Overview of sexual dysfunction & interventions

Joy Hall Head of Division ² Women·s Health MSc BEd(Hons) RN. BASRT Accredited UKCP Registered Psychosexual & Relationship Therapist Joy.hall@bcu.ac.uk

Sexual dysfunction ´ The persistent impairment of the normal patterns of sexual interest or responseµ [ Hawton,1985] ‡ Masters & Johnson (1970)Disorder based on ¶their· sexual response cycle ‡ DSMIV : Persistent or recurrent,deficient or absent, parital or complete. ‡ Kaplan [1979] triphasic model of sexual response : sexual desire, sexual arousal, orgasm

Type of disorder Male Female Desire Hypoactive sexual desire disorder Sexual aversion disorder Erectile dysfunction Hypoactive desire disorder Sexual aversion disorder Female sexual arousal disorder Inhibited female orgasm Arousal Orgasm Inhibited male orgasm Premature ejaculation Dyspareunia Pain Dyspareunia Vaginismus .

sexual orientation issues. ‡ Therapists will also work with : Post rape/sexual assault. ‡ Primary/secondary. . ‡ Generalised/situational.CSA. substance misuse ‡ Paraphilias ‡ Gender identity disorders.DSM IV also categorises ‡ Sexual dysfunction due to : general medical condition. Etc.

Prevalence ‡ WOMEN : 35 ²60%: Mostly inmpaired sexual interest & arousability. ‡ MEN : Rapid ejaculation : 20 ² 40% Erectile dysfunction : 7 ² 10% [ 25% at 65yrs] Retarded ejaculation : 4% . 10 ²15 % anorgasmia.

ASSESSMENT ‡ History ‡ Examination ‡ Investigations ‡ Formulation .

.‡ Physical causes/factors ‡ Psychological factors: Predisposing/ Precipitating/perpetuating.

Predisposing factors Restrictive upbringing Disturbed family relationships Inadequate sexual information Traumatic early sexual experiences Poor self esteem Physical/emotional/ Sexual abuse childhood Psychiatric illness Early insecurity in psychosexual role .

Precipitating factors Childbirth Discord in general relationship Infidelity Unrealistic expectations Dysfunction in partner Random failure Ageing Reaction to organic factors Depression & anxiety Traumatic sexual Experience Work /financial stress Bereavement .

.Perpetuating factors ‡ Performance anxiety ‡ Anticipation of failure ‡ Loss of attraction between partners ‡ Guilt ‡ Poor communication ‡ Discord in general relationship ‡ Fear of intimacy ‡ Impaired self image ‡ Inadequate sexual information: sexual myths ‡ Restricted foreplay ‡ Psychiatric disorder.

nervous and vascular systems.Physical examination ‡ External for secondary sexual charactristics. ‡ Check normality of : endocrine. ‡ Bimanual examination (if appropriate) ‡ PR examination & PSA ( as appropriate) .

‡ Provides individual/couple with further understanding of the problem. & the therapist can check interpretation. ‡ Action plan for interventions ² rationale.Formulation ‡ Provides a ´diagnosisµ ‡ An assessment of individual or couples ability to change. .

Interventions ‡ An eclectic approach ‡ Behavioural ‡ Cognitive ‡ Relationship .

‡ Lifelong generalised mild vaginismus. Mrs H aged 32yrs ‡ 2 year history of secondary situational erectile dysfunction. . ‡ Mr H aged 27yrs.Case Study ‡ GP Referral. vaginismus.

orgasm & ejaculation ( masturbation x 2 per month ‡ Morning erections & erotic response present. ‡ Balanitis & slight phimosis. .History of presenting problem ‡ Non consummation of marriage ( 2 years) ‡ Erections on masturbation sufficient for penetration. ‡ Sound general relationship ‡ Currently x 2 per week ² mutual masturbation.

‡ Urinalysis: NAD .Investigations. chest/heart.pulse. ‡ Physical : Temp.BP. abdomen : NAD ‡ Scrotum & secondary sexual characteristics: NAD ‡ Penis : Balanitis : treated c/o saline bathing & sensilube.

5 mmols FSH : 5.2 mmols Thyroid function & FBC/U&E·s : NAD .Investigations continued ‡ ‡ ‡ ‡ ‡ Serum testosterone: 15.8 IU/l LH : 4.3 IU/l Plasma glucose : 5.

Medical history ‡ Mr H : Nil of note ‡ Mrs H : Migraines. ‡ Medication. . overweight ² later diagnosed with polycystic ovary syndrome.alcohol. irregular periods.smoking. use of recreational drugs : NIL.

‡ Both have strong Christian beliefs & upbringing. uneventful school histories. ‡ Mrs H : Medical secretary. .Social & school history ‡ Mr H :Telecommunications manager. ‡ Both single sex schools. help to run church youth club.

.Family history: Mr H.No sex education at home.Little open communication ( keep feelings to yourself) ‡ Described upbringing as restrictive.Little affection shown . ‡ Youngest of 2 children ( older married brother c/o children) parent in good health.

‡ Limited sex education .periods discussed.married c/o children) ‡ Parent in good health. ‡ Affection more openly between parent & towards Mrs H. .Family history : Mrs H ‡ Oldest of 2 children ( younger sister.

‡ Wedding night erectile failure. ´courtedµ for 3 yrs prior to marriage. ‡ Friends prior to partners. .Sexual History ‡ No abuse or homosexual experiences ‡ For both.Had decided to wait until married before intercourse. A lot of non genital body touching ² arousing. No genital contact/touching prior to marriage. each was first sexual partner. erections Ok.

covers up. Mr H looses erection. .Current sexual relationship ‡ Mutual masturbation ²at best 1-2 x per week 1‡ No oral or anal sex. No use of visual/audio aids etc. ‡ Both orgasmic via masturbation ‡ Restrictive ² Mrs H unhappy about her weight. ‡ Vaginismus when penetration attempted.

Formulation ‡ Predisposing Factors: Couples restrictive Factors: upbringing. Mr H·s slight phimosis. Mrs H·s perceived unattractiveness. Random failure on wedding night ² PERFORMANCE ANXIETY. ‡ Precipitating Factors: Unrealsitic goal Factors: focussed expections. . Mrs H·s vaginismus.Belief that ´all would be goodµ on wedding night. Inadequate sexual information.

Guilt ² sex was something to be endured not enjoyed . Anticipation of failure. Belief of sexual myths.Perpetuating factors ‡ ‡ ‡ ‡ Performance anxiety.

Interventions ‡ Ban on sexual intercourse. ‡ Showering & body exploration ( individual & together) . ‡ Education and permission giving ‡ A & P of genitalia & sexual response ( guided tour via video) ‡ Exploration of sexual expectations & myths.

‡ Enhancement of communication skills. .Interventions continued ‡ Kegal exercises.deep breathing & relaxation exercises ( Mrs H) ‡ Sensate focus programme ² including oral sex ( at which point good firm erections sufficient for penetration) ‡ Vaginal digital insertion & relaxation.

Outcome of therapy ‡ ‡ ‡ ‡ ‡ Full penetrative intercourse. . Number of sessions seen : 1 assessment 6 follow up 1 3 month review.

2nd edition.0208 543 2707 .Reading & useful contact·s Hawton. J (editor) (2005) ABC of Sexual Health. K (1985) Sex therapy : a handbook for practice. Tomlinson. London: BMJ British Association of Sexual & Relationship Therapists.

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