Meana Sexual Dysfunction in Women

1. Auflage 2012
ISBN: 978-1-61676-400-5
Verlag: Hogrefe Publishing
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 110 Seiten

Reihe: Advances in Psychotherapy - Evidence-Based Practice

"If you have time to read one book about female sexual dysfunction, this should be the one."
Sexual Dysfunction in Women is a concise yet detailed clinical guide to the treatment of sexual difficulties in women. Written with the general psychologist and therapist in mind and being published with the companion volume Sexual Dysfunction in Men, it takes the novel position that most clinicians interested and willing to help female clients with sexual concerns can do so effectively, even if they do not primarily consider themselves sex therapists. Many women will experience difficulties with desire, arousal, orgasm, or pain with intercourse at some point in their lives, yet most clinicians feel less equipped to treat sexual dysfunction than far less prevalent disorders. This book empowers general psychologists, therapists, and other practitioners to actively engage in the multidisciplinary treatment of sexual disorders and broaden their knowledge base about sexuality, an important component of most clients’ quality of life. It is both a go-to guide for professional clinicians in their daily work and an ideal resource for students and practice-oriented continuing education.

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Autoren/Hrsg.

Meana, Marta

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizinische Fachgebiete Psychiatrie, Sozialpsychiatrie, Suchttherapie
• Sozialwissenschaften Psychologie Psychotherapie / Klinische Psychologie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Urologie, Andrologie, Venerologie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Allgemeinmedizin, Familienmedizin
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Klinische und Innere Medizin Gynäkologie, Geburtshilfe

Inhaltsverzeichnis

1;Sexual Dysfunctionin Women;1
2;Preface;6
3;Dedication;8
4;Table of Contents;10
5;1 Description;12
6;2 Theories and Models of Sexual Dysfunction;32
7;3 Diagnosis and Treatment Indications;36
8;4 Treatment;54
9;5 Case Vignette;94
10;6 Further Reading;97
11;7 References;99
12;8 Appendix: Tools and Resources;107

Leseproben

Sexual interest/arousal disorder in women is the new diagnostic category currently proposed for the coming edition of the DSM (DSM-5) (American Psychiatric Association, 2012). This category would subsume the current diagnoses of HSDD and FSAD with the rationale that (1) neither the empirical literature nor women themselves reliably distinguish desire from arousal, and (2) the high degree of comorbidity between the two diagnoses makes their separation questionable. In its preliminary draft, this proposed diagnostic category consists of a polythetic Criterion A requiring at least three out of five indicators of lack of sexual interest/arousal (absent or reduced interest in sexual activity, erotic thoughts/fantasies, initiation/receptivity, excitement/pleasure, genital/ nongenital sensations) that have persisted for at least 6 months. Criterion B maintains distress or impairment. In addition to typifying whether the dysfunction is of the lifelong or acquired type, there is also a proposed list of six specifiers intended to reflect the various contextual and medical factors that can be implicated in any one woman’s difficulty (generalized/situational, partner factors, relationship factors, individual vulnerability factors, cultural/religious factors, medical factors).

This new proposed diagnostic category recommended by the DSM-5 Workgroup on Sexual and Gender Identity Disorders will be subjected to further review and expert feedback, which may result in significant changes to this draft. The Workgroup has also recommended that SAD be removed as a distinct sexual dysfunction given its greater similarity to specific phobia.

Orgasm Disorder

Female orgasmic disorder (FOD) is defined as persistent or recurrent delay or absence of orgasm following a normal arousal phase. The DSM definition acknowledges that there is a wide variability in the type and intensity of stimulation that triggers orgasm and, as such, leaves it up to the clinician to determine if the woman’s orgasmic capacity is less than might be expected for her age, sexual experience, and the competence of the stimulation she receives.

One would think that FOD would be relatively easy to diagnose since, unlike desire and arousal, it purportedly pertains to a discrete event. However, this is not necessarily the case. Unlike men, who usually ejaculate with orgasm, no such discrete event occurs with orgasm in women. Attempts to define orgasm have thus relied on extremely varied subjective descriptions (Mah & Binik, 2001), and a significant number of women are unsure whether or not they have experienced an orgasm (Meston, Hull, Levin, & Sipski, 2004). The other complicating factor in defining FOD relates to the competence of the stimulation the woman is receiving.

Despite decades of data indicating that the majority of women require clitoral stimulation to reach orgasm, there is a persistent expectation in the public that women should be having orgasm through intercourse. It is thus not unusual for couples to present in therapy with concerns about the woman’s orgasmic capacity because she fails to reach orgasm through penetration alone. Another factor that makes the diagnosis of FOD far from obvious is the fact that, in contrast to men, there is great variability in the extent to which women find orgasm an important component of their sexual experience and satisfaction.

The DSM-5 Workgroup on Sexual and Gender Identity Disorders recommends that the diagnosis of FOD be maintained but that it be elaborated to include reduced intensity of orgasmic sensations and to account for the expected high comorbidity with sexual interest/arousal disorders as well as the varied contextual factors (the aforementioned six specifiers) that could be affecting the experience of orgasm (American Psychiatric Association, 2012).

Sexual Pain Disorders

The DSM-IV-TR lists two sexual pain disorders. One is applicable to both men and women: dyspareunia (not due to a general medical condition). The other is specific to women: vaginismus (not due to a general medical condition).

Dyspareunia is described simply as recurrent or persistent genital pain associated with sexual intercourse. The pain cannot be caused exclusively by vaginismus or lack of lubrication. Pain associated with sexual intercourse occurs primarily during penetration, but in some women, it can last for hours and even days after the sexual encounter. Although this pain had traditionally been linked etiologically with sexual activity, the genital pain of dyspareunia is also experienced with other types of penetration or stimulation to the genital area (e.g., tampon insertion, finger insertion, gynecological examinations, and varied other types of genital contact) (Meana, Binik, Khalife, & Cohen, 1997a). In fact, research indicates that the pain–sex link might be incidental in the majority of cases (Binik, 2010a). Pain is experienced during sex not because of any psychosexual or relational conflict, but rather because sex involves the mechanical stimulation of a hyperalgesic area. The penis, speculum, and tampon are all simply pain stimuli making contact with tissue that has become hypersensitive.

The clinical presentation of dyspareunia is typically quite clear. Women generally report a significant amount of distress about the fact that they find intercourse anywhere from moderately painful to excruciating. However, the question of how to rule out – or even whether we should rule out – a general medical condition is not clear at all. There are a number of conditions of unknown etiology (provoked vestibulodynia [PVD] being the most prominent) that probably account for the majority of cases of dyspareunia in premenopausal women. PVD is characterized by a severe, burning/sharp pain that occurs in response to pressure localized in the vulvar vestibule, which is essentially the entry point to the vagina. Conditions such as these often go unrecognized because the only obvious symptom to the untrained professional is pain with intercourse. Consequently, it is easy to psychologize or sexualize the symptoms, despite the fact that there are very few accounts in the empirical literature of what could reasonably be termed “psychogenic dyspareunia.” Psychological and relational factors are important mediators of the experience of dyspareunia, but there are precious few data indicating that they give rise to the disorder. Vaginismus is described as a recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse. Interestingly, no mental health professional is in a position to verify this uniquely physical criterion appearing in a mental health manual. Furthermore, no woman presents clinically with this description. Typically the woman with vaginismus presents with intense fear of vaginal penetration, descriptions of penetration attempts as painful and distressing, and assertions that penetration is either impossible or close to impossible much of the time. Many of these women have similar fears and avoidance of gynecological exams. In fact, the vaginal muscle spasm definition of vaginismus appears to be based primarily on expert opinion, as there is no empirical evidence to support vaginal/pelvic muscle spasm as the defining characteristic of vaginismus (Binik, 2010b). Recent research has cast doubt on our ability to reliably distinguish vaginismus from certain types of dyspareunia (e.g., PVD). They both share reports of pain with sexual intercourse and with gynecological examinations, and both are characterized by an avoidance of penetration. It could be that vaginismus exists on the extreme end of a behavioral/affective continuum of dyspareunia. The one distinguishing characteristic may be fear and distress about vaginal penetration and pain, with women who typically receive the diagnosis of vaginismus suffering more from both (Reissing, Binik, Khalife, Cohen, & Amsel, 2004).

Genito-pelvic pain/penetration disorder is the new diagnostic category proposed for the DSM-5 (American Psychiatric Association, 2012). Originally, the radical recommendation was that this diagnostic category be entirely removed from the sexual disorders section of the DSM and be reclassified into the pain disorders section of the manual. The rationale was that the data support a conceptualization of dyspareunia and vaginismus as pain disorders that happen to interfere with sex, much as other pain disorders interfere with sex and other aspects of daily living. Calling them sexual pain disorders and classifying them with the other sexual dysfunctions inaccurately elevates the role of sex in their development. Furthermore, the new category would subsume the current diagnoses of dyspareunia and vaginismus, with the rationale that there is no current empirical basis for the differentiation between these two diagnoses. The latest draft of the proposal (last updated July 29, 2011) appears to indicate that genito-pelvic pain/penetration disorder, if adopted, will continue to be classified as a sexual dysfunction. The proposed criteria require persistent or recurrent difficulties with at least one of the following: inability to have vaginal intercourse/penetration, vulvovaginal or pelvic pain during penetration attempts, fear or anxiety about pain or penetration, tensing of pelvic floor muscles during vaginal penetration attempts. As in the case of the other two proposed categories, the distress criterion and onset sub-type are retained, while a list of specifiers is added to cover contextual influences.

1.3 Epidemiology

After decades of reliance on convenience and clinical samples, large-scale national and cross-national epidemiological surveys providing valuable prevalence data have been conducted in the last 15 years. Other than variations in the wording of question items, there are two important points to consider…