Treatment Psychological Treatments

Currently, we are in a climate that overlooks and dismisses psychological treatments (99). One of the reasons for this may be that due to sociocultural pressure in the medical and larger culture, physiological treatments are seen as superior

(100). The emphasis on impaired genital unresponsiveness in the DSM-IV and the success of pharmacological treatments for men's erectile dysfunction have undoubtedly contributed as well.

Prior to publication of Masters and Johnson's seminal book on sex therapy

(101), sexual problems were seen as consequences of (nonsexual) psychological conflicts, immaturity, and relational conflicts. Masters and Johnson proposed to directly attempt to reverse the sexual dysfunction by a kind of graded practice and focus on sexual feelings (sensate focus). If sexual arousal depends directly on sexual stimulation, that very stimulation should be the topic of discussion (masturbation training). A sexual dysfunction was no longer something pertaining to the individual, rather, it was regarded as a dysfunction of the couple. It was assumed that the couple did not communicate in a way that allowed sexual arousal to occur when they intended to "produce" it. Treatment goals were associated with the couple concept: the treatment goal was for orgasm through coital stimulation. This connection between treatment format and goals was lost once Masters and Johnson's concept was used in common therapeutic practice. People came in for treatment as individuals. Intercourse frequency became the goldstandard indicator of sexual function. Male orgasm through coitus adequately fulfills reproductive goals, but it is not very satisfactory for many women because they do not easily reach orgasm through coitus. What has remained over the years since 1970 is a direct focus on dysfunctional sex and a focus on sexual sensations and feelings as a vehicle for reversal of the dysfunction.

Psychological treatment of sexual arousal problems generally consists of sensate focus excercises and masturbation training, with the emphasis on becoming more self-focussed and assertive (38). A lack of meaningful treatment goals for women, the difficulty in obtaining adequate control groups, and a lack of clear treatment protocols, may explain the paucity of well-controlled randomized trials of psychological therapy (50).

In the mid-1990s, a number of reviews of treatments for sexual dysfunctions following the criteria for validated or evidence based practice were published (39,102,103). Almost all of the data on psychological treatments were collected in the mid-1980s or earlier. The high success rates published by Masters and Johnson (101) have never been replicated. In their 1997 review, Heiman and Meston concluded that only the directed-masturbation treatments for primary anorgasmia fulfil the criteria of "well-established," and directed-masturbation treatment studies for secondary anorgasmia fall within the "probably efficacious" group. This conclusion is still valid up to date. There are no psychological treatments for FSAD that can be considered "evidence-based" treatments, but as we have argued earlier, directed-masturbation or comparable treatments may be as effective for FSAD as they are for FOD.

Recently, a new nonpharmacological approach to treatment was developed. The EROS Clitoral Therapy Device consists of a small cup that can be placed over the clitoris, and a pump that creates a vacuum over the clitoris. A study in 20 women with sexual arousal complaints and 12 women without sexual problems found improvements in genital sensation, vaginal lubrication, ability to reach orgasm, and sexual satisfaction relative to pretreatment (104). The authors speculate that "the increased vaginal lubrication resulting from clitoral engorgement with the EROS-CTD is due to activation of an autonomic reflex that triggers arterial vasodilatation with subsequent increases in transudate and lubrication." The EROS-CTD is marketed as an effective medical device for female sexual dysfunction (105), even though there was no control treatment such as clitoral vibration (cf. 106). For us, this "medical" device again demonstrates that, if proven effective in larger groups of women with sexual arousal difficulties, many if not most sexual arousal problems are due to a lack of adequate sexual stimulation.

Despite our support for evidence-based practice, care for people with sexual problems, according to the rules of "good clinical practice," must continue, even without solid proof of efficacy. There clearly is a great need for controlled efficacy studies in this area. From our analysis that the majority of sexual arousal problems in healthy women are not related to impaired genital responsiveness, it follows that we expect more benefit for FSAD from psychological treatments than from pharmacological treatments.

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