HSX5555 - SECTION 9: CLINICAL CASES AND THERAPISTS' RESPONSES
Section 9: Clinical Cases and Therapists’ Responses
In order to bring the information from this training closer to the experience of a mental health clinician, it may be helpful to see a number of different scenarios in which sexual problems were identified. These cases will help to illustrate the importance of conducting an assessment that addresses all aspects of the client’s sexual life: medical and physical, cultural, intrapsychic, and relational.
For the first case, we will demonstrate the use of the PLISSIT Model to establish an overview of the treatment approach. This will help clarify how best to use this model in actual clinical situations.
For some of these cases, there will also be information concerning different viewpoints taken by a group of sex therapists. This will help to demonstrate how different points of view can help to maintain flexible thinking on complex problems.
Case Concerning Delayed Orgasm
A 37 year-old woman in a lesbian marriage relationship came to a therapist telling of a lifelong history of difficulty with orgasm. She had her first orgasm at age 22 with oral sex, and she is able to orgasm now with a vibrator and with oral sex, but not with manual stimulation. Her concern is that orgasm is taking 30 minutes, she believes this is too long, and she gets concerned that her spouse (a woman she married in Canada last year) is getting tired.
The spouse states that she is not getting tired and her major concern is that her partner (the client) is upset about it. Recently the client saw a television program on Lifetime, Secrets of the Sexually Satisfied Woman (Berman & Berman) that showed a test to determine the sensitivity of the clitoris. Because the test indicated the woman on the program was not suffering from lack of sensitivity, the show did not focus on the potential treatment for lack of sensitivity.
The client would like to know what treatments are available if sensitivity in the clitoris is the problem. The client was on tricyclic antidepressants beginning at age 17, and for the past 5 years has been taking Zoloft. She realizes the Zoloft could be playing a role in lengthening the time to orgasm, but she states that she has always had the problem. Also, the Zoloft has had no impact on her sexual desire - she continues to have much desire and would like to be sexual with her spouse 2-3 times a week.
USING THE PLISSIT MODEL OF COUNSELING
P = PERMISSION
1. Bring up the topic of sex.
“How has___________ affected your sexuality?”
“Many people who come to the clinic have concerns about sexuality. What concerns do you have?”
2. Use words the patient understands.
3. Determine if the problems with reaching orgasm are primary, secondary, or situational.
4. Ask for a word picture of her experience--”Tell me what happens when _______”
5. Validate with the patient your understanding of what she is telling you
6. Explore self-concept, body image, values, knowledge, beliefs, cultural influences, family messages, current practices, feelings about touching body, past experiences, expectations of what is supposed to happen, fears involved, reactions of and to partner, nature of the relationship, fantasies, religious background.
7. Ask questions in a way that normalizes the experience.
8. Ascertain the meaning of her experience to her, to her partner.
9. Determine her expectations of treatment and the impact she believes the anticipated outcome will have in her life.
LI = LIMITED INFORMATION
1. Give general information related to orgasmic experiences – normative information of and beliefs about orgasms, societal and cultural influences on women’s sexuality, the effects of thinking vs. feeling during a sexual experience, common medication side effects
2. Address myths, misconceptions, and fears
3. Discuss anatomy and physiology
4. Give information about medical considerations that may affect orgasmic delay
SS = SPECIFIC SUGGESTIONS
1. Complete the Sexual Problem History
a. Description of current problem
b. Onset and course
c. Patient’s concept of cause and maintenance of problem
d. Past treatments and outcome
e. Medications, medical conditions, surgeries
f. Current expectations and goals of treatment
2. Recommend books and videotapes
3. Teach about the pubococcygeus muscle and Kegel exercises
4. Discuss client’s use of a vibrator - advantages and possible drawbacks
5. Suggest increasing awareness of turn-ons and time for self-exploration
IT = INTENSIVE THERAPY
Intensive therapy involves referral to a therapist who deals with sexual and other relationship issues. If this person is you, you will deal with the more chronic deep-seated personal and relational concerns such as past traumatic experiences; fears of loss of control and/or abandonment; unresolved anger; lack of communication skills; the relationship of sexuality and intimacy; the effects of medications and medical, surgical, & disabling conditions; cultural issues; and the meaning and value the symptom may hold for the patient.
Therapists’ Discussion of Case
a) When I heard the description of the client's situation, my first response was, "What's the problem? She's totally normal!" My understanding is that it takes the average woman 20 minutes of stimulation to reach orgasm -- but that's an average, so it means that it takes half of women MORE than 20 minutes. So she's on the slightly longer than average side, but given the huge continuum of normal human sexual diversity, 30 minutes seems not uncommon.
b) She's worried her spouse is getting tired, but the spouse says she is not getting tired--so no problem there.
c) The main reason they came is to find out if there is indeed some type of pill or device that will facilitate orgasm. There is a device -- it's called a vibrator, and it works for her!
d) She can orgasm now with a vibrator and with oral sex, but not with manual stimulation. Isn't that also incredibly common? When I hear women talk about their orgasms, many say, "I can come from oral sex but not intercourse," or "with my vibrator but not with my hand," or "from intercourse but not oral sex," etc. Again, it seems to be to be very much in the normal range of the continuum of human sexual diversity. If anything, she can be celebrating that she has two different "methods" that work for her to be able to have an orgasm. Some women would be jealous!
e) From my perspective the problem may not be with the woman's body, but with a culture that is constantly sending women the message that their bodies may be defective. The client could seek out all kinds of tests and devices and pills. But I wonder if what she needs more is just loads of reassurance from the therapist, whom she has sought out as an expert, that her body is normal and that LOTS of women have very similar experiences related to orgasm. I guess this is basically one more message in agreement with those who have said that she seems to have very high standards for herself.
Has the patient had her estradiol and free testosterone levels measured?
My first thought certainly would be to de-emphasize the method of orgasm....make sex less 'goal-oriented'....I’d wonder about the variety of sexual technique in this couple...... wonder how arousing sex ever is, really, or if she/they are just doing it to 'get to the orgasm.' Second....I wouldn't rule out the role of the antidepressants, but....if she needs SSRI's, she might not do much differently than she's doing now with Zoloft, no matter what she tries (my psychiatrist friend tells me that although Lexapro has fewer sexual side effects than other SSRI's, the difference is like 30-50% instead of 50-70%. Third, oral sex and vibrator...not bad....her standards surely sound high.
Bupropion (Wellbutrin) could be introduced with gradual weaning of the SSRI. Also consider a trial of decreased use of the vibrator; many women develop clitoral desensitization from chronic vibrator usage.
You could suggest the Eros:
You need a prescription to get it. It's a medical device - though I am told there is a similar device over the counter (OTC) for $50! However, one needs to rule out circulatory problems first, so suggest the OTC model with caution. What it does is give suction to the clitoris & surrounding tissues & so there is greater blood flow - it’s like a little vacuum for the clitoris. I just read an article that women who received radiation treatment used it with great success, and I saw an article saying it MIGHT be helpful for women who take SSRI's. However, I've got to tell you that it is such a weird little device that I've had virtually no takers.
Regarding the Eros: It’s the cost (around $395) and the embarrassment of having to ask insurance about it. And frankly, some women just accept that for them, being on psychotropic medication is more important than an orgasm. If you have postpartum depression managed by meds, an orgasm is often at the bottom of the list of things to do.
Regarding the Eros: We have heard from women who have had success with the Eros; in particular those who have had nerve damage or those who have received radiation treatment in the pelvic area. It is worth considering for the right population of women. Also, for those who seem squeamish about using a device, education is key.
Three Clinical Cases for Vaginismus
A young woman aged 20 and her 22 year old husband presented for therapy for vaginismus. The couple had been married for two years and had not been able to have intercourse. History revealed that the couple had been together as a couple since junior high school and had made a decision to wait until marriage to have intercourse.
After marriage, they were unable to have intercourse due to the wife’s vaginismus. Therapy lapsed for a time, and several months later the wife returned alone and admitted that she had become involved in an ongoing extramarital affair. She also admitted that she no longer had vaginismus—her first experience of intercourse had occurred in the affair and happened on her 21st birthday.
At the time of her return to therapy, she was considering leaving her husband and marrying the other man. Once again, the client dropped from therapy, and several months later she returned, saying that she had stopped the affair, she and her husband were back together and doing well, and they were considering having a baby. When the therapist asked her what had happened, her response was, “I grew up.” Interestingly, the husband credited the therapist with the successful treatment of the vaginismus.
Cultural influences can also play a role in vaginismus. An Indian couple presented complaining of inability to consummate their marriage of two years. Their primary objective for attempting to resolve the problem at the time they came for therapy was their desire to become pregnant.
The couple was in an arranged marriage, and had had very little contact with one another prior to marriage. When the therapist asked if difficulty with intercourse was a common problem in these types of Indian marriages, the husband responded, “Yes, but it usually gets better in six months. And you can tell from all the little Indian children running around that the problem does go away.”
In terms of solutions the couple had thought of prior to coming to therapy, the husband had considered possibilities such as getting his wife drunk and then attempting intercourse when she had passed out. The wife was not enamored with this idea. This case resolved quickly with education and exploration of concerns and some sex therapy exercises, and the couple was successful in having intercourse. Interestingly their first or second intercourse experience resulted in a pregnancy.
Not all cases of vaginismus resolve as quickly. One young woman, age 31, has been coming to therapy every two-four weeks for a period of four years. Her presenting complaint was vaginismus, and she was referred by a nurse practitioner who was unable to perform a routine pelvic exam on the woman. This young woman had formerly been engaged, for a two year period, to be married, and was unaware she had vaginismus until her pelvic exam.
Earlier attempts in her life to use tampons had been unsuccessful, so she had stopped trying. History and ensuing sessions uncovered no history of trauma, but revealed a woman acutely fearful of any invasive procedures done to her body. In the past she had fainted when she took her cat to the veterinarian and when she herself received injections. Attempts to draw blood resulted in severe anxiety and the necessity of her having to lie down on a table.
The young woman, then age 26, was still living at home with her parents, and although she was a college graduate, she had been working for five years at a job requiring much commitment and responsibility that paid her $21,000 a year and gave her a one week vacation annually. She rarely took sick leave and was largely content, because she “really likes the job.” In the past four years she has asked for a raise (she’s now up to $26,000) and another week’s vacation (she now has two weeks per year), and she has moved out of her parents’ home and into her own apartment. She can receive injections and give blood samples while sitting in a chair.
Her vaginismus continues to be unresolved, and there seems to be no sense of urgency on her part to address the issue directly. She avoids pelvic exams, and a recent highly-valued romantic relationship ended with the boyfriend’s statement that he isn’t ready for a committed relationship. It is unclear how much of a role the vaginismus played in the breakup; earlier he told her that it wasn’t so important and that he would work with her on resolving it. No actual attempts at any type of insertive activities were made by the couple.
Clinical Cases for Addressing Dyspareunia
A young nursing student, originally from Iran, reported that she and her husband of two years had not been able to have intercourse because each attempt led to severe pain for her. History revealed that prior to her marriage she had been to a female physician for a premarital exam, thinking a woman physician would be more gentle and empathetic. She said the exam was very painful, but the physician made no comment.
The couple married and for the next two years was unable to have intercourse. Both were in school, so the sexual problem was “put on the back burner” for the time being. Finally the young woman went to a young male physician who examined her and remarked, “I’ve never seen anything like this before,” and called in his older male colleague to examine her. The older physician said to the young woman, “Oh, yes, I’ve seen this before. You need surgery.”
No one gave her any information about what the problem was, and she was too shy to ask. She left the office that day wondering how big her problem was and even if she might have a life threatening condition. She said, “How do I know that surgery won’t make it worse—I don’t even know what’s wrong.” She called a nursing faculty member who heard the history and sent her to be examined concurrently by a nurse practitioner/midwife and OB/GYN female physician.
The exam revealed that the young woman had hymenal strands that pulled across the opening of the vagina when she and her husband attempted penetration. A simple office surgical procedure of snipping the strands resolved the problem. This story illustrates vividly the importance of giving patients information about their health conditions. This young woman and her husband had suffered needlessly for over two years due to lack of information from health care providers.
Case Two and Therapists’ Responses
A 38 year-old woman presented with painful intercourse. She described the pain as feeling that her perineum was going to tear upon penetration. The symptoms only occurred when sexual frequency was up, i.e., she experienced no pain if she waited three to five days between intercourse experiences. She first began to experience the problem after she gave birth to her first of two children eight years ago. Her most recent child was born five years ago and she reported that internal and external stitching was required to repair the perineum. Her gynecologist said there was nothing physically wrong and suggested that he could perform another episiotomy and see if it healed differently, but there were no guarantees.
A discussion among therapists about this case yielded the following:
“The Pelvic and Sexual Health Institute in Philadelphia is a very good resource for information about painful intercourse. They do a great assessment. Susan Kellogg-Spadt, PhD, CRNP references some work underway in which a gene has been discovered in some people such that when the rubbing of intercourse occurs or when some nerve damage happens, more rubbing calls forth an inflammatory response, which causes the pain. In this client's case this may account for the 3 to 5 day vacation from intercourse helping the situation. Maybe the inflammatory response dies down by then. Possibly the ‘trauma’ of childbirth started this cascade. Perhaps meds for neuropathy may help. Another talk I heard by Christopher Jayne, MD suggests that Interstitial cystitis is an overlooked cause of painful intercourse.”
“I am a women's health nurse practitioner and I see many women with the scenario that is described. In my opinion what she needs is a pelvic floor evaluation from a physical therapist that specializes in pelvic floor rehabilitation. Often what happens after pregnancy and delivery is the pelvic floor muscles as well as the vulvar and vaginal tissues get "shortened" and need a type of stretching (vulva/vaginal yoga!). I have fantastic results from my local physical therapy women's specialist. It's usually only a few visits where an evaluation is done and subsequent exercises are taught for home use.”
“Often when doctors say nothing is physically wrong, they of course are referring to the absence of infection or disease. As we know, however, there are many causes of painful intercourse, some that are musculoskeletal, neurological, some having to do with increased pain perception...or a combination. What is unfortunate is that many in the medical community are still unaware of the role that physical therapy has in treating intercourse related pain. Particularly if the pain is in the perineum and directly related to the episiotomy (which is only an assumption, after all the pain was present after the first birth) then certainly manual therapy as well as oils, massage , stretching, possibly dilators and pelvic floor biofeedback are all possible options.
If you are interested, I have published several articles on the subject. Here are links to a couple of them:
Rosenbaum, T. (2005). Physiotherapy treatment of sexual pain disorders. Journal of Sex & Marital Therapy, 31, 329-340.
This completes the course on sexuality assessment and intervention. Following presentation of references, you may continue to the test section.