1. Couple Therapy and the Treatment of
Sexual Dysfunction
2011

2. Background
• Masters and Johnsons were founders of modern couple
sex therapy
• One of the most enduring and important aspects of their
work has been the four stage model of sexual response,
which they described as the human sexual response
cycle.
• They defined the four stages of this cycle as:
1. Excitement phase (initial arousal)
2. Plateau phase (at full arousal, but not yet at orgasm)
3. Orgasm
4. Resolution phase (after orgasm)

3. Masters and Johnson
Human Sex Response Cycle

4. DSM-IV-TR
Sexual Disorders
1- Sexual Desire Disorders
• – Hypoactive Sexual Desire (HSDD)
• – Sexual Aversion
2- Disorders of Sexual Arousal
• – Female Sexual Arousal Disorder
• – Male Erectile Disorder
3- Disorders of Orgasm
• – Female Orgasmic Disorder
• – Male Orgasmic Disorder
• – Premature Ejaculation
4- Sexual Pain Disorders
• – Dyspareunia
• – Vaginismus

5. What is the term “Sexual function”?
It is the ability to experience
• “desire" positive anticipation and feel deserving of sexual
pleasure,
• “arousal” receptivity and responsively to erotic touch,
resulting in subjective arousal and lubrication for woman
and erection for man,
• “orgasm" a voluntary response that is a natural culmination
of high arousal and
• “satisfaction” feeling emotionally and sexually fulfilled
and bonded

6. What is “sexual dysfunction”?
• Sexual dysfunction is broadly defined as the
inability to fully enjoy sexual intercourse
• sexual dysfunctions are disorders that
interfere with a full sexual response cycle
• These disorders make it difficult for a
person to enjoy or to have sexual
intercourse

7. Female Sexual Dysfunction
Hypoactive Sexual Desire Disorder (HSDD)
• characterized as a lack/absence or low levels of sexual
fantasies* and desire for sexual activity for some period of
time though aroused and orgasmic once.
• Primary desire problems can be caused by anti-sexual
family learning, poor body mage, lack of experiences with
self exploration/masturbation, childhood sexual trauma,
fear of pregnancy, HIV, fear of sexual humiliation,
conservative religious backgrounds,…etc
• Secondary HSDD causes are disappointment, anger with
partner and negative sexual experience (i.e. rape)
*Not fantasizing is not considered a hypoactive desire disorder!

8. Orgasmic Dysfunction
• Orgasmic disorder is lack of or delay in sexual climax (orgasm) even
though sexual stimulation is sufficient and the woman is sexually
aroused.
• Usually men are more upset about this than woman. He wants her to
function the way he function( having orgasm during intercourse
without additional stimulation).
• This has been traditionally considered the “right” way to be orgasmic.
• In fact, many women who are regularly orgasmic with couple sex are
not orgasmic during intercourse.
• This is not dysfunction but a normal variation in female sexual
response. Female sexual response is more variable and complex than
male sexual response.
• In truth, many women who are sexual orgasm during intercourse often
use multiple stimulation.
• A woman may be non orgasmic, single orgasmic or multiple orgasmic.

9. Female arousal Dysfunction
• Absence of or markedly diminished feelings of sexual
arousal, (sexual excitement and sexual pleasure), from any
type of sexual stimulation
• Genital Sexual Arousal Disorder: Complaints of absent or
impaired genital sexual arousal. Self-report may include
minimal vulval swelling or vaginal lubrication from any
type of sexual stimulation and reduced sexual sensations
from caressing genitalia
• The objective (physiological) measure of arousal are ease
and amount of vaginal lubrication. The subjective measure
is feeling “turned on”.*
* Combined Sexual Arousal Disorder: Absence of or markedly diminished
feelings of sexual arousal (sexual excitement and sexual pleasure),
from any type of sexual stimulation as well as complaints of absent or
impaired genital sexual arousal (vulval swelling, lubrication).

10. EROS CTD
Female Vacuum Therapy
• FDA approved to treat FSD
(vasculogenic)
• Requires prescription
• Creates gentle suction over
the clitoris to cause
engorgement
• Improves vaginal blood flow
and lubrication
• Urometrics

11. Painful Intercourse
• Dyspareunia: Persistent or recurrent pain with attempted
or complete vaginal entry and/or penile vaginal
intercourse. Most common cause of dyspareunia:Vulvar
Vestibulitis Syndrome (VVS)
• Vaginismus: Persistent or recurrent difficulties to allow
vaginal entry of a penis, finger, and/or any object, despite
the woman’s expressed wish to do so. Often phobic
avoidance and anticipation of pain.
• The problem of painful intercourse is paradoxical! Where
as some cases are easy to resolve, others need the
coordinated efforts of a gynecologist, sex therapists, and a
female physical therapist( to direct teach the control over
pelvic floor musculature).

12. Male Sexual Dysfunction
Premature Ejaculation:
• Persistent or recurrent ejaculation with minimal sexual
stimulation before, on, or shortly after penetration and
before the person wishes it.
• The clinician must take into account factors that affect
duration of the excitement phase, such as age, novelty of
the sexual partner or situation, and recent frequency of
sexual activity.
• Also known as Rapid Ejaculation
• Most prevalent sexual dysfunction in men

13. Erectile Dysfunction
• Persistent or recurrent inability to attain, or to
maintain until the completion of sexual activity, an
adequate erection.
• With introduction of Viagra 1998, there has been a
paradigm shift in ED. “the friendly-user”
intervention. It is much easier to take a pill than
use other interventions such as surgeon, external
pump, penile injections,…etc. However, Viagra
has resulted in the medicalization of male
sexuality.
• Unfortunately, many men who face ED avoid any
affectionate or sexual contact, in fear to face “the
embarrassment of erectile failure”.

15. Hypoactive Sexual Desire Disorder in men
• For majority of men, HSDD is a secondary dysfunction. It affects 15%
of men and increases by age.
• Primary HSDD is rare (less than 10%), because of the culture link
between masculinity and sexuality and adolescence experience with
masturbation.
• Male HSDD secondary usually is linked to a dysfunction and primary
usually caused by a sexual secret (affair, history of sexual trauma, guilt
or shame of sexuality or afraid of sexual failure).
• Usually men with HSDD who attend couple therapy usually are forced
by their partners. Their goal is to avoid self disclosure and therapy.
They want to keep their sexual life secret away from partner and
therapist.
• HSDD does not necessary make couple therapy the treatment of
choice. Severe relationship problems (partner abuse, lack of respect,
..etc) and severe individual problems (bipolar, alcoholism, panic
disorder, …etc) can sabotage sex therapy.

16. Ejaculatory Inhibition
• EI is the least common sexual dysfunction.
• Usually the man can ejaculate with
masturbation and some man can ejaculate
with manual or oral stimulation but not
during intercourse (or only rarely).

17. Thank You
Shoukran