Sexual Dysfunction

Sexual dysfunction associated

with pain
Dyspareunia (Not due to a general
medical condition)
Vaginismus (Not due to a general medical
condition)

Human Sexual Response

Masters and Johnson: four phases
Excitement/arousal
Plateau
Orgasm
Resolution

1956-1966

Masters & Johnsons Sexual

Response Cycle
4 Phase Sexual response cycle
Excitement phase: erection, lubrication,
muscular tension, ^ heart rate, sex flush
Plateau phase: advanced state of
arousal, orgasmic platform builds, sex
skin appears
Orgasmic phase: 3-15 contractions, rush,
warmth, explosion, release
Resolution phase: return to prearoused
state, men have refractory period
unresponsive to stimulation, women may
be rearoused to multiple orgasm

Female Sexual Response Cycle

Male Sexual Response Cycle

 The sexual
response cycle in
humans
progresses
through four
phases:

Excitement
Plateau
Orgasm (climax)
Resolution

Sexual Response
Plateau Phase
The second phase of the sexual response
cycle and is characterized by:
Increases in vasocongestion, muscle tension,
heart rate, and blood pressure
Orgasmic platform, which is the thickening of
the walls of the outer third of the vagina, due to
vasocongestion
Sex skin, which is the reddening of the labia
minora
Rapid breathing and heart rate, blood pressure
increases
Copyright 2008 Allyn & Bacon

 Plateau:
Both males and females continue
vasocongestion to max
Heart rate, respiration rate and blood
pressure continue to increase
Copious perspiration
Increased myotonia

Plateau (Contd)
Females:
orgasmic platform:
outer third of vagina
thickens, swells:
condition sine qua
non: without it, no
orgasm
tenting complete
clitoris erect

Plateau (Contd)
Males:
Cowpers glands
secrete fluid through
tip of penis.
WARNING: may
contain live sperm!
scrotum even higher
and testicles bigger

Each phase shows age changes

Excitation:
Men:
fastest 16-20 years, then show decline

Middle Age:
very noticeable, need direct stimulation

Old Age:
need lots of direct stimulation

Women:
slower in teens, early 20s
faster 30s on

Plateau:
Men:
capacity for longer with age

Women:
same, but never a big problem

Orgasmic:
Men:
intensity lessens from mid- to late 20s

Middle Age:
really noticeable
ejaculate less volume, less forceful

Resolution:
Refractory period increases

Intensity of
Response

Females

Males

20
80

30

40

50

60
Age

70

PHYSIOLOGY OF THE SEXUAL RESPONSE

Neural and hormonal
involvement in sexual responses:
Parasympathetic:
arousal

Sympathetic:
orgasm

Spinal reflexes:
erection and ejaculation
Erection:
sacral cord responds to
stimulation, sends message via
parasympathetic to relax penile
arteries: more blood flows to penis.
Also, message to brain,
awareness (not if spine severed
above sacrum)
Ejaculation:
higher in spinal cord, message to
sympathetic that causes muscle
contractions. Also, message to
brain, awareness, possibility of
control

Hormonal Influences on Sex

PHYSIOLOGY OF THE SEXUAL RESPONSE

Hormonal Influences on Sex (Contd):

Hormones are NOT directly responsible for
human sexual behaviour, as they are in most
animals.
Psycho-social context and culture are the
most important determinants.
In real life, people in good relationships say
that sex is better than in casual situations.

PHYSIOLOGY OF THE SEXUAL RESPONSE

Anatomy and physiology of sex only give

us an idea of how our biological
equipment tends to work, but it does not
give us an understanding of human sexual
behaviour. Knowing car mechanics does
not make you a good driver!
In order to get this, we need to explore our
psychology, our communication styles, our
culture/s, our interpersonal skills, etc.

Percentage of Women*

Prevalence
of Sexual Complaints in Women
50
40
30

43% of women experienced a sexual problem

32%
28%
27%
21%

20
10
0

Lack of
Sexual
Interest

Unable to
Achieve
Orgasm

*Women aged 18-59 years

Laumann EO, et al. JAMA. 1999;281:537-544.

Sex Not
Pleasurable

Pain During
Sex

Comorbidity of Anxiety and Depression With

Sexual Problems

Odds Ratio*

Increased association between anxiety or

depression with sexual problems

*Odds ratio for association between anxiety and depression and sexual
problems
Dunn KM, et al. J Epidemiol Community Health. 1999;53:144-148.

Comorbidity of Marital Difficulties and

Sexual Problems
Increased association of marital problems with
8
arousal, orgasm, or enjoyment problems
Odds Ratio*

6
4
2
0

*Odds ratio for association between marital difficulty and sexual problems
Dunn KM, et al. J Epidemiol Community Health. 1999;53:144-148.

Female Sexual Dysfunctions

Desire
Lack of sexual desire
Desire discrepancy with partner
Aversion to sexual activity
Arousal
Difficulties with physical and/or subjective sexual arousal
Difficulties lubricating
Difficulties sustaining arousal
Orgasm
Difficulties experiencing orgasm
Pain
Pain with sexual activity
Difficulties with vaginal penetration (anxiety, muscle tension)
Lack of sexual satisfaction and pleasure

Categories of Female Sexual

Dysfunction
Sexual
desire disorders

Hypoactive sexual desire disorder

Sexual aversion disorder

Sexual
arousal disorder

Female sexual arousal disorder

Sexual
orgasmic disorder

Female sexual orgasm disorder

Sexual pain
disorders

Dyspareunia
Vaginismus
Noncoital sexual pain disorder

Basson R, et al. J Urol. 2000;163:888-893.

Physiological

Neurological problems
Cardiovascular disease
Cancer
Urogenital disorders
Medications
Fatigue
Hormonal loss or
abnormality

Interpersonal
relationships
Partner performance
and technique
Lack of partner
Relationship quality
and conflict
Lack of privacy

Psychological
Depression/anxiety
Prior sexual or
physical abuse
Stress
Alcohol/substance
abuse

Female
Sexual
DysfunctionSociocultural
influences

Inadequate education
Conflict with religious,
personal, or family
values
Societal taboos

Sexual Pain Disorders

Dyspareunia

Genital pain associated with sexual intercourse

Vaginismus

Involuntary spasm of the musculature of the outer

third of the vagina that interferes with vaginal
penetration, which causes personal distress

Noncoital

sexual pain disorder

Genital pain induced by noncoital sexual stimulation

Basson R, et al. J Urol. 2000;163:888-893.

Dyspareunia

Etiology:

Primary dyspareunia: it is often psychological

inadequate stimulation or forced inhibition of arousal leading
to inadequate vaginal lubrication and coital pain.
Inadequate lubrication, may be secondary to improper or
insufficient foreplay.

Secondary dyspareunia: It is an acquired disorder,

unrelated to the first coitus, and develops years later.
Organic causes of dyspareunia include the following:

Superficial dyspareunia:
1)Vaginal opening (introital lesions): inflammatory
conditions (e.g., vestibulitis), infections (e.g. herpes,
abscesses of Bartholin's glands or ducts).
- Tight introitus: secondary to episiotomy, plastic
repair of the vagina or radiotherapy.

2) Vulval skin lesions: hymenal tears, laceration of the

fourchette, painful superficial ulcerations, congenital
septum, rigid hymen, and circumcision scar tissue.
Dermatologic disorders as lichen sclerosis.
3) Clitoris and urethra: Irritations and infections, and
suburethral diverticulum.
4) Vagina: Infections as vulvovaginitis (trichomonas or
candida).
Menopausal involution with dryness and thinning of the
vaginal skin.
5) Reactions to local contraceptives:
1- Improperly fitted or inadequately lubricated condoms.
2- Allergic reactions to the contents of contraceptive
foams, jellies and condoms.
6) Radiation therapy for malignancy

(B) Deep dyspareunia:

1. Endometriosis.
2. Pelvic inflammatory disease.
3. Marked retroflexion of the uterus with ovaries prolapsed
into the cul-de-sac "ovarian entrapment syndrome".
4. Shortening of the vagina after surgery.
Diagnosis: The location and nature of the pain may help in
the diagnosis:
1- Deep dyspareunia: pain on deep thrusting at intercourse
may indicate lesions of the uterus
and/or broad ligament.
2- Local examination: introital lesions and uterine
displacement or other pelvic pathology.

Treatment:
1) Existing lesions or defects should be
corrected.
2) Advice husband on posterior intromission
to avoid pressure on the sensitive urethra.
3) If the vulva is swollen and painful, a wet
dressing of dilute aluminum acetate
solution may be applied locally. An
analgesic, is indicated if the pain is severe.

Wincze & Barlow Model (1997)

Medical
Indications

Medical
Stabilization

Minimal Couple
Distress

Medical
Evaluation
Assessment
& Integration
Psychosocial of Information
Evaluation

One partner
Sexual
problem

Individual Sex
Therapy

Possible
Couple Therapy

One partner
Psychological
problem

Individual
Psychotherapy

Possible
Couple Therapy

Significant
Couple
Distress

Couple
Therapy

Substance
Abuse

Substance
Abuse Tx

Couple Sex
Problems
Only

Possible
Couple Therapy

Sex Therapy

Universal CBT Tools

1. Cognitive Restructuring

Goals:

Strategies to challenging negative cognitions:

1.
2.
3.

Identify cognitions and beliefs about sexual encounter

Normalize feelings of anxiety, frustration, disappointment
Identify possible precipitating factor leading to acquired vs. lifelong SD
Challenge negative thoughts
Provide education
Stick to the facts
Decatastrophize

Useful across various SDs & integrated throughout treatment

course

Universal CBT Tools

2. Stimulus Control

Goals:

Method involves manipulation of environmental factors to

facilitate a given behavior or outcome
Creating conditions conductive to healthy sexual functioning

Methods:
1.

Generating lists of conditions or factors which positively &

negatively affect arousal, such as:

2.

Setting
Mood (self & partner)
Atmosphere
Performance concerns
Faulty beliefs

*Maximize positive factors & minimize negative factors

Sex Therapy
Desire Disorders
Primary Goals & Strategies:
Communication Training
Cognitive Restructuring
Education
Behavioral Intervention