chapter 28
Psychological Management of
Sexual Dysfunctions
Rejani Thudalikunnil Gopalan, N Kumaraswamy
INTRODUCTION
Human sexual behavior is complex, which
involves biological, psychological, social and
cultural factors and thus sexual dysfunctions. It
can cause distress to the individual as well as to
the partner. Sexual dysfunction is an inability
to experience arousal, to engage in sexual
intercourse or to achieve satisfaction. They are
classified into four major categories: (i) sexual
desire disorders, (ii) sexual arousal disorders,
(iii) orgasmic disorders, and (iv) sexual pain
disorders. Causes can be either physical,
psychological, or both. Physical problems
include hormonal imbalances, neurological
disorders, and diabetes, problems related to
heart and kidney. Psychiatric disorders like
depression and alcohol and drug addiction and
side effects of certain medications. Psychological
causes include tiredness, stress, anxiety,
depression, feeling of guilt, history of sexual
abuse and trauma and marital issues.
A wide variety of treatment techniques have
been used for treating sexual dysfunctions, which
include both pharmacological and psychological
modalities. Different approaches and techniques
are available under the umbrella of psychological
management of sexual dysfunctions. The present
chapter outlines briefly on the psychological
treatment approaches and techniques used in the
treatment of sexual dysfunctions and treatment
techniques for specific conditions.
Different approaches and
techniques
Psychodynamic, behavioral, cognitive,
cognitive-behavioral, and many other approaches
have been used in the treatment of sexual
dysfunctions. Psychoanalytic, psychodynamic
approach conceptualize sexual problems as
conflict between sexual drives and its expression
(mainly the conflict between id and superego)
and main aim of psychodynamic oriented
therapies are to resolve this internal conflict.
According to cognitive behavioural approach,
sex and sexual dysfunctions are learned behavior
by classical and operant conditioning and by
modeling. Cognitive behavioral therapy aims to
identify the stimuli, response, consequences of
sexual behavior, maintaining factors of sexual
dysfunctions and to alter cognitive errors and
emotional difficulties associated with it. Couple
therapy, couple communication training (specific
focus on sex and sexual activity, verbalizing
and exchanging sexual needs and feeling),
psychodynamic couple therapy and couple sex
therapy are other important approaches in the
treatment of sexual dysfunctions.1
Though different techniques are listed under
different approaches, major components of
psychological treatment for sexual dysfunctions
are sensate focus exercises, cognitive-behavioral
therapy, relaxation training, hypnosis and
guided imagery, and group therapies. Specific
techniques, such as directed self-stimulation,
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362
stop-start and squeeze techniques, systematic
desensitization and Kegel exercises are added
therapies when appropriate. Marital therapy to
improve communication and resolve conflict is
also part of standard therapy.2
Major techniques
Comprehensive Textbook of Sexual Medicine
Psychoeducation and sex counseling
Much sexual distress is based on incorrect
information and unrealistic expectations. Basic
counseling allows patient to talk about sexuality
and her sexual problems. Therapist needs to
explore patient’s concepts of love and sexuality,
values and priorities, Passion, intimacy, and
commitment. Therapist can educates the patient
about the large variety of sexual expressions
and responses, similarities and differences
between male and female sexuality and also
need to dispel destructive sexual myths about
sexuality which can have a negative effect on the
patient’s sexual life and relationships. Accurate
and relevant information about sexual anatomy
and physiology (along with encouragement of
self-exploration), cultural norms and averages,
the changes of ageing, relationship development,
dealing with external and internal performance
pressures from advertising, peers, partner, and
other sources can all be helpful. Educational
books and videos may be useful. Explanation
and exploration of the sexual arousal circuit can
demonstrate to patients the interconnectedness of
the sexual problem with other aspects of life.1,3
Couple sex therapy (Sensate Focus
Stages)
This approach was introduced by Masters
and Johnson and its main principles are as
follows.4 Each person has the opportunity to
explore their own preferences and feelings in
an understanding atmosphere. It enables the
couple to engage in intimate physical contact
without any expectation of a particular outcome.
It facilitates communication at a number of
levels. It is a very pleasant and nurturing thing
to do. When agreed homework tasks are not
performed. that offers the opportunity for
further exploration and communication within
the couple. It follow certain ground rules, such
as ban on intercourse throughout therapy and a
ban on genital touching for first four sessions,
focus on the personal experience and not on
pleasing or arousing the partner. This therapy
is tailored to the individual or couple needs and
involves prescribing certain sexual assignments.
It has different stages.
Stage 1: Sensate focus without genital contact—
touching for own pleasure
This stage allows exploration of partner’s body
and focus on the feelings experienced in both
the ‘active’ and ‘passive’ roles. Exploration and
touching is avoided for breasts and genital areas.
This stage is mainly to increase familiarity and
trust between the partners, to experiment with
different types of touches, to make and guide
specific types of preferred touches. According
to Bancroft, this particular stage is characterized
by two aspects: setting limits indicates that both
partners experience relaxation and enjoyment
in the physical intimacy and thus reduce
performance anxiety and increase feeling of
trust; and touching for own pleasure indicates
focusing on own pleasure which would leads to
self-assertion.5
Stage 2: Sensate focus without genital contact—
touching for own and partner’s pleasure
Partners are instructed to give feedback
on touching, what they are experiencing,
whether they like it or not, guiding hands for
preferred touching and pressure, and giving
encouragement. This stage would facilitate the
sexual communication between the partners.
Stage 3: Sensate focus with genital contact
This stage includes genital touching and
exploration. Focus is more on the genitals
to discover the sensations resulting from
different pressures and strokes in the different
areas of the genitals. Orgasm is not a must

Psychological Management of Sexual Dysfunctions
but can occur by mutual masturbation or by
self-stimulation.
Stage 4: Sensate focus with genital contact—
simultaneous caressing
This stage involves mutual caressing with
genital contact. Both verbal and nonverbal
feedback, encouragement and enhancement of
communications are emphasized in this stage.
Stage 5: Vaginal containment
Couples need to continue all the previous
exercises including touching and mutual
caressing. This stage is for the experience of
containment—allowing the penis to rest in the
vagina and to experience sensations of vaginal
containment in relaxes state. Before this it is
important to make sure that male partner is
getting firm erection and female partner have
vaginal lubrication and then man lies back and
the woman sits on him introducing the penis
into the vagina.
Stage 6: Vaginal containment with movement
This stage allows vaginal containment with
movement, gently thrusting or rotating, and
to try for different positions and to experience
different sensations associated with movements.
This is to make sex as a pleasurable and mutually
enjoyable experience.
Behavior therapy techniques
Assertion training (being more assertive
will improve sexual performance and sexual
satisfaction), behavioral analysis, behavioral
rehearsal in which learns and rehearses behavior
through homework exercises), direct education,
behavioral sex therapy (uses combination of
techniques including education, communication
skills training, and sensate focus exercises),
history taking, modeling (models through films,
or in group therapies the clients are models
for each other), psychoeducational program,
relaxation therapy, social skills training and
systematic desensitization treatment are found
to be useful behavior therapy techniques for the
treatment of various sexual dysfunctions.6
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Directed masturbation
Directed masturbation is based on the sex therapy
format introduced by Masters and Johnson.
Women are educated as to how she can bring
herself to orgasm. It involve exercises to
increase body awareness, body acceptance,
visual and tactile exploration of the body,
Comprehensive Textbook of Sexual Medicine
exploration of areas of the body which gives
pleasure when touched, and then instruct the
technique of masturbation and also to use
fantasy and imaging to use sexual excitement
and orgasm. This technique is mainly used for
female orgasm disorder.7
Orgasm consistency training (OCT)
It is a cognitive-behavioral intervention consists
of directed masturbation, sensate focus exercises
and coital alignment technique. This technique
is useful for hypoactive sexual desire disorder.
Kegel exercises
These are pelvic-floor contractions, similar
to postnatal exercises. It is used to strengthen
pubococcygeus (PC) muscles of the pelvic
floor. The woman tightens the muscles of her
pelvic floor as if to stop the flow of micturition,
holds tight for 10 seconds, then relaxes the
muscles again, and repeats several times; this
is done several times a day. Such exercises
can encourage improvement in muscle tone;
can increase awareness of pelvic sensation;
may increase orgasmic potential; and, in cases
of vaginismus, are a means of enabling the
woman to begin to gain some control over her
pubococcygeal spasm.3
Anterior fornix erogenous (AFE) zone
stimulation
Anterior fornix erogenous (AFE) zone or
second G-spot is a female erogenous zone and
stimulation of this part (erogenous centre in the
inner half of the anterior wall of the vagina)
which would result in onset of reflex vaginal
lubrication, erotic sensitivity and orgasm.8
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Coital alignment technique
In this technique male lies above the female and
strokes upward in order to maximize clitoral
stimulation during sexual intercourse.9
Stop-start technique
The penis is stimulated until the man feels
Comprehensive Textbook of Sexual Medicine
premonitory sensations of ejaculation and the
stimulation has to be discontinued. Stimulation
is resumed after the sensation subsides and
to stop until he again gets the premonitory
sensation of ejaculatory inevitability. This stop
and start procedure can be practiced until the
person become confident of tolerating penile
stimulation without ejaculation for longer time.
This technique is mainly used for premature
ejaculation problem.10
Squeeze technique
This technique involves penile stimulation to
the point of signals of oncoming ejaculation
and partner needs to squeeze around the coronal
ridge of the penis to stop the urges of ejaculation.
It is mainly used for delaying ejaculation and
premature ejaculation problem.11
PSYCHOLOGICAL MANAGEMENT
FOR MALE SEXUAL DYSFUNCTIONS
The most common types of sexual problems
in men are ejaculation disorders (premature
ejaculation, inhibited or retarded ejaculation,
retrograde ejaculation), erectile dysfunction
and inhibited sexual desire (decreased libido).
It could be due to medical or psychological
reasons.
Ejaculation disorders
There are four different types of ejaculation
disorders in men, which can cause personal
distress and distress to partner. Premature
ejaculation refers to ejaculation that occurs
before or soon after penetration. Inhibited or
retarded ejaculation means ejaculation is slow
to occur. Retrograde ejaculation occurs when,
at orgasm, the ejaculate is forced back into
the bladder rather than through the urethra
and out the end of the penis. Both organic
and psychogenic factors can cause ejaculation
disorders. Premature ejaculation is the most
common form of sexual dysfunction in men
which usually caused by performance anxiety.
Psychological factors like guilt, shame, anxiety,
co morbid psychiatric disorders like mood
disorders can also cause premature and inhibited
ejaculation. Retrograde ejaculation usually has
medical reasons, such as diabetics.
Diagnosis of premature ejaculation (PE)
encompasses seven key steps: (i) obtaining the
patient’s general medical and sexual history, (ii)
classifying the symptom on the basis of onset
(e.g. lifelong or acquired PE), timing (e.g.
prior to or during intercourse), and type (e.g.
absolute/generalized or relative/situational),
(iii) involving the partner to determine their
view of the situation and the impact of PE on
the couple as a whole, (iv) identifying sexual
comorbidities (e.g. erectile dysfunction) to
define whether PE is simple (occurring in
the absence of other sexual dysfunctions) or
complicated (occurring in the presence of
other sexual dysfunctions), (v) Performing
physical examination to check the man’s sexual
organs and reflexes, (vi) Identifying underlying
etiologies and risk factors (e.g. endocrine-,
urological-, relational-, or psychosexual-risk
factors) to determine the primary cause of
PE and any associated comorbidities, and
(vii) Discussing treatment options to find
the most suitable intervention, according
to the needs of the man and his partner. 12
The mainstay of treatment is a combined
approach using behavioral therapies and non-
licensed medication such as topical anesthetic
preparations, selective serotonin reuptake
inhibitors and phosphodiesterase-5 inhibitors.13
Behavior therapies include stop and start
technique, squeezing methods and relaxation
methods are found to be useful.

Psychological Management of Sexual Dysfunctions
Erectile Dysfunction
Erectile dysfunction (ED) is defined as the
consistent or recurrent inability of a man to attain
and/or maintain a penile erection sufficient for
sexual activity. It is also known as impotence.
It can be induced by biological or psychological
reasons. The treatment strategy includes sex
education, to patient and partner, relaxation
therapy, treatment for comorbid condition (e.g.
depressive illness) and treatment strategies by
Master and Johnsons.4
Inhibited Sexual Desire
Inhibited desire, or loss of libido, refers to
a decrease in desire for, or interest in sexual
activity. Psychological or medical reasons can
lead to reduced sexual desire. Psychological
factors like stress, anxiety, depression,
relationship issues, negative attitude towards
sex, and history of sexual abuse can cause loss
of libido. Medical factors, such as hormonal
imbalance, medical illness side effect of certain
medicines can also lead to inhibited sexual
desire. Sex education and psychotherapy are
found to be effective in treating this condition.
PSYCHOLOGICAL MANAGEMENT
FOR FEMALE SEXUAL
DYSFUNCTIONS
Both DSM-IV and ICD-10 classified female
sexual dysfunction. It includes persistent or
recurrent disorders of sexual interest/desire,
disorders of subjective and genital arousal,
orgasm disorder, pain and difficulty with
attempted or completed intercourse. Many
interventions are available for specific conditions
and a comprehensive diagnostic assessment is
required for a good treatment plan. According
to Wincze and Carey an assessment of female
sexual dysfunction includes: (i) an evaluation of
current sexual functioning, including feelings
and thoughts of desire and receptivity to sexual
activity, (ii) an accurate elucidation of the
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presenting problem and any comorbid problems,
(iii) the formulation of “working hypotheses”
of the most relevant etiological and maintaining
factors, (iv) identification of treatment goals
and a treatment plan, and finally, (v) clear,
constructive feedback to the woman and her
partner.14
From a psychotherapeutic prospective, it
Comprehensive Textbook of Sexual Medicine
is essential to see the woman individually as
well as together with her partner to obtain
critical diagnostic information. Interviewing
the couple emphasizes that sexual difficulties
and their resolution occur within the couple’s
relationship and that sexual problems invariably
affect both partners. Seeing the couple together
permits the clinician to observe the “emotional
climate” between the couple, the degree of
discrepancy between the woman and her
partner’s view of the problem, and any power
and intimacy conflicts that may characterize the
overall relationship. Both nonverbal and verbal
interactions are observed. The assessment needs
to cover important areas like demographic
factors, problem elucidation (its onset, duration,
frequency, severity, as well as related areas of
sexual functioning), psychological/emotional
functioning (assessment of co morbid psychiatric
disorders), current environmental stressors ,
relationship distress (especially with sexual
partner), secrets, psychosexual history , history
of sexual abuse or trauma and medical history.15
Hypoactive sexual desire disorder
The DSM-IV lists two types of desire disorders:
hypoactive sexual desire (HSD) and sexual
aversion. Low sexual desire disorder is
characterized by the persistent or recurrent
deficiency (or absence) of sexual thoughts/
fantasies, and/or desire for or receptivity to
sexual activity, which causes personal distress.16
Prior to the intervention, level of hormone,
especially level of androgens needs to be checked
as it may affect sexual desire. Both assessment
and management should focus on focus on
factors reducing arousability and satisfaction.
These include women’s mental health and
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feelings for their partner, generally and at
the time of sexual activity. Psychotherapeutic
interventions focus on creating a pressure-
free, loving context in which to enjoy physical
intimacy, one in which the woman feels safe and
valued. In addition, the use of erotic materials,
non-demand touching, or orgasmic training can
be helpful once the relationship roadblocks have
Comprehensive Textbook of Sexual Medicine
been addressed.15,17
Female sexual aversion disorder
It is characterized by strong feeling of revulsion
in sexual activities and sexual situations. Sexual
aversion disorders can be originated from early
childhood trauma, sexual abuse and violation.
It is always conceptualized as a specific form of
phobic disorders. As for other phobic disorders,
exposure based interventions are useful for
treating this disorder. It is advisable to proceed
exposure therapy slowly and hierarchical
fashion. Partner can involve in therapy when
client is confident of sexual activities and
sharing.15
Female sexual arousal disorder
In the DSM-IV, female sexual arousal disorder
(FSAD) is described in terms of lubrication and
vasocongestion problems. It is characterized by
a lack of physiological and/or subjective sexual
arousal which causes distress to the individual.
A large component of women’s sexual desire
is responsive rather than spontaneous. In ongoing
relationships, a woman’s motivation appears to
be largely influenced by her emotional intimacy
with her partner and her wish to enhance it.
A woman’s sexual arousal is composite and
complex, correlating well with how mentally
exciting she finds the sexual stimulus and
its context and poorly with objective genital
blood flow changes. 18 So therapist need to
explore various factors like over all relationship
satisfaction, relationship issues with the partner,
existence of extramarital relation, possibility of
psychiatric disorders such as depression and
anxiety, negative emotions, such as guilt and
shame. Management approaches focus on factors
reducing arousability and satisfaction;19 and to
look for factors, which increase the arousability.
Female orgasm disorder
Female orgasmic dysfunction is characterized
by persistent or recurrent delay in or absence
of orgasm following a normal sexual excitement
phase that cause marked distress or interpersonal
difficulty. It can be divided into lifelong and
acquired subtypes. Psychological factors,
e.g. anxiety, fatigue, pain, feeling of guilt,
anti-masculine feelings and embarrassment in
sexual relationships are found to be higher in
the anorgasmic group.20
Various treatment strategies are available for
female orgasm disorder. Directed masturbation
training is found to be more effective for this
condition. 21 Directed masturbation training
teaches how to masturbate effectively and
eventually to reach orgasm during sexual
interactions. The coital alignment technique
(CAT) is also found to be effective in the
treatment of female orgasmic disorder.22
Cognitive-behavioral therapy for anorgasmia
promotes attitude and sexually relevant thought
changes and anxiety reduction using behavioral
exercises, such as directed masturbation, sensate
focus, and systematic desensitization treatments
as well as sex education, communication
skills training, and Kegel exercises. 23 The
psychophysiological treatments for female
orgasmic dysfunction are on the whole
successful. However, in anorgasmia proven to
be biological in etiology, following menopause
for example, physiological changes occur that
cannot be resolved by these strategies alone.24
Nonpharmacological approaches should be used
first, focusing on lifestyle and psychosexual
therapy. If required, proven effective hormonal
and nonhormonal therapeutic options are
available.25

Psychological Management of Sexual Dysfunctions
Dyspareunia
Dyspareunia is genital pain associated with
sexual intercourse and sexual activities involve
touching genital area. It can be due to medical
reasons like urethral disorders, cystitis and
interstitial cystitis or due to psychological
reasons. Women with dyspareunia are found to
have more physical pathology, psychological
distress, sexual dysfunction, and relationship
problems, more negative attitudes toward
sexuality, higher levels of impairment in
sexual function, and lower levels of marital
adjustment. 26 In addition to catastrophizing
thoughts and hypervigilance, it is possible
that repeated pain may pain leads to increased
genital muscle tension that can further increase
pain by adding muscle pain to the original pain,
interfering with penetration, and reducing genital
blood flow.27
Dyspareunia is a heterogeneous disorder
which requires gynecologic and psychosocial
assessment to determine differentiated treatment
strategies. The focus of the treatment strategies to
be on pain reduction as pain is the central feature
of this disorder. Various methods like changing
the sexual posture, long duration of foreplay to
increase vaginal lubrication which reduces the
pain at penetration, exercise to relaxation of
pelvic muscles, vaginal and/or pelvic massage
and biofeedback are useful to reduce the pain. Sex
education regarding normal anatomy and sexual
functions can reduce the misconceptions related
to sex. It is also important to explore any kind of
trauma or sexual abuse in the past and presence of
marital discord. In addition to cognitive behavior
therapy, abuse focused therapy and marital therapy
can be used if such conditions are present.17,19
Vaginismus
Vaginismus refers to tension in the vaginal
muscles or involuntary muscle spasms, which
in turn causes painful intercourse. A variety
of psychological treatments have been used for
the treatment of vaginismus, such as marital,
interactional, existential–experiential, relationship
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enhancement therapies and hypnosis. Most
successfully used treatment for vaginismus was
behaviourally oriented sex therapy with vaginal
dilation by Masters and Johnsons. It consists of
the physical demonstration of the vaginal muscle
spasm to the patient (and her partner) during
a gynecological examination, then insertion of
a series of dilators of graduated sizes at home
Comprehensive Textbook of Sexual Medicine
guided by both the patient and her partner which
desensitize the patient to vaginal penetration,
and sex education emphasizing the development
and maintenance of vaginismus. In the first ever
randomized controlled therapy outcome study
for vaginismus, cognitive-behavioral sex therapy
(which included the sexual education and vaginal
dilatation technique as in Masters and Johnson’s
treatment protocol, cognitive therapy, relaxation
and sensate focus exercises) was found to be
effective having had successful intercourse.28
Assessment needs to explore the feelings
and fears related to sex, misconceptions, sexual
abuse or trauma, attitude towards intercourse
and sexual activity. It is important to avoid pain
and discomfort throughout the treatment and
emphasis treatment goal as mutual pleasurable
sexual activities and intercourse.
Conclusion
Published guidelines for the treatment and
assessment of sexual dysfunctions are limited.
It is important to consider medical, sexual
and psychosocial assessment procedure before
starting the treatment. Psychological treatments
can be used as main stream or adjunct to medical
treatment. Psychological management needs to
be patient-centered. There is a need for more
research on the assessment and management of
sexual dysfunctions so as to provide evidence
based treatment procedures.
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