Sexual Dysfunction From the Sex Therapist’s Perspective:
Important Points to Keep in Mind
By Dan Pollets
Sexuality is a complicated mind/body/relationship phenomenon. Physical factors such as hormones, blood flow, and anatomical structural issues will impact on sexual response. Psychological factors such as early social learning and attitude, permission to enjoy sexual behaviors, and religious background will also impact on sexual response. Further, emotions that become associated with the sexual acts such as anxiety, depression, fear, worry, guilt, and disgust can act to inhibit ones sexual response and lessen the joy of the pleasurable acts. Finally, a personal history that involved some sexual trauma or sexual behaviors at an early age (prior to latency) inevitably becomes negatively conditioned to future sexual behaviors and creates conflicts around sexual behavior.
It follows that a purely medical approach that focuses entirely on the physical dimension may limit the scope and ultimately the success of a particular treatment for sexual dysfunction. Sexual dysfunction is a multi-factorial problem that takes interdisciplinary assessment and intervention for successful management. The sex therapist is a trained and experienced psychotherapist in this field. Working in concert with the Urologist or physician trained in sexual medicine, the patient with sexual dysfunction is best attended to. The sex therapist can ascertain the contribution of non-medical (physical issues) relevant to sexual dysfunction and treat these issues.
Importance of the Relationship:
Relationship dynamics are often overlooked in a pure medical model approach and can play out in subtle and insidious ways, impeding effective treatment. For instance, the feeling that his partner needs him to perform in order for her to feel valued can further impact a man with erectile dysfunction. A man with early ejaculation is quite susceptible to his partner’s anger at his problem and will avoid sexual opportunities if they lead him to feel more inadequate. A woman with sexual arousal issues will be quite sensitive to a man’s frustration at her not responding well to his attempts to pleasure him. This all suggests the importance of attending to the relationship in the assessment of sexual dysfunction. The sex therapist is trained to evaluate this component of multiply determined sexual dysfunction. Again, this aspect of treatment is provided in conjunction with medical treatment that may be occurring at the same time.
Most men have difficulty talking about their sexual problem and feelings of inadequacy and shame often give rise to avoidance-based coping strategies. In other words, some men would rather not deal with the problem so as to avoid feeling worse about it. Men often need to be encouraged to verbalize. It is common for men to simply want the “pill” even if there are clear psychosocial or relationship issues going on. Men will often not tell their partners they are struggling with feelings around the physical problem. Middle-age men are dealing with issues of aging and loss and are very sensitive about losing sexual capability. Again avoidance, acting-out, or depression may be maladaptive ways these men can cope with this problem.
Many women express feelings of shame about their sexual dysfunction and have difficulty giving voice to their issue. Social learning experiences have led to woman feeling less “permission” to fully enjoy their sexuality. Guilt and anxiety about attractiveness, body image, and function can lead to inhibition and arousal difficulties in women. Often women who is experiencing sexual difficulty will benefit from a consultation with a sex therapist in order to help clarify feelings and factors that are influencing the problem. The sex therapist can arrange further medical evaluation if necessary.
What to Expect in a Sex Therapy Assessment:
You can expect a professional and confidential meeting where the therapist will sensitively help you describe your physical problem and emotions around it. A history of the problem and all the relevant details will be asked. The emotional reaction of the person to the sexual issue is relevant as is any history of mental disorder; for instance, history of depression, anxiety, feelings of loss, inadequacy, shame, anger, etc. It is important to inquire as to how the partner is coping with the issue. If the partner is in the dark or if relational difficulties are directly acknowledged, this aspect will be more fully covered in the assessment. The quality of communication between partners is highly relevant both in general terms and specific to the comfort in discussing sexual matters. How much hostility or anger expressed between is an obvious issue to evaluate. If any of the previous issues is operative, couples’ treatment will be recommended.
Sexual Dysfunction Definitions:
The following definitions of male and female sexual dysfunction are offered.
Female Sexual Dysfunction (FSD):
Hypoactive Sexual Desire Disorder (HSDD): persistent or recurrent deficiency and/or absence of sexual fantasies/thoughts and/or desire for, or receptivity to, sexual activity, which causes personal distress.
Sexual Aversion Disorder: Persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress.
Sexual Arousal Disorder (FSAD): Persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress. It may be expressed as a lack of subjective excitement, or a lack of genital lubrication, or swelling, or other somatic responses.
Orgasmic Disorder: Persistent or recurrent difficulty, delay in or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress.
Sexual Pain Disorders:
Dyspareunia: recurrent or consistent genital pain associated with genital intercourse.
Vaginismus: Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress.
Male Sexual Dysfunction (MSD):
Erectile Dysfunction (ED) or Impotence: Consistent or recurrent inability to attain and/or maintain a penile erection sufficient for sexual performance.
Early Ejaculation (premature ejaculation): Persistent or recurrent occurrence of ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it.
Delayed Ejaculation: Undo delay in reaching ejaculation during sexual activity.
Anorgasmia: Inability to achieve an orgasm during conscious sexual activity although nocturnal emission may occur.