SEXUAL DYSFUNCTION AND ITS

MANAGEMENT

Presented by:
Sanchita Agrawal
M.Phil. (Clinical Psychology) - II
AIBAS

Supervised by:
Ms. Saima Ayyub
Assistant Professor
AIBAS

DEFINITION:

Sexual Dysfunction:
The International Statistical Classification of Diseases and Related Health
Problems (ICD – 10) defines sexual dysfunction as individual’s inability to
participate in a sexual relationship as he or she would wish. There may be lack of
interest, lack of enjoyment, failure of the physiological responses necessary for
effective sexual interaction (e.g. erection), or inability to control or experience
orgasm.

Sexual Deviation:
Sexual deviation is a biomedical word for defining sexual arousal by objects,
people, or situations as abnormal. It is sexual behaviour and fantasy against public
morality.

SEX v/s GENDER

Sex: It refers to a person’s biological status and is typically categorized as male,

female, or intersex (i.e., atypical combinations of features that usually distinguish
male from female). There are a number of indicators of biological sex, including
sex chromosomes, gonads, internal reproductive organs, and external genitalia.
(APA guidelines).

Gender: It refers to the attitudes, feelings, and behaviours that a given culture
associates with a person’s biological sex. Behaviour that is compatible with
cultural expectations is referred to as gender-normative; behaviours that are
viewed as incompatible with these expectations constitute gender non-
conformity. (APA guidelines)

SEXUAL RESPONSE CYCLE

It is a conceptualization of a four-stage cycle of sexual response exhibited by both

men and women, differing only in aspects determined by male or female
anatomy.
The stages include the arousal/excitement phase, plateau phase, orgasm phase and
resolution phase. This conceptualization was introduced by U.S. sex researchers
William H. Masters and Virginia E. Johnson in 1966.

The Excitement phase

This phase of the sexual response cycle steams from any source of somatogenic
or psychogenic stimulation. The increase in sexual tension required to extend the
cycle is heavily based on this stimulation. If this stimulation meets the individual
demand, the intensity of the response increases rapidly but if it is physically or
psychologically objectionable, the excitement phase may get undesirably
prolonged or may even be aborted.

The Plateau Phase

This phase, characterised by extreme sexual tension is achieved if effective
stimulation is continued. The duration of the plateau phase is dependent on the
effectiveness of stimulation and the individual’s drive. In case of inadequate
stimulation or withdrawal of all forms of stimulation, the individual will not reach
the orgasm phase or will enter into an excessively prolonged resolution phase.
The Orgasm Phase
This phase is limited to the duration during which the vasoconstriction and
myotonia achieved from stimulation are released. The subjective awareness of
orgasm is concentrated it in the pelvic area, specifically in the clitoral body,
vagina and uterus of the female and in the penis, prostate and seminal vesicles of
the male.

The Resolution Phase

The involutionary pattern of tension loss develops as a reverse reaction pattern
that takes the individual through the plateau and excitement phase leading to an
unstimulated state. Women have the potential of retuning to another orgasmic
experience from any point on the resolution phase if they submit to the
reapplication of effective stimulation. For men, effective restimulation to higher
levels of sexual tension is possible only upon the termination of the resolution
phase.
MALE SEXUAL RESPONSE CYCLE
Organ Excitement Phase
Lasts several minutes to several hours;
heightened excitement before
orgasm, 30 seconds to 3 minutes
Skin Just before orgasm: sexual
flush inconsistently appears;
maculopapular rash originates on
abdomen and spreads to anterior
chest wall, face, and neck and can
include shoulders and forearms
Penis Erection in 1 0 to 30 seconds caused
by vasocongestion of erectile
bodies of corpus cavernosa of
shaft; loss of erection may occur
with introduction of asexual
stimulus, loud noise; with
heightened excitement, size of
glands and diameter of penile
shaft increase further
Scrotum and Tightening and lifting of scrotal sac and
testes elevation of testes; with heightened
excitement, 50°/o increase in size
of testes over unstimulated state
and flattening against perineum,
signaling impending ejaculation
Cowper's 2 to 3 drops of mucoid fluid that
glands contain viable sperm are secreted
during heightened excitement
Other Breasts: inconsistent nipple erection
with heightened excitement before
orgasm
Myotonia: semispastic contractions of
facial, abdominal, and intercostal
muscles
Tachycardia: up to 1 75 beats a minute
Blood pressure: rise in systolic 20 to
80 mm; in diastolic 1 0 to 40 mm
Respiration: increased
Orgasmic Phase Resolution Phase
3 to 1 5 seconds 1 0 to 1 5 minutes; if no orgasm,
1/2 to 1 day
Well-developed flush Flush disappears in reverse order
of appearance; inconsistently
appearing film of perspiration on
soles of feet and palms of hands
Ejaculation; emission phase marked Erection: partial involution in 5 to 1
by three to four 0.8 -second 0 seconds with variable refractory
contractions of vas, seminal period; full detumescence in 5 to
vesicles, prostate; ejaculation 30 minutes
proper marked by 0.8-second
contractions of urethra and
ejaculatory spurt of 1 2 to
20 inches at age 1 8, decreasing
with age to seepage at 70
No change Decrease to baseline size
because of loss of
vasocongestion; testicular and
scrotal descent within 5 to 30
minutes after orgasm; involution
may take several hours if no
orgasmic release takes place
No change
Loss of voluntary muscular control
Rectum: rhythmical contractions of
sphincter
Heart rate: up to 1 80 beats a minute
Blood pressure: up to 40 to 1 00 mm
systolic; 20 to 50 mm diastolic
Respiration: up to 40 respirations a
minute
FEMALE SEXUAL RESPONSE CYCLE
Organ Excitement Phase Orgasmic Phase Resolution Phase

Lasts several minutes to several hours; 3 to 1 5 seconds 1 0 to 1 5 minutes; if no orgasm, 1 /2 to

heightened excitement before orgasm, 1 day
30 seconds to 3 minutes
Skin Just before orgasm: sexual flush Well-developed flush Flush disappears in reverse order of
inconsistently appears; maculopapular appearance; inconsistently appearing
rash originates on abdomen and spreads film of perspiration on soles of feet and
to anterior chest wall, face, and neck; can palms of hands
include shoulders and forearms
Breasts Nipple erection in two thirds of women, Breasts may become Return to normal in about 30 minutes
venous congestion and areolar tremulous
enlargement; size increases to one fourth
over normal

Clitoris Enlargement in diameter of glands and shaft; No change Shaft returns to normal position in 5 to
just before orgasm, shaft retracts into 1 0 seconds; detumescence in 5 to 30
prepuce minutes; if no orgasm, detumescence
takes several hours
Labia . .
Nullipara: elevate and flatten against
Nullipara: decrease to normal size in 1 to
No change
maJora perineum 2 minutes
Multipara: congestion and edema Multi para: decrease to normal size in 1 0
to 1 5 minutes
Labia .
Size increased two to three times over Contractions of proximal Return to normal within 5 minutes
m1nora normal; change to pink, red, deep red labia minora
before orgasm
Vagina Color change to dark purple; vaginal 3 to 1 5 contractions of Ejaculate forms seminal pool in upper two
transudate appears 1 0 to 30 seconds after lower third of vagina at thirds of vagina; congestion disappears in
arousal; elongation and ballooning of intervals of 0.8 second seconds or, if no orgasm, in 20 to
vagina; lower third of vagina constricts 30 minutes
before orgasm
Uterus Ascends into false pelvis; labor-like Contractions throughout Contractions cease, and uterus descends
contractions begin in heightened orgasm to normal position
excitement just before orgasm
Other Myotonia Loss of voluntary muscular Return to baseline status in seconds to
A few drops of mucoid secretion from control minutes
Bartholin's glands during heightened Rectum: rhythmical Cervix color and size return to normal, and
excitement contractions of sphincter cervix descends into seminal pool
Cervix swells slightly and is passively Hyperventilation and
elevated with uterus tachycardia

•A desire phase consisting of sex fantasies and desire to have sex may precede or overlap with the excitement phase.
(Table by Virginia Sadock, M.D.)

CLASSIFICATION AND CLINICAL FEATURES OF SEXUAL

DYSFUNCTION:

F52.0 Lack or loss of sexual desire

 1. Loss of sexual desire is the principal problem and is not secondary to other
sexual difficulties, such as erectile failure or dyspareunia.
2. Lack of sexual desire does not prevent sexual enjoyment or arousal.
3. Makes the initiation of sexual activity less likely.

Includes: frigidity
hypoactive sexual desire disorder

F52.1 Sexual aversion and lack of sexual enjoyment

F52.10 Sexual aversion
The prospect of sexual interaction with a partner
1. is associated with strong negative feelings.
2. produces sufficient fear or anxiety that sexual activity is
avoided.

F52.11 Lack of sexual enjoyment

1. Sexual responses occur normally and orgasm is experienced.
2. There is a lack of appropriate pleasure.
3. This complaint is much more common in women than in men.

Includes: anhedonia (sexual)

F52.2 Failure of genital response

In men,
1. The principal problem is erectile dysfunction, i.e. difficulty in developing
or maintaining an erection suitable for satisfactory intercourse.

2. If erection occurs normally in certain situations, e.g. during masturbation

or sleep or with a different partner, the causation is likely to be
psychogenic.

In women,
1. The principal problem is vaginal dryness or failure of lubrication.

2. The cause can be psychogenic or pathological (e.g. infection) or estrogen

deficiency (e.g. postmenopausal).

3. It is unusual for women to complain primarily of vaginal dryness except as

a symptom of postmenopausal estrogen deficiency.

Includes: female sexual arousal disorder

male erectile disorder
psychogenic impotence
F52.3 Orgasmic dysfunction
1. Orgasm either does not occur or is markedly delayed.

2. This may be situational, in which case etiology is likely to be psychogenic,

or invariable, when physical or constitutional factors cannot be easily
excluded except by a positive response to psychological treatment.

3. Orgasmic dysfunction is more common in women than in men.

Includes: inhibited orgasm (male) (female)

psychogenic anorgasmy

F52.4 Premature ejaculation

1. The inability to control ejaculation sufficiently for both partners to enjoy
sexual interaction.

2. In severe cases, ejaculation may occur before vaginal entry or in the

absence of an erection.

3. Premature ejaculation is unlikely to be of organic origin but can occur as a

psychological reaction to organic impairment, e.g. erectile failure or pain.

4. Ejaculation may also appear to be premature if erection requires prolonged

stimulation, causing the time interval between satisfactory erection and
ejaculation to be shortened; the primary problem in such a case is delayed
erection.

F52.5 Nonorganic vaginismus

1. Spasm of the muscles that surround the vagina, causing occlusion of the
vaginal opening.

2. Penile entry is either impossible or painful.

3. Vaginismus may be a secondary reaction to some local cause of pain, in

which case this category should not be used.

Includes: psychogenic vaginismus

F52.6 Nonorganic dyspareunia

1. Dyspareunia meaning pain during sexual intercourse occurs in both women
and men.
 2. It can be because of a local pathological condition and should then be
appropriately categorized. In some cases, however, no obvious cause is
apparent and emotional factors may be important.

3. This category is to be used only if there is no other more primary sexual

dysfunction (e.g. vaginismus or vaginal dryness).

Includes: psychogenic dyspareunia

F52.7 Excessive sexual drive

1. Both men and women may occasionally complain of excessive sexual drive
as a problem is its own right.

2. The onset is usually during late teenage or early adulthood.

3. When the excessive sexual drive is secondary to an affective disorder or

when it occurs during the early stages of dementia, the underlying disorder
should be coded.

Includes: nymphomania
Satyriasis

EMPIDEMIOLOGY

i) An epidemiological study of sexual disorders in south Indian rural

population

• Prevalence of female sexual arousal dysfunction was found to be 6.65%,

female HSDD 8.87%, female anorgasmia 5.67%, dyspareunia 2.34% and
female sexual aversion disorder was found to be prevalent in 0.37% of the
subjects.

• Prevalence of erectile dysfunction was found to be 15.77%, male

hypoactive sexual desire disorder (HSDD) 2.56%; premature ejaculation
was found to be prevalent in 8.76% of the male subjects.

- T. S. Sathyanarayana Rao, M. S. Darshan, and Abhinav Tandon (2015)

ii) Another study Sexual dysfunction among men in secondary care in

southern India: Nature, prevalence, clinical features and explanatory
models found that Premature ejaculation and erectile dysfunction were
reported by 43.0% and 47.8% of men, respectively.
 • The most common perceived causes were loss of semen due to
masturbation and nocturnal emission. Popular treatments were herbal
remedies and resources used were traditional healers. The factors
associated with erectile dysfunction were diabetes mellitus, financial
stress, past history of psychiatric treatment and common mental disorders
such as depression and anxiety; those associated with premature
ejaculation were common mental disorders, older age and financial debt.
Sexual dysfunctions and concerns were under-diagnosed by physicians
when compared to the research interview.

- THANGADURAI, R. GOPALAKRISHNAN, V.J. ABRAHAM,J. PRASAD, A.

KURUVILLA, K.S. JACOB THE NATIONAL MEDICAL JOURNAL OF
INDIA VOL. 27, NO. 4, 2014

iii) A study on prevalence of female sexual dysfunction among Indian fertile

females found:

• The prevalence of Female Sexual Disorder (FSD) was 55.55% among

153 fertile females. FSD was more prevalent in the age group of 26– 30
years and with duration of marriage >16 years.
• FSD was also more common in females with middle education and
those belonging to upper middle socioeconomic status. Psychological
stress was significantly associated with FSD.

- Mishra, Vineet & Nanda, Sakshi & Vyas, Bhumika & Aggarwal, Rohina &
Choudhary, Sumesh & Saini, SuwaRam. (2016).

ETIOLOGY:

Factors affecting sexual performance:

i) Age: A review of the literature suggests that in men there is a decrease

in the frequency of sexual behaviour, to a lesser extent a diminution in
sexual interest and an increased prevalence of sexual dysfunction
associated with aging. However identification of the natural biologic
changes that mediate sexual function in the aged is confounded by the
effects of chronic medical illnesses and drugs in this age group.

ii) In a cross-sectional study in healthy men aged 45-75 years, significant

decreases in sexual desire, arousal and activity was documented but no
age differences in sexual pleasure and satisfaction. A proportion of
subjects in the oldest age group, however, had regular intercourse in the
 presence of marked decrements in erectile capacity as measured by noc-
turnal penile tumescence. Healthy aging men had a decrease in
bioavailable testosterone (bT) and an increase in Leutinising Hormone
(LH). Aging is associated with a decrease in gonadal function but the
evidence that androgen deficiency contributes to the decrease in sexual
desire and activity in older men is not compelling. Changes in central
receptor site sensitivity may contribute to the age related decreases in
sexual function.

iii) Epidemiologic data have demonstrated a significant diminution in

coital and orgasmic frequencies and an increase in the incidence of
sexual problems in post menopausal women. Estrogen deficiency is
primarily responsible for the de-crease in pelvic vasocongestion,
atrophy of vaginal epithelium and diminished vaginal lubrication.
However, even in women androgens are more important for sustaining
sexual desire.

iv) Psychiatric disorders: Crisp has presented a rough assessment of the

presence of sexual deterioration in a group of 375 consecutive new psy-
chiatric outpatients. He found that people with endogenous depression,
alcoholism, or the presence of anxious or sad moods or tension were
significantly more likely to report a reduction of sexual activity since
the onset of their problem, where as those with conversion disorder,
obsessional neurosis or paranoid psychosis were significantly less
likely to do so. Some of the studies focused on common psychiatric
illness are given below.

A. Depression: Depression remains an important associated factor for

sexual dysfunction. Studies have revealed that in untreated depression,
reduced libido is seen in 40-74%, arousal / erectile dysfunction in 16-
50% and orgasmic dysfunction in 15-22%.

B. Schizophrenia: Changes in behaviour, emotional reactions and

thought processes that manifest the schizo-phrenic states are often so
gross and so pervading that it would be surprising if sexual
repercussions do not occur. Studies have shown that majority of
untreated schizophrenics have reduced desire for sex, more in fe-
males as compared to males, though arousal and ejaculatory functions
remain intact. They have diminished fantasy, and schizophrenic men
often limit their sexual activity to masturbation.

C. Anxiety disorders: Aksaray and colleagues compared sexual

dysfunction among 23 patients of Obsessive Compulsive Disorder
(OCD) and 26 patients of Generalized Anxiety Disorder (GAD). All
were untreated female patients. They were assessed for orgasm,
vaginismus, avoidance and non-sensuality. Overall, 39% of OCD
patients had sexual dysfunction as compared to 19% in GAD. Another
study reported a wide range of sexual dysfunction in the patients of
social phobia. About 33% of males had reduced desire, premature
ejaculation and retarded ejaculation where as 10% had erectile
dysfunction. Among females 42% complained of dyspareunia, and
46% had reduced desire. Thus all anxiety disorders seem to be
associated with some kind of sexual dysfunction, but generalization of
prevalence rate needs further studies.

PSYCHOLOGICAL FACTORS ASSOCIATED WITH SEXUAL

DYSFUNCTION
MANAGEMENT:

The treatment of sexual disorders has evolved significantly since the 1970s, when
Masters and Johnson focused the attention of the psychiatric community on
sexual disorders. In many of the cases, successful treatment of the primary
physical/psychiatric disorder will remit the associated sexual dysfunction. A
thorough history is the fundamental tool to etiologically evaluate sexual
dysfunction, which further guides towards appropriate treatment. The aims of
assessment are to –

•Define the nature of sexual problems and what changes are desired.
•Obtain the information which allows formulating a tentative explanation of the
causes of the problem in terms of predisposing, precipitating and maintaining
factors.
•Assessment into medical disorders/medication that commonly lead to sexual
dysfunction.
•Thorough genitourinary examination including relevant laboratory studies like
serum prolactin levels.
•Assess what type of therapeutic intervention is indicated on the basis of this
formulation.

Psychoeducation:

Treatment of impaired sexual desire:

Historically, attempts to treat hypoactive sexual desire disorder typically
followed the sex therapy prototype developed by Masters and Johnson in 1970s.
However, recently researchers and practitioners have begun to explore
concomitant psychotherapies. Some of them are-

•Group therapy in conjunction with orgasm consistency training, which consists

of directed masturbation, sensate focus exercises, male self-control and the timing
of male orgasm.

•A comprehensive program of multimodal cognitive behavioural approach which

entails sexual intimacy exercises, sensate focus, communication skills training,
emotional skills training, reinforcement training, cognitive restructuring, sexual
fantasy training and couple sex group therapy.

•Multistage treatment approach.

•Affectual awareness training: to identify negative emotions through techniques

such as list making, role-playing and imagery.

•Insight and understanding: to educate couples about their feelings using variety
of strategies like Gestalt therapy and Transactional analysis.

•Cognitive and systematic therapies are included to provide coping mechanisms

as well as to resolve underlying relational problem.

•Behavioural therapy is aimed at initially improving non-sexual affectionate

behaviour with an eventual goal of introducing mutually acceptable sexual
behaviour.

Treating Erectile Dysfunctions:

Masters & Johnson approach: This therapy proceeds in three stages. The first
stage is called ‘non-genital sensate focus’ which aims to provide the couple with
an opportunity to establish closeness and physical intimacy but no genital
stimulation. This is followed by stage II known as ‘Genital sensate focus’ where
stimulation of the genitals is allowed. Final stage is called ‘Vaginal containment’
in which couples eventually engage in intercourse. However, it has been reported
that this technique has not been effective in all cases of erectile dysfunction.

Cognitive strategies: These are based on reinforcement of certain common

realities about sexuality. One such approach is acceptance of occasional erectile
problems as a normal variation and treating it as a lapse and not a relapse. Another
concept is to experience sexuality as “pleasuring play eroticism” i.e. not to be
distracted by performance demands and viewing intercourse as natural
continuation of erotic flow and not as pass-fail test. Yet another strategy is to
view the partner as an intimate friend rather than as a demanding critic for whom
he has to perform.

Behavioural strategies: This involves establishment of sensual and erotic

scenarios, which acts as transition if arousal does not result in intercourse.
Sensual scenarios are pleasure oriented ways of bonding, involving and satisfying
both people e.g. being playful and sharing intimacy, lying together and talking.
Erotic scenarios are non-intercourse ways of experiencing arousal and orgasm.
Ex: mutual oral and manual stimulation. Another helpful approach is to empower
the medicated member of the couple to engage in sexual activity with an
understanding that he or she can stop the process at any time.
Permission to stop, if the intimacy is not experienced as pleasurable, may
paradoxically reduce performance anxiety and allow for greater enjoyment. The
clinician can suggest that sexual activity can take place during the part of the
day when patient feels best and most capable rather than being deferred to late
night, when physical and/or emotional exhaustion might pose a further
impediment to success.

Treating Premature Ejaculation:

1. Traditional techniques:
• Squeeze Technique: It is used to raise the threshold of penile
excitability. Man/woman stimulates the erect penis until the earliest
sensations of impending ejaculation are felt. At this point
the woman forcefully squeezes the coronal ridge of the glans, the
erection is diminished and ejaculation is inhibited.

• Start – Stop Technique: This variant of squeeze technique was

developed by James H. Semans. The woman stops all stimulations
of the penis when the man first senses an impending ejaculation. No
squeeze is used.

2. Individual procedures:
• Physiological relaxation training: Quiet focus on breathing, body
awareness and muscle relaxation is encouraged. Its purpose is to
concentrate on physical sensation and to ease bodily tension.

• Pelvic floor rehabilitation training: Physiokinesiotherapy of the

pelvic floor, electrostimulation, and biofeedback are the 3
 techniques taught here to provoke contractions of the pelvic floor,
strengthening the muscles and improving self-awareness of motor
activity.

• Cognitive and Behavioural pacing techniques:

➢ Cognitive arousal continuum technique: A thought pacing
technique to regulate arousal and inhibit ejaculation by
focusing specifically on varying levels of sexually arousing
activities. Steps are:-
1. Identify, observe and distinguish those detailed thoughts
(fantasy), actions, feelings, scenarios and sequences that lead to
individual’s arousal pattern.

2. Make a hierarchy of them based on the understanding of the

individual’s incremental arousal.
3. Thereafter during intercourse, individual is better able to regulate
his level of stimulation by concentrating on items in order to increase
or decrease his level of arousal.

➢ Sensual awareness training/Enhancement arousal: PE is said

to occur commonly when ones erotic stimuli is outside one’s
own body, i.e. typically in the sexual partner. Hence the
individual is guided to focus on visual and tactile exploration
of his own body. Individual learns to be familiar with his own
physical sensation (awareness) and then learn to cognitively
and behaviourally orchestrate his sexual arousal.

3. Couple Procedures:
• Couple sensate focus pleasuring exercise: This involves homework
sessions with the couple relaxing and gently pleasuring each other until
the man relaxes physiologically and concentrates on his own physical
sensation during gentle stimulation by the partner.
• Partner genital exploration relaxation exercise: Partners become more
comfortable and relaxing with mutual exploration, observation and
stimulation of each other's own body including genitals.
• Intercourse acclimatization: After vaginal penetration, the man stops
movement and rests while the penis ac-climates to the internal vaginal
atmosphere until reaching a pleasure saturation point.

Medical management:
1. SSRIs – the adverse effect of retarded ejaculation is a benefit in PE.

2. Thioridazine also impairs ejaculation, hence used in PE.

3. Anxiolytic drugs (Ex: benzodiazepines) to allay anxiety which is most

commonly associated with PE.

4. Treatment of primary psychiatric illness where PE is secondary to it will many

times also set right PE.

v) Miscellaneous methods:
•The methods like watchful waiting, drug holiday, risk factor modification are all
applicable in case of PE too.
•Switching to alternative drug if PE is drug induced.
•Handling ‘performance anxiety’ with effective counseling and psychoeducation
where that is the cause of PE.

Treatment of Dyspareunia by physical therapy and behavioral therapy:

Treatment is given through manual or physical means. It includes modalities like
therapeutic exercises to desensitize, stretch and strengthen perineal soft tissue and
pelvic muscles through Kegels exercise, along with other procedures like
relaxation, postural education, and biofeedback.

In conjunction with other therapies, cognitive behavioural therapy has been

shown to be effective in reducing the anxiety and fear related to dyspareunia. It
is the most commonly used and studied behavioural intervention. Cognitive
behavioural therapy focuses on patterns of thinking and helps identify behaviours
associated with negative thoughts and feelings.

Treatment of vaginismus:
Recent researchers have found Cognitive Behaviour Therapy (CBT) useful in the
treatment of vaginismus, especially if it is of psychogenic origin. (35,36) CBT
strategies mainly consist of –
•Sensate focus- to reduce performance anxiety.

•Vaginal dilatation either with the help of instruments or use of self-finger

approach to desensitize.

•Cognitive restructuring- to change the dysfunctional thoughts interfering with

sexual functioning

Treatment of orgasmic dysfunction:

Directed Masturbation:
DM is a cognitive behavioural and mindfulness-based technique that involves
stepwise exposure to genital stimulation along with psychological tools for
improving attention to sexual cues, increasing comfort with sexual feelings and
stimulation, often including vibrator stimulation, reducing anxiety and
spectatoring, identifying and challenging unhelpful attitudes and beliefs about
sex, and implementing tools for increasing arousal such as fantasy or erotic
materials.

Treatment involving DM has taken several forms, the most common being group
therapy over the course of 5-10 weeks that focuses on the woman learning to
bring herself to orgasm through self-stimulation. Variations of this format have
included individual therapy, couple therapy, or individual or group therapy with
partner participation in some sessions. Findings are mixed on the effectiveness of
including partners in treatment. This may be most helpful when orgasmic
difficulty is situational (ie, only occurs during partnered sexual activity) oris
influenced by relationship factors (eg, conflict, poor sexual communication,
partner’s sexual dysfunction).

There is evidence that women who learn to orgasm via masturbation are able to
generalize to having orgasms with partner present and with partner stimulation.

Given the overall high success rate for DM, current best practice
recommendations are to include this component in first-line treatment of FOD.
Systematic Desensitization SD is an exposure-based therapy for a specific anxiety
whereby the person with anxiety creates a hierarchy of feared experiences

Systematic Desensitization:
SD is an exposure-based therapy for a specific anxiety whereby the person with
anxiety creates a hierarchy of feared experiences and exposes herself to each,
starting with the easiest and ending with the most anxiety-provoking, until very
little or no anxiety is felt in previously feared situations. For example, a hierarchy
of feared sex-related experiences might include, from easiest to hardest, dancing
with a partner fully clothed, a brief kiss, a lingering kiss, being undressed by
partner, and so on. SD can be in vivo or imaginal and has been tested for reducing
anxiety and promoting enjoyment and orgasm in sexual situations.

Sensate Focus:
SF is a mindfulness-based behavioural technique for reducing anxiety and
increasing attention to physical sensations during partnered activity.76It involves
partners exchanging body caresses in a non-demand context, first excluding
genital or breast touching and later incorporating those areas as the individuals
gain comfort and ability to attend to bodily sensations. The technique was
developed and used by Masters and Johnson to treat a variety of sexual problems.

SF has been tested as a component of treatment for FOD, especially for situational
FOD in partnered situations, and of tenas part of a program of treatment including
other forms of therapy. Carney et al tested a combination of SF therapy sessions
and testosterone or diazepam for women with secondary(situational) anorgasmia
and found greater frequency of orgasm for SF þ testosterone therapy than other
groups. Fichten et al tested couple or group therapy including SF for women with
secondary anorgasmia and found a trend toward greater frequency of orgasms
from before to after treatment. Golden et al tested couple or group therapy
including SF for women with Sex

secondary anorgasmia with partners with premature ejaculation and found

significant improvement in satisfaction with orgasms before to after treatment.
Mathews et al compared counselling þ SD, counselling þ SF, and minimal
therapist con-tact SF and found that SF þ counseling was most effective in
increasing female sexual pleasure ratings. Sarwer and Durlak found that
behavioural therapy including SF for women with orgasmic difficulty was
successful for 65% of couples.