Sexual Interest/Arousal Disorder

Changes in diagnostic criteria from DSM-IV to DSM-5:
Hypoactive sexual desire disorder (HSDD) + female sexual arousal disorder (FSAD) = Sexual interest and arousal disorder (SIAD)
  • Diagnostics changed from taking the perspective of Masters and Johnson’s linear model, to the Incentive Motivation Model, biopsychosocial circular process
  • Difficult for women and researchers to differentiate between desire and arousal
  • Growing divergence between theoretical approach to men and women
Disadvantages to DSM-IV
  • Linear model may not accurately depict way I which woman experiences arousal
  • Women experience their sexuality through more than just frequency and intensity of desire
  • Women who have satisfactory levels of sexual desire often report having no sexual fantasies, therefore it leads to inaccuracies to include this component in a disorder diagnosis
  • persistent and recurrent” were not accurate enough in the DMS-IV
  • The word “hypoactive” in HSDD implies a biological etiology for the sexual dysfunction
Advantages to DSM-5 criteria
Brotto and Luria (in Binik and Hall, 2014) share the advantages of the new DSM-5 diagnosis of SIAD compared to DSM-IV’s HSDD and FSAD are the following:
  1. It addresses the finding that sexual behavior alone is an unreliable referent for sexual desire
  2. it acknowledges that sexual response difficulties may be expressed differently across different women
  3. it expands the narrow focus on lubrication as a sole indicator of sexual arousal
  4. it seeks to depathologize normal variations (and reductions) in sexual response by requiring that symptoms occur on most sexual encounters for a minimum duration of 6 months. p. 20
Incentive?
Some suggest that the results of the DSM-5 change to SIAD will be beneficial for pharmaceutical companies
(Leiblum, 2005; Clayton, DeRogatis, Rosen, & Pyke, 2012)


Female Sexual Interest/Arousal Disorder (SIAD)

DSM-5 Diagnostic Criteria

DSM criteria.png
(American Psychiatric Association, 2013)

PREVALENCEWhat do women want.jpg

According to the DSM-5, given that SIAD is a new disorder, its prevalence is unknown.

“The prevalence of women’s sexual desire problems varies widely across different studies.” (McCabe & Goldhammer, 2013)
  • Disparities may be due to methodological inconsistencies, or in disparities that exist in how we define sexual desire problems.
    • Disparities may be due to methodological inconsistencies, or in disparities that exist in how we define sexual desire problems.
      • “Criteria used by researchers to define sexual desire problems will have an impact on the prevalence rate defined in the literature as well as in the clinical setting” (McCabe & Goldhammer, 2013)
    • There is a discrepancy between what has been defined as sexual arousal and what women perceive as sexual arousal
      • Women experiencing sexual dysfunction often deny awareness of the physiological responses despite measurable genital response, so although their body may be responding to the sexual stimuli, they are psychological distracted and rendered unable to recognize their own sexual stimulation (Brotto & Basson, 2014)
    • Regardless of these variations, sexual desire is consistently reported as the most common problem of the sexual disorder categories among women
      • Range from 8%-64% in clinical populations
      • One third of women surveyed by the National Health and Social Life Survey reported “lack of interest in sexual activity”
      • Sexual desire is the most common sexual problem identified by women aged 18-59.

PREDICTORS

“The causes of low sexual interest may include organic as well as psychogenic factors.”
Risk Factors.png
Etiology.pngRussell Brand.png

ASSESSMENT

  • Medical or organic causes
    • Physical Examination (gynecological exam)
    • Labs
  • Structured Biopsychosocial Interview
    • Individual vulnerability issues
    • Interpersonal and/or partner factors
    • Systemic issues
  • Sexual History Taking
    • History of sexual behavior, including childhood personal and religious upbringing.
    • Current sexual behavior
    • Attitude and cognitive factors
      • How the client thinks about her sexual disorderSexual History.png
      • How the client thinks about sex in general

Recommended Questionnaires:



TREATMENT“It is important to note that the treatment of female sexual dysfunction is more complex than in males.”
Theoretical Orientations:
  • Psychoanalytic Perspective
  • Cognitive-Behavioral Model (Masters and Johnson)Now....gif
  • Systems Theory

Psychological Interventions:
  • Cognitive-Behavioral Therapy (CBT)
  • Mindfulness-Based Interventions (MBIs)
    • Treatment Commonly Includes:
      • Sexual Education (psychoeducation)
      • Communication skills training
      • Couple’s counseling
      • Non-demand pleasuring
      • Physical awareness and sensuality exercises
        • Sensate focus
        • Directed masturbation
        • Coital Alignment techniqu
      • Exploration of past traumatic or negative experiences
      • Treatment of concomitant psychiatric conditions (i.e. depression or anxiety)


    • Poor emotional intimacy is often associated with loss of desire.
    • Sexual stimuli and sexual context is vital.

Pharmacotherapy:
There is currently no U.S. FDA approved medication available for treatment of sexual interest/arousal disorders in women.
  • Sildenafil citrate clinical trials – rejected
  • Testosterone – rejected

Other Considerations:
  • Feminist opposition to “medicalization” of female sexual problems.50 Shades.png
  • Aphrodisiacs – no scientific evidence to support Female Libido Pill.png

Cycle.pngNothing is Wrong.png


REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, (DSM-5®) American Psychiatric Pub.

Atwood, J. D. (2015). Sexual disorders and sex therapy. In J. L. Wetchler, L. L. Hecker, J. L. (. Wetchler & L. L. (. Hecker (Eds.), (pp. 431-467). New York, NY, US: Routledge/Taylor & Francis Group.

Basson, R. (2010). Women's difficulties with low sexual desire, sexual avoidance, and sexual aversion. In S. B. Levine (Ed.), Handbook of clinical sexuality for mental health professionals (2nd ed., pp. 159-179) Routledge.

Basson, R. (2000). The female sexual response: A different model. Journal of Sex and Marital Therapy, 26, 51-65.

Basson, R., Wierman, M. E., van Lankveld, J., & Brotto, L. (2010). Summary of the recommendations on sexual dysfunctions in women. Journal of Sexual Medicine, 7(1), 314-326. doi:10.1111/j.1743-6109.2009.01617.x

Brotto, L. A., & Basson, R. (2014). Group mindfulness-based therapy significantly improves sexual desire in women. Behaviour Research and Therapy, 57, 43-54.

Brotto, L. A., & Luria, M. (2014). Sexual interest/arousal disorder in women. In Y. M. Binik, & K. S. K. Hall (Eds.), Principles and practice of sex therapy (5th ed., pp. 17-41) Guilford Publications.

Brotto, L. A., & Smith, K. B. (2014). Sexual desire and pleasure. In D. L. Tolman, L. M. Diamond, J. A. Bauermeister, W. H. George, J. G. Pfaus, L. M. Ward, . . . L. M. (. Ward (Eds.), (pp. 205-244). Washington, DC, US: American Psychological Association. doi:10.1037/14193-008

Clayton, A. H., Segraves, R. T., Leiblum, S., Basson, R., Pyke, R., Cotton, D., & Wunderlich, G. R. (2006). Reliability and validity of the sexual interest and desire Inventory—Female (SIDI-F), a scale designed to measure severity of female hypoactive sexual desire disorder. Journal of Sex and Marital Therapy, 32, 115-135.

Clayton, A. H., DeRogatis, L. R., Rosen, R. C., & Pyke, R. (2012). Intended or unintended consequences? the likely implications of raising the bar for sexual dysfunction diagnosis in the proposed DSM-V revisions: 2. for women with loss of subjective sexual arousal. Journal of Sexual Medicine, 9(8), 2040-2046. doi:10.1111/j.1743-6109.2012.02859.x

Giraldi, A., & Graziottin, A. (2008). Sexual arousal disorders in women. In H. Porst, & J. Buvat (Eds.), Standard practice in sexual medicine (pp. 325-333) John Wiley & Sons.

Giraldi, A., Rellini, A. H., Pfaus, J., & Laan, E. (2013). Female sexual arousal disorders. Journal of Sexual Medicine, 10(1), 58-73. doi:10.1111/j.1743-6109.2012.02820.x

Giraldi, A., Rellini, A., Pfaus, J. G., Bitzer, J., Laan, E., Jannini, E. A., & Fugl-Meyer, A. (2011). Questionnaires for assessment of female sexual dysfunction: A review and proposal for a standardized screener. Journal of Sexual Medicine, 8(10), 2681-2706. doi:10.1111/j.1743-6109.2011.02395.x

Goldhammer, D. L., & McCabe, M. P. (2011). Development and psychometric properties of the female sexual desire questionnaire (FSDQ). Journal of Sexual Medicine, 8(9), 2512-2521. doi:10.1111/j.1743-6109.2011.02334.x

Leiblum, S. R. (2006). Principles and practice of sex therapy (4th ed.) Guilford Press.

Leiblum, S. R., & Rosen, R. C. (1988a). Sexual desire disorders. Guilford Press.

Leiblum, S. R. (2005). Editorial: Pharmacotherapy for women: Will we, won't we, should we? Sexual and Relationship Therapy, 20(4), 375-376. doi:10.1080/14681990500297022

Leiblum, S. R., & Rosen, R. C. (1988b). Introduction: Changing perspectives on sexual desire. In S. R. Leiblum, R. C. Rosen, S. R. (. Leiblum & R. C. (. Rosen (Eds.), (pp. 1-17). New York, NY, US: Guilford Press.

Levine, S. B. (2002). Re-exploring the concept of sexual desire. Journal of Sex & Marital Therapy, 28(1), 39-51.

McCabe, M. P., & Goldhammer, D. L. (2013). Prevalence of women’s sexual desire problems: What criteria do we use? Archives of Sexual Behavior, 42(6), 1073-1078. doi:10.1007/s10508-013-0107-z

Meston, C. M., & Derogatis, L. R. (2002). Validated instruments for assessing female sexual function. Journal of Sex &Marital Therapy, 28(S1), 155-164.

Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., & D'Agostino, R. J. (2000). The female sexual function index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. Journal of Sex and Marital Therapy, 26, 191-208.

Sand, M., Rosen, R. C., Meston, C., & Brotto, L. (2009). The female sexual function index (FSFI): A potential “gold standard” measure for assessing sexual function in women. Fertil Steril, 92, S129.

Schnarch, D. M. (1991). The problem of "problems of sexual desire". Constructing the sexual crucible: An integration of sexual and marital therapy (pp. 247-305) WW Norton & Company.

Sills, T., Wunderlich, G., Pyke, R., Segraves, R. T., Leiblum, S., Clayton, A., . . . Evans, K. (2005a). The sexual interest and desire inventory-female (SIDI-F): Item response analyses of data from women diagnosed with hypoactive sexual desire disorder. The Journal of Sexual Medicine, 2(6), 801-818. doi:JSM146 [pii]

Sills, T., Wunderlich, G., Pyke, R., Segraves, R. T., Leiblum, S. R., Clayton, A., . . . Evans, K. R. (2005b). An item-response analysis of the sexual interest and desire inventory: Refinement of a scale designed to measure severity in female hypoactive sexual desire disorder. J Sex Med, 2, 801-18.

Spector, I., Carey, M., & Steinberg, L. (1996). The sexual desire inventory: Development, factor structure, and evidence of reliability. Journal of Sex and Marital Therapy, 22, 175-190.

Spector, I. P., & Carey, M. P. (1990). Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Archives of Sexual Behavior, 19(4), 389-408. doi:10.1007/BF01541933

Spurgas, A. K. (2013). Interest, arousal, and shifting diagnoses of female sexual dysfunction, or: How women learn about desire. Studies in Gender and Sexuality, 14(3), 187-205. doi:10.1080/15240657.2013.818854

Wiegel, M., Meston, C., & Rosen, R. (2005). The female sexual function index: Cross-validation and development of clinical cutoff scores. J Sex Marital Ther, 31, 1-20.




Other Measures (see appendix of each article)


Arousal and Desire Disorders in Men

ERECTILE DISORDER

DSM-5:
At least one of the three following symptoms must be experience on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, all contexts):
1. Marked difficulty in obtaining an erection during sexual activity
2. Marked difficulty in maintaining an erection until the completion of sexual activity
3. Marked decrease in erectile rigidity
  • symptoms must persist for at least six months
  • symptoms cause clinically significant distress for the individual
  • sexual dysfunction is not better explained

Prevalence:

  • Kinsey survey for 50 years was the most comprehensive information available about prevalence; reported 42% of men experience ED, negatively correlated with age.
  • Difficulty determining exact prevalence: relying on self report, lack of report, different measurement standards.
  • Cite 8 different studies from 1994 to 2003 that ranged from 5% to 53% overall prevalence.
  • At least 10% of men under 35 years
  • At least 50% of men over age 60

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Predictors:

  • Age:
    • Even as incidence of erectile dysfunction increases with age, report of distress decreases with age- suggesting that even as incidence increases with age, overall distress from erectile disorder decreases with age.
  • Vascular Diseases
    • Such a high comorbidity between vascular diseases and erectile dysfunction that there is current consideration to consider erectile dysfunction a “vascular disease”:
    • coronary artery disease
    • cerebrovascular disease
    • peripheral arterial disease
  • Cardiovascular Diseases, such as:
    • Hypertension
    • Hypercholestrolmia
    • Diabetes Mellitus
    • Metabolic Syndrome
  • Other sexual dysfunctions:
    • Premature ejaculation
    • HSDD
  • Health Factors:
    • Smoking
    • Obesity
    • Lack of exercise
    • Excessive alcohol consumption
  • Hormonal of Endocrine Disease:
    • Hypogonadism (low testosterone levels)
  • Chronic Disease:
    • Men with multiple sclerosis report 40-80% prevalence of ED
    • Men with Parkinson’s Disease report both lower desire and erectile dysfunction
    • Men with multiple systems atrophy report 90% prevalence of erectile dysfunction
    • Chronic renal failure
    • Depression
    • Lower urinary tract infections (odds ratio of 3.1 for predicting ED)
  • Medications:
    • 25% incidence of drug- associated erectile dysfunction
    • Antihyertensive agents are associated with erectile dysfunction
    • SSRI inhibitors known to cause ED (prevalence ranges from small percentage to 80%)

TreatmentsIce Cream Viagra.png

  • PDE5 Inhibitors (such as Viagra)
    • has been used by over 100 million men world wide.
    • There are risks associated with this treatment, especially for patients who also have cardiac conditions.
    • There is also an elevated risk for clients with opthalmological disorders.
    • Likewise, a study of 58,000 men found that only 16% of the men who were prescribed PDE5’s continued use of the medication.
(Binik & Hall, 2014)
  • Holistic Assessment:
    • Because of the high usage of PDE5 drugs to treat erectile dysfunction, the problem is being addressed more and more by primary care physicians. Additionally, physicians are primarily on self-report instead of employing nocturnal penile tests, acquiring sexual histories, or using screening questionnaires. Nonmedical treatment should begin with an assessment to address these four issues:
1. Personal information about the client’s sexual inhibitions or performance anxiety
2. Personal information about client’s partner, and any inhibition or anxiety
3. Assessment of the overall quality of the relationship
4. Assess for any external stressors, such as financial concerns or familial discord
(Binik & Hall, 2014)
  • Positive Imagery Training:
    • Positive imagery training can accompany masturbation exercises or be utilized independently.
    • Creating positive sexual fantasies can help a client build confidence and develop sexual control.
(Binik & Hall, 2014)

ASSESSMENT FOR TREATMENT:
  • The International Index of Erectile Function (IIEF)


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Erectile Dysfunction Causes



HYPOACTIVE SEXUAL DESIRE DISORDER (HSDD)

"Low sexual desire remains the most mysterious of all male sexual dysfunctions" (Binik & Hall, 2014).


"... Unfortunately, there is a pronounced tendency in the literature to focus on low desire in women and overlook low desire in men, let alone gay men, except as curiosities and anomalies. This may stem from broader social norms that define 'sex' as penis-in-vagina intercourse..." (Kleinplatz, 2011).


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DSM-5 DIAGNOSIS:

“a persistent or recurrent deficiency or absence of sexual fantasies and a desire for sexual activity that causes a marked distress of interpersonal difficulty. The dysfunction should not be better accounted for by another psychiatric disorder (except another sexual dysfunction) and must not be due exclusively to the physiological effects of a substance or a general medical condition”

3 Criterion:

  1. deficiency of absence of sexual fantasy and desire for sexual activity
  2. marked distress or interpersonal conflict because of decreased desire
  3. low desire cannot be accounted for by a major psychiatric or medical condition or by substance abuse

Specifications:

  • lifelong or acquired
  • generalized or situational
  • psychological factors or combined factors

Definition from the 2nd International Consultation on Sexual Disorders (2004)

Sexual interest/desire dysfunctions: diminished or absent feelings of sexual interest or desire, absent sexual thoughts or fantasies, and lack of responsive desire. Motivations for attempting to become aroused are scarce or absent. The lack of interest is considered to be beyond a normative lessening with life cycle and relationship duration.”

CHALLENGES WITH DIAGNOSIS AND TREATMENT:

  • Older men, or men with health problems, assume the decreased desire is an expected function of their condition (age or disease), and therefore do not seek treatment.
  • Men may resist seeking treatment because of shame; masculinity is culturally connected to sexual virility.
  • Women are not as distressed by a male partner’s lower sex desire, so the decreased interest does not initiate interpersonal conflict.
  • Men are more focused on erectile functioning than levels of desire (despite the fact that the two issues have a high comorbidity).
"...In fact he does not register and recognize arousal without the cue of his previously erect penis and so has no way to identify his own desire" (Kleinplatz, 2011)
  • Both men and women find it hard to distinguish between arousal and desire, but men are more likely to present with arousal problems and women are more likely to present with desire problems.
  • Clinicians, clients, and partner expectations of ‘sex’ all determine whether lack of desires is pathological or dysfunctional


ETIOLOGY:

  1. significant biomedical involvement
  2. without biomedical involvement
  3. lack of desire with current partner- desire being fulfilled in a different way
  4. lack of desire with current partner- desire is being suppressed
  5. comorbidity with erectile dysfunction
  6. desire with primary partner as a result of desire being met elsewhere (masturbation, extramarital affairs, internet porn, paraphilia)- Hidden Sexual Desire Disorder


Special note on Etiology:
“There is shockingly little written about primary male HSDD. The core issue is usually a sexual secret” (p. 59).
  • In order of highest prevalence, these secrets include:
  1. variant arousal pattern
  2. a preference for masturbatory sex rather than intimate couple sex
  3. history of poorly processed sexual trauma
  4. conflict about sexual orientation


There is not an actual lack of desire in these cases, but a “secret/shameful desire/arousal pattern”.
Men enter relationships hoping the new one will be different; often there is an initial period of sexual functioning, then the cycle begins again.
(McCarthy & McDonald, 2008)

PREVALENCE:

  • in a study of 906 subjects, 65% presented with primary diagnosis of HSDD- subjective issue and widely varying rates of prevalence.
  • Prevalence increased with age:
    • ages 18-29: 14%
    • ages 16-59: 14-17% prevalence
    • ages 57-85: 28% prevalence
    • 50% of men over 80 still report interest in sex, but only 15% are able to functionally perform
  • Men tend to be diagnosed with HSDD at an older age than women
  • 30% of women report HSDD; 15% of men report HSDD
  • Cultural Prevalence:
    • Lowest prevalence: France, 3%
    • Highest prevalence: Australia, 25%
Screen shot 2015-02-19 at 11.11.33 AM.png

PREDICTORS:

  • Age:

    • Significantly associated with sexual dysfunction in both genders.
    • Should not only be considered as a physiological component, but also need to look at cultural and psychological context as well.
  • Hormones:

    • testosterone has a direct effect on men’s sexual desire
    • testosterone treatment to hypogonadal men does increase sexual desire, mood, and energy
    • testosterone treatments are only effective if man’s testosterone count is below a certain threshold; “extra” testosterone for a man with normal levels show no effect
    • may also be an imbalance between excitatory factors (dopamine) and inhibitory factors (serotonin)
  • Illness and Medication:

    • renal failure, cardiovascular disease, substance dependence, anxiety and depression disorders
    • medications for these problems can also interfere with sexual desire levels
    • Selective serotonin reuptake inhibitors (SSRIs) prescribed for depression and anxiety commonly lower desire
    • Men who are in subjective poor health are six times more likely to experience sexual dysfunction.
    • Diabetes Mellitus
  • Developmental and Cognitive-Affective :

    • “Psychological factors have been found to be stronger correlate of sexual desire than biomedical ones” (Binik & Hall, 2014; p. 47)
    • sexual abuse as a child, or other negative experiences in early life
    • family of origin messages about sexuality
    • societal context about male sexuality and how it should function
    • lack of erotic thoughts during sex
  • Relational:

    • “Desire is often used as currency in maladjusted relationships, making sex the battleground for any number of nonsexual conflicts” (Binik & Hall, 2014; p. 48)
    • most common in the context of a committed relationship
    • low satisfaction in sex with committed partner
    • relationship conflict: lack of communication, lack of intimacy, anger, hostility
    • Common for desire to decrease over span of committed relationship due to routineness of sex and other life stressors
    • sexual dysfunction in men predicts marital discord in 25% of relationships
    • men without a sexual partner are more likely to experience ED and lower levels of sexual desire than men in a committed relationship
  • Sociocultural:

    • masculinity is tied to sexual virility
    • easy access to pornography that consists of unrealistic sexual activity and unrealistic body images
    • narrowing view of what is considered sexually attractive
  • Other Sexual Dysfunctions:

    • High comorbidity of primary HSDD with secondary diagnosis of arousal or orgasm disorders
    • Only 13.4% of men with HSDD did not present with another sexual dysfunction
  • Psychological Issues:

    • Depression: people with depression twice as likely to report low sexual desire than people without depression
    • Anger
    • Lower levels of dominance
    • Childhood sexual trauma
    • Stress (odd ratio of 3.2)
    • Anxiety
  • Cognitive Factors:

    • sexual beliefs related to cultural values and erotic thoughts during sexual activity
    • Inaccurate beliefs about sex
    • Tendency to fuse sex and affection


iliev old doctor viagra (NXPowerLite)-M.jpg

TREATMENT:

“Although there is precious little HSDD treatment outcome data for either men or women, there is evidence that treatment approaches combining cognitive, emotion-centered, and behavioral strategies, along with relationship skills building, may be effective in helping individuals and couples with difficulties, sexual and otherwise” (Binik & Hall, 2014; p. 51)

  • Educate, Reduce Stress, Target Biomedical Influences:

    • Reestablish reasonable expectations
    • Set realistic goal treatments
    • Target cognitive distortions
    • Stress needs to be reduced if it is interfering with arousal
    • Normalize experiences
    • Lower anxiety through mindfulness techniques or CBT
    • Destigmatize the problem to the elicit the sensitive (secretive) material during the individual sexual history
    • Help client variant arousal is the powerful combination of shame, eroticisism, and secrecy resulting in a narrow, controlling pattern, which typically began in childhood or adolescence
(Binik & Hall, 2014; McCarthy & McDonald, 2008; Weeks, Hertlein, Gambescia, 2009)
  • Biomedical Treatments:

    • Testosterone Replacement Therapy for men with consistently low testosterone levels
    • For couples who qualify, testosterone treatments for the man have resulted in increased satisfaction for the female partner, as well as less pain and overall improved sexual functioning.
    • Restoring thyroid functioning
    • Switching antidepressants to ones with fewer sexual side effects
(Binik & Hall, 2014; Conaglen & Conaglen, 2009)
  • Cognitive Treatments:

    • Cognitive Refocusing: “Identifying and challenging maladaptive thoughts and restrictive sexual scripts”(Binik & Hall, 2014; p. 52)
    • Identify interlocking irrational sexual beliefs and replace them with more positive, factual cognitions
    • Address and correct unrealistic expectations
    • Help cognitively restructure sexuality and desire as an intimate, interactive process.
    • Focus on desire, pleasure, and satisfaction rather than intercourse and orgasm.
(Binik & Hall, 2014; McCarthy & McDonald, 2008; Weeks, Hertlein, Gambescia, 2009)
  • Improve General Health:

    • Increase physical exercise
    • Reduce alcohol consumptions
    • Smoking Cessation
    • Decrease alcohol intake
    • Decrease weight
(Binik & Hall, 2014; Kardag et. al, 2014)

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Dr. Brotto on the Discovery Channel's "The Science of Lust"



REFERENCES/ RECOMMENDED READINGS:

Binik, Y., Hall, K. (2014). Principles and Practices of Sex Therapy. Chpt 2,3. The Guilford Press.

Brotto, L. A. (2010). The DSM diagnostic criteria for hypoactive sexual desire disorder in men. Journal of Sexual Medicine, 7(6), 2015-2030. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-11123-008&site=ehost-live&scope=site

Conaglen, J. V., & Conaglen, H. M. (2009). ORIGINAL RESEARCH—COUPLES'SEXUAL DYSFUNCTIONS: The effects of treating male hypogonadism on couples’ sexual desire and function. The Journal of Sexual Medicine, 6(2), 456-463.

DeRogatis, L., Rosen, R. C., Goldstein, I., Werneburg, B., Kempthorne-Rawson, J., & Sand, M. (2012). Characterization of hypoactive sexual desire disorder (HSDD) in men. Journal of Sexual Medicine, 9(3), 812-820. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2012-05596-025&site=ehost-live&scope=site

Hatzimouratidis, K. (2007). Epidemiology of male sexual dysfunction. American Journal of Men's Health, 1(2), 103-125. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2013-03307-002&site=ehost-live&scope=site

Karadag, H., Oner, O., Karaoglan, A., Orsel, S., Demir, A. U., Firat, H., . . . Itil, O. (2014). Body mass index and sexual dysfunction in males and females in a population study. Klinik Psikofarmakoloji Bülteni / Bulletin of Clinical Psychopharmacology, 24(1), 76-83. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2014-26493-011&site=ehost-live&scope=site

Kleinplatz, P. J. (2011). Arousal and desire problems: Conceptual, research and clinical considerations or the more things change the more they stay the same. Sexual and Relationship Therapy, 26(1), 3-15.

Lue, T. F., Giuliano, F., Montorsi, F., Rosen, R. C., Andersson, K., Althof, S., . . . Kimoto, Y. (2004). Original research: Summary of the recommendations on sexual dysfunctions in men. The Journal of Sexual Medicine, 1(1), 6-23.

McCarthy, B., & McDonald, D. (2008). Assessment, treatment, and relapse prevention: Male hypoactive sexual desire disorder. Journal of Sex & Marital Therapy, 35(1), 58-67.
Rosen, R. C. (2000). Prevalence and risk factors of sexual dysfunction in men and women. Current Psychiatry Reports, 2(3), 189-195.

Segraves, K. B., & Segraves, R. T. (1991). Hypoactive sexual desire disorder: Prevalence and comorbidity in 906 subjects. Journal of Sex & Marital Therapy, 17(1), 55-58.

Weeks, G. R., Hertlein, K. M., & Gambescia, N. (2009). The treatment of hypoactive sexual desire disorder. Journal of Family Psychotherapy, 20(2-3), 129-149.


__
IN WORKING WITH COUPLES WITH SEXUAL DESIRE AND AROUSAL PROBLEMS


PRESENTATION: Physical problem or factors of relationship?
external image L8FgupN96W8nvwCJRZlAjix89iefsFtoyTWXkAoO-gMjzxBu8QlwsX3dCeBBWMjxl-PH9wkh-GUFD3LRPjxynaJ5tmsnbJa2OzudH445o1b458lAOkwL4mQmnHxXgO35D6SexvU
There are a number of reasons, aside from physical problems, that can lead to difficulties in desire and arousal. Following are some examples and beliefs from research studies and sexuality professionals

Research has demonstrated that relationship quality and sexual satisfaction are positively related (Sprecher & Cate, 2004; Meana found in Levine et al., 2011). Along these lines, Schnarch (1991) claims that “A couple’s sexual repertoire is more determined by the unresolved issues either spouse is avoiding than by efficacious technique”

•Meana (2010) states that when working with couples in sex therapy, most cases were:
“…emotionally moving manifestations of the human need for connection and the deep pain felt when this connection is damaged or altogether severed," (ch. 7 in Levine, Risen, & Althof,
2011)


“The type of sexual desire that is usually referred to as passion is typically highest at the start of a relationship and suffers a decrease in the lives of most couples over time” (Levine, 2003 found in Levine, Risen, & Althof, 2011).
external image Easier%20to%20eat%20him.gif


Baumeister and Bratslavsky (1999) suggest that sexual desire stems from when partners go from one level of intimacy to another, such as when partners first meet, and dissipates when intimacy becomes stable again.



In Meana and Sims (2008) study of 20 married women who reported difficulties in their sexual desire with their husbands, they found three overarching themes, including the “institutionalization” of the their marriage, the loss of their individuality as their marriage proceeded, and the effect that their everyday lives had on “desexualizing” their roles with one another.






“There is a substantial body of research which has explored the contribution of interpersonal influences to sexual functioning. These studies have focused on the role of the quality of the relationship on the sexual functioning of the partners. Snyder & Berg (1 983) found that the major causes of sexual problems in males and females related to their interactions with their partner.” (McCabe & Cobain, 1998).

In assessing women before their intervention trial, Trudel et al. (2001) found that women’s thoughts regarding sex included:
  • Men are always desiring sex
  • Sex is something that happens spontaneously
  • Couples should always maintain “normal” frequency of sex
  • Good sex ends with an orgasm
  • Negative thoughts regarding their personal self images
  • Feelings of performance anxiety
  • Preoccupied stress regarding family, finances, or work
  • Feeling that partner lacked intimacy and empathy
  • Negative feelings towards partner’s character
  • Feeling pressure by partner
  • Feeling controlled by partner
  • Feeling viewed as a sexual object to partner
  • Not feeling that she and partner are fully committed to one another
  • Lack of effective communication between partners
  • Lack of excitement in relationship and/or lifestyle
  • Fear of not overcoming sexual problems with partner
  • Experiencing negative self-talk surrounding sex life
  • Nervousness of how others perceive their sexuality
  • Lack of confidence in sexual selves

  • Trudel et al. (2001) found that from his interviews with couples, women reported feeling that their partners were always thinking and desiring sex, and lacked intimacy and empathy. They found that women in their study with HSD reported that “The most frequently reported self-directed negative thoughts among women refer to their physical appearance and self-image, the presence of performance anxiety and unrealistic expectations during sex, a lack of sexual interest, and family/financial and occupational preoccupations, (p. 151).


external image the-stage-of-sex-box.png?w=600

SEX BOX: oxytocin or performance anxiety?

Treatment for couples


Experts share that when working with couples presenting with sexual difficulties, it is important to continue to assess for any issues within the relationship dynamics that may be involved with the sexual complaint. The therapist will need to address these issues as they come up in therapy. (Meana, 2010). Meana emphasizes that not all couples will present with nonsexual problems. Some suggest that couples must actually maintain their own individualism, or as Bowen (1973) describes as differentiation, in order for partners to attain sexual intimacy (Meana in Levine et al., 2011; Schnarch 1991; Perel, 2006). Along these lines, Perel (2006) suggests that “...in cultivating security, stability, love, and commitment, a couple is at risk of losing the very ingredients that fuel their eroticism (e.g. passion, danger, the unknown).” p. 24 (found in Binik & Hall, 2014).

COUPLES THERAPY TREATMENTS INCLUDE: SEX THERAPY APPROACHES INCLUDE:

  • ¨Psychoanalytical couples therapy
  • ¨Object relations couple therapy
  • ¨Ego analytic couples therapy
  • ¨Behavioral marital therapy
  • ¨Integrative behavioral couples therapy
  • ¨Cognitive behavior marital therapy
  • ¨Emotionally focused therapy
  • ¨Structural strategic marital therapy
  • Psychoeducation
  • Cognitive behavioral therapy (CBT)
  • Mindfulness
  • Individual therapy
  • Couples therapy
  • Group therapy
  • Online (individual, couples, or group) therapy
  • Homework assignments

Several professionals emphasize the importance of meeting with both the individual as well as with the couple together to conduct a sexual history interview. During this interview it is important to ask about:
            • developmental history (both emotional and physical)
            • medical history
            • cultural background
            • family-of-originsexual history (including any traumas)
            • any issues regarding the nonsexual relationship
            • commitment between partners
            • Each partner’s perspective of the presentation
(Binik & Hall, 2014)
Studies looking at treatment approaches
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Trudel et al. (2001)
  • 74 couples in which the female had Hyposexual desire disorder
  • treatment group (n = 38) group CBT therapy
  • control group (n = 36) waiting list
  • Intervention: 12 weekly 2 hour group sex therapy sessions using CBT with 4-6 other couples

·Researchers utilized Trudel et al.’s (1996) multimodal therapeutic program
  • “The treatment program consisted of nine therapeutic techniques: analysis of immediate and long-term causal factors related to HSD, sexual information, couple sexual intimacy exercises, sensate focus, communication skills training, emotional communication skills training, mutual reinforcement training, cognitive restructuring, and sexual fantasy training.” P. 151

At the 3 month and the year follow up with couples who engaged in CBT, Trudel et al. (2001) found that 64 percent of women with a diagnosis of HSD no longer met criteria for the sexual disorder.

Hucker and McCabe (2014)

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  • Research has shown that better outcomes for female sexual difficulties occur when sex therapy works with a couple in which both partners are able to engage in treatment, rather than working solely with the individual.
  • Researchers have found that females presenting with sexual difficulties benefit from online CBT programs which focus on several practices (Jones & McCabe, 2011; Hucker & McCabe, 2014).

  • “In the context of female sexual difficulties, mindfulness exercises can help to decrease cognitive distractions and anxiety during sexual activity, while increasing present moment attention and the awareness of pleasurable sensations” (Brotto et al., 2008a; Brotto, Heiman, et al., 2008; Brotto, Seal, & Rellini, 2012; Silverstein, Brown, Roth, & Britton, 2011; Hucker & McCabe, 2014).

  • Hucker and McCabe (2014) created an online, mindfulness-based, CBT program called Pursuing Pleasure (PP) which aims to help women with sexual difficulties.
  • Through 6 modules of treatment on the program website, e-mail contact with an online therapist, online chat groups, and online surveys, the PP program addressed “change-based interventions (challenging negative automatic thoughts, behavioral exercises), and acceptance-based interventions (e.g. mindfulness, normalizing through psychoeducation)” (Hucker & McCabe, 2014, p. 566).

  • Recruited females with self-reported complaints of sexual difficulties (including desire, arousal, orgasm, and/or pain)
  • Study 1: treatment (n=26) controls (n = 31)
  • Study 2: treatment (31)

Hucker and McCabe (2014) found that compared to controls, females participating in the PP online mindfulness and CBT program demonstrated significant improvements in aspects of their relationship including sexual intimacy, emotional intimacy, and communication.

external image bernard-schoenbaum-mind-if-i-take-a-moment-to-check-with-my-sex-therapist-new-yorker-cartoon.jpg

Munns, Weber-Main, Lowe, & Raymond, (2011)

One treatment for overall sexual well-being is the Sexual Health Model which focuses on 10 areas including:
  • talking about sex
  • culture, gender, and sexual identity
  • sexual anatomy and functioning
  • sexual health care and safer sex
  • challenges and barriers to sexual health
  • body image; masturbation and fantasy
  • positive sexuality
  • intimacy and relationships
  • spirituality and religion
Professionals discuss these topics through individual, couple, and group therapy, as well as psychiatric care and sexual medicine

Munns et al. (2011) conducted a case study applying the Sexual Health Model with a woman complaining of sexual desire and arousal problems, in which the multifaceted treatment decreased her desire and arousal symptoms (Robinson, Bockting, Rosser, Miner, & Coleman, 2002; Munns et al., 2011)


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Couples Therapy in the Movies















Brotto, Basson, & Luria (2008)
In practicing sex therapy, as well as group sessions and assigning homework, researchers have delivered psychoeducation, CBT, and mindfulness in order to decrease self-reported symptoms of sexual desire and arousal problems in women

  • Pilot study
  • 26 women seeking treatment for desire and/or arousal concerns
  • Treatment: Mindfulness-based psychoeducation
  • three 90-minute sessions
  • 2 weeks apart
  • Groups of 5-7 women
  • Results: Decreased participants’ sexual desire and arousal distress, specifically for those who had experienced sexual abuse

external image medical-psychologists-psychiatry-psychiatrists-expensive-psychology-29608031_low.jpg


OTHER TREATMENT INTERVENTIONS




Bibliotherapy
  • recommends self-help and educational books to individuals or couples to address misinformation about issues surrounding erectile disorder.
  • can help individuals and their partners become better informed about the varying causes of dysfunction, including: the effects of illness and drugs, aging and gender differences in sexual response
  • Helps provide a more realistic understanding of sexuality if previous knowledge has been constructed largely through pornography Binik & Hall, 2014

Sexual Stimulation Techniques: Sexual Scripts
  • Limited sexual scripts can have poor effect on those with erectile disorder
  • Encouraging sexual scripts to include oral or manual stimulation in order to relieve intercourse performance pressure
  • Assess couple’s current sex script, and desired sex script
  • These two pictures create a platform for dialogue about creating different options that could improve the quality and diversity of the couple’s current sex script Binik & Hall, 2014

Sensate Focus
external image 8wEg5Gaza4l7YXecJ0lDygnvQSoB54A_slFdduhi70M8kSmR9413bdRU60qjBHIl05Hfjlt4hNSoGtfFZHejKS8zfGbawoQORKWwhVit6FK1qMNypyjpI7EjTz7tHcnjRNWjLdk
            • Couples are asked to interact sexually without having intercourse
    • Help individuals and couples focus on the moment: process > performance
  • Help couples discover other ways of achieving orgasm without penis-vagina intercourse
  • Therapists give the couple ideas of things to focus on: feels, smells, sounds
  • Once an increased comfort in sexual intimacy occurs, intercourse is reintroduced as an additional option for a sexual experience
Binik & Hall, 2014




IMPORTANT FACTORS TO CONSIDER
  • Emotionally Focused Therapy (EFT) suggests concentrating on emotional interactions between couples Johnson, (2012)
  • Some researchers emphasize importance of focusing on the structural problems associated with couples and working with couples to reach a balance between intimacy and distance Meana, (2010)
  • Some suggest that partners must be able to:
    • Not expect their partner to allay all of their anxieties (they can self-soothe)
    • Tolerate discomfort in the service of personal and relationship growth (it does not necessarily signal abandonment or narcissistic injury)
    • Not get swept up in each other’s reactivity Meana, (2010)

CONCLUSIONS
  • Although there are several ways in which mental health professionals have been successful in helping individuals with their desire and arousal disorders, many of these treatment strategies are similar in providing psychoeducation, exploring: relational issues, religion/spirituality, culture, family-of-origin issues, self-image, sensate focus, sexual-selves, and differentiation (Munns, Weber-Main, Lowe, & Raymond, 2011; Levine, Risen, & Althof, 2011; Schnarch 1991; Perel, 2006; Meana, 2010).
  • Many of these approaches also assign homework assignments, utilize individual, couples, and group therapy sessions, and the methods of mindfulness and CBT in order to help individuals (Brotto, Basson, and Luria, 2008; Jones & McCabe, 2011; Hucker & McCabe, 2014; Munns, et al., 2011; Levine et al., 2011).
  • It is important for clients to remember that they will need to continue to work on their sexual relationships throughout their lives. Research has shown that after two years following sex therapy, 30-60 percent of couples experience a decrease in their sexual functioning gained during therapy (Jacobson, Schmaling, & Holtzworht-Monroe, 1987; Meana, 2010).Therefore individuals will need to revisit their skills when necessary.
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REFERENCES

American Psychiatric Association, & American Psychiatric Association. (2013). Highlights of changes from DSM-IV-TR to DSM-5. Arlington, VA: American Psychiatric Association.

Baumeister, R. F., & Bratslavsky, E. (1999). Passion, intimacy, and time: Passionate love as a function of change in intimacy. Personality and social psychology review, 3(1), 49-67.

Binik, Y.M., & Hall, K.S. (Eds.) (2014). Principles and practice of sex therapy. 5th Edition, New York: Guilford Press.

Brotto, L. A., Basson, R., & Luria, M. (2008). ORIGINAL RESEARCH—PSYCHOLOGY: A Mindfulness‐Based Group Psychoeducational Intervention Targeting Sexual Arousal Disorder in Women. The journal of sexual medicine,5(7), 1646-1659.

Brotto, L. A., Basson, R., & Luria, M. (2008b). Group psychoeducational treatment. Unpublished manual. UBC Sexual Health Laboratory, Vancouver, British Columbia, Canada.

Brotto, L. A., Heiman, J. R., Goff, B., Greer, B., Lentz, G. M., Swisher, E., Tamimi, H., & Van Blaricom, A. (2008). A psychoeducational intervention for sexual dysfunction in women with gynecologic cancer. Archives of Sexual Behavior,37(2), 317-329.

Brotto, L. A., Seal, B. N., & Rellini, A. (2012). Pilot study of a brief cognitive behavioral versus mindfulness-based intervention for women with sexual distress and a history of childhood sexual abuse. Journal of Sex & MaritalTherapy, 38, 1–27.



Clayton, A. H., DeRogatis, L. R., Rosen, R. C., & Pyke, R. (2012). Intended or Unintended Consequences? The Likely Implications of Raising the Bar for Sexual Dysfunction Diagnosis in the Proposed DSM‐V Revisions: 2. For Women with Loss of Subjective Sexual Arousal. The journal of sexual medicine, 9(8), 2040-2046.


Hucker, A., & McCabe, M. P. (2014). An online, mindfulness-based, cognitive-behavioral therapy for female sexual difficulties: impact on relationship functioning. Journal of sex & marital therapy, 40(6), 561-576.

Jacobson, N. S., & Schmaling, K. B. y Holtzworth-Munroe, A.(1987). Component analysis of behavioral marital therapy: 2-year follow-up and prediction of relapse. Journal of Marital and Family Therapy, 13, 187-195.

Johnson, S. M. (2012). Practice of Emotionally Focused Couple Therapy: Creating Connection. Routledge.

Jones, L., & McCabe, M. P. (2011). The effectiveness of an Internet-based psychological treatment program for female sexual dysfunction. Journal of Sexual Medicine. 8, 2781–2792.

Leiblum, S.R.(2005). Editorial: Pharmacotherapy for women:Will we, won’t we, should we? Sexual and Relationship Therapy, 20(4), 375-376.

Levine, S. B., Risen, C. B., & Althof, S. E. (Eds.). (2011). Handbook of clinical sexuality for mental health professionals. Routledge.

McCabe, M. P., & Cobain, M. J. (1998). The impact of individual and relationship factors on sexual dysfunction among males and females. Sexual and Marital Therapy, 13(2), 131-143.

Meana, M. A. R. T. A. (2010). When love and sex go wrong: Helping couples in distress. Handbook of clinical sexuality for mental health professionals, 103-120.

Munns, R. A., Weber-Main, A. M., Lowe, M. A., & Raymond, N. C. (2011). Application of the sexual health model in the long-term treatment of hypoactive sexual desire and female orgasmic disorder. Archives of sexual behavior,40(2), 469-478.

Perel, E. (2006). Mating in captivity. Harper Audio.

Robinson, B. E., Bockting, W. O., Rosser, B. R. S., Miner, M., & Coleman, E. (2002). The Sexual Health Model: Application of a sexological approach to HIV prevention. Health Education Research, 17, 43–57.

Schnarch, D. M. (1991). Constructing the sexual crucible: An integration of sexual and marital therapy. WW Norton & Company.

Silverstein, R. G., Brown, A. C. H., Roth, H. D., & Britton, W. B. (2011). Effects of mindfulness training on body awareness to sexual stimuli: Implications for female sexual dysfunction. Psychosomatic Medicine, 73, 817–825.

Trudel, G., Marchand, A., Ravart, M., Aubin, S., Turgeon, L., & Fortier, P. (2001). The effect of a cognitive-behavioral group treatment program on hypoactive sexual desire in women. Sexual and Relationship Therapy, 16(2), 145-164.