Empirically Supported Treatments for Sexual Dysfunction
There are a variety of empirically validated psychotherapy treatments for sexual dysfunction, including: cognitive behavioral therapy CBT (e.g., stimulus control, cognitive restructuring), behavioral therapies based on the Masters & Johnson model (e.g., sensate focus), systematic desensitization, psychoeducation (individual/group format), systemic couples therapy and bibliotherapy.
Currently, sex therapy course may vary based on client/couple
- Some clients benefit from only 3-4 psychoeducation sessions
- Typical treatment is once a week for 10-12 weeks
- Or, based on need (up to 20 weeks)
Treatment Structure & Content
The following is a suggested treatment overview to address the main sexual dysfunctions outlined herein, desire, arousal and orgasmic disorders. Be advised that the following is only a suggested template, therapy course may vary dependent on client needs.
- Sex Education
- Anatomy & physiology of sex (diagrams, models)
- Address any unrealistic expectations of self & sexual encounter
- Address various "Myths of Sexuality"
- Level of detail will vary across clients (e.g., age, sexual maturity level)
- Often applied continually throughout course of therapy
CBT techniques (utilized when appropriate to help clients acknowledge distorted cognitions & gain perceived control over sexual encounter)
Apply particular therpeutic methods dependent on sexual dysfunction
- Communication Training
- Cognitive Restructuring
- Behavioral Intervention
Sample session structure
- Stage 1: Affectual Awareness
- Become aware of negative attitudes/beliefs about sex and/or partner
- Create set of lists (5 items per list)
- Benefits for gaining higher level of sexual desire
- Benefits for relationship
- Risks of increasing sexual desire to self & relationship
- Helps therapist & client gain understaning of:
- Fears of gaining sexual desire
- Influence of low desire on individual identity & within relationship
- Therapist may also explore emotions related to 'fear' lists
- Stage 2: Insight and Understanding
- Therapist explains multicausality of SD
- Clients consider initiating and maintaining causes of low desire
- Asked to identify common individual factors
- Consider power imbalance in relationship
Stage 3: Cognitive and Systemic Therapy
- Therapist and client consider how negative thoughts and beliefs mediate low sexual desire
- Develop healthy coping mechanisms
Stage 4: Behavioral Interventions
- Encourage engagement in more simply affectionate behavior
- Removes pressure created by performance anxiety
- Mutually enjoyable activities (e.g., hugging, kissing, etc.)
- Graduate to more sexually based activities (e.g., genital stimulation, intercourse)
- Role-play how partner may enjoy love-making
- Systematic desensitization has also shown effectiveness in treating desire disorders (often involving sexual aversion or fear of pain)
Client constructs fear hierarchy (10-15) activities
Rate from most to least anxiety-provoking on a 0-8 scale (e.g., 8=intercouse, 1=watching video of sexual activity, clothed)
Rate each item in terms of fear & avoidance
(Leiblum & Rosen, 2000; Wincze, Bach & Blume, 2008)
*Medical examination may rule out influence of GMC
Education, assessment of beliefs about sex & sexual ability
- Sensate Focus: A behavioral technique useful in most SDs, particularly arousal disorders
- Therapist clearly explains goals and activities involved
- Lessen and remove performance anxiety
- Draw attention to & augment pleasurable sensations (sexual/nosexual)
- Encourage couple to draw pleasurable from various forms of stimulation
- Series of homework assignments
- practice 1-3 times between therapy sessions
- 15-30 minutes per exercise
- Couple agrees not to engage in sexual intercourse (unless instructed) throughout this course of therapy
Sample series of assignments
- Assignment 1: Each partner gives the other a massage while clothed.
- Assignment 2: Each partner gives the other a massage while nude with genital contact. Partners communicate likes & dislikes, yet the goal is still not to become aroused.
- Assignment 3: Repeat assignment 2.
- Assignment 4: Each partner gives the other a massage while nude with genital contact. The partners continue to practice giving and taking feedback. If at any time, the partners become aroused (erection in the male) the therapist may instruct the female partner to allow the male's penis to become soft before resuming the exercise.
- Assignment 5 & 6: Repeat assignment 4
- Assignment 7: The couple engages in sexua activity that includes penetration without thrusting and attend to sensations
- Assignment 8: The couple engages in sexual activity that includes mild thrusting and attend to sensations.
- Assignment 9: The therapist lifts the ban on sexual intercourse
Other behavioral interventions:
- Systematic desensitization
- Stop-and-start method (Semans, 1957)
- Goal: Assist client to recognize pre-ejaculatory response and prevent it
- Involves manual stimulation of penis until sensation of "premonitory to ejaculation"
- Stimulation stopped, until sensation ceases, then reapplied
- Masters & Johnson "Squeeze Technique" (1970)
- Goal: Prolong physiological ejaculatory response
- When man feels ejaculatory sensation, he/partner squeeze the ridge and head of the penis, holding firmly (approx. 10 secs or until partially loses erection)
- Used before penetration or during intercourse (withdrawal of penis)
- Technique can be used multiple times during sexual encounter
- Then graduates to intercourse without motion & full intercourse
- Vary coital position (e.g., female superior & lateral coital position)
- Continue intercourse as long as possible after ejaculation
- Ejaculation does not signal end of intercourse
- Continue sexual activity after coitus is no longer possible
- Ejaculation does not signal end of sexual activity
- *Less emphasis placed on performance, reducing anxiety and lengthening IELT
(Wincze, Bach & Blume, 2008; Perelman, 2006)
This approach is well suited for marital relationships. It emphasizes differentiation, or experiencing oneself apart from the romantic relationship, and focuses on maximizing each partner's individual level of differentiation while facilitating intimacy within the relationship. There is no empirical research to support the efficacy of this form of treatment for sexual dysfunction however, it is practiced by many marital and family oriented therapists.
David Schnarch is a leading pioneer in this field of sexual therapy. His book entitled Constructing the Sexual Crucible, published in 1997, outlines his systemic theory and practice of treating sexual dysfunction.
(Leiblum & Rosen, 2000)
Bibliotherapy refers to treatment for mental and physical health problems in which written material plays a central role. It is often applied within treatment formats with minimal or absent therapist contact, such as self-help manuals, brief skills training, or education. It is cost effective and considered a succesful adjunct to psychotherapy for SDs, particularly orgasmic disorders. Growing research also indicates that sexual dysfunction, as compared to other psychological disorders, is particularly amenable to a bibliotherapy.
It is recommended to see a physician, counselor, therapist or other health care and human service provider when first addressing these concerns due to the multiple factors influencing the development of sexual problems (e.g., depression, anxiety and physical illness).
(van Lankveld, 1998)
Modern medicine is also capable of treating various sexual dysfunctions. Although many pharmacological treatments may be utilized in place of psychotherapy, it is important to recognize the limitations. Pharmacological treatment focuses primarily on restoring physiological sexual responses while leaving other important psychological and psychosocial concerns, such as poor couple communication, negative attitudes and inaccurate beliefs about sex. It is therefore recommended that these interventions be utilized as adjuncts to psychotherapy for sexual dysfunction.