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,
(ii) Education
(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 to treat erectile 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 intense 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 sex drive generally have a poor outcome.
