Adult Treatment Planner
17: Female Sexual Dysfunction
SNOMED Terms
- Female sexual arousal disorder
- Sexual aversion disorder
- Situational hypoactive sexual desire disorder
Goals
- Increase desire for and enjoyment of sexual activity.
- Attain and maintain physiological excitement response during sexual intercourse.
- Reach orgasm with a reasonable amount of time, intensity, and focus to sexual stimulation.
- Eliminate pain and achieve a presence of subjective pleasure before, during, and after sexual intercourse.
- Eliminate vaginal spasms that prohibit penile penetration during sexual intercourse and achieve a sense of
relaxed enjoyment of coital pleasure.
Behavioral Definitions
- Describes consistently very low or no pleasurable anticipation of or desire for sexual activity.
- Strongly avoids and/or is repulsed by any and all sexual contact in spite of a relationship of mutual caring
and respect.
- Recurrently experiences a lack of the usual physiological response of sexual excitement and arousal (genital
lubrication and swelling).
- Reports a consistent lack of a subjective sense of enjoyment and pleasure during sexual activity.
- Experiences a persistent delay in or absence of reaching orgasm after achieving arousal and in spite of
sensitive sexual pleasuring by a caring partner.
- Describes genital pain experienced before, during, or after sexual intercourse.
- Reports consistent or recurring involuntary spasm of the vagina that prohibits penetration for sexual
intercourse.
Diagnoses
- Hypoactive Sexual Desire Disorder
- Sexual Aversion Disorder
- Female Sexual Arousal Disorder
- Female Orgasmic Disorder
- Dyspareunia
- Vaginismus
- Sexual Abuse of Child, Victim
- Female Hypoactive Sexual Desire Disorder Due to Axis III Disorder
- Female Dyspareunia Due to Axis III Disorder
- Sexual Dysfunction NOS
Objectives and Interventions
- Provide a detailed sexual history that explores current problems and past experiences that have influenced
sexual attitudes, feelings, and behavior.
- Obtain a detailed sexual history that examines the client's current adult sexual functioning as well
as childhood and adolescent sexual experiences level and sources of sexual knowledge, typical sexual
practices and their frequency, medical history, drug and alcohol use, and lifestyle factors.
- Assess the client's attitudes and fund of knowledge regarding sex, emotional responses to it, and
self-talk that may be contributing to the dysfunction.
- Explore the client's family-of-origin for factors that may be contributing to the dysfunction (e.g.,
negative attitudes regarding sexuality, feelings of inhibition, low self-esteem, guilt, fear,
repulsion; or assign "Factors Influencing Negative Sexual Attitudes" in Adult Psychotherapy Homework
Planner, 2nd ed. by Jongsma).
- Discuss any feelings of and causes for depression.
- Assess the role of depression in possibly causing the client's sexual dysfunction and treat if
depression appears causal (see Depression chapter in this Planner).
- Participate in treatment of depressive feelings that may be causing sexual difficulties.
- Refer the client for antidepressant medication prescription to alleviate depression.
- Honestly report substance abuse and cooperate with recommendations by the therapist for addressing it.
- Explore the client's use or abuse of mood-altering substances and their effect on sexual
functioning; refer for focused substance abuse counseling.
- Honestly and openly discuss the quality of the relationship including conflicts, unfulfilled needs, and
anger.
- Assess the quality of the relationship including couple satisfaction, distress, attraction,
communication, and sexual repertoire toward making a decision to focus treatment sexual problems or
more broadly on the relationship (or assign "Positive and Negative Contributions to the
Relationship" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
- Participate in couples therapy as part of addressing sexual problems.
- If problem issues go beyond sexual dysfunction, conduct sex therapy in the context of couples
therapy (see Intimate Relationship Conflicts chapter in this Planner).
- Cooperate with a physician's complete examination; discuss results with therapist.
- Refer the client to a physician for a complete exam to rule out any organic or medication-related
basis for the sexual dysfunction (e.g., vascular, endocrine, medications).
- Cooperate with physician's recommendation for addressing a medical condition or medication that may be
causing sexual problems.
- Encourage the client to follow physician's recommendations regarding treatment of a diagnosed
medical condition or use of medication that may be causing the sexual problem.
- Verbalize an understanding of the role that physical disease or medication has on sexual dysfunction.
- Discuss the contributory role that a diagnosed medical condition or medication use may be having on
the client's sexual functioning.
- Practice directed masturbation and sensate focus exercises alone and with partner and share feelings
associated with activity.
- Assign the client body exploration and awareness exercises that reduce inhibition and desensitize
her to sexual aversion.
- Direct the client in masturbatory exercises designed to maximize arousal; assign the client
graduated steps of sexual pleasuring exercises with partner that reduce her performance anxiety and
focus on experiencing bodily arousal sensations (or assign "Journaling the Response to Nondemand,
Sexual Pleasuring [Sensate Focus]" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma).
- Report progress on graduated self-controlled vaginal penetration with a partner.
- Assign the client body exploration and awareness exercises that reduce inhibition and desensitize
her to sexual aversion.
- Direct the client's use of masturbation and/or vaginal dilator devices to reinforce relaxation and
success surrounding vaginal penetration.
- Direct the client's partner in sexual exercises that allow for client-controlled level of genital
stimulation and gradually increased vaginal penetration.
- Participate in sex therapy with a partner or individually if the partner is not available.
- Encourage couples sex therapy or treat individually if a partner is not available.
- Demonstrate healthy acceptance and accurate knowledge of sexuality by freely learning and discussing
accurate information regarding sexual functioning.
- Disinhibit and educate the couple by encouraging them to talk freely and respectfully regarding her
sexual body parts, sexual thoughts, feelings, attitudes, and behaviors.
- Reinforce the client for talking freely, knowledgeably, and positively regarding her sexual
thoughts, feelings, and behavior.
- State an understanding of how family upbringing, including religious training, negatively influenced sexual
thoughts, feelings, and behavior.
- Explore the role of the client's family of origin in teaching her negative attitudes regarding
sexuality; process toward the goal of change.
- Explore the role of the client's religious training in reinforcing her feelings of guilt and shame
surrounding her sexual behavior and thoughts; process toward the goal of change.
- Assist the client in developing insight into the role of unhealthy sexual attitudes and experiences
of childhood in the development of current adult dysfunction; press for a commitment to try to put
negative attitudes and experiences in the past while making a behavioral effort to become free from
those influences.
- Verbalize a resolution of feelings regarding sexual trauma or abuse experiences.
- Probe the client's history for experiences of sexual trauma or abuse.
- Process the client's emotions surrounding an emotional trauma in the sexual arena (see Sexual Abuse
chapter in this Planner).
- Verbalize an understanding of the influence of childhood sex role models.
- Explore sex role models the client has experienced in childhood or adolescence and how they have
influenced the client's attitudes and behaviors.
- Verbalize connection between previously failed intimate relationships and current fear.
- Explore the client's fears surrounding intimate relationships and whether there is evidence of
repeated failure in this area.
- Discuss feelings surrounding a secret affair and make a termination decision regarding one of the
relationships.
- Explore for any secret sexual affairs that may account for the client's sexual dysfunction with her
partner.
- Process a decision regarding the termination of one of the relationships that is leading to internal
conflict over the dishonesty and disloyalty to a partner.
- Openly acknowledge and discuss, if present, homosexual attraction.
- Explore for a homosexual interest that accounts for the client's heterosexual disinterest (or assign
"Journal of Sexual Thoughts, Fantasies, Conflicts" in Adult Psychotherapy Homework Planner, 2nd ed.
by Jongsma).
- State a willingness to explore new ways to approach sexual relations.
- Direct conjoint sessions with the client and her partner that focus on conflict resolution,
expression of feelings, and sex education.
- Assign books (e.g., Sexual Awareness by McCarthy and McCarthy; The Gift of Sex by Penner and Penner;
For Yourself: The Fulfillment of Female Sexuality by Barbach) that provide the client with accurate
sexual information and/or outline sexual exercises that disinhibit and reinforce sexual sensate
focus.
- List conditions and factors that positively affect sexual arousal such as setting, time of day, atmosphere.
- Assign the couple to list conditions and factors that positively affect their sexual arousal;
process the list toward creating an environment conducive to sexual arousal.
- Identify and replace negative cognitive messages that trigger negative emotional reactions during sexual
activity.
- Probe automatic thoughts that trigger the client's negative emotions such as fear, shame, anger, or
grief before, during, and after sexual activity.
- Train the client in healthy alternative thoughts that will mediate pleasure, relaxation, and
disinhibition.
- Discuss low self-esteem issues that impede sexual functioning and verbalize positive self-image.
- Explore the client's fears of inadequacy as a sexual partner that led to sexual avoidance.
- Communicate feelings of threat to partner that are based on perception of partner being too sexually
aggressive or too critical.
- Explore the client's feelings of threat brought on by the perception of her partner as too sexually
aggressive.
- Verbalize a positive body image.
- Assign the client to list assets of her body; confront unrealistic distortions and critical
comments.
- Explore the client's feelings regarding her body image, focusing on causes for negativism.
- Implement new coital positions and settings for sexual activity that enhance pleasure and satisfaction.
- Assign books (e.g., Sexual Awareness by McCarthy and McCarthy; The Gift of Sex by Penner and Penner;
For Yourself: The Fulfillment of Female Sexuality by Barbach) that provide the client with accurate
sexual information and/or outline sexual exercises that disinhibit and reinforce sexual sensate
focus.
- Suggest experimentation with coital positions and settings for sexual play that may increase the
client's feelings of security, arousal, and satisfaction.
- Engage in more assertive behaviors that allow for sharing sexual needs, feelings, and desires, behaving more
sensuously and expressing pleasure.
- Give the client permission for less inhibited, less constricted sexual behavior by assigning
body-pleasuring exercises with partner.
- Encourage the client to gradually explore the role of being more sexually assertive, sensuously
provocative, and freely uninhibited in sexual play with partner.
- Resolve conflicts or develop coping strategies that reduce stress interfering with sexual interest or
performance.
- Probe stress in areas such as work, extended family, and social relationships that distract the
client from sexual desire or performance (see Anxiety, Family Conflict, and Vocational Stress
chapters in this Planner).
- Verbalize increasing desire for and pleasure with sexual activity.
- Suggest experimentation with coital positions and settings for sexual play that may increase the
client's feelings of security, arousal, and satisfaction.
- Encourage the client to gradually explore the role of being more sexually assertive, sensuously
provocative, and freely uninhibited in sexual play with partner.
- Reinforce the client's expressions of desire for and pleasure with sexual activity.
Index