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 varies 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.