Psychosexual medicine

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CHAPTER 30 Psychosexual medicine

Susan V. Carr

Introduction

Human sexuality is important because it is inherent in everyone. It is an integral part of every human being and it is up to every individual to deal with their own sexuality in whichever way they choose. Although so fundamental to human existence, scientific documentation of sexuality is relatively recent. Historically, there was a persistent refusal to recognize that women could enjoy sex. In 1857, Acton stated that ‘Happily for society the majority of women are not much troubled with sexual feelings of any kind’. At the beginning of the 20th Century, Havelock Ellis, an English doctor, gave scientific voice to the idea that sexual activity was important in its own right, not just as a means of procreation. He wrote that ‘Reproduction… is not necessarily connected with sex, nor is sex necessarily concerned with reproduction’. Freud’s revolutionary theories of psychoanalysis put sex and the subconscious firmly on the scientific agenda, but it was not until some decades later that Kinsey published his ground-breaking study on male and female sexual behaviour in 1948 and 1953. These reports led to uproar in their day and spearheaded the ever-increasing interest in human sexuality from the scientific viewpoint.

The Role of the Gynaecologist

The gynaecologist has a major role to play in the field of psychosexual problems, in both their prevention and detection. Gynaecology is the branch of medicine which focuses on a woman’s sexual and reproductive system, which forms an essential essence of her femaleness and her perception of herself as a complete woman. Gynaecology is concerned with the area of the woman’s body that is integrally involved in sexual activity. Sexual activity and emotions are closely linked, and it is therefore important to be aware of the effect that any gynaecological problem may have on the woman’s sexuality and, indeed, that of her partner, if she has one.

Modern medical teaching tends to recognize the emotional needs of patients, but unfortunately, some everyday gynaecological situations may unwittingly set the scene for psychosexual problems in the future. Psychosexual therapy concentrates on individual cases, interpreting each doctor–patient interaction as unique. Nonetheless, there are patterns of aetiologies which emerge in practice, such as a history of clinical procedures. Women may often trace their problem back to what may seem a minor gynaecological procedure, such as sterilization, termination of pregnancy or even vaginal examination, which is thus of crucial importance not only from a gynaecological perspective but also from a psychosexual perspective.

Human Sexuality

For ease of understanding, human sexuality can be divided into different components: gender identity, sexual orientation and sexual response.

Gender identity

Just under 50% of the population are diagnosed at birth as being female. They are biologically and legally female, and most tend to follow female biopsychosocial pathways throughout their lifetimes. Similarly, a male gender identity is experienced by the other 50% of the population, who are diagnosed at birth to be male. However, a tiny proportion of the population are transsexual. These are individuals whose biological sex and gender identity do not match. They are, in effect, born into the wrong body and may spend many difficult years undergoing a gender reassignment process. As all transsexuals are female at some stage in their lives, they may come into contact with gynaecology services; therefore, it is important to have an awareness of this condition. A postoperative male-to-female transsexual presents on gynaecological examination as a hysterectomized female. The Gender Recognition Act 2004 allows change of birth certificate under UK law, and transwomen can now present to a gynaecologist without disclosing their trans status.

Sexual orientation

Sexual orientation is the definition of sexual attraction: the people to whom one’s sexual desire is directed. Approximately 93% of the population are heterosexual (i.e. attracted to individuals of the opposite sex). Between 5% and 10% of the population are homosexual (i.e. men who are sexually attracted to men). A further 0.5–2% of women are lesbian (i.e. women who are sexually attracted to women). Seven percent of the population are bisexual and are attracted to both men and women. In the UK National Survey of Sexual Attitudes and Lifestyles, over half of the men who had had a male sexual partner in the previous 5 years had also had a female partner; the figure was higher for females at 75.8% (Wellins et al 1994).

Sexual orientation has particular relevance in well-woman health care. Lesbians may be reluctant to discuss their sexual orientation with a clinician, but as the majority have experienced heterosexual sexual intercourse or had vaginal penetrative sexual activity with fingers or sex toys, they are at risk of cervical dysplasia and sexually transmitted infection. Lesbians should be included in national cervical screening programmes and have the same well-woman checks as the rest of the female population. Lesbians generally have positive attitudes to the new human papilloma virus vaccine programmes, but feel that any health promotion materials should recognize their sexual orientation (McNair et al 2009) in order to increase uptake (see Chapter 66, Lesbian health issues, for more information).

Bisexual women are at the highest risk of sexual morbidity, and may be reluctant to speak openly about their sexuality to clinicians.

The human physiological sexual response is dependent not only on intact endocrine, vascular and neurological input, but also on sensory input. This has been described as the ‘psychosomatic circle of sex’ (Bancroft 2008). Female sexual responsiveness is a result of sensory input through the peripheral nerves of the somatic and autonomic nervous system, as well as through the cranial nerves and psychogenic stimulation. Precisely where and how afferent information is processed within the spinal cord and brain is unknown (Yang 2000). The frontal and temporal lobes and anterior hypothalamus are all shown to have some function in mediating the sexual response, but the extent of this is still unclear. Genital motor responses include pelvic vasocongestion and vaginal lubrication. During sexual intercourse, the vagina lengthens, the labia increase in size, the uterus draws back and the clitoris retracts; at orgasm, there is also contraction of the uterine and pelvic muscles.

Clinical clarification of the human sexual response was based on the Masters and Johnson model of four phases: excitement, plateau, orgasm and resolution. This description was then modified by Kaplan to a triphasic model of desire, arousal and orgasm. These concepts provide the working models on which behavioural therapies for sexual problems are based. Recent scientific arguments have proposed that sexual desire is, in fact, the first early stage of arousal, triggered by a stimulus which has sexual meaning and is modified by situational and partner variables (Janssen et al 2000).

Most human sexuality is non-problematic and will not be within the domain of the clinician. It is only when something goes wrong with the patient’s sexual response that they may seek professional help.

Sexual Problems in General

Population prevalence

The majority of the population at any one time have a trouble-free sex life. There is, however, a substantial minority for whom dealing with and expressing their sexuality is problematic. These problems may only be temporary or situational. If they persist and become increasingly distressing, the individual may seek professional help. The population prevalence of some degree of sexual dysfunction is estimated to be approximately 20%. Prevalence increases with age; overall, 40–45% of women and 20–30% of adult men report at least one sexual dysfunction at any one time (Lewis et al 2004). In the National Health and Social Life Survey (Laumann et al 1999), one-third of women reported loss of libido. Almost 25% did not experience orgasm. Approximately 20% had problems with vaginal lubrication, and a similar number did not enjoy sex. This study suggested that there was a substantial comorbidity of sexual problems. A study of US women (West et al 2008) showed that whilst 26.7% of premenopausal women had low sexual desire, 52.4% of naturally menopausal women had the same complaint. For males, the prevalence of some degree of erectile dysfunction has been reported as 30% of all males between the ages of 40 and 70 years. Premature ejaculation occurs in 10–30% of men during their lifetime. In a control group of 591 members of the general population in a Dutch study, 8.7% of men and 14.9% of women reported a sexual dysfunction unrelated to age (Diemont et al 2000), which is lower than that reported in other countries.

Definitions of Sexual Dysfunction

In the recent literature, there has been much positive debate about redefining sexual disorders, especially in the female. It is generally agreed that the definitions need clarification, especially in relation to research (Derogatis and Burnett 2008). Clinically, there is a lot of overlap in presentation, and clearer definition would help preventive and treatment strategies. Much work has concentrated on female sexual dysfunction, helping in understanding the organic basis for some problems (Meston and Bradford 2007); however, massive treatment breakthroughs have yet to follow.

Having a sexual dysfunction does not necessarily mean that the individual has a sexual problem. This will depend on the effect, if any, that the dysfunction has on the life of the individual in terms of their feelings, relationships and lifestyle. Conversely, restoration of sexual function may not solve the sexual problem; in fact, it may serve to highlight an underlying emotional or relationship discord. Individuals with psychosexual problems usually have no organic sexual dysfunction whatsoever.

Problems of function or desire

Sexual disorders can be divided into problems of function or desire. They are often interlinked. For example, impaired sexual function, such as some degree of erectile problem, can result in the man protecting himself from the distress of failure by emotionally shutting himself off from coitus altogether. This results in loss of libido. If a woman is experiencing loss of function such as dyspareunia, she may subconsciously employ the same defensive mechanisms, and loss of desire develops.

The most common female sexual problems are vaginismus, loss of libido, dyspareunia and inorgasmia. There will be differences in the frequency of presenting sexual complaints in different clinical settings. An American gynaecology clinic sample showed loss of libido (87.2%) with inorgasmia (83%) and dyspareunia (72%) (Nusbaum et al 2000). In a community-based setting such as a family planning clinic, however, loss of libido, dyspareunia and vaginismus are the most common presenting complaints, with a low incidence of inorgasmia.

In males, erectile dysfunction, ejaculatory disorders and loss of libido are the most frequent presenting complaints, all of which will affect the partner to some degree.

Problems relevant to gynaecology

There are many gynaecological conditions which may predispose to sexual problems. Any disease or its treatment which results in alteration of the genitalia may cause functional sexual difficulties. These conditions may range from having colposcopy, where spontaneous interest in sex was found to be lower 6 months post procedure, irrespective of whether or not treatment was needed (Hellsten 2008), to traumatic obstetric delivery or gynaecological malignancy. Trauma or disease, however, may cause an alteration in the woman’s perception of herself, such as distorted body image causing sexual problems. This may or may not be directly related to physical reality. An exceptionally high rate of sexual dissatisfaction was found in a gynaecology clinic sample in the USA. Over 98.8% of the sample reported one or more sexual worries, and body image concerns were reported by 68.5% of the 1480 women who attended (Nusbaum et al 2000). A study of Dutch gynaecologists found that one in 14 of their patients presenting in the previous week had problems of a sexual nature, mainly dyspareunia or lack of sexual desire (Frenken and van Tol 1987). A significant degree of deterioration of sexual function was described in a study of 41 women who had undergone vulvectomy, attributed to disturbed body image rather than physical impairment (Green et al 2000). The rate of sexual problems in women with gynaecological cancers is approximately 50%. The main complaint of this client group is lack of opportunity to discuss these problems.

Once any gynaecological treatment is completed, the treatment approach for the sexual problem is the same as for any other patient.

Sexual Problems in the Female

Vaginismus

Vaginismus is a condition in which nothing is able to enter the vagina. This means that penetrative sexual intercourse does not take place. It is caused by psychogenically mediated involuntary spasm of the vaginal muscles. Vaginismus can be primary or secondary. In primary vaginismus, nothing has ever entered the woman’s vagina. A useful diagnostic question is ‘Have you ever used a tampon’. In a case of primary vaginismus, the answer will always be ‘no’. Secondary vaginismus can appear at any time in a woman’s life, sometimes after childbirth or any other life-changing event.

The vagina is physiologically intact in a case of vaginismus. There is no stenosis or organic disorder. This is a psychogenic condition for which the treatment is psychosexual, never surgical.

Behavioural methods

Evidence shows that cognitive behavioural therapy is effective (van Lankveld 2006), and can also be used with couples (Kabakci and Batur 2003). A useful adjunct to therapy is the use of vaginal trainers, which are plastic ‘pseudopenises’ made in graduated sizes, which the woman is taught to insert into her own vagina. The same effect can be gained by using fingers. This teaches her that she can be in control of what enters her body. This can be a good adjunct to psychodynamic therapy.

Supplying vaginal trainers without supportive therapy is unlikely to show sustained benefit.

Classic couple therapy, based on the Masters and Johnson model, is also shown to be effective, with success rates of 93% reported (Jeng 2006). Recent reports of the intravaginal use of botulinum toxin are promising (Ghazizadeh and Nikzad 2004). The use of surrogate male partners was shown to be effective in women without a cooperative partner (Ben-Zion 2007), but clearly raises many social and ethical issues in treatment.

Surgery has no place in the treatment of vaginismus.

Inorgasmia

Inorgasmia is the lack of ability to experience orgasm. There are two main areas of innervation in the female genital region that can produce orgasmic symptoms if stimulated. The main area is the clitoris and there is another inside the vagina, about two-thirds of the way up, close to the urethra. This is known as the ‘G-spot’.

Presentation

The woman will either complain of inability to experience orgasm or may say that she does not know whether or not the feelings she is having constitute orgasm. Presentation at a clinic with this complaint will usually have been prompted by the acquisition of a new partner, the inability to find a partner or by popular media interest in the topic.

Treatment

There are some women who have no feelings at all in the clitoral area. Women with selective serotonin reuptake inhibitor (SSRI)-induced loss of sensation and sexual dysfunction showed improvement on taking sildenafil (Nurnberg et al 2008). Combined oestrogen and androgen therapy may improve sexual sensation in menopausally triggered inorgasmia. Sildenafil may also improve clitoral blood flow in menopausal women with orgasmic dysfunction and women with type 1 diabetes.

With women who have never experienced orgasm, however, drug treatment alone is unlikely to work. Encouraging body self-awareness, by discussion of female genital anatomy and physiology, will help. Encouraging masturbation is very rewarding. If this is combined with psychodynamic input, the patient usually responds.

Loss of libido

Loss of libido is loss of sexual desire. It is generally associated with loss of self-esteem due to a multitude of underlying causes. There may be a traumatic event in the past which has not been dealt with emotionally and which may cause problems, such as loss of libido, at a later stage in the woman’s lifetime. Examples of this are rape, sexual or emotional abuse, or a loss such as bereavement or redundancy leading to loss of status and loss of self-esteem.

There are associations between loss of desire and hormonal status in postmenopausal women. Hypoactive sexual desire disorder is much more common in menopausal women, especially young women with surgical menopause. There is, however, no physiological marker for loss of libido, and there is rarely a ‘quick fix’ solution to the problem.

Presentation

Loss of libido may present as depression or as a relationship problem. The woman may be uncomfortable broaching the subject but, if prompted by an empathetic clinician, may disclose the problem. In areas of gynaecological health care where body image becomes problematic, such as oncology, menopause and continence, loss of libido may be an overlooked complaint.

Treatment

The core treatment for loss of libido is psychosexual therapy, which deals with the underlying psychogenic origin of the problem. Counselling before procedures can allow women to explore their feelings in relation to these procedures. A past history of abortion is not uncommon in women with loss of libido. Pretermination of pregnancy counselling is, of necessity, information based and time limited. After termination of pregnancy, however, there is an opportunity for the woman to come to terms with what has happened, thus preventing the development of sexual problems later in life and hopefully preventing repeat unwanted pregnancy. After sterilization, there will be some women who suffer loss of libido. Even if they have no regrets over the procedure, they may not have realized the emotional impact of losing their fertility as they have not understood the difference between choosing not to have a child and not being able to conceive.

In cases where the loss of libido can be clearly linked to a hormonal trigger, such as starting a different combined oral contraceptive, changing contraception can improve the problem.

There is some evidence for the addition of androgens to oestrogen replacement therapy for menopausal loss of libido (Kingsberg 2007). Hormonal therapy alone, however, can only return a woman to her premenopausal status and cannot change any underlying emotional blocks to sexual desire. The menopause is a time of major social and emotional upheaval for many women, which can be as overwhelming as adolescence, so psychosexual therapy combined with appropriate hormone replacement therapy would seem to be best practice.

Dyspareunia

Dyspareunia is painful sexual intercourse. It may be described as deep or superficial. There are organic causes for this, such as post delivery, after gynaecological operations, genital infections and in any condition which causes vaginal dryness, such as menopause. Vulval pain syndrome, or vulvodynia, is a complex condition which causes severe dyspareunia.

Vaginal dryness can be physiological, caused by lack of sufficient sexual stimulation during intercourse.

Presentation

Dyspareunia is a common presenting complaint to the gynaecologist. Some women (and doctors!) find it easier to discuss than some other sexual problems, as it seems more likely than other sexual complaints to have an organic origin. Postdelivery dyspareunia is reported frequently but, on average, women resume sexual intercourse at 7 weeks post partum (Byrd et al 1998). Approximately 15% of women have chronic dyspareunia of unclear origin (Weijmar Schultz et al 2005), and as well as causing distress to the patient, this presents an enormous challenge to the gynaecologist.

Treatment

If dyspareunia persists despite clinical evidence of cure of the underlying condition, or no clinical findings despite full appropriate genitourinary and gynaecological investigation, psychosexual therapy should be considered. Recommended therapy for vulval pain syndromes is multidisciplinary with psychosexual input in coordination with gynaecological treatment (Nunns 2000). There is now a recognition that more research and clarification of definitions of sexual pain, particularly in relation to vulvar vestibulitis and vaginismus, is required in order to focus treatment (Weijmar Schultz et al 2005).

Various treatments now have evidence to recommend their use. Pelvic floor physiotherapy is an important tool of modern assessment and treatment (Rosenbaum 2005). The use of vibrators (Zolnoun et al 2008) is helpful and can be easily accessed and used by the women without clinical intervention. Hypnosis (Pukall et al 2007) and vaginal botulinum toxin type A have been reported as having positive therapeutic effects, and can increase the ability to have relatively pain-free and pleasurable sexual intercourse.

The emotional aspects of vulvar pain should never be ignored. Sometimes the memory of a previous painful condition may lead to expectation of pain on intercourse. This can produce involuntary vaginal muscle spasm, causing secondary vaginismus and thereby perpetuating the dyspareunia despite treatment of the original cause.

Physiological dyspareunia is caused by vaginal dryness due to lack of sufficient and appropriate sexual stimulation. It is treated by helping the woman to understand the cause of the problem. Discussion of sexual technique may help, emphasizing foreplay. Enabling the woman to gain insight into the nature of her relationship with her partner is an essential part of this process.

Sexual problems of lesbians

Gynaecologists should remember that not all women are heterosexual. Lesbians have similar sexual problems to other women but, as they find it difficult to disclose their sexual orientation to doctors, it may be even harder for them to discuss sexual problems than it is for heterosexuals. Women complaining of loss of libido, inorgasmia or dyspareunia may be in same-sex relationships. Vaginal penetration, as with all women, may occur with fingers and sex toys. Once organic causes have been excluded, psychosexual therapy should be offered. Synchronicity of menstruation in women living together, possibly due to pheromonal influence, has been documented (McClintock 1998). This is not universal but, where it exists, the coincidence of severe premenstrual symptoms can trigger domestic violence in lesbian couples, which can be an underlying cause of sexual problems (see Chapter 66, Lesbian health issues, for more information).

Sexual Problems in the Male

Gynaecologists are unlikely to be in the front line when dealing with male sexual problems, but as many of their female patients have male partners, it is important to have an overview of this area. If her partner has sexual problems, the woman can feel hurt and rejected, and will frequently blame herself, presenting at a clinic for help in solving the problem.

Erectile dysfunction

Erectile dysfunction is the inability to sustain a penile erection sufficient to achieve satisfactory penetrative sexual intercourse. According to the oft-quoted Massachusetts Male Aging Study, the incidence of erectile dysfunction in men aged 40–69 years is 25.9 cases per 1000 man-years; 60% of cases are organic in origin, 15% are psychogenic and 25% are of mixed origin (Aytac et al 2000).

Aetiology

Erectile dysfunction can be caused by any disruption of the neurological, endocrine or vascular supply to the genitalia. It can also occur for entirely psychogenic reasons. Associated factors are age, diabetes, alcohol intake, hypertension and the side-effects of many medications. Erectile dysfunction reduces quality of life and may lead to other associated sexual problems, such as loss of libido.

Presentation

The man with erectile dysfunction may present to a doctor himself, although it is not unusual for the female partner of a male with a sexual problem to present herself as the patient. She may say that she is experiencing either loss of sexual interest or painful sex. The couple themselves may not recognize where the problem lies.

Treatment

The treatment depends on the cause and falls into four basic categories: chemical, mechanical, surgical and psychosexual.

Oral therapy is now available which has revolutionized treatment of this distressing condition. The phosphodiesterase type 5, cyclic GMP inhibitors are now widely used worldwide. The drugs are facilitators, not initiators, of erections. These oral medications have reported efficacy rates of approximately 70% for sexual intercourse. They produce a vasodilatory effect and must not be used routinely for patients with coronary insufficiency on nitrates. The recreational use of amyl nitrate ‘poppers’, employed to facilitate anal intercourse, is strongly contraindicated with these drugs.

Locally acting chemical treatments can also be used. Alprostadil, which is prostaglandin E, can be injected into the base of the penis, causing smooth muscle relaxation and resulting in an erection. It can also be introduced by a tiny pellet into the urethra, causing an erection. Both methods have success rates of approximately 70%. Success rates with this urethral medication have been improved by the use of a penile constriction band which augments local retention. A newer combination of alprostadil and an α-adrenergic antagonist enhances erection rates, and other medications are being researched. This causes smooth muscle relaxation, leading to engorgement of the corpora cavernosa and erection of the penis. Although there can be some local discomfort, there are few contraindications to this therapy. It does, however, require manual dexterity and a willingness to inject or to insert medication into the penis. Unsurprisingly, there are fairly high discontinuation rates for this type of invasive therapy.

The simplest, non-invasive treatments are vacuum devices. A constriction ring is first applied to the base of the flaccid penis, then a vacuum is created, causing engorgement of the corpora cavernosa which is maintained by the constriction ring. This method creates a slightly blue, cold erection which may be sufficient for intercourse, and which is suitable for some men who prefer non-chemical treatment methods. Surgery is required if a venous shunt has been demonstrated or to insert a prosthesis, if there are no other options for treatment.

Psychosexual therapy is an important therapy to consider in cases of erectile dysfunction, either on its own or as an adjunct to physical therapy, as 40% of cases of erectile dysfunction have a psychogenic element. This form of treatment allows the man to explore all the issues surrounding his problem, and also allows him to include his partner in treatment if he wishes. It also takes a whole-person approach, rather than merely focusing on the genitalia.

Premature ejaculation

Premature ejaculation is the most common male sexual problem worldwide. It is a condition where the male reaches the point of orgasm and ejaculates very rapidly, before satisfactory sexual intercourse has taken place. It is frequently a complaint of young men but may present in all age groups.

Presentation

The man suffering from premature ejaculation will ask for clinical help if it is affecting his sexual satisfaction or relationships.

Treatment

A psychodynamic approach will help the man to understand and cope with his anxieties related to the problem.

The ‘squeeze’ technique can be used. If the thumb and forefinger are used to squeeze firmly at the base of the glans penis at the point of ejaculation, ejaculation will be delayed. This technique, however, requires a good degree of coordination.

The mainstay of treatment, however, is the use of antidepressant medication, such as clomipramine or SSRIs, which have been shown to increase ejaculation latency. Daily use of SSRIs is more effective than on-demand treatment (Waldinger 2007).

Delayed ejaculation

Delayed ejaculation is a condition which is usually psychogenic in origin. Infrequently, it can be a side-effect of some medications. It can be extremely distressing to the female partner, and if penetrative, thrusting sexual intercourse becomes prolonged due to a failure of the man to become orgasmic, it can lead to dyspareunia. The male may be able to ejaculate when masturbating but is unable to do so intravaginally. This could be for various subconscious reasons, some of which are fear of losing control, fear of causing pregnancy or unwillingness to make a commitment to his partner (Thexton 1992).

Treatment

Psychosexual therapy is the treatment of choice. This problem may take a prolonged course of therapy before positive outcomes are achieved.

Loss of libido

This can affect men as well as women. Rarely, lack of testosterone may be implicated but the cause is usually emotional and will frequently be linked to some cause of loss of self-esteem in the man.

Treatments

Most problems of a sexual nature have a psychogenic origin. Even sexual problems with clear organic origins tend to have some degree of psychogenic overlay, as sexual activity, or the lack of it, has emotional impacts.

There are three main treatment modalities for sexual problems: psychodynamic methods, behavioural methods and drug treatments.

Psychodynamic methods

Psychodynamic medicine is concerned with understanding how emotional factors interfere with sexual activity and enjoyment. These emotional factors may not be at the conscious level. The aim of treatment is to enable the patient to resolve the problem by removing the psychological blocks to satisfactory sexual activity and relationships (Skrine 1989). This is achieved by taking a ‘mind–body’ approach to the patient and their sexual problem. The psychosexually trained clinician will explore the problem with the patient by interpreting the doctor–patient interaction, and feeding these observations back to the patient in order to elicit their response.

An important part of this treatment is the psychogenic genital examination. Many of the patient’s underlying attitudes, fears and fantasies related to their sexual problem may be revealed in relation to this part of the consultation.

The philosophy of treatment is that the patient is ‘whoever presents’ at the consultation. This mode of treatment is suitable for individuals, regardless of whether or not they are in a relationship. It is also appropriate for couples, regardless of gender identity or sexual orientation.

Not all psychosexual problems require prolonged specialist treatment. A single consultation with a suitably trained doctor is sufficient help for some patients.

Behavioural methods

Behavioural methods involve a more didactic, ‘hands-on’ approach to treatment. This philosophy of treatment was developed through the early work of Masters and Johnson, and Helen Singer Kaplan. Patients are given practical tasks in order to learn or relearn how to experience and enjoy sexual activity. This approach maintains that the many causes of sexual dysfunction can be treated effectively by a programme combining education, homework assignments and counselling. A staged approach to re-establishing healthy sexual contact can be a useful therapeutic tool when dealing with couples, and has been modified to treat single individuals although it is felt to be of most use for people with partners.

Cognitive behavioural therapy is increasingly used as a practical and effective method of treatment of sexual problems.