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397
Specic Sexual Difculties
What is the most common problem that brings people to sex
therapists?
What are the symptoms of sexual aversion?
What is the denition of male erectile disorder?
What percentage of women has never experienced orgasm?
How common is the problem of premature ejaculation?
What conditions can cause painful intercourse in men and in
women?
Origins of Sexual Difculties
What kinds of medical problems and medications can interfere with
sexual function?
What relationship factors can create sexual problems?
Basics of Sexual Enhancement and Sex Therapy
How can individuals increase their sexual self-awareness?
What are the guidelines for sensate focus?
What are the steps for a woman who wants to learn to experience
orgasm?
What is the process for resolving vaginismus?
How can a man learn to prolong his arousal before ejaculating?
What is the typical course of therapy for a man having difculty
with erections?
What medications are available for women with hypoactive sexual
desire disorder?
How might someone select a sex therapist?
397
BananaStock/Jupiterimages
14
Sexual Difculties
and Solutions
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
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398 CHAPTER 14
I wish my first time had been better. I would have had sex with someone I at
least liked, instead of just with someone who would do it with me. We were
both pretty drunk, but not drunk enough to forget how fast I came. Word got
around about it, and I avoided sex for a long time. My first girlfriend after that
was cool about it, and after a while I could relax and last longer. (Authors’ files)
Sexual health, a state of physical, emotional, mental, and sexual well-being related to
sexuality, goes beyond identifying and treating sexual problems (Sadovsky & Nus-
baum, 2006, p. 3). This definition of sexual health by the World Health Organization
is what guides us in this chapter’s discussion about a number of relatively common
sexual problems, the factors that frequently contribute to them, and self-help and sex
therapy approaches to help resolve sexual difficulties.
As you read this chapter, it is important to remember that sexual satisfaction is a
subjective perception (McClelland, 2010). A person or couple could experience a spe-
cic sexual problem and yet be satised with their sex lives, or they could experience no
problem in physical sexual functioning and be very dissatised with their sexual expe-
riences (Balon, 2008; Basson et al., 2003).
Figure 14.1 shows how men and women
around the world rate the pleasure of sexual interaction.
Research indicates that sexual problems as typically identied by medical, clinical,
and research literature are quite common. For example, in the National Health and
Social Life Survey (NHSLS), 43% of women stated that they experienced some type of
sexual dysfunction, according to the study’s criterion of having experienced the sexual
problem for 3 or more of the last 12 months. e prevalence of sexual problems in the
NHSLS sample is shown in
Table 14.1.
Critical Thinking Question
The NHSLS used the criterion of an individual
having experienced the sexual problem
for 3 or more of the last 12 months. Do you
think this period is long enough to identify
someone as having a sexual problem? Under
what life circumstances might 3 months of
lack of sexual desire and/or response be
“normal” instead of appropriately dened as
a sexual problem?
Men Women
12
%1
7%
53%
45%
35%
37%
Extremely or very Moderately Slightly or not at all
How physically pleasurable is your relationship?
Figure 14.1 Men and women worldwide were asked, “How physically pleasurable is your relation-
ship?”
The Pfizer Global Study of Sexual Attitudes and Behaviors, the first worldwide study of its kind,
surveyed more than 26,000 men and women in 29 countries around the globe.
SOURCE: From Global Study of Sexual Attitudes and Behaviors funded by Pfizer Inc. Copyright 2002 Pfizer Inc.
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Sexual Difculties and Solutions399 399
However, individuals who have what researchers or clinicians consider sexual prob-
lems may not feel distressed and sexually dissatised. A subsequent random phone
survey (less rigorous than the NHSLS) by the Kinsey Institute also asked women sub-
jects whether they considered their lack of interest, arousal, or orgasm to be a problem.
Slightly over 24% of the subjects reported distress about their sexual dysfunction (Ban-
croft et al., 2003). A more current study found that of women who had sexual prob-
lems, 36.5% reported feeling distress about their sexual functioning. In the same study,
16.5% of women without sexual problems reported feeling distress (Burri et al., 2011).
For readers currently in a sexual relationship, the self-assessment inventory in the Your
Sexual Health box on page 401 will give you an indication of your level of satisfaction.
Studies have found that women were most likely to report distress about sex in the
context of other factors. For example, they were more likely to report distress about sex
when also reporting poor personal emotional well-being, feelings of general anxiety, or
a negative emotional relationship with their partners (Bancroft et al., 2003; Burri et al.,
2011). Research does indicate that sexual problems can be associated with overall well-
being. People with sexual problems report lower satisfaction with overall life than do
those without sexual diculties (Hellstrom et al., 2006; Mallis et al., 2006).
To be accurately considered a sexual disorder, the problem happens in spite of the
person having adequate physical and psychological sexual stimulation. For example, in one
study, “too little foreplay” was reported by 42% of women who reported sexual distress and
problems (Witting, Santtila, & Varjonen, 2008). On the other side of the coin, research has
found a correlation between greater physical stimulation and increased sexual response:
Women who routinely experience orgasm engage in a relatively greater repertoire of sexual
techniques than do women who do not reliably experience orgasm (Fugl-Meyer et al.,
2006). Further, with a longer duration of stimulation prior to orgasm, womens orgasms
tend to be more intense than after shorter lengths of time of stimulation (Laan, 2009).
Adequate psychological stimulation is also essential. For example, a man who ejacu-
lates quickly after his partner demands, Hurry up and get it over with!” is not receiving
adequate physical and psychological stimulation and cannot be considered to have a
problem with premature ejaculation from that situation alone. In another example, a
diagnosis of lack of sexual desire would be inappropriate for a woman whose partner
continually pressures her to be sexual in ways that he likes but that she does not enjoy
or nd arousing.
I wish my first time had been better. I would have had sex with someone I at
least liked, instead of just with someone who would do it with me. We were
both pretty drunk, but not drunk enough to forget how fast I came. Word got
around about it, and I avoided sex for a long time. My first girlfriend after that
was cool about it, and after a while I could relax and last longer. (Authors’ files)
Sexual health, a state of physical, emotional, mental, and sexual well-being related to
sexuality, goes beyond identifying and treating sexual problems (Sadovsky & Nus-
baum, 2006, p. 3). This definition of sexual health by the World Health Organization
is what guides us in this chapter’s discussion about a number of relatively common
sexual problems, the factors that frequently contribute to them, and self-help and sex
therapy approaches to help resolve sexual difficulties.
As you read this chapter, it is important to remember that sexual satisfaction is a
subjective perception (McClelland, 2010). A person or couple could experience a spe-
cic sexual problem and yet be satised with their sex lives, or they could experience no
problem in physical sexual functioning and be very dissatised with their sexual expe-
riences (Balon, 2008; Basson et al., 2003).
Figure 14.1 shows how men and women
around the world rate the pleasure of sexual interaction.
Research indicates that sexual problems as typically identied by medical, clinical,
and research literature are quite common. For example, in the National Health and
Social Life Survey (NHSLS), 43% of women stated that they experienced some type of
sexual dysfunction, according to the study’s criterion of having experienced the sexual
problem for 3 or more of the last 12 months. e prevalence of sexual problems in the
NHSLS sample is shown in
Table 14.1.
Critical Thinking Question
The NHSLS used the criterion of an individual
having experienced the sexual problem
for 3 or more of the last 12 months. Do you
think this period is long enough to identify
someone as having a sexual problem? Under
what life circumstances might 3 months of
lack of sexual desire and/or response be
“normal” instead of appropriately dened as
a sexual problem?
TABLE 14.1 Prevalence of Sexual Problems by Selected Demographic Characteristics
Lack Interest
in Sex
Cannot Achieve
Orgasm
Erectile
Dysfunction
Pain During
Sex
Climax Too
Early
Women (%) Men (%) Women (%) Men (%) Men (%) Women (%) Men (%)
Age
a
18–29 32 14 26 7 7 21
30–39 32 13 28 7 9 15
40–49 30 15 22 9 11 13
50–59 27 17 23 9 18 8
Education
Less than high school 42 19 34 11 13 18 38
High-school graduate 33 12 29 7 9 17 35
College graduate 24 14 18 7 10 10 27
a
Sexual problems are most common among younger women and older men.
SOURCE: Laumann et al. (1999).
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
400 CHAPTER 14
Specic Sexual Difculties
In this section, we consider some of the specific problems that people encounter with
desire, excitement, orgasm, and pain during intercourse. In reality, the line between nor-
mal” and a disorder” is not clearly defined in clinical practice (Althof et al., 2005). For
example, how many times would a man need to have difficulty with his erections to have
erectile disorder? In what context would not being able to become erect be normal instead
of an indication of a problem? In addition, there is often considerable overlap: Problems
with desire and arousal also affect orgasm, and orgasm difficulties can easily affect a per-
sons interest and ability to become aroused. For example, about 44% of men who have
problems with experiencing erections also frequently ejaculate rapidly (Fisher et al., 2006).
e sexual problems that we will discuss also vary in duration and focus from one
person to another. A specic diculty can occur throughout life (lifelong sexual disorder)
or be acquired at a specic time (acquired sexual disorder). A person can experience the
problem in all situations with all partners (generalized type) or only in specic situations
or with specic partners (situational type) (American Psychiatric Association, 2000).
e categories and labels for the problems that we discuss come from the Second Inter-
national Consultation on Sexual Medicine: Sexual Dysfunctions in Men and Women (Lue,
Basson, et al., 2004), A New View of Women’s Sexual Problems (Kaschak & Tiefer, 2002),
and from the International Society of Sexual Medicine, and the American Psychiatric
Associations Diagnostic and Statistical Manual (DSM-IV and DSM-5); we have added
a few categories and labels of our own.
Desire-Phase Difficulties
In this section, we discuss inhibited sexual desire, desire discrepancy, and sexual aversion.
Hypoactive Sexual Desire Disorder
Hypoactive sexual desire disorder (HSDD) is the absence or minimal experi-
ence of sexual thoughts, fantasies, and interest prior to sexual activity, as well as
a lack of sexual desire during the sexual experience (Basson et al., 2004). Until
recently, HSDD was defined exclusively by lack of sexual interest, thoughts, and
fantasies outside sexual activity. However, many women and some men who do
not experience a sexual appetite do enjoy and become aroused by and desirous
of a sexual experience after it has begun (Elton, 2010). Therefore, the pattern of
sexual desire following, rather than preceding, sexual excitement is not consid-
ered hypoactive sexual desire disorder (Laan, 2008). Although desire difficulties
are the most common sexual difficulty experienced by women (see Table 14.1),
significant numbers of men also experience low sexual desire and seek help for it
in counseling (McCarthy & McDonald, 2009).
Desire Discrepancy
Sexual partners usually have discrepancies in their preferences for frequency,
type, and timing of sexual activities, often referred to clinically as desire discrep-
ancy (Willoughby & Vitas, 2011). A couples incompatibility in terms of these
preferences can contribute to sexual dissatisfaction, even when either of their
preferences is, in itself, not a sexual problem (A. Smith et al., 2011). Male–female
differences stand out when it comes to the frequency with which they desire sex:
The 2005 Global Sex Survey found that 41% of men and 29% of women want
sex more frequently (Durex, 2006). Sometimes the relationship can accommo-
date these individual differences. However, when sexual differences are a source
In what situations would you consider
it normal for a man to lose his erection?
In what context would you consider his
difculty with erections to be a disorder?
Critical Thinking Question
Hypoactive sexual desire disorder frequently
reects relationship problems.
Tomasz Trojanowski, 2009. Used under license from Shutterstock.com.
hypoactive sexual desire disorder
(HSDD)
Lack of interest prior to and during
sexual activity.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Sexual Difculties and Solutions401 401
of significant conflict or dissatisfaction, a couple can experience considerable distress.
Instead of moving toward some compromise, the couple polarizes, and each individual
believes that his or her partner either never” or always wants to be sexual.
Sexual Aversion Disorder
A fear of sex and a compelling desire to avoid sexual situations are considered a sexual
aversion disorder. Sexual aversion can range from feelings of discomfort, repulsion,
and disgust to an extreme irrational fear of sexual activity. Even the thought of sexual
contact can result in intense anxiety and panic. A person who experiences sexual aver-
sion exhibits physiological symptoms such as sweating, increased heart rate, nausea,
dizziness, trembling, or diarrhea as a consequence of fear.
Excitement-Phase Difficulties
Inhibited sexual excitement occurs when physiological arousal, erotic sensation, or the
subjective feeling of being turned on is chronically diminished or absent. Excitement-
phase disorders among women take the form of lack of vaginal lubrication or lack of
For readers who are sexually involved, this questionnaire
is designed to measure the degree of satisfaction you have
in the sexual relationship with your partner. It is not a test,
so there are no right or wrong answers.
Answer each item
as carefully and accurately as you can by placing a number
beside each one according to the following scale:
1. Rarely or none of the time
2. A little of the time
3. Some of the time
4. A good part of the time
5. Most or all of the time
1. I feel that my partner enjoys our sex life. ___
2. My sex life is very exciting. ___
3. Sex is fun for my partner and me. ___
4. I feel that my partner sees little in me except for the
sex I can give. ___
5. I feel that sex is dirty and disgusting. ___
6. My sex life is monotonous. ___
7. When we have sex, it is too rushed and hurriedly
completed. ___
8. I feel that my sex life is lacking in quality. ___
9. My partner is sexually very exciting. ___
10.
I enjoy the sex techniques that my partner likes
or uses. ___
11. I feel that my partner wants too much sex from me. ___
12.
I think sex is wonderful. ___
13.
My partner dwells on sex too much. ___
14.
I try to avoid sexual contact with my partner. ___
15.
My partner is too rough or brutal when we have sex. ___
16.
My partner is a wonderful sex mate. ___
17.
I feel that sex is a normal function of our relationship. ___
18.
My partner does not want sex when I do. ___
19.
I feel that our sex life really adds a lot to our
relationship. ___
20. My partner seems to avoid sexual contact with me. ___
21.
It is easy for me to get sexually excited by my
partner. ___
22.
I feel that my partner is sexually pleased with me. ___
23.
My partner is very sensitive to my sexual needs and
desires. ___
24. My partner does not satisfy me sexually. ___
25.
I feel that my sex life is boring. ___
Scoring
Items 1, 2, 3, 9, 10, 12, 16, 17, 19, 21, 22, and 23 must be
reverse-scored. (For example, if you answered 5 on one of
these items, you would change that score to 1.) After these
positively worded items have been reverse-scored, if there
are no omitted items, the score is computed by summing
the individual item scores and subtracting 25.
This assess-
ment has been shown to be valid and reliable.
Interpretation
Scores can range from 0 to 100, with a high score indica-
tive of sexual dissatisfaction.
A score of 30 or above is
indicative of dissatisfaction in one’s sexual relationship.
SOURCE: Adapted from Hudson (1992).
Index of Sexual Satisfaction
YOUR SEXUAL
HEALTH
sexual aversion disorder
Extreme and irrational fear of sexual
activity.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
402 CHAPTER 14
subjective awareness of physical arousal (Basson, 2002), whereas in men an inability to
achieve or maintain erection is typical.
Female Sexual Arousal Disorder
As we saw in Chapters 3 and 6, vaginal lubrication is a womans first physiological
response to sexual arousal. The persistent inability to attain or maintain the lubrication-
swelling response indicates female genital sexual arousal disorder. In contrast, female
subjective sexual arousal disorder is indicated when physical signs of arousal are pres-
ent but feelings of sexual excitement and pleasure are absent or markedly diminished.
Combined genital and subjective sexual arousal disorder is a combination of both
disorders (Basson et al., 2004).
Persistent Genital Arousal Disorder
Persistent genital arousal disorder (PGAD) is spontaneous, intrusive, and unwanted
genital arousal—tingling, throbbing, pulsating—in the absence of sexual interest
(Leiblum & Goldmeier, 2008). One or more orgasms do not relieve the uncomfortable
feelings of arousal, and the arousal can persist for hours or days (Basson, 2009). It is
an uncommon disorder, first identified in 2001. Most of the women who are evaluated
for this disorder have normal findings from laboratory tests and psychiatric evaluations,
although using or stopping the use of SSRI antidepressants has been related to develop-
ing PGAD (Leiblum & Goldmeier, 2008). Preliminary research has found that some of
the women also have problems with restless leg syndrome and overactive bladder syn-
drome, which indicates a possible common cause for the three problems (Waldinger &
Schweitzer, 2009). Tests using MRI and transvaginal ultrasonography have found pelvic
varicose veins (abnormally dilated veins) in women with PGAD (Waldinger et al., 2009).
Male Erectile Disorder
Erectile disorder (ED) is defined as the consistent or recurrent inability over at least
3 months to have or maintain an erection sufficient for sexual activity (Ryan-Berg,
2011). An estimated one in five men older than 20 years experiences ED, and ED
is a frequent reason that men seek sex therapy (Saigal et al., 2006). The incidence
of ED increases with age, as shown in
Figure 14.2. A man in his 50s is over two
times more likely to experience erection problems than a man in his 20s.
Special procedures have been developed to evaluate physical factors in erec-
tion problems. Some techniques involve recording erection patterns during sleep,
because erections normally occur during this time. Other instruments measure
penile blood pressure and ow to determine whether erectile diculties are caused
by vascular problems. Injections of medications that produce erections can also be
used to detect possible diculties: If no erection occurs following an injection, then
vascular impairment is likely (Lue, Giuliano et al., 2004).
Orgasm-Phase Difficulties
Other sexual difficulties specifically affect orgasmic response, and both men and
women report a variety of such difficulties. Some of these difficulties involve total
absence or infrequency of orgasms. Others involve reaching orgasm too rapidly or
too slowly. We also consider faking orgasm to be problematic.
Female Orgasmic Disorder
Female orgasmic disorder means the absence, marked delay, or diminished
intensity of orgasm, despite high subjective arousal from any type of stimulation
40
Percentage of men with erectile disorder
0
20
40
60
100
80
50 60 70
Age of men
Figure 14.2 The incidence of erectile dis-
order related to age (Kim & Lipshultz, 1997).
female genital sexual arousal
disorder
Persistent inability to attain or main-
tain the lubrication-swelling response.
female subjective sexual arousal
disorder
Absent or diminished awareness of
physical arousal.
combined genital and subjective
sexual arousal disorder
Absent or diminished subjective and
physical sexual arousal.
persistent genital arousal disorder
(PGAD)
Spontaneous, intrusive, and
unwanted genital arousal.
erectile disorder (ED)
Consistent or recurring lack of an erec-
tion sufciently rigid for penetrative
sex, for a period of at least 3 months.
female orgasmic disorder
The absence, marked delay, or dimin-
ished intensity of orgasm.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Sexual Difculties and Solutions403 403
(Basson et al., 2004). About 5–10% of adult women in the United States have never
experienced orgasm by any means of self or partner stimulation, but data indicate
that the number of women who have never experienced orgasm has decreased since
the 1960s (LoPiccolo, 2000). This apparent decrease may be due to a cultural shift
to acceptance of women being more sexually expressive and to the excellent self-help
books and DVDs that were not previously available for women who want to learn to
experience orgasm.
A woman who has situational female orgasmic disorder is
orgasmic when masturbating but not when stimulated by a part-
ner. Women who have experienced orgasm sometimes have di-
culty doing so: About 25% of women reported having problems
with orgasm within the last year (Laumann et al., 1994). Women
most likely to experience diculty with orgasm are unmarried
and younger and have less education than women without prob-
lems with orgasm (Laumann et al., 1999). For many women,
experiencing orgasm is something they learn to do: One survey
found that almost 62% of women were 18 years old or older when they rst experienced
orgasm (Ellison, 2000).
Table 14.2 shows the incidence of orgasm in college students.
Female Orgasm During Intercourse
Most sex therapists believe that women who enjoy intercourse and experience orgasm
in some way other than during coitus do not have a sexual problem (Hamilton, 2002;
LoPiccolo, 2000). Many more women experience orgasm from masturbation, manual
stimulation by a partner, and oral sex than women who experience it during inter-
course (Fugl-Meyer et al., 2006). For many women the stimulation that occurs during
coitus is simply less effective than direct manual or oral stimulation of the clitoral area.
As sex therapist pioneer Helen Kaplan stated, There are millions of women who are
sexually responsive, and often multiply orgasmic, but who cannot have an orgasm dur-
ing intercourse unless they receive simultaneous clitoral stimulation (1974, p. 397).
Unfortunately, women and men may not always understand this: A Canadian study
found that 23% of the women participants identified infrequent orgasm during inter-
course as a problem (Gruszecki et al., 2005).
Male Orgasmic Disorder
The term male orgasmic disorder, also referred to as inhibited ejaculation, generally
refers to the inability of a man to ejaculate during sexual activity with a partner (Sand-
strom & Fugl-Meyer, 2007). Masturbation is most often the preferred method for
men with male orgasmic disorder to experience orgasm (Robbins-Cherry et al., 2011).
Eight percent of men experience this difficulty (Laumann et al., 1994). The terms male
coital anorgasmia (difficulty with orgasm only during intercourse) and partner anorgas-
mia (difficulty with orgasm by partner manual and oral stimulation) are more descrip-
tive than the general term male orgasmic disorder (Apfelbaum, 2000).
Premature Ejaculation
The most common male sexual difficulty is premature ejaculation (PE) (Strassberg,
2007). Almost all men ejaculate quickly during their first intercourse, which may be dis-
appointing but should not be seen as a sexual problem unless it persists after more expe-
riences. The International Society for Sexual Medicine defines premature ejaculation as
a pattern of quick ejaculations (under one minute) combined with a mans inability to
delay ejaculation during vaginal penetration and with distress about or avoidance of sex-
ual intimacy because of his rapid orgasm (McMahon, 2008). In general, approximately
TABLE 14.2 College Students Answer the Question
“Have You Ever Had an Orgasm?”
Female (%) Male (%)
Ye s 87 94
No 13 6
SOURCE: Elliott & Brantley (1997).
male orgasmic disorder
The inability of a man to ejaculate
during sexual stimulation from his
partner.
premature ejaculation (PE)
A pattern of ejaculations within 1 min-
ute and an inability to delay ejacula-
tion, resulting in a man’s impairing his
or his partner’s pleasure.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
404 CHAPTER 14
22% of sexually active men experience PE (Steggall et al., 2008), and about 30% of those
men ejaculate early without a full erection (Lue, Giuliano et al., 2004). Research indi-
cates that men with PE underestimate the intensity of their physical arousal, experience
rapid high arousal to penile stimulation, ejaculate before reaching full sexual arousal,
and report less enjoyment of orgasm than men who do not have problems with rapid
ejaculation (Rowland et al., 2000). Some men with PE may also have penile hypersensi-
tivity that contributes to their rapid ejaculation (Wylie & Hellstrom, 2011).
Faking Orgasms
A final orgasmic difficulty we discuss is faking orgasms—pretend-
ing to experience orgasm without actually doing so. Some men fake
orgasm, and a growing number of young, healthy men whose com-
pulsive viewing of pornography make arousal with a partner diffi-
cult are faking orgasm (Robinson, 2011; Rothbart, 2011). However,
faking orgasm is typically discussed in reference to women.
Table
14.3 shows rates of faking orgasm. Women report faking orgasm
most often during intercourse, but also during oral sex, manual
stimulation, and phone sex (Muehlenhard & Shippee, 2010). The
most common reasons given by women for pretending orgasm is
to avoid disappointing or hurting their partners, a desire to get sex
over with (sometimes due to discomfort or pain), or poor commu-
nication about or limited knowledge of sexual techniques (Ellison,
2000; Muehlenhard & Shippee, 2010).
Can heterosexual men tell if their women partners experience
orgasm? One study found a 20% discrepancy in how many men
believed that their partners climaxed compared to the women who
said that they did. About 85% of men reported that their partner
had an orgasm at their most recent sexual event. However, 64% of
women said that they experienced an orgasm at their most recent
sexual event (Reece et al., 2010).
Men are also more likely than women to believe that men can tell
if a woman is faking orgasm (Knox et al., 2008).
Faking orgasm often leads to a vicious cycle. e persons partner
is likely not to know that his or her partner has pretended to climax.
Consequently, the deceived partner continues to do what he or she
has been led to believe is eective, and the other partner continues to
fake to prevent discovery of the deception. Once established, a pat-
tern of deception can be dicult to break. Although some women and men nd faking
orgasm to be an acceptable solution in their individual situations, others nd that fak-
ing itself becomes troublesome. At the least, faking orgasms creates emotional distance
at a time of potential closeness and satisfaction (Masters & Johnson, 1976; Sytsma &
Taylor, 2008).
Do you think it’s okay for a partner to fake
orgasm to spare your feelings? Why or
why not?
Critical Thinking Question
TABLE 14.3 College Students Answer the Question “Have You Ever Faked
an Orgasm?”
Female
Heterosexual (%)
Lesbian or Bisexual
Female (%)
Male
Heterosexual (%)
Gay or Bisexual
Male (%)
Ye s 60 71 17 27
No 40 29 83 73
SOURCE: Elliott & Brantley (1997).
Is this woman faking it, or not? How could you tell?
B2M Productions/Photodisc/Jupiterimages
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Sexual Difculties and Solutions405 405
Dyspareunia
The medical term for painful intercourse is dyspareunia (dis-puh-ROO-nee-uh).
Both men and women can experience pelvic and coital pain, although it is more com-
mon for women to have this problem.
Dyspareunia in Men
Painful intercourse in men is unusual but does occur. If the foreskin of an uncircum-
cised male is too tight, he can experience pain during an erection. Under such circum-
stances minor surgery may be indicated. Inadequate hygiene of an uncircumcised penis
can result in the accumulation of smegma beneath the foreskin, causing irritation of the
glans during sexual stimulation. This problem can be prevented by routinely pulling back
the foreskin and washing the glans area with soap and water. Infections of the urethra,
bladder, prostate gland, or seminal vesicles can induce burning, itching, or pain during or
after ejaculation (Davis et al., 2009; Davis & Noble, 1991). Proper medical attention can
generally alleviate these sources of discomfort during coitus.
Another possible source of pain or discomfort for men is Peyronie’s (PAY-run-eez)
disease, in which brous tissue and calcium deposits develop in the space above and
between the cavernous bodies of the penis. is brosis results in pain and curvature of
the penis upon erection that can interfere with erection and even intercourse (Casabe et al.,
2011). Peyronie’s disease is usually caused by traumatic bending of the penis during inter-
course or by medical procedures involving the urethra (Rees, 2008). Surgical procedures
can sometimes be eective in addressing this condition (Djinovic, 2011; Shaeer, 2011).
Dyspareunia in Women
The new Diagnostic and Statistical Manual of the American Psychiatric Association has
relabeled pain with partial vaginal entry, during intercourse, and after intercourse as
Genito-Pelvic Pain/Penetration Disorder. It is common among women, and many
who experience pain have done so since their first intercourse experience (Coady &
Fish, 2011; Donaldson & Meana, 2011). When it is severe and ongoing, it is likely to
create severe distress in a womans sexual experiences (Smith & Pukall, 2011).
A variety of factors can cause vaginal discomfort and pain related to penetration.
Discomfort at the vaginal entrance or inside the vaginal walls is commonly caused by
inadequate arousal and lubrication. Physiological conditions such as insucient hor-
mones can reduce lubrication. Using a lubricating jelly can provide a temporary solution
so that intercourse can take place comfortably, but this may bring only short-term relief.
Yeast, bacterial, and trichomoniasis infections cause inammations of the vaginal walls
and can result in painful intercourse. Foam, contraceptive cream or jelly, condoms, and
diaphragms can irritate the vaginas of some women. Pain at the opening of the vagina
can also be attributed to an intact or inadequately ruptured hymen, a Bartholins gland
infection, or scar tissue at the opening (Kellog-Spadt, 2006). If smegma collects under
the clitoral hood, it can irritate the clitoris when the hood is moved during sexual stimu-
lation. Gentle washing of the clitoris and hood can help prevent this.
About 10% of women experience severe pain at the entrance of the vagina known
as vestibulodynia, and this may be the most common cause of painful intercourse
(Bergeron, 2009). Typically, a small reddened area is painfully sensitive, even to light
pressure, but the area may be so small that it is dicult for even a health-care practi-
tioner to see. Treatment options include topical medicines and surgery to excise the
hypersensitive area (Goldstein et al., 2006).
Pain deep in the pelvis during coital thrusting can be due to jarring of the ovaries
or stretching of the uterine ligaments. A woman may experience this type of discom-
fort only in certain positions or at certain times in her menstrual cycle, usually during
dyspareunia
Pain or physical discomfort during
sexual intercourse.
Peyronies disease
Abnormal brous tissue and calcium
deposits in the penis.
Genito-Pelvic Pain/Penetration
Disorder
Pain with partial vaginal entry, during
intercourse, and after intercourse.
vestibulodynia
A small area at the entrance of the
vagina that causes severe pain.
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
406 CHAPTER 14
ovulation or menstruation. If the woman controls positions and pelvic movements dur-
ing coitus, she can avoid what is painful. Another source of deep pelvic pain is endo-
metriosis, a condition in which tissue that normally grows on the walls of the uterus
implants on various parts of the abdominal cavity (Tripoli et al., 2011). is extra
tissue can prevent internal organs from moving freely, resulting in pain during coitus.
Birth control pills are sometimes prescribed to control the buildup of tissue during the
monthly cycle (Reiter & Milburn, 1994).
Gynecological surgeries for uterine and ovarian cancer and infections in the uterus,
such as those from gonorrhea, can also result in painful intercourse. In fact, pelvic pain
is often the rst physical symptom noticed by a woman who has gonorrhea. If the infec-
tion has caused considerable scar tissue to develop, surgery may be necessary.
Vaginismus
Vaginismus (vah-juh-NIZ-mus) is characterized by strong involuntary contractions
of the muscles in the outer third of the vagina. These contractions make attempts to
insert a penis into the vagina extremely uncomfortable or painful for a woman. The
painful contractions of vaginismus are a conditioned, involuntary response, usually
preceded by a history of painful intercourse (Van Lankveld et al., 2006). A woman
with vaginismus usually experiences the same contracting spasms during a pelvic exam
(Weiss, 2001). Even the insertion of a finger into her vagina can cause great discom-
fort. It is important for women and their partners to know that intercourse, tampon
use, and pelvic exams should not be uncomfortable. If they are uncomfortable, it is
essential to investigate the cause of the discomfort.
Although a woman who experiences vaginismus can learn to prevent the contrac-
tions, she does not consciously will them to occur. In fact, the deliberate eort to over-
come the problem by having intercourse despite the pain can have just the opposite
eect, contributing to a vicious cycle that makes the vaginismus worse. Sexual coercion
in marriage can contribute to this problem. For example, a study of sexual problems in
traditional Islamic cultures found that 58% of women who had been married without
their consent had vaginismus (Aziz & Gurgen, 2009).
Some women who experience vaginismus are sexually responsive and orgasmic with
manual and oral stimulation, but others are uncomfortable with most sexual activity
and do not experience desire and arousal (Borg et al., 2011; Leiblum, 2000). Because
many heterosexual couples regard coitus as a highly important component of their sex-
ual relationship, vaginismus typically causes great concern, even if the couple is sexually
involved in other ways.
Origins of Sexual Difculties
In the following paragraphs, we examine some of the physiological, cultural, individual,
and relational factors that can contribute to sexual difficulties. Significant interaction
among these factors also occurs. For example, any degree of physiological impairment
can make a persons sexual response and functioning more vulnerable to disruption by
negative emotions or situations. Thus a man with moderate diabetes may have no dif-
ficulty achieving an erection when he is rested and feeling comfortable with his partner,
but he may be unable to do so when he is under stress—after a hard day at work or
after an argument with his partner. It is also important to keep in mind that it is usu-
ally difficult to identify a consistent cause of a specific sexual difficulty because the
same type of sexual problem will be caused by different factors in different individuals
(Vardi et al., 2008; Waldinger, 2008).
Unfortunately, the aerobic and
strength-building benets of bicycle
riding can come at a cost to sexual
functioning.
Pressure on the genitals
from the seat can damage nerves and
impair blood ow, resulting in sexual
problems.
Active cyclists can get
genital-friendly bike seats to prevent
problems (Carr, 2006).
Courtesy of Wilderness Trail Bikes, Inc.
© Image Source/Alamy
vaginismus
Involuntary spasmodic contractions of
the muscles of the outer third of the
vagina.
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Sexual Difculties and Solutions407 407
Physiological Factors
Physiological factors often play a role in sexual problems, so it is often wise to have a
general physical and a gynecological or urological exam to help rule out such causes.
Hormonal, vascular, and neurological problems can contribute to sexual disorders
(Beckman et al., 2006). Unfortunately, research has shown that only about one third
of individuals with sexual problems talk to their physicians about it.
As more research about physiological contributions to sexual problems has been
conducted, some diculties that in the past were believed to be primarily due to psy-
chological causes have been shown to have physical components as well. For example,
premature ejaculation is sometimes associated with hyperthyroidism and improves
when thyroid levels have returned to normal following treatment (Cihan et al., 2009). A
genetic component may even play a role for some men. Compared to men without life-
long premature ejaculation, men with this condition are more likely to have a genotype
that is associated with less activity of the neurotransmitter serotonin in the section of
the brain that is involved in ejaculation (Janssen et al., 2009).
Recent research suggests that individual variations, such as sensitivity to touch,
can contribute to sexual disorders. For example, some men with a rapid ejaculation
problem may have an innate biological hypersensitivity that causes them to ejaculate
quickly (Waldinger & Schweitzer, 2006). Evidence also suggests that some women with
diculty becoming sexually aroused have lower levels of general sensitivity to touch
(Frohlich & Meston, 2005). Research on sexual function continues to increase knowl-
edge about the physiological aspects of sexual problems. At this time, more is known
about the eects of illnesses, medications, and disabilities on male sexuality than on
female sexuality because of the greater amount of research that has been conducted on
male sexual function (Heiman, 2009).
Good Health Habits = Good Sexual Functioning
Good health is closely tied to sexual health. A healthy diet and exercise that result
in a normal weight form the foundation of sex drive and functioning (Frisch et al.,
2011). For example, obese men and women tend to report low sexual quality of life
stbye, 2011). Body fat, especially around the abdomen, reduces testosterone levels
in men. A high waist circumference and low levels of physical activity are associated
with increased likelihood of having erectile disorder (Janiszewski et al., 2009). A study
of more than 22,000 healthy men over 14 years found that men who were obese were
90% more likely to develop erectile disorder. In contrast, men with the highest exercise
levels were 30% less likely than other men to develop ED (Bacon et al., 2006).
Avoiding the use of tobacco and recreational drugs is another health habit that can
contribute to sexual functioning. For example, women who do not smoke, who have a
history of moderate or less alcohol use, and who are a healthy weight are much less likely
to have sexual dissatisfaction and disorders than those with the opposite characteristics
(Addis et al., 2006). Tobacco use can have a dramatic negative eect on male sexual
functioning: Men who smoke are twice as likely to have erectile diculties than men
who do not smoke (Harte & Meston, 2008a). In one study, even nonsmoking women
who used nicotine gum experienced decreased sexual arousal (Harte & Meston, 2008b).
Table 14.4 lists other recreational drugs that can impair sexual functioning.
Chronic Illness
Many of us will confront chronic illness in ourselves or our partners at some point in
our lives. The illness may impair the nerves, hormones, or blood flow essential to sexual
functioning. Some medications and side effects of treatments for the illness can also
negatively affect sexual interest and response. Any accompanying pain and fatigue can
SEXUALHEALTH
A limp cigarette makes a graphic
statement about the detrimental effects
of smoking on sexual functioning.
©David Young-Wolff/PhotoEdit
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408 CHAPTER 14
distract from erotic thoughts and sensations or limit specific sexual activities (Schover,
2000). For example, erectile dysfunction is often associated with diabetes, high blood
pressure, and cardiovascular problems. In fact, when men are unable to experience
erections, health-care practitioners often see the sexual problem as a predictor of these
serious medical problems, particularly cardiovascular disease. In contrast, research
indicates that men who experience erections but have difficulty maintaining them are
more likely to have a psychological cause behind the problem (Corona et al., 2006).
e following paragraphs describe the sexual eects of specic illnesses.
Diabetes Diabetes is a disease of the endocrine system that results when the pancreas
fails to secrete adequate amounts of insulin or when cells in the body are insulin resis-
tant. Nerve damage and circulatory problems from diabetes cause about 50% of diabetic
men to have a reduction in or loss of capacity for erection. Some diabetic men experi-
ence retrograde ejaculation (ejaculating into the bladder). Heavy alcohol use and poor
blood sugar control increase the chances of erectile problems in diabetic men. Women
with diabetes are likely to have problems with sexual desire, lubrication, and orgasm
(Diabetes Care, 2009; Wessells et al., 2011).
Cancer Cancer and its treatments can be particularly devastating to sexuality because
they can impair hormonal, vascular, and neurological functions necessary for normal sex-
ual interest and response. Chemotherapy and radiation therapy can cause hair loss, skin
changes, nausea, fatigue, and permanent hormonal changes—all of which can negatively
affect sexual feelings (Hill et al., 2011; Incrocci, 2006). Some cancer surgeries result in per-
manent scars, loss of body parts, or an ostomy (a surgically created opening for evacuation
of body wastes after removal of the colon or bladder)—all of which can result in a negative
body image (Hill et al., 2011; Ogden & Lindridge, 2008). Pain from the cancer or its treat-
ments can also greatly interfere with sexual interest and arousal (Fleming & Pace, 2001).
Although all forms of cancer can aect sexual functioning, cancers of the repro-
ductive organs often have the worst impact. For example, men who have had prostate
cancer often experience the absence or signicant reduction of ejaculation and are 10 to
15 times more likely to experience sexual problems because of treatment (Glina, 2006;
Harvard Health Publications, 2006).
Multiple Sclerosis Multiple sclerosis (MS) is a neurological disease of the brain and
spinal cord in which damage occurs to the myelin sheath that covers nerve fibers. Vision,
sensation, and voluntary movement are affected. Studies have found that most MS
patients experience changes in their sexual functioning and that at least half have sexual
At a Glance
TABLE 14.4 Sexual Effects of Some Abused and Illicit Drugs
Drug Effects
Alcohol Chronic alcohol abuse causes hormonal alterations (reduces size of testes and suppresses hormonal func-
tion) and permanently damages the circulatory and nervous systems.
Marijuana
Reduces testosterone levels in men and decreases sexual desire in both sexes.
Tobacco Adversely affects small blood vessels in the penis and decreases the frequency and duration of erections
(Mannino et al., 1994).
Cocaine Causes erectile disorder and inhibits orgasm in both sexes.
Amphetamines High doses and chronic use result in inhibition of orgasm and decrease in erection and lubrication.
Barbiturates Cause decreased desire, erectile disorders, and delayed orgasm.
SOURCE: Finger et al. (1997).
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Sexual Difculties and Solutions409 409
problems. A person with MS can experience either a reduction in or a loss of sexual
interest, genital sensation, arousal, or orgasm; he or she can also experience uncomfort-
able hypersensitivity to genital stimulation (Smeltzer & Kelley, 1997).
Strokes Strokes, or cerebrovascular accidents, occur when brain tissue is destroyed as
a result of either blockage of the blood supply to the brain or hemorrhage (breakage of
a vessel, causing internal bleeding). Strokes often result in limited mobility, altered or
lost sensation, impairment of verbal communication, and depression. Stroke survivors
frequently report a decline in their frequency of sexual interest, arousal, and activity
(Giaquinto et al., 2003; Rees et al., 2007).
Medication Effects on Sexual Functioning
At least 200 prescription and nonprescription medications have negative effects on
sexual desire and/or functioning (Finger et al., 2000). Research indicates that even
use of nonsteroidal anti-inflammatory drugs may contribute to erectile dysfunction
(Gleason et al., 2011). As much as 25% of cases of ED are related to medication side
effects (Miller, 2000). Health-care practitioners do not always discuss potential sexual
side effects of medications, so you may need to ask about the possible effects of any
prescribed medicines on sexuality. Often another medication can be substituted that
will have fewer or milder negative effects on sexual interest, arousal, and orgasm.
Psychiatric Medications Antidepressants called SSRIs cause reduced sexual interest
and arousal and delayed or absent orgasm in up to 60% of users (Apantaku-Olajide et
al., 2011; Corona et al., 2009; Simon, 2010). The use of the antidepressant Wellbutrin
(bupropion), Viagra, or ginkgo biloba (240–900 mg a day) can sometimes reverse
the sexual side effects from SSRI antidepressants (Balon & Segraves, 2008; Heiman,
2008). Antipsychotic medications frequently cause lack of desire and erection and delay
or absence of ejaculation and orgasm, and tranquilizers such as Valium and Xanax can
interfere with orgasmic response.
Antihypertensive Medications Medications prescribed for high blood pressure can
cause problems with desire, arousal, and orgasm. Some hypertension medications are
more likely than others to have negative sexual effects.
Miscellaneous Medications Prescription gastrointestinal and antihistamine medica-
tions can interfere with desire and arousal function. Methadone (a synthetic opioid)
can cause decreased desire, arousal disorder, lack of orgasm, and delayed ejaculation.
Some over-the-counter antihistamines, motion sickness remedies, and gastrointesti-
nal medications have been associated with desire and erection problems. Research also
indicates that women who use hormonal forms of contraception report less arousal, less
frequent sex, and fewer orgasms than women using nonhormonal methods of birth con-
trol. However, both groups report similar levels of sexual satisfaction (M. Smith, 2011).
Disabilities
Major disabilities, such as spinal cord injury, cerebral palsy, blindness, and deafness, have
widely varying effects on sexual responsiveness. Some people with these disabilities can
maintain or restore satisfying sex lives; others find that their sexual expression is perma-
nently reduced or impaired by their difficulties. In the following sections, we look at some
of these problems and discuss sexual adjustments that people with disabilities can make.
Spinal Cord Injury People with spinal cord injuries (SCIs) have reduced motor control
and sensation because the damage to the spinal cord obstructs the neural pathways
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410 CHAPTER 14
between body and brain. Although the SCI does not necessarily impair sexual
desire and psychological arousal, a person with an SCI may have impaired
physical ability for arousal and orgasm; this impairment varies greatly accord-
ing to the specific injury (Alexander & Rosen, 2008). Research indicates that
86% of men and women with SCIs feel sexual desire, more than half experience
arousal from physical stimulation, about 30% become aroused from psycho-
logical stimulation, and 33% experience orgasm or ejaculation (Mathieu et al.,
2006). Research has found that Viagra can increase arousal and erection for
some men with SCIs (DeForge & Blackmer, 2005).
Cutting-edge research on women with complete spinal cord injuries has found
that vaginal/cervical self-stimulation can cause orgasm. Brain imaging techniques
that have identied brain activity occurring during orgasm in uninjured women
have identied similar activity from vaginal/cervical self-stimulation in women
with complete spinal injuries (Pappas, 2012). e physiological data indicate
that the vagus nerve provides an alternate pathway from the vagina/cervix to the
brain, bypassing the spinal cord (Whipple & Komisaruk, 2006).
Much of the sex counseling for individuals and couples faced with SCIs con-
sists of redening and expanding sexual expression. us, sensory amplication
developing heightened sexual responsiveness in the inner arm, breasts, neck,
or some other area that has retained some feeling—can enhance pleasure and
arousal (Rosengarten, 2007).
Cerebral Palsy Cerebral palsy (CP) is caused by damage to the brain that can
occur before or during birth or during early childhood. It is characterized by
mild to severe lack of muscular control. Involuntary muscle movements can dis-
rupt speech, facial expressions, balance, and body movement. Severe involuntary
muscle contractions can cause limbs to jerk or assume awkward positions. A persons intel-
ligence may or may not be affected. Unfortunately, it is often mistakenly assumed that peo-
ple with CP have low intelligence because of their physical difficulty in communicating.
Genital sensation is unaected by CP. However, spasticity and deformity of arms and
hands can make masturbation dicult or impossible without assistance, and the same
problems in the hips and knees can make certain intercourse positions painful or dicult.
For women with CP, chronic contraction of the muscles surrounding the vaginal opening
can create pain during intercourse. Options that can help individuals with CP include try-
ing dierent positions, propping legs up on pillows to ease spasms, and exploring nongeni-
tal lovemaking. Partners can help with positions, and focusing on genital pleasure can help
to distract from pain. e sexual adjustment of a person with CP depends not only on what
is physically possible but also on environmental support for social contacts and privacy.
People with CP and SCIs may require the help of someone who can assist in preparation
and positioning for sexual relations (Joseph, 1991; Renshaw, 1987).
Blindness and Deafness The sensory losses of blindness and deafness can affect a persons
sexuality primarily when the visual or hearing deficits interfere with learning the subtleties
of social interaction skills and with a persons independence (Mona & Gardos, 2000). Sexu-
ally, other senses can play an expanded role, as a man who was born blind explained:
During lovemaking, my other senses—touch, smell, hearing, and taste—serve as the
primary way I become aroused. The caress of my partner, and the way she touches me,
is tremendously exciting, perhaps even more so than for a sighted person. The feel of
her breasts on my face, the hardness of her nipples pressing into my palms, the brush
of her hair across my chest . . . these are just some of the ways I experience the incred-
ible pleasures of sex. (Kroll & Klein, 1992, p. 136)
Good communication and creative exploration
can help individuals and couples minimize the
sexual effects of disabilities and illnesses.
© Chuck Savage/Corbis
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Sexual Difculties and Solutions411 411
Enhancement Strategies for People With Chronic Illnesses
and Disabilities
Individuals and couples can best cope with the sexual limitations of illness or disability
by accepting those limitations and developing the options that remain. For example,
couples can minimize the effects of pain by planning sexual activity at optimal times of
the day, using methods of pain control such as moist heat or pain medication, finding
comfortable positions, and focusing on genital pleasure or arousing erotic images to
distract from pain (Schover & Jensen, 1988). As we emphasize in the Basics of Sexual
Enhancement and Sex Therapy” section of this chapter, expanding the definition of
sexuality beyond genital arousal and intercourse to include dimensions such as erotic
thoughts and sensual touch, and developing flexibility in sexual roles and innovation in
sexual technique can be helpful.
Cultural Influences
Culture strongly influences both the way we feel about our sexuality and the way we
express it. In this section, we examine some influences in Western society—particularly
in the United States—that affect our sexuality and can contribute to sexual problems.
Negative Childhood Learning
We learn many of our basic, important attitudes about sexuality during childhood.
While growing up, we observe and integrate the models of human relationships from
our families. We notice how our parents use touch and how they feel about one another.
For example, one research study found that women with low sexual desire perceived their
parents attitudes toward sex and their affectionate interaction with each other to be sig-
nificantly more negative than did women with higher sexual desire (Stuart et al., 1998).
A variety of therapist researchers have reported that religious orthodoxy that creates
guilt about sex by equating it with reproduction or labeling it as sinful is common to the
backgrounds of many sexually troubled people (Fox et al., 2006; Hunt & Jung, 2009). One
study found that women who reported more guilt about sex had lower sexual desire than
women with little or no guilt (Woo et al., 2011). Further, research indicates that people
who leave their religion report dramatic improvement in their sexual lives. e more sexu-
ally conservative the religion was, the greater the improvement reported (Ray, 2012).
The Sexual Double Standard
Global research on sexuality indicates that equality of gender roles is associated with
mens and womens sexual satisfaction. In the male-dominated cultures in Asia, Africa,
and the Middle East, significantly fewer people report that they have satisfying sex-
ual lives than people in the Western world (Laumann et al., 2006). As greater equal-
ity between men and women has developed over time, the sexual double standard has
diminished in the United States. However, opposing sexual expectations for women and
men are still prevalent in U.S. society and can negatively affect sexuality (Fugere et al.,
2008). Women may learn to be sexually restrained to avoid acquiring the reputation of
being a slut, while men frequently learn that sexual conquest is a measure of “manliness”
and that men should always be capable of responding sexually, regardless of the time and
place, our feelings about ourselves and our partners, or any other factors (Zilbergeld,
1978, p. 41) As a result of these expectations, men tend to see sexual interaction as a
performance, in which their highest priority is to act like a man to confirm their male
gender role in every sexual experience. Acting like a man for many men makes it difficult
to express “feminine” characteristics, such as tenderness or receptivity. The requirements
of masculine self-reliance and dominance can make asking for guidance from a sexual
The way others react to childhood
genital exploration can affect how
children learn to feel about their
sexual anatomy.
© Maya Barnes/The Image Works
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412 CHAPTER 14
partner more difficult. The restrictions of gender-role expectations can lead to anxiety,
frustration, and resentment for both women and men (Bonierbale et al., 2006).
In contrast, sexual intimacy that transcends gender-role stereotypes—when both
individuals are active and receptive, wild and tender, playful and serious—moves beyond
caricatures of men and women and expresses the richness of humanness (Kasl, 1999;
McCarthy, 2001). Same-sex couples may not have to struggle with opposing gender-
role expectations in their sexual expression. ey tend to have a more varied sexual
repertoire than heterosexuals, in part because of the lack of rigid gender-role scripts and
of a concept of how sex should” happen (Nichols, 2000).
A Narrow Definition of Sexuality
As we have seen repeatedly in this textbook, the notion that sex equals penile–vaginal
intercourse can contribute to inadequate stimulation for women and place burdensome
and anxiety-provoking expectations on intercourse. For example, research indicates that
women are more likely to orgasm when they engage in a variety of sexual behaviors and
when oral sex or vaginal intercourse is included (Reece et al., 2010). Sex therapist Leonore
Tiefer observes that the current emphasis on medical treatments that enhance erection,
such as Viagra, reinforces the overemphasis on intercourse. For every dollar devoted to
perfecting the phallus, I would like to insist that a dollar be devoted to assisting women
with their complaints about partner impairments in kissing, tenderness, talk, hygiene,
and general eroticism. Too many men still cant dance, write love poems, erotically mas-
sage the clitoris, or diaper the baby and let Mom get some rest” (Tiefer, 1995, p. 170).
Performance Anxiety
Performance anxiety can block natural sexual arousal by diminishing the pleasurable
sensations that would produce them. Marty Klein, sex therapist and author of Sexual
Intelligence: What We Really Want from Sex and How to Get It, describes this experi-
ence. Many people are watching themselves during sex more than they are experiencing
sex, which typically undermines sexual enjoyment” (Klein, 2012a, p. 16). For example,
a woman monitoring how aroused she is because she believes that she should have an
orgasm during a sexual experience—and she should hurry up about it—can inter-
fere with her experiencing the physical and emotional feelings that could arouse her
Maxine! Comix © Marian Henley. Reprinted by permission of the artist.
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Sexual Difculties and Solutions413 413
(Lavie-Ajayi & Joffe, 2009). Studies found that men were more likely than women to
be distracted by performance concerns during sexual experiences (Meana & Nunnink,
2006; Nelson & Purdon, 2011) A transitory sexual problem, such as an inability to
achieve an orgasm or erection because of fatigue or just not being in the mood, can
produce enough anxiety for the problem to occur in the next sexual encounter as well
(Benson, 2003). Problems with erectile dysfunction frequently begin with the worry
that follows a first-time incident. Inhibited orgasm in both men and women can result
from extreme performance pressure and an inability to be selfish and pursue ones own
heightened arousal instead of focusing on the partner’s pleasure (Apfelbaum, 2000).
Individual Factors
Beyond the cultural influences on sexual feelings and expression, sexual difficulties can
stem from psychological factors that are usually unique to each individual.
Sexual Knowledge and Attitudes
Our knowledge and attitudes about sex have a direct influence on our sexual expres-
sion. When difficulties are based on ignorance or misunderstanding, accurate informa-
tion can sometimes alleviate sexual dissatisfaction. For example, if a woman knows
about the function of her clitoris in sexual arousal, she will most likely have experiences
different from those of a woman who lacks this knowledge. The fact that women have
fewer sexual problems as they get older and have more self-knowledge supports the
idea that sexuality develops throughout our lives (Leland, 2000a).
Self-Concept
The term self-concept refers to the feelings and beliefs we have about ourselves. Our self-
concept can influence our relationships and sexuality (Coleman, 2007; Foley, 2003).
Research has found that self-esteem and self-confidence correlate with higher sexual
satisfaction and lack of sexual problems (Galinsky & Sonenstein, 2011; Higgins et
al., 2011). For example, a woman who feels comfortable with her body, believes she
is entitled to sexual pleasure, and takes an active role in attaining sexual fulfillment is
likely to have a more satisfying sexual relationship than a woman who lacks those feel-
ings about herself (Nobre & Pinto-Gouveia, 2006; Sanchez et al., 2006). Conversely, a
sexual problem can negatively affect self-concept (Althof et al., 2006). For example, in a
study about Viagra use, prior to treatment, men with erectile disorder had lower scores
on self-esteem tests than men without ED. After 10 weeks of taking Viagra, the mens
scores increased to equal the scores of the men without ED (Capellen et al., 2006).
Body image is an aspect of self-concept that can strongly aect sexuality. e more
one is distracted by negative thoughts about ones body, the less one will be able to go with
physical and emotional pleasures during sexual activity (Seal & Meston, 2007). In West-
ern cultures womens bodies are looked at, evaluated, and sexualized more than mens bod-
ies, and thinness and beauty are often equated with sexual desirability. Womens concerns
about weight begin earlier than mens do. Even when boys and girls have the same per-
centage of body fat, girls express greater dissatisfaction with their body weight and body
image than boys do (Rierdan et al., 1998; Wood et al., 1996). Eve Ensler, author of e
Vagina Monologues, claries: We Americans like to tell ourselves we are free, but we are
imprisoned. We are controlled by a corporate media that decrees what we should look like
and then determines what we have to buy in order to get and keep that look (2006, p. 47).
Studies have found that comparing oneself to thin models can result in body image
problems (Bergstrom et al., 2009). In the last decades, media images of women have
become less and less representative of the average size of women and have contributed
Body weight for today’s supermodels
is super-skinny compared with the
typical model of 30 years ago.
China Photos/Getty Images
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414 CHAPTER 14
to the perceived importance of thinness (Gazzar, 2008). In the early 1980s the average
model weighed 8% less than the average American woman; she now weighs 23% less (Jef-
fery, 2006). In an unprecedented action in 2006, the internationally prominent Madrid
Fashion Week imposed minimum weight criteria on models. e show banned too-thin
models who did not meet the World Health Organizations guidelines for healthy height-
to-weight ratios. Over 30% of the models who had participated in the previous years
show were disqualied, including top models such as Britains Kate Moss.
A womans self-consciousness about her nude body during physical intimacy with
a male partner is quite common, and the more concerned women are about being nude
with a partner, the less sexual satisfaction they report (Penhollow & Young, 2008;
Pujois et al., 2010). A research study of college women in the Midwest found that
35% reported physical self-consciousness during physical intimacy with a male part-
ner, agreeing to statements such as If a partner were to put a hand on my buttocks,
I would think, My partner can feel my fat’” and I would prefer having sex with my
partner on top so that my partner is less likely to see my body. Women who were less
self-conscious about their bodies viewed themselves as good sexual partners, were more
assertive with partners, and had more heterosexual experience than women who were
more self-conscious—even when their bodies were similar in size (Wiederman, 2000).
Familiarity and attachment with a partner may make a dierence: Women who were in
exclusive relationships reported less self-consciousness during sexual activity than did
women who were not in exclusive relationships (Steer & Tiggemann, 2008).
Problematic concerns about body image may be greater among White heterosexual
women than among women in some minority groups. Research indicates that African
American women rate themselves more sexually attractive than White women do (Ban-
croft et al., 2011). Further, other studies nd that women in sexual relationships with
other women feel more comfortable with their bodies than do women involved with
men (Huxley et al., 2011).
Men are less likely to report body image concerns during sexual activity than women
are (Nelson & Purdon, 2011). However, recent trends suggest that media images of men
contribute to mens insecurity about their bodies as well, and consequently men compro-
mise their sex lives by concerns about their appearance. For example, college men who
spend more time reading mens magazines and watching music videos and prime-time
TV are much less comfortable with their body hair and sweat than men who have less
exposure to mass media (Schooler & Ward, 2006). Men in magazines and on television
usually have no visible body hair. Male body hair is often a subject for jokes, as in the
movie e 40-Year-Old Virgin, in which the protagonist tries to have his chest hair waxed
o to be more appealing to his partners. Furthermore, mens dissatisfaction with their
own bodies was indicated by a study of body preference; most men preferred photos of
bodies with 30 pounds more muscle than their own (O’Neill, 2000). One study found
that men who were more satised with their strength, build, and exercise frequency and
were more comfortable with being nude were also more sexually satised than men who
felt less satised about these variables (Penhollow & Young, 2008).
Even though many partners do not put a priority on penis size, a mans concern about
the size of his penis can interfere with his arousal and enjoyment. In a survey of over
52,000 heterosexual men and women, only 55% of men were satised with their penis
size, but 85% of women were satised with their sexual partners penis size (Lever et al.,
2006). Unlike viewing typical-sized penises in classic artwork, such as Michelangelos
nude sculpture David, watching pornography can contribute to a mans distorted sense
of what is normal, because male porn stars are selected for their oversized genitals.
A study of over 27,000 men ages 20 to 75 in eight countries (the United States,
Britain, Germany, France, Italy, Spain, Mexico, and Brazil) provided a positive sign that
Hair removal by waxing was once the
province of women only.
AP Photo/Lucas Jackson
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Sexual Difculties and Solutions415 415
men perceive their masculinity dierently from the way popular media typically portray
it. Men were found to value many qualities more than their physical attractiveness and
sexual prowess. Being honorable, self-reliant, and respected by friends and having good
health and a positive relationship with their wives were deemed most important to them
(Sand et al., 2005).
e Western world is not unique in its concerns about cultural denitions of beauty,
as the following Sexuality and Diversity discussion explains.
SEXUALITY and DIVERSITY
Suffering for Beauty
Brazil’s 4,700 miles of coastline and Brazilian mens preference for women with large,
curvy bottoms have made butt-enhancing cosmetic surgery common in Brazil’s cities. One
of two methods is used: taking fat from the thighs and injecting it into the buttocks or
inserting implants to create a fuller rear. In Asia, the most frequently performed cosmetic
surgery, called the hitch and stitch, creates a fold above each eye to make a womans eyes
look rounder and more Western. Women in South Africa who consider lighter skin to
be the ideal of beauty use bleaching creams and soaps containing a substance that has been
banned for causing skin damage and dis-
figurement (Jones, 2003).
Personal ads in China often specify
height—the taller the better. Hundreds
of women each year undergo surgeries
to increase their leg length so they will be
2 to 4 inches taller. A team of ve surgeons
spends 3 hours sawing, drilling, and ham-
mering; then a frame is secured around
the leg with screws drilled through the leg
and into the bone. e frame forces the leg
to lengthen while the bone regenerates—a
process that takes at least 1 year.
Emotional Difficulties
The NHSLS found that unhappiness with life correlated with sexual problems. The
data did not clarify whether one causes the other, but women and men who were expe-
riencing sexual problems were considerably more likely to be unhappy with their lives
in general than were respondents without sexual difficulties (Laumann et al., 1999).
Emotional intelligence—the ability to identify, feel comfortable with, and manage one’s
emotions—appears to have significant effects on sexuality. One study found that
women who were better able to identify and manage their emotions had more fre-
quent orgasms during intercourse and masturbation than did women with less ability
to do so (Burri et al., 2009). Research has found that men with orgasmic inhibition
have difficulty relaxing, being playful, and releasing the sense of being in control. They
also have difficulty feeling emotionally dependent with a partner (Sandstrom & Fugl-
Meyer, 2007).
Lack of sexual interest and response is a common symptom of depression (Quinta
& Nobre, 2011). Moreover, stressful life problems such as a death in the family, divorce,
or extreme family or work diculties can interfere with a persons ability to focus on the
pleasure of the sexual experience (De Jong, 2009). Severe stress and trauma, as experi-
enced by combat veterans, can also interfere with emotional intimacy and sexual func-
tioning (Helng, 2008; Letourneau et al., 1997).
Eyes before and after surgery to make them
appear more Caucasian.
Courtesy of Charles S. Lee, MD/Enhance Plastic Surgery
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416 CHAPTER 14
Sexual Abuse and Assault
The essential conditions for positive sexual interaction—consent, equality, respect, trust,
and safety—are absent in sexual abuse. Boys and girls who are sexually abused are robbed
of the opportunity to explore and develop their sexuality at their own age-appropriate
pace (Maltz, 2003). According to the NHSLS, 12% of men and 17% of women were sex-
ually abused before adolescence (Laumann et al., 1999). It is important to note that not all
sexual abuse results in sexual problems in adulthood. Research shows that women with a
history of childhood sexual abuse have more negative feelings about sex, report less sexual
satisfaction, and are two to four times more likely than other women to have chronic pel-
vic pain and to experience depression, anxiety, and low self-esteem (Meston et al., 2006;
Rellini & Meston, 2011; Rellini et al., 2011). Research on male survivors is very limited,
but male survivors often have deep-seated concerns about their masculinity from having
been a sexual victim (Lew, 2004). In addition, survivors of sexual abuse often experience
aversion reactions to sexual behaviors that are similar to what was done to them during
the abuse. They may have flashbacks—sudden unwanted memories of the smells, sounds,
sights, feelings, or other sensations of past sexual abuse—that dramatically interrupt any
positive feelings and sexual pleasure (Courtois, 2000a, 2000b; Koehler et al., 2000).
Even teenage girls who engage in unwanted sex because they fear their boyfriends
will be angry if they say no experience subsequent anxiety and depression. One study
found that almost 41% of girls between 14 and 17 had been sexual when they did not
want to be, and 10% said their boyfriends forced them to have sex. In addi-
tion, the teen girls who experienced unwanted sex were also more likely to
have sexually transmitted infections and unwanted pregnancies, and their
partners were less likely to use condoms (Blythe et al., 2006).
Research has also indicated serious sexual consequences for survivors
of sexual assault during adulthood (Lutfey et al., 2006). One study of 372
female survivors of sexual assault found that almost 59% experienced sexual
problems after the assault—with about 70% of this group linking these prob-
lems to the assault. Fear of sex and lack of desire or arousal were the most
frequently mentioned problems (Becker et al., 1986). In addition, the eects
of sexual assault can be long-lasting; 60% of rape victims had sexual prob-
lems for more than three years after the assault (Becker & Kaplan, 1991).
e problems following childhood sexual abuse and adult sexual assault
are often dicult for partners of survivors to understand and to cope with
eectively (Haansbaek, 2006). Wendy Maltz, a sex therapist, developed e
Sexual Healing Journey and the DVD or video Partners in Healing specically
to help survivors of sexual abuse and their partners resolve problems origi-
nating from that abuse.
Relationship Factors
Besides personal feelings and attitudes, relationship factors strongly influence the sat-
isfaction and quality of a sexual relationship. One research study indicated that famil-
iarity and security support mens sexual function because men reported fewer problems
with erectile function during sex with an ongoing partner than with a nonrelationship
partner (Herbenick et al., 2010). Other studies have shown that greater satisfaction
with the overall relationship was related to higher sexual satisfaction and fewer sexual
problems (Witting et al., 2008). People in satisfying relationships may even experi-
ence benefits from sex that individuals in unsatisfying relationships do not. A study
that explored the link between stress and sexual activity found that sexual intercourse
relieved stress for men and women in satisfying relationships, but did not relieve stress
for those in unsatisfying relationships (Ein-Dor & Hirschberger, 2012).
The lm The Reader portrays the intense sexual
involvement between a teenage boy and an older
woman (Kate Winslet) and the impact it has on
the boy’s adult life (
Ralph Fiennes).
WEINSTEIN COMPANY, THE/THE KOBAL COLLECTION
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Sexual Difculties and Solutions417 417
Unresolved resentments, lack of trust or respect, or dislike of a partner can easily
lead to sexual disinterest and problems with arousal and orgasm. One partner can even
use his or her lack of sexual interest, consciously or subconsciously, to hurt or punish the
other. A person who is frequently pressured to engage in sex or who feels guilty about
saying no can feel less and less desire. In addition, someone who experiences a lack of
power and control in the relationship can lose her or his sexual desire or responsive-
ness (Hall, 2008; LoPiccolo, 2000). Sexual diculties can also occur when partners are
too dependent on each other; partners need a balance of togetherness and separateness
(DeVita-Raeburn, 2006; Perel, 2006). Even without specic relationship conicts, lack
of emotional intimacy can interfere with sexual interest and response (S. Levine, 2007).
Lack of sexual desire may reect unresolved relationship problems and negative inter-
action patterns (Dennerstein et al., 2009; Hayes et al., 2008). One study found that women
with HSDD reported more dissatisfaction with relationship issues than did women with
other sexual problems, such as diculty reaching orgasm (Stuart et al., 1998). In this
study, diminished desire was associated with a few specic relationship characteristics:
e womans partner did not behave aectionately except before intercourse.
Communication and conict resolution were unsatisfactory.
e couple did not maintain love, romance, and emotional closeness.
Ineffective Communication
Without effective verbal and nonverbal communication, couples must base their sexual
encounters on assumptions, past experiences, and wishful thinking—all of which can
make a sexual experience feel routine and unsatisfying. Research has found that sexual
satisfaction is correlated with the use of sexual terms and a greater degree of self-
disclosure about sexual preferences (Hess & Coffelt, 2011; MacNeil & Byers, 2009). A
frequent source of communication problems is stereotyped gender roles—in particu-
lar, the myth that sex is primarily the mans responsibility and that sexual assertiveness
in a woman is unfeminine. For example, women who do not experience orgasm have
more difficulty communicating their desire for direct clitoral stimulation to a partner
than women who do experience orgasm (Kelly et al., 1990).
© The New Yorker Collection 1998 P. C. Vey from cartoonbank.com. All rights reserved.
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418 CHAPTER 14
Fears About Pregnancy or Sexually Transmitted Infections
The fear of an unwanted pregnancy can interfere with coital enjoyment in a hetero-
sexual relationship, especially when couples do not use an effective method of contra-
ception (Sanders et al., 2003). On the other hand, many couples who want to conceive
and have difficulties doing so often find that their sexual relationship becomes anxiety
ridden, especially if they have to modify and regulate the timing and pattern of sexual
interaction to enhance the possibility of conception.
Anxiety about contracting a sexually transmitted infection, particularly HIV, can
interfere with sexual arousal in both homosexual and heterosexual relationships. For
people who are not in a monogamous, infection-free relationship, some risk exists.
Guidelines for safer sex are outlined in Chapter 15.
Sexual Orientation
Another reason that a woman or man experiences sexual dissatisfaction or has sexual prob-
lems in a heterosexual relationship can be a desire to be involved with individuals of the
same sex (Althof, 2000). Although much progress has been made in establishing gay rights,
following ones homosexual orientation still involves facing significant societal disapproval, if
not outright discrimination. To avoid these repercussions, some homosexual people attempt
to live in heterosexual relationships despite their lack of sexual desire in such relationships.
Sexual diculties can also occur in homosexual men or women who are in same-sex
relationships but have not yet been able to rid themselves of internalized negative beliefs
about homosexuality (Nichols, 1989), as this woman explained:
It had been a 10-year struggle for me to accept myself as a lesbian. I tried dating
men, but always found that a special, meaningful feeling was missing. I had sev-
eral relationships with women that didn’t work out. Then I met Carol. I liked her,
respected her, and was very attracted to her. I was looking for a long-term relation-
ship, and the compatibilities and feelings were right. Sex was great until she told
me she loved me. A switch went off, and I stopped feeling interested. In therapy,
I was able to realize that the lingering feelings of my mother’s disapproval had
stopped me cold from allowing myself to be fully happy and complete in a “queer”
relationship. I worked through those feelings and am now enjoying my sexuality
in a loving, committed relationship for the first time in my life. (Authors’ files)
© The New Yorker Collection 2007 Alex Gregory from cartoonbank.com.
All Rights Reserved.
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Sexual Difculties and Solutions419 419
Basics of Sexual Enhancement
and Sex Therapy
The various self-help and sex therapy suggestions offered in the following sections have
proved helpful to many people in enhancing sexual relationships or resolving sexual
problems (Van Lankveld, 2009). However, the same techniques do not work for every-
one, and exercises often need to be individually modified. Furthermore, professional
help may be called for when individual efforts, couple efforts, or both do not produce
the desired results. Recognizing that therapy is sometimes necessary to promote change,
we have included guidelines for seeking sex therapy in the last section of this chapter.
Increased self-knowledge is often an important step in sexual enhancement. With
this in mind, we briey outline procedures for improving awareness and acceptance of
your body and present activities that provide the most pleasurable stimulation.
Self-Awareness
Physical and emotional self-awareness and self-expression are crucial elements in satisfy-
ing sexual experiences (Morehouse, 2001; Schwartz, 2003). A good way to increase self-
awareness and comfort with our sexuality is to become well acquainted with our sexual
anatomy, as described in Chapters 3 and 4. Experimenting with masturbation is also an
effective way for both men and women to learn about and expand sexual response, as we
explained in Chapter 8. Self-stimulation and exploration are frequently an important part
of womens learning how to experience orgasm and mens learning to delay ejaculation.
People may have a style of masturbation that interferes with their ability to be
aroused by a partner. For example, 65% of men who sought help for ejaculatory inhibi-
tion had patterns of intensity, pressure, and speed of self-stimulation that were impos-
sible to reproduce during intercourse. Some of the men rubbed against specic surfaces
or used very heavy manual pressure or exceptionally fast strokes (Helien et al., 2005).
Women can also have patterns of masturbation, such as crossing their legs and rocking,
which a partner is unable to replicate. Modifying masturbation techniques to resem-
ble partner stimulation and intercourse more closely is one step toward experiencing
orgasm from partner stimulation.
Communication
One of the primary benefits of sex therapy—whether the immediate goal is learning to
have orgasms with partners, overcoming premature ejaculation, or solving almost any
other problem—is that partners participating together in the treatment often develop
more effective communication skills. This quotation from our files illustrates how
important communication can be in solving sexual difficulties:
He would say he was sorry he was so fast, and that maybe it would get better
with time. Finally, I asked him to come to class with me the day you showed the
film demonstrating the technique. Once we really talked openly things began to
work well. He showed me how he liked to be stimulated, things he had never
told me before. He became much more aware of my needs and what I needed
to be satisfied. We really started getting into a lot of variety in our lovemaking,
instead of just kissing and intercourse. By the way, the technique did work in
slowing him down, but I think the biggest benefit has been breaking down the
communication barriers. (Authors’ files)
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420 CHAPTER 14
We encourage you to review the communication strategies in Chapter 7 to help
improve your communication.
It can be particularly valuable for partners to communicate with each other about
what kind of touching they nd arousing by showing each other how they masturbate.
is activity is often a part of sex therapy for women learning to experience orgasm
with a partner and for resolving premature ejaculation and erectile diculties. Mastur-
bation is also a way to accommodate a potentially problematic dierence in sex drive in
a couple. e partner who wants sexual release more often than the other can mastur-
bate while the other partner kisses and caresses him or her without needing to become
aroused or experience orgasm.
Sensate Focus
One of the most useful couple-oriented activities for enhancing mutual sexual enjoy-
ment is a series of touching exercises called sensate focus (
Figure 14.3). Masters and
Johnson developed the technique of sensate focus to use as a basic step in treating sexual
problems. Sensate focus can help to reduce anxiety caused by goal orientation and to
increase communication, pleasure, and closeness (De Villers & Turgeon, 2005). This
technique is also useful for any couple wanting to enhance their sexual relationship.
In the sensate focus touching exercises, partners take turns touching each other while
following some essential guidelines. Both homosexual and heterosexual couples can benet
from sensate focus. In the following descriptions, we assume that the one doing the touch-
ing is a woman and the one being touched is a man. To start, the person who will be doing
the touching takes some time to set the scene” so that the environment will be comfort-
able and pleasant for her; for example, she might turn o any phones and arrange a warm,
cozy place with relaxing music and lighting. e two people then undress, and the toucher
begins to explore her partner’s body, following this important guideline: She is to touch
not to please or arouse her partner but to please herself. e goal is for the toucher to focus
on her perception of textures, shapes, and temperatures. e person being touched notices
how the touching feels, and he remains quiet except when any touch is uncomfortable. In
that case, he describes the uncomfortable feeling and what the toucher could do to make it
more comfortable. For example: “at tickles. Please touch the other side of my arm. is
guideline helps the toucher attend fully to her own sensations without worrying about
whether something she is doing is unpleasant for her partner. e nondemanding quality
Figure 14.3 The process of sensate
focus, in which partners sensually
explore each others body, can con-
tribute to the mutual enhancement of
a couple’s sexual enjoyment.
sensate focus
A process of touching and com-
munication used to enhance sexual
pleasure and to reduce performance
pressure.
© Cengage Learning
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Sexual Difculties and Solutions421 421
of this kind of touching helps reduce or eliminate performance anxiety and allows the
couple to expand touch beyond goal-directed stimulation.
In the next sensate focus exercise, the two people switch roles, following the same
guidelines as before. In these initial sensate focus experiences, intercourse and touching
the breasts and genitals are prohibited. Only after the partners have focused on touch
and on communicating uncomfortable feelings do they include breasts and genitals as
part of the exercise. Again, the toucher focuses on his or her own interest and pleasure,
not the partner’s. After the inclusion of breasts and genitals, the partners progress to a
simultaneous sensate focus experience. Now they touch one another at the same time
and experience feelings from both touching and being touched.
Modern Western sex therapy is based on the assumption that the values of open
communication, emotional intimacy, and physical pleasure for both partners guide treat-
ment and are its goals. However, these principles are antithetical to many cultures norms
(Goodman, 2001), as we explain in the following Sexuality and Diversity discussion.
SEXUALITY and DIVERSITY
How Modern Sex Therapy Can Clash With Cultural Values
Cultural beliefs influence sexual practices, the perception of sexual problems, and
modes of treatment. For example, in much of the Middle East the marital sexual rela-
tionship is based primarily on the two dimensions of male sexual potency and couple
fertility. For both men and women, only when intercourse itself is impaired—not inter-
est or pleasure—do couples seek treatment. Unconsummated marriage is a common
complaint in conservative societies of the Middle East (Ghanem, 2011).
A study conducted in Saudi Arabia found that the most common problem leading
a couple to sex therapy was erectile disorder. Women in Saudi Arabia, who are raised
to inhibit their sexual desires, came to sex therapy only with problems of painful inter-
course. Unlike their counterparts in Western countries, the women did not seek help
for lack of desire, arousal, or orgasm (Osman & Al-Sawaf, 1995). A study of Islamic
sex therapy centers found that 80% of female clients came for treatment of vaginismus
(Aziz & Gurgen, 2009).
Many cultural traditions allow for little or no education or communication about
sexual matters. Asians may consider it shameful to discuss sex, especially with someone
outside the family. Muslims are often taught to avoid talking about sexuality with people
of the other sex (including their spouses). Taking a sex history can be distressing for cli-
ents with these beliefs, especially when the husband and wife are interviewed together.
In cultures in which women are expected to be innocent about sex, the sex-education
component of therapy conicts with the prevailing values. In Pakistan the lack of formal
sex education leads to misinformation. For example, men who experience premature
ejaculation usually believe that masturbation and ejaculation during sleep have dam-
aged muscles and blood vessels in the penis, causing their sexual problem (Bhatti, 2005).
Western sex therapy techniques often contradict cultural values. For example, mas-
turbation exercises to treat anorgasmia, erectile diculties, or premature ejaculation
conict with religious prohibitions of Orthodox Jews and some fundamentalist Chris-
tians and Muslims (Sungur, 2007). e gender equality inherent in sensate focus exer-
cises and the avoidance of intercourse in such exercises are also often objectionable to
many religious and ethnic groups.
Sex therapy needs to take into account the clients cultural values and the implica-
tions they have for intimate behavior (Nasserzadeh, 2009). erapists should attempt
to adjust therapy to their clients well-integrated ethnic and religious perspectives (Rich-
ardson et al., 2006; Shtarkshall, 2005). is is likely to be more helpful than attempting
to impose the cultural norms inherent in Western sex therapy (Ribner, 2009).
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422 CHAPTER 14
In the remainder of this chapter, we look at some strategies and sex therapy approaches
that are used to deal with female and male sexual problems and sexual desire disorder.
Specific Suggestions for Women
In this section, we describe procedures that may help women learn to increase sexual
arousal and reach orgasm by themselves or with a partner. We also include suggestions
for dealing with vaginismus.
Becoming Orgasmic
Therapy programs for learning to experience orgasm are based
on progressive self-awareness activities that a woman does at
home between therapy sessions. At the beginning of treatment,
body exploration, genital self-exam, and Kegel exercises (see
Chapter 3) are emphasized; then therapy and home exercises
move progressively to self-stimulation exercises similar to those
described in Chapter 8 (see Self-Pleasuring Techniques”). One
advantage of self-stimulation is that a woman who does not have
a partner can learn to become orgasmic.
A vibrator is sometimes used to help a woman experience
orgasm for the rst time so she knows that she can have this
response. (A vibrator is often less tiring to use than the ngers and
supplies more intense stimulation.) After she has experienced a
few orgasms with the vibrator, it is helpful for her to return to
manual stimulation. is step is important because it is easier for
a partner to replicate a womans own touch than the stimulation of
a vibrator. Another method, involving the EROS Clitoral erapy
Device (shown in
Figure 14.4), is designed to increase blood ow
to, and thereby arousal of, the clitoris (Munarriz et al., 2003). e
hormones and products discussed in the section on treating low
sexual desire may also be useful for increasing arousal.
Experiencing Orgasm With a Partner
Once a woman has learned to experience orgasm through self-
stimulation, sharing her discoveries with her partner can help
her partner know what forms of stimulation are most pleasing
to her. Each partner takes turns visually exploring the other’s
genitals, locating all the parts discussed in Chapters 3 and 4.
After looking thoroughly, they experiment with touch, noticing
and sharing what different areas feel like. The next step is for the
woman to stimulate herself in her partner’s presence, and her partner can be holding
and kissing her or lying beside her, as shown in
Figure 14.5. This step is often a dif-
ficult one. One woman described how she dealt with her discomfort:
When I wanted to share with my partner what I had learned about myself
through masturbation, I felt anxious about how to do it. Finally, we decided
that to begin with, I would be in the bedroom, and he would be in the living
room, knowing I was masturbating. Then he would sit on the bed, not looking at
me. The next step was for him to hold and kiss me while I was touching myself.
Then I could be comfortable showing him how I touch myself. (Authors’ files)
Small, soft plastic
cup that is placed
on clitoris
Battery-operated
pump that creates
suction to increase
blood flow to clitoris
Figure 14.4 The EROS Clitoral Therapy Device, approved
by the FD
A in 2000, works by increasing vasocongestion of
the clitoris.
Courtesy of Nugyn, Inc.
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Sexual Difculties and Solutions423 423
Next the partner begins nondemanding manual genital pleasuring. e couple can do
this in any position that suits them. e woman places her hand over her partners hand
on her genitals to guide the partner’s touch. ey can use lubricants to increase pleasure
of the sensations. e purpose of the initial sessions is for the woman to teach her partner
what feels good rather than to produce orgasm. Once the woman thinks she is ready to
experience orgasm, she indicates to her partner to continue the stimulation until she expe-
riences climax. Orgasm will probably not occur until the couple has had several sessions.
Couples can use several specic techniques to increase a womans arousal and the
possibility of orgasm during intercourse. e rst has to do with when to begin inter-
course. Rather than beginning intercourse after a certain number of minutes of fore-
play or when there is sucient lubrication, a woman can be guided by her feeling of
what might be called readiness. Readiness is a vaginal sensation of wanting intercourse.
Not all women experience this feeling of readiness, but for those who do, beginning
intercourse at this time (and not before) can enhance the ensuing erotic sensations. Of
course, the womans partner will have to cooperate by waiting for her to indicate when
she is ready and by not attempting to begin intercourse before then.
A woman who wants increased stimulation dur-
ing coitus might benet from initiating the kinds of
movements and pressure she nds most arousing.
A woman can also stimulate her clitoris manually
or with a vibrator during intercourse, as shown in
Figure 14.6 on page 424. Her partner’s manual
stimulation of her clitoris during intercourse will
likely also enhance arousal.
Table 14.5 high-
lights how women who are routinely orgasmic
during intercourse facilitate experiencing orgasm
(Ellison, 2000).
Dealing With Vaginismus
Treatment for vaginismus usually begins during a
pelvic exam, in which the health-care practitioner
demonstrates the vaginal spasm reaction to the
woman or couple. Subsequent therapy starts with
relaxation and self-awareness exercises, including a
Figure 14.5 Masturbating in the
presence of a partner can be an effec-
tive way for an individual to indicate
what kind of touching she or he finds
arousing.
At a Glance
TABLE 14.5 Facilitating Orgasm
In this study, 2,371 women completed the sentence “In addition to getting
specic physical stimulation, I often have done the following to help me
reach orgasm during sex with a partner.
Activity Percentage
Positioned my body to get the stimulation I needed 90
Paid attention to my physical sensations 83
Tightened and released my pelvic muscles 75
Synchronized the rhythm of my movements to my partner’s 75
Asked or encouraged my partner to do what I needed 74
Got myself in a sexy mood beforehand 71
Focused on my partner’s pleasure 68
Felt/thought how much I love my partner 65
SOURCE: Ellison (2000, p. 244).
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424 CHAPTER 14
soothing bath, general body exploration, and manual external genital pleasuring. Next
the woman learns to insert first a fingertip, then a finger, and eventually three fingers into
her vagina without experiencing muscle contractions. At each stage the woman prac-
tices relaxing and contracting the vaginal muscles, as with Kegel exercises (see Chapter
3). Dilators, which are cylindrical rods of graduated sizes, are also sometimes used to
accustom the vaginal walls to relaxing (Leiblum, 2000). Biofeedback and physical therapy
treatments to lessen muscle tension in the pelvic floor can also be helpful for vaginismus
and other forms of dyspareunia (Goldfinger et al., 2009; Rosenbaum, 2011).
Once the woman has completed the preceding steps, her partner can begin to partici-
pate by following the same steps that she completed by herself. After the man can insert
three ngers without inducing a muscle spasm, the woman controls a slow insertion
of her partners penis, with many motionless pauses that allow the woman to become
familiar with vaginal containment of the penis. Pelvic movements and pleasure focusing
are added later, only when both partners are comfortable with penetration.
Specific Suggestions for Men
In the following paragraphs, we outline methods for dealing with the common difficul-
ties of premature ejaculation and erectile disorder. We also discuss a way to treat the
less common condition of orgasmic disorder.
Lasting Longer
Some self-help and sex therapy approaches to learning ejaculatory control are easy to
implement—in many cases, without professional guidance.
Strategies for Delaying Ejaculation In some cases, men can gain considerable control
over ejaculation by practicing a few simple strategies. Men for whom premature ejacu-
lation is not a problem and women readers may find the following discussion valuable
simply because they would sometimes like sexual intercourse to last longer.
Ejaculate more frequently. Men with premature ejaculation problems sometimes
nd that they can delay ejaculation when they are having more frequent orgasms,
by masturbation or partner sex.
Come again! A couple can experiment with continuing sexual interaction after the
mans rst ejaculation, then resume intercourse when his erection returns. is
SEXUALHEALTH
Figure 14.6 The use of a vibrator for
clitoral stimulation during coitus.
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Sexual Difculties and Solutions425 425
strategy is most useful for younger men, who experience erections again soon after
ejaculation.
Change positions. If a man wants to delay ejaculation, he may gain some control by
lying on his back and increasing physical relaxation. (See page 244 for variations of
the woman-above position.) However, if a man attempts energetic pelvic move-
ments in this position, it will be counterproductive because he will be increasing
muscle tension by moving both his own weight and his partners.
Talk with each other. To delay climax, the man often nds it essential to slow down
or completely cease movements. He needs to tell his partner when to reduce or
stop stimulation.
Consider alternatives. To minimize performance anxiety about rapid ejaculation
(and most of the other problems discussed here), it is often useful to think of
intercourse as just one of several options for sexual sharing.
The Stop-Start Technique James Semans, a urologist, developed the stop-start tech-
nique, which enables the man to become acquainted with and ultimately control his
ejaculatory reflex. The partner is instructed to stimulate the mans penis, either manu-
ally or orally, to the point of impending orgasm—at which time stimulation is stopped
until the preejaculatory sensations subside (Semans, 1956). (A man can also practice
this technique on himself during solo masturbation sessions [Zilbergeld, 1992].) These
sessions generally last 15 to 30 minutes and occur as often as once a day for several days
or weeks. During each session, the couple repeats the stimulation and the stop-start
procedure several times and then allows ejaculation to occur on the last cycle. The cou-
ple should reach an agreement about sexual stimulation and orgasm for the mans part-
ner. If the partner desires these, the couple can engage in nonintercourse sexual activity.
As the mans ejaculatory control improves, the couple progresses to intercourse. For
heterosexual couples, the best position is the woman above, sitting up. e rst step is
for the man to guide his penis in the womans vagina and lie quietly for several moments
before beginning slow movements. When he begins to feel close to orgasm, they lie
quietly again. is stop-start intercourse technique is continued as the man experiences
progressively better ejaculatory control.
Medical Treatments A combination of sex therapy and medical treatments can be more
helpful than either alone in helping men extend their arousal prior to ejaculation (Steg-
gall et al., 2008). Small doses of selective serotonin reuptake inhibitors (SSRIs), medi-
cation usually prescribed for depression, can help men to delay ejaculation. One of the
side effects of these medications is suppressed orgasm in men and women, which is
often helpful in treating rapid ejaculation. Other medications for treating premature
ejaculation are under study, including dapoxetine, which has been developed specifically
for such treatment and has shown positive results in research studies (Douglass & Lin,
2010; McMahon et al., 2011b; Serefoglu et al., 2011).
Reducing the sensitivity of the penis is another approach to reducing rapid ejacula-
tion (Carson & Wyllie, 2010). In a placebo-controlled study, using an anesthetic spray
ve minutes before intercourse helped men extend the length of time of intercourse
before they ejaculated from an average of 36 seconds to nearly 4 minutes. eir experi-
ence of orgasm improved as well: About 62% said that their orgasm was good or very
good, whereas only 20% had said so prior to treatment (Hellstrom, 2010).
Dealing With Erectile Dysfunction
Besides physically caused erection difficulties, performance anxiety is a major source
of erectile dysfunction. Therefore, most sex therapy concentrates on reducing or
stop-start technique
A treatment technique for premature
ejaculation, consisting of stimulating
the penis to the point of impending
orgasm and then stopping until the
preejaculatory sensations subside.
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426 CHAPTER 14
eliminating anxiety. Initially, a couple uses the sensate focus exercises, understanding
that at this point the touching is intended not to result in erection, ejaculation, or
intercourse, but to focus on and enjoy the touch without a further goal. The following
account shows a common reaction to the exercise:
When the therapist told us that intercourse was off limits, at least for the time
being, I couldn’t believe how relieved I felt. If I couldn’t get hard, so what? After
all, I was told not to use it even if I did. Those first few times touching and get-
ting touched by my wife were the first really worry-free pleasurable times I had
experienced in years. (Authors’ files)
If a couple wants to, they can agree in advance for the partner to have an orgasm at the
close of a session by whatever mode of stimulation other than intercourse seems comfort-
able to both (self-stimulation, being touched by the partner, oral stimulation, etc.). When
the couple has progressed to a point where both partners feel comfortable with sensate
focus, the couple explores what kinds of genital stimulation other than intercourse are
particularly pleasurable for the man. When the man experiences a full erection, his partner
should stop doing what has aroused him. It is crucial that they allow his erection to sub-
side at this point to alter the mans belief that once his erection is lost it will not return. e
couple spends this time holding each other close or exchanging nongenital caresses. Once
the penis is completely accid, the mans partner resumes genital pleasuring.
e nal phase of treatment for heterosexual couples who desire intercourse involves
penetration and coitus. With the man on his back and the woman astride, the couple
begins with sensate focus and then moves to genital stimulation. When the man has an
erection, his partner lowers herself onto his penis, maintaining stimulation with gentle
pelvic movements. It is important to allow the man to be selsh, concentrat-
ing exclusively on his own pleasure (Kaplan, 1974). Occasionally a man loses
his erection after penetration. If this happens, his partner returns to the oral or
manual stimulation that originally produced his erection. If his response con-
tinues to be blocked, it is wise to stop genital contact and return to the original
nondemand pleasuring of sensate focus before moving forward again.
Medical Treatments Some men who have impaired erectile functioning as the
result of physiological problems make a satisfactory sexual adjustment to the
absence of erection by emphasizing and enjoying other ways of sexual sharing.
For other men with erection difficulties, several types of medical treatments
are available. Viagra, a pill for erectile problems, became available in 1998.
Originally developed for cardiovascular disease, it became the fastest-selling
prescription drug in history. Almost 40,000 prescriptions were dispensed in
the first 2 weeks on the market (Holmes, 2003). In 2003 and 2004 the FDA
approved two additional Viagra-like drugs, Levitra and Cialis. These medica-
tions work by prolonging the vasodilator effects of nitric oxide in the body.
Blood vessels in the penis expand, and erections result from the increase in
blood flow (Hoffman, 2009). Research has consistently shown that a combi-
nation of ED medication and couple sex therapy is more effective in helping
this problem than medication alone (Aubin et al., 2009).
Viagra, Levitra, and Cialis have similar side eects; the most common are
ushing, headaches, upset stomach, and nasal congestion (Gotthardt, 2003;
Hazell et al., 2009). Erectile dysfunction drugs can also cause priapism, in
which an erection does not subside and can result in permanent damage to
penile tissue unless medical treatment is obtained (Adams, 2003). Hydrogen
Viagra ads initially focused on older men with
erectile dysfunction.
Ads now tend to appeal to
a wider variety of ages, including younger men
and even women who use Viagra for sexual
enhancement rather than treatment.
© Bill Aron/PhotoEdit
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Sexual Difculties and Solutions427 427
sulde is a vasodilator found in small amounts in the human body, and researchers are
studying it as another potential treatment for ED (Conner, 2009).
For many couples, erection-enhancing drugs can be wonder drugs that restore the
intimacy of intercourse (Verheyden et al., 2007). Many studies have shown signicant
improvement in the partner’s feelings of sexual desirability and satisfaction as well as
her own sexual functioning when the man uses erection-enhancing medications (Eard-
ley et al., 2006; M. McCabe et al., 2011). However, some men have found that rm
erections are secondary to a good relationship (Metz & McCarthy, 2008). In a troubled
relationship the use of such a medication can clarify for the couple that they have other
relationship problems, which may lead the couple to work toward resolving them (Coo-
per, 2006).
Viagra has greatly increased general conversation and awareness about erectile prob-
lems. In fact, men who do not have erectile dysfunction are using erection-enhancing
drugs for rmer and longer-lasting erections. e appeal to men to be able to extend
intercourse beyond one or more ejaculations contributes to the recreational use of such
drugs. Reports also indicate that Viagra has emerged among college students and oth-
ers as a party drug for recreational and casual sex (Apodaca & Moser, 2011; Harte &
Meston, 2011). Unfortunately, mixing Viagra and recreational drugs combines endur-
ing erections with the poor judgment of an altered mental state in which men engage in
high-risk sexual behaviors that they otherwise would avoid (Adams, 2003).
Mechanical Devices Devices that suction blood into the penis and hold it there during
intercourse have been available since the mid-1980s (Korenman & Viosca, 1992). Exter-
nal vacuum constriction devices, which are available by prescription, consist of a vacuum
chamber, pump, and penile constriction bands. The vacuum chamber is placed over the
flaccid penis. The pump creates a negative pressure inside the chamber and draws blood
into the penis. The elastic band is then placed around the base of the penis to trap the
blood, and the chamber is removed (Levy et al., 2000). Another mechanical device recently
approved by the FDA to help men experience erections is the VIBERECT device. It pro-
vides vibrations to two surfaces of the penis, stimulating reflexive reactions that initiate
blood flow for an erection to occur (Ostrovsky, 2011).
Surgical Treatments A surgically implanted penile prosthesis is
an option for men who are not helped by Viagra or other meth-
ods. The main reason for implants is radical prostatectomy.
The surgery is expensive and involves risks, including infection,
and men should evaluate this option carefully and include their
partner in pre- and postsurgical counseling. There are two basic
types of penile implants. One type consists of a pair of semi-
rigid rods made of metal wires or coils inside a silicone cover-
ing; the rods are placed inside the cavernous bodies of the penis.
Although this type is easier to implant than the second type,
a potential disadvantage is that the penis is always semierect.
The second type of prosthesis is an inflatable device that enables
the penis to change from flaccid to erect (
Figure 14.7). Two
inflatable cylinders are implanted into the cavernous bodies of
the penile shaft. They are connected to a fluid-filled reservoir
located near the bladder and to a pump in the scrotal sac. To
become erect, a man squeezes the pump several times, and the
fluid fills the collapsed cylinders, producing an erection. When
an erection is no longer desired, a release valve causes the fluid to
go back into the reservoir (Shaw & Garber, 2011).
Reservoir
Cylinder
Pump
Figure 14.7 An inflatable penile prosthesis.
© Cengage Learning
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428 CHAPTER 14
Neither of these devices can restore sensation or the ability to ejaculate if it has been
lost as a result of medical problems. Furthermore, the surgery to implant the devices may
diminish sensation. ey do, however, provide an alternative for men who want to mechan-
ically restore their ability to have erections. Most men who have them report improved
sexual activity, and about 85% are satised with the results of the surgery (Cortez-Gonzales
& Glina, 2009; Richter et al., 2006).
Reducing Male Orgasmic Disorder
Sex therapy usually begins with a few days of sensate focus, when the man should
not have an ejaculation by masturbation or partner interaction. If his partner desires
orgasm, this can be accomplished in whatever fashion is comfortable for both partners.
The next step is for the man to stimulate himself to orgasm with his partner pres-
ent. Once both partners feel comfortable with the man masturbating, the couple can
move on to the next phase, where the partner attempts to bring him to orgasm with
whatever stimulation is most arousing. It may take several sessions before the partner’s
stimulation produces an ejaculation, and it is important for the man not to ejaculate by
masturbation during this period. Most therapists agree that once he can reach orgasm
by his partner’s touch, an important step has been accomplished.
When the man is ejaculating consistently in response to partner stimulation, the
couple can move on to the nal phase of treatment, in which ejaculation takes place
during penetration. After building arousal by other means, the couple tries penetration.
If he does not ejaculate shortly after penetration, he should withdraw and resume other
stimulation until he is about to ejaculate, at which point the couple resumes penetration.
Once the man experiences a few ejaculations during penetration, the mental block that
is usually associated with ejaculatory disorder often disappears. In addition, psycho-
therapy to understand and resolve deeper personal or couple problems may be necessary
to resolve male orgasmic disorder.
Treating Hypoactive Sexual Desire Disorder
Many aspects of the treatment for hypoactive sexual desire disorder are similar to spe-
cific suggestions for resolving other sexual problems. These include
Encouraging erotic responses through self-stimulation and arousing fantasies
Reducing anxiety with appropriate information and sensate focus exercises
Enhancing sexual experiences through improved communication and increased skills—
both in initiating desired sexual activity and in refusing undesired sexual activity
Expanding the repertoire of aectionate and sexual activities
Most therapists combine suggestions for specific activities with insight therapy, which
can help a person understand and resolve any subconscious conflicts about sexual plea-
sure and intimacy. When low sexual desire is a symptom of unresolved relationship
problems, therapy focuses on the interactions between partners that contribute to the
lack of sexual desire (Alperstein, 2001).
Medical Treatments
Men with low levels of testosterone often use testosterone supplementation—usually
a transdermal gel—to increase their sex drive (Tomlinson et al., 2006). The number of
testosterone prescriptions has tripled in recent years as a growing number of men are
taking testosterone to offset the normal age-related decline of the hormone (Harvard
Health Publications, 2006).
A review of controlled studies on estrogen and testosterone and postmenopausal
womens sexual functioning found that both estrogen and testosterone therapies are
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Sexual Difculties and Solutions429 429
associated with increased sexual interest, arousal, and satisfaction with masturbation
and partner sexual activity (Davis, 2007; Leventhal-Alexander, 2005). Testosterone
can also increase sexual interest for premenopausal women with below-normal levels
of testosterone (Berga & McCord, 2005; Reinberg, 2006). In 2004 the FDA turned
down an application for Intrinsa, a testosterone patch for women, in spite of studies
showing improvement in desire and pleasure for postmenopausal women (Dennerstein
& Goldstein, 2005; Herper, 2011). erefore, testosterone is available to women only
by prescription for o-label use. Physicians wrote over 2 million such prescriptions for
women in 2006 and 2007, a rate that indicates a need for FDA-approved testosterone
products for women (Snabes & Simes, 2009). Research about side eects, especially
cancer and heart disease, from testosterone therapy for both men and women continues
in order to clarify risks and benets (Reinberg, 2006). e testosterone patch has been
available in several European countries since 2007 (Whittelsey, 2007).
e search for the “female Viagra remains elusive, and several medications have not
met FDA approval. Research into other medical possibilities for improving sexual inter-
est and arousal in women is under way (Jordan et al., 2011; Nappi et al., 2010). Two
nonprescription products that have been researched in accordance with FDA standards
and published in peer-reviewed journals are Zestra, an oil applied to the clitoris and
vulva, and ArginMax, a nutritional supplement. Zestra was found to increase sexual
response (Ferguson et al., 2010), and study participants using ArginMax reported
increased clitoral sensation, sexual desire, vaginal lubrication, frequency of orgasm, and
sexual satisfaction (Ferguson et al., 2003; Ito et al., 2001).
Seeking Professional Assistance
Although some people with sexual problems improve over time without professional
help, sometimes therapy is necessary. In fact, sometimes alleviation of sexual problems
is a side effect of successful psychotherapy for general psychological problems (Hoyer
et al., 2009). However, seeking therapy is often a difficult step. A community medi-
cal practice found that, when asked, many men reported various sexual problems, but
none had previously sought professional help (Rosenberg et al., 2006).
What Happens in Therapy?
Many people are apprehensive about going to see a sex therapist,
so it can be helpful to have some idea about what to expect. Each
therapist works differently, but most therapists follow certain steps.
During the first appointment, the therapist will help the client (or
clients, if a couple) clarify the problem and his or her feelings about
it and identify the client’s goals for the therapy. The therapist will
usually ask questions about when the problem began, how it has
developed over time, what the client thinks caused it, and how she
or he has already tried to resolve it. Sometimes the therapist may
only need to provide specific information that the client lacks or
to reassure the client that his or her thoughts, feelings, fantasies,
desires, and behaviors that enhance personal satisfaction are nor-
mal. On the other hand, some people may benefit from permission
not to engage in certain sexual activities they dislike.
Over the next few sessions (most therapy occurs in 1-hour weekly
sessions), the therapist may gather more extensive sexual, personal,
and relationship histories. e therapist will likely obtain informa-
tion about medical history and current physical functioning to make
any necessary referrals for further physical screenings. During these
The Gottman Institute, founded by John and Julie
Gottman (pictured here), is a well-known center for
research-based couples therapy. It has a web-based
sexual enhancement program at www.gottsex.com. It
is designed to help couples in long-term relationships
develop and maintain loving, intimate sex.
Courtesy of The Gottman Institute
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430 CHAPTER 14
sessions, the therapist will also explore whether the client has a lifestyle conducive to a
good emotional and sexual relationship and determine whether she or he has problems
with substance abuse or domestic violence.
Once the therapist and the individual (or couple) more fully realize the nature of the
diculty and have dened the therapy goals, the therapist helps the client understand
and overcome obstacles to meeting the goals as the sessions continue. e therapist often
provides psychoeducational information and gives assignments, such as masturbation
or sensate focus exercises, for the client to do between therapy sessions (Althof, 2006).
Successes and diculties with the assignments are discussed at subsequent meetings.
In some cases personal emotional diculties or relationship problems are causing the
sexual issue, and various forms of intensive therapy are necessary.
erapy is terminated when the client reaches his or her goals. e therapist and cli-
ent may also plan one or more follow-up sessions. It is often helpful for a client to leave
with a plan for continuing and maintaining progress.
Selecting a Therapist
To select a therapist, you might ask your sexuality course instructor or health-care
practitioner for referrals or contact either the American Association of Sex Educators,
Therapists, and Counselors or the American Board of Sexology. After consulting some
of these sources, you should have several potential therapists from which to choose. A
professional who has specialized in sex therapy should have a minimum of a master’s
degree and credentials as a licensed psychiatrist, psychologist, social worker, or coun-
selor. To do sex therapy, he or she should also have participated in sex therapy training,
supervision, and workshops. It is very appropriate for you to inquire about the specific
training and certification of a prospective therapist.
To help determine whether a specic therapist will meet your needs, pay attention
to how you feel about talking with the therapist. erapy is not intended to be a light
social interaction, and it can be quite uncomfortable to discuss personal sexual concerns.
However, for therapy to be useful, you need to have the sense that the therapist is open
and willing to understand you.
After the initial interview, you can decide to continue with that particular therapist
or ask for a referral to another therapist more appropriate to your personality or needs.
If you become dissatised once you begin therapy, discuss your concerns with your
therapist. Decide jointly, if possible, whether to continue therapy or to seek another
therapist. It is usually best to continue for several sessions before making a decision to
change. Occasionally, clients expect magic cures rather than the dicult but rewarding
work that therapy often demands.
Unethical Relationships: Sex Between Therapist and Client
It is highly unethical for professional therapists to engage in sexual relationships with cli-
ents they treat—both during therapy and after it has ended (Lamb et al., 2003; Reamer,
2003). It is the professional’s responsibility to set boundaries that ensure the integrity of
the therapeutic relationship. Psychiatry, psychology, social work, and counseling profes-
sional associations have codes of ethics against sexual relations between psychotherapists
and their clients. In addition, some states have criminalized sexual behavior with patients.
However, research has found that up to 3% of female therapists and 12% of male thera-
pists admit to having sexual contact with a current client (Berkman et al., 2000).
Sexual involvement between client and therapist can have negative eects on the cli-
ent. Research has indicated that women who experienced sexual contact with their thera-
pists (including psychotherapists in general, not just sex therapists) felt greater mistrust
of and anger toward men and therapists than did a control group of women. ey also
SEXUALHEALTH
SEXUALHEALTH
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Sexual Difculties and Solutions431 431
experienced more psychological and psychosomatic symptoms, including anger, shame,
anxiety, and depression (Finger, 2000; Regehr & Glancy, 1995). If at any time a thera-
pist makes verbal or physical sexual advances toward you, you have every right to leave
immediately and terminate therapy. Furthermore, it will be helpful to others who might
become victims of this abuse of professional power if you report the incident to the state
licensing board for the therapist’s profession.
Sexual health is a state of physical, emotional, mental, and
sexual well-being.
e National Health and Social Life Survey (NHSLS)
found that many people reported problems in their sex lives.
Sexual problems can contribute to lower satisfaction with
overall life.
Specic Sexual Difculties
A sexual problem must occur within the context of
adequate physical and psychological stimulation to be
considered a disorder.
Hypoactive sexual desire disorder (HSDD) is characterized
by the absence or minimal experience of sexual interest prior
to and during the sexual experience.
Dissatisfaction with frequency of sexual activity occurs
when individual dierences in sexual interest result in rela-
tionship distress.
Sexual aversion disorder is an extreme irrational fear or dis-
like of sexual activity.
Female genital sexual arousal disorder is an inhibition of the
vasocongestive response; female subjective sexual arousal
disorder is a lack of subjective feelings of arousal when
physical signs of arousal are present; combined genital and
subjective sexual arousal disorder involves both.
Persistent sexual arousal disorder is spontaneous and
unwanted genital arousal that is not relieved by orgasm.
Male erectile dysfunction is the consistent or recurring inabil-
ity over at least 3 months to have or maintain an erection.
Female orgasmic disorder is the absence, marked delay, or
diminished intensity of orgasm despite high subjective arousal.
Situational female orgasmic disorder occurs when a woman
can experience orgasm during masturbation but not with a
partner.
Coitus provides mostly indirect clitoral stimulation, and for
many women it does not provide sucient stimulation to
result in orgasm.
Male orgasmic disorder is the inability of a man to ejaculate
during sexual activity with a partner.
Summary
Premature ejaculation occurs when a man consistently
ejaculates quickly and is unable to control the timing of his
ejaculation.
Both men and women fake orgasm, although women do
so more often. Pretending usually perpetuates ineective
patterns of relating and reduces the intimacy of the sexual
experience.
Dyspareunia, or pain during coitus, is disruptive to sexual
interest and arousal in both women and men. Numerous
physical problems can cause painful intercourse. Vestibulo-
dynia may be the most common cause of painful intercourse
for women.
Peyronies disease, in which brous tissue and calcium
deposits develop in the penis, can cause pain and curvature
of the penis during erection.
Vaginismus is an involuntary contraction of the outer vagi-
nal muscles that makes penetration of the vagina dicult
and painful. Many women who have vaginismus are inter-
ested in and enjoy sexual activity.
Origins of Sexual Difculties
Physiological conditions can be the primary causes of sexual
problems or can combine with psychological factors to result
in sexual dysfunction. It is important to identify or rule out
physiological causes of sexual problems through medical
examinations.
Good sexual functioning correlates with good health habits,
including a healthy diet, exercise, moderate or no alcohol
use, and not smoking.
Chronic illnesses and their treatments can greatly aect
sexuality. Diseases of the neurological, vascular, and endo-
crine systems can impair sexual functioning.
Diabetes causes damage to nerves and the circulatory sys-
tem, impairing sexual arousal.
Cancer and its therapies can impair the hormonal, vascu-
lar, and neurological functions necessary for normal sexual
activity. Cancer of the reproductive organs often has the
worst impact.
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
432 CHAPTER 14
Multiple sclerosis is a neurological disease of the brain and
spinal cord that can aect sexual interest, genital sensation,
arousal, or capacity for orgasm.
Cerebrovascular accidents, or strokes, can reduce a persons
frequency of interest, arousal, and sexual activity.
Most people with spinal cord injuries remain interested in
sex, and more than half experience some degree of sexual
arousal.
People with cerebral palsy, which is characterized by mild to
severe lack of muscular control, may need help with prepa-
ration and positioning for sexual relations.
Blind and deaf individuals can enhance sexual interaction by
developing increased sensitivity with their other senses.
Medications that can impair sexual functioning include
drugs used to treat high blood pressure, psychiatric disorders,
depression, and cancer. Use of recreational drugs (including
barbiturates, narcotics, and marijuana), alcohol, and tobacco
can interfere with sexual interest, arousal, and orgasm.
Equality of gender roles is associated with greater sexual
satisfaction for men and women.
An emphasis on intercourse can increase performance anxi-
ety and reduce pleasurable options in lovemaking.
Sexual diculties can be related to personal factors such as
limited or inaccurate sexual knowledge, problems of self-
concept and body image, or emotional diculties.
Experiencing sexual abuse as a child or sexual assault as an
adult often leads to sexual problems. As a result of the abuse
experiences, a survivor often associates sexual activity with
negative, traumatic feelings.
Relationship problems, ineective communication, and fear
of pregnancy or sexually transmitted infections can often
inhibit sexual satisfaction.
A woman or man whose sexual orientation is homosexual
will often have diculty with sexual interest, arousal, and
orgasm in a heterosexual sexual relationship.
Basics of Sexual Enhancement
and Sex Therapy
Exploring one’s own body, sharing knowledge with a partner,
and establishing good communication between partners are
important elements of therapy.
Sensate focus is a part of therapy for many dierent sexual
problems.
Masturbating in each others presence can be an excellent
way for partners to indicate to each other what kind of
touching they nd arousing.
erapy programs for women to learn to experience orgasm
are based on progressive self-awareness activities.
Women who wish to become orgasmic with a partner can ben-
et from programs that start with sensate focus, mutual genital
exploration, and nondemand genital pleasuring by the partner.
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Also access links to chapter-related websites, including
American Association of Sex Educators, erapists, and
Counselors, and the American Board of Sexology.
Media Resources
Treatment for vaginismus generally involves promoting
increased self-awareness and relaxation. Insertion of a lubri-
cated nger (rst ones own and later the partner’s) into the
vagina is an important next step in overcoming this condi-
tion. Penile insertion is the nal phase of treatment
for vaginismus.
A variety of approaches can help a man learn to delay his
ejaculation, and a couple can use the stop-start technique.
Certain antidepressant medications can also help delay
ejaculation.
A behavioral approach designed to reduce performance anx-
iety is used to treat psychologically based erectile disorder.
Medications to stimulate blood ow to the penis are in
widespread use, and vascular surgery, surgically implanted
penile prostheses, external vacuum constriction, and vasoac-
tive injections are available if medication does not help.
A behavioral approach to male orgasmic disorder com-
bines self-stimulation, sensate focus, and partner manual
stimulation, ultimately leading to ejaculation by the partners
stimulation.
Many of the basic sex therapy techniques are used to help
with hypoactive sexual desire disorder, and therapists also
often include insight therapy and couples counseling.
Testosterone can be helpful for men and women with low
sexual desire, but because of its possible links to cancer and
heart disease, its safety is not well established.
Two nonprescription products have been shown in research
to be helpful with low desire and arousal in women, and other
products are being studied.
Professional counseling is often helpful and sometimes nec-
essary in overcoming sexual diculties, but few people with
problems seek help.
A skilled therapist can provide useful information, problem-
solving strategies, and sex therapy techniques.
It is unethical for a therapist to have sexual relations with a
client, either during or after treatment.
Copyright 2012 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.