Questions for sex therapy

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Questions for sex therapy

Describe the four major trends in the practice of sex therapy. How have these trends impacted the professional field of sex therapy and counseling?

The four major trends in the practice of sex therapy that are emerging in the 21^st century include, i) the preference for psychotherapy interventions over medical approaches, ii) the increasing use of mindfulness-based interventions, iii) continued expansion of inclusivity and iv) increasing inclusion of the couple’s perspective in addressing sexual dysfunctions (Weir, 2019). Each of these trends is having an impact of the professional field if sex therapy and counseling in the following ways. Firstly, the increasing focus on psychological interventions rather than medications is base on the increasing evidence that has demonstrated that sexual dysfunctions are often accompanied by psychological ramifications and that medical interventions also have some psychological effects as well. This has resulted in the conclusion that pharmaceuticals alone are not able to cure most of the sexual disorders that are experienced by both men and women. In addition, psychosocial interventions help address the risk factors associated with sexual dysfunctions and as such, may help in the prevention of the occurrence of sexual dysfunctions in the first place, hence diminishing the necessity for medication interventions. In this regard, sex therapy professionals is prioritizing sex education and counseling as ways of mitigating the emergence of sexual dysfunctions. Secondly, mindfulness-based interventions are increasing in sex therapy practice because of their broad applicability in addressing a wide variety of sexual problems and their effectiveness, when compared to other interventions. Mindfulness addresses the feeling of disconnection from one’s body and the lack of the sense of self that are experienced by people with sexual problems. Mindfulness is integrated into psychological interventions such as in the mindfulness-based cognitive therapy in which the patients are taught how to connect with their bodies and erotic sensations by focusing in the present moment. Thirdly, inclusivity is being extended beyond the traditional stereotype of people that were predisposed to sexual problems as being middle and upper class married white couples. The realization that sexual problems can afflict anyone including those in same sex relationships has motivate the inclusion of minorities and the underserved segment of the population among sex therapy professionals. Fourthly, the couples’ perspective is permeating sex therapy practice because it has emerged that a sexual dysfunction in one person often affects the sexual partner. As such, sexual therapy professionals are increasingly treating sexual dysfunctions involving couples to improve the outcomes.

Summarize the sexual response cycle as applied to a very brief case study of your design

A young woman who has been married recently engages in regular sexual intercourse with her husband, and although their sex is not perfect, it is filled with discovery of erotic emotions and their differences in their partners. This woman experiences the sexual response cycle that occurs in four phases, namely excitement, plateau, organism and resolution (Todd, 2018). Her sexual response begins with the anticipation of engaging in sex with her partner in the evening and is characterized with the making of phone calls to her husband and the promise of a romantic diner. On arrival to her home, she embarks of preparing dinner and this triggers the first phase of the sexual response cycle; excitement. This phase persists through dinner with her husband and into the onset of foreplay. During this phase, she an increase in muscle tension, the hardening and erecting of her nipples, the flushing of her skin, the quickening of her heart rate and breathing, the and lubrication of her vagina. These feelings and changes increase as the foreplay intensifies. She then transits into the plateau phase at the onset of intercourse and continues until the onset of orgasm. During this phase, she experiences intensified changes that occurred in the excitement phase such as the tensioning of muscles and the occurrence of muscular spasms, the increased sensitivity of her clitoris accompanied by the increased swelling of her vagina and high rate of heartbeat and breathing. She then experiences organism which lasts for an extended period until her husband ejaculates. During this period, she experienced uncontrolled muscular contractions, gasping for breath, tightening of her virginal muscles and a forceful and sudden release of sexual tension. Thereafter, she enters the resolution phase in which she feels a heightened sense of satisfaction, intimacy and wellbeing.

Explain how Female Sexual Interest/Arousal Disorder (FSIAD) is diagnosed and treatment options.(two pages)

Female Sexual Interest/Arousal Disorder (FSIAD) is diagnosed using three approaches that are used to supplement a questionnaire, which include a structured interview using open-ended questions, a physical examination that is undertaken in a clinical setting an a laboratory investigation (Binik & Hall, 2014).

Usually, a questionnaire is used in the initial phases of diagnosis to provide baseline information such as the demographic details of the patient such as age, status of her sexual relationship and discernable symptoms of the disorder. This facilitates the gathering of initial information related to Female Sexual Interest/Arousal Disorder (FSIAD) in a patient while developing a rapport that would help the patient to open up for a candid discussion about her sexual problem. (Rogers et al., 2018).

A structured interview is used to gather detailed information about the patient and her sexual problem by undertaking a comprehensive biopsychosocial assessment. The interview is administered using open ended questions that can allow the patient to expound on her responses about her history, observations, feelings, attitudes and perceptions related to sexuality and her sexual problem (Binik & Hall, 2014). The inclusion of the sexual partner in the interview either alone or together with the patient is vital because it enriches the information gathered. To this end, the assessment commences by gathering information related to the demographics of the patient, a complete medical history of the patient and the details of sexual and nonsexual relationship with her spouse, and the emotional and physical developmental history of the patient. The demographic information gathered includes the family of origin, and sociocultural environment that may have influenced her views about sexuality. The information of medical history should include the hormonal status and fluctuations, and the moods experienced by the patient over an extended period. Information related the perceptions of the partner about the symptoms of his partner are gathered at this stage. The developmental history will include information related to past sexual experiences. After that, the interview proceeds to unearth the deep-seated motivations, responses, techniques that are related to the sexual functioning of the patient using the Sexual Interest/Arousal Disorder (SIAD) criteria stipulated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) regarding sexual dysfunctions. In this regard, the patient is considered to be sexually dysfunctional if she experiences at least three symptoms within a period of six months.

A physical examination that is undertaken by a gynecologist in a clinical setting aids diagnosis. The physical examination includes the evaluation of tone and voluntary control of the pelvic floor muscles, the presence of pain, infection, discharge and epithelial disorders of the pelvic organs, the size of introitus and the presence of vaginal atrophy. The physical examination also presents an opportunity to explore the attitudes, beliefs and perceptions of the patient regarding her genitals and her body (Binik & Hall, 2014).

A laboratory investigation is used to determine the levels of estrogen, estradiol, prolactin, thyroid-stimulating hormone (TSH) and follicle-stimulating hormone (FSH), which may inform on the sexual dysfunction in a patient (Binik & Hall, 2014). Although this approach is rarely used, it can supplement the interview and the physical examination where findings from these are inadequate and inconclusive.

Treatment options include nonpharmecological and pharmacological treatment approaches. The nonpharmecological treatments, whose evidence of their effectiveness is increasing, include cognitive-behavioral therapy (CBT) and mindfulness-based interventions (MBIs). In turn, the pharmacological treatment approaches that are gaining consideration through investigations include the use of prostaglandins, α-andrenergic antagonists, dopaminergic agonists, hormonal treatment such as the use of melanocortin-stimulating hormones and nitrogen oxide delivery systems (Binik & Hall, 2014).

Explain in detail the discussion in the text about Male hypoactive sexual desire disorder versus hidden sexual desire disorder, for example what are the differences and similarities

Low sexual desire is a sexual dysfunction as categorized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association and the International Classification of Diseases (ICD-10) by the World Health Organization.

Low sexual desire in men is largely misunderstood and mysterious because it is manifested in two ways mainly, which are often confusing; low sexual desire and lack of sexual interest (Binik & Hall, 2014). Specifically sexual desire and sexual interest are often used interchangeably and therefore confused for each other. In this regard, hidden sexual desire disorder is often thought to be part of male hypoactive sexual desire disorder (HSDD) and therefore share many similarities owing to the low understanding of the desire mechanisms in men. One similarity between the two conditions is that they are both related to low sexual desire and therefore thought to be similar. As such low sexual desire is thought to be similar to, and inseparable from low sexual interest. For this reason, low sexual desire can result from low sexual interest. Secondly, the two conditions involve a complex interaction of psychological, biological, sociocultural and relational forces that influence the sexual health of the male individual (Binik & Hall, 2014). Therefore, distinguishing the two types of sexual disorders are often difficult to distinguish using the psychological, biological, sociocultural and relational factors unless there is full and candid disclosure by the male patient, which is often difficult to encounter. In many cases, men experiencing low sexual desire do not confess that they may be fulfilling their sexual desires through other avenues other than those involving their sexual partners. Indeed, in many occasions, the men attend clinical attention of the low desire issues from the insistence of their sexual partners or spouses regardless of the type of sexual dysfunction they may be experiencing.

However, with increasing evidence from research, the differences between male hypoactive sexual desire disorder (HSDD) and hidden sexual desire disorder have emerged and become recognizable. Specifically, it is now possible to differentiate hidden sexual desire disorder from male hypoactive sexual desire disorder (HSDD). Notably, the criteria for diagnosis of the male hypoactive sexual desire disorder (HSDD) provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the American Psychiatric Association helps distinguish between the two conditions. These criteria include firstly, the absence or deficiency of desire for sexual activity and sexual fantasy; secondly, the existence of the association to interpersonal conflict or marked distress; and thirdly, that the low desire is not attributed to substance abuse, or any major medical or psychiatric condition (Binik & Hall, 2014). In this regard, while the male hypoactive sexual desire disorder is often attributed to the lack of the desire for sexual activity accompanied by the absence of sexual fantasies, the hidden sexual desire disorder is accompanied by the presence of sexual fantasies that cannot be acted out with the current sexual partner. As such, the man experiences low sexual desire only when relating to his current sexual partner, and their sexual desire resumes when sexual activity is enacted with other sexual partners or under different circumstances other than those presented by his present sexual partner such as pornography, masturbation and extramarital activities. In addition, sexual attitudes may help differentiate between the two conditions, with the hidden sexual desire disorder differing from male hypoactive sexual desire disorder because of the general inability to engage in unusual sexual activity with female sexual partner that is harbored in his sexual fantasies. In this regard, the man is able to act out his sexual fantasies through other activities such as engagement in pornography and masturbation in the absence of partnered sex. As such, this individual lacks interest in normal sexual activity with female partners, which is dissimilar to the general lack of sexual interest in HSDD.

You have a client who is experiencing Delayed Ejaculation. Please explain what that means and describe what type of treatment might be indicated.( one page)

Delayed ejaculation is identified as a sexual disorder afflicting the men by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the American Psychiatric Association. Specifically, delayed ejaculation is the difficulty in men in ejaculating and experiencing orgasm in men (Binik & Hall, 2014). However, delayed ejaculation is not associated with the difficulty to attain or maintain erections as men afflicted with delayed ejaculation experience erections are able to engage in normal sexual activity and experience sexual pleasure.

For a man to be diagnosed with delayed ejaculation, two symptoms should be manifested together or individually. Firstly, the man should experience a marked delay in ejaculation in occasions ranging between 75 and 100 % of the occasions of sexual activities within a six-month period. Secondly, the man should experience a marked absence or infrequency of ejaculation in similar occasions for at least six months. It has been suggested that delayed ejaculation may caused by masturbation-relation issues such as high frequency of over three times a week, a disparity between the sexual fantasies preferred by the man during masturbation and the reality in partnered sex, and the engagement in idiosyncratic masturbatory styles (Binik & Hall, 2014).

Delayed ejaculation can be treated in a variety of ways in which masturbatory retraining is a pivotal aspect of the sex therapy. The treatment aims at reducing the anxiety of the man and his sex partner alongside the reduction of mutual recriminations. The ultimate goal of the delayed ejaculation therapy is to induce a higher level of psychosexual arousal within an experience that is satisfying to the man and his sex partner. In this regard, masturbation training engages in stimulation and self-exploration that helps the patient to identify his sexual arousal preferences. The masturbation exercises should progress from neutral to pleasurable sensations that are not accompanied by orgasm and fantasizing to eliminate the demand for performance and block thoughts the interfere with arousal respectively. In addition, autosexual orientation is used to remove the stigma associate with the withholding of sexual activity from a sex partner. Further, techniques for the reduction of general anxiety in the man are also effective in treating delayed ejaculation. Moreover, couple therapy is often incorporated in the treatment regime because it encourages the man and his sexual partner to share their sexual preferences with the aim of meeting their sexual needs mutually (Binik & Hall, 2014).

A couple has come to see you for sex therapy. Describe what you would say to them when explaining Genito-pelvic pain penetration disorder? (Remember, from one of our slides: Genito-Pelvic Pain/Penetration Disorder is new to the DSM-5 and combines the previous diagnoses of vaginismus and dyspareunia. You can use your text to answer this with presenting symptoms of vaginismus and/or dyspareunia) (two pages).

I would explain to them that genito-pelvic pain / penetration disorder (GPPPD) is a sexual disorder that afflicts women mostly, although some men may experience similar symptoms. I would tell them that it is a sexual dysfunction that is characterized by difficulty in having intercourse and the feeling of significant amounts of pain upon vaginal penetration, with the severity of the dysfunction ranging from the ability to experience vaginal penetration in one circumstance and not another to the total inability to experience the penetration of the vagina. In other words, the condition is a sexual dysfunction because it impairs the ability of the couple to engage in regular and healthy sex because it is accompanied by extreme pain, the inability to penetrate the vagina and the fear and anxiety that is associated with these difficulties. I would tell them that the disorder afflicts, particularly the experiencing of pain recurrently during intercourse afflicts about 15 % of women in the United States and therefore it is not such as rare occurrence, although when well diagnosed, it can be treated thus allowing the couple to resume having healthy, pleasurable and satisfying sexual intercourse.

I would explain to them the different manifestations of the genito-pelvic pain / penetration disorder and the complexity of differentiation between the different symptoms, which has seen the evolution of diagnostic criteria into what is currently used under the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria from the American Psychiatric Association. Specifically, prior to 2013, the genito-pelvic pain / penetration disorder was known as sexual pain disorder which comprised of two conditions that manifested differently and therefore were categorized differently as vaginismus and dyspareunia as indicated in the fourth edition (DSM-IV-TRR). However, since the symptoms of vaginismus and dyspareunia overlap in many aspects, the diagnostic criteria was merged for the two under the new category that is now known as the genito-pelvic pain / penetration disorder as published in the fifth edition (DCM-5) (Binik & Hall, 2014).

To differentiate between vaginismus and dyspareunia, I would explain their distinguishing characteristics alongside the characteristic they share. Notably, vanigismus is a sexual problem that is characterized by the tightening of the vulva and specifically the pelvic floor muscles such that it prevents the insertion of any object into the vagina, including the penis. Usually, the tightening of the pelvic floor muscles is involuntary and occurs in the muscles surrounding one third of the outer end of the vagina, giving the semblance that the woman is a virgin, and therefore making sexual intercourse impossible or uncomfortable. Sometimes, the muscles in the rectum, the thighs and buttocks of the woman may undergo similar muscular contraction that is presented as severe vaginismus. These contractions can be induced by real, anticipated or imagined attempts to penetrate the vagina. On the other hand, dyspareunia is the extreme pain experienced by the woman during coitus and included discomfort that is persistent and recurrent during attempts or actual engagement in coitus. These two conditions can be categorized as primary, secondary, situational and complete depending with the severity and context of the condition. For instance, vaginismus is characterized by the involuntary spasm of the muscle at the opening of the vagina upon attempts to insert anything inside, while the secondary form, muscular contractions occur due to painful experiences related to the penetration of the vaginal, which can be real or imagined. Likewise, primary dyspareunia is indicated by the sensation of pain while the penis is inside the vagina during coitus while in the secondary form, pain is felt after the occurrence of comfortable coitus. In addition, the conditions are situational if the symptoms are experienced under certain circumstances and not others, while in the complete category, the symptoms are experiences in all circumstances.

Summarize what you believe are the most important parts of Chapter 14 Therapy with LGBTQ Clients to consider when working with LGBTQ+ clients

This chapter dwells on the perspectives that should be used by sex therapy professional when treating the sex problems among LGBTQ individuals. In this regard, the lesbian, gay, bisexual, transgender or queer (LGBTQ) community should be considered as a minority even in the manner in which sex therapy is conducted by sex therapy professionals. As such, although the member of this community experience many sexual problems that are similar to those of other people, the treatment of their problems should not be based on the heterosexual standards of healthy, ideal or normal sexuality. As such, the treatment should be focused on the improvement of sexual satisfaction rather than on the facilitating the LGBTQ individuals to accept or change their sexual orientation. Therefore, sex therapy should address the treatment of those with gender expression issues and atypical sexuality as well as those with sexual dysfunctions, thus making it inclusive. This can only be done if same sex behavior, feelings and attractions’ are viewed as a normal variant of human sexuality, as prescribed in the normal variance model and transgender or crossgender identity is not a psychiatric disorder (Binik & Hall, 2014).

Due to the challenges and complexities surrounding orientation such as the blurring of gender lines, the increasing overlap in LGBTQ assignments and the changing notions of fixed orientation and identity, the need to approach gender nonconformity is becoming more pertinent. Therefore, the use of DSM-5 diagnostic categories can be employed to diagnose sexual disorders because their workings are unbiased while sex therapists should consider paraphilias and gender atypicality as issues of concert to the LGBTQ community. However, the chapter goes on to outline the major sexuality issues that arise among lesbians, gay man, and bisexuals that would be useful to the sex therapist.

Describe what is meant by Gender Dysphoria. Is there a recommended treatment?

Gender dysphoria (GD) is the discomfort experienced by an individual that is related the discrepancy or incongruence between his or her biological gender and the expressed or experienced gender. The disconnection between the two gender perspectives should be profound for the condition to be termed as gender dysphoria. However, it is not necessarily a sexual dysfunction and controversy exists around whether the condition is a nonpsychiatric medical condition or a psychiatric disorder. People that are afflicted by gender dysphoria experience sense of discomfort and awkwardness towards the incongruence in their gender role alongside desiring to possess part or the whole body of the opposite sex. People with this condition also experience negative effects emanating from the incongruence in their natal gender and their expressed gender such as distress and/or impairment (Binik & Hall, 2014).

The treatment of gender dysphoria is implemented differently for children, adolescents and adults. For children, the three approaches commonly used include psychosocial treatment approaches, the watchful waiting approach and the facilitation of early gender social transition using psychosocial support. Among adolescents, biomedical treatment approaches are used to address gender dysphoria, and involve the gradual reassignment of sex using hormonal medications that are prescribed to delay or suppress the inset of somatic puberty before the age of 16 years, cross-sex hormonal therapy at the age of 16, and sex change surgery once the adolescent reaches the majority age. However, if there is comorbidity between gender dysphoria and psychiatric disorders such as severe trauma from sexual abuse, borderline personality disorder and autism spectrum disorder, the treatment of the psychiatric disorder may help the dissipation of gender dysphoria. In adults, gender dysphoria is treated using hormone therapy and surgical sex change.

Summarize what you believe are the most important parts of Chapter 15 Culturally Sensitive Sex Therapy to consider when working with clients from a culture different than your own

This chapter emphasizes the importance of cultural consideration when addressing sexuality issues and undertaking treatment for sexual problems because people come from diverse cultures, some of which do not have sexual perceptions similar to those of the western population. Therefore, this chapter calls for the diversification of perceptions and approaches to accommodate the cultural and ethnic minorities who are often underserved by the sexual therapy regimes, which are premised on the western-defined sexual dysfunctions and therapeutic approaches (Binik & Hall, 2014).

The chapter dwells on the influence of culture on sexual dysfunction such as the phenomenology of symptoms, the syndromization of symptoms into patterns and the diagnostic processes and goes on to notes that the diagnostic criteria for sexual dysfunctions provided by DSM-5 is inclusive of cultural considerations. In this regard, cultural sensitivity rather than cultural competence among sex therapists is thought to lead to better sex therapy outcomes. In this regard, the mutual understanding of the meaning of the sexual problem by the therapist and the patient, who may be an individual or a couple, requires cultural sensitivity rather cultural competence because culturally sensitive treatments have been evidenced to be effective. From this understanding, sex therapists are advised tailor their sex therapy techniques culturally because culture should be considered as a potential source of strength and not a source of problems alone (Binik & Hall, 2014).

The chapter also dwells on the importance of expanding the application of sexual therapy to cultures that are not aware of such approaches of in cultures that still harbor and practice harmful cultural beliefs and practices that often worsen the sexual problems and make treatment ineffective. In this regard, practices such as sex trafficking of children and women, forced marriages, female genital mutilation and culturally-sanctioned make violence against women are some of the harm cultural practices that cause sexual dysfunctions and make their treatment ineffective (Binik & Hall, 2014).

Summarize what you believe are the most important parts of Chapter 17 The Treatment of Sexual Dysfunctions in Survivors of Abuse to consider when working with Survivors of Abuse

This chapter dwells on the challenges presented by sexual abuse when addressing the causes and treatments of sexual dysfunction among individuals that have been sexually abused especially during their childhood. Importantly, the sexual therapist is advised not to make assumptions that the sexual dysfunctions afflicting an individual who has undergone sexual abuse have been cause by the abuse; such conclusions should only arrived at after the information gathered indicates that the patient fits the clinical profile of the sexual abuse survivors who have experienced sexual problems. In this regard, although sexual dysfunction and sexual abuses are associated significantly patients of sexual dysfunction that have undergone sexual abuse also experience other psychological disorders such as posttraumatic stress disorder, eating disorders, borderline personality disorders and other anxiety disorders (Binik & Hall, 2014). However, adults exhibit a significant relationship between their sexual functioning and sexual abuse and as such; their sexual dysfunction can be closely correlated to the sexual abuse they have experienced as adults. However, in children, the development of sexual dysfunction is preceded by child sexual abuse, considering that children may be sexually abused before they become sexually mature.

The diagnosis of sexual dysfunction in survivors of sexual abuse is supported largely by the DSM-5 diagnosis criteria although some symptoms such as having unwanted sexual abuse fantasies or engaging in promiscuous and risky sexual behavior is not accounted for in the diagnostic criteria (Binik & Hall, 2014). As such, sex therapists are advices to gather as much information as possible about the history of the patient regarding the sexual abuse experiences, sexual functioning and sexual satisfaction. In this regard, the article brings to the attention of sex therapists to the importance of delving comprehensively into the history of sexual satisfaction even for patients that do not confess having sexual problems because the capturing of sexual difficulties among sex abuse survivors is incomplete when using the sexual abuse definitions that are currently in use. In the same vein, diagnosis is also complicated by the negative connotation accompanying the sexual abuse label and therefore, patients often have difficulties in revealing the occurrences of sexual abuse during interviews. Considering that information about sexual abuse experiences may shed light on the causes of sexual dysfunctions, sex therapists are advised to use non-judgmental and supportive language with carefully chosen words that are devoid of the term ‘sexual abuse’ and other intimidating or degrading terms alongside exhibiting patience during the interview. In this regard, therapists are advised to look out for the patient’s perceptions of abusive experiences as being pleasurable and with this, the positive experience associated with some sexual abuse occurrences, the association of sexual abuse with love especially if the abuse occurred during childhood, and the acceptance of sexual abuse due to socialization.

The chapter also goes on to emphasize on the importance of the consideration of the various forms of abuse during the formulation of a sexual dysfunction treatment plan, considering that sexual abuse commonly occurs alongside psychiatric conditions. While sexual dysfunctions and psychiatric conditions require to be treated in survivors of sexual abuse, the sex therapist is often left with the decision about which condition to address before the other, although it has been evidenced that the treatment of some types of psychiatric conditions may lead to the disappearance of some sexual dysfunctions.

References

Binik, Y. M., & Hall, K. S. (Eds.). (2014). Principles and practice of sex therapy. Guilford Publications.

Rogers, R. G., Pauls, R. N., Thakar, R., Morin, M., Kuhn, A., Petri, E., … & Lee, J. (2018). An international Urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction. International urogynecology journal, 29(5), 647-666.

Todd, N. (2018). Your guide to the sexual response cycle. WebMD. Retrieved 19 July 2019 from https://www.webmd.com/sex-relationships/guide/sexual-health-your-guide-to-sexual-response-cycle#1.

Weir, K. (2019). Sex therapy for the 21^st century: five emerging directions. American Psychological Association. Retrieved 19 July 2019 from https://www.apa.org/education/ce/sex-therapy.pdf.

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