5 stages of family life cycle

Application: Family Life-Cycle Stages

Although every individual experiences family life-cycle transitions in unique ways, common challenges and experiences often arise at these transition periods. For example, many couples experience changes in their sexual relationship after they become parents. Likewise, adults’ understanding of what it means to have “positive” sexual functioning may differ at different stages in the family life cycle. It is important for helping professionals to pay attention to the unique needs of the individual clients they serve, while also keeping in mind these common challenges and experiences that may arise.

The family life-cycle stages you will consider for this assignment are:

Single adulthood
Committed, long-term relationships
Becoming parents
Divorce/relationship termination and remarriage/re-partnering
Older adulthood
The Assignment (2- to 3-page paper):

Use the five family life-cycle stages listed in the Sexuality in Adulthood Across the Family Life Cycle chart to organize your thoughts for this assignment. For this paper:

Describe two common sexuality-related transitions or concerns at each stage.
Provide two examples of how research and theory characterize positive sexual functioning during each stage.
Briefly describe how you might intervene or use this information to assist clients.
Support your Assignment with specific references to all resources used in its preparation. You are to provide a reference list for all resources, including those in the resources for this course.

The behavioral and cognitive-behavioral treatment of female sexual dysfunction: how far we have come and the path left to go

Rebecca D. Stinson*

Department of Psychological and Quantitative Foundations, University of Iowa, USA

(Received 16 December 2008; final version received 22 July 2009)

Over the past several decades, researchers have been trying to determine efficacious treatments for sexual dysfunctions. While sexual dysfunction is problematic for both men and women, studies have shown women consistently deal with it at higher rates than men. Proposed treatment modalities come in many forms, yet many outcome studies support the use of behavioral or cognitive-behavioral interventions when addressing female sexual dysfunction. This paper will review the prevalence of female sexual dysfunction, provide a brief history of its treatment, and outline studies that used behavioral and cognitive- behavioral treatments. Lastly, a discussion will address the need for psychologists to continue researching, improving and promoting the use of psychological interventions for women who present with concerns related to sexual functioning.

Keywords: sexual dysfunction; sexual difficulties; women; behavioral treatment; cognitive-behavioral treatment; female sexual disorders

Introduction

While classifications for female sexual dysfunction have changed over time, according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV-TR: American Psychiatric Association, 2000) the current classification stipulates six female-specific disorders within four categories. These categories include sexual desire disorders (hypoactive sexual desire disorder and sexual aversion disorder), sexual arousal disorder (female sexual arousal disorder), orgasmic disorder (female orgasmic disorder) and sexual pain disorders (dyspareunia and vaginismus). Within these disorders, subtypes are defined as lifelong versus acquired and generalized versus situational.

Although professionals have worked with female sexual dysfunction for decades, there is much to learn regarding its treatment. The first part of this review will explore the prevalence of female sexual dysfunction. Part two will describe both the treatment history of sexual dysfunction and outcome studies related to behavioral and cognitive-behavioral (B/CB) treatments proposed for female sexual disorders. Last, a discussion about the need for continued research and improvement of psychological interventions is included. Especially given recent medicalization of sexual dysfunction treatments, it is important for professionals to continue working toward psychological interventions that can be used in conjunction with, or

*Email: rebecca.d.stinson@gmail.com

Sexual and Relationship Therapy

Vol. 24, Nos. 3–4, August–November 2009, 271–285

ISSN 1468-1994 print/ISSN 1468-1749 online

� British Association for Sexual and Relationship Therapy DOI: 10.1080/14681990903199494

http://www.informaworld.com

independent from, medical interventions. Being able to provide a variety of efficacious treatments empowers clients to decide which treatment(s) they would feel comfortable with.

The current state of female sexual dysfunction

Over the past decade, studies have explored the prevalence of female sexual dysfunction worldwide (see Table 1). Despite this literature, we still do not have a full understanding of its impact on women. Determining the prevalence of sexual dysfunction is difficult for several reasons. As noted in Table 1, studies vary widely in their design, methodology, sampling and reporting (e.g., age range). Nevertheless, results highlight that sexual difficulties are common and deserve the attention of both medical and psychological communities. Low desire is most common, followed by orgasm, arousal and sexual pain difficulties. Researchers have posited that between 26 and 71% of women worldwide contend with sexual dysfunction.

In addition to variable methodology, contention exists about whether or not what is labeled ‘‘sexual dysfunction’’ is dysfunctional. According to the DSM-IV-TR (APA, 2000), distress must be present to qualify for a diagnosis, yet few studies measure distress. Some researchers find this very problematic (Hayes, Bennett, Fairley, & Dennerstein, 2006; Shifren, Monz, Russo, Segreti, & Johannes, 2008). If not perceived as distressing, it may be inappropriate to label experiences as problematic. This contention, and the inconsistent methodology listed above, restricts generalizability. Prevalence estimates may not be accurate representations of experience.

Two factors appear to play a large role in sexual difficulties for women. Mental health issues are detrimental to women’s healthy sexual functioning (Addis et al., 2006; Shifren et al., 2008). However, it is unknown whether they are the cause or the effect of sexual difficulties. Sexual functioning also decreases with age (Hayes & Dennerstein, 2005; Shifren et al., 2008), yet older women show less sexual distress (Hayes & Dennerstein, 2005; Hayes et al., 2007), which may be a result of more comfort with themselves and their sexual relationships.

If women are struggling with sexual problems at the rate research is reporting, it is important for professionals to know how many are seeking help. Studies that gather such information report alarming results. Moreira and colleagues (2005) found that of 48% of women indicating sexual problems, 78% sought no help from any sort of a health professional, 4% sought help from a psychologist, psychiatrist or marriage counselor, while 18% sought help from a medical doctor. Kadri, Alami and Tahiri (2002) found that 17% of women indicating sexual problems sought help from a medical professional. Berman and colleagues (2003a) found that 40% of women who endorsed sexual problems did not seek help from their doctor even though 54% reported wanting to.

Two explanations could rationalize low help-seeking rates: (1) women who do not find sexual difficulties distressing do not seek help and (2) many women may want to obtain help, but do not have the resources to do so or believe professional interventions will not help. This is concerning given our job is to ensure patients can obtain services and that treatment enhances their quality of life.

Results of prevalence studies show that sexual problems are a struggle for women worldwide. Male sexual dysfunction has garnered much deserved attention over the past several decades. However, studies examining efficacious and innovative treatments for female sexual dysfunctions have lagged behind (Basson et al.,

272 R.D. Stinson

T a b le

1 .

P re v a le n ce

st u d ie s in v es ti g a ti n g fe m a le

se x u a l d y sf u n ct io n .

S tu d y

L o ca ti o n

S a m p le

N (a g e)

P ro ce d u re

T im

e sp a n

D es ir e

(% )

O rg a sm

(% )

A ro u sa l

(% )

P a in

(% )

O v er a ll

(% )

A d d is et

a l.

(2 0 0 6 )

U S A

2 1 0 9 (4 0 – 6 9 )

P er so n a l

in te rv ie w ;

su rv ey s

P a st

4 w ee k s

2 2 .7

1 8 .9

1 7 .3

– 3 2 .6

L a u m a n n

et a l. (1 9 9 9 )

U S A

1 7 4 9 (1 8 – 5 9 )

P er so n a l

in te rv ie w

4 se v er a l m o n th s

in p a st

y ea r

3 0 .3

2 4 .8

– 1 4 .3

4 3

L a u m a n n

et a l. (2 0 0 5 )

G lo b a l

1 3 ,8 8 2 (4 0 – 8 0 )

V a ri o u s

4 2 m o n th s in

p a st

y ea r

2 5 .6 – 4 3 .4

1 7 .7 – 4 1 .2

1 6 .1 – 3 7 .9

9 .0 – 3 1 .6

–

K a d ri

et a l. (2 0 0 2 )

M o ro cc o

4 9 1 (2 0 – 8 0 )

P er so n a l

in te rv ie w

P a st

6 m o n th s

1 8 .3

1 2

8 .3

7 .5

2 6 .6

B a n cr o ft

et a l. (2 0 0 3 )

U S A

9 8 7 (2 0 – 6 5 )

P h o n e

in te rv ie w

P a st

4 w ee k s

7 .2

9 .3

3 1 .2

3 .3

4 5 .3

M er ce r et

a l.

(2 0 0 5 )

B ri ta in

5 5 3 0 (1 6 – 4 4 )

C o m p u te r

in te rv ie w

P er io d w it h in

p a st

y ea r

4 0 .6 /1 0 .2

(4 1 m o ./

4 6 m o s. )

1 4 .4 /3 .7

(4 1 /4

6 )

9 .2 /2 .6

(4 1 /4

6 )

1 1 .8 /3 .4

(4 1 /4

6 ) 5 3 .8 /1 5 .6

(4 1 /4

6 )

N a jm

a n

et a l. (2 0 0 3 )

A u st ra li a

9 0 8 (1 8 – 5 9 )

P h o n e

in te rv ie w

4 se v er a l m o n th s

in p a st

y ea r

3 3 .9

2 0 .5

2 1 .3

1 6 .7

6 0 .5

R ic h te rs

et a l. (2 0 0 3 )

A u st ra li a

9 1 3 4 (1 6 – 5 9 )

P h o n e

in te rv ie w

4 1 m o n th

in p a st

y ea r

5 4 .8

2 8 .6

2 3 .9

2 0 .3

7 0 .9

S h if re n

et a l. (2 0 0 8 )

U S A

3 1 ,5 8 1 (1 8 – 1 0 2 )

M a il ed

su rv ey s

N o t n o te d

3 8 .7

2 0 .5

2 6 .1

– 4 4 .2

Sexual and Relationship Therapy 273

2000). It is now time to revisit this important area and develop more efficacious treatments for all sexual difficulties that women experience.

Treatment of sexual dysfunction

The treatment of sexual dysfunction goes back many years and takes many different forms. Included here is a brief summary (see Duterte, Segraves and Althof [2007] for more thorough information).

Psychoanalysis was the treatment for many psychological problems in the earlier half of the twentieth century; sexual difficulties were no exception. It sought to treat difficulties by uncovering unconscious urges and neuroses. By the end of the 1960s, however, another option had formed – behaviorism. Behavioral approaches were modeled after the classical conditioning paradigm and viewed sexual problems as learned anxiety responses. While behavioral approaches such as systematic desensitization continue to be popular treatment approaches for sexual disorders, they ignore contextual factors impacting the patient.

For clinicians unsatisfied with ignoring relationship and environmental factors, Masters and Johnson’s (1970) groundbreaking work opened up opportunities for researchers and clinicians to blend behavioral techniques with cognitive therapy or psychodynamic approaches emphasizing interpersonal dynamics. Treatment also shifted from solely individualized work to that involving the individual, couple or group.

With the coming of medical progression, the 1980s began the psychobiological approach still emphasized today. Medical advancements have shaped treatments for sexual dysfunction and ultimately shifted care from mental health professionals to physicians. Male sexual dysfunctions have been met with great success from pharmacological agents; it is on this treatment track that female sexual problems seem to be headed as well (e.g. Berman, Berman, Toler, Gill, & Haughie, 2003b).

Behavioral and cognitive-behavioral interventions for female sexual dysfunction

A search for B/CB interventions related to female sexual disorders returns many results. Currently, some female sexual disorders appear to be more receptive to B/CB interventions than others. Female inorgasmia has garnered the most attention and success over time. This is reflected in the fact that some B/CB interventions are classified as empirically validated treatments for female orgasmic disorder (Heiman & Meston, 1997), but not desire, arousal or sexual pain disorders.

Despite evidence of efficacy, Heiman and Meston (1997) explain that evaluating the effectiveness of treatments is difficult because studies often lack sufficient research methodologies. They state that sample sizes are often too small for satisfactory statistical analysis, relatively few studies use pre- and post-measures, the problem is usually not clearly defined, outcome measures are not accompanied by their psychometric properties, the variables in question for treatment are not specified adequately and the treatment program itself is not described in sufficient detail to replicate. While these drawbacks are troublesome, outcome studies that have been published suggest there is hope in B/CB interventions.

The studies that are reviewed here (Table 2) demonstrate the potential of B/CB interventions for female sexual disorders. While some include alternate treatments as comparison groups, each investigates at least one B/CB intervention. The databases

274 R.D. Stinson

T a b le

2 .

B eh a v io ra l a n d co g n it iv e- b eh a v io ra l st u d ie s in v es ti g a ti n g fe m a le

se x u a l d is o rd er s.

S tu d y

S a m p le

T re a tm

en t

se ss io n s

F o ll o w -u p

(m o n th s)

T re a tm

en t( s)

O u tc o m e

D es ir e d is o rd er s

H u rl b er t (1 9 9 3 )

3 9

8 3 ,6

1 . C o g n it iv e- b eh a v io ra l

C o g n it iv e b eh a v io ra l w it h

d ir ec te d m a st u rb a ti o n

g re a te r se x u a l a ro u sa l,

a ss er ti v en es s, a n d

sa ti sf a ct io n ; b o th

g ro u p s

h ig h er

se x u a l d es ir e

2 . C o g n it iv e- b eh a v io ra l w it h d ir ec te d

m a st u rb a ti o n

M cC

a b e (2 0 0 1 )

4 3

1 0

– C o g n it iv e- b eh a v io ra l (i n cr ea se

co m m u n ic a ti o n , se x u a l sk il ls ; d ec re a se

p er fo rm

a n ce

a n x ie ty )

6 7 %

st il l re p o rt ed

sy m p to m o lo g y p o st -

tr ea tm

en t

T ru d el

et a l. (2 0 0 1 )

7 4

1 2

3 ,1 2

1 . C o g n it iv e- b eh a v io ra l g ro u p

6 4 %

tr ea tm

en t g ro u p

co n si d er ed

im p ro v ed

o r

cu re d th ro u g h 1 y ea r fo ll o w -

u p ; tr ea tm

en t m o re

eff ec ti v e

th a n n o tr ea tm

en t

2 . W a it -l is t co n tr o l

A ro u sa l d is o rd er

M cC

a b e (2 0 0 1 )

1 8

1 0

– C o g n it iv e- b eh a v io ra l (i n cr ea se

co m m u n ic a ti o n , se x u a l sk il ls ; d ec re a se

p er fo rm

a n ce

a n x ie ty )

4 4 %

st il l re p o rt ed

sy m p to m o lo g y p o st -

tr ea tm

en t

M o ro k o ff &

H ei m a n (1 9 8 0 )

2 2

1 5

– 1 . C o g n it iv e- b eh a v io ra l fo r cl in ic a l

P o st -t re a tm

en t: cl in ic a l a n d

n o n -c li n ic a l g ro u p s h a d sa m e

p h y si o lo g ic a l a n d su b je ct iv e

a ro u sa l re sp o n se s

2 . N o n e fo r n o n -c li n ic a l

O rg a sm

ic d is o rd er s

L o b it z a n d

L o P ic co lo

(1 9 7 7 )

2 2

1 5

6 C o u p le s sy st em

a ti c d es en si ti za ti o n w it h

m a st u rb a to ry

tr a in in g

1 3 o f 1 3 p ri m a ry

in o rg a sm

ic w o m en

1 0 0 %

su cc es sf u l

th ro u g h fo ll o w -u p ; 3 o f 9

se co n d a ry

in o rg a sm

ic 1 0 0 %

su cc es sf u l

(c o n ti n u ed )

Sexual and Relationship Therapy 275

T a b le

2 .

(C o n ti n u ed ).

S tu d y

S a m p le

T re a tm

en t

se ss io n s

F o ll o w -u p

(m o n th s)

T re a tm

en t( s)

O u tc o m e

M cC

a b e (2 0 0 1 )

3 6

1 0

– C o g n it iv e- b eh a v io ra l (d ec re a se

a n x ie ty

b y a d d re ss in g in h ib it iv e co g n it io n s

a n d b eh a v io rs )

1 6 %

st il l re p o rt ed

sy m p to m o lo g y p o st -

tr ea tm

en t

R il ey

& R il ey

(1 9 7 8 )

3 5

1 2

1 2

1 . C o n v en ti o n a l: se n sa te

fo cu s,

su p p o rt iv e p sy ch o th er a p y

5 3 %

su cc es s fo r co n v en ti o n a l

g ro u p th ro u g h fo ll o w -u p ;

9 0 %

su cc es s fo r

m a st u rb a to ry

tr a in in g

th ro u g h fo ll o w -u p

2 . C o n v en ti o n a l p lu s m a st u rb a to ry

tr a in in g

S ex u a l p a in

d is o rd er s – v a g in is m u s

S ch n y d er

et a l. (1 9 9 8 )

4 4

6 (a v er a g e)

6 – 2 2

1 . In

v iv o d es en si ti za ti o n

9 8 %

su cc es s fo r tr ea tm

en ts ;

5 0 %

st il l so m e p a in ; n o

d iff er en ce

b et w ee n th er a p ie s;

fo ll o w -u p : 5 0 %

n o

v a g in is m u s, 4 8 %

im p ro v ed

2 . In

v it ro

d es en si ti za ti o n

te r K u il e et

a l. (2 0 0 9 )

1 0

3 1 ,1 2

S el f- co n tr o ll ed

ex p o su re

9 0 %

su cc es s fo r in te rc o u rs e

p o st -t re a tm

en t th ro u g h

fo ll o w -u p

te r K u il e et

a l. (2 0 0 7 )

1 1 7

1 – 1 0 (g ro u p

C B T

2 .6

(b ib li o )

3 ,1 2

1 . C B T

T h o se

w h o a ch ie v ed

in te rc o u rs e,

si g n ifi ca n tl y le ss

fe a r o f co it u s a n d m o re

n o n -

co it a l p en et ra ti o n

2 . B ib li o th er a p y

3 . W a it -l is t co n tr o l

v a n L a n k v el d

et a l. (2 0 0 6 )

S ee

te r K u il e &

W ei je n b o rg

(2 0 0 6 ) fo r re se a rc h d es ig n

1 4 %

su cc es s fo r tr ea tm

en t

g ro u p s v er su s 0 %

su cc es s fo r

w a it -l is t co n tr o ls p o st -

tr ea tm

en t; 3 m o . ¼

1 7 % (g )/

1 4 % (b ); 1 2 m o . ¼

2 1 % (g )/

1 5 % (b ); tr ea tm

en ts

d o n o t

d iff er

(c o n ti n u ed )

276 R.D. Stinson

T a b le

2 .

(C o n ti n u ed ).

S tu d y

S a m p le

T re a tm

en t

se ss io n s

F o ll o w -u p

(m o n th s)

T re a tm

en t( s)

O u tc o m e

D y sp a re u n ia

(f ro m

v u lv a r v es ti b u li ti s)

B er g er o n et

a l. (2 0 0 1 )

7 8

1 .8

(C B T ) 2 .3

m o (b f)

6 1 . G ro u p C B T

C o m p le te

re li ef

o r

im p ro v em

en t: 3 9 %

G C B T ,

3 6 %

b io fe ed b a ck , 6 8 %

su rg er y

2 . E M G

b io fe ed b a ck

3 . su rg er y (v es ti b u le ct o m y )

D a n ie ls so n et

a l. (2 0 0 6 )

3 7

1 .4

m o (b f) 2 .4

m o (c re a m )

6 ,1 2

1 . E M G

b io fe ed b a ck

B o th

si g n ifi ca n tl y im

p ro v ed

p a in

th re sh o ld

q u a li ty

o f li fe ,

a n d p sy ch o se x u a l

fu n ct io n in g , n o d iff er en ce

b et w ee n tr ea tm

en ts

2 . to p ic a l li d o ca in e

M cK

a y et

a l. (2 0 0 1 )

2 9

M o n th ly

ev a lu a ti o n s

4 – 6

E M G

b io fe ed b a ck

6 9 %

b ec a m e se x u a ll y a ct iv e;

8 9 %

n eg li g ib le

o r m il d p a in

te r K u il e a n d

W ei je n b o rg

(2 0 0 6 )

6 7

1 2

1 – 3 w ee k s

G ro u p C B T

S ig n ifi ca n tl y le ss

co it a l p a in

a n d v a g in a l te n si o n

Sexual and Relationship Therapy 277

of PsycINFO and EBSCOhost were searched using the terms ‘‘hypoactive sexual desire’’, ‘‘sexual arousal disorder’’, ‘‘female orgasmic disorder’’, ‘‘inorgasmia’’, ‘‘vaginismus’’, ‘‘dyspareunia’’, ‘‘female sexual dysfunction’’, female sexual disorder’’, ‘‘treatment’’ and ‘‘intervention’’. Case studies were excluded, as were those that did not describe the treatment in enough detail to warrant inclusion.