Sex Therapy for Women's Sexual Concerns
Sex therapy starts with the correct diagnosis of the sexual dysfunction presented by the patient. This is not an easy task considering the vague diagnoses provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR, American Psychiatric Association, 2000), the high comorbidity of sexual dysfunctions, and the lack of age-related norms for the female sexual response. The common agreement is to look at medical etiology of the sexual complaints and then to follow with the investigation of personal and relational aspects. After this initial phase, the most liberal therapists discuss potential goals and patient’s expectations which are not limited to sexual intercourse but could include skills such as communication and assertiveness, or feelings of enjoyment and comfort during sexual behaviors. The techniques used in sex therapy vary according to treatment goals, dysfunction, and patient characteristics. Because sex therapy is a symptom-oriented approach, much of the rational is borrowed from the cognitive-behavioral school. In order to select the most appropriate form of sex therapy and therapy goals, patient characteristics such as age, sexual orientation, ethnic background, and cultural expectations need to be considered.
SEXUAL DESIRE DISORDERS
Hypoactive Sexual Desire Disorder
Women with hypoactive sexual desire disorder (HSDD) complain of a low interest in general sexual activities. There are currently no empirically validated treatments for HSDD. Sex therapy techniques generally consist of 15 to 45 sessions of cognitive therapy aimed at restructuring thoughts or beliefs that may adversely impact sexual desire (e.g. “women should not initiate sexual activities,” “sex is dirty”) and to address negative underlying relationship issues. Behavioral approaches are utilized to teach patients to express intimacy and affection in both nonsexual (e.g. holding hands, hugging) and sexual ways, to incorporate new techniques into their sexual repertoire that may enhance their sexual pleasure, and to increase sexual communication. Testosterone is effective in restoring sexual desire in women with abnormally low testosterone levels (e.g. secondary to removal of the adrenal glands, bilateral removal of the ovaries, menopause).
Sexual Aversion Disorder
Defined as the avoidance of sexual genital contact with a partner, sexual aversion disorder (SAD) has a high comorbidity with history of sexual abuse, vaginismus, and dyspareunia. Treatment for this condition often combines couple and cognitive therapy and focuses on solving conflict areas within the couple, emotional differences, and issues of control. Anxiety reduction techniques such as systematic desensitization are used when the aversion is accompanied by strong feelings of anxiety. Systematic desensitization consists of identifying a hierarchy of sexual activities that provoke anxiety and then pairing relaxation techniques with imagining the sexual activity. The goal is for the patient to feel relaxed while imagining each sexual activity and eventually while actually engaging in each sexual activity. Some therapists feel that, when treating sexual abuse survivors, trauma related issues need to be resolved before addressing SAD.
Female Sexual Arousal Disorder
Female sexual arousal disorder (FSAD) is operationalized as the difficulty in reaching and maintaining vaginal lubrication or genital swelling until the completion of the sexual activity (DSM-IV TR). Recently, theorists have argued that diagnosis of FSAD should consider not only the physiological dimension of sexual arousal (i.e. lubrication) but the psychological experience as well. Women of all ages may experience difficulty lubricating although it tends to be more of a problem in later life, typically after menopause. Female sexual arousal disorder is generally assessed and treated in conjunction with female orgasmic disorder or HSDD. To date, there are no validated treatments that focus exclusively on treating female arousal problems, although a number of pharmacological agents for enhancing vaginal engorgement and lubrication are currently under investigation. Techniques are often employed to help the patient become aware of her anxiety or her sexual turn-off thoughts, emotions, or behaviors. To help facilitate arousal, the patient is sometimes trained in the development of sexual fantasies, communication skills, sexual assertiveness, sensate focus, and the use of erotica or vibrators. Lubricants such as K-Y Jelly or Astroglide are often recommended to help compensate for decreased lubrication. Recently, the Federal Drug Administration approved a hand-held battery-operated device called EROS-CTD for the treatment of FSAD. This suction device is placed over the clitoral tissue and draws blood into the genital tissue.
Female Orgasmic Disorder
Female orgasmic disorder (FOD) is defined in the DSM-IV (TR) as the delay or absence of orgasm following a normal sexual excitement phase. The cognitive-behavioral treatment approach has received the greatest amount of empirical support for treating FOD. Reported success rates range between 88%-90%. This therapy technique aims at reducing anxiety-producing thoughts associated with sexual activities and increasing positive behavioral experiences. The treatment is moderately short, averaging 10 to 20 sessions. The major treatment components include sensate focus, directed masturbation, and systematic desensitization. Sensate focus involves exchanging physical caresses; moving from nonsexual to increasingly sexual touching of one another’s body over an assigned period of time. Directed masturbation involves a series of at-home exercises which begin with visual and tactile total body exploration and moves toward increased genital stimulation with the eventual optional use of a vibrator. Directed masturbation is the technique with the best success rates; systematic desensitization is particularly useful when anxiety plays a primary role in the dysfunction. Couples therapy which focuses on enhancing intimacy and increasing communication has also been used for the treatment of FOD, but the success rates of this approach have not been well established.
SEXUAL PAIN DISORDERS
Dyspareunia refers to genital pain associated with intercourse (DSM-IV TR). Vulvar vestibulitis is the most common type of premenopausal dyspareunia, while vulvar or vaginal atrophy is mostly reported by postmenopausal women. Women with these types of dyspareunia complain of pain in the vulvar area or anterior portion of the vagina upon penetration. The assessment of the type of dyspareunia should include information on the location, quality, intensity, time course, and meaning of the pain. The few studies which have examined treatment efficacy showed a moderate success rate of cognitive-behavioral techniques and biofeedback. The cognitive behavioral approach includes education and information about dyspareunia, training in progressive muscle relaxation and abdominal breathing, Kegel exercises to train the patient to identify vaginal tenseness and relaxation, use of vaginal dilators, distraction techniques to direct the patient’s focus away from pain cues, communication training, and cognitive restructuring of negative thoughts. During biofeedback, the patient is instructed to contract and relax her vaginal muscles while a surface electromyographic sensor inserted in her vagina provides her with feedback on muscular tenseness.
Vaginismus is the involuntary contraction of the outer third of the vagina, which impedes penetration of fingers, tampons, or penis. Sex therapy for vaginismus often consists of a form of systematic desensitization which involves instructing the woman to insert graded vaginal dilators into her vagina. The woman’s control over the insertion of the dilators is an important aspect of the therapy. The role of the partner in the exercise is passive if at all present. The emotional and psychological aspects of vaginismus are approached through patient education and control. Exercises that reduce anxiety and substitute anxiety-provoking thoughts with positive sexual thoughts are sometimes used in conjunction with the behavioral techniques.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association.