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Initial episodes of sexual dysfunction in the elderly are often precipitated by a major psychosocial stress, such as the loss of a job or loved one, a medical crisis or prolonged illness, or a hospitalization. Such major stresses may break sexual patterns and lead to uncertainty as to how to resume sexual activity. The loss of a partner is particularly devastating, making the idea of sexuality moot in the short term and often suppressing sexual desire and the willingness to seek out a new partner in the long run if grief or survivor guilt persists. In the face of an acute illness, such as a recent heart attack or respiratory compromise, older individuals can suffer from performance anxiety if they anticipate pain, self-injury (or injury to a debilitated partner), or even death during sex.

Some people may feel less sexual because they are embarrassed by changes in their personal appearance (e.g., due to a surgical scar or colostomy bag) or are fearful of body odors or incontinence during sex. Chronic illness can also sap one's energy and enthusiasm for sex.

Sexual dysfunction in late life is often comorbid with psychiatric illness, particularly mood and anxiety disorders, in which loss of libido is a frequent symptom (Clayton, 2001). At baseline, 40–50% of individuals suffering from depression experience loss of sexual desire as a cardinal symptom, but up to 90% may experience any form of sexual dysfunction prior to being started on antidepressants (Montejo et al., 2001). Individuals with schizophrenia and other psychotic disorders may have fewer problems with sexual function per se but more difficulty with managing sexual relationships.

**SEXUAL DYSFUNCTION AND DEMENTIA**

The effect of dementia on sexual function poses a number of complex issues. On the one hand, sexual function and sexual needs continue throughout the course of most dementias and can play an important role as a nonverbal form of communication and intimacy for couples. As dementia progresses, however, individuals become more prone to sexual dysfunction and to sexually disinhibited behaviors. Caregivers bear the brunt 479

of these changes, as they struggle to maintain a relationship in the face of uncertainty about the appropriateness of sex with someone who is slowly losing the capacity to understand and consent to mutual sexual relations (Davies et al., 2010). In addition, caregivers may lose the desire for sex with a cognitively impaired partner, perhaps due to being "turned off" by the effects of the disease or frustrated by a partner who acts inappropriately, has lost all desire for sex, or repeatedly or perhaps uncharacteristically requests sexual gratification. Some partners may be torn by conflicting feelings of love and fidelity for the partner with dementia and desires for both emotional and physical intimacy from an individual without dementia.

In the early and middle stages of Alzheimer's disease (AD) and other dementias, there is no predictable change in sexual desire, with it declining in some individuals and increasing in others, perhaps due to changes in the degree of cognitive disinhibition.

Sexual activity does decline, however; one study found that 46% of couples with a partner suffering from dementia were sexually active 3 years after diagnosis, dropping to 41% after 5 years and 28% after 7 years (Eloniemi-Sulkava et al., 2002). ED and female orgasmic disorder are the two most commonly reported forms of sexual dysfunction in men and women with dementia, respectively (Zeiss, Davies, Wood, & Tinklenberg, 1990). Sexual dysfunction may result in part from the cognitively impaired individual's declining ability to maintain a coherent focus on physical or mental stimulation during sex or to initiate and sequence components of lovemaking (Duffy, 1995; Rosen, Lachs, & Pillemer, 2010).

The ability to consent to sexual activity is a particularly sensitive issue for many partners, who fear that they may be coercing their loved one into something they can no longer fully understand (Rosen et al., 2010). This is also an important issue in long-term-care facilities, where an individual with dementia may be engaging in or attempting to engage in sexual activity with another individual with cognitive impairment. This behavior raises sensitive ethical dilemmas when neither individual can truly consent to sexual activity and when there is a spouse or partner without dementia living outside of the facility who might not approve. Both legally and ethically, the rights of an individual in a long-term-care facility to engage in sexual activity depend on his or her ability to understand the nature of the relationship and provide reasonable consent.

When there is concern about an individual's capacity to provide such consent, clinicians should attempt to determine how well the individual is able to understand the nature of the relationship, including its risks, and to what degree the individual with cognitive impairment can avoid coercion or exploitation (Lichtenberg & Strzepek, 1990).

Sexually disinhibited behaviors include inappropriate sexual comments or requests, public exposure or masturbation, and aggressive fondling, groping, or forced sexual activity. Not surprisingly, such behaviors generate a considerable amount of anxiety on the part of caregivers. They have been reported in 2–7% of individuals with dementia and in 25% of residents in dementia units, and they tend to be more common in men (Guay, 2008; Kumar, Koss, Metzler, Moore, & Friedland, 1988; Hajjar & Kamel, 2003b).

Risk factors include frontal and temporal lobe impairment, mania, psychosis, substance abuse, stroke, head trauma, premorbid sexual aggression, and certain medications, such as dopaminergic agents used to treat Parkinson's disease (Guay, 2008; Hashmi, Krady, 480

Qayum, & Grossberg, 2000; Bowers, Woert, & Davis, 1971; Uitti et al., 1989).

**ASSESSMENT**

The assessment of sexual problems in late life will generally follow guidelines for younger individuals, varying by the type of disorder being addressed. These are discussed in detail in other chapters, but several age-specific issues are reviewed here.

The assessment of sexual dysfunction in an older individual depends, first and foremost, on an educated clinician who is comfortable and knowledgeable about late-life sexuality.

If the clinician is embarrassed or uncomfortable asking questions about sexual function to aged individuals, it is unlikely that an adequate history will be gathered. The clinician must be able to ask direct questions using common language and to listen carefully and patiently, keeping in mind that older people will have many of the same sexual concerns as younger people (Swabo, 2003). An indispensable source of information about a sexual problem is the partner. The partner's presence during an interview will help facilitate open communication with the affected partner that will prove critical during the treatment phase.

The role of the clinician in the treatment of sexual dysfunction is to provide reassurance, education, and counseling or formal sex therapy as necessary. Sometimes this approach is sufficient; in other cases, a specialist is needed to treat physical causes related to other comorbid disorders. For example, an endocrinologist may be needed to address low testosterone, which is more common in late life, or a urologist might be consulted for a prostate problem. Reassurance of the patient depends on an enlightened clinician who understands that sexuality in general and sexual intercourse in particular remain important to many older patients. The clinician should listen empathically and then emphasize, in clear and nontechnical language, the normality of sexuality in late life and the possibility of effective treatment for sexual problems. In addition, the clinician should emphasize the wide range of potential expressions of sexuality, in addition to sexual intercourse. Keep in mind that many older patients have internalized negative perspectives on late-life sexuality. The act of providing reassurance builds trust between patient and clinician, and this relationship will lay the basis for the patient's feeling comfortable with being open about emotional reactions to the problem and seeking follow-up treatment.

The current cohort of individuals in their 80s and 90s grew up in an era when any mental health issue carried tremendous stigma and psychotherapy was not the norm.

Thus the very act of going to see a clinician may seem foreign and threatening. This reluctance is amplified by a fear of ageism, the fear that the younger clinician will not take the older patient seriously or will see his or her problem as only a normal consequence of old age. Such stereotypes often become internalized, prompting further pessimism on the part of patients.

Educating patients about both normal and pathological changes in sexual function in late life can reduce excessive fear and increase acceptance of these changes (Bitzer et al., 481

2008; Swabo, 2003). For example, a man who does not understand the normal changes in erectile function may misinterpret them and believe he is suffering from a sexual problem. Similarly, a woman may misinterpret the experience of vaginal dryness to mean that she does not want to have sex. The clinician should review with the patient the normal changes in sexual function throughout each stage of the sexual response cycle and discuss ways in which the patient's physical or mental state may be influencing these changes. For example, an older man with diabetes or atherosclerotic disease may have a more pronounced decline in erectile function or even ED, given possible compromise of penile blood flow. An older woman with a history of an arthritic hip might experience more limited pelvic movement or even pain during sex, in addition to potential discomfort due to decreased vaginal lubrication. A depressed patient may report significant reductions in libido. In each case, the patient can be reassured that his or her sexual changes have clearly identified causative factors and that treatment can improve or even alleviate these concerns.

Education should also focus on improving the quality of an individual's sexual relationship with his or her partner. Sometimes the clinician can provide a forum for the couple to discuss basic difficulties during sexual activity and strategize about ways to improve them. When there is significant discord, couple therapy should be the initial therapeutic modality. The clinician should emphasize to the couple that sex can be more than just intercourse and that physically pleasing each other can occur through massage and masturbation and does not always have to be mutual. Couples often have to adapt sexual techniques and refocus more time on foreplay in order to preserve previous levels of sexual function and enjoyment.

When one or both partners suffer from chronic medical illness or disability, sexual practices may need to be adapted to account for physical limitations, fatigue, loss of muscle strength, and pain (Schover & Jensen, 1988). A physician who treats the condition in question should be consulted on ways to minimize pain or discomfort and maximize function, perhaps by taking analgesics or other treatments (e.g., specific muscle stretches, nasal oxygen, inhalers) prior to sex. The couple can be instructed to find sexual positions that minimize physical exertion or stress on certain parts of the body.

**Case Discussion**

Mr. J, a 78-year-old widower, was seen in a geriatric psychiatry clinic for symptoms of depression. He was started on an antidepressant but thought it was not helping. During the initial assessment, the psychiatrist asked Mr. J about his sexual functioning, which prompted an outpouring of grief. Mr. J confided that he had suffered from ED ever since undergoing a prostatectomy 6 months prior to the appointment. Mr. J had asked the surgeon about changes in his sexual function, and he paraphrased the surgeon's response as, "Impotence is quite common after this surgery, but why would you worry about that anyway at your age?" Feeling humiliated and hopeless about regaining his sexual function, Mr. J broke up with his girlfriend and lapsed into a depression. The 482

subsequent use of an antidepressant reduced his libido further and felt like a double blow.

The sex therapist spent a session reassuring Mr. J that treatment was available and encouraged him to see a urologist who specialized in ED in order to consider an oral erectogenic agent. He also educated Mr. J about erectile physiology and discussed with him other potential causes of his ED, such as medication effects and unresolved grief over the death of his wife that manifested in anger directed toward his girlfriend. Even before treatment for his ED began, Mr. J reported feeling less depressed and more hopeful. Eventually, Mr. J got involved in another relationship and felt more confident and positive about being intimate. However, he was not as focused on sexual intercourse as the only means of intimacy and was able to enjoy kissing and caressing without thinking that he needed to have an erection to feel like a man. His depression lifted, and he was able to stop the antidepressant. As the relationship progressed, he was able to have satisfying sexual relations that sometimes involved sexual intercourse. He used an oral erectogenic agent to strengthen his erection but did not feel dependent upon it.

**SEX THERAPY**

Sex therapy is described in detail elsewhere in this book, but several age-associated issues are worthy of mention. The use of sex therapy has been eclipsed by the introduction of oral erectogenic agents, because many older couples believed incorrectly that the simple correction of ED with a pill would resolve long-standing sexual and other relationship problems. In those situations and many others, enduring issues such as low desire, relationship discord, physical deconditioning, and medical problems must be dealt with at the outset of sex therapy. In order to accomplish this, a multidisciplinary approach is particularly critical with older individuals in order to identify and address these various conditions.

For the older individual or couple, an initial supportive and educational approach can help in building a crucial alliance with the therapist and in promoting understanding of the problem and optimism about improvement. Sometimes practical suggestions on sexual technique can bring immediate improvement; in other situations, the therapist needs to impose a moratorium on sex to reduce tension and eventually reintroduce a more relaxed and sensuous approach. In some cases, intensive couple therapy is necessary; in others, pharmacological treatment of debilitating psychiatric symptoms (e.g., depression, panic attacks, psychosis) is needed, or the patient may need to be referred back to a specialist for further treatment of an enduring medical issue (e.g., joint or chest pain or shortness of breath during exertion). In general, these approaches to sexual dysfunction will not differ substantially across the age span.

**Case Discussion**

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Mr. and Mrs. B, a couple in their late 70s, had been married for 45 years. They had previously experienced an enjoyable sexual relationship into their early 70s but had stopped having sexual intercourse several years ago after Mrs. B was treated for breast cancer with a mastectomy and radiation therapy. Mrs. B began seeing a geriatric psychiatrist for treatment of depression and became quite tearful when describing the impact of her experience with breast cancer, feeling that it had ruined her as a sexual being. A hip fracture had only made things worse for her, she believed, as any sexual activity was associated with pain. The psychiatrist referred the couple to a colleague trained in sex therapy.

After taking a careful sex history, the therapist felt that although Mrs. B's medical problems had disrupted the couple's sex life, they were not insurmountable obstacles.

Mrs. B's poor sexual desire was attributed to the loss of her breast being a blow to her body image and self-confidence. The therapist also learned that although Mrs. B

experienced limited hip movement and pain after her surgery, this had largely resolved, whereas her fear of recurrent pain had not.

After discussing these issues with the couple, a series of sensate focus exercises were prescribed. The couple was amazed to find that just by gently massaging each other in bed without any expectation of sex, their sexual desire improved. The therapist encouraged Mrs. B to wear loose-fitting lingerie that made her feel sexy and minimized the contour of her chest, helping her to lessen the focus on her surgical scars. After consulting with Mrs. B's orthopedist, the therapist recommended that the couple engage in mutual massage and genital fondling in a sexual position that put minimal stress on Mrs. B's hip joint. Within several sessions Mr. and Mrs. B had progressed to sexual intercourse, which they both described as being comfortable and satisfying.

**CONCLUSIONS**

Sexuality continues to play a vital role in the lives of aging individuals, and most surveys show that although the frequency of sexual activity declines with age, satisfaction continues to be quite strong. Despite the predictable changes in physiology that may slow sexual response and the increase in medical disorders and medication use associated with sexual dysfunction, there are many ways in which individuals can adapt sexual activity or seek treatment to mitigate sexual problems. Dementia presents unique limitations on sexual activity and the potential for inappropriate sexual behaviors that require attention by specialists.

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**CONCLUSION**

Sex Therapy in Transition

Are We There Yet?

Marta Meana, Kathryn S. K. Hall, and Yitzchak (Irv) M. Binik

**F** rom its first edition in 1980, Principles and Practice of Sex Therapy (Leiblum & Pervin, 1980) has observed a tradition of stepping back from individual treatment-focused chapters to gauge the overall temperature of sex therapy as a discipline. How is it doing? How has it changed? Where is it going? A sense of momentum has always been recorded, arguably accelerated over the past two editions in concert with advances in sexual medicine. This state of perpetual transition may be the hallmark of a healthy discipline adjusting to and incorporating new knowledge. It can also indicate a failure to effectively chart a unified direction—a stalling of sorts. In the past decade, the latter concern has informed some commentaries that have sounded alarms about the state of sex therapy and its possibly threatened future (e.g., Binik & Meana, 2009; Kleinplatz, 2003; Rowland, 2007). The discipline is clearly undergoing a period of existential self-reflection that stands in stark contrast to its self-assured origins.

The heady early days of sex therapy held the promise of targeted interventions for clearly defined sexual problems with easily assessed outcomes. Masters and Johnson had taken sexual function and dysfunction out of the morass of psychodynamic constructions and into the supposed clarity of behaviorism and stimulus control. The journey from dysfunction to function was sequentially mapped, with the estimated arrival time much earlier than that indicated by previous treatment approaches.

Over the ensuing 50 years, research and practice in a number of disciplines effected numerous modifications to the traditional models proposed by Masters and Johnson (1966) and later Kaplan (1977) and Lief (1977). The accumulation of empirical data invariably resulted in downward revisions of inflated original outcome predictions.

Sexuality and the treatment of its problems appeared to be not so simple, after all. The complexity that traditional sex therapy had eschewed would not be denied (if not psychoanalyzed), and its sources would be far more numerous than imagined. This multifactorial complexity is evidenced in the literature, from the very questioning of an archetypal sexual response and associated constructs to deliberations about what constitutes successful treatment outcome. The acknowledgement of complexity may result in a reconfiguration of sex therapy that elevates its relevance, or it may result in its 487

disintegration. A review of factors that are driving or complicating the current transition is here offered in the hope that we can collectively rise to the very real challenges facing our still young, though somewhat weathered, discipline.

**QUESTIONS ABOUT CONSTRUCT UTILITY**

The past couple of decades have witnessed the emergence of questions about the nature of basic constructs that had long been taken for granted in sexology. The very notions of function and dysfunction have been reevaluated as potentially problematic imports from a medical model that cannot capture the nuances of human sexuality. The concept of sexual function has been criticized as reductive in its emphasis on the mechanics and hydraulics of sex. The concept of dysfunction has been called into question for failing to encompass gender differences in sexual function and for altogether missing the possibility that both sexual difficulties and associated distress may be culturally defined and influenced (Tiefer, 2001).

Constructs within the traditional sexual response model are also teetering under scrutiny. Research indicates that sexual desire, once considered a biological drive that sprung spontaneously and had sexual activity and/or orgasm as its goal, is much more unwieldy. With few reliable physiological, cognitive, and behavioral referents in women, sexual desire is now a construct undergoing reconsideration as a simple motivational state with clear goals (Meana, 2010). Furthermore, the difficulty reported by both men and women in differentiating desire from subjective or even physiological arousal has raised concerns about the utility of distinguishing between the two (Brotto, Heiman, & Tolman, 2009; Graham, Sanders, Milhausen, & McBride, 2004; Janssen, McBride, Yarber, Hill, & Butler, 2008). Even when a clear demarcation can be made between desire and arousal, their temporal sequence in the triphasic model of the sexual response is now in doubt. Clinical case reports and empirical data emanating from research on the incentive model of the sexual response suggest that arousal may often precede desire (Basson, 2007; Both, Everaerd, & Laan, 2007). Whether this rearrangement of the sequence is warranted or simply further evidence that desire and arousal are hard to tease apart remains a question.

The third phase of the triphasic sexual response, orgasm, appears to be a little sturdier, although attempts to define this construct have failed to reach consensus (Mah

& Binik, 2001; Levin, 2004). When this failure is coupled with the minimal empirical research on orgasm, the perception of sturdiness may be illusory. The sexual pain disorders have also posed some conceptual problems. They have underlined the difficulty in establishing how we define a sexual dysfunction in the first place. The research of the past 15 years has effectively demonstrated that, in most cases, dyspareunia constitutes a pain disorder whose connection with sexuality is mostly incidental (Binik, Meana, Berkley, & Khalife, 1999). The hyperalgesic genital area happens to interfere with sexual intercourse. This interference can undoubtedly result in myriad sexual and relational difficulties, but there are few data to suggest that its origins 488

are psychosexual. The question then becomes: Why is dyspareunia considered a sexual dysfunction instead of a pain disorder that happens to interfere with sexual function, as undoubtedly many other pain disorders do (Binik et al, 1999)? This raises an even broader question as to what the nine sexual dysfunctions share, other than their nonunique interference with sexual activity and the experience of pleasure therein. After all, what does premature ejaculation (PE) really share with dyspareunia, other than an interference with sexual activity and pleasure? Couldn't this interference with sex also be claimed by headaches and lower back pain, which are not categorized as sexual dysfunctions? Anxiety (about sex, sexual performance and/or intimacy), once thought to be the common denominator of sexual dysfunction, has given way to a biopsychosocial model that postulates multiple contributing factors, many of them unique to each dysfunction.

The DSM-5 (American Psychiatric Association, 2013) sub-work group on sexual dysfunction did not really address the question of construct validity in the concept of sexual dysfunction. Their response has essentially consisted of tinkering with existing diagnostic categories. This has included creating a greater differentiation between men and women (each now have their own desire-related dysfunction category) and collapsing across dysfunctions for which differentiation has been problematic (hypoactive sexual desire disorder and female sexual arousal disorder into sexual interest/arousal disorder in women; dyspareunia and vaginismus into genito-pelvic pain/penetration disorder). Whether the gender differentiation or dysfunction collapsing is an effective clinical response to the complexity of the sexual experience only research and field trials will tell. Some have argued that complexity calls for more rather than fewer distinctions (Derogatis, Clayton, Rosen, Sand, & Pyke, 2011).

The debunking of these once sacrosanct constructs challenges clinicians to modify, amend, or devise (new) treatments. Women worried about the loss of spontaneous sexual desire are now counseled to focus on responsive desire that may coincide with or even follow sexual arousal. Understanding that dyspareunia is primarily a pain disorder rather than an anxious, avoidant sexual response rooted in intrapsychic or relational difficulty has also had important treatment ramifications. Informed by the literature on chronic pain, psychological therapies and medical treatment now dovetail to improve clinical outcomes. The clinical isolationism that once defined sex therapy appears to be over, as mindfulness meditation, eye movement desensitization and reprocessing (EMDR), and various cognitive-behavioral therapy (CBT) strategies continue to be incorporated in sex therapy.

**ENCOMPASSING MULTIDIMENSIONALITY AND DIVERSITY**

The idea of an archetypal sexual response that crosses individual, gender, age, sexual orientation, relationship longevity, health/ability status, or cultural boundaries has definitely been challenged in the past few years. The aforementioned recognition that men and women may have differing sexual responses has been a catalyst for the 489

consideration of diversity beyond gender. Even within gender, individuals speak of significantly different experiences and endorse different models of the sexual response as reflective of their experience (e.g., Sand & Fisher, 2007). The ages of individuals and of their relationships may be central to the "morphology" of their sexual response.

Although this type of diversity is probably endemic to many psychophysiological phenomena, the simplicity that had been attributed to the sexual response probably delayed what should have been relatively obvious considerations of its diversity across individuals and groups.

Cultural diversity has been difficult to address, as there are precious few cross-cultural data or even data from different ethnic groups within North America. The few we do have are plagued by a Western-centric focus. This is certainly true of surveys asking and finding that Western-defined sexual dysfunctions exist elsewhere in the world. However, the importance placed on these dysfunctions varies. In many parts of the world sexual dysfunctions that interfere with reproduction are deemed worthy of treatment, whereas dysfunctions that interfere with pleasure, especially for women, are not universally considered problematic. Culture-specific sexual dysfunctions, relegated to an appendix of DSM-IV-TR (American Psychiatric Association, 2000) under the rubric "culture-bound syndromes," are as yet little known or understood in the West.

Regardless, there does appear to be a growing consciousness in sex therapy of the potential diversity of sexual response and expression. The search for one model that captures the experience of all individuals seems less of a concern and maybe even a dubious endeavor.

In direct response to this complexity, the DSM-5 Work Group on Sexual Dysfunctions has removed the overly simplistic and often categorical etiological specifiers in the DSM-IV (American Psychiatric Association, 1994; i.e., due to psychological or combined factors). Instead, the descriptive text emphasizes contextual factors (e.g., culture, relationships, stressors) for all dysfunctions. The consideration of individual vulnerability, relationship, medical, and sociocultural and religious mediators is a testament to the growing, though dispersed, body of research indicating that sexuality is heavily influenced by multiple contextual factors (e.g., Bancroft, 2009). It also acknowledges the difficulty (and possible futility) in distinguishing between psychological and physical etiological factors in a literature that has found single-cause pathways elusive.

The new view of women's sexual problems had been espousing this type of multidimensional coverage for years, in reaction to mechanistic and medicalized models of human sexuality and its problems (Tiefer, 2001). The impact, however, on actual DSM-5 (American Psychiatric Association, 2013) diagnoses was not that significant.


Input: Could not generate response.

Response:
The descriptive text that mentions contextual factors appears to be little more than a reminder to clinicians to consider the multiple forces potentially acting on or affected by the sexual difficulty. Because these contextual factors are not included as specifiers in the actual diagnosis, we wonder if many clinicians will continue to ignore these factors.

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**THE RISE OF SEXUAL MEDICINE AND INTERDISCIPLINARITY**

The multidimensionality of sexuality necessarily calls for assessment and treatment strategies that can account for all the potential dimensions at play when an individual encounters sexual difficulties. Evident though this may seem, there has been much hand-wringing over the meteoric rise of medical approaches to sexual problems. Some have argued that the latter risks making sex therapy obsolete, unless sex therapy is able to empirically demonstrate added value (Rowland, 2007). One could alternately argue that sexual medicine has increased sex therapy's relevance in light of high rates of medical treatment failures (Althof & Rosen, 2010). There are no empirical data evaluating the impact of medical approaches on sex therapy or how it is playing out. It is, however, undeniable that the PDE5 inhibitors and the use of androgens for desire and erection problems in men and desire difficulties in women have changed the treatment landscape.

On the surface, there does not appear to be a crisis, with sexuality journals flourishing and professional sexology conferences bursting at the seams. Clients who want medical solutions and for whom these solutions are deemed sufficiently effective will simply not seek out sex therapy. Some clients for whom these solutions do not work will consider sex therapy as alternative or adjuvant treatment. Others will not. It is hard to know how the numbers compare with those of the pre-sexual-medicine era. It is quite possible that the popularization of treatment for sexual dysfunction effected by the sexual-medicine juggernaut has mitigated what otherwise may have been a reduction in the number of clients who sought sex therapy for lack of any other choice.

If nothing else, the rise of sexual medicine has accelerated the movement of sex therapy toward interdisciplinarity, and that is a roundly positive development from a patient care perspective. The expansion of treatment options puts appropriate pressure on the sex therapy enterprise to demonstrate effectiveness and on sex therapists to expand their knowledge base so that they can collaborate with other health professionals.

As the preceding chapters have shown, combination treatments for erectile dysfunction (ED) and PE are state of the art. The treatment for the sexual pain disorders now calls for the involvement of physical therapists, as well as gynecologists and, possibly, dermatologists. Curiously, these interdisciplinary approaches are relatively new to the treatment of sexual problems. Sex therapy has lagged well behind the treatment of other psychological difficulties (e.g., depression, anxiety), which have involved combination therapy for decades (Althof & Rosen, 2010). The delay may be in part explained by the faux simplicity of early models of the sexual response or, alternately, by the historic reticence of nonpsychological fields to consider sexual function as an integral part of health. Regardless, all relevant disciplines are relatively new to the interdisciplinary treatment of sexual problems, and there is much to learn about how to do it well. The most important guideline may be that the multiple disciplines coming to bear on a problem do so concurrently. The theory behind combination therapy posits that the best outcome is likely to occur when treatments are concurrently rather than sequentially administered, allowing for a positive interaction of the different strategies.

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For example, the PDE5 may provide the physical trigger that encourages the client to entertain and address, through sex therapy, the psychological and relationship factors that in turn facilitate or even make possible the erectile function. Without the PDE5

facilitated erection, the client might have had little patience for what felt like indirect psychological and couple interventions. Without the psychological and couple work, the erection may have been beside the point, even if attained. Such an approach is best described as "interdisciplinary," rather than "multidisciplinary" as it concurrently capitalizes on the contributions of multiple disciplines. One of the burdens of interdisciplinarity is the expansion of our knowledge base to include a working, if not in-depth, familiarity with the expertise of our health care coproviders and vice versa.

Another is the investment of time needed to coordinate and integrate client care. These are not insignificant concerns, and they require a commitment to the interdisciplinary model and a willingness to share in both the success and the failure of our outcomes.

Theory and research, however, increasingly point to interdisciplinary treatment of sexual problems as the appropriate and expected standard of care.

**RECONCEPTUALIZING TREATMENT OUTCOME**

A research and theoretical literature questioning definitions of sexual function and dysfunction and its constructs, their generalizability, and the extent to which they are sociopolitically determined is inevitably going to raise questions about appropriate treatment outcome variables. If we are not sure what the sexual problem is or whether there is even a sexual problem, it can be questionable to speak categorically about solutions. Some cases are clear: A woman presents with dyspareunia or a man presents with PE and both are incapable of having desired intercourse. A reduction in her pain or its resolution and the extension of his ejaculation latency would be evidently reasonable goals. Other instances are trickier. Is the goal of sex therapy to increase a woman's supposed low desire? Why not decrease her husband's higher desire?

The point here is that either in cases of clear dysfunction (e.g., pain) or in cases of questionable dysfunction (e.g., desire discrepancy), sometimes we do succeed in improving "function," and sometimes we do not because improvement is outside the reach of available treatments (e.g., some cases of provoked vestibulodynia; normal differences in sexual drive). What we can always target, however, is the individual's and couple's level of adjustment to circumstances and the ways in which they process their problem and their relationship dynamics.

On some level, the ultimate goal of sex therapy is increasing sexual satisfaction.

Although sexual satisfaction and sexual function are positively correlated, some studies with women have found the association to be less than hardy (Ferenidou et al, 2008).

Dundon and Rellini (2010) found that psychological well-being and relationship adjustment were strong predictors of sexual satisfaction over and above sexual function.

Rosen and Bachmann (2008) have gone as far as to deemphasize function in a conceptual paradigm that focuses on the relationship of sexual satisfaction to overall 492

health and happiness.

The current focus on sexual satisfaction is also emerging in discussions about eroticism and the meanings attached to sexuality on the part of both researchers and clinicians. The work of Kleinplatz and colleagues (2009) on "optimal sexuality" is decidedly free of references to "function," and her respondents describing great sex are more likely to speak of "transcendence" than lubrication. Sexual function may even be a problem, as she proclaims that "Nothing kills desire more than doing what works—

relentlessly" (Kleinplatz, 2006, p. 345). Leonore Tiefer (2009) bemoans our abandonment of the art of sex for its mechanics. Esther Perel (2006) privileges eroticism over function when discussing the sexual problems of long-term relationships with floundering sex lives. It is noteworthy that the eroticism that these authors allude to was actually present in early sex therapy interventions, such as sensate focus, that sought to deemphasize function and focus on sensuality. Perhaps we have come full circle, or perhaps those early interventions inadvertently stifled eroticism with their directives and homework exercises.

**LACK OF SEX THERAPY OUTCOME RESEARCH**

As most of the chapters in this volume attest, there is a troubling lack of sex therapy outcome research. A review of the randomized controlled trials of the past 15 years reveals an impressive number of studies investigating the impact of pharmacological agents on sexual function, a much smaller number comparing pharmacological or other nonpsychological interventions with sex therapy, and a handful focusing exclusively on some version of sex therapy or combination therapies. The current reasons for this are relatively clear. Pharmacological interventions are far easier to administer and likely to be funded by an industry interested in promoting the use of its products. In contrast, there is no organized profit motive for sex therapy research. Nonindustry funding for sexuality research continues to be minimal. It is simply not a priority area for governmental funding (at least in the United States). This, however, does not explain why, in the heyday of sex therapy and ample U.S. federal funding, such research was not carried out. Perhaps sex therapists believed their own rhetoric about simple and easy cures. On the other hand, there does appear to be significant and recent therapy outcome research mostly outside the United States, at least with respect to the sexual pain disorders (e.g., van Lankveld et al., 2006; Masheb, Kerns, Lozano, Minkin, & Richman, 2009; Bergeron et al., 2001; ter Kuile et al., 2009).

The complexity of psychological interventions for sexual problems may, however, also pose a significant challenge to the identification of effective interventions.

Generally, sex therapy includes cognitive reframing, emotional regulation, stimulus control techniques, and relationship skill building. Researchers interested in isolating active ingredients are hard-pressed to parse these treatments, and replication invariably requires manualization. However, these challenges are no different from those encountered by treatment outcome researchers for any number of psychological 493

disturbances.

Importantly, the proliferation of pharmacological studies has had some benefits outside of the testing of its agents. It has spawned the development and standardization of numerous self-administered measures that are now widely used both in research and clinical practice. Outcomes in these studies have also been expanded from mere function to satisfaction and well-being. All of this speaks well of the impact of sex therapists on the development and investigation of pharmacological agents, but is it enough? Sex therapy is likely to remain on the sidelines if it does not reenter the randomized clinical outcome study arena.

It is possible that, even without outcome data, sex therapy will survive as long as people continue to seek help in figuring out their sexual problems and dilemmas; as long as people find it gratifying and useful to consult with smart, caring people about issues they cannot share with anyone else. In terms of psychotherapy, surveys show that client satisfaction with general psychotherapy often outstrips its demonstrated efficacy in symptom reduction (Lunnen, Ogles, & Pappas, 2008). If this is also true of sex therapy, it may reflect a failure of outcome research to effectively measure psychotherapeutic change or to adequately measure sexual satisfaction over and above sexual performance.

This is potentially easily remediable, given the development of several psychometrically promising inventories to measure sexual satisfaction (Byers, 2005; Meston & Trapnell, 2005).

**INABILITY OF SEX THERAPY TO ARTICULATE ITS UNIQUE**

**CONTRIBUTION**

In 2009, two of us (Binik & Meana, 2009) wrote a target article in the Archives of Sexual Behavior about the future of sex therapy. Within that article, we argued that sex therapy might have overstated its claim to specialization, with the attendant consequences of (1) inhibiting general psychologists from engaging in the treatment of sexual problems, which happen to be more prevalent than depression or anxiety, and (2) marginalizing sex therapy to the extent that it is not included in anthologies of types of psychological treatments. We also questioned its claim to uniqueness given its use of interventions (e.g., CBT, stimulus control, communication skills) common to the treatment of myriad other difficulties, not to mention their undifferentiated use across all dysfunctions.

If, in fact, sex therapy has a unique contribution to make, it has to date failed to articulate it as well as it could. The commentaries on our target article and our consequent self-reflection have led us to conclude that the unique contribution of sex therapy may be the willingness to talk about sex with clients. On the surface, this may sound simplistic, but the general societal discomfort with sexuality appears to pervade the health professions, including psychology. It has been consistently documented that medical doctors fail to ask questions about sexual health during history taking and routine check ups and that patients are reticent to raise the issue if doctors do not (Moreira, Glasser, & Gingell, 2005; Moreira, Glasser, Nicolosi, Duarte, & Gingell, 2008).

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Although no such data are available on general psychologists, the lack of sexuality training in clinical psychology programs would indicate that the discomfort in all likelihood extends to them as well (Miller & Byers, 2010). It is common for even couple therapists to refer clients out to sex therapists when sexual issues come to the fore.

Perhaps the unique contribution of sex therapy extends beyond comfort with discussing sexual concerns. Perhaps sex therapy stands out as the ultimate integrative and interdisciplinary psychological intervention with tendrils into more disciplines than other mental health areas. With physical therapy, urology, gynecology, dermatology, and endocrinology as common collaborators, sex therapy could position itself at the vanguard of interdisciplinary treatment. It has yet to do so. The ongoing failure to properly articulate what sex therapy does and how it does it could result in a true marginalization of a practice with much to offer for very mainstream problems.

**DEFENSIVENESS AND FRAGMENTATION**

Although sex therapists understandably rail against reductive and overmedicalized approaches to the treatment of sexual problems, we need to ensure that such criticisms emanate from evidence-based clinical concerns rather than from a defensive stance against the encroachment of other disciplines. Sexual medicine has as much to offer as does sex therapy. The benefits of interdisciplinarity notwithstanding, some cases will not require sex therapy at all. In some men with uncomplicated erectile difficulties, a PDE5

inhibitor will be all that is needed. In some women whose desire has tanked with menopause, low-dose androgen therapy may restore desire levels to their satisfaction as well as that of their partners. There may be nothing to talk about or to process. The principle of interdisciplinarity does not imply that all potentially relevant disciplines will in fact be needed in any given case. It is their consideration that is imperative, just in case.

Undoubtedly, sexual medicine and sex therapy have different orientations, which may sometimes complement each other but at other times clash. Sexual medicine is based upon a disease model and aims to "cure" or ameliorate the effects of said disease.

Sex therapy has always considered the enhancement of sexual pleasure as a worthwhile treatment goal. When these two different approaches zero in on the same sexual problem, there may be contention. Nowhere has this been more evident than in the treatment of low sexual desire in women. The standard applied by the Food and Drug Administration (FDA) envisions sexual function, but not sexual pleasure, as a health issue. In fact, the virulent debate that occurred during the FDA hearings regarding Flibanserin (a drug proposed for the treatment of low desire in women) was characterized by one side insisting that low desire in women is a disease worthy of treatment and the other side decrying the "disease mongering" attitude of "big pharma."

In an eloquent post on a sex therapy listserv, Margaret Nichols (2010) suggested:

"perhaps we could reconcile these positions by taking a different stance about drug use, and admit that people, more and more, will want medications for 'enhancement'

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purposes, much like surgery for cosmetic purposes. . . . If we could even discuss the merits of medications/'good drugs' used for enhancement, we might be able to give up the pretense that, for example, the desire to increase sexual desire has to be a 'disease.' "

In other words, if we do not chastise sex therapy for dealing in the enhancement of people's sex lives (disordered or not), why should we chastise sexual medicine for its version of the same endeavor? The problem remains that, although sexual medicine physicians indeed prescribe "off label" medications for improved sexual pleasure, the discipline has remained mum on the subject of pleasure. Perhaps this will not always be the case, and sex therapy and sexual medicine will be able to join forces to improve the sexual lives of men and women without first diagnosing them with a disease. For the moment, the "better loving through chemistry" niche is occupied by herbal and holistic remedies that have yet to undergo the scrutiny of randomized controlled clinical trials.

Another potential threat to the progress of those of us interested in the interdisciplinary treatment of sexual problems is the fragmentation of sexology and sexual medicine into professional factions that inevitably compete with each other.

Despite the fact that health professionals interested in the treatment of sexual problems remain few in number, comparatively speaking, our efforts are divided into numerous professional societies, each vying for members and conference attendees and each appealing to different types of sex researchers and therapists. Within North America there is the Society for Sex Therapy and Research (SSTAR), the Society for the Scientific Study of Sex (SSSS), the Canadian Sex Research Forum (CSRF), the American Society of Sexuality Educators, Counselors and Therapists (ASSECT), the International Academy of Sex Research (IASR), the International Society for the Study of Women's Sexual Health (ISSWSH), and the Society for Sexual Medicine (SSM). It is questionable whether this type of fragmentation serves our discipline or splinters and disempowers it.

Although some of these groups strive for multidisciplinarity in their membership, the extent to which they promote one vision (sexual health, medicine, therapy) over another does not speak to the interdisciplinary unification that the literature seems to be calling for.

As a group, sex therapists have not systematically attempted to set standards for interdisciplinary treatment. Even when definitive treatments are lacking, other groups have organized consensus conferences in an attempt to instruct and guide the field. It is time for sex therapists to do the same through existing journals, professional groups, and conferences. Imagine the effect if representatives from all the professional groups just listed sat down and developed a set of standards for the assessment and treatment of DSM-5 (American Psychiatric Association, 2013) defined sexual dysfunctions.

The certification of sex therapists may also be working against the principles of interdisciplinarity. Most licensing for the health professions is general in nature and occurs at the state and provincial levels. Individual practitioners can then decide to claim areas of particular competence based on their training and experience. We do not certify individuals as being depression or anxiety specialists, as the treatment of these disorders is expected of the general mental health practitioner. Considering that most sexual dysfunctions are more prevalent than depression or anxiety disorders, it is hard to rationalize special certification for the treatment of sexual difficulties. More 496

important, the insistence on certification is likely to dissuade many other health care providers from assisting their clients with sexual problems, when in fact the treatment of sexual problems draws liberally from the arsenal of general psychotherapy interventions (Binik & Meana, 2009). These attempts at formalizing specialization, although possibly driven by concerns over quality control, may in the end only serve to marginalize sex therapy and restrict the help available to clients.

**POLEMIC/POLITICAL/DISCIPLINARY DEBATES**

Discussions of sexual dysfunction, especially in regard to women, have become highly politicized and emotionally charged. This was most evident in the debates during the DSM-5 (American Psychiatric Association, 2013) development process concerning the proposal to collapse desire and arousal problems in women into one diagnostic category. The reason that the arguments became heated is clear. The construct of desire is sociopolitically loaded, as we have yet to tease apart gendered social constructions about its experience and expression and its more essential characteristics. Perhaps we never will. Perhaps these debates about distinguishing what clients want from what we think they might want, given different social and power structures, are ultimately of little immediate clinical relevance. How likely is it that an individual requesting treatment for what he or she considers a problem, regardless of its sociopolitical framing, will be interested in or helped by these debates? It is hard to know.

The situation can be further complicated by different disciplines being exposed to and "seeing" the same supposed disorder in markedly different ways. For example, the sex therapist who sees a heterosexual couple presenting with distress over the woman's comparatively low desire level may hear a set of circumstances quite divergent from that of the gynecologist who sees a woman reporting low desire in the context of a routine checkup. Furthermore, each discipline will be biased toward the consideration of etiologies in which they have the greater expertise and for which their specific help is sought. The loss of the female sexual arousal disorder in DSM-5 (American Psychiatric Association, 2013) as a stand-alone dysfunction may seem of little consequence to sex therapists who rarely see arousal problems decoupled from desire ones. On the other hand, this change may seem incomprehensible to gynecologists who are consulted more often by women who suffer exclusively from physical arousal problems.

Once entrenched, interdisciplinarity in the treatment of sexual dysfunctions should moderate these disagreements, with outcome research focusing on the effectiveness of interactions. The natural tension among disciplines is precisely why interdisciplinary treatment is likely to be more effective than a unidisciplinary approach. The key, however, will be the extent to which the relevant disciplines can come together as a team, with the optimization of client care as the primary goal.

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**PUBLIC DEMAND FOR EASY SOLUTIONS**

If the exaggerated claims of early sex therapy primed the public for easy solutions, the advent and widespread promotion of pharmacotherapies may have come perilously close to cementing that expectation. It is an expectation that can only frustrate both clients and their health care providers, as the empirical literature and clinician reports consistently indicate that easy solutions are few and far between. Sex therapy outcome research remains scarce and boasts moderate success. The outcome research on pharmacotherapies is actually quite impressive in comparison, but it also suggests that drugs fail to be a panacea for many patients. In the case of the PDE5 inhibitors, research has shown that they are not efficacious in 30% of men with ED and that many others discontinue treatment even when the drug significantly improves erectile function (Althof & Rosen, 2010).

As disciplines reach the realization that the treatment of sexual difficulties is a complex endeavor and that we need each other to succeed, we must communicate effectively with clients so as to dispel damaging myths. Aligning the expectations of our clients with reality, while maintaining hope, will be crucial to client care. It is essential to distinguish actual treatment failure from negative outcomes that arise out of client impatience and/or misunderstanding about the full nature of the problem. It is undeniable that in our consumer culture, this effort will be up against the formidable foe of industry advertising efforts that promise quick solutions. Our interdisciplinary story is harder to tell and to sell.

**ACCESS TO AND COST OF INTERDISCIPLINARY TREATMENT**

Perhaps the biggest threats to the transition that sex therapy is attempting to make into interdisciplinarity are cost and access to services. Teams of health care providers specializing in the treatment of sexual problems are likely to be mostly confined to large urban centers. Even within these, sex therapists are not very numerous. This makes it likely that the interdisciplinary approach will remain an ideal outside of the reach of many clients. Furthermore, in countries in which both medical care and sex therapy are costly, the majority of individuals may not be able to afford the kind of interdisciplinary care we believe to be optimal.

Although at first hand it may seem as if this problem is outside the power of sex therapy to address, the Internet may provide partial solutions to the problems of access and cost. It was clear 20 years ago that technology (Binik, Meana, & Sand, 1994) could provide help where services were not available. Research into interactive Internet-delivered sex therapy is growing and showing promising results (Jones & McCabe, 2011). There are likely other types of applications yet to be investigated that may be able to fill some of the holes in the interdisciplinary net. This will require that sex therapists and their collaborators collectively think about ways to deliver services that at first may appear unusual or even counterintuitive. Innovation in health care delivery is a concern 498

across health areas (Hwang & Christensen, 2008). It may be a speeding train that sex therapy cannot afford to miss.

**CONCLUSIONS**

The tongue-in-cheek title of this chapter implied a number of possibilities: that sex therapy may be stuck; that there is impatience with our progress; that we appear to be in a constant state of transition. We think that there is some truth to all of these.

At times, sex therapy has appeared to be stuck. With hardly any outcome data to support our claims to relevance, some have wondered whether we could end up becoming obsolete (Rowland, 2007). There is little doubt that sex therapy is being outresearched by pharmacology. The reasons for that are not hard to invoke (e.g., industry funding and ease of delivery), but the reasons do not change the fact. Two of us (Binik & Meana, 2009) have bemoaned sex therapy's claim to specialization and wondered whether this turf entrenchment has resulted in less rather than more progress. Sexuality is barely covered in general psychology graduate programs and has all but disappeared from medical training. These are not heartening developments.

On the other hand, documented concerns about sexual dysfunction and its treatment date back to the earliest written records in history. Currently, sexuality and its problems are covered by the media at unprecedented levels, and the public's thirst for knowledge about sex seems insatiable. There are numerous publications about the adaptation of sex therapy to non-Western cultures and groups (Hall & Graham, 2012; So & Cheung, 2005). North American-based sexuality journals are receiving a large number of foreign submissions, even from countries in which issues of sexuality have been traditionally suppressed. All of this bodes well for our discipline, at least in terms of demand.

Sex therapists and researchers, however, need to remain impatient with their progress, as this impatience may be central to momentum. A perpetual state of agitated, outward-reaching transition may be exactly where we need to be to ensure that we do not recede into the shadows of insularity and marginalization. The relatively dramatic changes in DSM-5 (American Psychiatric Association, 2013) speak to a lively research effort in the past 20 years, although one woefully short on treatment outcome. With a lack of field trials to test the new, proposed categories, we are assured of continuing controversy and more changes in the sixth edition.

We are definitely not there yet, but there is likely no there, no bacteria or virus to target. The treatment of sexual dysfunctions is no different from the treatment of any disorder with a diagnostic category in the DSM. It involves whole individuals with complex lives and histories, and it targets perhaps the most socioculturally loaded of human experiences; sexuality. May the state of transition never ease up. May we never think we have arrived.

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Moreira, E. D., Glasser, D. B., & Gingell, C. (2005). Sexual activity, sexual dysfunction and associated help-seeking behaviours in middle-aged and older adults in Spain: A population survey. World Journal of Urology, 23, 422–

429\.

Moreira, E. D., Glasser, D. B., Nicolosi, A., Duarte, F. G., & Gingell, C. (2008). Sexual problems and help-seeking behaviour in adults in the United Kingdom and continental Europe. British Journal of Urology International, 101, 1005–1011.

Nichols, M. (2010, June 17). Push to market pill stirs debate on sexual desire. Message posted to sstargaze-maurice@interchange.ubc.ca.

Perel, E. (2006). Mating in captivity: Reconciling the erotic + the domestic. New York: HarperCollins.


Input: Craft a detailed prompt for a medical journal article focusing on the diagnosis and treatment of various sexual disorders. This article should include sections on delayed ejaculation, erectile dysfunction, gender dysphoria, genital pain, and orgasm disorders in women. For each disorder, provide information on the epidemiology, etiology, assessment, and treatment options. Additionally, include a discussion on the potential role of biological, psychological, and sociocultural factors in the development and maintenance of these disorders. Finally, mention any relevant updates or changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) regarding these disorders.

Response:
Rosen, R. C., & Bachmann, G. A. (2008). Sexual well-being, happiness, and satisfaction in women: The case for a new conceptual paradigm. Journal of Sex and Marital Therapy, 34, 291–297.

Rowland, D. L. (2007). Will medical solutions to sexual problems make sexological care and science obsolete?

Journal of Sex and Marital Therapy, 33, 385–397.

Sand, M., & Fisher, W. A. (2007). Women's endorsement of models of female sexual response: The nurses' sexuality study. Journal of Sexual Medicine, 4(3), 708–719.

So, H. W., & Cheung, F. M. (2005). Review of Chinese sex attitudes and applicability of sex therapy for Chinese couples with sexual dysfunction. Journal of Sex Research, 42, 93–101.

ter Kuile, M. M., Bulte, I., Weijenborg, P. T. M., Beekman, A., Melles, R., & Onghena, P. (2009). Therapist-aided exposure for women with lifelong vaginismus: A replicated single-case design. Journal of Consulting and Clinical Psychology, 77(1), 149–159.

Tiefer, L. (2001). Arriving at a "new view" of women's sexual problems: Background, theory and activism. Women and Therapy, 24, 63–98.

Tiefer, L. (2009). The marketing of female sexual dysfunction: Illuminating current issues in sex and public health.

Retrieved April 15, 2009, from www.fsd-alert.org.

van Lankveld, J. J., ter Kuile, M. M., de Groot, H. E., Melles, R., Nefs, J., & Zandbergen, M. (2006). Cognitive-behavioral therapy for women with lifelong vaginismus: A randomized waiting-list controlled trial of efficacy.

Journal of Consulting and Clinical Psychology, 74(1), 168–178.

501

Index

The pagination of this electronic edition does not match the edition from which it was created. To locate a specific passage, please use the search feature of your e-book reader or select a page number link below.

The letter f following a page number indicates figure; the letter t indicates table.

**A**

Acceptance, chronic illness and, 440–441

Acceptance and commitment therapy (ACT), 388

Accommodation model,  244–245

Acquired vaginismus. See Vaginismus

Acupuncture, 168. See also Treatment

Addiction, sexual. See Sexual compulsivity/addiction

ADDRESSING mnemonic, 466

Adolescents. See also Lifespan view of sexuality; Young adults

assessment and diagnostic issues,  515–517

case example of, 519–522

epidemiology, 513–515

etiology, 517

gender dysphoria and, 237,  246–249

gender-variant youth,  325–327

overview, 511–513,  522–523

treatment and,  518–519

Adults, 237–238, 249–258\.  See also Lifespan view of sexuality; Young adults Affective factors, 163–164

Age, 46\.  See also Lifespan view of sexuality

Aging. See also Menopausal status

assessment and,  532–535

case example of, 534–535,  535–536

delayed ejaculation and, 142

dementia and,  531–532

homosexuality,  528

long-term-care settings, 528–529

overview, 525–527,  536

prevalence, 527–528

sexual dysfunction and,  529–532

sexually transmitted infections (STIs) and,  529

treatment and,  535–536

AIDS epidemic,  323–325\.  See also HIV; Sexually transmitted infections (STIs) Alcoholic neuropathies, 142–143\.  See also Medical problems Alzheimer's disease (AD),  531–532

American Society of Sexuality Educators, Counselors and Therapists (ASSECT),  551

Androgen levels, 23,  47, 66

Andropause, 527

502

Anteportal premature ejaculation, 115–116. See also Premature ejaculation (PE) Anti-androgenic medications,  227, 296–297

Antidepressants. See also Pharmacological treatment

aging and, 530–531

hypersexual disorders (HDs), 296–297

hypoactive sexual desire disorder (HSDD) in men,  51

persistent genital arousal disorder (PGAD),  267, 273

premature ejaculation and, 132

Antipsychotic medication,  514–515

Anxiety. See also Anxiety disorder; Performance anxiety

body image and,  368–369

erectile dysfunction and, 72

mindfulness skills and,  271

persistent genital arousal disorder (PGAD),  266–267

premature ejaculation and, 120

sexual abuse and,  384–385

Anxiety disorder. See also Anxiety

chronic illness and,  442

erectile dysfunction and, 72–73

hypersexual disorders (HDs) and,  287–288

hypoactive sexual desire disorder (HSDD) in men,  47

orgasm disorders in women and,  98

Anxiety reduction techniques, 102,  103f,  428–429

Appearance. See Body image

ArginMax,  101

Arousal. See also Hypersexual disorders (HDs); Persistent genital arousal disorder (PGAD); Sexual interest arousal disorder

adolescents and young adults,  515

aging and, 530–531

bisexuality and,  325

compared to desire,  45–46

construct utility,  542–544

hypersexual disorders (HDs) and,  288

mindfulness skills and,  386

persistent genital arousal disorder (PGAD) and,  272–273

sexual abuse and,  379,  386

Assertiveness skills training,  385, 428–429

Assessment

adolescents and young adults,  515–517

aging and, 532–535

body image and,  366–367

chronic illness and,  445–446

culturally sensitive sex therapy (CSST) and,  343–346

delayed ejaculation and, 143–145,  144f,  145f

disability and,  461–466

erectile dysfunction,  65–69, 71–81

gender dysphoria and, 237,  240–241

genital pain, 161–163

hypersexual disorders (HDs), 283–284,  286–289,  287f

hypoactive sexual desire disorder (HSDD) in men,  49–50

infertility and,  422–426, 424f

infidelity and,  408

orgasm disorders in women,  91,  93–98

overview, 545–546

paraphilias, 201–202

persistent genital arousal disorder (PGAD),  268–270, 269f

premature ejaculation and, 121–123, 124f

sexual abuse and,  380–382

503

sexual interest arousal disorder (SIAD) and,  26–29, 27f

sexually transmitted infections (STIs) and,  487,  503

vaginismus,  181–184

Assessment instruments,  344–346,  462–463

Assessment/treatment algorithm, 26,  27f. See also Assessment; Treatment Association for the Treatment of Sexual Abusers (ATSA), 230

Attention-deficit/hyperactivity disorder (ADHD),  287–288

Attraction, 75,  239–240\.  See also Body image Atypical neuroleptics,  296–297

Atypical sexuality,  198. See also Paraphilias

Autogynephilia, 250–251, 316–317. See also Gender dysphoria Aversion therapy, 296

Avoidance,  182–183

**B**

Bacterial STIs, 495–496. See also Sexually transmitted infections (STIs) Behavior therapy,  244–245

Behavioral activation, 52

Behavioral change, 27f

Behavioral factors

delayed ejaculation and, 140–142,  143–145,  144f, 145f

genital pain and,  163–164

Behavioral masturbatory retraining, 145\.  See also Masturbation; Treatment Behavioral therapy techniques, 296,  468, 468–469

Behavioral-learning perspective,  119–120

Biological factors

delayed ejaculation and, 142–143

gender dysphoria and, 241–242

LGBTQ clients,  311

premature ejaculation and,  114,  118

queer theory paradigm and,  313–314, 315

Biomedical risk factors. See also Medical problems

adolescents and young adults,  517

genital pain and,  163

hypoactive sexual desire disorder (HSDD) in men,  46–47, 49–50,  50–51

Biomedical treatment, 246–247, 258

Biopsychosocial perspective, 28,  335–336. See also Assessment Bipolar spectrum disorders, 288

Bisexuality, 6–7, 319, 319–320,  325\.  See also LGBTQ clients Blame, 290t

Body image. See also Self-esteem

assessment and,  366–367

case example of, 362–363,  367, 369–370, 370–372

chronic illness and,  441

infertility and,  421–422

overview, 359–360,  372

research on, 360–365

therapeutic challenges for, 7

treatment and,  367–370

Bondage, dominance, sadism, masochism (BDSM),  202, 318–319.  See also Paraphilias; Queer individuals Brain functioning,  242

Breast body image,  361–364\.  See also Body image Brief Index of Sexual Functioning for Women, 516

Brief Sexual Function Questionnaire,  516

Buproprion, 34,  530–531. See also Pharmacological treatment 504

**C**

Canadian Sex Research Forum (CSRF), 551

Cancer, 24,  47, 56–58\.  See also Medical problems Cardiovascular diseases. See also Medical problems

case example of, 63–64

erectile dysfunction and, 63,  64–65, 66

hypoactive sexual desire disorder (HSDD) in men,  47

Catastrophizing thoughts, 180–181, 180f,  182\.  See also Cognitive distortions Causal mechanisms. See Etiology

Celibacy, 290t

Central nervous system,  238

Child Behavior Checklist (CBCL), 237

Child molestation,  222. See also Pedophilia; Sex offenders; Sexual abuse Child pornography, 223,  406–407\.  See also Pedophilia Childhood Trauma Questionnaire (CTQ),  381

Children. See also Early experiences; Lifespan view of sexuality

gender dysphoria and, 237,  244–246

gender identity disorder (GID) and,  317

gender-variant youth,  325–327

Chlamydia, 495–496,  500. See also Sexually transmitted infections (STIs) Chronic illness. See also Medical problems

assessment and,  445–446

case example of, 446–447,  450–453

"conspiracy of silence,"  444–445

overview, 436–437,  453

prevalence of sexual dysfunction in people with,  437–438

relationship factors and, 442–444

sexual problems in,  438–439

sexuality,  444

stepped care, 448–449

treatment and,  446–450

Circles of Support and Accountability (COSA) program, 203,  294

Cisgender, 319–320,  319n

Classic prenatal hormone theory, 241

Clinical interview. See Structured interview

Cognitive disorder,  266–267

Cognitive distortions

body image and,  368

premature ejaculation and,  127–128

vaginismus and, 180–181,  180f, 182

Cognitive factors, 163–164, 464

Cognitive interventions,  78

Cognitive processing, 27f.  See also Treatment

Cognitive refocusing, 52

Cognitive reframing, 548

Cognitive restructuring,  78, 468–469

Cognitive-affective risk factors, 47–48

Cognitive-affective-behavioral therapy,  51–53,  54f

Cognitive-behavioral therapy (CBT). See also Treatment

body image and,  367–370

erectile dysfunction and, 78

genital pain and,  159,  166–167, 167–168

hypersexual disorders (HDs), 295–296

orgasm disorders in women and,  99–100,  102, 103f

paraphilias and,  202

pedophilia and,  222–223

people with disabilities and,  468–472

505

persistent genital arousal disorder (PGAD),  270–271

sexual abuse and,  386

sexual interest arousal disorder (SIAD) and,  27f,  30–31

vaginismus and, 184–185

Cognitive-development models, 243

Coital alignment technique,  31, 100\.  See also Treatment Combined therapy, 133–134\.  See also Treatment Commitment, 24–25. See also Relational aspects Communication, 98

Communication skills training

orgasm disorders in women and,  99

people with disabilities and,  468–469

sexually transmitted infections (STIs) and,  487–488

Community containment model,  6

Community support, 203

Comorbidities

aging and, 531

erectile dysfunction and, 64–65,  72–73

hypersexual disorders (HDs) and,  286–288

male sexual desire and,  45–46

orgasm disorders in women and,  94

sexual abuse and,  382–383

vaginismus and, 181–182

Complete blood count (CBC), 66

Comprehensive Psychosocial History for Infertility, 425

Compulsions, 271

Compulsive Sexual Behavior Inventory,  283–284

Compulsivity, sexual. See Sexual compulsivity/addiction

Condoms,  486, 487–488,  490, 503

Confidentiality, 227–229

Congenital disease, 444\.  See also Chronic illness

Construct utility, 542–544

Control, 98–99

Conversion therapy, 312–313

Coronary artery disease (CAD), 64–65

Cortisol,  47, 384–385

Couple conflict, 74

Couple therapy. See also Treatment

aging and, 535

body image and,  366–367

hypersexual disorders (HDs) and,  287f

infidelity and,  406

sexual interest arousal disorder (SIAD) and,  27f

sexually transmitted infections (STIs) and,  490–493

Criminality factors, 198–199. See also Paraphilias; Sex offenders Cross-cultural factors,  336–339\.  See also Culturally sensitive sex therapy (CSST) Cultural competence,  346–347\.  See also Culturally sensitive sex therapy (CSST) Cultural factors. See also Culturally sensitive sex therapy (CSST); Sociocultural factors culture of disability,  459–461

delayed ejaculation and, 140–141,  143–145,  144f, 145f

disability and,  465–466

infertility and,  428

infidelity and,  407–408

masturbation and,  94

overview, 335–336,  544–545

premature ejaculation and, 122

queer theory paradigm and,  315

Culturally sensitive sex therapy (CSST)

506

acculturations,  339–341

assessment and,  343–346

case example of, 347–353

cultural competence and, 346–347

diagnosis and,  342–343

future directions, 353–354

how culture influences sexual dysfunction, 341–342

overview, 334–335

religion and,  341

sexual dysfunctions in a global context and,  336–339

Culture-bound syndromes (CBS),  338–339,  544

Cyclothymia, 288

**D**

Dapoxetine, 131–132. See also Pharmacological treatment Delayed ejaculation

biological models, 142–143

case example of, 147–151

in the DSM-5,  4

etiology, 140–141

evaluation and diagnosis, 143–145,  144f, 145f

gay male sexuality and, 323

overview, 138–140,  151, 152f

psychological and behavioral models,  141–142

treatment and,  145–147,  150–151, 152f

Dementia, 531–532, 536

Depression

chronic illness and,  442, 443

erectile dysfunction and, 63,  72–73

gender dysphoria and, 247–248

hypoactive sexual desire disorder (HSDD) in men,  47

infertility and,  421–422

mindfulness skills and,  271

pedophilia and,  225–226

sexual interest arousal disorder (SIAD),  25

Derogatis Interview for Sexual Functioning (DSFI-SR), 425

Desire. See also Hypoactive sexual desire disorder (HSDD) in men; Hypoactive sexual desire disorder (HSDD) in women; Low desire; Male sexual desire; Sexual interest arousal disorder

adolescents and young adults,  513–514

aging and, 526–527, 530

construct utility,  542–544

erectile dysfunction and, 75

hypoactive sexual desire disorder (HSDD) in men and, 48,  49–50

incentive motivation model of sexual response and,  21–22

infertility and,  421–422, 422

lesbian sexuality and,  321–323

in men,  3

origins of,  200

persistent genital arousal disorder (PGAD) and,  268

relationship factors and, 48

sexual abuse and,  379

Developmental factors, 47–48,  290t

Developmental view of sexuality, 8–9,  444\.  See also Adolescents; Adults; Aging; Lifespan view of sexuality; Young adults

Deviance model,  311–313\.  See also Sexual deviance DHEA (dehydroepiandrosterone),  34

507

Diabetes. See also Medical problems

case example of, 446–447

delayed ejaculation and, 142–143

erectile dysfunction and, 66

infertility and,  421

Diagnosis. See also Diagnostic and Statistical Manual of Mental Disorders (DSM-5); Symptoms/criteria adolescents and young adults,  515–517

chronic illness and,  438–439

culturally sensitive sex therapy (CSST) and,  342–343

delayed ejaculation and, 143–145,  144f,  145f

disability and,  461–466

erectile dysfunction and, 65

gender dysphoria and, 238–240, 249

genital pain and,  161–163

hypersexual disorders (HDs), 282–286,  283f, 286–289, 287f

infertility and,  422–426, 424f,  428

infidelity and,  413

male dyspareunia,  165

orgasm disorders in women,  91–93, 93–98

paraphilias, 197–200

pedophilia and,  229–230

persistent genital arousal disorder (PGAD),  264–265,  268–270, 269f

premature ejaculation and, 114

queer theory paradigm and,  314

sexual interest arousal disorder (SIAD) and,  26–29

vaginismus and, 181–184

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). See also Symptoms/criteria; specific diagnoses adolescents and young adults,  515–517

chronic illness and,  438

construct utility,  543

cultural factors and, 544–545

culturally sensitive sex therapy (CSST) and,  342–343

debates in the field of sex therapy, 551–552

defensiveness and fragmentation in the field of sex therapy,  551

delayed ejaculation,  139

disability and,  461–462

erectile dysfunction and, 81

criteria for,  65

female orgasmic disorder (FOD) and,  90–91, 93

criteria for,  96–98

future of sex therapy and,  10

gender dysphoria,  235, 236,  238–240

genitopelvic pain/penetration disorder,  164–165

criteria for,  161

hypersexual disorders (HDs), 283,  284–286

criteria for,  283–284, 283f

infertility and,  425–426

infidelity and,  413

LGBTQ clients,  311, 316–317,  320

male dyspareunia,  165

paraphilias, 197–200

criteria for,  199–200

premature ejaculation and, 117

criteria for,  114

sexual disorders,  5–6

sexual dysfunction and,  2–4

sexual interest arousal disorder,  17, 37–38

criteria for,  19–20

508

treatment outcome and, 554

vaginismus,  178,  190–191

Diagnostic and Statistical Manual of Mental Disorders (DSM-II), 282

Diagnostic and Statistical Manual of Mental Disorders (DSM-III), 282

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),  139

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)

cultural factors and, 342–343,  544–545

female orgasmic disorder (FOD), criteria for,  96–97

gender dysphoria,  236, 238–240

hypersexual disorders (HDs), 282

hypoactive sexual desire disorder (HSDD) in men, criteria for,  44

male dyspareunia,  164–165

male sexual desire, 44

paraphilias, 197

premature ejaculation and, 115,  117

vaginismus,  177–178

Diminished ejaculatory disorders (DEDs),  139. See also Premature ejaculation (PE) Directed masturbation. See also Masturbation; Treatment

infertility and,  428–429

orgasm disorders in women and,  99–100,  101–102, 103f

sexual interest arousal disorder (SIAD) and,  31

Disability. See also Medical problems; People with disabilities (PWD)

assessment and diagnostic issues,  461–466

case example of, 460,  471,  474–477

culture of, 459–461

overview, 457–459,  477

therapeutic challenges for, 8

treatment and,  466–474

Disability-affirmative therapy (DAT), 467–468

Disciplinary debates in the field of sex therapy,  551–552

Disclosure

hypersexual disorders (HDs), 289,  290t

premature ejaculation and, 122–123

sexual abuse and,  380–381

Dissatisfaction, sexual, 438\.  See also Satisfaction, sexual Distraction, 98

Distress, 50–51

Diversity,  544–545\.  See also Cultural factors Dopamine system,  22, 23,  288

DSM-5 Work Group on Gender Identity Disorders, 317

Dunkelfeld, Prevention Project,  225–226

Duty to warn/report, 227–229

Dyspareunia. See also Genital pain

assessment and diagnosis of,  161–163

case example of, 170–173

compared to vaginismus, 178

deletion of in the DSM-5,  3

in the DSM-IV,  3–4

male dyspareunia,  164–165

multidisciplinary model of care, 169–170

overview, 160–161,  173, 543

treatment and,  165–170

Dysthymic disorder, 288

**E**

Early ejaculation. See Premature ejaculation (PE)

509

Early experiences. See also Children

erectile dysfunction and, 73

gender dysphoria and, 242–243

genital pain and,  163–164

hypoactive sexual desire disorder (HSDD) in men,  47–48

orgasm disorders in women and,  95–96

premature ejaculation and, 122–123

vaginismus and, 181–182

Eating disorders, infertility and,  421

Educational pelvic examination (EPE), 181,  185–186

Ejaculation. See also Delayed ejaculation; Orgasm; Premature ejaculation (PE)

aging and, 527

gay male sexuality and, 323

overview, 90

Ejaculatory tipping point, 143–145, 144f,  145f

Electromyography (EMG) biofeedback,  166–167,  179

Emotion dysregulation,  388

Emotional regulation, 52,  548

Endocrine control, 118

Endometriosis,  421

Environmental factors,  75–76,  421

Ephebophilia, 229

Epidemiology

adolescents and young adults,  513–515

aging and, 527–528

chronic illness,  437–438

gender dysphoria,  236–238

infertility,  420–422

male sexual desire, 44–45

orgasm disorders in women,  91–93

premature ejaculation and, 117

sexual abuse and sexual dysfunctions,  377–380

sexual dysfunctions in a global context and,  336–339

sexual interest arousal disorder (SIAD),  20–21

sexually transmitted infections (STIs),  485–486,  488–490, 489f,  503

Erectile dysfunction

aging and, 529–530, 534

assessment and,  65–69,  71–81

cardiovascular disease and,  64–65

case example of, 63–64,  67–69,  79–80,  521–522

chronic illness and,  437–438

diagnosis and classification of,  65

disability and,  466

in the DSM-5,  3

etiology, 65–69

gay male sexuality and, 323

hypersexual disorders (HDs) and,  288

hypoactive sexual desire disorder (HSDD) in men and, 50–54,  54f

medical management of,  69–71

overview, 61–64,  81

people with disabilities and,  468–469

treatment and,  50–54, 54f,  71–81,  546, 552–553

Erection Quality Scale (EQS), 77

Erections, 527\.  See also Erectile dysfunction

Eros clitoral therapy device, 101

Erotica, 223

Estradiol,  22–23

Estrogen, 22–23, 29,  47

510

Estrogen therapy, 32–33. See also Hormonal treatment Ethnicity,  25–26

Ethnocultural factors, 26\.  See also Cultural factors; Ethnicity; Sociocultural factors Etiology

delayed ejaculation,  140–141

erectile dysfunction,  65–69

gender dysphoria and, 241–243

genital pain, 163–164

hypoactive sexual desire disorder (HSDD) in men,  46–49

orgasm disorders in women and,  98–99