Aline P Zoldbrod
Sexuality is a biopsychosocial phenomenon. Sexual feelings and expression are infinitely malleable. Thus, each individual woman’s sexuality is different from every other woman’s, a result of all of the various forces and experiences that have affected her over her lifetime. Our patients come to us for help, yet there is no single goal in treating sexual problems in women, and no one formula for healthy sexuality or perfect functioning. Each woman’s “sexual recipe” for success and pleasure is unique and complex.
This chapter focuses on the responsibility of the psychologist, a nonphysician, to understand, assess, and explain the impact of intrapsychic, familial, historic, relational, and cultural forces on each woman’s sexuality; to understand her special vulnerabilities, strengths, and goals; and to interpret and explain all this information to the patient and to the medical team. The psychologist helps the patient assimilate medical and psychologic findings and remain hopeful. Finally, the psychologist applies her professional knowledge, skills, empathy, creativity, and resources to enhance each patient’s sexual pleasure and comfort.
This is an exciting and promising time to be working in the field of female sexual dysfunction (see Chapter 1.1 of this book). Medical information is expanding and changing; understanding of female anatomy is improving; old diagnoses are being challenged; and new medications, treatments, and devices are being quantified and tested scientifically1,2 (see Chapters 4.1-4.4). New treatments show promise for specific groups of women, including the use of selective phosphodiesterase type 5 inhibitors in treating antidepressant-associated sexual dysfunc- tion,3 and the use of the EROS pump, selective phosphodiesterase type 5 inhibitors, and/or topical vasodilators in certain cases of female sexual arousal disorder (see Chapters 13.1-13.3, 14.1, and 14.2). Our understanding of vulvar pain has been enhanced by new conceptualizations of the disorder4 (see Chapters 12.1-12.6). In addition, new advances in understanding of and success in treating the sexual sequelae of emotional, physical, and sexual trauma are an important innovation in sex therapy for women (see Chapters 11.1-11.5).5,6
It is not a simple time to work in the field of sex therapy, however. Women demand the latest medical treatments, hoping for a rapid solution, as selective phosphodiesterase type 5 inhibitors have been for men. However, given the complexity and highly contextual nature of women’s sexual experience, medical advances, in and of themselves, will not be able to solve most women’s sexual problems.7 The history of psychologic treatments has been reviewed in Chapter 11.1. For many diagnoses, there is no standard, reliable psychologic protocol of treatment at this time.8 Before beginning any treatment approach, the psychologist must be prepared to deal with patients’ and partners’ high expectations, impatience, and disappointment at the lack of a quick fix.
Women’s feelings about sexuality are embedded in nonphysiologic factors
Most women’s sexual problems have a mixed etiology, part psychologic, part relational, part cultural, part biologic; all areas must be evaluated. Meston9 cautioned that medications that promote physiologic arousal in men may not be effective in the opposite sex, because, for women, “Evidence suggests that external stimulus information (e.g., relationship issues, sexual scenarios) may play a more important role in assessing feelings of sexual arousal than do internal physiological cues.”
Studies have found that relationship satisfaction is the most important contributor to sexual satisfaction.10,11 Beck found that anger reduces sexual desire in women, but not in men.12 Thus, evaluating the woman’s current and past satisfaction with her partner is a critical piece of the diagnostic puzzle.
Women juggle multiple roles and many have difficulty allowing themselves to take the time to focus on eroticism, even when desired. This may create a “vicious cycle” in which a lack of satisfying erotic encounters diminishes positive sexual imagery and memories, reducing future sexual desire and perpetuating the problem. Further, cultural demands on women to look young and sexy are relentless and, in some women, contribute to body dissatisfaction. Women with poorer body images reported less sexual satisfaction, lower rates of orgasm, and more sexually dysfunctional experiences in general.13,14
The woman with the sexual problem: the psychology of being “the patient”
Patients who come into treatment for sexual problems feel vulnerable. Many of them feel defective, unable to have or to enjoy normal sexual relations. They may feel hopeless or frightened. The clinician’s questions about sexual function and history can themselves seem intimidating, awkward, meddling, humiliating, and even inappropriate. The health-care provider can enhance her empathy with the patient by considering whether or when she has ever discussed these topics with anyone.15
Some women come to treatment under duress to try to save a troubled relationship. Others have never experienced sexual pleasure and believe that women’s sexual pleasure is a myth. Some women, who have embraced and valued their own sexuality, come highly motivated to resolve a secondary sexual dysfunction that has taken away one of life’s great pleasures.
It is common for patients to hope for an easy cure. Unfortunately, some must confront the fact that their sexuality was damaged by the abuse or neglect they suffered in their family of origin. It is painful to identify oneself as a victim, and the standard set of physical examinations and procedures can be especially stressful for women with a history of sexual abuse. Westerlund’s16 research on sexual abuse survivors found that survivors may experience uncomfortable feelings in any situation that appears to be sexual, such as a vaginal ultrasound or sensory testing. Thus, the psychologist must screen for sexual or physical abuse. When an abusive history is present, the psychologist should alert the other members of the medical team, with the patient’s permission. In turn, physicians and other staff members who will come in contact with an abuse survivor should be asked to take care to modify treatment protocols to help her maintain a sense of control during evaluation and treatment. Changes to medical protocols might include giving the patient written descriptions of all possible procedures in advance, taking care to explain orally what will occur in the office each step of the way, helping the patient determine whether she will need any help in feeling safe during each described process, and making sure that no unnecessary personnel are present during procedures.
The pros and cons of diagnosis
Many patients come to treatment in search of a diagnosis, hoping that a correct identification of the problem equals a cure. Sometimes receiving the accurate diagnosis feels like a triumph, but at other times it can feel like a death knell.
The physician and the psychologist’s language and imagery with patients can have a far-reaching influence on sexuality, sexual self-image, and self-esteem.17 For example, terms such as “senile vaginitis” can be shocking and demoralizing. Test results can be devastating,18 and negative results should be described to the patient in a way that will minimize negative psychologic impact. For example, if Doppler ultrasound shows severe nerve damage in the pelvis, the patient should be advised of the results gently and told that the psychologist on the team can help her learn other physical and mental ways to raise her sexual arousal.
Evaluating intrapsychic, historic, cultural, and relational factors
Creating a safe environment in the therapist-patient relationship
To learn about the genesis and history of the woman’s problem, the psychologist must create a safe environment in the patient-therapist relationship. The patient must feel curious about her sexual history and feel secure in sharing private and potentially upsetting information. In the interests of time, the sexual questions posed to the patient by the medical team may be framed in an objective manner. The psychologist’s stance during the initial interview needs to be less goal-driven and more relaxed, with attention to the woman’s communicated sense of discomfort, hesitancy, embarrassment, or shame. Once rapport has been formed, the psychologist can use standardized tests, questionnaires, and interview sessions to gather data, generate hypotheses, and plan treatment.
Assessing family-of-origin factors: issues with touch, trust, empathy, gender, and power (Fig. 17.2.1)
Part of the psychologist’s role is to find the hidden, unconscious factors that cause sexual inhibition and discomfort. Many patients have never recognized deep-seated problems with sexuality and intimacy,19 based on their early childhood experiences with milestones of sexual development20 such as touch, empathy, trust, and power. Touch is the “ground zero” of sexuality. Good associations with touch allow caresses by a loved partner to create a cascade of pleasurable associations, leading to feelings of safety and sexual arousal. Without positive experiences with touch as an infant and a girl, the woman will not grow up to be able to enjoy embodied feelings of pleasure, including appropriate familiarity with the sights, touches, tastes, and smells of bodily intimacy, even with a beloved partner. Adult body image also is affected by whether or not the girl was touched lovingly by her parents. The psychologist must evaluate and treat early developmental blocks to experiencing physical pleasure.
Figure 17.2.1. Milestones in Sexual Development (with permission20).
Childhood experiences with trust and empathy are basic determinants of whether a woman will be motivated to be in a psychologically and physically intimate relationship.21 If she learned that it was safe to trust her parents to address her emotional and physical needs as a child, now she will allow herself to share deep sentiments with her partner. If her parents had empathy and could tolerate her strong feelings, as an adult she can feel safe with intense, visceral feelings and can choose to lose control and experience deep sexual pleasure in her body.22
Sexual and nonsexual traumatic events in past family life cause sexual dysfunction
The startling prevalence of sexual abuse among women is reviewed elsewhere in this book. However, many kinds of families inflict “sexual trauma” in a more diffuse way, affecting the platform upon which healthy sexuality must be built. Male violence against women, including wife abuse, is an international epidemic, affecting from one in five to four out of five families, depending on the nation involved.23 Women who witnessed their mothers being physically and emotionally abused but who were not battered themselves may present with varied sexual dysfunctions, according to their changed associations with touch, trust, feelings about their own gender, and concerns about male/female power.
Alcoholism,24 drug abuse, child abuse, and mental illness are problems in families around the globe. For women who grew up in families with parents who were alcoholics, emotionally or physically abusive, neglectful, or mentally ill, sexual trauma and inhibition occur because of negative assumptions about human relationships, which can interfere with the woman’s wish for sexual vulnerability and closeness as an adult.20
Guilt, inhibition, and socialization
The double standard exists worldwide, and women’s socialization to be pure, non-sexual beings is an obstacle to achieving sexual fulfillment. Cultural influences have been reviewed by Amaro et al.25 One part of the psychologist’s role with the patient is to give her permission to explore her sexuality through masturbation, touch, sexual fantasy, erotica, books, movies,26 and the internet.27 However, research has shown that experiencing negative familial and cultural attitudes toward sex does not, by itself, create adults who have problematic sexual functioning.28 The psychologist “giving permission to be sexual” may be a minor part of treatment for many women. If early associations to touch, trust, empathy and power were negative, giving patients permission to be sexual and assigning standard sexual homework is premature and will not lead to clinical success. Similarly, if a patient has any kind of trauma, appropriately staged work on safety must be the first therapeutic step.
Women come late for help, often in crisis
Oftentimes, even when the medical team identifies an important, even crucial, aspect of the difficulty, simply remediating the problem medically is not enough. Patients frequently address sexual problems with us only after suffering for a long time, fruitlessly. Some tried resolution by themselves. Others ignored sexual issues for years, even decades. Sex therapists see quarreling, angry couples with serious, longstanding sexual dysfunctions who spent years in conjoint therapy which avoided the sexual issues completely. Their therapists believe that sexual harmony will miraculously be restored when the couple’s other tribulations abate. Instead, conflicts and hurts escalate. When such a woman reaches us, the situation is much more complicated psychologically, relationally, and biologically than it would have been had she sought treatment earlier. Her sexual self-esteem, self-image, sexual imagery, and memories are damaged. Patients commonly report feeling “unlike other women” or “broken”.
If she has a partner, the patient’s relationship may be in distress from the lack of sexual intimacy. Her partner may feel “revolting” or lacking because sexual advances have been spurned repeatedly, or sexual interludes have been obligatory, wooden, and joyless. Tension and blame creates years of hurtful interaction. Impairment may even have occurred in her sexual organs, from lack of proper medical attention. Patience and skill are required to treat such cases and promote forgiveness and trust between partners (Table 17.2.1).
Women’s sexuality will forever be a complicated, multidimensional phenomenon. Each patient, no matter what her past history or medical status, can maximize her sexual function and work to find her unique recipe for sexual pleasure. The psychologist can be of great assistance in this exploration. There are few situations in which a motivated patient or couple cannot be helped by psychotherapy, resources, and education. However, outreach is essential to ensure that this information is available. Educating colleagues in mental health and medicine to refer patients and couples with sexual issues to certified sex therapists for specialized treatment can prevent prolonged suffering and treat the sexual problems more efficiently.
The Internet provides support for women around the globe. Problems with sexuality are private, and patients are helped if they do not feel isolated in their struggles. Confidential, anonymous chatrooms and groups are available for women with many different sexual issues, including low sexual desire, effects of prior abuse, vulvodynia, sexual fears and inhibitions, or sexual side effects as a result of illness. Clinicians should be familiar with these resources.
Patience and skill is required to treat cases of sexual dysfunction. Clinical work with highly distressed couples is often intense, particularly in the beginning of treatment. Couples may need to be seen more than once a week in order to learn how to manage their anger and increase positive interactions. Couples in crisis may need referral to a therapist who has the time and the setting best to meet their needs. If so, the psychologist will make the referral, communicate with the other therapist, and coordinate the couple’s sexual and marital treatment.
Psychologists must stay abreast of the latest safe and effective advances in sexual medicine that can help patients. As women live longer, rates of illness and disability increase. Advancement in sexual medicine has the potential to help women regain lost sexual function or even to transform their sexuality in their forties, fifties, sixties, and beyond. While some women choose to phase out the sexual part of their lives as they age, another group will embrace their sexuality into old age. At its best, sexual pleasure is as life-affirming an activity as has ever existed.
Table 17.2.1. The psychologist's clinical stance in providing sex therapy
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