WALID SARHAN A Brief History Psychoanalytic approach sexual problems were linked to unresolved unconscious conflicts during specific developmental periods Rise of behavioral techniques involving systematic desensitization pairing relaxation amp exposure methods ID: 724558
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Slide1
Female sexual dysfunctions
WALID SARHANSlide2
A Brief History
Psychoanalytic approach -sexual problems were linked to unresolved, unconscious conflicts during specific developmental periods
Rise of behavioral techniques involving systematic desensitization pairing relaxation & exposure methods
1900-1950
1950-1970
Masters & Johnson initiated a more biopsychosocial model consisting of physical examinations, history of dysfunction, education, behavioral & cognitive tasks, interpersonal issues; proposed brief, problem focused solutions
1970 - 1974Slide3
A Brief History continued
1974-1980
1980 - current
Neo-Masters & Johnson Era
Helen Singer Kaplan’s The New Sex Therapy integrating M&J approach with psychodynamic methods
Mid-1980’s dawned the medicalization era; including combined CBT & pharmaceutical treatments; but has not had as significant an impact on female sexual dysfunctionSlide4
Healthy Sexuality
Lack of
training
Time
Personal
issues
Women’s sexuality is complex
It is less studied, understood than male sexuality
Many theories, beliefs about female sexuality are inaccurate or outdated
Clinicians may find
topic difficult to address
Berman
Fertil Steril
2003
Kingsberg
Sexuality, Reproduction & Menopause
2004Slide5
Phases of the Sexual Response
As a function of “normal” sexual responding
:
Desire
: Defined by an interest in being sexual and in having sexual relations by oneself or with an appropriate partner
Arousal
: Refers to the physiological, cognitive & affective changes that serve to prepare an individual for sexual activity (vaginal lubrication, expansion & swelling of vulva)Orgasm: Refers to climatic phase with release of sexual tension and rhythmic contraction of the perineal muscles and reproductive organs:
Contractions in the outer third of the vaginaResolution: Refers to sense of muscular relaxation and general well-being; men are physiologically refractor while women may respond to further stimulation (APA, 2000)Slide6
Excitement
Linear Model of Female Sexual Response
Plateau
Orgasm
Resolution
Resolution
Resolution
A B C
(C)
(A)
(B)
Masters and Johnson
Human Sexual Response
1966
Kaplan
Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy
1979Slide7
Circular Model of
Female Sexual Response
Emotional Intimacy
Sexual Stimuli
Sexual Arousal
Spontaneous
Sexual Drive
Emotional and
Physical Satisfaction
Arousal and
Sexual Desire
Psychological
Seeking Out
and Being Receptive to
Biologic
Basson
Obstet Gynecol
2001Slide8
Variables Affecting Female Sexual Response: Physiologic & Psychosocial
Basson
Menopause
2004
Past sexual
experiences
or
sexual abuse
Sexual self-image
and/or
body image
Relationship with
sexual partner
(male or female)Slide9
W SARHAN
Female Sexual Response Cycle
Masters and Johnson characterized cycle with four phases:
Excitement
Plateau
Orgasmic
ResolutionKaplan proposed idea of “desire” and a three-phase model.DesireArousal
OrgasmSlide10
Female Sexual
Response
Physiological indicators of arousal
Vasocongestion in the pelvis
Vaginal lubrication
Labia minora may darken
Clitoris hardens leading the vaginal hood (prepuce of clit) to appear enlargedCausing the vulva to lengthen and widen Areola hardens & nipples become erectBreast tumescenceSlide11
Female Sexual Response
Experts on female anatomy contend that there is an area in the outer third of the vagina, also responsible for orgasm, the Grafenberg or the G-spot
Located in the front of the body, 2” from entrance of the vagina
Clitoral vs. vaginal orgasm??Slide12
Female sexual disorders include:
Sexual desire disorders:
Hypoactive sexual desire disorderSexual aversion disorderSexual arousal disorder
Orgasmic disorder
Sexual pain disorders:
Dyspareunia
VaginismusSlide13
W SARHAN
Sexual Desire Disorders:
Hypoactive sexual desire disorder
Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context of the person's life.
The disturbance causes marked distress or interpersonal difficulty.
The sexual dysfunction is not better accounted for by another
disorder It is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Slide14
W SARHAN
Sexual Desire Disorders:
Sexual aversion disorder
Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.
The disturbance causes marked distress or interpersonal difficulty. Slide15
W SARHAN
Sexual Arousal Disorder
Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement.
The disturbance causes marked distress or interpersonal difficulty.
The sexual dysfunction is not better accounted for by another
disorder
It is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Slide16
W SARHAN
Orgasmic Disorder
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm.
The disturbance causes marked distress or interpersonal difficulty.
The orgasmic dysfunction is not better accounted for by
disorder
It is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Slide17
W SARHAN
Sexual Pain Disorders:
Dyspareunia
Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female.
The disturbance causes marked distress or interpersonal difficulty.
The disturbance is not caused exclusively by Vaginismus or lack of lubrication,
It is not better accounted for by another disorder it is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Slide18
W SARHAN
Sexual Pain Disorders:
Vaginimus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse.
The disturbance causes marked distress or interpersonal difficulty.
The disturbance is not better accounted for by another
disorder It is not due exclusively to the direct physiological effects of a general medical condition.Slide19
W SARHAN
Populations who may experience female sexual dysfunction (FSD):
Abused
Perimenopausal
Pregnancy
Multiple sclerosis
Childhood sex abuseChemotherapyGenital mutationPost menopausalLack of sensitivity
Gynecological cancerRadiationBatteredNuerogenic diseaseSexual traumaSpinal cord injuryVascualr diseasePost-hysterectomyPost-partumSlide20
W SARHAN
Etiology
“The etiologies of female sexual dysfunction affect a variety of populations and may be caused by psychological, emotional, or physiological reasons. Often, the etiology is multifactorial And interrelated.”Slide21
Psychological Causes
As with most disorders, female sexual dysfunction can be caused and aggravated by psychological causes.Slide22
W SARHAN
There are five main Psychological Causes to FSD.
Sexual or Emotional Abuse
Depression
Relationship Issues
Stress
Self Esteem Cultural factors in the Arabic society Slide23
Depression
Depression is a prevalent cause of sexual dysfunction in both men and women.
Most women, when grieving, experience a loss of sexual desire.Depression can be a double edged sword for some, due to the increase of sexual dysfunction caused by anti-depressants.Slide24
W SARHAN
Relationship
A healthy relationship is based on trust, intimacy, and communication.
sexual
dysfunction is highly associated with negative experiences in sexual relationships and overall well-being. Slide25
Relationship (cont.)
Other factors that can affect the sexual health of a relationship are conflicts about cultural, social or religious beliefs
.
These can invoke feelings of guilt during sexual activity and affect the ability of a women to be aroused, obtain an orgasm, or have any desire to have sex.Slide26
Female Orgasmic DisorderDelay, infrequency or absence of orgasm or reduced intensity of orgasm sensations lasting more than 6 months
Wide estimates of prevalence: 10%-42%
10% of women do not report experience of orgasmLifelong vs. acquired; generalized v. situational, also never; mild, moderate or severe
Diagnostic and Statistical Manual of Mental Disorders DSM-5 2013Slide27
Female Sexual Interest/Arousal DisorderAbsent/reduced interest/arousal related to sexual activities, thoughts, encounters, cues, etc.
Becomes persistent problem for relationships
Lifelong vs. acquired; generalized v. situational; mild, moderate or severe
Diagnostic and Statistical Manual of Mental Disorders DSM-5 2013Slide28
Genito
-Pelvic Pain/Penetration DisorderDifficulties with
1vaginal penetration during intercourse, 2 pain during intercourse,
3
fear or anxiety about pain or penetration, or contraction of pelvic floor muscles during sex
lasting more than 6 months
15% of women report some pain during intercourseLifelong vs. acquired; mild, moderate or severe
Diagnostic and Statistical Manual of Mental Disorders DSM-5 2013Slide29
How common is sexual dysfunction?
Laumann
, Paik,& Rosen
1999 estimate
about
43% of women
and about 31% of men
have experienced
sexual
dysfunction
based on a
national survey of Americans
.
This makes sexual dysfunction the most common psychological problem in US.Slide30
How Common is Inadequate Lubrication?
Approximately
40% of females in the United States have reported inadequate lubrication during sexual activity, making it the second most common sexual difficulty reported by females after low arousal.
Inadequate
lubrication is a physiological sign that a female is insufficiently sexually aroused. Sexual arousal is both a psychological and physiological
response.
Without proper vaginal lubrication, intercourse can be painful and can result in bodily injuries, such as chaffing or tearing of the vaginal mucosa (inner vaginal wall)Slide31
Female Sexual Disorders: Prevalence
Bancroft
Arch Sex Behav
2003
Geiss
Urology
2003
Laumann
JAMA
1999
Nazareth
BMJ
2003
Interest
Lubrication/Arousal
Orgasm
Total
Laumann
31.6%
20.6%
25.7%
43%
Bancroft
7.2%
31.2%
9.3%
45%
Geiss
28.8%
23.0%
17.8%
48%
Nazareth
16.8%
3.6%
18.9%
39.6%Slide32
National Health and Social Life
Survey (NHSLS)
In-person surveysexually active
18-59 years
Asked if problems in any one of seven areas of sexual function
Laumann
JAMA
1999
0
10
20
30
40
50
60
70
80
90
100
Women
Men
43%
31%
% of respondents Slide33
Distress About Sex:
Kinsey 2000 Survey
Telephone survey987 white and black
♀
20
–65 years oldBest predictors of distress: General emotional well-beingEmotional relationship with partner during sexual activity
Bancroft
Arch Sex Behav
2003
Women reporting marked distress
0
10
20
30
40
50
60
70
80
90
100
% of respondents
24.4%Slide34
Patients, physicians, and asking about sex
25% of primary care physicians take a sex history
(Jonassen, et al 2002)75% patients believe that their physicians would dismiss their sexual health concerns or embarrass the physician (Marwick 1999)
Over 90% of patients believe it is physician’s role to address sexual health concerns and are grateful when this happens
(Ende, et al 1984)Slide35
Reluctance to seek help
Studies show that over 50 % of individuals with sexual problems do not ask for help from health care provider
Studies indicate that of those seeking help (from any health care provider), less than 50% found the assistance helpfulSlide36
Patient Perceptions
Although 85% of adults want to discuss sexual functioning with their physicians…
71% believe their physicians doesn’t have the time
68% don’t want to embarrass their physician
76% thought no treatment was available for their problems
They also report…
Non-empathic and/or judgmental responses
Physician discomfort
Concern about privacy and/or confidentiality
Lack of cultural sensitivity
Marwick C. JAMA 1993; 281:2 173-4
Maurice WI, Bowman MA, Sexual Medicine in Primary Care 1999:1-41Slide37
Treatment Approaches
Sex Therapy (CBT + Master’s & Johnson)
Pharmacotherapy & Medical DevicesA Systemic ApproachBibliotherapySlide38
Bibliography
Basson, R., Berman, J., Burnett, A., Derogatis, L., Ferguson, D., Fourcroy, J., Goldstein, I., Graziottin, A., Heiman, J., Laan, E., Leiblum, S., Padma-Nathan, H., Rosen, R., Segraves, K., Segraves, R. T., Shabsigh, R., Sipski, M., Wagner, G., & Whipple, B. (2001). Report of the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and classifications.
Journal of Sex & Marital Therapy
,
27
, 83-94.
Berman, J.R., Berman, L., and Goldstein, I. (1999). Female Sexual Dysfunction: incidence, Pathophysiology, evaluation, and treatment options.Urology, 45, 385-391.Brassil, D.F, Keller, M. (2002). Female Sexual Dysfunction: Definitions, Causes, and Treatment. Urologic Nursing, 22, 237-242.Laumann, E.O, Paik, A., Rosen, R.C. (1999). Sexual Dysfunction in the United States.
Journal of the American Medical Association, 281, 537-544.Sarwer, D.B, Durlak, J.A. (1996). Childhood Sexual Abuse as a Predictor of Female Sexual Dysfunction: A Study of Couples Seeking Sex Therapy. Child Abuse & Neglect, 20, 963-972.Segraves, R.T. (2002). Female Sexual Disorders: Psychiatric Aspects. Canadian Journal of Psychiatry, 419-426. Retrieved April 6, 2004 from Ebsco host.Tiefer, L., Hall, M., & Travis, C. (2002). Beyond dysfunction: A new view of women’s sexual problems. Journal of Sex & Marital Therapy
, 28, 225-232.http://www.behavenet.com/ (2004). Behavenet Clinical Capsule: DSM-IV-TR (Text Revision). Reprinted with permission from the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). Slide39
Thank you
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