1. society
2. sex

Female Sexual
Dysfunction
Assessment and Counselling
Case Presentations
Jocelyn Verry
Counsellor /Therapist
Melbourne Sexual Health Centre
A Thought
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Ever since Queen Victoria
died, men have been trying to
tame the female orgasm. As
long ago as 1913 Alfred
Adler published his
conclusion that 80 per cent
of women were sexually nonresponsive. In those days
they would have been called
frigid; these days we say they
suffer from female sexual
dysfunction (FSD).
Germaine Greer Jan2003
What is Female Sexual dysfunction??
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Disorder Descriptions
Hypoactive sexual desire disorder †Persistent lack of desire for sexual activity and or lack of
responsive desire This is beyond normative lessening with relationship duration or aging
Sexual aversion disorder Persistent or recurrent phobic avoidance of sexual contact with a partner
Female Sexual arousal disorder† Persistent or recurrent inability to attain or maintain sexual
excitement
Female Orgasmic disorder† Persistent or recurrent delay in, or absence of orgasm following a
normal sexual excitement phase
Dyspareunia Recurrent or persistent pain associated with vaginal penetration or attempted
vaginal penetration
Vaginismus Recurrent or persistent inability to allow vaginal entry in spite of expressed wish to
have vaginal intercourse
Noncoital sexual pain Genital pain following stimulation during foreplay† These must cause the
woman distress in order to qualify as FSD
.Source: Basson R, et al. “Report of the International Consensus Development Conference on Female Sexual
Dysfunction: Definitions and Classifications,” Journal of Urology (March 2000), 163:888–895.
Causes of Diminished Sexual
Passion
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Age
Past Sexual Satisfaction
Stress
Children
Power & Control
Intimacy Trust
Betrayal
Conflict Resolution
Communication Skills
Commitment/Cohabitation
(Sandra Lieblum 2006)
Biological risk factors
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Although psychological
factors might account for
much of the risk of
dysfunction its possible that
biological factors play a part
The roles of oestrogen and
testosterone in maintaining
women’s sexual health are
not clearly understood.
Basson R International Journal of Impotence Research 2008
PLISSIT Model
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The American psychologist Jack Annon (19292005) developed a simple model illustrating the
fact that most people with sexual problems do
not need an intensive course of therapy. He
used the acronym PLISSIT for four basic forms
of sex therapy:
The PLISSIT Model of Sex Therapy
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P stands for Permission, since many sexual problems are caused by anxiety, guilt feelings, or
inhibitions. It follows that a therapist who, using his professional authority, simply "gives
permission" to do what the patient is already doing, can alleviate much unnecessary suffering.
(Example: Guilt feelings and anxiety because of masturbation)The next step of therapeutic
intervention is called
LI or Limited Information. Often it is enough to give patients correct anatomical and
physiological information to restore their sexual functioning. It is not at all uncommon that
patients have erroneous notions about the functioning of their own body and thus fall victim to
unrealistic expectations. In such cases little more than factual information and education is
necessary.The next step –
SS, Specific Suggestions, requires practical hints or exercises tailored to the individual case.
Many of the exercises of mutual pleasuring recommended by Masters and Johnson belong in this
category.Only the last step –
IT or Intensive Therapy, requires a long-term intervention addressing complex underlying
causes. Annon is convinced, however, that these cases are relatively rare.Thus, the whole PLISSIT
model represents a graduated system of therapeutic sieves, in which the easy cases are caught
and eliminated first, while the more difficult cases sink to the bottom in steadily diminishing
numbers. Thus, Annon's pragmatic and practical model is a useful reminder for all therapists and
their clients that not every sexual problem requires the whole therapeutic arsenal.
Jane
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27 year old woman presented to the clinic with
thrush. She was referred to counselling as has
she had pain with sex and low sexual desire
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Jane has been to counselling but has never
discussed this with the counsellor as never felt
comfortable
Cycle of sexual dysfunction.
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Example showing how a client can
enter the cycle of sexual
dysfunction in one area (i.e.,
decreased orgasm) and proceed to
another area (i.e., decreased desire)
so that the presenting complaint
may not represent the problem that
actually requires evaluation and
treatment.
Adapted with permission from Phillips NA. The clinical evaluation of dyspareunia. Int. J Impotence
Res 1998;10 (suppl 2):S117-20.
Jane
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Has seen many doctors (10 in total) re: her
condition and also had a laparoscopy trying to
seek a solution
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Jane stated she believed the thrush keeps him
away and she does not have to have sex
Jane
Jane’s Relationship History:
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First boyfriend at 16yrs (for 2 yrs)
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First sexual experience at 17yrs; she describes it
as painful and scary
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At 19yrs she had a relationship with a man aged
44 (for 3yrs) as she thought elder man to be
more knowledgeable but he was not sensitive to
her needs
Jane
Jane’s Relationship History cont…
 Then a few short term relationships (no casual
relationships)
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Currently in a relationship with Mark (aged
22yrs) for the last two years
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“Mum told me growing up sex was only for the
special person in your life and in marriage’
Jane
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When Jane was 10yrs she was at a playground
with a friend. As she came down the slide she
was groped all the way down by a teenage boy.
She went home and did not tell anyone
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At the age of 14yrs kissed by her fathers friend
in his office
Jane
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Jane has an elder brother that she described as
not close. She was unaware of her sexuality until
she was in her teens
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Mum and Dad’s relationship growing up: “Mum
was the ‘Boss’ Dad was very shy and didn’t say
much. There was not a great deal of affection
shown towards each other.
Jane
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Jane and Bill have not had intercourse for a
couple of months as every time they try it hurts
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Jane fears cuddling Bill as she always thinks he
will want sexual penetration
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Bill initiates sex usually, as Jane rarely does
Jane
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Jane struggles with the belief that the male
partner does not want intimacy with her he just
wants to “fuck her”
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When having sexual intercourse with Bill she is
distracted, thinking about what she has to get
from the shops tomorrow
Jane
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Bill is very supportive of Jane and says he will
do what ever he needs to do as he loves her a
lot, but he does miss the connection achieved
with intercourse
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Bill will attend for 1 session - as difficult with
work commitments
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Aware they can have ‘couples work’ at an after
hours practitioner
Jane
Plan of Action:
 Plan to work with Jane for six weeks and then
review
 Looking at; Jane’s fear of being objectified and
used, her belief she is being seen as an object
and her trepidation of giving herself over and
opening up to the experience
 The more she hides the more likely she will be
objectified
Jane
Plan of Action cont…
 Unpack what she means regarding her belief
that he is not interested in her
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Challenges with Bill, mistrust in self and to get
on with what she wants
Ann and Mark
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Ann and Mark (both 32yrs) referred to
counselling for sexual therapy as Ann had
Hypoactive Sexual Desire Disorder and Female
Sexual Orgasmic Disorder
Ann and Mark
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Ann had Mark had had couple counselling twice
and had just recently stopped. They never
discussed their sex life
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Ann had counselling for sexual abuse as a child
Ann and Mark
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Ann and Mark have been in a relationship for 12
yrs
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For both it’s their first long term relationship
(previous relationships were casual)
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They have moved here from the country
Queensland
Ann and Mark
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Sixteen months into the relationship Ann fell
pregnant
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They both decided to terminate the pregnancy
with one session of post termination
counselling
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They remain using natural family planning
methods which Ann feels works well
Ann and Mark
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Ann describes their sexual life as initially great
“Couldn’t have enough of each other” but after
the termination sexual desire became low
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Mark describes developing premature
ejaculation after the termination. He believed
their sexual life was ok but not ever great
Ann and Mark
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Recently whilst Mark was away working interstate Ann
bought a little vibrator and for the first time had an
Orgasm
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She was so excited and phoned Mark who initially
reacted in a very dismissive way as he felt totally
rejected and which in turn shut Ann down
Ann and Mark
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When Mark masturbated Ann would walk in on him
and start talking, not respecting his space so he
stopped feeling safe to do so
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Also occasionally when having sex Ann would make an
insensitive comment and spoil the moment
Ann and Mark
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Ann and Mark have little contact with both
families
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Ann's stepfather sexually abused her
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Mark had a very dominant mother
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Ann had a history of walking away from
relationships and this time did not want to
despite Mark having one incident of infidelity
with her female friend
Ann and Mark
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Ann and Mark are committed to making
changes around their sexual intimacy
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In the ‘Sexual Quality of Life Questionnaire’*
Ann scored 16% (a higher score=higher sexual
quality of life)
* which is a self reported questionnaire developed to address the impact of a
sexual dysfunction on quality of life
Ann and Mark
Plan of Action:
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Plan to work for 6 weeks and review
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Initial interventions
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Explored individually; What do they want
sexually? Who they are sexually? What they like?
What they don’t like? What does sex represent ?
What do they find attractive about each other?
Ann and Mark
Plan of Action cont…
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Reporting back I asked them both what that they had
heard, what stood out for them and what was it like to
hear that. Helping them discover who are they together
sexually
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Five months later both Ann and Mark have achieved
the ability to masturbate individually, together and feel
safe
Conclusion
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For women with desire and arousal disorders, such as
the women in the case scenarios the evaluation involves
taking a detailed history of sexual difficulties from both
partners if possible
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Sessions should be focused on unreasonable
expectations, maladaptive thoughts, misinformation on
women's sexuality
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Any apparent relationship issues should be addressed
before pursuing further sexual therapy