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Unit 6. Cognitive Behavioural Sex Therapy

1. What are the uses of sensate focus in sex therapy?

It is useful in enhancing the sensual experiences though focus on pleasurable sensations and exploration of pleasurable areas. It helps to:

• defocus attention from performance; 
• improve communication between the couple and 
• facilitate mutual responsibility of sexual interaction.

2. Outline the management of premature ejaculation.

• Sensate focus and relaxation training can be used to reduce the performance anxiety. 
• Specific techniques like squeeze and start-stop technique can be used to prolong the ejaculatory latency.

3. Enumerate the treatment of vaginismus.

• To begin with relaxation training helps in reducing the anxiety associated with sexual intercourse. 
• The fear can be addressed through desensitization techniques followed by gradual insertion (aiming at dilation of vagina) of the objects to achieve the vaginal flexibility.
• In addition misconceptions related to pain have to be addressed.

4. What are the misconceptions that the couple seems to have?

The wife seems to believe that:

• “males should get erection at will and should maintain as long as it is required”, 
• “man is responsible for penetration and intercourse”, 
• “sexual intercourse is highly painful and some damage may occur to her vagina during the intercourse”.

The man seems to believe that 

• “he should be able to penetrate, otherwise he may be having some problem”, and 
• “he is inadequate as a man because he is not able to hold the erection”.

5. What are the predisposing, precipitating and maintaining factors for the target problems?

• Predisposing factors: in both of them are restrictive upbringing and lack of adequate knowledge leading to misconceptions about sexual performance.
• Repeated failures to insert have led to performance anxiety and secondary erectile dysfunction in the man.
• For the woman, the fear that it is going to be painful has led to development of vaginismus in the first attempt.

6. What are the negative cognitions reported in the couple?

Negative cognitions in the man are:

• “whether I will be able to penetrate successfully?”, 
• "what if I fail", 
• "my wife would think that I am sexually inadequate". 

Similarly, wife seems to have cognitions related to pain such as:

• “what if it hurts and there is damage to the vagina?”, 
• “I cannot tolerate the pain”, 
• “my vagina cannot accommodate the size of the penis”, and 
• “I cannot conceive if I continue to have pain”.

7. What are the kinds of sexual dysfunctions seen in men and women?

Male Sexual Dysfunctions

• Hypoactive Sexual Desire Disorder
• Sexual Aversion Disorder
• Erectile Dysfunction
• Premature Ejaculation
• Post-Coital Dysphoria
• Post-Coital Headache

Female Sexual Dysfunctions

• Hypoactive Sexual Desire Disorder
• Aversion Disorder
• Sexual Arousal Disorder
• Female Orgasmic Disorder
• Vaginismus
• Dyspareunia

8. What are the psychological factors implicated in sexual dysfunctions?

1. Predisposing Factors

• restrictive upbringing
• inadequate sexual information
• disturbed family relationships
• traumatic early sexual experiences which damage the self-concept
• early insecurity in psychosexual role which may include attitude towards own body, about sexual thoughts and urges, maturity etc. 
• guilt about earlier sexual relationships.

2. Precipitating Factors

• Random failure resulting in anticipatory anxiety
• Child birth
• Discord in the general relationship
• infidelity
• unreasonable expectations
• dysfunctions in the partner
• reaction to organic factors
• ageing
• depression and anxiety
• traumatic sexual experience
• hesitant sexual experiences.

3. Maintaining Factors

• Performance anxiety and anticipation of failure resulting in avoidance and playing spectators’ role in turn can lead to failure.
• Guilt
• loss of attraction between partners 
• poor communication between partners 
• discord in relationship 
• fear of intimacy 
• impaired self-image 
• inadequate sexual information 
• sexual myths 
• restricted foreplay 
• psychiatric disorder in any of the partners
• negative cognitions.

9. What are the components of history taking in sexual dysfunctions?

• Nature
• Frequency
• Severity
• Distress
• Duration
• Factors contribute to improving or worsening
• Cognitions
• Method of coping
• Beliefs 
• Attempts to treat

10. Outline the management of premature ejaculation and vaginismus.

Premature Ejaculation

• Sensate focus and relaxation training can be used to reduce the performance anxiety. 
• Specific techniques like squeeze and start-stop technique can be used to prolong the ejaculatory latency.

Vaginismus

11. What are the prerequisites for sex therapy?

If the problem is secondary and psychological in nature, it is amenable for therapy. 

Treatment progress is better if: 

• partners are motivated to get treated and willing to cooperate
• there are no major problems in the general relationship
• there is absence of physical or psychiatric illness.