SEXUAL DYSFUNCTIONS

• Sexual functioning is affected by a complex interplay of

physiological, psychological, and contextual factors (e.g.,
physical health, life stress, past interpersonal
experiences, current relationship quality) and may
therefore change over time with age, life stages, and
duration of relationships.
• Indeed, everyone may experience ups and downs in his
or her sexual functioning. However, when sexual
difficulties are persistent or recur frequently and cause
marked distress and interpersonal difficulties, then one
may have a sexual dysfunction.
• The general heading of sexual dysfunctions
encompasses a variety of disorders that are
characterized by disturbances in the various
phases of the sexual response cycle of desire,
arousal, orgasm, and resolution, as well as
sex-related pain disorders.
The Sexual Response Cycle
• Desire
• Sexual desire is often defined as a desire or want to experience sexual feelings
and/or activities, intimacy or gratification  without or with a partner(s).
• Excitement – Sexual Arousal
• Arousal is the next part of sexual pleasure, when a person is becoming sexually
excited. Sexual arousal usually begins in the brain. The brain sends messages
 throughout the body to prepare us for sex. This arousal can be stimulated by
thought, fantasy, conversation, smell, touch, taste, sound, sight, etc. There is
huge diversity in what a person finds sexually exciting and this may vary from
person to person as it is influenced by culture, age, stages, relationships,
cycles, etc. Sexual arousal may occur suddenly and intensely or it may be a
slower progression. Each person is unique in their experiences of sexual
arousal.
• In all people:
• Heart rate increases
• Blood pressure increases
• Muscles throughout the body become more tense
• Nipples become erect
• Skin may become flushed
Differing Genital changes:
• vagina relaxes and begins to lubricate
• the clitoris becomes larger and more erect
• the inner labia swells and outer labia separate
• the uterus and cervix retracts slightly
• Penis becomes erect
• Scrotum thickens
• Testicles rise closer to the body
• Plateau
• Contrary to the word, the plateau phase of sexual response is
not a leveling off of sexual excitement; it actually continues to
grow and this phase may last several seconds to minutes. A
person may feel physical and emotional excitement and have
physically sensations of sensitivity, warmth and even appear
flushed. This phase can take a person to a level of altered
consciousness – it’s often referred to as “the heat of the
moment or the throes of passion.” It can feel incredibly
intoxicating and be difficult to make intentional decisions at
this point in the response cycle.
• Orgasm
• Orgasm is an intense, pleasurable feeling that occurs at the end of the Plateau phase.
Orgasm is usually the most intense peak of the sexual response cycle. It is also the
shortest of all phases in the cycle. It occurs when the sexual and muscular
tension(especially those in the pelvis) built up is released in a series of quick
pleasurable contractions. It is the peak of sexual arousal, and is also called the climax.
The experience of orgasm differs from person to person and experience to experience.
It can feel quick and intense or slow and relaxed.  Not all sexual experiences result in
orgasm; this is normal.
• This does not mean that a sexual experience cannot be pleasurable. There is often a
lot of pressure (from many sources!) to achieve orgasm during sex and if a person
does not experience this, they may feel inadequate or as if they’ve done something
wrong. Having a comfortable relationship with your partner can challenge
these feelings and reassure you. Orgasm and ejaculation in people with penises often
occur at the same time but it is possible to ejaculate with an orgasm and orgasm
without ejaculating.
• Resolution
• The end stage of sexual arousal is called resolution. During the
resolution period, a relaxation of the muscles as well as psychologically
will occur. The blood that has moved into the genitals will drain out
slowly. The body returns to the way it was before sexual arousal.
Resolution happens whether or not someone experiences an orgasm.
• When a person with a penis enters the resolution phase, they lose their
erection and experiences what is called the refractory period.  This is
the period of time it takes a person with a penis to experience another
erection. the duration of the refractory period usually increases with
age and/or other medical conditions. People with vaginas do not
experience a refractory period, they may be sexually aroused again
quickly.
Changes in DSM5
• DSM-5 has three categories of sexual
dysfunction:
1. Sexual desire, arousal, and interest disorders
• In women: Sexual interest/arousal disorder
• In men: Male hyposexual disorder and Erectile disorder
2. Orgasmic disorders
• In women: Female orgasmic disorder
• In men: Premature ejaculation and delayed ejaculation
3. Sexual pain disorders
• In women: Genito-pelvic pain/penetration disorder
 Disorders Involving
Sexual Interest, Desire, and Arousal
• Sexual interest/arousal disorder in women
– Persistent deficits in sexual interest (fantasies or
urges), biological arousal, or subjective arousal

• Hypoactive sexual desire disorder in men

– Deficient or absent sexual fantasies and urges
• Male erectile disorder
– Failure to attain or maintain an erection of penis
 Erectile dysfunction
• Erectile dysfunction (ED) and premature ejaculation
are the two most common complaints of male
patients presenting with sexual dysfunction.
• ED is defined as a man’s consistent or recurrent
inability to attain and/or maintain penile erection
sufficient for satisfactory sexual activity.
• Symptoms include a marked difficulty in obtaining an
erection during sexual activity and/or maintaining an
erection until the completion of sexual activity, and a
marked decrease in erectile rigidity
• Clinical evaluation
• Up to 50% of men with ED also experience
premature ejaculation (PE).
• Detailed history-taking that is sensitive to the
patient’s personal, cultural and ethnic
background, and having the partner attend and
engage in the clinical interview, assist in
clarifying symptoms and refining the diagnosis.
 Physical examination
• The physical examination
• (i) assists in corroborating aspects of the medical history;
• (ii) reveals unsuspected physical findings;
• (iii) assists in identifying specific aetiologies or comorbidities; and
• (iv) creates an opportunity to inform the patient about aspects of
his sexual anatomy or physiology while providing reassurance
about body appearance and function.
• However, the physical examination can be a source of shame,
embarrassment, or discomfort for many and every effort should
be made to ensure the patient’s privacy, confidentiality and
personal comfort.
• Treatment
• The primary goal is to enable the individual or couple to enjoy
a satisfactory sexual experience. This involves
(i) identifying and treating any curable causes of ED;
(ii) initiating lifestyle change and risk factor modification; and
(iii) providing education and counselling to patients and their
partners.
Medical treatments for ED include oral agents, local therapies
and vacuum constriction devices. All patients with ED should
be evaluated for testosterone levels before treatment
begins.
• Psychotherapy
• Psychotherapy focuses on
(i) reducing or eliminating performance anxiety;
(ii) understanding the context in which men or a couple make
love;
(iii) implementing psychoeducation; and
(iv) modifying sexual scripts, and identifying and reducing
resistance to premature discontinuation of pharmacotherapy.
While a variety of psychological interventions are available,
efficacy and effectiveness studies are lacking.
• Premature ejaculation
• The prevalence of PE is estimated at 24.9%.
• Lifelong PE is defined as ejaculation that  ‘always or nearly always occurs prior to or
within about one minute of vaginal penetration’, and/or ‘the inability to delay
ejaculation on all or nearly all vaginal penetrations’, coupled with ‘negative personal
consequences such as distress, bother, frustration and/or the avoidance of sexual
intimacy’.
• PE may be the result of urological dysfunction, thyroid dysfunction or psychological
and/or relationship problems. While most men with lifelong PE do not suffer from
concomitant ED, PE coexists in about one-third of patients complaining of ED.
• All patients with PE must be carefully screened for ED. In some instances, PE and ED
reduce a man’s level of excitation (which can lead to ED), or a man trying to achieve an
erection attempts to do so by increasing his excitation and arousal (which can lead to
PE). PE may also occur when a man has an unstable erection because of a fluctuation in
penile blood flow. In this case, the man may reach ejaculation quickly to compensate for
the weak erection
• Clinical evaluation
• Family practitioners should elicit details from the patient about
the ejaculatory response, including his subjective assessment of
his intravaginal ejaculatory latency time and sense of ejaculatory
control.

• Furthermore, clinicians should enquire about the patient’s level

of sexual dissatisfaction, distress, and frequency of sexual activity.
Included in this evaluation should be the partner’s assessment of
the patient’s complaint and whether the partner suffers from
sexual dysfunction. It is important to note that ejaculation is not
equal to orgasm.
 Treatment
• All symptomatic therapies for PE aim to
reduce excitation. Therefore, these treatments
must be prescribed to patients who are able
to obtain and maintain an erection until their
(premature) ejaculation.
• Psychotherapy
• Besides teaching self-control techniques to delay
ejaculation, psychosexual therapies attempt to help the
patient to recover his self-confidence and confidence in
his sexual performance, reduce performance anxiety,
solve rational problems, increase communication
between partners, and resolve interpersonal issues that
precipitate and maintain the dysfunction.
• However, efficacy and effectiveness studies are lacking.
• Male hypoactive sexual desire disorder Male
hypoactive sexual desire disorder is defined as
persistently or recurrently deficient (or
absent) sexual/erotic thoughts or fantasies
and desire for sexual activity. This may be the
result of common medical conditions including
substance-use disorders, social and
interpersonal factors, or use of
pharmacological agents
• A comprehensive history should address the patient’s sexual behaviour,
psychological manifestations of sexual stimuli and body changes in
response to sexually arousing stimuli.Laboratory investigations should
determine the patient’s serum testosterone and prolactin levels.

• Treatment Treatment should focus initially on targeting and treating

sexual difficulties, e.g. pain and ED.[30] Furthermore, the clinician
should assess the patient-partner relationship and teach sexual
communication and erotic skills. Finally, the clinician should attempt to
maximise enhancers (e.g. varied lovemaking, novelty) and reduce
inhibitors (both physical, e.g. anaemia and thyroid disease, and
emotional, e.g. anxiety and depression). Testosterone replacement
therapy may be considered in some cases.
 FEMALE SEXUAL DYSFUNCTIONS
• The WHO (World Health Organization) defines
reproductive health as a ‘state of complete physical,
mental and social well being and not merely the absence
of disease or infirmity in matters related to the
reproductive system and to its functions and processes’
• Female sexual dysfunction (FSD) is a continuum of
psychological and organic disorders focused on sexual
desire with interrelated problems of arousal, orgasm,
and sexual pain that impairs quality of life for many
women
• Symptoms
• Symptoms vary depending on what type of sexual dysfunction you're
experiencing:
• Low sexual desire. This most common of female sexual dysfunctions
involves a lack of sexual interest and willingness to be sexual.
• Sexual arousal disorder. Your desire for sex might be intact, but you have
difficulty with arousal or are unable to become aroused or maintain
arousal during sexual activity.
• Orgasmic disorder. You have persistent or recurrent difficulty in
achieving orgasm after sufficient sexual arousal and ongoing stimulation.
• Sexual pain disorder. You have pain associated with sexual stimulation or
vaginal contact.
• Causes
• Sexual problems often develop when your hormones are in flux, such
as after having a baby or during menopause. Major illness, such as
cancer, diabetes, or heart and blood vessel (cardiovascular) disease,
can also contribute to sexual dysfunction.
• Factors — often interrelated — that contribute to sexual
dissatisfaction or dysfunction include:
• Physical. Any number of medical conditions, including cancer, kidney
failure, multiple sclerosis, heart disease and bladder problems, can
lead to sexual dysfunction. Certain medications, including some
antidepressants, blood pressure medications, antihistamines and
chemotherapy drugs, can decrease your sexual desire and your body's
ability to experience orgasm.
• Hormonal. Lower estrogen levels after menopause may lead to changes in your
genital tissues and sexual responsiveness. A decrease in estrogen leads to decreased
blood flow to the pelvic region, which can result in less genital sensation, as well as
needing more time to build arousal and reach orgasm.
• The vaginal lining also becomes thinner and less elastic, particularly if you're not
sexually active. These factors can lead to painful intercourse (dyspareunia). Sexual
desire also decreases when hormonal levels decrease.
• Your body's hormone levels also shift after giving birth and during breast-feeding,
which can lead to vaginal dryness and can affect your desire to have sex.
• Psychological and social. Untreated anxiety or depression can cause or contribute to
sexual dysfunction, as can long-term stress and a history of sexual abuse. The worries
of pregnancy and demands of being a new mother may have similar effects.
• Long-standing conflicts with your partner — about sex or other aspects of your
relationship — can diminish your sexual responsiveness as well. Cultural and religious
issues and problems with body image also can contribute.
• Risk factors
• Some factors may increase your risk of sexual dysfunction:
• Depression or anxiety
• Heart and blood vessel disease
• Neurological conditions, such as spinal cord injury or multiple sclerosis
• Gynecological conditions, such as vulvovaginal atrophy, infections or
lichen sclerosus
• Certain medications, such as antidepressants or high blood pressure
medications
• Emotional or psychological stress, especially with regard to your
relationship with your partner
• A history of sexual abuse
 Hypoactive sexual desire disorder
• Hypoactive sexual desire disorder (HSDD) is a spectrum
of diseases that cause personal distress owing to
persistent or recurring deficiency (or absence) of sexual
fantasies and thoughts and a lack of receptivity to
sexual activity . Medically induced menopause,
depression and its treatments, and endocrine disorders
are the most common causes that can disrupt the
normal female hormonal milieu, resulting in
HSDD .Long-term conflicting relationships have also
been shown to adversely affect sexual desire.
• Sexual aversion disorder -In this disorder women have a persistent or recurrent
phobic aversion, leading to avoidance of sexual contact and precipitating
personal distress (1). It is generally a psychological or emotionally based
problem. It can occur for a variety of reasons, including physical or sexual abuse
and childhood trauma.
• Sexual Arousal Disorder -Sexual arousal disorder is a persistent or recurring
inability to attain or maintain adequate sexual excitement, which leads to
personal distress . Sexual arousal disorder may be experienced as a lack of
subjective excitement, somatic responses, or genital lubrication/swelling.
Decreased labial and clitoral sensation and engorgement and lack of vaginal
smooth muscle relaxation can also cause sexual arousal disorder. This
phenomenon is particularly important in patients who have undergone pelvic
surgeries. This may cause iatrogenic damage to the pelvic nerves, leading to
decreased arousal. Psychological factors are among the other important causes
of sexual arousal disorder
• Orgasmic Disorders 
• Orgasmic disorder is either complete absence or recurrent difficulty in
attaining orgasm after sufficient sexual stimulation . Orgasmic disorders
can be primary (a woman never has achieved orgasm) or secondary (a
woman was able to achieve orgasm previously but is no longer able to do
so). It is a prevalent problem among women who present to sex therapy
clinics. Anorgasmia is noticed in 24%–37% of women presenting to sex
therapy clinics for various reasons . Primary orgasmic disorder is usually
due to emotional trauma or sexual abuse. Hormonal deficiency, surgical
trauma, or medications are the common causes for secondary orgasmic
disorder. Anorgasmia is also a common complaint in women taking
selective serotonin reuptake inhibitors. Depending upon the dose and
type of the drug, up to 50% of women have been shown to suffer from a
lack of orgasm
• Sexual Pain Disorders
• There are two types of sexual pain disorders: vaginismus and
dyspareunia .
• Vaginismus is defined as recurrent or persistent involuntary spasm
of vaginal musculature that interferes with vaginal penetration.
• Dyspareunia is defined as recurrent or persistent genital pain
associated with sexual intercourse. Dyspareunia rates reported in
the literature range from 14% to 18% .
• Pain may also be induced by noncoital stimulation in certain
disorders like genital herpes, endometriosis, and vestibulitis.
Psychological factors, such as fear, anxiety, and interpersonal
conflict, are the cause of dyspareunia in one third of cases.
• Disorders of the pelvic floor and postmenopausal decreased
vaginal lubrication can also cause pain with sexual activity .
• Dyspareunia is also seen in women with decreased vaginal
lubrication. This is usually seen in women with damage to
the pelvic nerves as a complication of pelvic surgeries.
• Multiparous women are at increased risk of pelvic floor
disorders because of the muscular and vascular changes that
occur during childbirth. Sexual dysfunction due to problems
with vaginal lubrication and sexual intercourse are
commonly seen in older women.
 Sexual pain disorders
• Vaginismus
• Vaginismus is an involuntary tensing of the vagina. People experience it
at the start of sex, while inserting a tampon or while getting a pelvic
exam. Vaginismus can make intercourse painful (dyspareunia). Kegels,
vaginal dilators and cognitive behavioral therapy (CBT) can help relax
muscles and stop spasms.
• Vaginismus is the involuntary tensing or contracting of muscles around
the vagina. The vagina is part of the female reproductive system. It
connects the lower part of the uterus (cervix) to the outside of the
body.
• These unintentional muscle spasms occur when something — a penis,
finger, tampon or medical instrument — attempts to penetrate the
vagina. The spasms may be mildly uncomfortable or very painful.
• What causes vaginismus?
• Healthcare experts aren’t sure why some people experience vaginismus. It can cause physical,
psychological and sexual issues. Bladder infections, UTIs and yeast infections can worsen
vaginismus pain.
• Factors that may contribute to vaginismus include:
• Anxiety disorders.
• Childbirth injuries, such as vaginal tears.
• Prior surgery.
• Fear of sex or negative feelings about sex, perhaps due to past sexual abuse, rape or trauma.
• What conditions are similar to vaginismus?
• These problems can cause symptoms similar to vaginismus:
• Vaginal atrophy: Lack of estrogen after menopause makes the lining of the vagina thinner and
drier (vaginal atrophy.
• Vulvar vestibulitis (provoked vestibulodynia): This condition causes painful sex (dyspareunia).
People may have pain from initial penetration throughout the entire experience.
• What are the symptoms of vaginismus?
• Signs of vaginismus include:
• Discomfort or pain during vaginal penetration.
• Inability to have sex or have a pelvic exam due
to vaginal muscle spasms or pain.
• Painful intercourse.
• Vaginismus treatments focus on reducing the reflex of your muscles that causes them to
tense up. Treatments also address anxieties or fears that contribute to vaginismus.
• Topical therapy: Topical lidocaine or compounded creams may help with the pain
associated with this condition.
• Pelvic floor physical therapy: A physical therapist will teach you how to relax your pelvic
floor muscles.
• Vaginal dilator therapy: Vaginal dilators are tube-shaped devices that come in various
sizes. Their primary purpose is to stretch the vagina. People with vaginismus use dilators
to become more comfortable with, and less sensitive to, vaginal penetration. Your
provider may recommend first applying a topical numbing cream to the outside of the
vagina to make insertion easier.
• Cognitive behavioral therapy (CBT): CBT helps you understand how your thoughts affect
your emotions and behaviors. It’s an effective treatment for anxiety, depression and post-
traumatic stress disorder (PTSD).
• Sex therapy: Trained sex therapists work with individuals and couples to help them find
pleasure again in their sexual relationships.
 MANAGEMENT OF SEXUAL DYSFUNCTION

• Principles of management
• Management of sexual dysfunction involves
patient centered approach and clinicians are
expected to consciously adopt the patient's
perspective and respect the ideas, feelings,
expectations and values of their patients.
• Formulation: After complete assessment, the first step in the management is to
provide the patient/couple a brief and simple account of the nature of their
problems and possible contributory factors. The aims of the formulation are
threefold. First, it helps the couple to understand their difficulties. This can be a
source of encouragement, especially if the therapist also explains how common such
problems are. Second, the therapist point out the likely contributory factors,
particularly the maintaining factors which will be the focus of therapy, and thus
establish a rationale for the treatment approach. Finally, providing a formulation also
helps to check that the information obtained during the assessment has been
correctly interpreted. So the couples need to be always asked to give a feedback of
the formulation.
• Balancing the partners: It is important for the therapist to understand the
contribution of individual partner to the problem and need to strike a balance
between individual partners. The therapist must emphasize the need of collaboration
between the partners for the success of the therapy. The therapist needs to
emphasize positive aspects of the couple's relationship.
• General Non-pharmacological measures: Education about sexuality
• The first step in the treatment of any sexual dysfunction is sex
education/psychoeducation. The sex education needs to aim at
normalization of the individual's experiences and reduce anxiety
about sex by providing accurate information. 
• Understand and clarify sexual myths: For some individuals,
inappropriate sexual beliefs or myths can cause problems within a
relationship. Individuals acquire expectations about what sex should
be like and how they or their partner should behave. One of the
components of sex-education is to help the individual and his or her
partner alter any sexual beliefs that interfere with the individual's
enjoyment of sex. 
• Relaxation exercises
• Relaxation therapy should be taught to patient
using Jacobson's Progressive Muscular
Relaxation Technique.
 Masters and Johnson’s Treatment
• The stages of this programme are labeled
using the terminology introduced by Master
and Johnson (1970) is: non-genital sensate
focus, genital sensate focus and vaginal
containment. 
• Non-genital sensate focus: This assignment is particularly helpful for a couple to establish
physical intimacy in a comfortable and relaxed fashion, and allows open communication
about feelings and desires. The basis aim of this stage is to help the partners develop a
sense of trust and closeness, to become more aware of what each one likes and to
encourage communication. It is to be explained to the couple that they need to “refrain
from sexual intercourse and touching of each other's genitalia and the women's breast” to
ensure that they are not continually confronted by those aspects of sexuality that is most
likely to cause anxiety, and to enable them to concentrate on rebuilding their physical
relationship by first learning to enjoy general physical contact. Initial reactions to these
sessions vary according to the nature of the couple's problem. Some couple's may find
this enjoyable and others may react negatively. In some cases it will be appropriate for the
therapist to just acknowledge the problem and reassure and encourage the couple. In
some cases therapist have to explain that this is understandable and expected, but that in
order to overcome a sexual problem like theirs it is necessary to approach it in a systemic
fashion and with due course of time they will begin to get pleasure out of their sessions
and these would come as spontaneous behaviour.
• Genital sensate focus: The couples, who go through the
non-genital sensate focus sessions successfully, need to be
told to move to the genital sensate focus sessions. As with
the non-genital sensate focus, some couples immediately
find these sessions pleasurable while others would react
adversely. This stage is particularly likely to generate
anxiety, especially about sexual arousal or intimacy, so it is
very important that the therapist specifically encourages
partners to focus on pleasurable sensations. Some of the
techniques for dealing with specific dysfunctions also need
to be introduced at this stage.
• Vaginal Containment: This stage is an intermediate one in the introduction of sexual
intercourse to the therapy programme. It is relatively minor stage for couples whose
difficulties have by now largely resolved. For others it is extremely important,
especially when vaginal penetration is the key step (e.g. ED, PME, and vaginismus).
The couple is instructed that when they both are feeling relaxed and sexually aroused
the women can introduce her partner's penis into her vagina and the partner to then
lie still, concentrating on any pleasant genital sensations. The best position to attempt
vaginal containment is female superior position or a side to side position. The couple
be asked to maintain containment as long as they wish, and then they can return to
genital and non-genital pleasuring. The couple can repeat the containment up to three
times in any one session. Once this stage is well established the couple to introduce
movement during containment, with preferably women starting the movements first.
With this the general programme of sex therapy is completed and now the treatment
need to include superimposition of treatment for specific sexual dysfunctions.
• It is important to remember that during the whole therapy feedback be taken after
every session and any doubts/misconceptions be clarified.
 Premature Ejaculation (PME)
• Specific Non Pharmacological for specific sexual dysfunctions
• It is considered that behavioural management is to be the first line of therapy where ever
possible. The specific behavioural techniques for PME involves stop- start or squeeze
techniques, which are usually introduced during genital sensate focus.

• The stop-start technique developed by Masters and Johnson is highly effective for the
treatment of premature ejaculation with success rates of as high as 90%. The technique aims
to increase the frequency of sexual contact and sensory threshold of the penis. It is best
carried out in the context of sensate focus exercises because some males ejaculate so early
that direct stimulation of the penis of any kind can trigger ejaculation straight away. Starting
with non-genital caresses allows the male more time to identify the sensations that occur
immediately prior to ejaculation. The stop-start technique consists of the man lying on his
back and focusing his attention fully on the sensation provided by the partner's stimulation of
his penis. When he feels himself becoming highly aroused he is to indicate this to her in pre-
arranged manner at which point she need to stop caressing and allow his arousal to subside.
After a short delay this procedure is repeated twice more, following which the woman
stimulates her partner to ejaculation. At first the man may find himself ejaculating too early,
but usually gradually develops control. Later a lotion can be applied to the man's penis during
this procedure, which will increase his arousal and make genital stimulation more like vaginal
containment.
• The squeeze technique is an elaboration of the stop-start
technique, and probably only needs to be used if the latter proves
ineffective. The couple proceeds as with the stop-start procedure.
When the man indicates he is becoming highly aroused his partner
should apply a firm squeeze to his penis for about 15-20 seconds.
• During applying the pressure, the forefinger and middle finger are
placed over the base of the glans and shaft of the penis, on the
upper surface of the penis, with the thumb placed at the base of
the undersurface of the glans. This inhibits the ejaculatory reflex.
• As with the stop-start technique this is repeated three times in a
session and on the fourth occasion the man may ejaculate.
• Vaginismus
• It is important to remember that many women who present with vaginismus
have negative attitude towards sex and quite a few are victim of sexual
assault. Some may also have the belief that premarital sex is wrong or sinful.
This belief may be so ingrained that, even when intercourse is sanctioned by
marriage, it may be difficult to relax physically or mentally during sexual
intercourse. Some times the cause of vaginismus may be a fear that is
instilled by friends or family by suggesting that the first experience of
intercourse is likely to be painful or bloody. Another important cause of
vaginismus is fear of pregnancy.
• The sex education needs to focus on clarifying normal sexuality and reducing
negative attitude for sex. Besides the use of general relaxation exercises, the
relaxation procedure also needs to focus on teaching the women to relax
muscles around the inner thigh and pelvic area.
• The specific management involves the following stages:
• Helping the woman develop more positive attitudes towards her genitals. After fully
describing the female sexual anatomy, the therapist need to encourage the woman to
examine herself with a hand mirror on several occasions. Extremely negative attitudes
(especially concerning the appearance of the genitals, or the desirability of examining
them) may become apparent during this stage, possibly leading to failure to carry out
the homework. Some women find it easier to examine themselves in the presence of
the partners; others may only get started if the therapist helps them do this first in the
clinic. If this is necessary a medically qualified female therapist is to be involved.
• Pelvic muscle exercises. These are intended to help the woman gain some control over
the muscles surrounding the entrance to the vagina. If she is unsure whether or not she
can contract her vaginal muscles she may be asked to try to stop the flow of urine when
she next goes to the toilet. The woman can later check that she is using the correct
muscles by placing her finger at the entrance to her vagina where she need to be able
to feel the muscle contractions. Subsequently she is advised to practice firmly
contracting these muscles for an agreed number of times (e.g. 10) several times a day.
• Vaginal penetration. Once the woman has become comfortable with
her external genital anatomy she is advised to explore the inside of her
vagina with her fingers. This is partly to encourage familiarity and
partly to initiate vaginal penetration. Negative attitudes may also
become apparent at this stage (e.g. concerning the texture of the
vagina, its cleanliness, fear of causing damage, and whether it is ‘right’
to do this sort of thing). The rationale for any of these objections is to
be explored. At a later stage the woman might try using two fingers
and moving them around. Once she is comfortable inserting a finger
herself, her partner need to begin to do this under her guidance
during their homework sessions. A lotion (e.g. K-Y or baby lotion) can
make this easier. Graded vaginal dilators can be used. However, clinical
experience has shown that the use of fingers is just as effective.
• Vaginal containment. When vaginal containment is attempted the
pelvic muscle exercises and the lotion are used to assist in relaxing the
vaginal muscles and making penetration easier. This is often a difficult
stage and the therapist therefore needs to encourage the woman to
gain confidence from all the progress made so far. Persisting concerns
about possible pain may need to be explored, including how the
woman might ensure that she retains control during this stage.
• Movements during containment: Once containment is well
established the couple is asked to introduce movement during
containment, with preferably women starting the movements first.
With this the general programme of sex therapy is completed and now
the treatment needs to include superimposition of treatment for
specific sexual dysfunctions.