List the 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.

Sexual desire disorders

Hypoactive sexual desire disorder (HSDD) is considered one of the most difficult sexual disorders to treat psychologically given its complexity and relatively poor prognosis (Kaplan, 1979). According to the DSM-IV-TR (APA, 2000), HSDD is defined as a persistent deficiency or absence of sexual fantasies and desire for sexual activity causing marked distress. Although psychological processes have long been assumed to be the core of HSDD, within the past decade medical interventions such as testosterone therapy have gained momentum (e.g. Davis et al., 2008). Despite promising medical interventions, B/CB treatments are employed to help women regain a sense of sexual desire given motivational and emotional factors contribute to HSDD.

Traditionally, a lack of desire is seen as avoidance related to anxiety toward sexual intimacy (Kaplan, 1979) or a result of relationship problems (Verhulst & Heiman, 1988). The goal of B/CB treatments is to alter the way women feel, think and approach sex by addressing anxiety and negative cognitions/attitudes. While outcome research is limited, the few studies that have demonstrated positive outcomes consist of treatment modalities using systematic desensitization (including sensate focus exercises) and cognitive-behavioral therapy (CBT) (see Table 2).

Sensate focus, much like other forms of systematic desensitization, is a set of exercises aimed at gradually introducing sexual touching and stimulation into a relationship over the course treatment. Proceeding through graded exposure steps that move from non-sexual to sexual allows women to acquaint themselves with sexual pleasure within the confines of a safe environment and open communication.

Hurlbert (1993) sought to determine whether orgasm consistency training in addition to a standard CB program was more effective than the CB intervention alone. Included were 39 women who completed either the standard CB or multimodal treatment. At the three-month follow-up, women who received the combined treatment reported greater sexual desire, arousal and sexual assertiveness than women in the standard group. These gains were maintained at the six-month follow-up with the addition of greater sexual satisfaction. Overall, both groups of women had positive increases in their sexual desire, yet there were added benefits for women in the combined treatment.

Another study conducted by McCabe (2001) focused on a CB treatment addressing inhibitive cognitions and behaviors as well as partner communication and sexual skills to decrease anxiety related to sexual performance. Forty-three women reported low sexual desire pre-treatment. Post-treatment, the number of women reporting low desire decreased to 29. While not exceptional, results suggest that CB interventions may be helpful for increasing sexual desire.

The most well-controlled study thus far of HSDD employed a short-term, CB group format with both a treatment and wait-list control group (Trudel et al., 2001). Seventy-four couples were randomly assigned and evaluated at pre-treatment,

278 R.D. Stinson

post-treatment and two follow-ups. Couples assigned to the treatment condition engaged in weekly group sex therapy sessions focused on examining the dysfunctional cognitions related to hypoactive sexual desire. Results showed a decrease in symptomology and increases in overall cognitive, behavioral and marital functioning. Seventy-four percent were considered improved at post-treatment and held steady at 64% three-months and one year later. At post-treatment, 28% judged they were completely symptom-free; this rose to 31% at three-month follow-up and ended at 38% at the one-year follow-up. Based on these results, CB approaches should be considered treatment options for women with HSDD.

Sexual arousal disorders

Sexual arousal disorder is difficult to study given that it often does not occur independent of other sexual dysfunctions (Segraves & Segraves, 1991). According to the DSM-IV-TR (APA, 2000), female sexual arousal disorder is defined as the persistent or recurrent inability to attain, or maintain until the completion of sexual activity, an adequate lubrication-swelling response of sexual excitement, which causes marked distress. Much like desire disorders, B/CB interventions have been considered helpful for treatment (see Table 2).

The McCabe (2001) study discussed previously also included women with sexual arousal problems. Pre-treatment, 18 women reported sexual arousal difficulties. After the ten-week CB intervention, eight women continued to report difficulties. With more than half of the women reporting treatment gains, this suggests that CB interventions are even better suited to arousal problems than HSDD. However, note that many women have multiple sexual dysfunctions. Thus, the results cannot be interpreted as independent from one another.

Another study targeted at overcoming arousal problems was conducted by Morokoff and Heiman (1980). They used both a clinical and non-clinical sample comprised of 11 women each. Both groups engaged in five erotic stimulus conditions pre- and post-treatment. The clinical sample, however, engaged in 15 sessions of CB intervention between pre- and post-treatment, while the non-clinical sample did not. At pre-treatment, both groups had similar physiological responses to erotic stimuli, but subjective reports of sexual arousal were higher in the non-clinical group. After the clinical sample received therapy, both groups had similar genital responses and reports of subjective arousal. The authors concluded that treatment for inhibited arousal should target cognitive and emotional experiences instead of only the physiological responses of the body.

Orgasmic disorders

Female orgasmic disorder (or inorgasmia) is the most studied of all female sexual dysfunctions; outcome research dates back decades. Thus, we are aware of more efficacious treatments for this sexual disorder than any other. Behavioral and cognitive-behavioral treatments for lifelong (or primary) inorgasmia are considered ‘‘well-established’’ and efficacious and treatments for acquired (or secondary) inorgasmia ‘‘probably efficacious’’ (Heiman, 2002; Heiman & Meston, 1997). According to the DSM-IV-TR (APA, 2000), female orgasmic disorder is the persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase, causing marked distress.

Sexual and Relationship Therapy 279

Behavioral and cognitive-behavioral treatments have been the methods of choice for treating female inorgasmia and include directed masturbation, sensate focus, systematic desensitization and CB therapy in multimodal treatment combinations (see Table 2). Generally, the ability to orgasm is drastically improved with B/CB treatment.

Lobitz and LoPiccolo (1977) employed a behavioral approach to increase orgasm. A masturbatory program was used in conjunction with a time-limited behavioral program involving both partners. Based on classical conditioning, in vivo graded exposure (systematic desensitization) was used to decrease performance anxiety and introduce orgasm to participants. Clients were instructed to focus on erotic stimuli they found arousing during intimate activity with their partner and, once aroused, masturbate to orgasm. Thus, sexual arousal and orgasm became paired with sexual activity with their partner. Treatment gains were maintained after six-months. All primary inorgasmic women remained orgasmic while three out of nine secondary inorgasmic women maintained orgasmic functioning.

Riley and Riley (1978) also employed directed masturbation. Fifteen patients underwent a conventional approach (sensate focus and supportive psychotherapy), while twenty experienced masturbatory training in addition to the conventional approach. Post-treatment, 90% of women in the directed masturbation group had attained the ability to orgasm by any means, while 53% in the conventional approach had attained the same ability. Also, 85% in the combined approach were able to orgasm during intercourse by any means while 47% in the conventional approach had attained the same ability. At a 12-month follow-up, all women had maintained the ability to orgasm.

In her study of CB interventions for sexual dysfunctions, McCabe (2001) included women with inorgasmia. Pre-treatment, 36 women were inorgasmic. After the program aimed at decreasing anxiety through addressing inhibitive cognitions and behaviors, six women continued to report the inability to orgasm. This level of improvement was the best across all sexual difficulties suggesting orgasmic difficulties are responsive to CB interventions.

In general, outcome research for B/CB treatments of female orgasmic disorder show that women can learn to shift self-induced orgasm to sexual situations involving an intimate partner.

Sexual pain disorders

Sexual pain disorder treatments are frustrating given the physiological and psychological mechanisms responsible are not yet fully understood. However, it is believed that both physical and psychological components are involved and should be part of a multidimensional treatment (Basson et al., 2004). What makes diagnosis and treatment more complicated is the fact that dyspareunia and vaginismus overlap (de Kruiff, ter Kuile, Weijenborg, & van Lankveld, 2000). Some researchers even question them as sexual dysfunctions (Binik, Bergeron, & Khalife, 2007).

Despite our limited understanding of vaginismus and dyspareunia, B/CB treatments have been studied (see Table 2). Perhaps complicating things further is contention over what should be considered the goal of treatment. Most researchers use vaginal penetration as evidence of treatment success (e.g. McKay et al., 2001; van Lankveld et al., 2006), while others posit treatment success should encompass other forms of sexual pleasure (Basson et al., 2004).

280 R.D. Stinson

Vaginismus

According to the DSM-IV-TR (APA, 2000), vaginismus consists of a recurrent involuntary spasm of the outer third of the vaginal musculature that interferes with intercourse causing distress or interpersonal difficulty. An international committee (Basson et al., 2004) recommends a more comprehensive definition including ‘‘phobic avoidance, involuntary pelvic muscle contraction and anticipation/fear/ experience of pain’’ (p. 30) be used.

Treatment is generally systematic desensitization with graded dilators, sex therapy, cognitive restructuring, education and relaxation training despite limited controlled research. Outcome studies that include B/CB treatments for vaginismus show promising results (see Table 2).

Schnyder, Schnyder-Luthi, Ballinari and Blaser (1998) compared in vivo versus in vitro desensitization with vaginal dilators. Treatment sessions were continued until symptoms abated. After an average of six sessions, 98% were able to engage in intercourse. Although 50% still experienced some pain, they reported satisfying sexual experiences. At follow-up, 50% reported their vaginismus had disappeared while 47% said symptoms had greatly improved.

Another research group (ter Kuile et al., 2009) treated 10 women with exposure therapy. At post-treatment and one- and twelve-month follow-up, 90% were able to successfully engage in intercourse. While a small sample size, the success rate from only three therapy sessions demonstrates impressive gains.

A large controlled study conducted by ter Kuile and colleagues (ter Kuile et al., 2007; van Lankveld et al., 2006) compared group cognitive-behavioral therapy (GCBT) with bibliotherapy and wait-list controls. Treatments consisted of psycho- education, behavioral exercises and cognitive restructuring among others. At post- treatment, results indicated that the two treatments showed superiority over wait-list controls (14% success versus 0%; van Lankveld et al., 2006). At each follow-up the percentage of success continued to increase, suggesting treatment gains were ongoing. Those who were successful at achieving intercourse showed significantly less fear of sex and were more able to accept non-penile penetration (ter Kuile et al., 2007).

Dyspareunia

Dyspareunia is defined as recurrent or consistent pain associated with sexual intercourse causing distress or interpersonal difficulty. Treatments include biofeed- back, medications, CB therapy and surgery among others. The etiology appears to be both psychological and physiological, yet recent studies have focused on vulvar vestibulitis (provoked vulvar pain) as its cause.

Investigations by ter Kuile and Weijenborg (2006) and McKay and colleagues (2001) show promising results for B/CB treatments. Electromyographic (EMG) biofeedback was taught to 29 women. After four to six months of use, over two- thirds reported increased sexual activity and 89% reported greatly reduced pain (McKay et al., 2001). Alternately, GCBT was used with 67 women and after 12 sessions participants reported significantly less vaginal pain and tension (ter Kuile & Weijenborg, 2006).

Danielsson, Torstensson, Brodda-Jansen and Bohm-Starke (2006) compared a topical cream with EMG biofeedback. After treatment completion and at

Sexual and Relationship Therapy 281

two follow-ups, women reported significantly improved pain thresholds and psychosexual functioning. They found no significant difference between the two treatment regimens.

In the most well-controlled study, Bergeron and colleagues (2001) compared GCBT, EMG biofeedback and surgery. All participants reported decreased pain. Complete relief and improvement was experienced by about one-third of the GCBT and EMG biofeedback groups versus two-thirds of those obtaining surgery. However, it should be noted that the surgery group did not include those who had been assigned, but dropped out not wanting surgery.

When addressing sexual pain, it is important to remember that these disorders are multi-dimensional and influenced by a multitude of factors including behavior, affect, cognition, relationship dynamics and medical status (Binik, Bergeron, & Khalife, 2007). Assessment must explore each of these areas and treatment must address each component contributing to women’s sexual pain.