The Wiley Handbook of Sex Therapy

The Wiley Handbook of Sex Therapy is a comprehensive and empirically-based review of the latest theory and practice in the psychotherapeutic treatment of sexual problems across client populations.

• Structured in four sections covering specific sexual dysfunctions, theoretical approaches to sex therapy; working with client diversity; and future directions in sex therapy
• Advocates a holistic approach to sex therapy with a focus on using a range of psychotherapeutic theories and techniques rather than only the most popular behavioral strategies
• Includes case studies which highlight the broad spectrum of diverse conditions that clients can experience and which sex therapists can therefore encounter in the consulting room
• Includes contributions by more than 60 experts from a wide range of disciplines

• Language: English
• Publisher: Wiley
• Release date: Mar 13, 2017
• ISBN: 9781118510414

Book preview

1

Introduction

Zoë D. Peterson

What is Sex Therapy?

Sex therapists will tell you that one of the fundamental uncertainties that often drives clients into sex therapy is the worry: Am I normal sexually? I, in turn, often wonder: Am I a normal sex therapist? In my own work as a therapist treating sexual concerns, I sometimes use traditional sex therapy techniques such as sensate focus, but I also rely heavily on my broader training as a clinical psychologist and on my overarching feminist and constructivist psychotherapeutic theoretical orientation. Am I still doing sex therapy if I am not explicitly discussing the sexual response cycle, assigning sex‐related behavioral homework, or helping my clients to discuss pharmaceutical treatment options with their doctors?

Thus, one of the most challenging aspects of editing this volume was determining what counts as sex therapy. As I set out to choose chapter authors and select the topics that would be addressed, I was forced to consider my own insufficiently‐articulated viewpoints regarding questions such as, Where does sex therapy stop and general psychotherapy begin? and What are the qualifications for a ‘sex therapist’?

I am certainly not the first to raise these questions about the definition of sex therapy. Tiefer (2012) pointed out that—broadly speaking—across time, sex therapies have included ancient love potions, bloodletting, Masters and Johnson behavioral techniques, Viagra, and YouTube kissing advice videos, among others (p. 312). Yet, she acknowledged that, in contrast to this broad expanse of sex therapies, the term sex therapy has become nearly synonymous with a dysfunction‐focused behavioral or pharmaceutical treatment approach.

Similarly, Levine (2009) reported that he now rejects his former identity as a sex therapist because, to him, sex therapy is too narrow and simplistic. He argued that sex therapy has become tantamount to treating DSM‐defined sexual dysfunctions with an overly simplistic, behavioral‐technique‐focused approach. He contended that sexual problems are far too broad and complicated to be explained and treated using a single theory or treatment approach.

Binik and Meana (2009) agreed that the term sex therapy originally referred to the techniques championed by Masters and Johnson (1970)—psychoeducation about sexual functioning, behavioral homework, and so on—but they maintained that, over time, sex therapists began to use the same techniques and theoretical orientations that were used to treat other psychological problems. The authors argued that sex therapy is just therapy. Given (1) the lack of clear distinction between sex therapy, as it is typically practiced, and general psychotherapy; (2) the lack of a unifying theory of sex therapy; and (3) the lack of regulation regarding who may call themselves a sex therapist, Binik and Meana (2009) proposed that the treatment of sexual problems should be integrated into general psychotherapy practice rather than being treated as a separate subspecialty.

What Problems do Sex Therapists Treat?

Indeed, there is perhaps an even more basic question that must be answered before we can define sex therapy, and that is, What is a sexual problem? The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM‐5; American Psychiatric Association, 2013) codifies the sexual difficulties that are officially acknowledged by the field of psychiatry. The DSM sexual dysfunction diagnoses are exclusively focused on sexual performance: desire, arousal, orgasm, and pain‐free intercourse. This focus on genital performance in the DSM‐5 and in earlier versions of the manual has been heavily critiqued for being heterosexist and phallocentric; for promoting an anxiety‐provoking, performance‐oriented approach to sex; for ignoring cultural differences and gender‐based power differences; and for sidelining essential facets of sexuality such as relationships, emotions, and pleasure (e.g., Apfelbaum, 2012; Kleinplatz, 2012; Tiefer, 2001).

Despite these cogent critiques, there is no denying that, for clients, it is often the symptoms of DSM sexual dysfunctions (e.g., lower levels of desire than they wish, erectile difficulties, orgasmic difficulties) that drive them into sex therapy. Of course, this raises a chicken‐and‐egg conundrum: Did these issues become the focus of the DSM diagnoses because they were the most troubling sexual issues for clients, or are clients most troubled by these sets of symptoms because they have been conceptualized and labeled as dysfunctional by the medical establishment and, in turn, by popular culture? In either case, clients do present with these difficulties, and as sex therapists, we frequently must address them in some manner. Depending on the sex therapist’s viewpoint, this might involve suggesting medications or behavioral exercises with the goal of relieving symptoms; it might involve helping the client to re‐think the assumption that firm erections and timely orgasms are the only path to sexual pleasure and connection; it might involve addressing the underlying psychological and relational distress that is seen as leading to the sexual symptoms; or it might involve some combination of all three of these. Thus, although some sex therapists reject the performance‐oriented, genital‐focused nature of the DSM sexual dysfunction diagnoses, all sex therapists will be forced to confront these in the therapy office.

There is no question, however, that the DSM sexual dysfunctions do not capture the full range or complexity of the sexual concerns that propel our clients to seek therapy. Levine (2010) categorized sexual difficulties as disorders (those identified by the DSM), problems (frequent sources of suffering that are not captured by the DSM disorders), and worries (concerns about sexual issues that detract from sexual pleasure). In many cases, problems (e.g., anger and resentment about a partner’s infidelity, discomfort with or shame about sexual attractions) and worries (e.g., concerns about body image, fears that one is not sexually pleasing a partner) may actually be more distressing and have a more pervasive negative impact on sexual pleasure and enjoyment than relatively more straightforward disorders of physiological function. It is very often these problems and worries—rather than diagnosable disorders—that motivate clients to come to see a sex therapist.

What Techniques do Sex Therapists Use?

As noted by Kleinplatz (1996), Masters and Johnson’s behavioral techniques have become synonymous with sex therapy; as she put it, these techniques are the Kleenex of sex therapy (p. 190). This tendency to equate sex therapy with symptom‐focused behavioral interventions—such as sensate focus and the squeeze technique—obscures the fact that there are actually many different brands of sex therapy. In reality, sex therapists, like all psychotherapists, employ a variety of therapeutic techniques and are guided by a variety of theoretical orientations when they work with clients to address sexual problems. Despite this fact, with a very few notable exceptions (e.g., Hall, 2012; Hertlein, Weeks, & Gambescia, 2009), little is written about theoretical approaches to sex therapy.

Many sex therapists advocate for a biopsychosocial approach to sex therapy. This approach recognizes the importance of integrating medical, psychological, and relational components of treatment. Despite the importance of an integrated approach to treatment, however, the label biopsychosocial is uninformative in revealing the theoretical assumptions that guide the psychological and relational work that occurs in psychotherapy. Thus, a therapist working from a biopsychosocial approach might treat the psychosocial aspects of the problems using behavioral, cognitive, systemic, narrative, or emotion‐focused interventions.

What Should Sex Therapy Be?

I agree with Tiefer (2012) that sex therapy is politics (p. 31). For that matter, all therapy is politics, but this is especially apparent in the case of sex therapy because issues of sexuality and sexual behavior are so highly politically contested. Thus, how expert professionals define a sexual problem and sex therapy speaks to their values—and helps to shape the values of the broader culture—around what is and is not sexually healthy or normal and which treatments are legitimate for addressing sexual concerns. Given that, in this volume, I wanted to represent a diversity of individual values and politics related to what counts as a sexual problem and as sex therapy.

However, to acknowledge my own values and politics, I also wanted to adopt an expansive definition of sex therapy as any therapy that values and promotes enjoyable sexuality as an integral part of overall physical and mental health. Levine (2009), in describing his rejection of the sex therapist label, said:

Sex therapy has no relevance to the management of gender identity disorders, sex perpetrators, paraphilics, the sexually compulsive, sexual victims, sexual risk taking, nonsexual relationship conflict, the anxieties of sexual beginners, and so on, unless, of course, by sex therapy we mean all things involving any aspect of sexuality brought to our clinical attention. (p. 1033)

I hope that the version of sex therapy advocated in this volume does, in fact, have relevance to all of those important sexual issues noted by Levine. Of course, given the breadth of my aspirational definition, no single volume could fully discuss all types of sexual problems, sex therapy clients, or sex therapy techniques; thus, I think of this volume as a mere sampling.

Section I: Treating Specific Sexual Problems

As noted, sex therapists will inevitably treat sexual problems that correspond to the DSM‐5 sexual dysfunctions. Not surprisingly, for many individuals, sexual desire (Althof & Needle, Chapter 3; Both, Weijmar Schultz, & Laan, Chapter 2), erections (Nobre, Chapter 4), orgasms (Carpenter, Williams, & Worly, Chapter 5; Rowland & Cooper, Chapter 6), and pain‐free intercourse (Meana, Fertel, & Maykut, Chapter 7) contribute to pleasure, enjoyment, and satisfaction, and in turn, difficulty with these aspects of functioning detracts from sexual enjoyment. Thus, treatment of these diagnoses is addressed in Section 1 of this handbook. However, sex therapists also treat other issues that interfere with sexual pleasure, enjoyment, and satisfaction, such as difficulties in controlling unwanted (Grubbs et al., Chapter 8) or illegal sexual behaviors (Berg, Munns, & Miner, Chapter 9), and lack of sexual passion (Mintz, Sanchez, & Heatherly, Chapter 10). Thus, these non‐diagnostic problems are also addressed in Section 1 of this volume. Further, throughout all sections of this volume, the rich case material unmistakably illustrates that the entirety of clients’ sexual problems and concerns are not cleanly captured by the dysfunctions listed in the DSM‐5.

Section II: Theoretical Approaches to Sex Therapy

Despite my contention that sex therapy is not synonymous with Masters and Johnson behavioral techniques, many (maybe most) sex therapists use at least some of the classic sex therapy techniques, and these are described by Avery‐Clark and Weiner in Chapter 11; however, the authors also note that traditional sex therapy techniques, such as sensate focus exercises, have often been misrepresented and oversimplified. Their chapter reveals that even simple behavioral exercises involve thoughtful attention to complex psychological and relational factors.

Additionally, at noted above, sex therapists increasingly describe their approach as biopsychosocial to acknowledge the importance of biological, psychological, and relational contributions to sexual problems. However, in Chapter 12, McCarthy and Wald describe why they have abandoned the biopsychosocial approach in favor of a psychobiosocial approach—foregrounding the psychosocial and backgrounding the biological.

There is no doubt that cognitive and behavioral techniques are extremely popular approaches to treating sexual concerns, and this is evident throughout all the chapters in this volume. This is unsurprising, as cognitive‐behavioral therapies currently represent the most popular psychotherapeutic treatment approaches for most mental health problems (Gaudiano, 2008). However, the remaining chapters in Section 2 describe how some sex therapists’ theoretical approaches to sex therapy extend well beyond cognitive‐behavioral therapy to integrate techniques from systemic (Hertlein & Nelson, Chapter 13), existential‐experiential (Kleinplatz, Chapter 14), narrative (Findlay, Chapter 15), and emotionally‐focused (Johnson, Chapter 16) therapeutic traditions.

Bancroft (2009) identified theoretical diversity as one of the strengths of sex therapy, and I agree. Mood disorders have been shown to be effectively treated using a variety of different theoretical approaches, including cognitive‐behavioral therapy, mindfulness‐based cognitive therapy, brief dynamic therapy, and emotion‐focused therapy (Hollon & Ponniah, 2010). Why shouldn’t we similarly expect that sexual problems would likely be responsive to a variety of different treatment approaches?

Section III: Sex Therapy with Specific Populations

Over time, sex therapy has been criticized for being limited in terms of its target population—typically young, able‐bodied, white, middle‐class heterosexuals (e.g., McCormick, 1994). Recent publications (e.g., Hall & Graham, 2013), though, have attempted to expand culturally‐competent sex therapy practice, and as demonstrated in Section 3 of this volume, sex therapists are providing sensitive and affirmative therapy for extraordinarily diverse client populations.

In this section, the chapter authors highlight considerations in treating sexual problems in sexual (Cohen & Savin‐Williams, Chapter 17) and gender (Spencer, Iantaffi, & Bockting, Chapter 18) minorities; clients ranging in age from children (Lamb & Plocha, Chapter 19) to aging adults (Hillman, Chapter 20); clients who face barriers to sexual wellness in the form of intellectual (Hough et al., Chapter 21), psychological (Buehler, Chapter 22), physical health (Zhou & Bober, Chapter 23), and trauma‐related (Hall, Chapter 24) challenges; and clients with diverse sexual ethics, including those with conservative religious values (Turner, Chapter 25) and those who embrace creative and kinky sex (Nichols & Fedor, Chapter 26).

Section IV: Future Directions in Sex Therapy

Although some argue that sex therapy has remained stuck in the 1960s and 1970s with Masters and Johnson, in reality the psychotherapeutic treatment of sexual problems has moved forward in all kinds of ways. In some cases, this forward movement is guided by creative clinical experimentation, but in many cases, it is advanced by outstanding basic and clinical research findings. The final section of this book, Section 4, summarizes the empirical literature on four topics that represent highly promising future directions in the field of sex therapy.

In Chapter 27, Barker provides an overview of the theory and research on mindfulness interventions for sexual problems. Mindfulness is arguably not at all new to sex therapy. Indeed, as described by Avery‐Clark and Weiner (Chapter 11), it is the cornerstone of sensate focus, one of the most traditional and widely‐used sex therapy techniques. However, mindfulness as an explicitly articulated approach to treating a wide variety of sexual problems (not to mention other mental health problems, e.g., Baer, 2003) has recently received very encouraging empirical support, and thus the entire field of sex therapy is taking notice. Indeed, many authors throughout this volume mention mindfulness as a promising adjunct to other sex therapy interventions. In light of the strong empirical support for mindfulness interventions, these types of interventions seem likely to become an essential component of sex therapy going forward.

Given the controversial but undeniable movement toward a medicalized approach to conceptualizing and addressing sexual concerns (which is discussed—and sometimes bemoaned—throughout the chapters in this volume), sex therapists, regardless of their personal views on the issue of pharmacological treatments for sexual problems, will inevitably work with patients who are also using medication to treat their symptoms. Thus, Conaglen and Conaglen (Chapter 28) offer a framework for effectively incorporating partners into individualized medical treatments for sexual dysfunction. Their chapter provides guidance on how sex therapists might continue to incorporate the psychosocial aspects of sex therapy even in the face of an increasingly biomedical orientation towards the treatment of sexual concerns.

Finally, because traditional, face‐to‐face psychotherapy is expensive, time‐consuming, and sometimes hard to access for individuals outside of urban areas, there is increased interest in the broader field of psychotherapy in promoting minimal contact therapies, such as technology‐assisted and bibliotherapy interventions (e.g., Newman, Szkodny, Llera, & Przeworski, 2011). Because sex therapy is often focused on single, circumscribed sexual difficulties and because some individuals are very uncomfortable discussing sexual issues in a face‐to‐face context, some sex therapy clients may be particularly good candidates for these minimal‐contact therapeutic interventions. The final chapters in this section describe the promising empirical research findings on biblio‐sex therapy (van Lankveld, Chapter 29) and internet‐based sex therapy (Connaughton & McCabe, Chapter 30) as treatments for a variety of different sexual concerns. Selective use of these types of minimal contact interventions may allow the field of sex therapy to expand by ensuring that sex therapy remains accessible and affordable to a wide range of client populations.

What are the Values of Sex Therapy?

Certainly the chapters in this volume illustrate the very real conflicts and divides within the field of sex therapy. For example, some authors celebrate new biomedical advances in the treatment of sexual problems (e.g., Conaglen & Conaglen). Other authors lament the medicalization of sexual problems (e.g., Kleinplatz; McCarthy & Wald)—that is, the framing of complex sociocultural, psychological, and relational problems as simple medical conditions that can be treated with a pill. Some authors praise the continued influence and effectiveness of Masters and Johnson’s traditional behavioral sex therapy techniques, including sensate focus and squeeze techniques (e.g., Avery‐Clark & Weiner; Rowland & Cooper), while others argue that such approaches are too mechanistic, reductionist, and heavily focused on symptoms rather than promoting optimally enjoyable and pleasurable sex (e.g., Barker; Kleinplatz; Turner). Some authors argue that close, long‐term, committed intimate relationships provide the context for the most passionate sex (e.g., Johnson); other authors problematize this position, suggesting that the security and closeness provided by long‐term relationships can often result in an overfamiliarity that can contribute to loss of sexual passion (e.g., Mintz et al.).

These disagreements among authors about the nature of and solution to sexual problems are unsurprising, especially given the diversity in region, culture, and profession among the authors in this volume, and those in the field of sex therapy more broadly. Indeed, the authors in this volume represent seven different countries and include psychologists, social workers, endocrinologists, and gynecologists. Some authors are primarily researchers, and others are primarily clinicians. Given the extraordinary diversity of the authors, differing perspectives seem inevitable. Indeed, these conflicts within the field are not new, and some authors have suggested that the intensity of these differences of opinion has led to a damaging splintering of the field of sex therapy (e.g., Kleinplatz, 2012).

However, it is important to note that the disagreements reflected in this volume are generally a matter of degree rather than kind. For example, although some authors are clearly more open than others to integrating biomedical treatments into their sex therapy practice, no author in this volume advocates pharmaceutical interventions implemented in isolation from psychosocial assessment and intervention.

Further, by focusing on disagreements within the relatively small field of sex therapy, it is easy to overlook the many shared values espoused, to at least some degree, by every author in this volume. These values include the essential role of sex and sexuality in overall psychological health; the importance of providing clients with thorough and accurate information about sexuality and sexual functioning; the potentially damaging effects of repressive and shaming messages about sex from families, religion, and the broader culture; the multifaceted nature of sexual problems and sexual pleasure; and the relevance of sexual pleasure and enjoyment as a psychotherapeutic goal. In a cultural context in which middle‐school teachers can be fired for saying the word vagina (Bethencourt, 2016) and state Houses of Representatives are attempting to pass measures to allow for legal discrimination on the basis of sexual orientation (Suntrup, 2016), these are clearly values with which not every therapist, doctor, or member of the general public would agree, so the fact that these values are consistently endorsed across every chapter of this volume is truly meaningful. To me, these values are the foundational components of sex therapy, and they are what unite our field even in the face of substantial disagreements about more specific conceptual and clinical questions. Thus, I ultimately agree with Pukall’s (2009) simple conclusion that what … makes ‘sex therapy’ special is that it deals with sex (p. 1039).

Conclusions

Just as I don’t believe that there is one narrow version of normal sexuality, I hope that this volume illustrates that there is no one way to be a normal sex therapist. There are multiple ways to be an effective sex therapist. This is important, in part, because the numbers of sex therapists are rapidly dwindling (Bancroft, 2009; Kleinplatz, 2012). The field of sex therapy badly needs to attract clinical, counseling, and social work graduate students who are in the process of choosing their career path, as well as established mental health professionals who are looking to expand their practice in new directions. If these students and mental health professionals believe that sex therapy involves merely referring men with erectile dysfunction for Viagra prescriptions, telling women with vaginal dryness where to purchase lubricants, or training men with premature ejaculation in the squeeze technique, then sex therapy may only attract a small group of individuals who enjoy short‐term, structured, and highly focused treatment approaches. These types of interventions may be an important part of sex therapy for some clinicians, but they do not reflect the range of challenging and multifaceted sexual problems that are encountered or the diverse and complicated interventions that are employed in sex therapy. Indeed, reducing sex therapy to exclusively behavioral or pharmaceutical interventions would be equivalent to reducing treatments for depression to mere behavioral activation; behavioral activation is important and often useful, but most therapists treating depression do far more than assigning behavioral homework, and some therapists may never assign behavioral homework as a treatment for depression.

When mental health professionals select to specialize in sex therapy, they need not and should not set aside their broader theoretical understanding of psychological problems, their advanced training in psychotherapy techniques, or their carefully honed therapeutic communications skills (e.g., empathy, authenticity). Those conceptualizations and skills—when combined with a genuine valuing of healthy sexuality as part of overall wellness—are essential for good sex therapy.

Therefore, I hope that this volume will provide some interesting new ideas and techniques for those who already identify professionally as sex therapists. I also hope that it will function as a starting place for students and psychotherapists who do not—or do not yet—identify as sex therapists, but who value sexual health and wellness as an essential part of general mental health and wellness and who thus hope to work better with sexual concerns as part of their general psychotherapy practice.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

Apfelbaum, B. (2012). On the need for a new direction in sex therapy. In P. J. Kleinplatz (Ed.), New directions in sex therapy: Innovations and alternatives (2nd ed.) (pp. 5–20). New York, NY: Routledge.

Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143. doi:10.1093/clipsy.bpg015

Bancroft, J. (2009). Sex therapy needs building not deconstruction. Archives of Sexual Behavior, 38, 1028–1030. doi: 10.1007/s10508‐009‐9471‐0

Bethencourt, D. (2016, April 27). Saying vagina got me fired, Battle Creek middle school teachers says. Detroit Free Press. Retrieved from http://www.freep.com/story/news/local/michigan/2016/04/26/teacher‐says‐vagina‐in‐class‐battle‐creek‐vword/83571076/

Binik, Y. M., & Meana, M. (2009). The future of sex therapy: Specialization or marginalization? Archives of Sexual Behavior, 38, 1016–1017. doi:10.1007/s10508‐0099475‐9

Gaudiano, B. A. (2008). Cognitive‐behavioral therapies: Achievements and challenges. Evidence Based Mental Health, 11, 5–7. doi:10.1136/ebmh.11.1.5

Hall, K. S. K., & Graham, C. A. (Eds.) (2013). The cultural context of sexual pleasure and problems: Psychotherapy with diverse clients. New York: Routledge.

Hall, M. (2012). The honeymoon is over: Narrative sex therapy for long‐term lesbian partners. In P. J. Kleinplatz (Ed.), New directions in sex therapy: Innovations and alternatives(2nd edition) (pp. 285–302). New York, NY: Routledge.

Hertlein, K. M., Weeks, G. R., & Gambescia, N. (Eds.) (2009). Systemic sex therapy. New York, NY: Routledge.

Hollon, S. D., & Ponniah, K. (2010). A review of empirically supported psychotherapies for mood disorders in adults. Depression and Anxiety, 27, 891–932. doi: 10.1002/da.20741

Kleinplatz, P. J. (1996). Transforming sex therapy: Integrating erotic potential. The Humanistic Psychologist, 24, 190–202. doi: 10.1080/08873267.1996.9986850

Kleinplatz, P. J. (2012). Advancing sex therapy or is that the best you can do? In P. J. Kleinplatz (Ed.), New directions in sex therapy: Innovations and alternatives (2nd ed.) (pp. xix–xxxvi). New York, NY: Routledge.

Levine, S. B. (2009). I am not a sex therapist! Archives of Sexual Behavior, 38, 1033. doi:10.1007/s10508‐009‐9474‐x

Levine, S. B. (2010). Preface to the first edition. In S. B. Levine, C. B. Risen, & S. E. Althof (Eds.), Handbook of clinical sexuality for mental health professionals (2nd ed.) (pp. xi–xiii). New York, NY: Routledge.

Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. New York, NY: Little, Brown.

McCormick, N. B. (1994). Sexual salvation: Affirming women’s sexual rights and pleasures. Westport, CT: Praeger.

Newman, M. G., Szkodny, L. E., Llera, S. J., & Przeworski, A. (2011). A review of technology‐assisted, self‐help, and minimal contact therapies for anxiety and depression: Is human contact necessary for therapeutic efficacy? Clinical Psychology Review, 31, 89–103. doi:10.1016/j.cpr.2010.09.008

Pukall, C. F. (2009). Sex therapy is special because it deals with sex. Archives of Sexual Behavior, 38, 1039–1040. doi:10.1007/s10508‐009‐9468‐8

Suntrup, J. (2016, April 13). Religious liberty measure draws praise, scorn at Missouri House hearing. St. Louis Post‐Dispatch. Retrieved from http://www.stltoday.com/news/local/govt‐and‐politics/religious‐liberty‐measure‐draws‐praise‐scorn‐at‐missouri‐house‐hearing/article_e7e997da‐37e5‐57e4‐b51a‐7c7b368d4b94.html

Tiefer, L. (2001). A new view of women’s sexual problems: Why new? Why now? Journal of Sex Research, 38, 89–96. doi:10.1080/00224490109552075

Tiefer, L. (2012). Medicalizations and demedicalizations of sexuality therapies. Journal of Sex Research, 49, 311–318. doi:10.1080/00224499.2012.678948

Section I

Treating Specific Sexual Problems

2

Treating Women’s Sexual Desire and Arousal Problems

Stephanie Both, Willibrord Weijmar Schultz and Ellen Laan

Phenomenology

According to the definition in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM‐5; American Psychiatric Association, 2013), female sexual interest/arousal disorder (FSIAD) is characterized by a lack of, or significantly reduced, sexual interest and/or arousal, as manifested by at least three of the following symptoms (criterion A): (1) absent/reduced interest in sexual activity; (2) absent/reduced sexual/erotic thoughts or fantasies; (3) no/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate; (4) absent/reduced sexual excitement/pleasure during sexual activity in almost all or all sexual encounters; (5) absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual); and (6) absent/reduced genital or nongenital sensations during sexual activity in almost all or all sexual encounters. For a diagnosis to be given, the symptoms must be present for a minimum duration of approximately 6 months (criterion B), and they must cause clinically significant distress in the individual (criterion C; American Psychiatric Association, 2013, p. 433). Furthermore, in order to classify the complaints under this diagnosis, the complaints should not be better explained by a nonsexual mental disorder, severe relationship distress, or other significant stressors. Also, they must not be exclusively associated with the consequences of a medical condition, and when substance or medication use can explain the complaints, the diagnosis of substance/medication‐induced sexual dysfunction should be made. The presence of another sexual dysfunction does not rule out a diagnosis of FSIAD because it is common that women experience more than one sexual dysfunction concurrently. For example, a sexual pain disorder may go along with a lack of sexual interest and arousal.

Thus, differently from the DSM‐IV‐TR (American Psychiatric Association, 2000), in which sexual desire and arousal disorders were described as two separate disorders, in the DSM‐5 desire and arousal disorders are merged into one female sexual interest/arousal disorder. One of the reasons for merging the categories of female sexual desire and sexual arousal disorders in the DSM‐5 was the observation that low sexual desire is often seen in combination with arousal problems (Brotto, 2010). Studies show that many women with a lack of sexual desire also have sexual arousal problems, and vice versa (Hendrickx, Gijs, & Enzlin, 2013; Segraves & Segraves, 1991).

Also differently from the DSM‐IV‐TR, in the DSM‐5 no distinction is made between low sexual interest/arousal disorder and sexual aversion disorder. In clinical practice these sexual problems are often differentiated such that low interest/arousal chiefly refers to a lack of interest in sex even though the sex itself can be experienced as neutral or positive, whereas sexual aversion refers to responding to sex with negative emotions such as disgust or anxiety (Borg, de Jong, & Elgersma, 2014). The DSM‐5, however, includes the category of other specified sexual dysfunction, which applies to presentations in which symptoms cause clinically significant distress but do not meet the criteria for any specific sexual dysfunction. In the description of this category, it is explicitly stated that sexual aversion can be specified as the reason for the distress. Clinically, the distinction between lack of sexual interest/arousal and sexual aversion is relevant; in the case of sexual aversion, desensitization and counter‐conditioning procedures are important in treatment, but in the case of low interest/arousal, these interventions are generally not necessary.

In practice, single women seldom present with the complaint of no sexual interest or arousal. Usually the complaint comes from women in a steady relationship and is related to differences in sexual desire between her and her partner. In the DSM‐5, it is explicitly stated that a desire discrepancy, in which a women has lower desire for sexual activity than her partner, is not sufficient to diagnose FSIAD. Also, the DSM notes that a normative decline in sexual thoughts and response with age should be taken into account. But how much disinterest does a woman need to show in order to qualify for a sexual interest/arousal disorder? The DSM lacks objective criteria, which means that the diagnosis has to be based on the subjective judgement of the clinician, who must also consider factors that might influence sexual functioning, such as gender or age. Gender is known to be an important factor. On the basis of a review of a large number of studies on differences in sexual motivation between men and women, Baumeister, Catanese, and Vohs (2001) concluded that women generally have lower and less frequent sexual motivation than men. Women masturbate less, fantasize less about sex, have less frequent desire for sex, and report more complaints of not feeling like having sex.

Recently, a new disturbance has been described related to sexual arousal in women—the so‐called persistent genital arousal disorder. This syndrome is characterized by spontaneous, unpleasant, and unwanted genital arousal in the absence of feelings of sexual interest or desire (Leiblum, Seehuus, & Brown, 2007). As data on the nature, prevalence, and possible treatment of this disorder are scarce, this chapter does not elaborate further on this arousal disturbance.

Prevalence/Incidence

Little or no sexual desire is the most common sexual problem reported by women. Recent prevalence studies, which still made use of the separate DSM‐IV‐TR criteria for hypoactive sexual desire and sexual arousal disorder, investigated the occurrence of symptoms of sexual dysfunction and also the degree of distress caused by the problems (Shifren, Monz, Russon, Segreti, & Johannes, 2008; West et al., 2008; Witting et al., 2008). Although these studies differed in their diagnostic criteria and study methods, the prevalence of low sexual desire in the general population of women was consistently found to be about 20–30%. When distress about the low desire was used as a necessary criterion for dysfunction, the prevalence rates decreased by about half. The prevalence of sexual arousal problems across studies was between 11–31%, but in combination with the criterion of distress, these rates also decreased sharply. These findings show that sexual interest and arousal problems are fairly common in women, but that only a proportion of the women experience real distress from them and thus would qualify for a sexual dysfunction diagnosis. In a study on a representative group of American women, it was found that subjective distress over sexual problems could best be predicted by general emotional wellbeing and the emotional bond with the partner during sexual contact (Bancroft, Loftus, & Long, 2003). Thus, in many cases, sexual complaints could be a normal reaction to unfavourable circumstances.

Etiology

Models of female sexual arousal and desire

The DSM‐IV‐TR classification of sexual disorders was based on a linear model of sexual response, in which the phase of sexual desire precedes the phases of sexual arousal, orgasm, and resolution (Kaplan, 1977; Masters & Johnson, 1970). This model implies that sexual desire occurs spontaneously and that it is independent of the sexual arousal response. Various authors criticized this strict distinction made between the phase of sexual desire and the phase of sexual arousal, and emphasized that sexual motivation stems from the processing of sexual stimuli, which leads to sexual arousal as well as sexual desire (Basson, 2001; Both, Everaerd, & Laan, 2007; Everaerd & Laan, 1995). As noted above, based on this criticism and the high comorbidity of sexual desire and arousal problems, the categories of female sexual desire and sexual arousal disorders were merged in the DSM‐5. According to this recent view, which corresponds with modern incentive motivation theories, the origin of sexual arousal and desire is the result of an interplay between a person’s internal sexual response system and external stimuli (incentives) that activate this system. Not only the sensitivity of the system plays a role, but also the meaning and intensity of the real or imaginary stimuli.

It follows from this notion that sexual desire does not precede arousal, but is a consequence of arousal or a simultaneous occurrence. Sexual motivation is not seen as something that comes from within—as something that one can have a lot or a little of—but as something that manifests itself when certain conditions are met. The conditions necessary to activate the sexual process have three parts: (1) there must be an intact system that enables sexual responsiveness; (2) stimuli with a sexual meaning must be present that can activate the sexual system; and (3) the circumstances must be suitable to pursue sexual activity (Singer & Toates, 1987). In this process, motivation starts to emerge and becomes stronger as the three conditions are met to a greater and greater degree. In contrast, if one or more of these conditions are lacking or absent, then the sexual process breaks down.

Sexual activity is not always a consequence of a process in which sexual arousal and sexual desire are involved. In a large group of study subjects, Meston and Buss (2007) made an inventory of people’s motives to have sex with a partner. Men and women reported a wide variety of motives, such as experiencing physical pleasure, showing affection, satisfying the partner, relieving boredom, or fulfilling a perceived obligation. Although the top ten motives of the men and women were closely matched, the men were more inclined towards physical motives, such as seeing an attractive body, whereas the women were more inclined towards relational motives, such as showing love. In the female sexual response model developed by Basson (2001), the need for intimacy plays an important role as a motive for sexual activity. Basson emphasized that, particularly in long‐term relationships, a woman’s willingness to be sexual derives from her wish for intimacy and that this can lead to sexual arousal and sexual desire. The rewarding value of the sexual interaction then determines the extent to which the woman will be receptive to sexual stimuli in the future.

The above‐described recent views of sexual desire and sexual arousal are in line with an information processing model of sexual arousal (Janssen, Everaerd, Spiering, & Janssen, 2000). In this model, two information processing pathways are distinguished. The first pathway concerns, in particular, the automatic and unconscious processes, whereas the second pathway concerns attention and regulation. Activation of genital sexual arousal (via the automatic pathway) largely occurs unconsciously and quickly, whereas the conscious significance attributed to the experience (via the conscious pathway) occurs relatively slowly. The genital response (i.e., blood flow to the genitals and vaginal lubrication) and the subjective conscious experience (i.e., feeling psychologically aroused) do not necessarily need to be in concordance. In women, relatively low concordance is generally found between genital responses and feelings of sexual arousal; feelings of arousal seem to be determined to a larger extent by the situational context than by the strength of the genital response (Laan, Everaerd, & Both, 2005). Lack of concordance between the genital response and the subjective response can occur when a stimulus activates not only sexual meanings (facilitating genital arousal), but also nonsexual or negative meanings (inhibiting subjective arousal).

According to the information processing model, biological as well as psychological factors can hinder the activation of the sexual system. Hormonal disorders can, for example, decrease the sensitivity of the sexual system, otherwise referred to as arousability or sexual excitability, while cognitive processes, such as negative thoughts or distraction, can repress genital or subjective sexual arousal (Barlow, 1986). Thus, the information processing model underlines the importance of the meaning of the stimuli. Although there are stimuli that by nature cause sexual responses and pleasurable feelings in most people—such as stroking the genitals—it is likely that the majority of sexual stimuli derive their meaning from learning processes (Brom, Both, Laan, Everaerd, & Spinhoven, 2014). Learning about sexual stimuli generally leads to positive sexual associations, but stimuli can also become associated with negative emotions. Therefore, the potential of stimuli to evoke sexual desire and arousal depends on the sexual learning history of the individual.

Arousability: the role of hormones and somatic disease

Oestrogens and androgens

There is agreement in the literature that sex hormones (oestrogens and androgens) play conditional roles in sexual response (Davis, Guay, Shifren, & Mazer, 2004). However, it is not yet clear precisely how these hormones influence sexual functioning. In addition, it is not clear what critical threshold of sex hormones enables sexual responsiveness and what level represents a deficit.

The most important hormones for women are the oestrogens, including oestradiol. During menopause, oestrogen levels decrease sharply. Decreased oestradiol levels can cause complaints such as hot flushes, sleep disorders, mood swings, vaginal atrophy, and vaginal dryness. These symptoms can have negative effects on sexual functioning. There are indications that basic vaginal blood circulation is poorer in postmenopausal women than in premenopausal women (Both et al., 2015; Laan & van Lunsen, 1997; Pieterse et al., 2008). Low oestrogen levels have been shown to be correlated with poor basic blood circulation, but not with a weaker vaginal engorgement in response to erotic stimulation. Thus, when there is sufficient erotic stimulation, lower oestrogen levels do not necessarily seem to obstruct the genital arousal response.

In addition to oestrogen, women produce androgens, including testosterone. In the blood, a maximum of 3% of the total testosterone is freely available, while the rest is strongly bound to sex hormone binding globulin (SHBG) and is not biologically available. The amount of SHBG is related to factors such as the oestrogen level in the blood. High oestrogen levels lead to higher SHBG production, which reduces the biologically available testosterone fraction (Simon, 2002). Physiologically, the testosterone concentration gradually decreases in women starting at the age of 25 to 30 years (Davis, Davison, Donath, & Bell, 2005). In postmenopausal women, the testosterone levels are about half of what they were at the age of around 30 years. After iatrogenic menopause (e.g., as a result of treatment for breast cancer or of preventive (prophylactic) bilateral oophorectomy (the surgical removal of the ovaries) in case of BRCA gene mutation), androgen levels are often even more strongly decreased to about a third to a quarter of premenopausal levels (Lobo, 2001).

As women have low testosterone levels, it is difficult to obtain accurate measurements. The most sensitive analysis methods are expensive and time‐consuming and therefore unsuitable for application in clinical practice. In addition, good reference values are lacking for (free) testosterone in women and it is doubtful whether the testosterone level is a reliable measure of androgen activity. For these reasons, it is recommended not to perform testosterone measurements routinely in clinical practice to establish whether women have androgen deficiency, but only in the case of specific medical conditions that are known to be associated with testosterone deficiency (Labrie et al., 2006; Lobo, 2001). As oestrogen levels decrease sharply during the menopause, it is no longer possible to obtain reliable oestradiol measurements from postmenopausal women (Buckler, 2005).

Discussions are ongoing about the level of influence that androgens have on sexual functioning in women. There are indications that sexual desire and particularly arousability are linked with androgens, but the research findings are not unequivocal. A few studies indicated reduced testosterone levels in women with complaints of low sexual desire (Riley & Riley, 2000; Turna et al., 2005), or observed an association between low testosterone and complaints such as a reduced feeling of wellbeing, lack of energy, depression, and low sexual desire and sexual satisfaction (Bachmann et al., 2002; Davison, Bell, Donath, Montalto, & Davis, 2005). However, in large population studies no relationship, or only weak correlations, were found between androgen levels and the sexual functioning of women (Alexander, Dennerstein, Burger, & Graziottin, 2006; Gerber, Johnson, Bunn, & O'Brien, 2005). Deficiencies in freely available testosterone can arise due to low testosterone production, as observed in patients with pituitary dysfunction, ovarian dysfunction (e.g., premature ovarian failure, Turner’s syndrome, preventive removal of the ovaries in the case of mutation in the BRCA gene, adrenal dysfunction associated with chemotherapy and radiotherapy, hypothyroidism, use of corticosteroids or anti‐androgens (e.g., in the Diane contraceptive pill), or due to excessive SHBG under the influence of medication (e.g., oestrogens in oral contraceptives). In women after bilateral oophorectomy (removal of both ovaries), a relationship was found between reduced androgen levels and decreased sexual desire. In these patients, androgen substitution had positive effects (Shifren et al., 2006). Over the past few years, various studies have been published in which transdermal testosterone administration in combination with oestrogens had positive effects on decreased sexual desire in women who entered premature menopause after bilateral oophorectomy (e.g. Braunstein et al., 2005; Davis et al., 2006). Recently, positive effects have also been reported in women after natural menopause (Shifren et al., 2006) and in premenopausal women with low sexual desire (Schwenkhagen & Studd, 2009).

Very few psycho‐physiological data are available on the effect of testosterone on the sexual arousal response in women. A small number of studies found that the administration of methyl testosterone increased the genital response, but did not affect subjective sexual arousal (Heard‐Davison, Heiman, & Kuffel, 2007; Tuiten, van Honk, Verbaten, Laan, & Everaerd, 2002; Tuiten et al., 2000). In a study on surgically postmenopausal women that measured brain activity in reaction to erotic stimulation, the activity in the limbic system was stronger after they had received oestrogens and testosterone than after oestrogens alone or no medication (Archer, Love‐Geffen, Herbst‐Damm, Swinney, & Chang, 2006). Subjective sexual arousal was not measured in this study. In summary, it can be concluded that androgens certainly influence the sexual arousability of women, but as yet, the only clear empirical evidence of a relationship between decreased testosterone levels and low sexual desire is in studies of women with bilateral oophorectomy.

Somatic disease and medical interventions

Somatic disorders or medical interventions can lead to decreased sexual desire or disruption of the arousal response. In addition to physiological mechanisms, psychological factors related to chronic disease, such as fatigue, pain, or depression, can affect sexual functioning. Chronic diseases that are known to disrupt sexual functioning physiologically as well as psychologically are neurological disorders such as multiple sclerosis and transverse spinal cord injury (Rees, Fowler, & Maas, 2007); endocrine disorders such as hypothyroidism, hyperprolactinaemia, and diabetes mellitus (Bhasin, Enzlin, Coviello, & Basson, 2007); and renal failure (Basson & Weijmar Schultz, 2007). Recently, there is increasing attention on the negative effects of cancer and cancer treatment on female sexual function (Abbott‐Anderson & Kwekkeboom, 2012; Incrocci & Jensen, 2013; Krychman & Millheiser, 2013; see also Zhou & Bober, this volume). Although multiple physical conditions have been associated with impaired subjective arousal and desire, currently only women with transverse spinal cord injury (Sipski, 2001), women with nerve damage as a result of oncological surgery to the uterus, and women with diabetes mellitus (Both et al., 2015; Pieterse et al., 2008; Wincze, Albert, & Bansal, 1993) have been found to show weaker genital arousal responses to sexual stimulation compared with healthy controls.

Various drugs that act on the neurotransmitter systems, such as antidepressives (selective serotonin reuptake inhibitors; SSRIs) and antipsychotics (dopamine antagonists), have negative effects on sexual desire and sexual arousal (Meston & Frohlich, 2000). A few antidepressants seem to have weaker antisexual side‐effects than others (agomelatine, bupropion, moclobemide, mirtazapine), and there are indications that the addition of bupropion to pharmacological treatment for depression (Serretti & Chiesa, 2009) may be a promising approach to reduce antidepressant‐induced sexual dysfunction (Taylor et al., 2013).

Arousability: psychological factors

Stimuli and meaning

The incentive motivation model emphasizes the importance of the attractiveness of the stimuli in the origination of sexual arousal and sexual desire. According to the information processing model, different cognitive processes can influence how sexual stimuli are interpreted, which can mean facilitation of the sexual arousal response, or indeed, its collapse. In studies that measured genital responses in physically healthy women with sexual arousal problems, it appeared that these women showed comparable increases in genital engorgement in response to erotic stimulation as women without arousal problems (Basson et al., 2003; Levin et al., 2016). However, women with sexual arousal problems reported fewer positive sexual feelings and more negative feelings in response to erotic stimuli than women without sexual problems (Laan, van Driel, & van Lunsen, 2008). This demonstrates that physically healthy women with sexual arousal problems are equally able to achieve genital sexual arousal as women without problems. Therefore, in physically healthy women, arousal problems are more likely to be related to inadequate erotic stimulation in everyday life or to negative evaluations of the sexual stimulus or the sexual context, than to disturbances in genital responsiveness.

Various mechanisms can have a negative influence on the attractiveness of sexual stimuli, such as habituation or associations with negative outcomes. For instance, experimental research has shown evidence of habituation of genital and subjective sexual arousal by repeated exposure to the same sexual stimulus (Meuwissen & Over, 1990). When a new stimulus was subsequently introduced, arousal increased again. In this respect, it is interesting that questionnaire research in women showed that a longer relationship duration correlated with diminishing sexual desire (Klusmann, 2002; Murray & Milhausen, 2012), and that starting a new relationship was accompanied by stronger feelings of desire (Avis et al., 2005). Also, in qualitative research, women with sexual desire disorder report perceiving the institutionalization of the relationship, overfamiliarity with their partner, and desexualization of the roles in the relationship as causes of their waning desire (Sims & Meana, 2010). It is possible that habituation and/or a lack of variety are involved in the origination of decreased sexual desire in longer relationships.

Another mechanism that may be involved is classical conditioning (Agmo, 1999; Brom, Both, Laan, Everaerd, & Spinhoven, 2014; Hoffmann, Janssen, & Turner, 2004). Laboratory studies on women have shown that the sexual arousal response to a specific stimulus can be positively conditioned by repeatedly pairing the stimulus with pleasurable sexual stimulation. Thus, stimuli can be given sexually activating characteristics using basic learning processes. This implies that, when a women has gained very little rewarding sexual experience, there will be very few positive associations, and consequently very few stimuli that can elicit sexual desire and arousal. Recently, support for this notion has been found in a study on premenopausal women with acquired low sexual desire, in whom sexual stimuli elicited fewer conscious and unconscious positive associations than in women without sexual problems (Brauer et al., 2012). Sexual stimuli can also lose their attractiveness when sex repeatedly results in negative outcomes, such as anxiety, disappointment, or pain. A laboratory study showed that when an erotic stimulus was repeatedly followed by a pain stimulus, this suppressed the sexual arousal response and the subjective appreciation of the erotic stimulus (Both et al., 2008).

A more negative attitude towards sexuality in general also coincides with more sexual problems (Nobre & Pinto‐Gouveia, 2009). For example,the experience of sexual violence can lead to strong negative associations with sex. A history of sexual violence can play a role in sexual desire or arousal problems and particularly in sexual aversion. Negative opinions and attitudes regarding sex that originated during sexual development can also influence sexual functioning.

Mood and cognitions

It is well known that depression is associated with low sexual interest and sexual response. There is evidence of lower self‐esteem and higher rates of mood problems in women with low sexual desire compared with women without desire problems (Hartmann, Heiser, Ruffer‐Hesse, & Kloth, 2002). In a US study it was found that women who presented with the complaint of low sexual desire had suffered almost three times as many depressive episodes in their lives as women without sexual desire problems (Schreiner‐Engel & Schiavi, 1986). In a recent large observational study including 1088 premenopausal women with diagnosed hypoactive sexual desire disorder, in 34% there were current symptoms or a diagnosis of depression; of those, 56% used antidepressant medication. Women with sexual desire disorder and depression reported poorer sexual function compared with women with sexual desire disorder and no depression, and antidepressant use was associated with sexual dysfunction predominantly among women with unresolved symptoms of depression (Clayton et al., 2012).

In questionnaire research, women reported that feeling depressed or anxious decreased their interest in sex (Lykins, Janssen, & Graham, 2006), while in laboratory studies, it has been confirmed that a depressed mood and negative sexual self‐image can have inhibiting effects on subjective sexual arousal (Kuffel & Heiman, 2006; Middleton, Kuffel, & Heiman, 2008; ter Kuile, Vigeveno, & Laan, 2007). Laboratory studies also suggested an inhibiting effect of stress and fear of pain on women’s genital and subjective arousal response (Brauer, ter Kuile, Janssen, & Laan, 2007; ter Kuile, Both, & van Uden, 2009), but there are also indications of a potentially facilitating effect of fear on the sexual arousal response (Palace & Gorzalka, 1990). The exact cognitive, affective, or physiological processes through which depression and anxiety influence sexual response are as yet unknown.

In the model developed by Barlow (1986), fear of failure in a sexual situation leads to a focus of attention on negative non‐sexual stimuli instead of on sexual stimuli, which prevents the progress of the arousal response. Thoughts related to fear of failure can include thoughts that the partner will be disappointed because the woman’s arousal response does not occur fast enough, or thoughts that the partner will perceive the woman’s body as unattractive. The degree to which a woman feels physically and sexually attractive is related to sexual self‐confidence and sexual functioning (Dove & Wiederman, 2000; Satinsky, Reece, Dennis, Sanders, & Bardzell, 2012). Cognitive distraction during the processing of sexual stimuli leads to weaker sexual arousal in women with and without sexual problems (Salemink & van Lankveld, 2006). On the basis of their clinical experience with sexual problems, Masters and Johnson described that spectatoring (i.e., when a person observes and judges him/herself from a third‐person perspective during sexual activity) inhibits the sexual response (Masters & Johnson, 1970). Laboratory research showed that, in women without sexual problems, a so‐called hot focus (i.e., the woman immerses herself as much as possible in the sexual situation and focuses her attention on her emotional and physical reactions) enhances feelings of sexual arousal (Both, Laan, & Everaerd, 2011). In addition, it appears that expectations influence feelings of sexual arousal: Women with and without sexual arousal problems experienced greater sexual arousal when they received positive feedback about their physical arousal response (McCall & Meston, 2007).

Relational context

In women, there is a strong correlation between sexual desire and relational satisfaction. A large European study found that women with low sexual desire were significantly less satisfied with their sexual relationship and their relationship in general than women without desire problems (Dennerstein, Hayes, Sand, & Lehert, 2009). It is not possible on the basis of these data to determine whether low desire is a cause or a consequence of relational dissatisfaction, but particularly in women, sexual desire seems to be sensitive to the interpersonal aspects of the relationship (Impett & Peplau, 2003). Research into sexual desire in heterosexual relationships has found that people who more strongly pursued depth and pleasure in the relationship showed stronger and more consistent sexual desire (Impett, Strachman, Finkel, & Gable, 2008). In addition, on days with more positive relational interactions, there was more sexual contact. Thus, the dynamics in the relationship play an important role in the sexual motivation of women.

The way that people deal with differences in sexual desire within relationships is also influenced by norms and values related to sexuality and relationships. Whereas in the past sex was often viewed as a marital duty, nowadays it seems to be the norm that both partners have to be willing before there is any sexual contact. This norm, although an improvement over obligatory marital sex, can have an unintended inhibiting effect because desire is especially likely to originate during sexual interaction (Everaerd & Laan, 1995).

Interestingly, recent research on sexual desire in long‐term relationships shows that individuals who are motivated to meet their partner’s sexual needs (high in sexual communal strength) experience higher levels of sexual desire (Muise, Impett, Kogan, & Desmarais, 2013). In a daily experience study of long‐term couples, individuals higher in sexual communal strength reported higher levels of daily sexual desire, and reported engagement in sex because meeting the sexual needs of their partner is satisfying for themselves. Importantly, however, unmitigated sexual communion (an exclusive focus on partner’s need as opposed to own needs) was associated with negative feelings and lower sexual desire in both partners (Muise & Impett, 2014). Approach goals such as experiencing pleasure yourself or giving pleasure to your partner, as opposed to avoidance goals such as to avert own stress or a partner’s disappointment or anger, are associated with heightened sexual desire (Impett et al., 2008). These observations indicate that having sex to avoid negative consequences is not a fruitful approach to maintain sexual desire, while being motivated for sex to meet a partner’s sexual needs can help keep the desire of both partners alive in relationships.

Assessment of Desire and Arousal Problems in Women

Initial interview

Owing to the fact that sexual functioning in women is strongly influenced by the relational context, as part of the assessment process, it is of great importance to talk to both the woman and her partner in order to map the problems of low desire and arousability; preferably, the couple should be seen together. It is worthwhile asking specific questions about situations or stimuli that could elicit sexual interest and arousal in the past. Subsequently, attention can be focused on the degree to which these situations or stimuli are lacking in present life and on whether the woman does not seek the situations or stimuli or perhaps even actively avoids them because they are not (or are no longer) acceptable or pleasant to her or her partner. For example, is the woman avoiding any intimate physical contact because she is afraid that the partner will then expect her to have intercourse that she does not desire? Is there hardly any time for emotional and physical intimacy due to lack of privacy or overfull agendas? Does the woman feel physically unattractive? In addition, it is important to ask the woman how she experienced sexual activity in the past and, if still sexually active, at the present time. Sexual interest can only be elicited when there are expectations of reward. To what degree and in what way was or is sex with the partner (and masturbation) a positive and rewarding experience and/or a negative and disappointing experience? Did the woman experience sexual violence in the past, which may have resulted in negative associations with sex? Specific attention should also be paid to relational satisfaction and the woman’s feelings for her partner. For example, does she still find her partner attractive? Are there any problems in other relational areas that are influencing the woman’s feelings for her partner?

With respect to sexual arousability, it is worthwhile enquiring about the subjective as well as the genital components of the sexual arousal response. To what extent now and in the past does/did the woman experience feelings of sexual arousal in sexual situations (e.g., during masturbation, intimate kissing, having her genitals stroked, stroking her partner)? To what extent does the woman become lubricated during sexual stimulation? In order to evaluate the extent to which sexual stimulation is adequate, it is important to establish what the couple or the woman actually does during sex or masturbation. Furthermore, there should be evaluation of whether there are feelings or thoughts that seem to stimulate arousal or, in contrast, hinder the process.

When there are indications that somatic or psychiatric disorders may (partly) form the background of the sexual problems, the woman can be referred for further medical or psychiatric tests. Obviously, the health professional must be alert to a possible depressive disorder. When somatic or psychiatric factors are involved, it should be considered whether their treatment needs to take priority. If there are other dominant problems, such as a depressive disorder, post‐traumatic stress disorder, or serious relational problems, these should be dealt with first. If necessary, this can be followed by sex therapy to help the couple to reintegrate sexuality into their sexual relationship or to learn to cope with the existing limitations. If the woman is taking medication that can have a negative influence on the sexual response, the treating physician can be contacted to decide whether the medication can be adjusted.

Further diagnostic tools: questionnaires, physical examination, and/or laboratory tests

Information from the interview can be extended using questionnaires that measure sexual function, psychological problems, and relationship satisfaction. Suitable questionnaires are, for example, the Female Sexual Function Index (FSFI) (Rosen et al., 2000) to measure problems in the domain of sexual desire, arousal, pain, and orgasm; the Golombok Rust Inventory of Sexual Satisfaction (GRISS) (Rust & Golombok, 1986) to measure sexual dissatisfaction and problems in heterosexual women and men; the Symptom Checklist 90‐R (SCL‐90) (Derogatis, Lipman, & Covi, 1973) to measure psychological problems and symptoms of psychopathology; the Trauma Screening Questionnaire (TSQ) (Brewin et al., 2002) for screening for post‐traumatic stress symptoms; the Beck Depression Inventory (BDI‐II) (Beck, Steer, & Brown, 1996) for screening for symptoms of depression; and the Maudsley Marital Questionnaire (MMQ) (Arrindell & Schaap, 1985) to measure relational functioning. To diagnose sexual interest/arousal disorder, standard physical examination and/or laboratory tests are not indicated. However, if there are comorbid complaints of sexual pain or, in older women, complaints of vaginal dryness that might indicate oestrogen deficiency, it is worthwhile taking a combined approach that comprises targeted psychological and physical examination. When an androgen deficiency is suspected, laboratory testing can be considered, although there is ongoing debate about the reliability and value of testosterone analysis in women.

Treatment Options

The incentive motivation model implies that sexual interest/arousal problems can be the result of decreased arousability of the sexual system, a lack of stimuli, and the presence of cognitive and affective processes that disrupt the onset of the arousal response. In the majority of women that seek help for complaints of low interest/arousal, the problems are not associated with hormonal disorders or specific somatic disorders; the women are mostly physically healthy. In these women, sexual interest/arousal problems, therefore, seem chiefly associated with inadequate erotic stimulation in everyday life or with negative evaluations of the sexual and relational context, which lead to inhibition of arousal and sexual desire. This implies that treatment should mainly be aimed at helping the woman and her partner to employ (new) sexual stimuli that can lead to arousal, strengthen the rewarding value of sex by promoting pleasant sexual feelings, decrease any negative feelings, and optimize communication and intimacy within the relationship.

Psychological treatment

Here, we describe psychological treatments for sexual interest/arousal disorder whose effectiveness is empirically supported: sex therapy and cognitive‐behavioral therapy. It should be noted that very little effectiveness research has been conducted and that, therefore, very little can be said with any certainty about the effectiveness of various techniques and procedures (ter Kuile, Both, & van Lankveld, 2009). Effective treatments seem to have a broader approach, treat the couple instead of the woman alone, and apply techniques that not only focus on sexual interest, but also on improving arousal, orgasm, and sexual satisfaction. In case of sexual arousal problems, often extra attention is given to masturbation exercises, with the aim of teaching the woman and the couple step by step how to achieve adequate erotic stimulation (Laan et al., 2005).

Classical sex therapy comprises sex education,