Portraits

Virginia’s mother taught her about sex at a young age. She told Virginia that sex is dirty and it is an obligation women have. Today she is married, and avoids sex with her husband when she can.

Rob admits, “I’ve never had much of a libido.” He can perform sexually just fine, he just isn’t that interested in sex.

Definitions and Key Thoughts

The Diagnostic and Statistical Manual for Mental Disorders IV (DSM-IV) offers two separate diagnoses of low sexual desire disorder. They are “Hypoactive sexual desire disorder” and “sexual aversion disorder.”

With hypoactive sexual desire disorder, a person experiences a persistent lack of sexual desire. However, once sexual behavior is initiated sexual performance may be adequate.

Hypoactive sexual desire disorder occurs in approximately 20 percent of persons.

With sexual aversion disorder, a person feels repulsed by sexual contact. Sexual activity is minimized or avoided.

Causes of low sexual desire disorders include but are not limited to:

• Emotional problems in a relationship
• Lack of affection in a relationship
• Lack of trust in a relationship
• Personal stress
• Past sexual abuse
• Side effects of medication
• Physical illness
• Lessons learned about sex being dirty or immoral
• Negative sexual experiences

While hormonal and physical issues can affect sexual desire, in most cases the origin of hypoactive sexual desire and sexual aversion are psychological, not physical.

Action Steps for Overcoming Low Sexual Desire Disorder

1. Get a thorough checkup.

Stated above, problems with a decreased interest in sexual activity can be a response to emotional, relational, or physiological factors.

A positive first step includes getting a medical evaluation, as well as addressing any emotional experiences or relationship problems that may be occurring.

2. Improve the relationship

Once a medical cause is ruled out, talk with your partner about how the two of you can team together in improving the relationship.

Common problems couples face that effect sexual desire include destructive arguments, current or past affairs, outside stressors, and a lack of quality time together.

3. Face any emotional roadblocks

An issue, separate from one’s relationship, may be affecting sexual desire.

Consider that stresses at work, money problems, and any current fears or anger one is harboring can negatively affect sexual desire.

Also, emotional issues from one’s past—such as pain from past sexual abuse or feelings of betrayal—can effect sexual desire.

4. Consider medical treatment

After consulting with a physician, if it is considered likely that decreased sexual desire has a physiological cause, there are several treatments that have been found to be effective.

Hormone therapy for women, including low doses of testosterone, have been found effective in treating female hypoactive sexual desire disorder.

5. Counseling and psychotherapy

Counseling can be effective in the treatment of sexual desire disorder by addressing any emotional issues behind the problem. Common emotional issues that interfere with sexual desire include depression, stress and anxiety, and past sexual trauma.

In addition, couples with present relationship problems often experience sexual difficulties. By improving one’s relationship through couples counseling, symptoms of low sexual desire could dissipate.

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Brian and Cindy feel they are not ready to have their first child and are looking for a safe and reliable contraceptive. Knowing there is some theological controversy about birth control, they come to you in pursuit of accurate information and guidance.

Dana and her husband have four kids, and are expecting another one soon. And they could not be happier. They feel that God will give them as many kids as He wants, and they are not to tamper with God’s plan for their family.

Jenny had a good night last night, maybe too good. Thinking she might become pregnant, she looks into the newer Plan B method of birth control.

Definitions and Key thoughts

Birth control and family planning can involve a difficult set of decisions for couples

There are many methods of birth control that can be considered. The following is only a very brief overview. As a counselor, if you will be dealing with this issue regularly, you will need to keep abreast of relevant medical trends and advances as they appear (and in this field changes and advances do happen regularly).

Some basic advice to give to the couple is that no contraceptive is 100% effective all the time (except abstinence or surgery). However, many are quite good when used properly and the greatest number of contraceptive failures occur when the methods are used carelessly or improperly.

The following details some common contraception options for couples:

Barrier Methods

Male condoms. Male condoms are the most common type of barrier contraception. Most commonly, condoms are made of latex or polyurethane (though ‘natural’ pigskin and new synthetic materials do exist). Latex condoms are the most popular, being the most affordable and very effective. It should be noted that latex condoms can only be used with water based lubricants—not oil based lubricants as they harm the integrity of the latex. In addition, a small number of people have an allergic reaction to latex.

Polyurethane condoms are becoming widely available. These condoms are thinner and transmit heat more readily that latex condoms, making intercourse feel more natural. It is not clear which are stroger—latex or polyurethane condoms, though some studies suggest neither is more likely to break. However, others claim that since polyurethane condoms stretch less than latex condoms, there is an increased chance of breakage or slippage if a condom is sized too tight or too loose. Also, both oil and water based lubricants can be used with polyurethane condoms.

Condoms are probably the least enjoyable method of contraception for most men and many women. Condom size (width and length) affects both comfort and effectiveness. To be most effective, condoms should be put on before there is any genital contact. After ejaculation, during intercourse, the penis must be withdrawn before any loss of erection, and the base of the condom needs to be held in place during withdrawal.

Recent studies have found that sexually active women who use condoms have a higher rate of depression than sexually active women who do not use condoms (2). There is a current theory that semen may function as an antidepressant when absorbed by a woman’s vagina.(3)

Female condoms. The female condom has been available in Europe since 1992 and it was approved by the US Food and Drug Administration (FDA) in 1993. The female condom is a polyurethane sheath about 6.5 inches in length that is worn by a woman during sex. It lines the vagina and it helps to prevent pregnancy and sexually transmitted diseases (STDs). Female condoms have about twice the failure rate of male condoms, though are thought to be better at protecting women from STDs. At each end of the condom is a flexible ring. The closed end of the sheath, which has a slightly smaller ring, is inserted into the vagina to hold the prophylactic in place. At the other/open end of the condom, the ring stays outside the entrance to the vagina to act as a guide during penetration and to prevent the sheath from bunching up inside the vagina. Since the condom does not move with the penis the sensation is more natural and enjoyable for the man, than male condom. However, some women find female condoms uncomfortable. Note: The female condom should not be used with a male condom because the friction between the two condoms may cause them to break. For more information on the female condom visit www.avert.org.

Diaphragms, Cervical Caps, and Shields. Diaphragms, cervical caps, and shields are all similar in that they are all inserted into the vagina before sex, and cover a woman’s cervix to prevent the union of sperm and egg.

• A Diaphragm is a shallow, dome shaped cup with a flexible rim.
• A Cervical Cap is a silicone cup shaped like a sailor’s hat. It is smaller in diameter than a diaphragm though still fits securely to cover the cervix.
• A shield (e.g., Lea’s Shield) is a silicone cup similar to a cap, with an air valve and a tab to aid in removal.

Each method must be used with spermicidal cream or jelly. The spermicidal ingredient kills sperm, while the inserted device prevents sperm from entering the woman’s cervix.

Diaphragms, caps and shields are reusable items that must be fitted to the woman’s body by a doctor. A new fitting is required if the woman gains or loses weight, or has a vaginal birth. Moreover, caps are more difficult to fit in women who have given birth, and failure rates are higher. Accordingly, Sixteen out of 100 women who use a diaphragm will become pregnant during the first year of typical use. Fourteen out of 100 women who have never been pregnant and use a cervical cap (FemCap brand) will become pregnant during the first year of typical use. 29 of 100 women who have given birth vaginally and use FemCap will become pregnant during the first year of typical use. Fifteen out of 100 women who use the shield will become pregnant during the first year of typical use (4).

Regarding user satisfaction, some people find using diaphragm, cap or shield to be a major interruption before sex, while others see it as a minor issue. Once in place, these methods are very comfortable for both the man and the woman, as neither should be aware of the product during intercourse. (5)

Sponges: Made infamous by a Seinfeld episode, the contraceptive sponge is a doughnut shaped piece of polyurethane foam containing spermicide that is inserted into the vagina and placed over the cervix. Because of the spermacide, sponges work both as a block and by killing sperm. Similar to diaphragms and caps, a sponge can be left in place for 24 hours and is good for multiple acts of intercourse (though more spermacide may need to be applied). Also similar to caps, the sponge must be left in the vagina for 6 hours after the last act of intercourse. On the negative side, some men claim they can feel the sponge, or its removal tab, during intercourse. Also, the failure rate with sponges is high: 9% for women who have not had a child, and up to 20% for women who have. Note: In 1995, the Today® Sponge was removed from the US market by its manufacturer. However, according to the Today® Sponge website; “The Sponge is Back! The Today® Sponge, once the most popular over-the-counter female contraceptive, has won re-approval for marketing in the U.S. and Canada. Soon it will be available in the UK and the EU.” For more information visit www.todaysponge.com.

Hormonal Methods

Pills. Birth control pills, despite their widespread use are quite controversial for some Christians. This is because, while some birth control pills (as well as the other hormonal contraceptives listed below) prevent fertilization of an egg, others prevent implantation on a fertilized egg (which to some is sacred life). To further complicate the topic, with some hormonal methods, there is considerable debate about which prevent fertilization, and which prevent implantation. Basically, all hormonal methods of contraception contain a progestin, a synthetic form of progesterone (that prevents implantation), and some also contain a synthetic estrogen (that prevents ovulation/fertilization). These two chemicals are presented in different amounts and strengths depending on the contraceptive being used.

There are two common types of birth control pills, progestin only pills (POPs) and combined oral contraceptives (COCs) that contain both progestin and estrogen. POPs allow ovulation at least some of the time. This means that fertilization is possible, while implantation is inhibited. Therefore, if a person understands life to begin at fertilization, POPs are a poor choice. In contrast, COCs are so effective at preventing ovulation that fertilization cannot occur. Theoretically, the progestin in the pills could interfere with implantation, but if fertilization never occurs this is irrelevant. Hence, COCs should be an acceptable form of contraception, even for couples that believe life begins at fertilization.

The Birth Control Shot. The birth contron shot, also know as Combined Injectable Contraceptives, are injections that are given monthly. This method is gaining populatiry because of the ease of use (one does not need to remember to take a daily pill), low side effects, and efficacy of the contraceptive. CIC’s contains both estrogen and progestin, and it’s likely that they are very effective at preventing ovulation, but because of the newness of CICs conclusive data is not available. (6)

Implants: Implants consist of about 6 match-sized tubes containing progesterone that are surgically inserted, by a physician, under the skin in a woman’s upper arm. The rods slowly release progesterone into the woman’s blood stream. Even though this method is progestin only, which thins the uterine lining making implantation impossible, because the delivery system provides a constant secretion of the progesterone hormone, ovulation is fully suppressed. Therefore, fertilization cannot occur. Implants, in general, work for between 3 to 5 years. They are 99% effective, and are literally user-error free. Also, the cost of an implant is quite reasonable at 450-900 dollars, for 5 years, as well as a removal charge of around 100-300 dollars. After an implant is removed, women generally experience a fairly quick return of fertility.

The Ring: The ring method, the most popular being NuvaRing ®, is a flexible circle of about two inches in diameter which is worn in the vagina for three weeks each month, then removed for one week (in which menstruation usually takes place). The ring is not felt by the women once inserted, and most men report they cannot feel the ring during intercourse. The hormones contained within the ring, which are a combination of estrogen and progestin, are absorbed directly into the blood stream through the vaginal wall. This method is very effective at preventing ovulation. In addition, with the use of the NuvaRing the uterine lining also becomes thinner than usual, which would inhibit implantation of a fertilized egg—if an egg were to become fertilized.

The patch: Patches are becoming increasingly popular for many kinds of medication, from smoking cessation meds to antidepressants. Their popularity is rooted in the possibility of receiving medication in a convenient form, with less chance of missing a dose. With a birth control patch, the woman wears a small patch of approximately 1 inch, for about 3 weeks a month. From this patch the same hormones from traditional pill contraceptives are delivered into the woman’s body.

Plan B® (levonorgestrel) prevents pregnancy (by 89%) if taken within three days of intercourse, though efficacy increases the sooner the pill is taken after intercourse. Though it is intended to be used after intercourse has occurred Plan B^® is not RU-486 (the abortion pill); it will not work if one is already pregnant. Still, because the method destroys fertilized eggs, the method has been widely condemned by Christians. However, there is growing scientific evidence that Plan B stops ovulation, but does not have any effect on a fertilized egg.(7) Plan B^® is considered an emergency contraceptive that can prevent a pregnancy after contraceptive failure (such as forgetting to take a pill, or having a condom break), unprotected sex, or sexual assault. You can learn more about Plan B by visiting their website at www.goplanb.com.

Intrauterine Device: An Intrauterine Device (IUD) is a small object that is placed in the uterus to prevent pregnancy. IUDs can last 1-10 years. The IUD is not noticeable during intercourse. While some claim that IUDs work by affecting the movements of eggs and sperm to prevent fertilization, generally they function by making the uterine liner unsuitable for implantation of a fertilized egg.

Sterilization Methods

Spermicides. Spermicides have been around for a long time, some claiming they have been used in some form since 1850BC. Today there are a number of spermicides available as suppositories, gels, creams, foams, and even a plastic film.( Many women and men like to use spermicides, either alone or in combination with some other form of birth control, because they are relatively inexpensive, easy to use and can be purchased without prescription. Also, spermacides have gained gain favor for they do not cause a physical separation of the male and female genital organs, as do condoms.

However, spermacides do have disadvantages; the foremost is that they have limited reliability when used alone. Hence, many persons who use spermacides use them in conjunction with condoms or a cervical cap type device. Other downsides include timing issues. That is, spermicides are only effective for a limited time–typically an hour–and some need to be applied up to fifteen minutes before intercourse can occur. In addition, some persons are irritated by nonoxynol-9, a common active ingredient in spermicides available in the USA. It has been found that for women, frequency of use significantly increases the chance of irritation (9), and that when use is limited to no more than every other day irritation is rare (only 3% over placebo).

Vasectomy. The vasectomy has been described as the most reliable form of birth control available. For example, the UK national sterilization guidelines came to the conclusion that “The failure rate of vasectomy should be quoted as approximately 1 in 2000 (0.05%)”.⁽¹⁰⁾ On rare occasion a vasectomy can reverse itself, however it occurs in only.025% or one in 4,000 vasectomies.⁽¹¹⁾

A vasectomy involves cutting (and more recently blocking) the vas deferens, which are the tubes that transport sperm from the testicles. Procedure failure is very rare, and complications uncommon. In addition, no change in sex drive is caused by vasectomy, although a few men seem to develop a psychosomatic response that interferes with normal sexual function. Also, since the testicles provide less than 5% of the seminal fluid with is ejaculated during orgasm, no difference in ejaculation is felt or noticed. Although vasectomies can sometimes be reversed, this is never assured and the operation should be considered a permanent fix.

New methods of a vasectomy include Vasclip, a method where a small plastic clip, about the size of a grain of rice is clipped over the vas deferens, effectively closing off the vas deferens. You can learn more about this procedure, and see pictures of the Vasclip, at www.vasclip.com.

Female tubal ligation. Female tubal ligation, sometimes referred to as “getting your tubes tied,” is a permanent birth control option in which women undergo a surgical procedure to close off their fallopian tubes. A completed procedure stops the egg, during ovulation, from traveling to the uterus from the woman’s ovary. The procedure also prevents sperm from reaching the fallopian tube. Hence, the surgery is 99.5% effective in preventing pregnancy.

Female tubal ligation involves cutting and tying, burning, or blocking (with bands, rings, or clips) a woman’s fallopian tubes. This is abdominal surgery and carries far more risk than a vasectomy. For this reason, a female tubal ligation seems a poor choice unless the woman already cut open, such as with a cesarean section—however some sources maintain female tubal ligation is a minor outpatient surgery.

One rare but serious complication of a tubal ligation is an ectopic pregnancy. In an ectopic pregnancy the fertilized egg implants in a fallopian tube rather than in the uterus. This is an extremely dangerous situation that results in death of the mother unless the pregnancy is identified and terminated. The overall rate of ectopic pregnancy for traditional tubal ligations is low as 0.7%. The age of the woman has an impact on the chances of an ectopic pregnancy; women having a tubal ligation under the age of 30 having double the risk, when compared to older females (12).

Timing Methods

Natural Family Planning/Fertility Awareness Method: The idea behind natural family planning (NFP) and the fertility awareness method (FAM) is this: A woman is fertile during only a small window of time each month. This small window is believed to be between 100 to 120 hours. Hence, if a couple is to avoid sexual intimacy during this time, pregnancy can be avoided. Conversely, NFP/FAM could be used to help achieve pregnancy by couples who are wishing to have a child.

The question that various NFP/FAM ask is “How can I determine exactly when the window of fertility is?” If the time-frame could be determined with 100% accuracy, then NFP/FAM would be a perfect method of birth control. However, the window can only be estimated–though with high probability if done correctly. Couples using NFP/FAM methods correctly have a much lower failure rate than condom users, and close to that of users of birth control pills.

To determine the window of fertility, NFP and FAM involve knowing when the woman is fertile by charting factors such as menstrual cycle length, morning body temperature, and cervical mucous. NFP is the only birth control method approved by the Roman Catholic Church. However, some persons have theological problems with NFP because it violates the Biblical command to only abstain from sex for the purpose of fasting and prayer (see 1 Cor 7:1-5, and Wise Counsel, below). To help with NFP/FAM there are numerous devices on the market to help determine when a woman is fertile.

(2) Research from New York University, published in Archives of Sexual Behavior May 20, 2002

(3) Birth Control, Paul & Lori Byerly, 2005, July, retrieved from http://www.themarriagebed.com/pages/biology/birthcontrol.shtml

(4) Planned parenthood, Diaphragms, Caps, and Shields: What They Are and How They Work, retrieved from http://www.plannedparenthood.org/birth-control-pregnancy/birth-control/diaphragms-caps-and-shields.htm

(5) Birth Control, Paul & Lori Byerly, 2005, July, retrieved from http://www.themarriagebed.com/pages/biology/birthcontrol.shtml

(6) IBID.

(7) ‘Emergency Contraception’s Mode of Action Clarified’ Population Briefs May 2005, Vol. 11, No. 2 link

(8) Birth Control, Paul & Lori Byerly, 2005, July, retrieved from http://www.themarriagebed.com/pages/biology/birthcontrol.shtml

(9) Roddy, R., et al. (1993). “A Dosing Study of Nonoxynol-9 and Genital Irritation. International Journal of STD & AIDS, 4(3), 165-70

(10) RCOG. UK national sterilisation guidelines 2004.

(11) Harvard Medical School “Well connected”, 2001.

(12) “The Risk of Ectopic Pregnancy After Tubal Sterilization” March 13, 1997 issue (336:762-767) of The New England Journal of Medicine.

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Diane and her husband Dan have been trying new things to spice up their sex life. “Here’s something we haven’t tried,” Dan says.

Coleen wants to preserve her virginity, but her boyfriend wants sex. A girlfriend of hers said that there is a way both can get what they want. “I’m not sure about that,” Coleen says.

Definitions and Key Thoughts

Anal sex generally refers to the act of inserting one’s penis into another person’s rectum. However, the term anal sex may also be used to refer to the act of inserting one’s fingers or other object into a person’s rectum for the purpose of sexual pleasure. Also, anilingus, the act of orally stimulating another person’s rectum is also sometimes referred to as anal sex.

Anal sex is a widely practiced by both homosexual and heterosexual persons.

A 2005 survey conducted by the Centers for Disease Control and Prevention (CDC) determined the practice of anal sex is increasing with the heterosexual population. Reported in the study, 40 percent of men and 35 percent of women between 25 and 44 had engaged in heterosexual anal sex (in 1992 a similar survey of persons 18-59 found 25.6 percent of men and 20.4 percent of women had participated in anal sex).[i]

According to the famous sex researcher Alfred Kinsey, he found (in the 1940s) that the number of persons who have participated in anal sex is approximately 40%.

In 2005, the University of British Columbia published a study suggesting between 30-50 percent of heterosexuals have participated in anal sex.

Anal Sex is a sexual practice considered to be somewhat “high risk,” due to the potential for physical damage that can occur during the act, infections that can occur due to the septic nature of the rectum, and the increased potential for transmitting sexually transmitted diseases.

Some of these risks of Anal sex can be managed by wearing a condom, using a personal lubricant (Note: lubrication is important with anal sex because the natural rectal mucosa does not provide much lubrication), and good communication between partners during the anal sex act.

Anal sex is sometimes practiced to avoid an unwanted pregnancy, or to engage in sexual activity that does not break the woman’s hymen—preserving a woman’s virginity.

Anal sex is also practiced for sexual pleasure. The anus is generally known to be tighter than the vagina, which may yield more physical pleasure, or a different physical sensation during sex, for both men and women. The anus also contains a cluster of nerves which can create sexual pleasure for the person receiving. With men, the prostate gland is in close proximity to the rectum. This anatomical positioning has been suggested to make anal sex sexually satisfying for men.

Safe Anal Sex Tips

1) Don’t be pressured into Anal Sex.

While some couples practice anal intercourse, others are not interested or against having it.

While some persons have practiced anal sex for birth control reasons, more conventional methods of birth control including condoms, oral contraceptives, spermicidal gels, and abstinence. These may be better practices if one is not interested in having anal sex.

While it is true anal sex will not damage a woman’s hymen and will technically preserve a woman’s virginity according to the medical definition, if one is not ready to have sex or desires to remain a virgin, talking to one’s partner about not being ready or not wanting to have sex may be preferable to having anal sex.

2) Safe anal sex practices.

If you and your partner decide to have anal sex, here are several preparation tips

Use a personal lubricant

The rectal mucosa tissue does not lubricate the way a vagina will lubricate during sexual intercourse. Using a lubricant will make the act of anal sex more enjoyable for both partners, and reduce the risk of physical injury.

Wear a condom

In terms of health risks, anal sex is not a safer practice than vaginal sex. In fact, practicing anal sex increases one’s risk of contracting an STD due to the higher risk of tearing or bleeding that can occur.

Note: due to the septic nature of the rectum, one should always change the condom before engaging in vaginal sex after anal sex.

Sexual communication

Communication between partners is extremely important during anal sex. Talking to your partner about what feels good, and what is painful, will reduce the risk of physical injury as well as make anal sex a more enjoyable experience.

If the “receiving” partner is not accustomed to anal sex, the “giving” partner will likely need to be very gentle and use very slow movements.

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Portraits

Since he was a teenager, Carl has had reoccurring fantasies about being restrained, humiliated, or abused in a sexual way. His fantasies took root when he found a group of others who routinely participate in these behaviors.

Jenny was reading the personals section of the classifieds when she came across an ad from a person requesting a “sex slave.” She immediately ignored the ad, but then found herself excited by it, and drawn back to it.

“Sex isn’t the same for me as it is for other people,” Ryan explains. “I can’t get aroused with normal sexual touching. I need to dominate another person to feel anything. I want to tie someone up, then blindfold and paddle them.”

Definitions and Key Thoughts

Sexual Sadism and Sexual Masochism are two separate psychological disorders and each are categorized by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) as a paraphilia, which is a sexual disorder characterized by socially unacceptable preoccupations or behaviors (other paraphilias include voyeurism, exhibitionism, and Fetishism).

Sadism and masochism are characterized by feelings of sexual pleasure or gratification when inflicting suffering on another person, or having it inflicted upon one’s self, respectively.

The official DSM-IV criteria for sexual sadism are:

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

B. The person has acted on these urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

The official DSM-IV criteria for sexual masochism are:

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

A person with a diagnosis of sexual sadism is known as a sadist. The name is derived from Marquis Donatien de Sade (1740-1814), a French aristocrat who became famous for writing novels around the theme of inflicting pain as a source of sexual pleasure.

A person with a diagnosis of sexual masochism is known as a masochist. Like sadism, the term masochist is derived from a proper name; Leopold von Sacher-Masoch (1836-1895), an Austrian novelist who described the disorder in his works.

The term Sadomasochism is used to describe either the co-occurrence of sadism and masochism in one individual, or as a replacement for both terms.

In 1905, Sigmund Freud described “Sadism” and “Masochism” in his Drei Abhandlungen zur Sexualtheorie (”Three papers on Sexual Theory”) as diseases developing from an incorrect development of the child psyche.

The first use of the compound term Sado-Masochism was by the Viennese Psychoanalyst Isidor Isaak Sadger in his work Über den sado-masochistischen Komplex (”Regarding the sadomasochistic complex”) in 1913.[i]

In some extreme cases, sexual sadism can lead to serious injury or death for the target of the sadistic behaviors. According to the DSM-IV these occurrences are often when the paraphilia is diagnosed as severe, and when antisocial personality disorder is also present.

Some acts of sadism are not physically harmful, and are aimed at humiliation. These include:

· Urinating on someone

· Insults

· Restraining a person with handcuffs, chains, ropes, or cages.

Act of physical sadism include:

· paddling

· spanking

· whipping

· burning

· beating

· administering electrical shocks

· biting

· urinating or defecating on the other person

· cutting

· rape

· murder

· physical mutilation.

Action Steps and Treatment Plan for Sadism and Masochism

Treatment of sexual sadism or sexual masochism may be complicated by health problems related to promiscuous sexual behavior. Sexually transmitted diseases (STDs) and other medical problems may be present.

Note: Acts of sexual sadism or sexual masochism tend to grow more violent or bizarre over time. However, as persons with either disorder grow older, their ability or desire to participate in such behaviors begins to decrease. For example, sexual sadism is rarely diagnosed in men over 50 years of age.

1) Replace Violent Behaviors

Sadistic behaviors range in terms of their violent nature. Some sadistic behaviors are focused on humiliation and mild pain, while others are aimed toward severe pain.

Also, a practicing sadist will either find a willing partner to participate in these behaviors, or will find a sexual victim.

Replacing violent behaviors with less violent behaviors, and making a commitment to only participate in rough sexual activities with persons who are willing to participate is a preliminary way to ensure the safety of the sadist, masochist, and other persons involved.

2) Focus on Healthy Sexuality

Identifying and focusing on sexual practices that are gratifying and that do not incorporate sadistic or masochistic behaviors will help one to participate in normal sexual behavior.

Encouraging and expanding normal sexual practices is a way to use the strengths and assets and tendencies toward normal sexual practices that a person already has.

3) Make a Commitment to Change

Even if a person is fantasizing about sadism or masochism, one can make a conscious commitment to not outwardly participate in such behaviors.

One method for encouraging this is by helping one see that other persons are innately valuable and should be treated with respect and even care. This understanding of another person’s value is to supersede any desire to practice violent or humiliating acts against them. Similarly, seeing one’s self in this same way (as valuable) should supersede one’s masochistic desire to have violent or humiliating acts inflicted upon them.

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Portraits

“It was pretty cut and dry” Monica explained. “My supervisor, in no uncertain terms said that if I want to keep my job I was going to have to put out. I refused, and I was fired.”

“It seems silly for me to be reporting sexual harassment, but I’m going to do it anyway,” John said. “I work in an office of all women and half the day I am really uncomfortable. The conversations about sex and men, the names they have for me, the excessive touching; I can’t take another day of it.”

Kathy is COO of a medium sized company in Nashville, TN. “My first executive maneuver when coming onboard was to put in place a program to educate the staff about sexual harassment, and a system to report any hint of sexual harassment in the workplace. I got a few odd looks from the other managers when I did this—there had never been a problem with sexual harassment at our company. And now, perhaps there never will be.”

Definitions and Key Thoughts

Sexual harassment is a form of sexual discrimination that violates Title VII of the Civil Rights Act of 1964.

Sexual harassment occurs when sexually oriented conduct explicitly or implicitly affects an individual’s employment, interferes with an individual’s work performance, or creates an intimidating, hostile or offensive work environment.[i]

Sexual harassment may resemble one or more of the following examples:

· Unwelcome sexual advances

· Requests for sexual favors

· Verbal conduct of a sexual nature

· Physical conduct of a sexual nature

Sexual harassment can occur in a variety of circumstances, including but not limited to the following:

• The target may be male or female.
• The harasser may be male or female
• The target may be the same sex or the opposite sex of the harasser.
• The harasser can be the target’s supervisor, an agent of the employer, a supervisor in another area, a co-worker, or a non-employee.
• The target does not have to be the person harassed but could be anyone affected by offensive conduct.
• Sexual harassment may occur without economic injury to, or terminated employment, of the target.
• The harasser’s conduct must be unwelcome.[ii]

In many cases it is helpful for the target to directly inform the harasser that his or her conduct is unwelcome and request its immediate cessation. Conversely, the target may use any complaint mechanism or grievance system available at the place of employment. Often sexual harassment will cease after an internal complaint is filed.

According to one official US government department, The U.S. Supreme Court has simplified matters concerning sexual harassment by describing two basic types of unlawful sexual harassment in the workplace.

Type One: Quid Pro Quo

The first type of sexual harassment includes a tangible employment action. An example of this could be a supervisor who tells a subordinate that he or she must be sexually cooperative or he or she will be terminated, passed up for promotion, punished, etc., and who then an takes an action when the employee does not cooperate. This is referred to as the quid pro quo type of sexual harassment because of its “this for that” nature.[iii]

Type Two: Hostile Environment

A second type of sexual harassment is referred to as the “hostile environment” type. Unlike the quid pro quo type where a supervisor imposes an ultimatum, the hostile environment type can result from the unwelcome conduct of supervisors, co-workers, customers, or anyone else with whom a harassed employee Interacts. Behaviors that constitute hostile environment type harassment include:

• Threats to impose a sexual quid pro quo
• Discussion of sexual activities
• The telling of off-color jokes
• Unnecessary or excessive touching
• Comments on physical attributes of an employee
• The displaying of sexually suggestive pictures
• The use of inappropriate nicknames, such as “Honey,” “Doll,” or “Babe”
• Threatening or hostile physical conduct
• The use of crude, crass, and offensive language[iv]

Action Steps for Sexual Harassment

Step One: Prevention

According to the U.S. Equal Employment Opportunity Commission, prevention is the best tool to eliminate sexual harassment in the workplace.

Prevention begins with employers and managers, not employees or potential targets of sexual harassment.

Employers and managers are to clearly communicate to employees that sexual harassment will not be tolerated, and also create an open environment where sexual harassment, or even potential sexual harassment, can be reported without fear or recourse.

This can be accomplished in part by establishing complaint or grievance processes, and also by taking immediate and appropriate actions if and when employee complaints occur.

Step Two: Reporting Sexual Harassment

If one believes or suspects they have been a target of sexual harassment, it is appropriate to report the incident.

One may report the incident to the management at their place of employment, or can file a charge of sexual harassment with the U.S. Equal Employment Opportunity Commission (EEOC).

To file a charge with the EEOC:

Charges may be filed in person, by mail or by telephone. If there is not an EEOC office in within a suitable distance to visit in person, one can call EEOC toll free at 800-669-4000 (or call 800-669-6820 for the hearing impaired (TDD)) for more information on filing a charge of sexual harassment.

There are strict time limitations in which charges of sexual harassment or discrimination can be filed. To ensure the ability of EEOC to act on one’s behalf and to protect one’s right to file a private lawsuit (should one ultimately need to be filed), be sure to follow any guidelines provided by the EEOC when filing a charge.

For more detailed information, locate an EEOC office nearest to you online at: http://www.eeoc.gov.

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Profiles

Andy has a secret he has never told anyone—“No one would understand. I don’t even understand it myself,” he thinks to himself. Even though he has never acted on his sexual urges toward children, he feels overcome with guilt, and feels so very dirty. He hated himself so much for what goes on in his head he is even considering killing himself.

Lois spent the afternoon at the police station, bailing out her husband. “Child pornography!?” she says to Bob. “You should be ashamed of yourself. You make me sick!” Bob sits quietly during the car ride home, feeling both ashamed and sick.

John has suffered from pedophilia since he was a teenager. He speaks to a room of men and women with the same problem. “We all have our struggles, and this one is mine” He says. “I’m happily married, and I’m proud to say I have never in my life acted on ‘the urge’.” He assures the group that no matter what has occurred in their pasts that there is healing to be found.

Definitions and Key Thoughts

As a medical diagnosis, pedophilia (sometimes spelled paedophilia) is a psychological disorder where the sufferer presents a sexual attraction to prepubescent children.

Pedophilia is classified by the American Psychiatric Association in the Diagnostic and Statistical Manual for Mental Disorders IV (DSM-IV) as a paraphilia, which is a sexual disorder involving socially unacceptable desires or practices (other paraphilias include exhibitionism, voyeurism, and sexual sadism).

The International Statistical Classification of Diseases and Related Health Problems defines pedophilia as “a sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age.”[i]

A person who practices pedophilia is a pedophile.

Most pedophiles are men, though pedophilia occurs in women as well.[ii]

While many persons guilty of child sexual abuse are pedophiles, not all persons who suffer from pedophilia have acted on their sexual urges toward children. Put another way, not all persons who experience the urges of pedophilia participate in pedophilic behavior.

The causes of pedophilia are not fully known. However, research on the origins of pedophilia is ongoing.[iii]

Diagnostic Criteria

The American Psychiatric Association’s publication, the DSM-IV, provides the following diagnostic criteria for Pedophilia. The following criteria must be met for a diagnosis of pedophilia:

• Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger);
• The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty;
• The person is at least age 16 years and at least 5 years older than the child or children in Criterion A.

The diagnosis of pedophilia is further specified by the sex of the children the person is attracted to. Moreover, a specific designation is added if the impulses or acts are limited to incest. Also, the diagnosis of pedophilia is sometimes split further into the two following categories:

• Exclusive Type (attracted only to children)
• Nonexclusive Type (attracted to both children and adults)

According to a study of 2429 adult male pedophile sex offenders in the U.S., only 7% identified themselves as “exclusive.” This suggests that the majority of pedophiles, or at a minimum pedophiles prone to acting on their urges, are attracted sexually to both children and adults.[iv]

Action Steps and Treatment Plan for Pedophilia

Even with treatment, most people who experience pedophilia are never completely cured of their sexual urges toward children. However, counseling therapy can help one reduce their sexual urges, and help a person to live a life free of acting on inappropriate sexual urges. The following tips serve as a starting point for pedophilia treatment.

Step One: Make a Commitment to Act Responsibly

Even if a person suffers from pedophilia (that is a sexual attraction to children) a person never needs to act on those urges.

It is important to realize that feeling attracted to children is not a choice, and one who suffers from pedophilia should not feel guilty for having attraction and urges. One who suffers from pedophilia can feel good in him or herself in that even though they are prone to being sexually attracted to children they choose to (1) never act on those urges, (2) consistently work to decrease those urges, and (3) refuse to fantasize about children by refocusing their thoughts to another topic when sexual fantasies begin.

Step Two: Focus on Healthy Sexuality

According to a study of nearly 2500 adult male pedophiles residing in the U.S., only 7% of participants identified themselves as having an exclusive attraction to children. For the vast majority of participants (93%), they experiences sexual attraction to both children and adults.[v]

Focusing one’s sexual energy on healthy sexual behaviors, and having a satisfying sex life—one within a committed marriage—may help to quell unhealthy sexual attraction or tendencies.

Step Three: Accountability and Support

Pedophilia is a serious problem because it not only affects the person who experiences the disorder, it also has the potential to seriously damage the life and happiness of a victim of sexual abuse.

Because of the serious nature of the problem, it is highly important that a sufferer of pedophilia, or pedophilic symptoms, find a support system. This may include an accountability partner who the pedophile can talk to about his or her ongoing struggles (and who can protect the person from their actions if the pedophilia becomes too severe to control). This may also include an appropriate therapy group, or support group, where one can learn more about their struggles, and learn that others face similar challenges.

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Portraits

Sam was named after her father, and has always been “Daddy’s favorite.” “That’s not to be confused with Daddy’s little girl,” she says. She also says, “I hate being a girl—I’m more boy than girl.”

Pat had a normal childhood, but around the age of 13 starting feeling that something was wrong. Now at 16 years of age, he isn’t developing physically like the other boys, and socially he’s being picked on more and more. One classmate commented about Pat, “What the heck is he? He walks, talks, and even looks like a girl.”

Once called Danny, Danielle has been taking hormone treatments for the last year to develop secondary sex traits common for women. “Hips and Breasts is a good first step,” Danielle says. “As soon as I can afford it, I’m getting the surgery to become a woman. I’ve been a woman my entire life on the inside. Now I will finally be a woman on the outside too.”

Definitions and Key Thoughts

Gender identity disorder is a diagnosis given to persons who meet a certain number of clinical criteria related to feelings of discontent regarding one’s biological sex, and identification with the opposite biological sex.

According to the American Psychiatric Association and the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) the following criteria must be met before a person can be give the official diagnosis of gender identity disorder:

1. There must be evidence of a strong and persistent cross-gender identification.
2. This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex.
3. There must also be evidence of persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex.
4. The individual must not have a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia).
5. There must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The DSM-IV also provides diagnostic criteria for gender disorders that do not meet the criteria for the general gender identity disorder diagnosis. The following criteria are sufficient for a diagnosis of Gender Identity Disorder in Children as well as for Gender Identity Disorder Not Otherwise Specified (GIDNOS). For the former diagnosis, criteria must be identified before a person is 18 years of age.

1. Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria
2. Transient, stress-related cross-dressing behavior
3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex, which is known as skoptic syndrome

Regarding origins of gender identity disorder, gender identity disorder in children is often reported as “having always been present,” and persons with the disorder do not remember a time when they were satisfied with their gender. Other persons with the disorder report that synptoms began in adolescence or adulthood, and seemed to grow in intensity over time.

Issues regarding gender identity can manifest in a variety of ways. For example, some people may cross-dress, while others may seek a sex-change surgery. Below is a list of other common “side effects” of gender identity disorder.

Children often:

• Express a desire to be the opposite sex
• Find their genitals or indicators of their gender gross
• Believe that they will grow up to become the opposite sex
• Are often rejected by their peers
• Become isolated and shy
• Develop moderate to severe anxiety
• Present low self-esteem
• Drop out of school
• Develop moderate to severe anxiety

Adults often:

• Desire to live as a person of the opposite sex
• Pursue a sex reassignment operation
• Both dress and act in a way that is indicative of the opposite sex
• Become socially isolated or ostracized
• Develop moderate to severe depression
• Develop moderate to severe anxiety

Some persons with gender identity disorder have genitalia and secondary sex characteristics in line with their biological sex. Others may have ambiguous genitalia, or are hermaphroditic (this can often lead to gender identity issues). Note: while a person may have an external ambiguous gender appearance, they are not both or of no biological sex. The chromosomes what designate sex (XX, XY) are still designate the person as male or female.

Not all transsexual persons (persons who dress or act as persons of the opposite gender) have gender identity disorder. Transvestic fetishism is another clinical condition (categorized as a paraphilia), and is described in another chapter in this book.

Homosexuals do not (generally speaking) have gender identity disorder. The majority of homosexuals identify strongly with their biological gender. Homosexuality involves only a sexual attraction to persons of the same gender.

Action Steps and Treatment Plan for Gender Identity Disorder

Treating gender identity disorder can be a slow and complicated process. Consider the following steps as places to begin. Note: With gender identity disorder, better recovery outcomes are associated with early diagnosis and treatment.

Step 1: Identify and Challenge Negative Thoughts about One’s Biological Sex

First, identify any negative thoughts that are being had in regards to one’s gender. For example, a male suffering from gender identity disorder may say, “Men are pigs. They are crude, crass, and uncaring. Unlike me, men are athletic and sportsmanlike. Men don’t enjoy art and fashion.”

Look at these negative statements and note if there are any “lies” or half-truths that are being said. For example, many men are not crass, are un-athletic, and enjoy art.

Step 2: Find Ways that One Can Identify with One’s Biological Sex

A person with gender identity disorder generally believes they cannot identify with their biological sex.

Assess what things are present in one’s life that do correspond with their biological sex. For example, a woman suffering from gender identity disorder may feel that she does not identify with cosmetics. However, she does identify with Grey’s Anatomy—a show watched by more females than males.

Note these similarities and continue to identify things that one does have in common with others of the same biological sex.

Step 3: Neutralize Physical Issues

Some persons with gender identity disorder have genitalia and secondary sex characteristics in line with their biological sex (meaning they have physically developed normally). However, others may be experiencing either ambiguous genitalia, or a hermaphroditic physical condition.

If the later is present, consider that even though one’s external appearance is different from the average person of a particular sex, genetically one is always fully male or fully female. This male or female designation does not occur in one’s phenotype (the way their body looks externally), it occurs in their genotype, whether they present XX or XY chromosomes.

Confirming one’s gender based on genetics, and considering outward biology as only secondary, may be an effective tool in reframing thoughts about gender identity.

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Kate loves leather. She has leather pants. She has leather bed sheets. Leather is such an important part of her sex life that without it sex seems dull and listless.

Keith is what you call a ‘foot man.’ She’s said a number of times, “I don’t know if a woman is attractive until I see her feet. I got to see her feet.” Even in the winter he asks his wife wears her high-heeled sandals.

Something about the smell of rubber has always turned Megan on. She shyly admits this to her friends one day. “Is that weird or what?” she says.

Definitions and Key Thoughts

Fetishism is more accurately called sexual fetishism or erotic fetishism.

One who has a sexual fetish is known as a fetishist.

Fetishism is the sexual attraction to materials or objects not conventionally viewed as being sexual in nature. When a body part is the subject of a person’s fetish (known as partialism), to the fetishist the body part will often take sexual precedence over the rest of the owner.

The term sexual fetish was first introduced by Alfred Binet, the famous psychologists best known for developing the IQ test. [i]

Fetishism is categorized by the American Psychiatric Association as a paraphilia, a sexual disorder characterized by abnormal or socially unacceptable sexual behavior (other paraphilias include voyeurism and exhibitionism).

Many people never seek treatment for their sexual fetishes but instead embrace or even celebrate them. Some consider fetishes to be an element that enhances their sexual relationship.

In a review of the files from a teaching hospital; of 48 cases over a 20 year period who met criteria for fetishes, the objects of their fetishes included clothing (58.3%), rubber and rubber items (22.9%), footwear (14.6%), body parts (14.6%), leather and leather items (10.4%), and soft materials and fabrics (6.3%).[ii]

Today many psychologists and medical doctors regard a fetish as a normal variation of human sexuality. The practice of incorporating a fetish into sexual practice is often understood to be unobjectionable as long as all involved persons feel comfortable.

According to the International Classification of Diseases (ICD), fetishism is the use of inanimate objects as a stimulus to achieve sexual arousal and satisfaction. The diagnostic criterion for fetishism is as follows:

• Unusual sexual fantasies, drives or behavior occur over a time span of at least six months. Sometimes unusual sexual fantasies occur and vanish by themselves; in this case any medical treatment is not necessary.
• The affected person, her object or another person experience impairment or distress in multiple functional areas. Functional area refers to different aspects of life such as private social contacts, job, etc. It is sufficient for the diagnosis if one of the participants is being hurt or mistreated in any other way.

Action Steps and Treatment Plan for Sexual Fetishism

Sexual fetishism is rarely treated in the conventional sense. Some person have attempted to treat sexual fetishism with cognitive behavioral therapy (which helps one see how their thoughts effect their emotions) or through psychoanalysis (which could look into the origins of fetishism by seeking out a trauma from one’s past). However, treatment may be more successful if it focuses on keeping a fetish under control, and by making sure one’s sexual partner is comfortable with the sexual practices.

1) Keeping it under control

If you have a sexual fetish, try focusing on parts of your partner’s body that are customarily sexual in nature.

Allow yourself to become sexually aroused by all parts of your partners body, and take time to appreciate the body as a whole. Remember the whole is greater than the sum of its parts.

2) Establish comfort in the sexual relationship

Find a way to incorporate your sexual desires and your partner’s sexual desires into the sexual relationship.

The most important thing is that you and your partner feel safe and comfortable in the sexual process.

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Roger is a real man’s man. Except he has a secret ‘the guys’ would never approve of.

Jim started dressing as a woman when he was just a child. His older sister would dress him as a girl when they would play together. As he grew older, he never grew out of liking to dress in women’s clothing, and now finds it both entertaining and sexually gratifying.

Carl doesn’t just pass for a woman; he’s often the prettiest ‘woman’ in the room—tall, dressed to kill, and a sexy female voice to boot.

Definitions and Key Thoughts

Transvestic fetishism is categorized as a paraphilia by the American Psychiatric Association. A paraphilia is a sexual disorder characterized by socially inappropriate sexual conduct (other paraphilias include exhibitionism and voyeurism).

A person experiencing a transvestic fetish derives sexual gratification from dressing in clothing made for persons of the opposite gender.

Usually persons with a transvestic fetish are men who dress as women. It has been suspected that the majority of persons with transvestic fetish are men because females can often wear men’s clothing without anyone taking notice.

Related terms for a transvestic fetish are transvestism (the practice of having a transvestic fetish), and transvestite (one who has a transvestic fetish).

A transvestic fetish can range from dressing partially in clothing of the opposite gender, to dressing fully, to wearing cosmetics of the other gender, and speaking or using mannerisms of the opposite gender.

Some transvestites appear to be of the opposite gender to the degree that they cannot be distinguished as transvestites.

Persons who are transvestites should not be considered homosexual. According to the Diagnostic and Statistical Manual IV (DSM-IV), most men who dress as women are heterosexual.

Origins and Causes of Transvestitism

Transvestic Fetishism usually begins in adolescents, when boys begin to experiment with the clothing or cosmetics owned by their sisters or mother.

In some cases transvestic fetishism begins earlier, if a mother dresses her son as a girl. This practice is often associated with the mother’s anger toward men, preference of little girls over boys, or in some cases ‘hatred’ of the male gender.

Action Steps and Treatment Plan for Overcoming Transvestic Fetishism

One encyclopedia of mental disorders makes the following points about the treatment of Transvestic Fetishism:

· The use of aversion therapy, and particularly the use of electric shocks has been largely unsuccessful in treatment of transvestic fetishism.

· Persons with fetishes have also been treated by using a form of behavioral therapy known as “orgasmic reorientation.” This therapy attempts to help people learn to respond sexually to culturally appropriate stimuli. This also has had limited success outcomes.

· Most persons who have a transvestic fetish never seek treatment from professionals. A preoccupation with cross-dressing is viewed as essentially harmless to other persons, since transvestism is not associated with criminal activities or forcing one’s sexual preferences on others.[i]

A Desire to Change

Transvestic Fetishism is not an addiction, so often the willingness or desire of one to change their behavior is an effective step in putting transvestism in one’s past.

Also, most participants of transvestite behaviors are capable of achieving sexual gratification without dressing as the opposite gender.

Focusing or brainstorming on how one can experience sexual gratification in more socially acceptable ways will also help one to overcome transvestitism.

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Portraits

Blair has had a great sex life, and hasn’t experienced real painful sex since she lost her virginity—about 30 years ago. “I don’t want the sex life between my husband and I to be over” she says, but it’s hurting more and more all the time.

“It burns like crazy during intercourse,” says Joel. Is it an STD?

My husband and I like having rough sex. But sometimes it hurts pretty badly afterwards. What can I do to help the problem?

Definitions and Key Thoughts

There are two major classifications of sexual pain disorder, dyspareunia and vaginismus.

Dyspareunia can occur in both men and women and refers to pain in the pelvic area during or after sexual intercourse.

Vaginismus occurs in women only and involves an involuntary muscular spasm of the tissue surrounding the vagina. This causes the vagina to close, which results in penetration being painful, or impossible.

Vaginismus occurs in less than two percent of women.

According to the American Psychological Association, dyspareunia is due to physiological factors at least 75 percent to 80 percent of the time.[i] When psychological and emotional factors are a factor, the problem often involves feelings of guilt or shame about sexual contact, or memories of past sexual abuse.

Vaginal pain during sexual intercourse can be due to a variety of causes including:

• An aggressive or impatient sexual partner
• Premature lovemaking following childbirth or surgery (episiotomy)
• Decreased levels of female hormones during or after menopause (vaginal lining loses its normal moisture)
• Inflamed hemorrhoids
• Genitourinary tract infections (such as a bladder infection)
• Vulvar vestibulitis (inflammation of the vestibule of the vagina—the area of the perineum between the labia minora including the opening of the vagina and the urethra) is among the most common causes of dyspareunia in women, and is commonly overlooked
• Herpes sores[ii]

Note: Vaginal pain at entry that decreases over time is commonly caused by inadequate lubrication. This is often due to lack of sufficient sexual arousal and stimulation.

Male Dyspareunia also has common causes. Pain occurring while obtaining an erection may be associated with inflammation of the foreskin, psychical trauma to the penis, infections, genital allergies, or Peyronie’s disease. The most common causes of pain during male ejaculation are prostatitis and urethritis.

Assessment Interview for Sexual Pain Disorder

If one is experiencing sexual pain, a physical exam should be sought by a licensed physician.

1. When did the sexual pain begin?
2. Is there any time when it is not painful to have sexual intercourse?
3. Has anything helped decrease the amount of sexual pain experienced?
4. Is your sexual partner aware of the pain you feel during sex?
5. Does your sexual partner experience pain during sexual intercourse?
6. Where specifically does the pain occur? (Labia, vagina, glans of the penis?)
7. Do you have any history of sexual abuse?
8. Do you believe that your sexual activity is in anyway embarrassing, shameful, or unethical?

Action Steps and Treatment Plan for Sexual Pain Disorder

Treatment for sexual pain differs depending on the sufferers gender and the root cause of the pain.

For eliminating sexual pain, strategies include:

Patience

Being less aggressive and gentler during the act of sex will allow a female more time for vaginal lubrication.

Sexual foreplay. Stimulation by the hand or oral sex can also be used prior to intercourse to decrease sexual pain.

After a pregnancy or a surgery in the pelvic area, wait at least three weeks before attempting sexual intercourse.

Lubricants

If the problem is associated with vaginal dryness, a lubrication fluid, cream, or gel can be applied to the vagina, or the partner’s penis, to ease insertion of the penis during sex.

Medications

Certain medications can help to relax the vagina during intercourse, can increase sexual hormones such as estrogen or testosterone, and can help change the physical sensation of sexual intercourse.

In some instances, sexual surgery can be an effective treatment for sexual pain disorder in women.

For men; if one is experiencing painful intercourse due to a penile skin infection, or an infection of the urethra, antibiotics can be prescribed by a physician.

If painful intercourse is caused by herpes sores, allowing time for the sores to heal is often the best treatment. A physician may be able to prescribe a medication to promote healing and delay future outbreaks.

Psychological Care

If emotions or psychological issues are a factor, addressing one’s thoughts and feelings about sexual intercourse can be helpful.

Doe the sufferer consider sex to be dirty, shameful, or unethical? Is the sufferer associating sexual intercourse with past sexual abuse? These are just two areas that can be treated through counseling and psychotherapy.

Sexual Therapy for Vaginismus

The American Psychological Association has presenting the following advice on treating the sexual pain disorder vaginismus:

“The treatment of choice with vaginismus is an extensive therapy program combining education and counseling with behavioral exercises. Exercises include pelvic floor muscle contraction and relaxation (Kegel exercises) to improve voluntary control.

Vaginal dilation exercises are recommended using plastic dilators, and should be done under the direction of a sex therapist or other health care provider. Treatment should involve the partner. This should include gradually more intimate contact culminating in intercourse.

Educational treatment should provide information about sexual anatomy, physiology, the sexual response cycle, and common myths about sex.”[iii]

Resources

American Family Physician: Evaluation and differential diagnosis of dyspareunia

Kistner’s Gynecology & Women’s Health A comparison of urinary and sexual outcomes in women experiencing vaginal and Caesarean births

National Institutes of Health - National Library of Medicine. Medical management of endometriosis-associated pain

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