Specific treatment recommendations are treatment of sexual dysfunction. Many disorders will respond to pharmacological treatment. However, treatment of a broad range of sexual dysfunction may need more structured psychological treatment. In this form of treatment the couple is seen together whenever possible.
There are three stages:
(i) Improving communication,
(iii) Graded activities’.
1 Improving communication has two main aims: (i) to help the couple to talk more freely about their problems and (ii) to increase each partner’s understanding of the wishes and feelings of the other. These aims may be appropriate to various kinds of problems. For example, a woman may believe that her partner should know instinctively how to please her during intercourse; she may then interpret his failure to please as lack of affection rather than as the result of her not communicating her wishes to him. Alternatively, the man may wish the woman to take a more active role in intercourse but be unable to say this to her. A further aim of this stage of treatment is to enable the couple to achieve a general relationship that is more affectionate and satisfying.
2 Education focuses on important aspects of the male and female sexual responses; examples are the longer time needed for a woman to reach sexual arousal, and the importance of foreplay, including clitoral stimulation, in bringing about vaginal lubrication. Suitably chosen books on sex education can reinforce the therapist’s advice. Educational counselling is often the most important part of the treatment of sexual dysfunction, and it may need to be repeated when the couple have made some progress with the graded activities described next.
3 Graded activities begin by negotiating with the couple a mutually agreed ban on full sexual intercourse. The couple are encouraged instead to explore the pleasure that each can give the other by tender physical contact. The partners are encouraged to caress each other but not to touch the genitalia at this stage. When they can achieve caressing in a relaxed way that gives enjoyment to each partner, the next stage is genital foreplay without penetration. When genital foreplay can be enjoyed by both partners,the next stage is the resumption of full intercourse in a gradual and relaxed way, in which the partner with the greater problem sets the pace. In this stage a graduated approach starts with ‘vaginal containment’, in which the penis is inserted gradually into the vagina without thrusting movements. When this graded insertion is pleasurable for both partners, movement is introduced, usually by the woman at first. At each stage, each partner is encouraged to find out and provide what the other enjoys. The couple are advised to avoid checking their own state of sexual arousal. Such checking is common among people with sexual disorder, and has the effect of inhibiting the natural progression of sexual arousal to orgasm. Each partner should be encouraged to allow feelings and physical responses to develop spontaneously whilst thinking of the other person.
Hormones have no place in the treatment of sexual dysfunction except in cases where there is a primary hormonal disorder. The overall results of sex therapy are that about a third of cases have a successful outcome and another third have worthwhile improvement. Patients with low sexualdrive generally have a poor outcome.