Disease (diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis)

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1 COURSES ARTICLE - THERAPYTOOLS.US Individual Planning: A Treatment Plan Overview for Adult Men with Sexual Performance Problems Individual Planning: A Treatment Plan Overview for Adult Men with Sexual Performance Problems Spend at least one hour developinga treatment plan. Sexual difficulties may begin early in a person's life, or they may develop after an individual has previously experienced enjoyable and satisfying sex. A problem may develop gradually over time, or may occur suddenly as a total or partial inability to participate in one or more stages of the sexual act. The causes of sexual difficulties can be physical, psychological, or both. Emotional factors affecting sex include both interpersonal problems and psychological problems within the individual. Interpersonal problems include marital or relationship problems, or lack of trust and open communication between partners. Personal psychological problems include depression, sexual fears or guilt, or past sexual trauma. Physical factors contributing to sexual problems include: Injuries to the back An enlarged prostate gland Disease (diabetic neuropathy, multiple sclerosis, tumors, and, rarely, tertiary syphilis) Drugs, such as alcohol, nicotine, narcotics, stimulants, antihypertensives (medicines that lower blood pressure), antihistamines, and some psychotherapeutic drugs (used to treat psychological problems such as depression) Endocrine disorders (thyroid, pituitary, or adrenal gland problems) Failure of various organs (such as the heart and lungs) Hormonal deficiencies (low testosterone, estrogen, or androgens) Nerve damage (as in spinal cord injuries) Problems with blood supply

2 Some birth defects Sexual dysfunction disorders are generally classified into four categories: sexual desire disorders, sexual arousal disorders, orgasm disorders, and sexual pain disorders. Sexual desire disorders (decreased libido) may be caused by a decrease in the normal production of estrogen (in women) or testosterone (in both men and women). Other causes may be aging, fatigue, pregnancy, and medications -- the SSRI antidepressants which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are well known for reducing desire in both men and women. Psychiatric conditions, such as depression and anxiety, can also cause decreased libido. Sexual arousal disorders were previously known as frigidity in women and impotence in men. These have now been replaced with less judgmental terms. Impotence is now known as erectile dysfunction, and frigidity is now described as any of several specific problems with desire, arousal, or anxiety. For both men and women, these conditions may appear as an aversion to, and avoidance of, sexual contact with a partner. In men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity. There may be medical causes for these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease may also contribute to these difficulties, as well as the nature of the relationship between partners. As the success of Viagra attests, many erectile disorders in men may be primarily physical, not psychological conditions. Orgasm disorders are a persistent delay or absence of orgasm following a normal sexual excitement phase. The disorder occurs in both women and men. Again, the SSRI antidepressants are frequent culprits -- these may delay the achievement of orgasm or eliminate it entirely. Sexual pain disorders affect women almost exclusively, and are known as dyspareunia (painful intercourse) and vaginismus (an involuntary spasm of the muscles of the vaginal wall, which interferes with intercourse). Dyspareunia may be caused by insufficient lubrication (vaginal dryness) in women. There may also be abnormalities in the pelvis or the ovaries that can cause pain with intercourse. Vulvar pain disorders can also cause dyspareunia and inability to have intercourse due to pain. Poor lubrication may result from insufficient excitement and stimulation, or from hormonal changes caused by menopause or breast-feeding. Irritation from contraceptive creams and foams may also cause dryness, as can fear and anxiety about sex. It is unclear exactly what causes vaginismus, but it is thought that past sexual trauma such as rape or abuse may play a role. Another female sexual pain disorder is called vulvodynia or vulvar vestibulitis. In this condition, women experience burning pain during sex which may be related to problems with the skin in the vulvar and vaginal areas. The cause is unknown. Sexual dysfunctions are most common in the early adult years, with the majority of people seeking care for such conditions during their late 20s through 30s. The incidence increases again in the perimenopause and postmenopause years in women, and in the geriatric population, typically with gradual onset of symptoms that are associated most commonly with medical causes of sexual dysfunction. Sexual dysfunction is more common in people who abuse alcohol and drugs. It is also more

3 likely in people suffering from diabetes and degenerative neurological disorders. Ongoing psychological problems, difficulty maintaining relationships, or chronic disharmony with the current sexual partner may also interfere with sexual function. PREVENTION Open, informative, and accurate communication regarding sexual issues and body image between parents and their children may prevent children from developing anxiety or guilt about sex, and may help them develop healthy sexual relationships. Review all medications, both prescription and over-the-counter, for possible side effects that relate to sexual dysfunction. Avoiding drug and alcohol abuse will also help prevent sexual dysfunction. Couples who are open and honest about their sexual preferences and feelings are more likely to avoid some sexual dysfunction. One partner should, ideally, be able to communicate desires and preferences to the other partner. People who are victims of sexual trauma, such as sexual abuse or rape at any age, are urged to seek psychiatric advice. Individual counseling with an expert in trauma may prove beneficial in allowing sexual abuse victims to overcome sexual difficulties and enjoy voluntary sexual experiences with a chosen partner. SYMPTOMS Men or women: Inability to feel aroused Lack of interest in sex (loss of libido) Pain with intercourse (much less common in men than women) Men : Delay or absence of ejaculation, despite adequate stimulation Inability to control timing of ejaculation Inability to get an erection Inability to keep an erection adequately for intercourse Women: Burning pain on the vulva or in the vagina with contact to those areas Inability to reach orgasm Inability to relax vaginal muscles enough to allow intercourse Inadequate vaginal lubrication before and during intercourse Low libido due to physical/hormonal problems, psychological problems, or relationship problems TREATMENT Treatment depends on the cause of the sexual dysfunction. Medical causes that are reversible or treatable are usually managed medically or surgically. Physical therapy and mechanical aides may prove helpful for some people experiencing sexual dysfunction due to physical illnesses or disabilities. Sildenafil (Viagra) may be helpful for men who have difficulty attaining an erection. The medication increases blood flow to the penis. It must be taken 1 to 4 hours before intercourse. Men who take nitrates for coronary heart disease should not take sildenafil. Mechanical aids and penile implants are an option for men who cannot attain an erection and

4 find sildenafil is not helpful. Women with vaginal dryness may be helped with lubricating gels, hormone creams, and -- in cases of premenopausal or menopausal women -- with hormone replacement therapy. In some cases, women with androgen deficiency can be helped by taking testosterone. Kegel exercises may also increase blood flow to the vulvar/vaginal tissues, as well as strengthen the muscles involved in orgasm. Vulvodynia can be treated with numbing cream, biofeedback, or low doses of certain antidepressants that also treat nerve pain. Surgery has not been successful. Behavioral treatments involve many different techniques to treat problems associated with orgasm and sexual arousal disorders. Self-stimulation and the Masters and Johnson treatment strategies are among the many behavioral therapies used. Simple, open, accurate, and supportive education about sex and sexual behaviors or responses may be all that is required in many cases. Some couples may benefit from joint counseling to address interpersonal issues and communication styles. Psychotherapy may be required to address anxieties, fears, inhibitions, or poor body image. PROGNOSIS AND OUTCOME The prognosis (probable outcome) depends on the form of sexual dysfunction. In general, the probable outcome is good for physical dysfunctions resulting from treatable or reversible conditions. It should be noted, however, that many organic causes do not respond to medical or surgical treatments. Prolonged physical dysfunction can also create sexual dysfunction. In functional sexual problems resulting from either relationship problems or psychological factors, the prognosis may be good for temporary or mild dysfunction associated with temporary stress or lack of accurate information. However, those cases associated with chronically poor relationships or deep-seated psychiatric problems typically do not have positive outcomes. Behavioral Definitions for Adult Men with Sexual Performance Problems: Low desire for sexual activity. No pleasurable anticipation of sexual activity Strong avoidance of all sexual contact in spite of a relationship of mutual caring and respect. Lack of usual physiological response and arousal (erection). Lack of sexual excitement. Lack of subjective sense of enjoyment during sexual activity. Lack of pleasure during sexual activity Absence of reaching orgasm after achieving arousal and in spite of sensitive sexual pleasuring by a caring partner. Genital pain before, during, or after sexual intercourse.

5 Persistent delay in or absence of reaching ejaculation after achieving arousal and in spite of sensitive sexual pleasuring by a caring partner. Long Term Goals for Adult Men with Sexual Performance Problems: Improve desire for and enjoyment of sexual activity. Achieve and maintain physiological excitement response during sexual intercourse. Accomplish orgasm within a reasonable amount of time, intensity, and focus given to sexual stimulation. Reduce or eliminate pain and promote pleasure before, during, and after sexual intercourse. Reach ejaculation with a reasonable amount of time, intensity, and focus to sexual stimulation. Achieve a sense of relaxed enjoyment of coital pleasure. Short Term Goals for Adult Men with Sexual Performance Problems: Explore thoughts and feelings about relationship with sexual partner. Allow for open discussion of conflicts and unfulfilled needs in the relationship that lead to anger and emotional distance. Explore sexual attitudes or ideas learned in family of origin. Provide a detailed sexual history that explores all experiences that influence sexual attitudes, feelings, and behavior. Assess how religious training may negatively influence sexual thoughts, feelings, and behaviors. Explore any negative feelings regarding sexual experiences during childhood or adolescence. Allow for a resolution of feelings regarding sexual trauma or abuse experiences. Show an understanding of the role of family of origin experiences in the development of negative sexual attitudes and behaviors. Develop an understanding of the link between lack of positive sex role models in childhood and current adult sexual dysfunctions. Express negative cognitive messages that trigger fears, shame, anger, or grief during sexual activity. Develop and express positive and healthy automatic thoughts that produce relaxed pleasure. Develop and express positive and healthy sexual attitudes.

6 Assign patient to read and discuss books assigned on human sexuality. Develop an acceptance of sexual feelings and behavior as normal and healthy. Develop and show healthy and accurate knowledge of sexuality by freely verbalizing accurate information regarding sexual functioning using appropriate terms for sexual behavior and thoughts. Explore and agree to abstain from substance abuse patterns that interfere with sexual response. Show an understanding of the impact of physical disease and medication on sexual dysfunction. Refer to a physician's complete examination and report results. Take medication for impotence as ordered by the medical doctor, and report as to effectiveness and side effects. Explore and discuss feelings of and causes for depression. Understand the connection between previously failed intimate relationships as it relates to behaviors and emotions that caused failure. Discuss feelings surrounding secret affair and make termination decision on one of the relationships. Openly discuss, any possible homosexual attraction. Learn and practice sensate focus -exercises alone and with partner and discuss feelings associated with activity. Agree to write about sexual feelings and thoughts in a daily journal. Keep a journal of sexual fantasies that stimulate sexual erection or arousal. Explore new coital positions and sexual settings for sexual activity that enhance pleasure and satisfaction. Practice more assertive behaviors that allow for sharing sexual needs, feelings, and desires. Encourage to behave more sensuously and expressing pleasure. Explore conflicts within the relationship. Develop coping strategies that reduce stress interfering with sexual interest or performance. Explore low self-esteem issues that impede sexual functioning and develop in a more positive self-image. Explore feelings of threat and perception of partner being too sexually aggressive or too critical.

7 Learn to implement the squeeze technique during sexual intercourse and report on success in slowing premature ejaculation and feelings about self and the procedure. Express increasing desire for sexual pleasure with sexual activity. Interventions or Strategies for Adult Men with Sexual Performance Problems: Explore the level of harmony and fulfillment. Use conjoint therapy sessions that focus on conflict resolution, expression of sexual feelings, and sex education. Explore family 's history for causes of inhibition, guilt, fear, or repulsion. Gather detailed sexual history that examines current adult sexual functioning as well as childhood and adolescent experiences, sources and level of sexual knowledge, typical sexual practices and frequency, medical history, and history of use of mood-altering substances. Assess role of family of origin in impacting negative attitudes regarding sexuality. Assess role of religious training in reinforcing feelings of guilt and shame about sexual behaviors or feelings- Explore any history or experience of sexual trauma or abuse. Assess emotions and feelings surrounding an emotional trauma in the sexual area. Help patient in develop insight into the role of unhealthy sexual attitudes and experiences of childhood in the development of current adult dysfunction. Reinforce for a commitment to put negative attitudes and experiences in the past while making a behavioral effort to free himself or herself from those influences. Assess sex role models experienced in childhood or adolescence. Explore automatic thoughts that initiate negative emotions before, during, and after sexual activity. Help patient learn healthy alternative thoughts that will control pleasure, relaxation, and inhibitions. Encourage talking freely and respectfully regarding sexual body parts, sexual feelings, and sexual behavior. Give a list of reading books or information on sexual functioning., and assign sections to complete. Reinforce talking freely, knowledgeably, and positively about sexual thoughts, feelings, and behavior. Assess the role that substance abuse, diabetes, hypertension, or thyroid disease, and the

8 impact on sexual functioning. Review medications taken and their possible negative side effects on sexual functioning. Refer to a physician for a complete physical exam to rule out any organic basis for sexual dysfunction. Refer to a physician for medical evaluation and prescription of medication to overcome impotence (Viagra). Explore role of depression in its suppressing effects sexual desire or performance. Refer for an evaluation of antidepressant medication need. Assess fears surrounding intimate relationships and any evidence of a history of repeated failure in this area. Openly explore any secret sexual affairs that may account for sexual dysfunction or disinterest with partner. Assess homosexual tendencies or interest that accounts for heterosexual disinterest. Teach and assign body exploration and awareness exercises that lower inhibition and desensitize sexual aversion. Develop and teach graduated steps of sexual pleasuring exercises with partner that lower performance anxiety and focus on bodily arousal sensations. Allow patient to himself permission for less inhibited, less constricted sexual behavior by assigning body pleasuring exercises with partner. Keep a journal of sexual thoughts and feelings to increase awareness and acceptance of them as normal. Reinforce the development of an indulgence in sexual fantasies that enhance sexual desire. Suggest experimentation with new coital positions and new settings for sexual play that may increase security, arousal, and sexual satisfaction. Allow for a gradual exploration role of being more sexually assertive, and sensuously provocative, and uninhibited in sexual play with partner. Explores stress in areas such as work, extended family, and social relationships that impact sexual desire or performance. Assess fears of inadequacy as a sexual partner that leads to sexual avoidance. Assess any feelings of threat brought on by perception of having partner as sexually aggressive. Teach partner how to use of squeeze technique to retard premature ejaculation. Process the procedure and feelings about it.

9 Encourage expressions of desire and pleasure with sexual activity. Copyright 2011 THERAPYTOOLS.US All rights reserved