Fresh Perspectives & Self-Awareness in Female Sexual Dysfunction

1. Fresh Perspectives & Self-Awareness in Female Sexual Dysfunction   Nicole Flory, PhD Licensed Psychologist Clinical Instructor, Harvard Medical School 226 Massachusetts Ave, Arlington MA 02474 Phone 781-518-1818, drflory@drflory.com http://www.drflory.com

2. Overview Introduction Definitions Etiology Treatments Discussion

3. Introduction 43% of American women experience sexual difficulties (Laumann et al., 1999) ~ 1/3 lack of interest in sex ~ 1/4 lack of orgasms ~ 1/5 lack of pleasure

4. Sexual & Genital Pain Experts report 1/3 of women experience dyspareunia = pain during intercourse (Glatt et al., 1990) 16 % of reproductive aged women experience vulvodynia = chronic pain in the vulvar region (Harlow et al., 2001)

5. Female Sexual Dysfunction = FSD 1. Hypoactive Sexual Desire Disorder 2. Sexual Aversion Disorder 3. Sexual Arousal Disorder 4. Orgasmic Disorder 5. Dyspareunia 6. Vaginismus

6. Definitions: Sexual Dysfunctions 1. Hypoactive Sexual Desire Disorder = persistent or recurrent deficiency (or absence) of sexual fantasies/ thoughts, and/or desire for, or receptivity to, sexual activity, which causes distress or interpersonal difficulty

7. 2. Sexual Aversion Disorder = persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, which causes distress or interpersonal difficulty

8. 3. Sexual Arousal Disorder = persistent or recurrent inability to obtain or maintain sufficient sexual excitement (may be expressed by lack of subjective excitement or genital response), which causes distress or interpersonal difficulty

9. 4. Orgasmic Disorder = persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes distress or interpersonal difficulty

10. Sexual Pain Disorders 5. Dyspareunia = recurrent or persistent genital pain associated with sexual intercourse, which causes personal distress or interpersonal difficulty

11. 6. Vaginismus = recurrent or persistent involuntary spasm of the musculature of the vagina that interferes with vaginal penetration, which causes personal distress or interpersonal difficulty

12. Biopsychosocial Model • Multiple dimensions of sexual issues should be addressed • Integrative approach to maximize well-being works best

13. Etiology: Physical Factors Medications (antidepressants, birth control pills, & some hypertension drugs) Hypothyroidism, hormonal deficiencies Nerve damage through diabetes, hysterectomy, childbirth, atherosclerosis, spinal cord injury

14. Medical Interventions 1. Blood testing should include general panel & specific endocrine tests 2. Medications without sexual side-effects should be explored 3. Reproductive issues should be discussed 4. Physical assessment should include specific examination of the vulva, vagina, & perineum

15. Psychosocial Factors Lack of knowledge about one’s body & sexual response; unrealistic expectations Religious beliefs, social pressures History of sexual abuse, traumatic sexual & medical experiences Fear of intimacy & losing control

16. Sexual Health Approach Accurate knowledge about sexuality, personal awareness, & self-acceptance Sexual behavior should be congruent with one’s values & self-definition Ability to choose when & how to have sex, to communicate explicitly about sexuality & to set appropriate boundaries

17. Cognitive Interventions 1. Educating about the female sexual response cycle 2. Fostering assertiveness & self-control 3. Addressing negative thoughts (Self, others, future) “I rather have cancer” “My husband won’t help” “I will always be in pain”

18. Stress Management Stress related to performance anxiety, infertility, raising children or balancing professional & personal life Lack of quality time with the partner  relaxation training  increase of pleasurable activities

19. Relationship Issues Anger & resentment towards partner Sexual problems in partner Insensitive / unskilled partner can make sex unrewarding  vicious cycle of rejection

20. Partner Interventions 1. Communication skills / active listening 2. Conflict resolution 3. Assertiveness • Scheduling of couple time • Discussion of sexual values, orientation 6. Sharing of sexual preferences & fantasies

21. Behavioral Interventions 1. Increasing physical activities / sleep 2. Practicing mind-body exercises: • “Sensate focus” (Stage I, II, III, IV) - Meditation / Mindfulness - Hypnosis 3. Reading erotic literature (DISCUSSION) 4. Watching pornography (DISCUSSION) 5. Using sexual aids (DISCUSSION)

22. New Trends Mindfulness sign. improved women’s sexual response & decreased distress (Brotto et al., 2008) Pilot studies: acupuncture sign. improved sexual desire (Brotto et al., 2008) & reduced vulvodynia (Powell et al., 1999) Yoga increased female sexual function (Dhikav et al., 2009)

23. Hypnotic Intervention Relaxation Sensory awareness / alteration Cognitive restructuring 4. Ego-strengthening / trauma containment “I am in a safe place” “Connecting with sexual self” “Connecting to core that is strong & confident”

24. Sexual Pain Disorders - Medications, physical therapy, Kegels, dilatation & transcutaneous nerve stimulation - Surgery & botox injections may be considered, if all other treatments have been unsuccessful

25. Evidence Based Treatments • CBT effective (Bergeron et al., 2001) • Hypnosis effective (Pukall et al., 2007)  Psychological pain management & sex & couple’s therapy

26. Case Example:Presenting Problems • Chronic pain in the vulva area • Pain during sexual intercourse • No intercourse for 6 yr • Pelvic floor dysfunction • 0 desire for sexual intimacy

27. Vulvodynia • ~16 % of reproductive aged women • Pain in vulvar region lasting longer than 3 months (Harlow et al., 2001) • Localized vs. Generalized • Diagnosis of exclusion • No visible pathology / lesions • Most common cause for dyspareunia

28. Pain Assessment • Location, intensity, frequency & quality of pain?  vulva vestibule (6 o’clock), 2-10, upon touch, burning, raw • When / how did it start?  7 yrs, shortly after marriage • What makes it better?  Lidocaine, ice, physical therapy helpful

29. “Pain Channel” • Health problems (e.g. pelvic floor, urinary) • Loss of activity • Loss of pleasure • Relationship concerns • Negative thoughts, hopelessness

30. All pain is felt in the brain

31. VICIOUS CYLE OF PAIN Sexual pain problems are affecting all aspects of sexual experience: Decreased sexual interest Arousal Orgasmic response Sexual frequency Intimate relationship

32. DISCUSSION Sensate focus (Masters & Johnson, 1966) vs. mindfulness (Brotto et al., 2008) vs. hypnosis (Pukall et al., 2007)

33. Sensate Focus (Re)discovering forms of touch Paying attention to sensations Awareness of own body / partner’s body Open mind & body No fear of failure Feeling good in one’s skin

34. Pornography Debate Pornography supporters: Kinsey Institute (founded 1947), Joe Cort (2011)

35. Pros - Can increases sexual desire, fantasies, arousal, orgasm, & frequency of sex Can create a “private world”, “private vocabulary” Can facilitate numb discomfort; all in the safety of own home “I can get what I want when I want it”

36. Cons Decreases couple time? Ruins relationships? Deadens erotic senses? Akin to Adultery? Sexist, exploitative? Guilt, shame, anxiety, secrecy? Out of control, addictive? Pushing limits into illegal, risky behavior?