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A Clinician’s Guide to Systemic Sex Therapy

The Intersystem Approach to Sex Therapy Introduction The Historical Lack of Integration in Couple and Sex Therapy Traditional Sex Therapy is Non-Systemic A Lack of Theory in Combined Sexual Science, Research,and Practice A Lack of Integrative Training Emphasis in Credentialing Professionals A Lack of Integration of Sex and Couple Therapy Practice The Intersystem Approach Major Domains of the Intersystem Approach Integrational Constructs of the Intersystem Approach Social Interactional Theory Triangular Theory of Love Attachment Theory Clinical Use of Integrational Constructs Bringing it Together: An Integrative Paradigm Notes References Diagnosis of Sexual Disorders Introduction Diagnosing with the DSM-5 Overview of Sexual Disorders in DSM-5 Other Categories Specifiers Female Sexual Disorders Female Sexual Interest/Arousal Disorder Female Orgasmic Disorder Genito-Pelvic Pain/Penetration Disorder Male Sexual Disorders Male Hypoactive Sexual Desire Disorder Erectile Disorder Delayed Ejaculation Premature (Early) Ejaculation Limitations of the DSM Diagnostic Categories Disorder versus Problem Etiology: Physiology versus Psychology Comorbidity with Other Conditions Individual or Relational Problems Clinical Judgment Sexual Problems Not Currently in the DSM-5 “Out of Control” Sexual Behavior Persistent Genital Arousal Disorder Sexual Aversion Disorder Male Dyspareunia Diagnosis from the Intersystem Perspective References Intersystem Assessment of Sexual Disorders General Principles The Biphasic Assessment Process The Sexual History The Intersystem Sexual History Individual Biological Individual Psychological The Relationship Intergenerational Factors Contextual Elements Guidelines for Taking a Sexual History Promote Comfort and Ease Provide a Safe Environment Therapist Considerations Understand One's Own Sexuality Avoid Shaming Adopt a Stance of Both Never Assuming and Always Assuming Normalize Sex Talk Think Systemically Conducting the Clinical Interview Interviewing for Specific Disorders Male Sexual Desire Disorder and Female Sexual Interest/Arousal Disorder Sexual Thoughts and Fantasies Domains of Desire and Interest Additional Questions for Women with FSI/AD Additional Questions for Men with HSDD Erectile Disorder Assessing for Orgasm and Ejaculation Disorders Premature (Early) Ejaculation Female Orgasmic Disorder Disorders of Pain Genito-Pelvic Pain/Penetration Disorder Conclusion References The Sexual Genogram in Assessment Introduction Intergenerational Transmission of Sexual Attitudes and Beliefs The Sexual Genogram The Focused Genogram and Sexuality Expanding the Sexual Genogram Constructing the Sexual Genogram Beginning a Sexual Genogram Sample Focused Genogram Questions Sample General Questions Sample Gender and Related Questions Sexual Timeline Sample Timeline Questions Clinical Considerations References General Treatment Principles, Strategies, and Techniques General Treatment Considerations Beginning Treatment Initial Contact The Initial Session The Triage Tree Presenting Problem versus Other Clinically Relevant Problems Medical Problems Significant Individual Psychopathology Severe Relational Discord Multiple Dysfunctions in an Individual Sexual Dysfunctions in Both Partners Keeping Treatment Systemic Treatment Planning Beginning Treatment Readiness for Sex Therapy The Importance of Principle, Techniques, and Process References Treatment Principles, Strategies, and Techniques Specific to Men Treating Male Hypoactive Sexual Desire Disorder Identifying Physical Issues in the Man Uncovering Additional Sexual or Psychological Problems Reducing Response Anxiety Conducting Cognitive Work Working with Intimacy Fears Uncovering Secrets Providing Psychoeducation Addressing Relationship Factors Overcoming Pessimism and Skepticism Promoting Communication Other Techniques Treating Erectile Disorder Promoting Systemic Thinking Providing Bibliotherapy and Education Dissipating Performance Anxiety Conducting Cognitive Work Understanding Medical Treatments Assigning Appropriate Homework Non-genital Touch Genital Touch Focused Genital Touch Ejaculation Penetration Free Form Intercourse Final Issues in Treating ED Treating Premature (Early) Ejaculation Understanding Medical Treatments Providing Psychoeducation about Orgasm Implementing Behavioral Strategies and Techniques Teaching Start-Stop and Squeeze Techniques Teaching the Start-Slow Technique Teaching the Quiet Vagina Technique Treating Delayed Ejaculation Assessment Individual Factors Relationship Issues Intergenerational and Contextual Factors Conducting a Thorough Assessment Reduce Sensory Defensiveness and Anxiety Use Sensual Touch Exercises Explore Masturbatory Patterns and Fantasies Conclusion References Treatment Principles, Strategies, and Techniques Specific to Women Treating Female Sexual Interest/Arousal Disorder Assessment Biological Aspects Psychogenic Influences Relationship Issues Intergenerational Risk Factors Contextual Risk Factors Treatment Addressing Pessimism and Skepticism Setting Realistic Expectations Responsibility for Intimacy Cognitive Work Communication Skills Working with Sexual Fantasies Using Mindfulness Treating Other Sexual Disorders Medical Therapies Treating Female Orgasmic Disorder Individual Biological Issues Individual Psychological Issues Intergenerational Factors Relational Issues Strategies and Techniques Exploring Barriers to Orgasm Directed Masturbation Fantasy Work Partner Considerations Bibliotherapy for the Therapist and Couple Home Assignments Client Resources Treatment of Genito-Pelvic Pain/Penetration Disorder Prevalence Etiology Biological Factors Psychological Features Relational Factors Intergenerational Factors Contextual Factors Terminology Dyspareunia Vaginismus Vulvodynia Client Resources Strategies and Techniques Pain Assessment Demystifying Pain Psychoeducation of the Couple Establish Realistic Goals Cognitive-Behavioral Interventions Behavioral Strategies Mindfulness-Based Treatments Medical Treatments Other Strategies and Techniques References At-Home Assignments: General Principles Introduction Core Elements of Homework Common Structural Elements Assign Relevant, Acceptable, and Appropriate Homework Make Sure the Homework Is Appropriate for the Couple's Age, Abilities, and Lifestyle Assign Simple, Clear Homework with Specific Instructions Start Small and Build on Successes Make Assignments Single Focused and Specific Ensure Understanding Obtain an Investment Build in Contingency Plans and Offer Flexibility Offer Support Case Illustration Processing an Assignment Reading Assignments References Psychoeducation in Sex Therapy Introduction Bibliotherapy Sexuality Books Bibliography Videos/Multimedia Internet Resources Other Internet Sources Erotica References Sensate Focus and Mindfulness Introduction The Systemic Perspective Sensate Focus Exercises Nine Functions of Sensate Focus Readiness for Sensate Focus Assignments Structure and Application of Sensate Focus Using Metaphors Proscribing Intercourse Creating a Sensual Environment Touching and Sensual Pleasuring Sensual Pleasuring with Erotic Stimulation Transitioning to Intercourse Conclusion Into the Future References Factors that Complicate Treating Sexual Disorders Introduction Sexual Ignorance Sexual Mythology Faulty Cognitions Sexual Guilt, Anxiety, and Shame Dealing with Sexual Mythology Dealing with Common Intimacy Fears Fear of Intimacy Fear of Anger Fear of Feelings Fear of Losing Control Fear of Rejection/Abandonment Fear of Dependency References Physical/Medical Issues in Sex Therapy Introduction The Medicalization of Sexuality Sexuality and Clients with Physical Illness Neurological Ailments Multiple Sclerosis Cerebral Palsy Parkinson's Disease Stroke Cardiovascular Illness Cancer Prostate Cancer Breast Cancer Cancer Treatments and Sexuality Diabetes Sexuality and Disability Comprehensive Assessment and Treatment Attending to Sexual Mythology Sexuality and Aging Health Issues Men Women Summary Sexual Scripting Changing Roles Partner Availability Sexually Transmitted Illnesses Sexual Assessment Treatment Strategies for Physical/Medical Issues Keeping a Systemic Focus Collaborate with Medical Providers Psychoeducation Physical Realities Reducing Anxiety, Misinformation and Myths Addressing Relationship Issues in the Context of Illness Expanding the Sexual Repertoire Enhance Couple Communication Attend to Issues in the Therapist References Diversity in Sexual Expression Terminology Queer Clients Therapeutic Recommendations Kinky Clients Lesbian and Gay Clients Bisexual Clients Asexual Clients Transgender Clients Clinical Considerations Therapist Competency Non-monogamous Relationships Types of Consensual Non-monogamy Polyamory Rules and Agreements Therapeutic Considerations Client Resources Intersex Clients Categorization The Urgency of Medical Treatments Consent Emerging Consensus Client and Therapist Resources A Final Thought References

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The Intersystem Approach to Sex Therapy