Sexual dysfunctions involve difficulties in one or more of the following phases:
Desire: Thinking about sex, fantasies about sex, or desire to have sex.
Excitement: The phase of arousal, where the person feels pleasure and has corresponding physical changes in the body.
Orgasm: The peaking of pleasure.
Resolution: Post-sex there is a feeling of muscular relaxation and euphoria, to varying degrees.
A variety of sexual problems can develop, which include but are not limited to the following:
- Delayed or premature ejaculation
- Premature ejaculation: While perceptions of the average length of time before a man reaches orgasm varies widely (e.g. 7-14 minutes), ‘sooner than preferred’ is often considered to be 1-5 minutes after penetration.
- Delayed ejaculation: when the individual is unable to orgasm during a period where they usually would have been able to.
- Erectile Disorder
- Difficulty obtaining and maintaining an erection, and/or having an erection with decreased firmness. This relates to both intercourse and other sexual acts (e.g. oral sex).
- Orgasmic Disorder
- Being unable to orgasm, having great difficulty reaching orgasm, or very low intensity orgasms. This difficulty must be recurrent and persistent (i.e., isolated times of being unable to orgasm don’t imply a disorder).
- Sexual Interest / Arousal Disorder (and Hypoactive Sexual Desire Disorder)
- In both men and women, diminished or absent arousal or desire for sex. This includes reduced or no initiation of sexual activity and being unreceptive to a partner’s attempts to initiate sex. This said, numerous issues need to be considered and thoroughly assessed before identifying any of these issues as reflective of ‘disorder’.
- In couples, a “desire discrepancy” can be present, where one partner’s sex drive (or interest) is significantly higher than their partner’s – this does not necessarily indicate a ‘disorder’.
- Genito-pelvic pain / penetration disorder (formerly called ‘Pain Disorders’)
- For males, dyspareunia (painful intercourse)
- For females, vaginismus (an involuntary spasm of the muscles of the vaginal wall that interferes with intercourse).
- For these individuals there is persistent genital pain before, during or after sex (which isn’t solely because of a lack of lubrication or hardness).
Impact of Sexual Dysfunction
Sexual dysfunction can have a profound impact on an individual’s sense of self, their sex life and their relationships. There are many physical, personal and relationship factors that can contribute to sexual disorders. For example, emotions such as anxiety, guilt, stress, and worry, often play a large role in sexual problems, and assessing the presence and role of these is central to therapy.
In the context of relationships, not having sex (or reduced quality of sex) can significantly impact a partnership. Resulting low desire, poor body image and reduced self-esteem can feed back to further reduce sex drive (including reinforcement of unhelpful attitudes towards sex or avoidant behaviours). These in turn can augment low self-esteem and thus the cycle continues.
Although some sexual difficulties are premised with “male” or “female” (e.g. “female sexual arousal disorder”), they are essentially couple problems. Where the sufferer believes they are the ones with “the problem”, they can often blame themselves, believing they are “less desirable.” These beliefs, in turn can negatively impact on a couple’s relationship.
Related Psychological Difficulties
Sexual dysfunction is especially common among people who have anxiety and/or depression. While it is normal to experience some level of ‘performance anxiety’ before sex, clinical levels of anxiety (e.g. those found in Panic Disorder) can be related to the person avoiding sex. Unrealistic expectations and norms regarding the “appropriate” level of sexual interest or arousal, along with poor sexual techniques and lack of information about sexuality, may also be evident in those with sexual difficulties. These can reinforce feelings of anxiety about sex.
Factors Central to Treatment
No matter what difficulties are brought to therapy, the following factors are central to exploring the nature of sexual difficulties:
- Partner factors (e.g., partner’s sexual problems, partner’s health)
- Relationship factors (e.g., poor communication, discrepancies in desire for sexual activity, anger/resentment)
- Individual factors (e.g., poor body image, history of sexual or emotional abuse, other mental health issues (e.g., depression, anxiety), or stressors (e.g., job loss, bereavement))
- Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity; attitudes toward sexuality), and
- Medical factors (e.g., medications or chronic diseases that affect the sexual response)
Cognitive Behavioural Therapy is internationally recognised as effective treatment for sexual difficulties. This therapy involves the following techniques:
1. Cognitive therapy
Therapists begin by helping clients identify negative attitudes or thoughts about sex, explore the origins of those ideas and find new, helpful ways of thinking about sex.
2. Behavioural Strategies
The focus then shifts to changing behaviour. For example, relaxation strategies can be used to reduce anxiety about performance, and can also be effective in reducing pain during intercourse.
Therapy can also include behavioural training. For example, one effective technique in the treatment of premature ejaculation (PE) is to help men to understand the physical sensations of increasing sexual excitement. There are various “phases” or “zones” that men go through during sexual activity, but men with PE often feel out of control and as if their sexual excitement goes from 0 to 100 instantly. A man with PE with his partner’s help can also be exposed to stimulation for increasingly longer periods of time. This is often called systematic desensitisation.
Gradual (or graded) exposure to ideas and behaviours that were initially anxiety-provoking is also central to treatment. This can involve the client learning about their body and its responses to different stimulations, for example in viewing erotic images or masturbating.
Finally, modification of sexual activity can be problem-solved collaboratively with your therapist. For those who have pain on deep penetration because of pelvic injury or disease, changes in technique or positions that control the degree of penetration can be helpful.
(e.g. Acceptance and Commitment Therapy (ACT) or Mindfulness-based Cognitive Behaviour Therapy (MCBT)
People with sexual dysfunction tend to excessively focus their attention on the consequences of not being able to perform (or some other issue not directly related to erotic cues). Where there is significant anxiety, an individual can feel trapped within a cycle of negative thoughts.
Mindfulness-based strategies help an individual separate themselves from their thoughts and become more present in their experiences. These strategies include the following:
- Defusion: distancing from, and letting go of, unhelpful thoughts, beliefs and memories
- Acceptance: making room for painful feelings, urges and sensations, and allowing them to come and go without a struggle
- Contact with the present moment: engaging fully with your here-and-now experience, with an attitude of openness and curiosity
Values-directed and committed living (another component within ACT) can also help an individual or couple identify the central aspects of their relationship that are important to them and focus on ways in which they can behaviourally live these values out, despite the presence of uncomfortable thoughts and feelings..
In understanding the multidimensionality of the problems, other therapies may be useful in treating sexual difficulties. This may involve other modalities for safely exploring a person’s past history (where trauma has been experienced) and its impact on current difficulties and therapy directed towards recovery.
Importantly, sexual difficulties are very much about a relationship. Therapy that addresses the relationship is important and can be done parallel to the sex-specific therapy.
If you would like to find out more about our treatment for sexual difficulties, or to book an appointment with one of our clinical psychologists who provide treatment for these conditions, please email or call the clinic on 0405 430 530.