporting Selected
Sexual Problems Lasting 3 Months or More in the
Past Year

Access the text alternative for these images. 14-8

@2019 McGraw Hill Education. Source: Adapted from Mitchell et al., 2013.
 Figure 1b Percentage of Sexually Active Men and
Women in Britain, Aged 16 to 74; Reporting Selected
Sexual Problems Lasting 3 Months or More in the Past
Year

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@2019 McGraw Hill Education. Source: Adapted from Mitchell et al., 2013.
 Figure 2 Percentage of Self-Reported Sexual
Functioning at Most Recent Partnered Sexual
Event Among U.S. Adults Aged 18 to 59, 2009

Note: Percents are rounded; hence, the total may exceed 100%.
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@2019 McGraw Hill Education. Source: Adapted from Herbenick et al., 2010.14a.
 Figure 3 Percentage of Self-Reported Sexual
Function Difficulties in the Past 12 Months Among
U.S. Adults Aged 18 to 59, by Gender and Age

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@2019 McGraw Hill Education. Source: Adapted from Laumann et al., 1999.
 Figure 4 Percentage of Finnish Adults Who Indicated
That They Feel Sexual Desire at Least a Few Times a
Week

A Finnish study of 2,650 adults found that feelings of sexual desire decreased as
the individual aged and as a relationship continued through the years. Note the
slight upward trend for women around age 45 to 49, before resumed decrease
in interest.
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@2019 McGraw Hill Education. Source: Kontula, 2009.
 Figure 5 Percentage of Finnish Adults Who
Indicated That If They Could Choose Freely They
Would Like to Have Intercourse at Least Twice a
Week

Feelings of sexual desire decrease as a relationship continues through the years. Here,
note the steady decrease in interest among women as the relationship duration
increases, while for men, interest decreases around 6 to 9 years into the relationship,
increases again at around 10 to 19 years, and then decreases steadily thereafter.

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@2019 McGraw Hill Education. Source: Kontula, 2009.
 Disorders of Sexual Desire

Inhibited sexual desire is the number-one sexual function

problem of American couples.

DSM-5 diagnoses:
Female sexual interest/arousal disorder.
Male hypoactive sexual desire.
Erectile disorder.

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 Orgasmic Disorders

Female orgasmic disorder: difficulty experiencing orgasm

and/or markedly reduced intensity of orgasmic sensations in
women.

Female orgasm is not universal.

Premature (early) ejaculation: a recurring and continuing

pattern of ejaculation during partnered sexual activity within
1 minute of penetration.
Definition varies among individuals, populations, and
cultures.
Delayed ejaculation: marked delay or inability to ejaculate.
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 Sexual Pain Disorders

Genetic-pelvic pain/penetration disorder: one of four diagnostic

categories.
Marked difficulty having vaginal intercourse/penetration.
Marked vaginal or pelvic pain during a vaginal intercourse or
penetration attempt.
Marked fear or anxiety about vaginal or pelvic pain in anticipation
of as a result of vaginal penetration.
Marked tensing or tightening of the pelvic floor muscles during
attempted vaginal penetration.

Anodyspareunia: pain during anal intercourse.

Not included in the DSM-5.
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 Other Dysfunctions and Disorders

Substance/medication-induced sexual dysfunction: sexual

function difficulties that occur with intoxication use of
various drugs.

Peyronie’s disease: condition in which calcium deposits and

tough fibrous tissue develop in the corpora cavernosa within
the penis.

Priapism: prolonged and painful erection, occurring when

blood is unable to drain from the penis.

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 Physical Causes of Sexual Function Difficulties
and Dissatisfaction
Until recently, researchers believed most sexual function
difficulties and dissatisfaction were almost exclusively
psychological in origin.

Current research considers several factors, including:

Subtle influences of hormones.
Vascular, neurological, and endocrine systems; and various
related illnesses and disturbances.
Prescription drugs.
Cancer treatments.

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 Physical Causes in Men

Diabetes and alcoholism are the leading causes of male erectile

difficulties; other causes include:
Lumbar disc disease.
Multiple sclerosis.
Atherosclerosis.
Spinal cord injuries.
Prostate-cancer treatment.
Drug use.
Smoking.
Bicycle-induced sexual difficulties.
Diseases of the heart and circulatory system.
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 Physical Causes in Women

Physical causes for women are numerous, including:

Diabetes and heart disease.
Hormone deficiencies and neurological disorders.
General poor health, fatigue, drug use, and alcoholism.
Spinal cord injuries or multiple sclerosis.
Obstructed or thickened hymen, clitoral adhesions, infections,
scars, a constrictive clitoral hood, vulvodynia, or a weak
pubococcygeus—the pelvic floor muscle.
Antihistamines and marijuana.
Endometriosis and ovarian and uterine tumors and cysts.
Clitoral irritation; or vaginal or urinary tract infections.
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 Psychological Causes of Sexual Function
Difficulties and Dissatisfaction (1 of 2)
Immediate causes include:
Fatigue and stress.
Ineffective sexual behavior.
Sexual anxieties, evidenced by phenomena such as
spectatoring—in which a person becomes a spectator of his
or her own sexual behaviors.
Excessive need to please a partner.

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 Psychological Causes of Sexual Function
Difficulties and Dissatisfaction (2 of 2)
Various conflicts within the self can contribute.
For example, among gay men, lesbian women, and bisexual
individuals, internalized homophobia: self-hatred because of
one’s homosexuality.
Sources of severe difficulties include childhood sexual abuse,
adult sexual assault, and rape.

There are also relationship causes.

All couples at some point experience difficulties.
Challenge is balancing separateness with togetherness.

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 Sexual Function Enhancement

Sexual function enhancement refers to improving the

quality of a sexual relationship.

Sexual function–enhancement programs aim to:

Provide accurate information about sexuality.
Develop communication skills.
Foster positive attitudes.
Provide sexual homework for practicing techniques discussed in
therapy.
Increase self-awareness.

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 Developing Self-Awareness (1 of 2)

We will know we are having “good sex” if we feel good about

ourselves, our partners, our relationships, and our sexual
behaviors.
We should feel good before, during, and after being sexual.

To fully enjoy our sexuality, we need to explore our

“conditions for good sex”—and each individual has his or her
own unique conditions.

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 Developing Self-Awareness (2 of 2)

Typical “homework” exercises:

Mirror examination.
Body relaxation and exploration.
Masturbation.
Developing your own erotic “sexual voice”.
Kegel exercises for women and men.
Erotic aids or sex toys—products designed to enhance erotic
responsiveness.

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 Intensifying Erotic Pleasure

Developing and maintaining sexual desire is important to a

satisfying couple sexual style.
Key is to integrate intimacy and eroticism by “building
bridges to desire” (McCarthy and McCarthy).

Increasing sexual arousal has two elements:

Having your conditions for good sex met.
Focusing on the sensations you are experiencing.

Decline in sexual passion and satisfaction is not inevitable.

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 Table 2 Percentage of Sexually Satisfied Men and Women
Versus Those Dissatisfied Who Indicated They Had Done
Different Activities in the Past Year to Improve Their Sex
Life
Acts of Sexual Variety Past Year (% Yes) Sat. Men Dis. Men Sat. Women Dis. Women
At least one of us got a mini-massage or backrub 72% 48% 68% 40%

One of us wore sexy lingerie/underwear 67% 33% 71% 45%

Took a shower or bath together 64% 35% 66% 37%
Made a “date night” to be sure we had sex 63% 41% 55% 37%
Tried a new sexual position 59% 22% 63% 25%

Went on a romantic getaway 53% 30% 47% 28%

Used a vibrator or sex toy together 48% 28% 47% 30%

Tried anal stimulation 42% 19% 37% 19%

Viewed pornography together 40% 19% 45% 28%

Talked about or acted out our fantasies 40% 14% 37% 16%
Had anal intercourse 25% 10% 26% 14%
Had sexual contact in a public place 23% 6% 19% 6%

Integrated food into sex (e.g., chocolate/whipped cream) 22% 8% 22% 9%

Tried light S&M (e.g., restraints, spanking) 18% 6% 21% 9%

One of us took Viagra or a similar drug 17% 12% 9% 10%

Videotaped our sex or posed for pictures in the nude 15% 5% 13% 5%
Invited another person into bed with us 6% 2% 3% 2%

Participants were asked, “Have you done any of the following in the past year to improve your sex life? If so, select all
that apply.”
Participants provided their answers on a 7-point Likert scale: 1 = very dissatisfied, 7 = very satisfied. For this table,
dissatisfied represent answers 1 to 3 combined and satisfied as 5 to 7 answers combined. 14-27
source: Adapted from Frederick D. A., Lever, J., Gillespie, B. J., and Garcia, J .R., “What Keeps Passion Alive? Sexual Satisfaction Is Associated With Sexual Communication, Mood Setting,
@2019 McGraw Hill Education. Sexual Variety, Oral Sex, Orgasm, and Sex Frequency in a National U.S. Study,” The Journal of Sex Research, vol. 54, no. 2, February 2017, 186–201.
 Table 3 Percentage of Sexually Satisfied Men and
Women Versus Those Dissatisfied Who Indicated They
and Their Partner Had Talked About Sex in Any of These
Ways
Communication Past Month (% Yes) Sat. Men Dis. Men Sat. Women Dis. Women
I asked for something I wanted in bed 51% 28% 42% 15%
One of us praised the other about something they did in bed 50% 12% 56% 14%
My partner asked for something they wanted in bed 37% 8% 50% 21%
One of us asked for feedback on how something felt 34% 13% 33% 12%
One of us called/emailed to tease about doing something sexual 33% 11% 40% 14%
One of us gently criticized how the other did something in bed 7% 7% 7% 7%

Participants were asked, “In the past month, have you and your partner talked about sex
in any of these ways? Please select all that apply.”
Participants provided their answers on a 7-point Likert scale: 1 = very dissatisfied, 7 =
very satisfied. For this table, dissatisfied represent answers 1 to 3 combined and satisfied
as 5 to 7 answers combined.

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source: Adapted from Frederick D. A., Lever, J., Gillespie, B. J., and Garcia, J .R., “What Keeps Passion Alive? Sexual Satisfaction Is Associated With Sexual Communication, Mood Setting,
@2019 McGraw Hill Education. Sexual Variety, Oral Sex, Orgasm, and Sex Frequency in a National U.S. Study,” The Journal of Sex Research, vol. 54, no. 2, February 2017, 186–201.
 Treating Sexual Function Difficulties (1 of 6)

Masters and Johnson were pioneers in the cognitive-

behavioral approach.
Majority of sexual function problems are the result of sexual
ignorance, faulty techniques, or relationship problems.
Treated difficulties using a combination of cognitive and
behavioral techniques.
Treated couples rather than individuals.
Sensate focus: focus on touch and the giving and receiving
of pleasure.

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 Table 4 Strategies to Cope With Sexual
Difficulties
Explore ways to change the situation.
One could end the current relationship and seek to begin another, or look for ways to resolve the
problem psychologically or medically (e.g. erection-enhancing drugs).
Amend your goals to fit the circumstances.
One could take a flexible perspective toward the importance of sex by focusing more on other
relationship aspects and other priorities.
One could lower expectations by accepting a trade-off between having a relationship with a person
one loves and experiencing the perfect physical sexual experience.
A person could expect to have “good sex” less often.
One could adapt flexible definitions of “good-enough” sex by shifting from perceiving excitement as
most important to considering intimacy as the most important.
Live with a gap between one’s sexual goals and the circumstances.
One could perceive one’s experience as normal and favorably compare one’s experience with other
persons.
One could avoid thinking about the problem, initiating sexual relationships, and experiencing sexual
activity.
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@2019 McGraw Hill Education. source: Mitchell, R., King, M., Nazareth, I., & Wellings, K., “Managing Sexual Difficulties: A Qualitative Investigation of Coping Strategies,” The Journal of Sex Research, vol. 48, 2001, 325–333.
 Treating Sexual Function Difficulties (2 of 6)

Sex therapy utilizes different techniques for treatment

specific problems, including:
Female orgasmic disorders: partners are encouraged to support
the woman to have an orgasm any way it happens for her.
Erection difficulties: removal of fears and anxieties is the first step
in therapy.
Early ejaculation: therapy may include an exercise called the
squeeze technique, interrupting stimulation before ejaculation.
Delayed ejaculation: the man is coached to focus on the sensation
rather than trying to make ejaculation happen.

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 Treating Sexual Function Difficulties (3 of 6)

Common erection myths:

Erection is something that is achieved.
Men are sex machines, always ready, always hard.
During a sexual encounter, you get only one shot at an
erection.
I blew it last time; I will never get it up again.
If I can’t have an erection, my partner can’t be sexually
satisfied.

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 Treating Sexual Function Difficulties (4 of 6)

Helen Singer Kaplan modified Masters and Johnson’s

behavioral treatment program to include psychosexual
therapy.

Other nonmedical approaches attempt to work around the

expense in time and money of cognitive-behavioral and
psychosexual therapy.
PLISSIT model of therapy: permission, limited information,
specific suggestions, and intensive.
Self-help and group therapy.

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 Treating Sexual Function Difficulties (5 of 6)

Because sexual function difficulties are often a combination of

physical and psychological problems, there are medical
approaches.
Lubricating jelly or estrogen therapy for vaginal pain.
Testosterone therapy for loss of sex drive and function, low
energy and strength, depressed mood, and low self-esteem.
Microsurgery to improve a blood flow problem.
Viagra, Levitra, and Cialis.
Flibanserin (Addyi) to boost women’s sexual desire.
Homeopathic products.
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 Treating Sexual Function Difficulties (6 of 6)

For gay men, lesbian women, bisexual individuals, and

transgender individuals, sexual issues differ from those of
heterosexual people.
Context in which issues arise may differ significantly.
Behaviors, rather than intercourse, are more the focus.
Homophobia, societal and internal, may be an issue.

When treatment fails, individuals must find ways to cope

with and adjust to the difficulties.

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 Final Thoughts?

Sexual function difficulties: definitions, types, and prevalence.

Physical causes of sexual function difficulties and

dissatisfaction.

Psychological causes of sexual function difficulties and

dissatisfaction.

Sexual function enhancement.

Treating sexual function difficulties.

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