chapter 28

Psychological Management of
Sexual Dysfunctions
Rejani Thudalikunnil Gopalan, N Kumaraswamy

INTRODUCTION Different approaches and

Human sexual behavior is complex, which techniques
involves biological, psychological, social and Psychodynamic, behavioral, cognitive,
cultural factors and thus sexual dysfunctions. It cognitive-behavioral, and many other approaches
can cause distress to the individual as well as to have been used in the treatment of sexual
the partner. Sexual dysfunction is an inability dysfunctions. Psychoanalytic, psychodynamic
to experience arousal, to engage in sexual approach conceptualize sexual problems as
intercourse or to achieve satisfaction. They are conflict between sexual drives and its expression
classified into four major categories: (i) sexual (mainly the conflict between id and superego)
desire disorders, (ii) sexual arousal disorders, and main aim of psychodynamic oriented
(iii) orgasmic disorders, and (iv) sexual pain therapies are to resolve this internal conflict.
disorders. Causes can be either physical, According to cognitive behavioural approach,
psychological, or both. Physical problems sex and sexual dysfunctions are learned behavior
include hormonal imbalances, neurological by classical and operant conditioning and by
disorders, and diabetes, problems related to modeling. Cognitive behavioral therapy aims to
heart and kidney. Psychiatric disorders like identify the stimuli, response, consequences of
depression and alcohol and drug addiction and sexual behavior, maintaining factors of sexual
side effects of certain medications. Psychological dysfunctions and to alter cognitive errors and
causes include tiredness, stress, anxiety, emotional difficulties associated with it. Couple
therapy, couple communication training (specific
depression, feeling of guilt, history of sexual
focus on sex and sexual activity, verbalizing
abuse and trauma and marital issues.
and exchanging sexual needs and feeling),
A wide variety of treatment techniques have
psychodynamic couple therapy and couple sex
been used for treating sexual dysfunctions, which
therapy are other important approaches in the
include both pharmacological and psychological treatment of sexual dysfunctions.1
modalities. Different approaches and techniques Though different techniques are listed under
are available under the umbrella of psychological different approaches, major components of
management of sexual dysfunctions. The present psychological treatment for sexual dysfunctions
chapter outlines briefly on the psychological are sensate focus exercises, cognitive-behavioral
treatment approaches and techniques used in the therapy, relaxation training, hypnosis and
treatment of sexual dysfunctions and treatment guided imagery, and group therapies. Specific
techniques for specific conditions. techniques, such as directed self-stimulation,
 Section 6
Evaluation and Management
362
stop-start and squeeze techniques, systematic levels. It is a very pleasant and nurturing thing
desensitization and Kegel exercises are added to do. When agreed homework tasks are not
therapies when appropriate. Marital therapy to performed. that offers the opportunity for
improve communication and resolve conflict is further exploration and communication within
also part of standard therapy.2 the couple. It follow certain ground rules, such
as ban on intercourse throughout therapy and a
ban on genital touching for first four sessions,
Major techniques focus on the personal experience and not on
Comprehensive Textbook of Sexual Medicine

pleasing or arousing the partner. This therapy

Psychoeducation and sex counseling
is tailored to the individual or couple needs and
Much sexual distress is based on incorrect involves prescribing certain sexual assignments.
information and unrealistic expectations. Basic It has different stages.
counseling allows patient to talk about sexuality
Stage 1: Sensate focus without genital contact—
and her sexual problems. Therapist needs to
touching for own pleasure
explore patient’s concepts of love and sexuality,
values and priorities, Passion, intimacy, and This stage allows exploration of partner’s body
commitment. Therapist can educates the patient and focus on the feelings experienced in both
about the large variety of sexual expressions the ‘active’ and ‘passive’ roles. Exploration and
and responses, similarities and differences touching is avoided for breasts and genital areas.
This stage is mainly to increase familiarity and
between male and female sexuality and also
trust between the partners, to experiment with
need to dispel destructive sexual myths about
different types of touches, to make and guide
sexuality which can have a negative effect on the
specific types of preferred touches. According
patient’s sexual life and relationships. Accurate
to Bancroft, this particular stage is characterized
and relevant information about sexual anatomy
by two aspects: setting limits indicates that both
and physiology (along with encouragement of
partners experience relaxation and enjoyment
self-exploration), cultural norms and averages,
in the physical intimacy and thus reduce
the changes of ageing, relationship development,
performance anxiety and increase feeling of
dealing with external and internal performance
trust; and touching for own pleasure indicates
pressures from advertising, peers, partner, and
focusing on own pleasure which would leads to
other sources can all be helpful. Educational self-assertion.5
books and videos may be useful. Explanation
and exploration of the sexual arousal circuit can Stage 2: Sensate focus without genital contact—
demonstrate to patients the interconnectedness of touching for own and partner’s pleasure
the sexual problem with other aspects of life.1,3 Partners are instructed to give feedback
on touching, what they are experiencing,
Couple sex therapy (Sensate Focus whether they like it or not, guiding hands for
Stages) preferred touching and pressure, and giving
encouragement. This stage would facilitate the
This approach was introduced by Masters sexual communication between the partners.
and Johnson and its main principles are as
follows.4 Each person has the opportunity to Stage 3: Sensate focus with genital contact
explore their own preferences and feelings in This stage includes genital touching and
an understanding atmosphere. It enables the exploration. Focus is more on the genitals
couple to engage in intimate physical contact to discover the sensations resulting from
without any expectation of a particular outcome. different pressures and strokes in the different
It facilitates communication at a number of areas of the genitals. Orgasm is not a must
 chapter 28
Psychological Management of Sexual Dysfunctions
363
but can occur by mutual masturbation or by Directed masturbation
self-stimulation.
Directed masturbation is based on the sex therapy
Stage 4: Sensate focus with genital contact— format introduced by Masters and Johnson.
simultaneous caressing Women are educated as to how she can bring
This stage involves mutual caressing with herself to orgasm. It involve exercises to
genital contact. Both verbal and nonverbal increase body awareness, body acceptance,
feedback, encouragement and enhancement of visual and tactile exploration of the body,

Comprehensive Textbook of Sexual Medicine

communications are emphasized in this stage. exploration of areas of the body which gives
pleasure when touched, and then instruct the
Stage 5: Vaginal containment
technique of masturbation and also to use
Couples need to continue all the previous fantasy and imaging to use sexual excitement
exercises including touching and mutual and orgasm. This technique is mainly used for
caressing. This stage is for the experience of female orgasm disorder.7
containment—allowing the penis to rest in the
vagina and to experience sensations of vaginal
containment in relaxes state. Before this it is
Orgasm consistency training (OCT)
important to make sure that male partner is It is a cognitive-behavioral intervention consists
getting firm erection and female partner have of directed masturbation, sensate focus exercises
vaginal lubrication and then man lies back and and coital alignment technique. This technique
the woman sits on him introducing the penis is useful for hypoactive sexual desire disorder.
into the vagina.
Stage 6: Vaginal containment with movement Kegel exercises
This stage allows vaginal containment with These are pelvic-floor contractions, similar
movement, gently thrusting or rotating, and to postnatal exercises. It is used to strengthen
to try for different positions and to experience pubococcygeus (PC) muscles of the pelvic
different sensations associated with movements. floor. The woman tightens the muscles of her
This is to make sex as a pleasurable and mutually pelvic floor as if to stop the flow of micturition,
enjoyable experience. holds tight for 10 seconds, then relaxes the
muscles again, and repeats several times; this
Behavior therapy techniques is done several times a day. Such exercises
can encourage improvement in muscle tone;
Assertion training (being more assertive can increase awareness of pelvic sensation;
will improve sexual performance and sexual may increase orgasmic potential; and, in cases
satisfaction), behavioral analysis, behavioral of vaginismus, are a means of enabling the
rehearsal in which learns and rehearses behavior woman to begin to gain some control over her
through homework exercises), direct education, pubococcygeal spasm.3
behavioral sex therapy (uses combination of
techniques including education, communication Anterior fornix erogenous (AFE) zone
skills training, and sensate focus exercises),
history taking, modeling (models through films,
stimulation
or in group therapies the clients are models Anterior fornix erogenous (AFE) zone or
for each other), psychoeducational program, second G-spot is a female erogenous zone and
relaxation therapy, social skills training and stimulation of this part (erogenous centre in the
systematic desensitization treatment are found inner half of the anterior wall of the vagina)
to be useful behavior therapy techniques for the which would result in onset of reflex vaginal
treatment of various sexual dysfunctions.6 lubrication, erotic sensitivity and orgasm.8
 Section 6
Evaluation and Management
364
Coital alignment technique retarded ejaculation means ejaculation is slow
to occur. Retrograde ejaculation occurs when,
In this technique male lies above the female and
at orgasm, the ejaculate is forced back into
strokes upward in order to maximize clitoral
the bladder rather than through the urethra
stimulation during sexual intercourse.9
and out the end of the penis. Both organic
and psychogenic factors can cause ejaculation
Stop-start technique disorders. Premature ejaculation is the most
The penis is stimulated until the man feels common form of sexual dysfunction in men
Comprehensive Textbook of Sexual Medicine

premonitory sensations of ejaculation and the which usually caused by performance anxiety.
stimulation has to be discontinued. Stimulation Psychological factors like guilt, shame, anxiety,
is resumed after the sensation subsides and co morbid psychiatric disorders like mood
to stop until he again gets the premonitory disorders can also cause premature and inhibited
sensation of ejaculatory inevitability. This stop ejaculation. Retrograde ejaculation usually has
and start procedure can be practiced until the medical reasons, such as diabetics.
person become confident of tolerating penile Diagnosis of premature ejaculation (PE)
stimulation without ejaculation for longer time. encompasses seven key steps: (i) obtaining the
This technique is mainly used for premature patient’s general medical and sexual history, (ii)
ejaculation problem.10 classifying the symptom on the basis of onset
(e.g. lifelong or acquired PE), timing (e.g.
Squeeze technique prior to or during intercourse), and type (e.g.
absolute/generalized or relative/situational),
This technique involves penile stimulation to
the point of signals of oncoming ejaculation (iii) involving the partner to determine their
and partner needs to squeeze around the coronal view of the situation and the impact of PE on
ridge of the penis to stop the urges of ejaculation. the couple as a whole, (iv) identifying sexual
It is mainly used for delaying ejaculation and comorbidities (e.g. erectile dysfunction) to
premature ejaculation problem.11 define whether PE is simple (occurring in
the absence of other sexual dysfunctions) or
complicated (occurring in the presence of
PSYCHOLOGICAL MANAGEMENT other sexual dysfunctions), (v) Performing
physical examination to check the man’s sexual
FOR MALE SEXUAL DYSFUNCTIONS organs and reflexes, (vi) Identifying underlying
The most common types of sexual problems etiologies and risk factors (e.g. endocrine-,
in men are ejaculation disorders (premature urological-, relational-, or psychosexual-risk
ejaculation, inhibited or retarded ejaculation, factors) to determine the primary cause of
retrograde ejaculation), erectile dysfunction PE and any associated comorbidities, and
and inhibited sexual desire (decreased libido). (vii) Discussing treatment options to find
It could be due to medical or psychological the most suitable intervention, according
reasons. to the needs of the man and his partner. 12
The mainstay of treatment is a combined
approach using behavioral therapies and non-
Ejaculation disorders
licensed medication such as topical anesthetic
There are four different types of ejaculation preparations, selective serotonin reuptake
disorders in men, which can cause personal inhibitors and phosphodiesterase-5 inhibitors.13
distress and distress to partner. Premature Behavior therapies include stop and start
ejaculation refers to ejaculation that occurs technique, squeezing methods and relaxation
before or soon after penetration. Inhibited or methods are found to be useful.
 chapter 28
Psychological Management of Sexual Dysfunctions
365
Erectile Dysfunction presenting problem and any comorbid problems,
(iii) the formulation of “working hypotheses”
Erectile dysfunction (ED) is defined as the of the most relevant etiological and maintaining
consistent or recurrent inability of a man to attain factors, (iv) identification of treatment goals
and/or maintain a penile erection sufficient for and a treatment plan, and finally, (v) clear,
sexual activity. It is also known as impotence. constructive feedback to the woman and her
It can be induced by biological or psychological partner.14
reasons. The treatment strategy includes sex From a psychotherapeutic prospective, it

Comprehensive Textbook of Sexual Medicine

education, to patient and partner, relaxation is essential to see the woman individually as
therapy, treatment for comorbid condition (e.g. well as together with her partner to obtain
depressive illness) and treatment strategies by critical diagnostic information. Interviewing
Master and Johnsons.4 the couple emphasizes that sexual difficulties
and their resolution occur within the couple’s
Inhibited Sexual Desire relationship and that sexual problems invariably
affect both partners. Seeing the couple together
Inhibited desire, or loss of libido, refers to permits the clinician to observe the “emotional
a decrease in desire for, or interest in sexual climate” between the couple, the degree of
activity. Psychological or medical reasons can discrepancy between the woman and her
lead to reduced sexual desire. Psychological partner’s view of the problem, and any power
factors like stress, anxiety, depression, and intimacy conflicts that may characterize the
relationship issues, negative attitude towards overall relationship. Both nonverbal and verbal
sex, and history of sexual abuse can cause loss interactions are observed. The assessment needs
of libido. Medical factors, such as hormonal to cover important areas like demographic
imbalance, medical illness side effect of certain factors, problem elucidation (its onset, duration,
medicines can also lead to inhibited sexual frequency, severity, as well as related areas of
desire. Sex education and psychotherapy are sexual functioning), psychological/emotional
found to be effective in treating this condition. functioning (assessment of co morbid psychiatric
disorders), current environmental stressors ,
relationship distress (especially with sexual
PSYCHOLOGICAL MANAGEMENT partner), secrets, psychosexual history , history
of sexual abuse or trauma and medical history.15
FOR FEMALE SEXUAL
DYSFUNCTIONS
Hypoactive sexual desire disorder
Both DSM-IV and ICD-10 classified female
sexual dysfunction. It includes persistent or The DSM-IV lists two types of desire disorders:
recurrent disorders of sexual interest/desire, hypoactive sexual desire (HSD) and sexual
disorders of subjective and genital arousal, aversion. Low sexual desire disorder is
orgasm disorder, pain and difficulty with characterized by the persistent or recurrent
attempted or completed intercourse. Many deficiency (or absence) of sexual thoughts/
interventions are available for specific conditions fantasies, and/or desire for or receptivity to
and a comprehensive diagnostic assessment is sexual activity, which causes personal distress.16
required for a good treatment plan. According Prior to the intervention, level of hormone,
to Wincze and Carey an assessment of female especially level of androgens needs to be checked
sexual dysfunction includes: (i) an evaluation of as it may affect sexual desire. Both assessment
current sexual functioning, including feelings and management should focus on focus on
and thoughts of desire and receptivity to sexual factors reducing arousability and satisfaction.
activity, (ii) an accurate elucidation of the These include women’s mental health and
 Section 6
Evaluation and Management
366
feelings for their partner, generally and at anxiety, negative emotions, such as guilt and
the time of sexual activity. Psychotherapeutic shame. Management approaches focus on factors
interventions focus on creating a pressure- reducing arousability and satisfaction;19 and to
free, loving context in which to enjoy physical look for factors, which increase the arousability.
intimacy, one in which the woman feels safe and
valued. In addition, the use of erotic materials,
non-demand touching, or orgasmic training can
Female orgasm disorder
be helpful once the relationship roadblocks have Female orgasmic dysfunction is characterized
Comprehensive Textbook of Sexual Medicine

been addressed.15,17 by persistent or recurrent delay in or absence

of orgasm following a normal sexual excitement
Female sexual aversion disorder phase that cause marked distress or interpersonal
difficulty. It can be divided into lifelong and
It is characterized by strong feeling of revulsion acquired subtypes. Psychological factors,
in sexual activities and sexual situations. Sexual e.g. anxiety, fatigue, pain, feeling of guilt,
aversion disorders can be originated from early anti-masculine feelings and embarrassment in
childhood trauma, sexual abuse and violation. sexual relationships are found to be higher in
It is always conceptualized as a specific form of the anorgasmic group.20
phobic disorders. As for other phobic disorders, Various treatment strategies are available for
exposure based interventions are useful for female orgasm disorder. Directed masturbation
treating this disorder. It is advisable to proceed
training is found to be more effective for this
exposure therapy slowly and hierarchical
condition. 21 Directed masturbation training
fashion. Partner can involve in therapy when
teaches how to masturbate effectively and
client is confident of sexual activities and
eventually to reach orgasm during sexual
sharing.15
interactions. The coital alignment technique
(CAT) is also found to be effective in the
Female sexual arousal disorder treatment of female orgasmic disorder.22
Cognitive-behavioral therapy for anorgasmia
In the DSM-IV, female sexual arousal disorder promotes attitude and sexually relevant thought
(FSAD) is described in terms of lubrication and
changes and anxiety reduction using behavioral
vasocongestion problems. It is characterized by
exercises, such as directed masturbation, sensate
a lack of physiological and/or subjective sexual
focus, and systematic desensitization treatments
arousal which causes distress to the individual.
as well as sex education, communication
A large component of women’s sexual desire
skills training, and Kegel exercises. 23 The
is responsive rather than spontaneous. In ongoing
relationships, a woman’s motivation appears to psychophysiological treatments for female
be largely influenced by her emotional intimacy orgasmic dysfunction are on the whole
with her partner and her wish to enhance it. successful. However, in anorgasmia proven to
A woman’s sexual arousal is composite and be biological in etiology, following menopause
complex, correlating well with how mentally for example, physiological changes occur that
exciting she finds the sexual stimulus and cannot be resolved by these strategies alone.24
its context and poorly with objective genital Nonpharmacological approaches should be used
blood flow changes. 18 So therapist need to first, focusing on lifestyle and psychosexual
explore various factors like over all relationship therapy. If required, proven effective hormonal
satisfaction, relationship issues with the partner, and nonhormonal therapeutic options are
existence of extramarital relation, possibility of available.25
psychiatric disorders such as depression and
 chapter 28
Psychological Management of Sexual Dysfunctions
367
Dyspareunia enhancement therapies and hypnosis. Most
successfully used treatment for vaginismus was
Dyspareunia is genital pain associated with behaviourally oriented sex therapy with vaginal
sexual intercourse and sexual activities involve dilation by Masters and Johnsons. It consists of
touching genital area. It can be due to medical the physical demonstration of the vaginal muscle
reasons like urethral disorders, cystitis and spasm to the patient (and her partner) during
interstitial cystitis or due to psychological a gynecological examination, then insertion of
reasons. Women with dyspareunia are found to a series of dilators of graduated sizes at home

Comprehensive Textbook of Sexual Medicine

have more physical pathology, psychological guided by both the patient and her partner which
distress, sexual dysfunction, and relationship desensitize the patient to vaginal penetration,
problems, more negative attitudes toward and sex education emphasizing the development
sexuality, higher levels of impairment in and maintenance of vaginismus. In the first ever
sexual function, and lower levels of marital randomized controlled therapy outcome study
adjustment. 26 In addition to catastrophizing for vaginismus, cognitive-behavioral sex therapy
thoughts and hypervigilance, it is possible (which included the sexual education and vaginal
that repeated pain may pain leads to increased dilatation technique as in Masters and Johnson’s
genital muscle tension that can further increase treatment protocol, cognitive therapy, relaxation
pain by adding muscle pain to the original pain, and sensate focus exercises) was found to be
interfering with penetration, and reducing genital effective having had successful intercourse.28
blood flow.27 Assessment needs to explore the feelings
Dyspareunia is a heterogeneous disorder and fears related to sex, misconceptions, sexual
which requires gynecologic and psychosocial abuse or trauma, attitude towards intercourse
assessment to determine differentiated treatment and sexual activity. It is important to avoid pain
strategies. The focus of the treatment strategies to and discomfort throughout the treatment and
be on pain reduction as pain is the central feature emphasis treatment goal as mutual pleasurable
of this disorder. Various methods like changing sexual activities and intercourse.
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
Conclusion
and biofeedback are useful to reduce the pain. Sex Published guidelines for the treatment and
education regarding normal anatomy and sexual assessment of sexual dysfunctions are limited.
functions can reduce the misconceptions related It is important to consider medical, sexual
to sex. It is also important to explore any kind of and psychosocial assessment procedure before
trauma or sexual abuse in the past and presence of starting the treatment. Psychological treatments
marital discord. In addition to cognitive behavior can be used as main stream or adjunct to medical
therapy, abuse focused therapy and marital therapy treatment. Psychological management needs to
can be used if such conditions are present.17,19 be patient-centered. There is a need for more
research on the assessment and management of
sexual dysfunctions so as to provide evidence
Vaginismus based treatment procedures.
Vaginismus refers to tension in the vaginal
muscles or involuntary muscle spasms, which
in turn causes painful intercourse. A variety References
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Evaluation and Management
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