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WHY VA CLINICIANS SHOULD TALK
ABOUT SEX:
AN OVERVIEW OF DIAGNOSTIC
FEATURES, ASSESSMENT, & TREATMENT
OF SEXUAL DYSFUNCTION
Athena Yoneda, PhD
Objectives
1) Review phases of the sexual response cycle and
diagnostic features of corresponding sexual
disorders.
2) Provide information and generate discussion about
sexual health in the veteran population.
3) Provide an overview of frequently used assessment
measures and treatments for the more common
sexual dysfunction disorders.
SELF-ASSESSMENT
Let’s Talk About Sex
Let's Talk About…

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





Sex
Orgasm
Masturbation
Clitoris
Anal Sex
Cunnilingus
Pornography
Sex Toys




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Erection
Penis
Lubrication
Vagina
Nipples
Arousal
Foreplay
Fellatio
Which of these statements best describes your approach to
discussing sexuality with clients:
I always ask questions regarding level of sexual satisfaction
or functioning during an intake.
 I wait until I have established a good rapport with the client
before bringing up issues of sexuality.
 I wait until the client brings up a problem related to
sexuality.
 I only discuss sexual problems with my clients who are in
relationships.
 I rarely discuss issues of sexuality with my clients.
 I have never discussed sexuality with any of my clients.

(Bogey, 2008)
Barriers

Three factors contributing to clinicians’
avoidance of sexual topics:
 Knowledge
deficits
 Personal emotional reactions
 Discomfort using sexual language
(Risen, 1995)
SEXUAL DYSFUNCTIONS
Sexual Response Cycle
Diagnostic Features
Risk Factors and Implications
Prevalence Rates
Sexual Response Cycle
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
Phase 1:
Phase 2:
Phase 3:
Phase 4:
Desire
Excitement
Orgasm
Resolution
(APA, 2000)
Sexual Dysfunction

Characterized by:
 Disturbance


in sexual desire and the
psychophysiological changes that characterize the
sexual response cycle
or
 Pain associated with sexual activity
 Cause marked distress or interpersonal difficulty
Not better accounted for by another Axis I disorder
Not due solely to a medical condition or substance
(APA, 2000)
Subtypes

Onset:
 Lifelong

Type
Context:
 Generalized

Acquired Type
Type
Situational Type
Etiology:
 Due
to Psychological Factors
Due to Combined Factors
(APA, 2000)
Sexual Desire Disorders

Hypoactive Sexual Desire Disorder (302.71)
A
deficiency or absence of sexual fantasies or desire
of sexual activity
 Most common sexual disorder in women

Sexual Aversion Disorder (302.79)
 Aversion
to/active avoidance of genital sexual contact
with a sexual partner
(APA, 2000)
Sexual Arousal Disorders

Female Sexual Arousal Disorder (302.72)
 Persistent/recurrent
inability to attain or maintain
adequate lubrication-swelling response of sexual
excitement (until completion of sexual activity)

Male Erectile Disorder (302.72)
 Persistent/recurrent
inability to attain or maintain an
adequate erection (until completion of sexual activity)
(APA, 2000)
Orgasmic Disorders

Female Orgasmic Disorder (302.73)
 Persistent/recurrent
delay in/absence of orgasm
following normal sexual excitement phase and
adequate stimulation

Male Orgasmic Disorder (302.74)
 Persistent/recurrent
difficulties in attaining orgasm
following normal sexual excitement phase and
adequate stimulation

Premature Ejaculation (302.75)
 Persistent/recurrent
ejaculation with minimal sexual
stimulation
(APA, 2000)
Sexual Pain Disorders

Dyspareunia (302.76)
 Genital

pain associated with intercourse
Vaginismus (306.51)
 Persistent,
involuntary spasms of the vagina; interferes
with intercourse
(APA, 2000)
Others

Sexual Dysfunction Due to a General Medical
Condition
 Clinically
significant sexual dysfunction exclusively due
to a general medical condition

Substance-Induced Sexual Dysfunction
 Clinically
significant sexual dysfunction exclusively due
to substance use
 Differential: Substance Intoxication
 Specifiers used to describe predominant symptoms

Sexual Dysfunction NOS
(APA, 2000)
Risk Factors

What do you think are risk factors for developing a
sexual dysfunction?
 Emotional
problems/Poor psychological health
 Stress
 Relationship
dissatisfaction
 Physical health problems
 Low SES and lower levels of education
 Age
 Childhood abuse (sexual/emotional/physical)
 Trauma history
 Medications
(Heiman, 2002; Laumann et al.,1994; Lewis et al.,
Impact on Well-Being

Sexual dysfunction can negatively impact:
 Romantic
relationship functioning
 Ability to form intimate relationships
 Self-esteem and self-image
 Mental health
 Quality of life

Healthy sexual functioning predicts:
 General
well-being
 Physical health
 Healthy intimate relationships
(Heiman; 2002; Kauth, 2012)
Prevalence Rates:
General Population
 Sexual
Difficulties (Laumann et al., 1999)
 Women
 Sexual
= 43%
Men = 31%
Dysfunction in Females
 Hypoactive
Sexual Desire Disorder: 17-55%; ~33%
 Female Sexual Arousal Disorder: 8-28% ; ~20%
 Female Orgasmic Disorder: 7-25%
 Dyspareunia: ~ 15%
 Sexual
Dysfunction in Males
 Hypoactive
Sexual Desire Disorder: 0-7%
 ED: 12-19%; ~10%
 Premature Ejaculation: ~27%
 Dyspareunia: ~ 3 %
(APA, 2000; Heiman, 2002; Lewis et al., 2010; Simons & Carey,
VETERANS
Sexual Dysfunction
Veterans


What do rates of sexual dysfunctions look like for
veterans?
Do veterans’ sexual health and functioning concerns
differ from the general population?


Probably
Majority of studies look at:
 Medication
 SSRIs
 Effects
effects
impact on desire and arousal in male veterans
of Military Sexual Trauma (MST)
 Impact
of MST on female veterans’ sexual satisfaction
(Kauth, 2012)
Sexual Functioning in Veterans

OEF/OIF veterans
 Sexual
problems uniquely contribute to mental health
problems (Nunnink, Fink, & Baker, 2012)
 30.5% males with PTSD reported sexual problems (Nunnink
et al., 2010)

Male combat veterans with PTSD report more sexual
problems (vs. those without PTSD) (Cosgrove et al., 2002)
 Less
sexual satisfaction
 More orgasmic difficulties
 More erectile problems
Sexual Assault and Sexual
Functioning in Veterans

Female veterans
Those with MST history report greater dissatisfaction with their
sex lives (50% vs. 34%) (Skinner et al., 2000)
 Those who endorsed pain during sexual intercourse more likely to
have lifetime history of sexual assault (67% vs. 45%) (Sadler et al.,

2012)

OEF/OIF veterans with MST history (Turchik et al., 2012)

More likely to have sexual dysfunction diagnosis
Especially if have diagnosis of depression (males and females) or
PTSD (males only)
 Males: Sexual Desire Disorder, Sexual Arousal Disorder
 Females: Sexual Desire Disorder, Sexual Pain Disorder, Sexual
Arousal Disorder

Discussion

Experiences/thoughts about sexual dysfunction in
veterans based on clinical experience?
ASSESSMENT
Sexual Dysfunctions
Assessment: Considerations

What are important factors to consider when
assessing sexual dysfunction?
 Physical
health
 Substance use/Medications
 Mental health
 Age
 Trauma history
 Relationship status and quality
 Sexual orientation
 Sexual history
 Culture, beliefs, and expectations
(APA, 2000; IsHak et al., 2005)
Clinical Interviews
Structured Diagnostic Method (SDM; Utian et al., 2005)
 Structured Clinical Interview for DSM-IV-TR,
Axis I Disorders (SCID-I; First et al., 1994)
 Women’s Sexual Interest Diagnostic Interview

(WSID; DeRogitas et al., 2008)
Self-Report Questionnaires

Female Sexual Function Index (FSFI; Rosen et al., 2000; Wiegel et al.,
2005)

International Index of Erectile Function (IIEF; Rosen et al., 1997)

Sexual Desire Inventory-2 (SDI-2; Spector et al., 1996)

Brief Index of Sexual Functioning for Women (BISF-W; Taylor et al.,
1994)
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Arizona Sexual Experiences Scale (ASEX; McGahuey et al., 2000)

Quality of Sexual Function (QSF; Heinemann et al., 2005)

Brief Sexual Functioning Questionnaire for Men (BSFQ-M; Reynolds
et al., 1988)

Sexual Function Questionnaire (SFQ; Quirk et al, 2002)
Assessment

Other factors to consider?
 Setting:
Mental health vs. Primary care
 Clinician x Patient characteristics
 Others?

Thoughts?
PSYCHOSOCIAL INTERVENTIONS
Sexual Dysfunctions
Sensate Focus



No sex (yet…)!
Focus on sensations being experienced
Structured
 Sensate
Focus I
 Sensate Focus II
 Sensate Focus III

Erectile Dysfunction, Female Orgasmic Disorder
(Leiblum & Rosen, 2000)
Treatment Overview

Assessment
 Interview
and questionnaires
 Remember to assess for other Axis I disorders and
possible medical/substance-related causes



Psychoeducation
Identify unrealistic expectations
Therapeutic intervention specific to sexual
dysfunction
(Leiblum & Rosen, 2000)
Interventions: Desire and Arousal
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Individual or couples therapy
Cognitive Behavioral Therapy
Sensory awareness training
Insight-oriented treatment
Behavioral exercises
Sensate focus
(Leiblum & Rosen, 2000)
Interventions: Orgasmic Disorders

Females (Heiman, 2007)
 CBT
 Directed

masturbation
Males (Heiman, 2002)
 CBT
 Sensate
focus
 Premature ejaculation:
 “Squeeze”
and “Start-Stop” techniques
Interventions: Pain Disorders

CBT
 Individual

or couples
Biofeedback and relaxation therapy
(IsHak et al., 2005; Leiblum & Rosen, 2000)
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th
ed., text rev.). Washington, DC: Author.
Bogey, L. A. (2008). Addressing sexuality with clients: A manual for therapists in training. (Doctoral
dissertation). Retrieved from ProQuest. (UMI Number 3308670)
Cosgrove, D. J., Gordon, Z., Bernie, J. E., Hami, S., Montoya, D. Stein, M. B., & Monga, M. (2002).
Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology, 60, 881 –
884.
DeRogatis, L. R., Allgood, A., Rosen, R. C., Leiblum, S., Zipfel, L., & Guo, C. (2008). Development
and evaluation of the Women’s Sexual Interest Diagnostic Interview (WSID): A structured
interview to diagnose hypoactive sexual desire disorder (HSDD) in standardized patients.
Journal of Sexual Medicine, 5, 2827–2841.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured Clinical Interview for
DSM-IV Axis I Disorders, Clinician Version (SCID-CV). Washington, D.C.: American Psychiatric
Press, Inc.
Heiman, J. R. (2002). Sexual dysfunction: Overview of prevalence, etiological factors, and
treatments. The Journal of Sex Research, 39 (1), 73-78.
Heiman, J. R. (2007). Orgasmic disorders in women. In S. R. Leiblum (Ed.), Principles and practices
of sex therapy (4th ed., pp. 84-123). New York, NY: Guilford Press.
References
Heinemann, L. A. J., Potthoff, P., Heinemann, K., Pauls, A., Ahlers, C. J., & Saad, F. (2005). Scale for
Quality of Sexual Function (QSF) as an outcome measure for both genders?. Journal of Sexual
Medicine, 2, 82–95.
IsHak, W. W., Mikhail, A., Amiri, S. R., Berman, L. A. C., Vasa, M.(2005). Sexual dysfunction. Focus:
The Journal of Lifelong Learning in Psychiatry, 3(4), 520-525.
Kauth, M. R. (2012). Introduction to special issue on veterans’ sexual health and functioning.
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Laumann, E. O., Paik, A., Rosen, R. C. (1994). Sexual dysfunction in the United States: Prevalence
and predictors. Journal of the American Medical Association, 281, 537-544.
Leiblum, S. R., & Rosen, R. C. (Eds.). (2000). Principles and Practice of Sex Therapy, 3rd Edition. New
York, NY: The Guilford Press.
Lewis, R. W., Fugl-Meyer, K. S., Corona, G., Hayes, R. D., Laumann, E. O., Moreira, E. D., . .
.Segraves, T. (2010). Definitions/epidemiology/risk factors for sexual dysfunction. Journal of
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McGahuey, C. A., Gelenberg, A. J., Laukes, C. A., Moreno, F. A., & Delgado, P. L. (2000). The
Arizona Sexual Experience Scale (ASEX): Reliability and validity. Journal of Sex & Marital
Therapy, 26, 25-40.
References
Nunnink, S. E., Fink, D. S., & Baker, D. B. (2012). The impact of sexual functioning problems on
mental well-being in U.S. veterans from the Operation Enduring Freedom and Operation Iraqi
Freedom OEF/OIF) conflicts. International Journal of Sexual Health, 24, 14-25.
Nunnink, S. E., Goldwaser, G., Afari, N., Nievergelt, C. M., & Baker, D. G. (2010). The role of
emotional numbing in sexual functioning among Veterans of the Iraq and Afghanistan Wars.
Military Medicine, 175(6), 424 – 428.
Quirk, F. H., Heiman, J. R., Rosen, R. C., Laan, E., Smith, M. D., & Boolell, M. (2002). Development of
a sexual function questionnaire for clinical trials of female sexual dysfunction. Journal of
Women’s Health and Gender-Based Medicine, 11, 277-289.
Reynolds, C. F., Frank, E., Thase, M. E., Houch, P. R., Jennings, J. R., Howell, J. R., . . .Kupfer, D. J.
(1988). Assessment of sexual function in depressed, impotent, and healthy men: Factor analysis
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39-53.
Rosen. R., Brown, C., Heiman, J., Meston, C., Leiblum, S., & Shabsigh, R. (2000). The female sexual
function index (FSFI): A multidimensional self-report instrument for the assessment of female
sexual function. Journal of Sex & Marital Therapy, 26, 191-208.
References
Rosen, R. C., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick, J., & Mishra, A. (1997). The
International Index of Erectile Function (IIEF): a multidimensionalscale for assessment of erectile
dysfunction. Urology 49, 822–830.
Sadler, A. G., Mengeling, M. A., Fraley, S. S., Torner, J. C., & Booth, B. M. (2012). Correlates of
sexual functioning in women veterans: Mental health, gynecologic health, health status, and
sexual assault history. International Journal of Sexual Health, 24, 60-77.
Simons, J., & Carey, M. P. (2001). Prevalence of sexual dysfunctions: Results from a decade of
research. Archives of Sexual Health Behavior, 30 (2), 177-219.
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(2000). The prevalence of military sexual assault among female Veterans’ Administration
outpatients. Journal of Interpersonal Violence, 15, 291 – 310.
Spector, I. P., Carey, M. P., & Steinberg, L. (1996). The Sexual Desire Inventory: Development,
factor structure, and evidence of reliability. Journal of Sex and Marital Therapy, 22, 175–190.
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2, 627–643.
References
Turchik, J. A., Pavao, J., Nazarian, D., Iqbal, S., McLean, C., & Kimerling, R. (2012). Sexually
transmitted infections and sexual dysfunctions among newly returned veterans with and without
military sexual trauma. International Journal of Sexual Health, 24, 45-59.
Utian, W. H., Maclean, D. B., Symonds, T., Symons, J. Somayaji, V., & Sisson, M. (2005). A
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Directed Reading
Nunnink, S. E., Fink, D. S., & Baker, D. B. (2012). The impact of
sexual functioning problems on mental well-being in U.S.
veterans from the Operation Enduring Freedom and Operation
Iraqi Freedom OEF/OIF) conflicts. International Journal of
Sexual Health, 24, 14-25.