Psychology: Couple Therapy and Transsexual dysfunction sex, Dr. Steven Mendoza, Marriage and Family Therapy, Treatment of sexual dysfunction, Clinical Psychology,

1. Chapter 21: CoupleTherapy
and theTreatment of Sexual
Dysfunction
Dr. Steven Mendoza
December 11, 2014
Alyssa Balli, MFT/LPCCTrainee

2. Agenda
• Culture and Mass Media on Sexuality
• Conceptualization of Sexual Dysfunction
• Assessing a Couples Sexual History and Heirarcy of Questions
• The Role of theTherapist
• Therapeutic Goals and Interventions
• A Picture of ComprehensiveTreatment
• Treatment of Female and Male Sexual Dysfunction Disorders
• Relapse Prevention Plan
• Resources for Clinicians and Clients

3. What do you think of when you
hear “sex therapy and/or sexual
dysfunction?”

4. Culture and mass media on
sexuality and dysfunction
• https://www.youtube.com/watch?v=N_j8l6_u
6kg

5. Sexuality from “Then to Now”
• The importance of sexuality for couples and life satisfaction
is often overemphasized, resulting in confusion,
dissatisfaction, and performance anxiety.The cultural
milieu has gone from one extreme (repression, rigidity, lack
of information and communication) to the other (sexual
overload, confusion, intimidation about one’s body and
sexual performance, and emphasis on medical
interventions, especially for male sexuality). Clinical
Handbook of CoupleTherapy, (2008).

6. A Note on Gender Roles

7. How to conceptualize sexual
dysfunction
• First, sexual dysfunction is best conceptualized,
assessed, and treated as a couple issue. Second,
sexual comfort, skills, and functioning can be
learned. A crucial third concept in modern sex
therapy is the psychobiosocial approach to
understanding, assessing, and treating sexual
dysfunction (Metz & McCarthy, 2007a).

8. Assessing for Sexual History
The five “E’s”
• experience
• etiquette
• empathy
• ethnic or cultural understanding
• relaxed external environment

9. Intake: Hierarchy of Questioning
• Begin with general questions, e g,” How is your health,” to 'How is your sexual
health?”
• First ask questions related to the distant past (“Did you experience any problems in
adolescence / puberty?”) before inquiring about present complaints.
• While eliciting the present medical history find out about non sexual symptoms
(symptoms suggestive of skin infection or urinary tract infection) before trying to ask
questions regarding sexual function.
• During the sexual history first probe non-genital aspects ('Do you have any problems
with foreplay’‘), and then genital issues (Is there any difficulty with erection or
orgasm?”) Once genital aspects of sex have been broached, move from non
penetrative sex history (Is there a difficulty in erection?) to queries regarding
penetration (Is there any problem in insertion of the organ ?”)

10. Hierarchy of Questioning (cont.)
• A similar non threatening to threatening hierarchy is followed while taking history
of exposure to pre or extra martial contact. One can begin with queries about
adolescent fantasies, move on to pre marital sexual contact, experiences and
difficulties, and then probe current marital sexuality. Extra marital issues should be
asked later, and same sex fantasies, non penetrative sex, and penetrative
intercourse explored last of all [in this order].
• The slightest verbal or non-verbal cue of discomfort on part of the patient should
prompt a change in questioning. For example, the patient might appear relaxed
while talking about lack of erection, but may turn red or begin to fidget in his seat
when asked about extra-marital exposure. In other circumstances, a person may be
communicating very well with the counselor, but may suddenly become quiet when
questioned about incest.These are markers of possible etiology of dysfunction, and
at the same time, are pointers to the fact that the patient needs more time to relax
with the counselor.

11. Role of theTherapist
• Sexuality counselors and sex therapists typically
treat patients with desire, arousal, performance,
and satisfaction issues.They also counsel patients
and their partners who have experienced sexual
trauma or abuse, or those who may be struggling
with gender identity or sexual orientation issues,
fetishes, sexual pain, or sexual
compulsions/addictions.

12. Role of theTherapist (cont.)
Qualified specialists, including sex therapists, offer a variety of interventions that may help
a patient reconnect emotionally and sexually with their partner(s). Some common
strategies include:
• Helping patients develop realistic and appropriate expectations
• Identifying contextual catalysts for sexual activity and helping patients gain awareness
of positive sexual cues/triggers
• Assigning sensate focus exercises that help individuals and couples desensitize to
sexual activity that causes anxiety or avoidance and increase non-demanding pleasure
• Teaching the practice of mindfulness
• Exploring alternate forms of sexual expression
• Addressing sexual boredom
• Discussing the use of lubricants, moisturizers, dilators, vibrators, and sexual
enhancers.

13. Therapeutic Interventions and Goals of “SexTherapy”
Helping a patient develop realistic and appropriate goals.
• Patients may need help understanding female and male sexual response and what is arousing
for them as individuals. They may not have explored their sexual responses, they may be
pretending to have orgasms, they may be anxious or inhibited about their sexuality, or they may
engage in a set pattern of sexual activity that is not arousing or satisfying to them.1,2 Exploration
of wants, needs sexual turn ons or turn offs may also be used. Education about a sexual problem
is often the first step in the treatment process and helps the patient better define her needs,
goals, and expectations.3,4
Exploration of sexual fantasies.
• Fantasizing about sex is often a good step in recharging desire. Basson has suggested that many
women (particularly those in long-term relationships) are not having spontaneous sexual
thoughts or fantasies, but may be receptive to sex if mentally or physically stimulated.6,7 Sex
therapists may recommend bibliotherapy or the use of erotic books or videos to spur fantasies.
In addition, the sharing of fantasies with a partner can improve relationship communication
about what a woman finds arousing and may help a couple revive an otherwise boring sexual
script or repertoire.2,8

14. Therapeutic Interventions and Goals of “SexTherapy”
(cont.)
• Identifying contextual catalysts for sexual activity.
– Review of the context in which sexual activity typically occurs in a woman’s life—
i.e. the sexual script—including the time of day, the interval between sexual
encounters, and the way a partner indicates his/her desire for intimacy can be used
by the sex therapist to make recommendations about how to increase a woman’s
desire for sex, arousal, and satisfaction.1
• Cueing exercises.
– These exercises are designed to help a patient remember instances in their life
when they felt sexy and had a good and satisfactory level of sexual desire.The
patient is instructed to recall her physical appearance, the setting, the smells in the
air, the music she was hearing, and the foods she was eating at that time and use
these as “cues” for feeling sexual now.8

15. Therapeutic Interventions and Goals of “SexTherapy”
(cont.)
• Assigning sensate focus exercises.
– These behavioral exercises involve a couple taking turns pleasuring one another so each
person has a heightened awareness of what types of strokes and caresses are most arousing
and can convey that information to his/her partner. Sensate focusing can be both genital and
non-genital in nature. It often begins with limited sensual massage of the face, hands and
neck and progresses over time to include sexual intercourse. In fact, to reduce “performance
anxiety” and help the couple establish emotional intimacy, the exercises are not goal-
oriented (i.e., tied to intercourse) and intercourse is initially discouraged.8
• Teaching the practice of mindfulness.
– Most people have become multitaskers in an effort to keep up with everyday life.They may
take this approach to their sexual life, and rush unfocused through intercourse as well,
leaving little room for sufficient arousal, enjoyment, or satisfaction. Women with desire and
arousal disorders are particularly vulnerable to being distracted by stressors during sexual
encounters. The practice of mindfulness teaches the patient to focus on the here and now
and on all of her sensations—sight, smell, hearing, touch, and taste—and to push distracting
thoughts away.The technique can be particularly helpful in educating a woman about the
way her body responds to sexual stimuli.1,8

16. Therapeutic Interventions and Goals of “SexTherapy”
(cont.)
• Exploring alternate forms of sexual expression.
– This can include education on sensual massage; fondling and caressing; mutual masturbation; manual, oral, and
anal stimulation techniques; use of sexual enhancing toys (vibrators) and trying alternative sexual positions (other
than the missionary position) for sexual intercourse.8
• Addressing sexual boredom.
– A couple who has been together for many years often falls into a sexual routine that is unimaginative and boring,
often called a sexual rut, that can dampen desire. A sex therapist can offer a number of suggestions for reviving
this type of a sexual life, such as changing the venue for sex (moving it out of the bedroom, for instance, and into
the back seat of the car or to a hotel room), as well as sex education books and videos to cull for new techniques.2,8
• Discussing dilators or the EROS device.
– Sex therapists have a number of tools at their disposal to help patients. For a woman suffering from vaginismus,
they can suggest vaginal dilators along with a functionalized program that can help reduce patient anxiety and
help facilitate stretching of the vagina. Successful treatment hinges on the patient being taught how to insert and
use dilators appropriately—e.g., using them three times a week to once daily for 10 to 15 minutes and progressing
slowly through larger-sized dilators.8 For a woman with arousal and/or orgasm disorders, sex therapists may
recommend the EROS Clitoral Stimulator, a prescription-only device that utilizes suction to draw blood to the
clitoral region and has shown in limited clinical data to improve arousal in selected cases.8

17. ComprehensiveTreatment

18. Overview:Treating Female Sexual
Dysfunction
A general foundation for treating sexual concerns includes:
• Using the PLISSIT model for history-taking and therapy
• Facilitating patient and partner education
• Identifying and treating medical conditions that may contribute
• Considering medication and substance use (both current and past) as
a possible causative role, and resolving appropriately
• Providing sexual counseling, coaching, and intensive sex therapy,
when indicated

19. Female Hypoactive Sexual Desire Disorder
• Female hypoactive sexual desire disorder (HSDD) may occur in up to
one-third of adult women in the US.The essential feature of female
HSDD is a deficiency or absence of sexual fantasies and desire for
sexual activity that causes marked distress or interpersonal difficulty.
The evaluation of female HSDD generally requires careful and
thoughtful consideration of the patient and the multitude of factors
that impact on the various components of adult female sexual desire.
Several female reproductive life experiences may uniquely affect
sexual desire.These events include menstrual cycles, hormonal
contraceptives, postpartum states and lactation, oophorectomy and
hysterectomy, and perimenopausal and postmenopausal states.

20. HSDD (cont.)
• Sexual dysfunctions in women have strong positive associations with low
feelings of physical and emotional satisfaction and low feelings of
happiness.Thus, female HSDD can greatly impact on quality of life. In this
article, treatment options are discussed with special attention to
significant reproductive life events that may impact on sexual desire in
adult women. Depending on the particular phase of reproductive life that a
woman is experiencing, different recommendations are made.Various
options in the treatment of HSDD in women include lifestyle changes,
treatment of coexisting medical or psychiatric disorders, switching or
discontinuing medications that could impact on sexual desire, hormone
therapy and marital therapy.Clinical trials are presently underway to assess
medications that may potentially benefit female patients with HSDD.

21. Treatment for HSDD
• Desire is a relatively complex concept that comprises 3 distinct but interrelated components.
• Drive: biologic component based on neuroendocrine mechanisms and evidenced by spontaneous
sexual interest (i.e., feeling “turned on”)
• Cognitive: reflects person’s expectations, beliefs, and values related to sex
• Motivation (emotional/interpersonal): willingness of a person to engage in sexual activity
• Delineating the components of desire is essential because treatment approaches differ based on
which component or components of desire are impaired.Treatment options include:
• Individual cognitive behavioral therapy and/or couples sex therapy
• Pharmacotherapy
– Hormone therapy (e.g., exogenous testosterone replacement, DHEA-S)
– Centrally acting pharmacologic agents that may positively impact sexual functioning

22. Treatment for Female Sexual Arousal
Disorder
• A thorough sexual history is essential in making an accurate diagnosis.
Although not listed in the DSM IV-TR, many sexual medicine experts
would suggest that arousal disorder is best understood by subtypes:
• Generalized: no subjective awareness of genital or overall arousal and
no lubrication/vasocongestion or increased heart rate
• Missed arousal: genital engorgement present but no awareness
• Genital arousal: subjective excitement is present but no genital
engorgement

23. Treatment for Female Sexual Arousal
Disorder (cont.)
It is important to note there is significant overlap with arousal and orgasmic disorders, and distinguishing
between the two may be difficult.
• More randomized clinical trials are needed to evaluate the efficacy of treatment options for female
sexual arousal disorder. Current options include:
• Self stimulation and masturbation, sensate focus exercises coupled with improving communication
with partners— sexual accessories may be adjunctive aids as well as sexual education to understand
genitor-pelvic anatomy and sexual response
• Medical intervention:
– Mechanical (EROS clitoral stimulator, vacuum device)
– Hormonal (systemic or local estrogen therapy for arousal disorder acquired after menopause)
– Pharmacologic (nitric oxide promoters)
• Over-the-counter-lubricants, feminine arousal oil (e.g., Zestra® Essential Arousal OilsTM), and/or
long-acting
vaginal moisturizers

24. Female Orgasmic Disorder
• The etiology of orgasmic problems is likely multifactorial, including
physiologic and psychosocial factors.Treatment options include:
• Cognitive-behavioral approaches that alter negative attitudes and
reduce anxiety
• Permission-given by the clinician to:
– Become educated about sexual response including orgasmic response
– Practice and explore self-stimulation/masturbation in privacy
– Use fantasy, erotic literature, and/or self stimulators or vibrators to
heighten arousal
– Practice sensate focus exercises

25. Dyspareunia
• Dyspareunia is often viewed as a specific pain disorder with
independent psychologic and biologic contributors with context-
dependent etiologies. Physical examination may be required to rule
out underlying anatomic pathology. Specific testing, including pelvic
sonogram and vulvoscopy, may be useful in certain situations.
• Differential diagnosis: introital dyspareunia, vaginismus,
vulvovaginal atrophy, inadequate lubrication, vulvodynia, deep
dyspareunia, endometriosis, pelvic inflammatory disease
• Assess/consider concurrent psychologic or behavioral contributions
via sexual history

26. Treatment for Dyspareunia
• Treatment options include treating the underlying physiologic or psychologic source of the pain:
• Anti-irritant hygiene program
• Vulvovaginal atrophy
– Topical/local estrogen preparations (tablets, creams, rings)
– Premarin®Vaginal Cream is FDA-approved to treat moderate-to-severe postmenopausal dyspareunia
• Burning pain (indicative of neuroproliferation)
– Low-dose tricyclic antidepressants (e.g., amitriptyline), SSRIs (e.g., duloxetine), or anticonvulsants (e.g.,
gabapentin)
• Pelvic floor myofascial pain and guarding of pelvic floor muscle
– Refer for manual pelvic floor muscle physical therapy
– Low-dose muscle relaxing agent (e.g., cyclobenzaprine, diazepam)
• Anxiety management and coping
– Refer for cognitive behavioral therapy
• Referral for couples sexual counseling/therapy to explore non-penetrating pleasuring techniques
(as appropriate)

27. Vaginismus
• Vaginismus is persistent difficulty to allow vaginal entry
of a penis, finger, or any object despite the express wish
to do so.
• Important considerations during assessment:
• Vaginismus may be limited to sexual activity and may
not be seen during a pelvic examination
• Vaginismus may occur due to fear of pelvic
examinations, but not impact sexual activity

28. Treatment ofVaginismus
• Treatment is based on a combination of cognitive and behavioral
psychotherapeutic approaches to desensitize the woman to her
anxiety/panic and help achieve a sense of control over a sexual encounter
or a pelvic examination, and an understanding that she is no longer in
danger of experiencing pain.Treatment options may include:
• Cognitive behavioral therapy
• Pelvic floor physical therapy
• Relaxation training with systemic desensitization using graduated vaginal
dilators to help gain control over and relax muscles and stretch the vagina

29. Overview:Treating Sexual Dysfunction in
Males
• The Karnal Model relies on the cognitive behavioral therapy
approach, which follows the “antecedents' lead to behavior which
leads to consequences” (ABC) framework.The consequence that
the patient has presented with is the sexual dysfunction.This,
however, must have been preceded by a behavior(s) probably
dysfunctional.The behavior, in turn, would have had significant
antecedents.The consequence cannot be corrected unless the
preceding antecedents and behaviors are analyzed, identified, and
corrected.

30. Examples of Cases
• For example, a newly married man may present with premature ejaculation,
because he has been used to frequent masturbation and fast ejaculation. Once
this antecedent is identified, it becomes easier for the patient to analyse and
correct his behavior.
• Other patients may identify childhood abuse, premarital exposure to
pornography, unpleasant encounters with partners, same-sex encounters,
fantasies or episodes of paid sex as antecedents for dysfunctional sexual
behaviors.
• Common antecedents for sexual dysfunction include stress at work, difficulties
with working partners, financial strains, and physical exertion.All of these may
prevent a couple from realizing optimal sexual satisfaction.

31. Erectile Dysfunction
• Erectile dysfunction (ED), sometimes referred to as impotence, is the
inability of a man to achieve or maintain an erection hard enough for
sexual intercourse. Millions of men in the U.S. have erectile dysfunction. It
may be caused by diseases, complications from surgery, side effects of
certain medications, lifestyle factors, and psychological factors.
• Talk therapy may be the initial treatment option for men with anxiety or
stress-related erectile dysfunction. Relationship difficulties, work
problems, financial woes, and other, everyday stressors can trigger
erectile dysfunction.Talking about worries and stressors to a licensed
therapist can ease sexual anxiety and provide strategies to boost
intimacy. Usually only three to four sessions are needed. Including one’s
partner in therapy can also be helpful.

32. Video: Erectile Dysfunction:
Impact on Couples
• https://www.youtube.com/watch?v=dK4suRh
P_o0

33. Premature Ejaculation
• Premature ejaculation is uncontrolled ejaculation either
before or shortly after sexual penetration, with minimal
sexual stimulation and before the person wishes. It may result
in an unsatisfactory sexual experience for both partners.This
can increase the anxiety that may contribute to the
problem. Premature ejaculation is one of the most common
forms of male sexual dysfunction and has probably affected
every man at some point in his life.

34. Premature Ejaculation
• Clinicians or doctors may recommend that client and
partner practice specific techniques to help delay
ejaculation.These techniques may involve identifying and
controlling the sensations that lead up to ejaculation and
communicating to slow or stop stimulation. Other options
include using a condom to reduce sensation to the penis or
trying a different position (such as lying on one’s back)
during intercourse. Counseling or behavioral therapy may
help reduce anxiety related to premature ejaculation.

35. Relapse Prevention for both Male and Female
Clients
• Assist couple define intimacy, sexuality etc. based on their own wants and
needs, not on societal constructions and help the couple establish comfort
between each other
• Assisting clients to set realistic expectations for sexual encounters, reduce
shaming, guilt etc. between partners and encourage them to revisit sexual
experiences if there are “hiccups” and make light of these instances when
they do occur
• Review the idea of “good enough sex” with couple to normalize
expectations and reduce anxiety for partners
• Encourage each partner to be open, find their “sexual voice” and be an
active participant in each others’ desire, intimacy, wants and needs

36. Resources for Clinicians and Clients
• How to improve marital/couple intimacy
http://psychcentral.com/lib/how-can-i-improve-intimacy-in-my-
marriage/00011811
• Handbook on Female Sexual Health andWellness
http://www.arhp.org/Publications-and-Resources/Clinical-Practice-
Tools/Handbook-On-Female-Sexual-Health-And-Wellness/Treating-
Female-Sexual-Dysfuntion
• SexTherapy for Non-SexTherapists
http://www.arhp.org/publications-and-resources/clinical-fact-
sheets/shf-therapy

37. References
• Kaira, S. (2009). Counselling In Male Sexual Dysfunction:The Karnal Model.The Internet Journal of
Family Practice. Retrieved from: https://ispub.com/IJFP/9/1/8370
• Kingsberg, S., Iglesia, C., Kellogg, S. and Krychman, M. (2014). Handbook on Female Sexual Health
andWellness. Association of Reproductive Health Professionals Retrived from: http://
www.arhp.org/Publications-and-Resources/Clinical-Practice-Tools/Handbook-On-Female-
Sexual-Health-And-Wellness/Publication-Information
• Krychman, M. and Kellogg, S. (2010). SexTherapy for Non-SexTherapists. Sexual Health
Fundamentals. Association of Reproductive Health Professionals Retrived from: http://
www.arhp.org/publications-and-resources/clinical-fact-sheets/shf-therapy
• McCarthy,B. andThestrup, (2008). CoupleTherapy and theTreatment of Sexual Dysfunction. Clinical
Handbook of CoupleTherapy. Fourth EditionGuilford Publications. Kindle Edition.
• Thompson, E., (2012). Premature Ejaculation-TopicOverview. WebMD Retrieved from: http://
www.webmd.com/men/tc/premature-ejaculation-topic-overview
• Warnock, J. (2002). Female hypoactive sexual desire disorder: epidemiology, diagnosis and
treatment. CNS Drugs; 16(11) Retrived from http://www.ncbi.nlm.nih.gov/pubmed/12383030