SEX THERAPY

Content

o Sexuality – Recap
o Sexual Self- Schemas
o Sexual Scripts
o Basic Principles of Direct Treatment of Sexual Dysfunction
- Mutual Responsibility
- Information & Education
- Attitude Change
- Eliminating Performance Anxiety
- Increasing Communication and Effectiveness of Sexual Technique
- Changing Destructive life-Styles and Sex
- Prescribing Changes in Behaviour
o Sex Therapy Models -
o Techniques for different types of Sexual Dysfunction
- Premature Ejaculation
- Erectile Failure
- Ejaculatory Competence
- Orgasmic Dysfunction
- Vaginismus
o References
Sexuality – Recap

Sexual identity is the pattern of a person's biological

sexual characteristics: chromosomes, external and
internal genitalia, hormonal composition, gonads and
secondary sex characteristics.

Gender identity is a person's sense of maleness or

femaleness. By the age of 2 or 3 years, usually majority
Sexuality has a firm conviction that “I am male” or “I am female.”
depends on four
interrelated
psychosexual
factors Sexual behavior includes desire, fantasies, pursuit of
partners, autoeroticism, and all the activities engaged in
to express and gratify sexual needs.

Sexual orientation describes the object of a person's

sexual impulses for instance, heterosexual opposite sex),
homosexual (same sex), or bisexual (both sexes).

Sexual Self Schema –

Sexual self-schemas have been defined as “cognitive generalizations about sexual aspects of
oneself that are derived from past experience, manifest in current experience, influential
in the processing of sexually relevant social information, and guide sexual behavior”
(Andersen & Cyranowski, 1994). Sexual self-schemas represent basic or core beliefs about
sexual aspects of oneself. When positive, sexual self- views may facilitate sexual responding.
When sexual self- views are extremely negative, conflicted, or weak, however, they may
represent a significant vulnerability factor, or diathesis, for the occurrence of subsequent
sexual distress, difficulty, or dysfunction. The sexual self-schema construct has been
operationalized for both women and men using trait-adjective ratings on the Sexual Self-
Schema Scales (Andersen & Cyranowski, 1994; Andersen et al., 1999). This identified the
trait adjectives most associated with a semantic representation of a “sexual woman” (as held
by females), and that of a “sexual man” (as reported by males).
Research Findings –

Women with positive and nonconflicting sexual self-views describe themselves as

emotionally warm and passionate individuals who are behaviorally open to romantic and
sexual relationships. These women tend to be liberal in their sexual attitudes, and are
generally uninhibited by self-consciousness, embarrassment, or sexual anxiety. Conversely,
women with clearly negative sexual self-views describe themselves as relatively less
romantic or passionate, and as inhibited in their sexual and romantic relationships. These
women tend to view themselves as embarrassed, conservative, and at times anxious when
faced with sexual situations. Women with positive sexual self-views also display
emotionally intimate attachments to romantic partners. Thus, having a positive view of the
sexual self would appear to facilitate the development of romantic, as well as sexual,
attachments in women. In contrast, women with negative sexual self-views tend to report a
pattern of anxiety and avoidance in both sexual and romantic relationships (Cyranowski &
Andersen, 1998).

A sexually schematic man is one who views himself as loving and passionate, powerful and
independent, and is open-minded in his sexual attitudes. Data suggest that schematic and
aschematic men hold very different views of the sexual self, and that these sexual self-views
relate to differences in both sexual behaviours and responsiveness. Compared with
aschematic scorers, schematic men are clearly more sexually experienced. They report
more lifetime sexual activities, some of which occur without commitment, and they have a
wider repertoire of sexual behaviours. Men’s sexual self-views also relate to patterns of
sexual responsiveness, as schematic men report higher levels of sexual arousal than do
aschematic scorers. At the same time, males with highly positive sexual self-views may be
particularly capable of developing

romantic attachments to relationship partners.

When compared with aschematic scorers, sexually schematic men report greater feelings of
passionate love and are more apt to become involved in romantic relationships. Conversely,
aschematic scorers do not view themselves as particularly passionate, powerful, or open
individuals. Moreover, findings suggest that sexually aschematic males report a narrower
range of sexual activities, lower levels of sexual arousal, fewer sexual partners, and lower
rates of romantic relationship involvement —as compared with their sexually schematic
counterparts (Andersen et al.).

Sexual Scripts

Sexual Scripts are ideas of how males and females are supposed to interact with each
other, including how each gender should behave in sexual or romantic situations. Like a
script for a TV show or movie, a sexual script is a mental story detailing specific events and
assigning certain roles (parts that each actor plays in the story). Central to sexual script
theory is the notion of social constructionism—the interpretation of reality, including
human behaviour, is derived from shared beliefs within a particular social group. In this
case, the human behaviours in question are sexual, and the meanings attached to those
behaviours, including what makes them "sexual" behaviours, derives from metaphorical
scripts individuals have learned and incorporated as a function of their involvement in the
social group.

For example, if a male asks a female out to the movies, the sexual script suggests that he is
expected to pay for both his ticket and his date’s ticket. If he does not, then he is violating the
traditional sexual script for a date. If his date subscribes to the traditional version of this
script then he might fail to meet her expectations, with the possible consequence that she will
not go out with him again. Sexual scripts are based on shared cultural ideals and social
norms. They are learned from and reinforced by our family, friends, religion, the media, and
other people around.

Basic Principles of Direct Treatment of Sexual Dysfunction

The following principles are used by most clinicians who follow the direct treatment
approach.

1. Mutual Responsibility –
It must be stressed that all sexual dysfunctions are shared disorders; that is, the husband of
an inorgasmic woman is partially responsible for creating or maintaining her dysfunction, and
he is also a patient in need of help. Regardless of the cause of the dysfunction, both partners
are responsible for future change and the solution of their problems. Some patients will resist
the notion of mutual responsibility quite vigorously, in a defensive attempt to protect their
self-image as sexually adept, or to maintain a position of power and control in their marital
relationship. Reassurance, distinction of "responsibility" from "blame," and prognosis of
successful outcome will usually deal with the self-image issue. Use of sexual dysfunction in
a power struggle may be an indication for more general marital therapy instead of sex
therapy.
Involving both spouses is also made easier by the use of a co-therapy team, which gives each
patient someone to identify with. Such co-therapy is common in most sex therapy programs
but does not seem to be essential (Kaplan, 1974).

**Note - If reassurance does not eliminate resistance, raising the defensive spouse's anxiety
about his sexual ability may motivate him to enter therapy on an equal basis with his spouse.
Therapeutic anxiety can be engendered by such statements as "I agree that your spouse has
severe and long-standing sexual problems, but I know from clinical experience that had
you responded differently, she could have overcome these difficulties, and sex therapy
would never have been needed.”

2. Information and Education –

Most patients suffering from sexual dysfunction are unaware of both basic biology and
effective sexual techniques. Sometimes this can directly lead to the development of anxiety,
which in turn produces sexual dysfunction. The therapist ensures that the patients have
accurate knowledge of the sexual response cycle through verbal discussion, providing the
patient with appropriate reading materials, and the use of educational films. In addition,
specific information is provided (again, by lecture, books, and films) on the general principles
of effective sexual techniques of kissing, manual and oral foreplay, positions of intercourse,
and so forth.

For example, a patient dated the onset of her aversion to sex as beginning when she first
noted that her clitoris "disappeared" during manipulation. She interpreted this normal
retraction of the clitoral shaft during the plateau phase of arousal as a pathological sign that
she was not becoming aroused. This anxiety led to a complete loss of her arousal and
enjoyment of sexuality. Similarly, many cases of vaginismus seem to begin as a result of the
husband's forceful attempts to accomplish intromission in spite of his uncertainty about the
exact location of the vagina.
 3. Attitude Change –
Negative societal and parental attitudes toward sexual expression, past traumatic experiences,
and the current acute distress combine to make the dysfunctional patients approach each
sexual encounter with anxiety or disgust. The therapist must directly induce attitude change
in such patients. Procedures used may involve having the patient read positive material on
sexuality, arranging consultations with sympathetic clergy in the case of religiously based
negative attitudes, instructing the husband to make it clear to his wife that he will value
and respect her more, not less, if she becomes more sexual (which usually involves resolving
the husband's lingering ambivalence about female sexuality and his fears about her becoming
unfaithful or too demanding sexually), having the patients attend lectures or workshops on
sexuality and sexual values which may be offered by local colleges or social-interest groups,
and use of the therapeutic relationship itself.

The therapists can use their role and relationship to produce attitude change in the patients
through self-disclosure about their own enjoyment of sexuality (Lobitz and LoPiccolo, 1972).
Given that the patient has a negative attitude toward sex and a positive attitude toward the
therapist, the self-disclosure that the therapist enjoys sex creates cognitive dissonance
(Festinger, 1957) for the patient: "Someone that I like and respect enjoys something I think is
reprehensible, immoral, and disgusting." The resolution of this dissonance can lead to
acceptance of sex as decent, moral, and enjoyable. Alternatively, if such self-disclosure is
too extreme or used too early in therapy, the patients may resolve the dissonance by losing
respect for the therapist or by deciding that the therapist is simply a different type of
person. For this reason, self-disclosure probably produces the most attitude change when
used by the female co-therapist with the female patient, and by the male co-therapist with the
male patient.

4. Eliminating Performance Anxiety –

For therapy to succeed, the patients must be freed from anxiety about their sexual
performance. Patients, regardless of presenting complaint, are told to stop "keeping score,"
to stop being so goal centred on erection, orgasm, or ejaculation, and instead to focus on
enjoying the process rather than trying for a particular end result.

For example, the therapeutic procedure of forbidding intercourse in the treatment of erectile
failure makes it possible for the patients to enjoy mutual kissing, hugging, body massage, and
manual or oral stimulation of the genitals without anxiety about whether erection sufficient
for intercourse will occur. Other techniques include reassuring a woman that she need not
feel that she must reach orgasm in order to enjoy intercourse or to confirm her husband's
belief that he is a good lover for her, and instructing patients that they can each provide
sexual satisfaction for each other through manual and oral stimulation, even when they are
not capable or desirous of having intercourse.

5. Increasing Communication and Effectiveness of Sexual Technique -

Couples tend to be unable to clearly communicate their sexual likes and dislikes to each
other, due to inhibitions about discussing sex openly, have excessive sensitivity to what is
perceived as hostile criticism by the spouse, inhibitions about trying new sexual techniques,
and the incorrect assumption that a person's sexual responsiveness is unchanging, i.e., that an
activity that is pleasurable on one occasion will always be pleasurable.

Direct therapy encourages sexual experimentation and open, effective communication

about technique and response. Procedures that are used include having the patient couple
share their sexual fantasies with each other, read explicit erotic literature, and see explicit
sexual movies that model new techniques, and training the couple to communicate during
their sexual interaction. Patients are advised to train each other to be effective sexual
partners through demonstrating their own effective techniques to other, by guiding their
partner's hands and by giving each other effective feedback during sex. Patients are taught
the difference between ineffective, threatening communication and effective information-
rich feedback.

6. Changing Destructive life-Styles and Sex Roles –

Direct therapy for sexual dysfunction often involves the therapist stepping outside the usual
therapeutic posture of responding to the patient, and instead taking an active, directive,
and initiating role with the patient in regard to general life-style and sex-role issues.

For example, many patients make sex the lowest priority item in their life. This usually
ensures that sex occurs infrequently, hurriedly, late at night, and when both partners are
physically and mentally fatigued. In such a case, patients may be instructed to make "dates"
with each other for relaxing days or evenings (Annon, 1974). These dates may involve dinner
and the theater, a day in the sun at a park or a beach, or simply sending the children to the
baby-sitter and staying home with the telephone disconnected and a "Do Not Disturb" sign on
the door. This simple change in itself tends to make sex a more positive experience.
Similarly, patients may be advised to disengage from others who are a destructive influence
on their sexuality, to solve hopeless financial troubles that consume all their emotional
energy, or, to quit a job that requires the husband to commute four hours daily to and from
work.
While many men would usually resist taking on more household responsibilities, in the
context of sex therapy a change can be produced if the therapists take a strong, directive
position on this issue. An effective therapist statement to open discussion is, "You say your
wife never wants sex anymore and doesn't enjoy it. It's clear to us that her work load in the
evening prevents her getting in touch with her sex drive and her sexual responsiveness.
Are you willing to make some changes that will lead to a good sex life for both of you, but
will require some effort on your part?"

7. Prescribing Changes in Behaviour –

The hallmark of direct treatment of sexual dysfunction, it is the prescription by the therapist
of a series of gradual steps of specific sexual behaviours to be performed by the patients in
their own home. These behaviours are often described as "sensate focus" or "pleasuring"
exercises. Typically, intercourse, breast and genital touching are initially prohibited, and the
patients only examine, discuss, and sensually massage each other's. bodies. Forbidding more
intense sexual expression allows the patients to enjoy kissing, hugging, body massage, and
other sensual pleasures without the disruption that would occur if the patient anticipated these
activities would be followed by intercourse or other sexual behaviours that have not been
pleasurable in the past.
The couple's sexual relationship is then rebuilt in a graduated series of successive
approximations to full sexual intercourse. At each step, anxiety reduction, skill training,
elimination of performance demands, and the other components described above are used to
keep the couple's interactions pleasurable and therapeutic experiences.

Sex Therapy Models –

Wincze & Barlow Model (1997) –
The PLISSIT model –
The model was created in 1976 by Jack S. Annon. The letters of the name refer to the four
different levels of intervention that a sexologist can apply: permission (P), limited
information (LI), specific suggestions (SS), and intensive therapy (IT).
It four levels of increasing intervention and interaction related to what kind of and how much
help is given to a client. The varying levels largely revolve around what the client is looking
for and how comfortable they are in discussing sexuality and sexual health.

The first level is permission, which involves the therapist giving the client permission to feel
comfortable about a topic or permission to change their lifestyle or to get medical assistance.
This level was created because many clients only require the permission to speak and voice
their concerns about sexual issues in order to understand and move past them, often without
needing the other levels of the model. The therapist, in acting as a receptive, non-judgmental
listening partner, allows the client to discuss matters that would otherwise be too
embarrassing for the individual to discuss.

The second level is limited information, wherein the client is supplied with limited and
specific information on the topics of discussion.

The third level is specific suggestions, where the therapist gives the client suggestions related
to the specific situations and assignments to do in order to help the client fix the mental or
health problem. This can include suggestions on how to deal with sex related diseases or
information on how to better achieve sexual satisfaction by the client changing their sexual
behaviour. The suggestions may be as simple as recommending exercise or can involve
specific regimens of activity or medications.

The fourth and final level is intensive therapy, which has the therapist helps the client deal
with the deeper, underlying issues and concerns being expressed.

Techniques for different types of Sexual Dysfunction

While all patients seeking sex therapy· should receive a complete physical examination
before entering treatment, such an examination is especially important in erectile failure
cases. Unlike premature ejaculation and female orgasmic dysfunction, there are many organic
causes (such as diabetes and vascular disease) for erectile failure.

 Premature Ejaculation -
Ejaculation is a response that is innervated by the sympathetic nervous system (Kaplan,
1974). There are no objective criteria for what constitutes premature ejaculation. Thus, it has
been suggested that a latency to ejaculation of less than four minutes may be a tentative
indicator for treatment. There definition thus depends on various factors such as - How much
manual and oral foreplay stimulation of his genitals can the male tolerate without ejaculation;
whether the male is unrestrained in intercourse or can only delay ejaculation by slowing
thrusting, thinking unpleasant, antierotic thoughts, biting his tongue, or wearing a condom;
frequency of intercourse; age of the patient; and use of alcohol, drugs to dull sexual
responsivity and delay ejaculation. Both husband and wife agree that the quality of their
sexual encounters is not influenced by efforts to delay ejaculation, it’s not premature
ejaculation.
 1. Systematic desensitization (Wolpe, 1958).
In systematic desensitization, muscle relaxation is used to elicit parasympathetic arousal,
which then reduces sympathetic arousal through reciprocal inhibition. Procedurally, the
patient practices deep muscle relaxation while visualizing items from a hierarchy of sexually
arousing situations. This procedure is moderately successful in treating premature ejaculation
(Cooper, 1968; Kraft and Al-Issa, 1968).
2. James Seman’s Procedure –
The problem in premature ejaculation is the male's low threshold for amount of stimulation
required to elicit the ejaculation response. In the Seman’s procedure, the penis is stimulated
until ejaculation is imminent. At this point, stimulation is stopped. The male pauses until the
sensation of high arousal subsides, then begins stimulation of the penis again. This
procedure is repeated over and over again, until the male has experienced a massive
amount of stimulation, but without the occurrence of ejaculation. The number of pauses
required to sustain stimulation and delay ejaculation rapidly decreases over successive
occasions with this procedure, and the male soon gains the capacity for penile stimulation
of great duration without any pauses at all. The underlying mechanism in the Semans
procedure may be Guthrie's "crowding the threshold" process for extinguishing stimulus-
response connections, in this case, the connection between minimal stimulation and
ejaculation. According to Guthrie, such extinction is produced by gradually exposing the
subject to progressively more intense and more prolonged stimulation, but always keeping
the intensity and duration of the stimulus just below the threshold for elicitation of the
response (Guthrie, 1952).
 3. Squeeze Technique -
Masters and Johnson (1970) have modified the above procedure by having the wife stimulate
the husband's penis and squeeze firmly on the frenulum when a pause in stimulation is
needed. This "squeeze technique" is said to immediately eliminate the urge to ejaculate, and
it may also cause the male to lose 10% to 30% of his erection. While there has not been a
controlled experimental study of the relative effectiveness of the pause procedure versus the
squeeze procedure, at a clinical level, both procedures seem to be quite effective. If the
squeeze procedure is used, the patient should be cautioned to release the squeeze immediately
if he ejaculates as a result of not stopping stimulation early enough. Ejaculation while
physically holding the urethra closed can, in rare instances, produce retrograde ejaculation
with concomitant risk of physiological problems in the bladder, prostate, or seminal vesicles.

There is one additional procedure to enhance the effectiveness - Contraction of the scrotum
and elevation of the testicles occurs during high arousal and orgasm (Masters and Johnson,
1966). For some men, cupping the scrotum and pressing it against the perineum will trigger
orgasm during high arousal. Conversely, pulling down on the scrotum and testes seems to
work like the squeeze procedure to reduce arousal and the urge to ejaculate in many men.

4. Homework Assignments -
In prescribing homework assignments for the premature ejaculation patient -
1st step - masturbation with the pause procedure, to learn when to pause and to identify the
signals of approaching ejaculation. The advantages of beginning with masturbation are
threefold:
(1) The male gains confidence and reduces his anxiety by learning some ejaculatory control
before resuming sexual activity with his wife;
(2) the male can focus exclusively on learning when and how to pause or squeeze, free of any
pressure to also communicate this information to his wife; and
(3) the spouse's eagerness to learn and cooperate is enhanced by the husband's report of the
success of the procedure.

2nd step - the patient may be instructed to try the squeeze procedure, to see if this is more or
less effective for him than the simple pause.
3rd step - In the next sessions, the male patient will teach this procedure to his wife. When
good tolerance for manual and oral stimulation by the wife is achieved, the couple uses the
pause (or squeeze) procedure during stationary vaginal containment of the penis, during slow
pelvic thrusting, and finally during, full, unrestrained intercourse.

** Note - If the patient couple progresses through this procedure on a daily basis, the need to
use the pause or squeeze will quickly diminish. Latency to ejaculation could also be greatly
increased by frequent ejaculation. Such patients need to be placed on a "maintenance
program," which includes occasional training sessions with the pause-squeeze procedures, to
ensure that relapse does not occur following the intensive therapy period (Lobitz et al., 1974).

Model of Functional vs. Dysfunctional Sexual Arousal

 Erectile Failure -
It inability of the male to attain or maintain an erection sufficient for intercourse.
Model of Male Arousal (Erectile) and Female Arousal Disorder -
The treatment program for erectile failure consists of two basic components:
(l) ensuring that the patient is receiving a high level of physical and psychological sexual
stimulation from his wife
(2) eliminating anxiety and performance demands that interfere with erection despite such
adequate stimulation.
1. Educating the couple on mutual responsibility and performance demands -
Illustrating the mutual responsibility of both spouses for a sexual dysfunction, some cases of
erectile failure are at least partially the result of the wife's poor sexual technique and her
placing strong demands on the male to have erections. The therapist should instruct the
couple that erection is not subject to voluntary control and is neither spontaneous nor
instantaneous (especially in older males) but will automatically occur given sufficient
stimulation in an anxiety-free setting.

Performance demands on the husband and the wife's frustration can be reduced through
instructing the couple to assure orgasm for the female by means of manual, oral, or electric
vibrator stimulation of her genitals, none of which requires the male to have an erect penis.
Explicit films and books can be used to train the wife in effective stimulation techniques. If
the wife makes demanding or derogatory statements about her husband's sexual abilities, the
therapist should emphasize that such demands or criticism are counterproductive and increase
the anxiety that causes the male's erectile failure.

In extreme cases, when all else has failed to change the wife's attitude, an effective statement
is, "Most men would find it very difficult to have erections in a sexual relationship with
you at this time. We know you can change and learn to be a more skilled lover and less
demanding. Are you willing to accept responsibility and make these changes, with our
help?"

For example, in one case (Lobitz et aI., 1974), the patients were a couple in their fifties, both
married for the second time. The wife's first husband had always had an erection before
beginning lovemaking, and did not want her to touch his genitals at all. The male patient had
been previously married to a woman who manually and orally stimulated his genitals a great
deal before intercourse. When the patient couple began their sexual relationship, their very
different expectations about the role of foreplay in producing an erection led to conflict.
Because of communication difficulties, these conflicts were never resolved. Instead, the wife
became quite bitter, frustrated, and hostile about "his" sexual dysfunction. In such cases of
insufficient stimulation and excessive demands for performance by either the wife's or the
husband's own expectations, a number of therapeutic tactics are indicated.

Another source of anxiety is the male's own attitude toward sex, once erectile failure has
begun to occur. That is, a male with erectile failure tends to enter his sexual encounters as
an anxious observer rather than as an aroused participant. That is, he watches closely for
signs of erection, is upset by any lag in gaining erection or any signs of partial loss of
erection. Since this anxiety about erection obviously prevents erection from occurring, one
therapeutic approach is to use systematic desensitization to eliminate anxiety (Cooper, 1963;
Friedman, 1968; Kushner, 1965; Lazarus, 1965).

2. Systematic Desensitization -
Erection is mediated by the parasympathetic nervous system, the state of sympathetic arousal
associated with anxiety interferes with erection, and the parasympathetic arousal produced by
muscle relaxation in systematic desensitization presumably facilitates erection.

3. Homework Activities -
Prescribing a course of homework activities for the couple can reduce performance anxiety
and ensure adequate stimulation for the male.

 Paradoxical instructions by Annon –

The first set of activities might require the couple only to examine and massage each other's
nude bodies, not including any stimulation of the male's genitals. The male is paradoxically
instructed that "the purpose of this exercise is for you to learn to enjoy sensual pleasures,
without focusing on sexual goals. Therefore, you should try to not get an erection.
Erection would mean you are being sexual rather than sensual." Obviously, a nude
massage is a sexually stimulating experience. The paradoxical demand not to get an erection
in this setting effectively frees the man from anxiety about getting an erection. Over
successive occasions, the couple's repertoire of sexual activities can now be rebuilt (Annon,
1974).

 Teasing Technique by Masters and Johnson –

The next assignment might be for the wife to manually or orally stimulate the male's penis
but to stop such stimulation immediately should an erection occur. Only when the penis is
flaccid should stimulation be resumed. This procedure, which has been called the "teasing
technique", convinces the couple that if erection is lost, it can be regained.

The timing of these activities is such that they are only prescribed after the patients have seen
that they naturally and automatically occur if the male is stimulated and not anxious. For
example, ejaculation is "allowed" only after the male has been unable to restrain himself from
ejaculating intravaginally (LoPiccolo and Lobitz, 1973).

 Ejaculatory Incompetence -
It is the inability of the male to reach orgasm through stimulation by his wife. In treating
ejaculatory incompetence, it should be ascertained that the patient is not receiving any
tranquilizing drugs, especially phenothiazines. Ejaculation is a sympathetic response, and
ejaculatory incompetence can be a side effect of these sympathetic blocking agents.
Treatment of the ejaculatory incompetent couple follows a paradigm that combines elements
from the premature ejaculation and the erectile failure programs.
As in cases of premature ejaculation, the couple is instructed in the technique of providing
massive amounts of stimulation of the male's penis, but without use of the pause or squeeze
procedures.
Similar to treatment of erectile failure, the wife is trained to be an effective sexual partner for
her husband, and, perhaps most importantly, all performance demands upon him for
ejaculation are eliminated through the same procedures used to reduce performance anxiety
in erectile failure. To increase stimulation, an electric vibrator may be used by the wife or her
husband. The previously discussed procedure of cupping the testicles to elicit orgasm may be
used, as well as the body posture and muscular procedures used to trigger female orgasm, as
described in the following section.

 Orgasmic Dysfunction -
Primary orgasmic dysfunction applies to the woman who has never experienced an orgasm
through any means of sexual stimulation. Secondary orgasmic dysfunction applies to a
woman who usually cannot experience orgasm during coitus but who is able to have orgasm
through masturbation or through her husband's manual or oral stimulation of her genitals. It
has been suggested that secondary orgasmic dysfunction is associated with a distressed
marital relationship, and that it may be a symptom and result of this distress rather than a
sexual problem in its own right (McGovern, Stewart, and LoPiccolo, 1975). Such cases may
respond better to a combination of sex therapy and marital counselling than to pure sex
therapy (Snyder et aI., 1975).

A distinction can be drawn between those inorgasmic women who are inhibited and those
who suffer from performance anxiety. The inhibited woman approaches the stereotype of the
''frigid'' woman. Such a woman has a history of negative parental or religious indoctrination
about sex, finds sex repulsive, does not become aroused, and enters therapy reluctantly,
perhaps primarily to keep her husband from leaving her. These women need heavy exposure
to the information and education and attitude change procedures.

The woman with performance anxiety, on the other hand, often has an unremarkable parental
and religious history, enjoys sex, becomes aroused, and enters therapy eager for the
experience of orgasm for her own gratification. Alternatively, the husbands of such women
often have been found to have doubts about their own masculinity and abilities as lovers, and
put their wives under extreme pressure to have orgasms to reassure themselves on this issue.
The treatment program for primary orgasmic dysfunction involves four components :-
1st – For the woman who has never experienced an orgasm, a program of directed
masturbation is implemented. The rationale for the use of masturbation includes the fact that
it is the sexual technique most likely to produce an orgasm. In prescribing masturbation,
LoPiccolo and Lobitz (1972) describe a 9 step program.

2nd - Steps seven through nine of this program involve the second major component.
STEP 1 The woman visually examines her genitals with the aid of a hand mirror and
diagrams. At this time, she is also placed on a program of Kegel's (1952)
exercises to enhance her orgasmic potential through increasing strength and
vascularity of the pelvic musculature.
STEP 2 + 3 The woman tactually explores her genitals to locate pleasure-sensitive areas.
STEP 4 + 5 The woman learns to intensely stimulate these areas while using erotic
fantasies or explicit literature and photos to enhance arousal. She is also taught
to label her physiologic responses to such intense stimulation as sexual arousal
and pleasure, rather than, as often occurs, other states such as anxiety,
discomfort, or tension.
STEP 6 If orgasm has not yet occurred, in step six the woman masturbates using the
electric vibrator.
STEP 7 Husband observes his wife's masturbation to learn what is effective for her.
STEP 8 He learns to manipulate her to orgasm.
STEP 9 Manipulation is paired with coitus.
While this program has produced good results, it should be emphasized that it is not used in
isolation. Typically, the male is also placed on the same masturbation program to ensure his
cooperation and support of the female.

3rd - Disinhibition of arousal -

Many inorgasmic women are inhibited from reaching orgasm by fear of loss of control or
embarrassment about displaying intense sexual arousal and pleasure in front of their
husbands. Such a woman may be able to reach high levels of arousal (but not orgasm) in
masturbation, or to masturbate to orgasm when alone but not in the presence of her husband.
In such cases, the patient is instructed to repeatedly role-playa grossly exaggerated orgasm
with violent convulsions, screaming, and other extreme behaviour. Knowing that she is
merely acting, the couple can engage in this activity quite readily. With repeated role play of
exaggerated orgasm during the couple's prescribed homework activities, the initial fear and
embarrassment turns into amusement and eventually boredom (Lobitz and LoPiccolo, 1972).

4th - Teaching the woman certain behaviours that, if performed during high sexual arousal,
will often trigger the orgasm response. These behaviours tend to occur spontaneously or
involuntarily during intense orgasm (Singer and Singer, 1972) and, when performed
voluntarily, may initiate orgasm. These "orgasm triggers" include pelvic thrusting,
pointing the toes, tensing the thigh muscles, holding the breath, pushing down with the
diaphragm, contracting the vaginal musculature, and throwing the head back to displace
the glottis.
 Vaginismus -
Vaginismus refers to involuntary spastic contraction of the vaginal musculature such that
intromission cannot be accomplished or can only take place with great difficulty and pain.
If physical examination reveals no organic basis, vaginismus is usually an anxiety response.
The woman may fear penetration because of prior painful attempts at coitus due to lack of
lubrication, rape, extreme fear or guilt during the first attempt at coitus, or in rare instances,
an couple who mistake the anus or the urethral opening for the vagina.

In treating vaginismus, one addition is made to the usual program for orgasmic dysfunction.
A graduated series of dilators is used to enable the woman to learn to tolerate vaginal
intromission. This dilation program may be carried out by the gynaecologist in the office or
by the woman or her husband at home. Such dilation can also be accomplished with the
woman's (or her husband's) finger. In addition, the Kegel (1952) exercises may be utilized
not to strengthen the vaginal musculature but as a means of enabling the woman to attain
voluntary control of these muscles.

Summary Table -
Sexual Self Schema Cognitive generalizations about sexual aspects of oneself that are derived from
past experience, manifest in current experience, influential in the processing of
sexually relevant social information, and guide sexual behaviour.
Sexual Scripts Sexual Scripts are ideas of how males and females are supposed to interact with
each other, including how each gender should behave in sexual or romantic
situations.
Basic Principles 1. Mutual Responsibility – Sexual dysfunction is a shared disorder.
2. Information & Education – of basic biology and effective sexual
techniques, knowledge of sexual response cycle.
3. Attitude Change – of negative societal and parental attitudes toward
sexual expression, past traumatic experiences, and current distress
making the sexual encounter evoke feelings of anxiety and disgust.
4. Eliminating Performance Anxiety – Patients are told to stop "keeping
score," to stop being so goal centred on erection, orgasm, or ejaculation,
and instead to focus on enjoying the process rather than trying for a
particular end result.
5. Increasing Communication and Effectiveness of Sexual Technique -
Couples tend to be unable to clearly communicate their sexual likes and
dislikes to each other, due to inhibitions about discussing sex openly.
They have excessive sensitivity to what is perceived as hostile criticism
by the spouse and inhibitions about trying new sexual techniques. Direct
therapy encourages sexual experimentation and open, effective
communication about technique and response.
6. Changing Destructive life-Styles and Sex Roles – The therapist takes an
active, directive, and initiating role with the patient in regard to general
life-style and sex-role issues.
7. Prescribing Changes in Behaviour – A series of gradual steps of specific
sexual behaviours to be performed by the patients in their own home.
These behaviours are often described as "sensate focus" or "pleasuring".
The couple's sexual relationship is then rebuilt in a graduated series of
successive approximations to full sexual intercourse.
Techniques for types 1. Systematic desensitization (Wolpe, 1958) - muscle relaxation is used to
of dysfunction : elicit parasympathetic arousal, which then reduces sympathetic arousal
 Premature through reciprocal inhibition.
Ejaculation - 2. Seman’s procedure - The penis is stimulated until ejaculation is
imminent. At this point, stimulation is stopped. The male pauses until
the sensation of high arousal subsides, then begins stimulation of the
penis again.
3. Squeeze Technique - Masters and Johnson (1970) have modified the
above procedure by having the wife stimulate the husband's penis and
 squeeze firmly on the frenulum when a pause in stimulation is needed.
This "squeeze technique" is said to immediately eliminate the urge to
ejaculate, and it may also cause the male to lose 10% to 30% of his
erection.
4. Homework Assignment – 3 Steps –
1st step - masturbation with the pause procedure, to learn when to pause and to
identify the signals of approaching ejaculation.
2nd step - the patient may be instructed to try the squeeze procedure, to see if this
is more or less effective for him than the simple pause.
3rd step - In the next sessions, the male patient will teach this procedure to his
wife.
 Erectile 1. Educating the couple on mutual responsibility and performance
Failure - demands - The therapist should instruct the couple that erection is not
subject to voluntary control and is neither spontaneous nor instantaneous
(especially in older males) but will automatically occur given sufficient
stimulation in an anxiety-free setting.
2. Systematic Desensitization - Erection is mediated by the
parasympathetic nervous system, the state of sympathetic arousal
associated with anxiety interferes with erection, and the parasympathetic
arousal produced by muscle relaxation in systematic desensitization
presumably facilitates erection.
3. Homework Activities -
Paradoxical instructions by Annon - The paradoxical demand not to get an
erection in this setting effectively frees the man from anxiety about getting an
erection.
Teasing Technique by Masters and Johnson –
The next assignment might be for the wife to manually or orally stimulate the
male's penis but to stop such stimulation immediately should an erection occur.
Only when the penis is flaccid should stimulation be resumed.
 Ejaculatory As in cases of premature ejaculation, the couple is instructed in the technique of
Incompetence providing massive amounts of stimulation of the male's penis, but without use of
- the pause or squeeze procedures.
Similar to treatment of erectile failure, the wife is trained to be an effective
sexual partner for her husband, and, perhaps most importantly, all performance
demands upon him for ejaculation are eliminated through the same procedures
used to reduce performance anxiety in erectile failure. To increase stimulation,
an electric vibrator may be used by the wife or her husband.
 Orgasmic Primary orgasmic dysfunction applies to the woman who has never experienced
Dysfunction - an orgasm through any means of sexual stimulation. The treatment program for
primary orgasmic dysfunction involves four components :-
1st – For the woman who has never experienced an orgasm, a program of
directed masturbation is implemented.
2nd - Steps seven through nine of this program involve the second major
component.
3rd - Disinhibition of arousal -
Many inorgasmic women are inhibited from reaching orgasm by fear of loss of
control or embarrassment about displaying intense sexual arousal and pleasure
in front of their husbands. The patient is instructed to repeatedly role-playa
 grossly exaggerated orgasm with violent convulsions, screaming, and other
extreme behaviour.
4th - Teaching the woman certain behaviours that, if performed during high
sexual arousal, will often trigger the orgasm response.
Secondary orgasmic dysfunction applies to a woman who usually cannot
experience orgasm during coitus but who is able to have orgasm through
masturbation or through her husband's manual or oral stimulation of her genitals.
It has been suggested that secondary orgasmic dysfunction is associated with a
distressed marital relationship, and that it may be a symptom and result of this
distress rather than a sexual problem in its own right (McGovern, Stewart, and
LoPiccolo, 1975). Such cases may respond better to a combination of sex
therapy and marital counselling than to pure sex therapy (Snyder et aI., 1975).
 Vaginismus - In treating vaginismus, one addition is made to the usual program for orgasmic
dysfunction. A graduated series of dilators is used to enable the woman to learn
to tolerate vaginal intromission. This dilation program may be carried out by the
gynaecologist in the office or by the woman or her husband at home. Kegel
(1952) exercises may be utilized not to strengthen the vaginal musculature but as
a means of enabling the woman to attain voluntary control of these muscles.

References -
 The role of sexual self-schema in a diathesis–stress model of sexual dysfunction JILL M.
CYRANOWSKI et al.
 (Perspectives in Sexuality) Joseph LoPiccolo (auth.), Joseph LoPiccolo, Leslie LoPiccolo
(eds.) - Handbook of Sex Therapy-Springer US (1978)