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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
•
•
3)
4)
Desire-phase difficulties
Excitement/arousal-phase difficulties
Orgasm-phase difficulties
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
a. 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
Table 14.3
Asked college
students, “Have
you ever faked
an orgasm?”(%)
Female
Heterosexual
Female
Lesbian/Bi
Male
Heterosexual
Male
Gay/Bi
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
14.4
• 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
then
now
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. 8)
– 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
– Woman guides partner’s touch
by placing her hand over
partner’s hand on genitals
– At first, to show partner what
feels good
– Eventually, woman may
experience orgasm w/partner
Specific suggestions for women
• 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
Table 14.5
(cont.)
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 “goaloriented” 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 highrisk 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
• 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
(cont.)
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
(similar to Fig. 14.7 in book)
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"