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HSX8595 - SECTION 9: SPECIAL ISSUES IN FEMALE SEXUALITY

 

THE CLITORIS

There is continuing new information about the clitoris, long thought to be a small pea-sized organ similar in structure to the male penis and the sole source of female orgasm. Researchers have found that the clitoris is much larger than formerly believed and that it is a complex mass of erectile tissue with “legs” that wrap around the vagina and urethra. Beyond its significance during intercourse, one of the important implications of this new anatomical understanding of the clitoris is that it could help surgeons avoid cutting through clitoral tissue during genital surgeries. (Chalker, 2002).

Sexuality Factoid

The tip of a women's clitoris has more than 8000 sensory nerve endings, more than any other human body part.

Source: Chalker, Rebecca (2002). The Clitoral Truth, NY: Seven Stories Press

VIBRATORS

For women who have never experienced an orgasm, a vibrator may provide the necessary stimulation for an orgasm to occur. A vibrator provides what is typically the most intense form of stimulation, and the time to reach orgasm may be decreased with vibrator use. One of the downsides of vibrator use is that this may become the only way a woman is able to achieve an orgasm.

If this is the case, a woman who wants to shift to other methods of stimulation may need to “wean” herself from the vibrator. This can be done by gradually decreasing the vibrator stimulation (e.g. by placing clothing or other item between the body and the vibrator) and bringing in other forms of stimulation (e.g. hand or partner hand) along with the vibrator and then shifting to the other form of stimulation.

Another concern voiced by some clinicians is that long-term, frequent vibrator use may decrease the sensitivity of the clitoris. (David, et al., 1996; Heiman et al., 1993; Semans, 2004).

BODY IMAGE

Women in this culture frequently get the message that their bodies may be defective in any number of ways. As a result, there seems to be a plethora of eating disorders and all manner of plastic surgeries happening today. Seeing their bodies as defective includes concerns related to breasts and genitalia.

A young woman came to see a therapist complaining that her inner labial lips were too large. She had been sent by a psychiatrist who said to the therapist, “Please see if you can help with this—she’s almost delusional about it.”

History revealed that when the woman was 5 years old, her mother had said to her one day while giving her a bath, “Oh, my god, you’re deformed,” and rushed her to the family physician. The woman remembered the doctor examining her, but she didn’t remember anything else. From that point she grew up believing that she was physically deformed in some way. She married, had children, and over time became increasingly more troubled about this.

Another young woman with an identical complaint went to a plastic surgeon and actually had the size of her labial lips surgically reduced. She had become concerned about her labia because someone she was dating told her they were too large. Now she was sitting in a therapist’s office complaining that they were too small. An accurate assessment of this young woman would have revealed a long history of depression and dissatisfaction with her body.

PREGNANCY, POSTPARTUM SEXUALITY, AND ORAL CONTRACEPTIVES

General Information on Sexuality and Pregnancy

Although the vast majority of pregnancies came about as a result of a sex act, sexuality and sexual expression during pregnancy have frequently been a difficult-to-discuss topic - even for those in the OB/GYN profession.

Generally the rule of thumb has been that, during pregnancy, it is safe to continue any sexual practice that one participated in prior to pregnancy - with a few exceptions. As the uterus grows, the mother should avoid lying on her back. This may necessitate position changes (which provide opportunities to be creative). Women with high risk pregnancies may be advised to limit intercourse or orgasm (additional opportunities for creativity).

It is best to consult a trusted healthcare practitioner, listen to one’s own body, and use good judgment about types of sexual practices during pregnancy. One thing that should never be done is to blow air into the vagina, as this may cause a fatal air embolism. (Weiss, 2006).

Sexuality Factoid

Almost 1 million teenage women, 10% of all women aged 15-19 and 19% of those who have had intercourse, become pregnant each year

Source: www.plannedparenthood.org/library/sexuality/AdolescSexual.html
Teenage pregnancy: overall trends and state-by-state information. 1999. Alan Guttmacher Institute. New York: AGI

Postpartum Sexuality and Breastfeeding

Sexual desire can be decreased after childbirth for up to a year and perhaps longer, probably due to a host of factors, including hormone changes, lifestyle alterations, changes in body image, and lack of sleep. Sexuality expert Laura Berman of the Berman Institute sees a number of women who complain of an ongoing lack of desire following childbirth. She wonders if there are hormonal shifts during pregnancy and some women’s bodies do not seem to re-equilibrate afterward, even years later--particularly after the second child (Berman & Berman, 2001).

“At this point we don't know for sure because we don't have their pre-pregnancy hormonal levels, but when we test them post-pregnancy when they are symptomatic, we often find their testosterone levels are low. Obviously there are numerous psychosocial factors, including the stress the children place on the relationship and the loss of spontaneity.” (Berman, personal communication, AASECT listserve, 2006).

Women who are breastfeeding have increased prolactin and consequently may have diminished sexual desire and also decreased lubrication. Breastfeeding is regarded as a wonderful overall health benefit for the baby and a strong bonding opportunity for mother and child. Fathers are also important in this process and should be included in bonding activities with mother and child. For some men, seeing their wives breastfeeding is difficult and may lead to relationship issues.

Note: Breastfeeding women have been told they cannot get pregnant while breastfeeding, and although the chances are reduced, this should not be counted upon as a reliable method of birth control.

Oral Contraceptives (BCPs)

Oral contraceptives, birth control pills (BCPs), can result in decreased sexual desire in some women (and also depression in some women). The decrease in desire is likely a result of estrogen’s stimulation of sex hormone binding globulin (SHBG). Increased SHBG leads to a decrease in free testosterone and an accompanying decrease in sexual desire. (Panzer, et al., 2006). See Desire Section for additional information on this topic.

Progesterone may also impact sexual desire. There are different types of progestins in different pills, and each has a different potency in terms of progesterone sexual effects. In some research studies, women taking progestins experienced a decrease in sexual desire and vaginal blood flow, while in other studies, women experienced improvements in desire and arousal when they took a progestin in addition to estrogen.

More studies are underway to see if different progestin regimens, alone or in combination with estrogen and other hormonal agents, may benefit sexual function. One BCP, the Yasmin, contains a different type of progestin (drospirenone) and may have fewer negative effects on desire, although the reported effects vary dramatically in different women. Also, Yasmin may increase potassium levels and should be used with caution if patients have heart conditions. The pill should not be taken by patients with diseases of the kidneys, liver, or adrenal glands. Smoking is also contraindicated with BCP’s (Johnsen, 2004).

At the present time, progestins generally are prescribed to balance estrogen's effect on the uterus and not to treat sexual dysfunction.

Note: Emerging research is finding that women who use oral contraceptives may be exposed to long-term problems from low values of “unbound” testosterone, potentially leading to ongoing sexual, metabolic, and mental health consequences (Panzer, et al., 2006).

For women who have problems with depression, a BCP with lower progestin potency may be used. Pure progestogen treatment without estrogen, such as DepoProvera, is known to worsen depression in women who already have a tendency toward or clinical signs of depression (University of Illinois at Urbana-Champaign, 2005).

Certain medications, including the antibiotic Rifampin, certain drugs used as mood stabilizers or to control seizures such as Oxcarbazepine (brand name Trileptal), certain anti-fungals that are taken orally for yeast infections, certain HIV protease inhibitors, and herbs such as St. John’s Wort may reduce the effectiveness of combined hormone methods. If there is a concern about this, an additional method of birth control can be used while the other medication is being taken (Stacey, 2006).

CONTEMPORARY CONCEPTS:

-THE G-SPOT
-FEMALE EJACULATION
-CLITORAL VS. VAGINAL ORGASM

For many years, the clitoris was considered the sole source of sexual pleasure and orgasm. Among sexologists and researchers, there has been ongoing debate regarding the existence of what is commonly called the G-Spot and also about clitoral versus vaginal orgasms—are they different, are they the same? Freud spoke of immature versus mature orgasms—according to him, immature orgasms were those resulting from clitoral stimulation, while mature orgasms were those that arose from vaginal stimulation. The debate also includes whether or not some women expel fluid during sexual stimulation—in other words, do women ejaculate?

The G-Spot

In 1950 Dr. Ernst Grafenberg identified an area inside the vagina that was exquisitely sensitive. In ensuing years this became known as the G-Spot (Schubach, 2002). Dr. Alice Ladas, a noted researcher on Gräfenberg, states that the G "Spot" is not actually a "spot" on the anterior (upper) wall of the vagina but instead is the prostatic-like tissue which surrounds the urethra and which can be stimulated through the anterior wall of the vagina or from above the pubic bone.

This tissue, a.k.a., Skene's and/or paraurethral glands and ducts is a homologue of the male prostate. Dr. Ladas renames the area the “G area” (Ladas, et al., 2005). Dr. Gary Schubach prefers the term “G-Crest” because when swollen, the tissue feels like a protruding ridge or crest (Schubach, 1997). Dr. Beverly Whipple, another researcher on this topic, says that all women (and men) have a G-Spot. In men, it can be stimulated between the scrotum and the rectum or from inside the anus (Whipple, et al., 2004).

Female Ejaculation

In women, orgasm that occurs through stimulation of the prostatic-like tissue may or may not include ejaculation, and the amount of fluid emitted varies. Analysis of the fluid suggests that it may be a mixture of fluids from both the bladder and the urethral glands. Similar to men, it is also possible for women to have an ejaculation without G-Spot stimulation (Schubach, 2001).

Whipple, et al. (2004) believe that the “G-Spot” discussion finally puts to rest the old argument about whether the vagina or the clitoris is more important. The answer: they both are important. Not everyone is aroused by G-Spot stimulation and this stimulation is not necessary. The same thing is true in the question of female ejaculation. Not every woman ejaculates. But for those who do, it is important for them and for their partners to know that this is normal and that it is not urination.

Clitoral vs. Vaginal Orgasm
Orgasms with Intercourse

In regard to vaginal versus clitoral orgasms and whether or not one is “better” or “more mature,” women who report both types of orgasms describe them as pleasurable and satisfying. Also, research has determined that many, probably the majority, of women do not experience orgasm with penile-vaginal intercourse alone (Hite, 1987).


For those who experience orgasm as a result of clitoral stimulation, some type of stimulation is generally necessary before or during intercourse, because the location of the clitoris hinders stimulation with just penile-vaginal intercourse. For women who experience G-Spot stimulation, intercourse positions that facilitate this are rear entry positions and those in which the woman’s hips are elevated.

All that is currently known about sexuality and sexual pleasure will hopefully lead subsequent generations to the understanding that people have different pathways to pleasure. One way is not better than another. American society’s seemingly fixed beliefs that certain ways “don’t count,” or that “we’ve got to do it better in order to be real men or women,” primarily serve to stifle the pleasure and ultimately the joy that can be experienced sexually. With new awareness and acceptance, ultimately lovers may be able to enjoy their own experiences and not worry about what others are doing.


Sexuality Factoid

At least 70% of women cannot achieve orgasm through vaginal stimulation alone.

Source:www.bbc.co.uk/relationships/sex_and_sexual_health/probs_difficultyorgasm.shtml

This next section of the course will look at specific issues facing females in the area of sexual functioning, suggest different ways of considering these issues, and present various means for providing relief for client concerns.

ANORGASMIA

An inability to achieve an orgasm can become a major concern of women and their partners. Anorgasmia (a.k.a., nonorgasmia or inorgasmia) can be:

1) primary—never having experienced an orgasm by any means,
2) secondary—experienced an orgasm in the past, but is not able to do so at the present time, or
3) situational—is able to achieve orgasm in some situations, not others, with some partners, not others.

Secondary anorgasmia can be the result of certain illnesses such as diabetes and multiple sclerosis, the side effects of medications, or certain types of injuries or surgeries. Relationship problems can also be a factor.

Situational anorgasmia may result from physical issues such as fatigue or medication side effects or may be connected to relationship issues (anger at partner, lack of attraction to partner, etc.).
In today’s society the desire to have orgasms seems to have become almost “a cause,” resulting in intense pressure to succeed and leading to performance anxiety. One young woman told the author, “I’ve got to experience this at least one time in my life. Even if it never happens again, I’ve got to know what it feels like and what other women are talking about.” This type of thinking is a recipe for performance anxiety and can be a major inhibitory factor in experiencing an orgasm.


Sexuality Factoid

Approximately 12% of women never achieve an orgasm.

Source:www.bbc.co.uk/relationships/sex_and_sexual_health/probs_difficultyorgasm.shtml

Primary anorgasmia is frequently the result of one or more of the following:

1. Lack of information and/or awareness—about female anatomy, about how to stimulate herself, about what an orgasm feels like, about where to get accurate information. Many people have a lack of knowledge about their own anatomy, even basic anatomy, and this lack of knowledge is found among educated people as well as those with less education.

Recently a couple in their late twenties came to see a nurse midwife complaining of an inability to conceive a child after two years of marriage. The nurse midwife examined the woman and found that she had an intact hymen. For two years this young couple had been having anal intercourse and were unaware of this.

Another man in his thirties (a graduate of a well known engineering school) had been married for eight years, had three children, and was in dental school before he learned that the vagina and urethra were separate openings.

A very valuable aspect of assessment can be giving information and providing accurate resources for accessing information.

2. Communication problems—about how to tell a partner what she wants and ways for the partner to touch her. People will often “do” sex without talking about it. Difficulties in communicating about sexuality can create problems throughout life. Further, the sexual experience can become enhanced and increasingly intimate when people talk with one another.

Contributing to ineffective communication is the lack of accurate information as evidenced by the continuing high incidence of sexually transmitted infections (STIs) and unplanned pregnancies, the young father who fears touching his pregnant wife, the menopausal woman and her partner who do not understand what is happening to their bodies, the older couple who assume they are supposed to stop being sexual.

3. Fears—of what her behavior might be (screaming, clawing) or what might happen (passing out, falling out of bed, seeing fireworks). Popular literature serves to perpetuate these beliefs.

A few years ago the author spoke with the frequently published author of romance novels. The novelist said that every time she writes a new novel, it needs to be a little “racier” than the one before it. Readers get mental images of people engaged in sexual encounters doing things like swinging from chandeliers, tearing each other’s clothes off, having wildly passionate sex in speeding cars.

Although sexual experiences may incorporate some aspects of novelists’ descriptions, often their accounts of sexual encounters make readers wonder if their own sex lives might be a little, or perhaps very, dull.

4. Guilt—about sexual behaviors or about enjoying sex. Many women, particularly older women, grew up in an era when the idea of initiating or even enjoying sex was not a part of the expected experience for women. Even in today’s world, women who are open about their sexuality and enjoy sex may be referred to as sluts, whores, nymphomaniacs, and other derogatory terms. Men with the same desires and behaviors are called macho, studs, and “real” men. Guilt about past sexual behaviors/ indiscretions may give rise to difficulties in experiencing pleasure and orgasm in a current relationship.

5. Performance anxiety—the pressure to have an orgasm can certainly impact its happening. One way to understand the process is to picture a continuum with thinking at one end and feeling at the other end.

       THINKING_________________________________FEELING


The best way to be involved in a sexual experience is through feeling and not thinking. The thinking portion is best done before s/he becomes involved in a sexual encounter. Thinking is the enemy of sex, and it has been said that the largest sex organ is between the ears and not between the legs.

When performance anxiety becomes a part of the picture, both women and men may separate themselves from the feeling experience and become observers and judges of how they may or not be measuring up. In essence a person is standing outside herself or himself and rating the performance. This is known as spectatoring, a term coined by Masters and Johnson (1970). When someone becomes a spectator, s/he is largely in a cognitive, thinking mode.

One way to counter spectatoring is to incorporate fantasy. When women find themselves thinking or spectatoring, one way of moving to a feeling mode is to use some type of fantasy. A fantasy can involve a former wonderful sexual experience with her current partner, placing herself into an erotic scene from a book or movie, or seeing herself making wild passionate love with her favorite movie star or sex symbol. Sexual fantasies of an infinite variety are normal, and Nancy Friday’s “My Secret Garden” and “Forbidden Flowers” are classic examples of popular books about women’s sexual fantasies.

Two cautions about fantasies:

1) a person may spend time in the fantasy world to the exclusion of interpersonal relationships, and
2) it is not a good idea to spend large amounts of time fantasizing about the next door neighbor’s spouse.
Keeping the fantasy as an adjunct in one’s own sexual relationship is the primary purpose. Certain fantasies may be “wild” and never become reality, others may be acted out with oneself or a current partner, others may involve people far removed from the client’s realm of possibility - such as a movie star or sex symbol.

It is important for the clinician to attend to the patient’s values and beliefs system. For some people, fantasizing about an act is tantamount to actually carrying out the act. Remember when Jimmy Carter was ridiculed several years ago because of an interview with Playboy Magazine in which he stated, “I’ve looked on a lot of women with lust. I’ve committed adultery in my heart many times.”(Playboy Magazine, 1976)

Example:

The following story illustrates the importance of recognizing and working within the client’s values system. Several years ago a woman came to a therapist complaining that she and her husband had gotten in a rut sexually and had developed negative feelings about being together. The therapist asked her about the use of fantasies, and the woman said that she had never incorporated these into their lovemaking, but that it might be a way to begin to reconnect with her husband. Then the following happened: the woman said, “I think I could fantasize about Barbara Streisand and Robert Redford in the movie ‘The Way We Were.’ No, I can’t do that, because they weren’t married. I think I could fantasize about Paul Newman and Joanne Woodward because they ARE married. But if I fantasize about my husband being Paul Newman, it might hurt his feelings. So I’ll have to go home and ask him.” She did go home and ask him, and his response was, “If it’ll help, we’ll put Paul Newman posters on the wall.”

Some clients may object to the use of fantasy, from a moral point of view or from the belief that fantasy is only a crutch. Also, some clinicians may hesitate to encourage the use of fantasy, preferring clients to become more centered and involved in their own experiences of intimacy.

In some of these situations, the concept of fantasy used on a temporary basis as a bridge between thinking and feeling is acceptable. Once the performance anxiety caused by thinking is lessened, the use of fantasy may no longer be needed. Other people enjoy using erotic images fantasized and/or experienced through any or all of the senses, to stimulate sexual passion and to provide innovative ideas for sexual exploration and variety.

6. Medical conditions

One specialist states:
“I have found STRONG correlations between primary anorgasmia and elevated prolactin levels (indication of lots of conditions including pituitary adenoma and Cushing’s Disease). Prior to the institution of sex therapy, ALL clients should have a complete history and physical exam that includes appropriate lab work. Standard lab work generally includes thyroid function testing, estradiol and progesterone levels. As this lab work would NOT pick up pituitary adenoma, part of any initial workup with the diagnosis of anorgasmia that I complete now includes a fasting blood prolactin level. If that is elevated, referral to an endocrinologist is in order” (J. Seifer, personal communication, AASECT listserve, 2006).

Dr. Seifer further states,
“With elevated prolactin levels triggered by anterior pituitary adenoma, women would report random leakage from their breasts, ovulatory suppression, and irregular menses as the result of low progesterone levels. Basal Body Temp charts would indicate no temperature spike mid cycle. If not treated, visual changes (eye ground changes), peripheral edema, migraine like headaches, weight gain, and wide mood swings would ensue” (J. Seifer, personal communication, AASECT listserve, 2006).

Incidence

The incidence of primary anorgasmia in America is difficult to know. Some authorities believe the incidence is 10-15%, while others say the occurrence may be much higher. A study done several years ago determined that perhaps 2-5% of the population were totally anorgasmic and were not bothered by it at all.

For these people, sexuality was virtually, if not totally, unimportant. The next 10-15% were anorgasmic after 10 years of marriage. The next groups were orgasmic, but the majority did not reach orgasm with penile-vaginal intercourse only; they required other types of stimulation in order to be orgasmic.

Finally, this study determined that there may be 2-5% of women who are able to fantasize to orgasm with no body contact at all—a condition perhaps many women would hope to have (Kinsey et al., 1953).

Ross (2005) reported the following: Researchers and other advocates of positive sexuality in women are searching for factors involved in women’s sexual response. A study recently concluded that a woman’s ability to have an orgasm is to some extent determined by her genes.

In response to this finding, Dr. Virginia Sadock, Director of the Human Sexuality Program at New York University Medical Center, stated, “It'll be upsetting because some women will think, 'Oh my God, maybe I just can't.' On the other hand it takes away a kind of guilt or pressure.”

Specialists say that for the small number of women whose lack of orgasm may have a genetic component, this does not mean the situation is hopeless—it means that more time and patience are necessary. As Dr. Sadock states, “Factors influencing the ability to (reach) orgasm vary from woman to woman. What we do know is that psychologically women are more complex sexually.

For women, being in a relationship where they feel loved and feel secure is a big factor. Other big factors are how they feel about themselves and about sex and what their first experiences were”(Ross, 2005).

Interestingly the study was heavily criticized by those in the sexuality field who believe that the study was intrinsically flawed in a number of ways, that it was based on two poorly written, confusing questions about orgasm, and that it basically did not measure what it purported to measure. Critics of the study contended that while there may be a genetic link to orgasm, this study does not prove it (Ross, 2005).

With regard to the importance of orgasm for women, female orgasm expert Dr. Laura Berman, states, “Even if a woman is not able to achieve orgasm, this doesn't mean there's no joy for her in sex.” A survey she recently conducted found that among women enjoying satisfying sex lives, orgasm did NOT rate as a key element for fulfillment.

Dr. Berman and her colleagues collected data from a national random sample of women all over the US, looking at what women who consider themselves sexually satisfied have in common. They found that intimacy and the connection women felt to their partners were the strongest predictors of sexual satisfaction (Ross, 2005; Berman, Berman, & Schweiger, 2006).

Clinical Case and Clinicians’ Responses

In addition to lack of orgasm, other concerns related to orgasm are troubling to some women. One of these concerns is inability to have an orgasm during intercourse. Another is that it takes too long to reach an orgasm. This latter concern is presented in the following clinical case, and the varying responses from therapists illustrate the differing perspectives on how to approach this situation.

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, as she continues to have much desire and would like to be sexual with her spouse 2-3 times a week.

The following discussion among a group of sex therapists will illustrate how there are several of the ways of viewing and addressing this case – none of which is definitive or absolute.

Clinician 1

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 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.

Clinician 2

Has the patient had her estradiol and free testosterone levels measured?

Clinician 3

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.

Clinician 4

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.

Clinician 5

You could suggest the Eros:
You need a prescription to get it in the United States. 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.

Clinician 6

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.

Clinician 7

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.

NOTE: The Eros is a small, handheld medical device that is supposed to increase sexual responsiveness in women by increasing blood flow to the clitoris and external genitalia. See Resources for Professionals handout.


Sexuality Factoid

Females 30-44 report an average of 4 male sexual partners in their lifetime

Source: Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Advance data from vital and health statistics; no 362. Hyattsville, MD: National Center for Health Statistics. 2005

HANDOUT

The following printable handout is an overview of the assessment and treatment of anorgasmia utilizing the PLISSIT Model of Counseling. Note that 70% of sexual problems can be effectively addressed and satisfactorily resolved with the first three steps, i.e. the Permission, Limited Information, and Specific Suggestions (Annon, 1975):

NOTE: The application of the PLISSIT Model to anorgasmia is the work of the author who used Annon’s model for assessment and treatment. She has not published this work to date but offers it here as a tool that she has found to be effective.
THE TREATMENT OF ANORGASMIA IN WOMEN: 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 anorgasmia is 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 normalize the experience, e.g. “What happens when you touch yourself?” suggests that the practice of self stimulation is a common and ordinary behavior.
8. Ascertain the meaning of her experience to her, to a 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 anorgasmia: incidence of and beliefs about anorgasmia, 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 women’s descriptions of what an orgasm feels like to them.

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 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.



Female Sexuality Resources for Professionals

Medications

New reporting procedures by pharmaceutical companies to the public regarding both positive and negative outcomes of their clinical drug trials will be a good way for professionals to explore for themselves the background on the new drugs being released to treat sexual functioning. The database began operating on Oct. 1, 2006, at http://www.clinicalstudyresults.org

Client Self-education

Vulvar Anatomy

The following are educational sites for the female vulva. One site has some animated diagrams so that one can rotate the view: http://www.3dvulva.com and http://www.eros-therapy.com/index.cfm?optionid=523

Body Image

The website http://www.youtube.com/watch?v=uT4dpFpiTgk has a wonderful clip for helping young women understand what it takes to produce the “perfect images” of the women they see in the media. This woman actually sat for 10 hours in this fast forward timeline. The title is “Dove Evolution.”

Women’s Sexual Health

The Women's Sexual Health Foundation, in an effort to educate as many women, men and healthcare providers as possible, now will archive all issues of the Women's Sexual Health Journal that are over a year old at :
http://www.twshf.org/archived_sex_e_journal.html


Sexual Health Products

The Sinclair Intimacy Institute (www.intimacyinstitute.com) is a leading source of sexual health products for adults who want to improve the quality of intimacy and sex in their relationships and a resource frequently utilized by sex therapists. Their extensive library of videos and products includes the Better Sex Video Series covering everything from advanced sexual positions to erectile dysfunction solutions.

 

 

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