Athena Yoneda, PhD
1) Review phases of the sexual response cycle and
diagnostic features of corresponding sexual
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.
Let’s Talk About Sex
Let's Talk About…
Anal Sex
Sex Toys
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
 I only discuss sexual problems with my clients who are in
 I rarely discuss issues of sexuality with my clients.
 I have never discussed sexuality with any of my clients.
(Bogey, 2008)
Three factors contributing to clinicians’
avoidance of sexual topics:
 Knowledge
 Personal emotional reactions
 Discomfort using sexual language
(Risen, 1995)
Sexual Response Cycle
Diagnostic Features
Risk Factors and Implications
Prevalence Rates
Sexual Response Cycle
Phase 1:
Phase 2:
Phase 3:
Phase 4:
(APA, 2000)
Sexual Dysfunction
Characterized by:
 Disturbance
in sexual desire and the
psychophysiological changes that characterize the
sexual response cycle
 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)
 Lifelong
 Generalized
Acquired Type
Situational Type
 Due
to Psychological Factors
Due to Combined Factors
(APA, 2000)
Sexual Desire Disorders
Hypoactive Sexual Desire Disorder (302.71)
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
(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)
Sexual Dysfunction Due to a General Medical
 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
 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
 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,
Sexual Dysfunction
What do rates of sexual dysfunctions look like for
Do veterans’ sexual health and functioning concerns
differ from the general population?
Majority of studies look at:
 Medication
 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.,
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
Experiences/thoughts about sexual dysfunction in
veterans based on clinical experience?
Sexual Dysfunctions
Assessment: Considerations
What are important factors to consider when
assessing sexual dysfunction?
 Physical
 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.,
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.,
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)
Other factors to consider?
 Setting:
Mental health vs. Primary care
 Clinician x Patient characteristics
 Others?
Sexual Dysfunctions
Sensate Focus
No sex (yet…)!
Focus on sensations being experienced
 Sensate
Focus I
 Sensate Focus II
 Sensate Focus III
Erectile Dysfunction, Female Orgasmic Disorder
(Leiblum & Rosen, 2000)
Treatment Overview
 Interview
and questionnaires
 Remember to assess for other Axis I disorders and
possible medical/substance-related causes
Identify unrealistic expectations
Therapeutic intervention specific to sexual
(Leiblum & Rosen, 2000)
Interventions: Desire and Arousal
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)
 Directed
Males (Heiman, 2002)
 Sensate
 Premature ejaculation:
 “Squeeze”
and “Start-Stop” techniques
Interventions: Pain Disorders
 Individual
or couples
Biofeedback and relaxation therapy
(IsHak et al., 2005; Leiblum & Rosen, 2000)
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 –
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.
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.
International Journal of Sexual Health, 24, 1-5.
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
Sexual Medicine, 7, 1598-1607.
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.
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
of a brief sexual function questionnaire for men. Psychiatry Research, 24(3), 231-250.
Risen, C.B. (1995). A guide to taking a sexual history. The Psychiatric Clinics of North America, 18,
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.
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.
Skinner, K. M., Kressin, N. R., Frayne, S., Tripp, T. J., Hankin, C. S., Miller, D. R., & Sullivan, L. M.
(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.
Taylor, J. F., Rosen, R. C., & Leiblum, S. R. (1994). Self-report assessment of female sexual function:
Psychometric evaluation of the brief index of sexual functioning for women. Arch. Sex. Behav.
2, 627–643.
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
methodology study to validate a structured diagnostic method used to diagnose female sexual
dysfunction and its subtypes in postmenopausal women. Journal of Sex & Marital Therapy,
31(4), 271-283.
Weigel, M., Meston, C., & Rosen, R. (2005). The female sexual function index (FSFI): Crossvalidation and development of clinical cut-off scores. Journal of Sex & Marital Therapy, 3, 120.
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.

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