Application: Family Life-Cycle StagesAlthough every individual experiences family life-cycle transitions in unique ways, common challenges and experiences often arise at these transition periods. Fo

The behavioral and cognitive-behavioral treatment of female sexual dysfunction: how far we have come and the path left to go Rebecca D. Stinson* Department of Psychological and Quantitative Foundations, University of Iowa, USA (Received 16 December 2008; ﬁnal version received 22 July 2009) Over the past several decades, researchers have been trying to determine eﬃcacious treatments for sexual dysfunctions. While sexual dysfunction is problematic for both men and women, studies have shown women consistently deal with it at higher rates than men. Proposed treatment modalities come in many forms, yet many outcome studies support the use of behavioral or cognitive-behavioral interventions when addressing female sexual dysfunction.

This paper will review the prevalence of female sexual dysfunction, provide a brief history of its treatment, and outline studies that used behavioral and cognitive- behavioral treatments. Lastly, a discussion will address the need for psychologists to continue researching, improving and promoting the use of psychological interventions for women who present with concerns related to sexual functioning.

Keywords:sexual dysfunction; sexual diﬃculties; women; behavioral treatment; cognitive-behavioral treatment; female sexual disorders Introduction While classiﬁcations for female sexual dysfunction have changed over time, according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV-TR: American Psychiatric Association, 2000) the current classiﬁcation stipulates six female-speciﬁc disorders within four categories. These categories include sexual desire disorders (hypoactive sexual desire disorderand sexual aversion disorder), sexual arousal disorder (female sexual arousal disorder), orgasmic disorder (female orgasmic disorder) and sexual pain disorders (dyspareunia andvaginismus). Within these disorders, subtypes are deﬁned as lifelong versus acquired and generalized versus situational.

Although professionals have worked with female sexual dysfunction for decades, there is much to learn regarding its treatment. The ﬁrst part of this review will explore the prevalence of female sexual dysfunction. Part two will describe both the treatment history of sexual dysfunction and outcome studies related to behavioral and cognitive-behavioral (B/CB) treatments proposed for female sexual disorders.

Last, a discussion about the need for continued research and improvement of psychological interventions is included. Especially given recent medicalization of sexual dysfunction treatments, it is important for professionals to continue working toward psychological interventions that can be used in conjunction with, or *Email: [email protected] Sexual and Relationship Therapy Vol. 24, Nos. 3–4, August–November 2009, 271–285 ISSN 1468-1994 print/ISSN 1468-1749 online British Association for Sexual and Relationship Therapy DOI: 10.1080/14681990903199494 http://www.informaworld.com independent from, medical interventions. Being able to provide a variety of eﬃcacious treatments empowers clients to decide which treatment(s) they would feel comfortable with.

The current state of female sexual dysfunction Over the past decade, studies have explored the prevalence of female sexual dysfunction worldwide (see Table 1). Despite this literature, we still do not have a full understanding of its impact on women. Determining the prevalence of sexual dysfunction is diﬃcult for several reasons. As noted in Table 1, studies vary widely in their design, methodology, sampling and reporting (e.g., age range). Nevertheless, results highlight that sexual diﬃculties are common and deserve the attention of both medical and psychological communities. Low desire is most common, followed by orgasm, arousal and sexual pain diﬃculties. Researchers have posited that between 26 and 71% of women worldwide contend with sexual dysfunction.

In addition to variable methodology, contention exists about whether or not what is labeled ‘‘sexual dysfunction’’ is dysfunctional. According to the DSM-IV-TR (APA, 2000), distress must be present to qualify for a diagnosis, yet few studies measure distress. Some researchers ﬁnd this very problematic (Hayes, Bennett, Fairley, & Dennerstein, 2006; Shifren, Monz, Russo, Segreti, & Johannes, 2008). If not perceived as distressing, it may be inappropriate to label experiences as problematic. This contention, and the inconsistent methodology listed above, restricts generalizability.

Prevalence estimates may not be accurate representations of experience.

Two factors appear to play a large role in sexual diﬃculties for women. Mental health issues are detrimental to women’s healthy sexual functioning (Addis et al., 2006; Shifren et al., 2008). However, it is unknown whether they are the cause or the eﬀect of sexual diﬃculties. Sexual functioning also decreases with age (Hayes & Dennerstein, 2005; Shifren et al., 2008), yet older women show less sexual distress (Hayes & Dennerstein, 2005; Hayes et al., 2007), which may be a result of more comfort with themselves and their sexual relationships.

If women are struggling with sexual problems at the rate research is reporting, it is important for professionals to know how many are seeking help. Studies that gather such information report alarming results. Moreira and colleagues (2005) found that of 48% of women indicating sexual problems, 78% sought no help from any sort of a health professional, 4% sought help from a psychologist, psychiatrist or marriage counselor, while 18% sought help from a medical doctor. Kadri, Alami and Tahiri (2002) found that 17% of women indicating sexual problems sought help from a medical professional. Berman and colleagues (2003a) found that 40% of women who endorsed sexual problems did not seek help from their doctor even though 54% reported wanting to.

Two explanations could rationalize low help-seeking rates: (1) women who do not ﬁnd sexual diﬃculties distressing do not seek help and (2) many women may want to obtain help, but do not have the resources to do so or believe professional interventions will not help. This is concerning given our job is to ensure patients can obtain services and that treatment enhances their quality of life.

Results of prevalence studies show that sexual problems are a struggle for women worldwide. Male sexual dysfunction has garnered much deserved attention over the past several decades. However, studies examining eﬃcacious and innovative treatments for female sexual dysfunctions have lagged behind (Basson et al., 272R.D. Stinson Table 1. Prevalence studies investigating female sexual dysfunction.

Study Location SampleN(age) Procedure Time spanDesire (%)Orgasm (%)Arousal (%)Pain (%)Overall (%) Addis et al.

(2006)USA 2109 (40–69) Personal interview; surveysPast 4 weeks 22.7 18.9 17.3 – 32.6 Laumann et al. (1999)USA 1749 (18–59) Personal interview4several months in past year30.3 24.8 – 14.3 43 Laumann et al. (2005)Global 13,882 (40–80) Various42 months in past year25.6–43.4 17.7–41.2 16.1–37.9 9.0–31.6 – Kadri et al. (2002)Morocco 491 (20–80) Personal interviewPast 6 months 18.3 12 8.3 7.5 26.6 Bancroft et al. (2003)USA 987 (20–65) Phone interviewPast 4 weeks 7.2 9.3 31.2 3.3 45.3 Mercer et al.

(2005)Britain 5530 (16–44) Computer interviewPeriod within past year40.6/10.2 (41mo./ 46 mos.)14.4/3.7 (41/46)9.2/2.6 (41/46)11.8/3.4 (41/46)53.8/15.6 (41/46) Najman et al. (2003)Australia 908 (18–59) Phone interview4several months in past year33.9 20.5 21.3 16.7 60.5 Richters et al. (2003)Australia 9134 (16–59) Phone interview41 month in past year54.8 28.6 23.9 20.3 70.9 Shifren et al. (2008)USA 31,581 (18–102) Mailed surveys Not noted 38.7 20.5 26.1 – 44.2 Sexual and Relationship Therapy273 2000). It is now time to revisit this important area and develop more eﬃcacious treatments for all sexual diﬃculties that women experience.

Treatment of sexual dysfunction The treatment of sexual dysfunction goes back many years and takes many diﬀerent forms. Included here is a brief summary (see Duterte, Segraves and Althof [2007] for more thorough information).

Psychoanalysis was the treatment for many psychological problems in the earlier half of the twentieth century; sexual diﬃculties were no exception. It sought to treat diﬃculties by uncovering unconscious urges and neuroses. By the end of the 1960s, however, another option had formed – behaviorism. Behavioral approaches were modeled after the classical conditioning paradigm and viewed sexual problems as learned anxiety responses. While behavioral approaches such as systematic desensitization continue to be popular treatment approaches for sexual disorders, they ignore contextual factors impacting the patient.

For clinicians unsatisﬁed with ignoring relationship and environmental factors, Masters and Johnson’s (1970) groundbreaking work opened up opportunities for researchers and clinicians to blend behavioral techniques with cognitive therapy or psychodynamic approaches emphasizing interpersonal dynamics. Treatment also shifted from solely individualized work to that involving the individual, couple or group.

With the coming of medical progression, the 1980s began the psychobiological approach still emphasized today. Medical advancements have shaped treatments for sexual dysfunction and ultimately shifted care from mental health professionals to physicians. Male sexual dysfunctions have been met with great success from pharmacological agents; it is on this treatment track that female sexual problems seem to be headed as well (e.g. Berman, Berman, Toler, Gill, & Haughie, 2003b).

Behavioral and cognitive-behavioral interventions for female sexual dysfunction A search for B/CB interventions related to female sexual disorders returns many results. Currently, some female sexual disorders appear to be more receptive to B/CB interventions than others. Female inorgasmia has garnered the most attention and success over time. This is reﬂected in the fact that some B/CB interventions are classiﬁed as empirically validated treatments for female orgasmic disorder (Heiman & Meston, 1997), but not desire, arousal or sexual pain disorders.

Despite evidence of eﬃcacy, Heiman and Meston (1997) explain that evaluating the eﬀectiveness of treatments is diﬃcult because studies often lack suﬃcient research methodologies. They state that sample sizes are often too small for satisfactory statistical analysis, relatively few studies use pre- and post-measures, the problem is usually not clearly deﬁned, outcome measures are not accompanied by their psychometric properties, the variables in question for treatment are not speciﬁed adequately and the treatment program itself is not described in suﬃcient detail to replicate. While these drawbacks are troublesome, outcome studies that have been published suggest there is hope in B/CB interventions.

The studies that are reviewed here (Table 2) demonstrate the potential of B/CB interventions for female sexual disorders. While some include alternate treatments as comparison groups, each investigates at least one B/CB intervention. The databases 274R.D. Stinson Table 2. Behavioral and cognitive-behavioral studies investigating female sexual disorders.

Study SampleTreatment sessionsFollow-up (months) Treatment(s) Outcome Desire disorders Hurlbert (1993) 39 8 3,6 1. Cognitive-behavioral Cognitive behavioral with directed masturbation greater sexual arousal, assertiveness, and satisfaction; both groups higher sexual desire 2. Cognitive-behavioral with directed masturbation McCabe (2001) 43 10 – Cognitive-behavioral (increase communication, sexual skills; decrease performance anxiety)67% still reported symptomology post- treatment Trudel et al. (2001) 74 12 3,12 1. Cognitive-behavioral group 64% treatment group considered improved or cured through 1 year follow- up; treatment more eﬀective than no treatment 2. Wait-list control Arousal disorder McCabe (2001) 18 10 – Cognitive-behavioral (increase communication, sexual skills; decrease performance anxiety)44% still reported symptomology post- treatment Morokoﬀ & Heiman (1980)22 15 – 1. Cognitive-behavioral for clinical Post-treatment: clinical and non-clinical groups had same physiological and subjective arousal responses 2. None for non-clinical Orgasmic disorders Lobitz and LoPiccolo (1977)22 15 6 Couples systematic desensitization with masturbatory training13 of 13 primary inorgasmic women 100% successful through follow-up; 3 of 9 secondary inorgasmic 100% successful (continued) Sexual and Relationship Therapy275 Table 2. (Continued).

Study SampleTreatment sessionsFollow-up (months) Treatment(s) Outcome McCabe (2001) 36 10 – Cognitive-behavioral (decrease anxiety by addressing inhibitive cognitions and behaviors)16% still reported symptomology post- treatment Riley & Riley (1978) 35 12 12 1. Conventional: sensate focus, supportive psychotherapy53% success for conventional group through follow-up; 90% success for masturbatory training through follow-up 2. Conventional plus masturbatory training Sexual pain disorders – vaginismus Schnyder et al. (1998) 44 6 (average) 6–22 1. In vivo desensitization 98% success for treatments; 50% still some pain; no diﬀerence between therapies; follow-up: 50% no vaginismus, 48% improved 2. In vitro desensitization ter Kuile et al. (2009) 10 3 1,12 Self-controlled exposure 90% success for intercourse post-treatment through follow-up ter Kuile et al. (2007) 117 1–10 (group CBT 2.6 (biblio)3,12 1. CBT Those who achieved intercourse, signiﬁcantly less fear of coitus and more non- coital penetration 2. Bibliotherapy 3. Wait-list control van Lankveld et al. (2006)See ter Kuile & Weijenborg (2006) for research design 14% success for treatment groups versus 0% success for wait-list controls post- treatment; 3 mo.¼17%(g)/ 14%(b); 12 mo.¼21%(g)/ 15%(b); treatments do not diﬀer (continued) 276R.D. Stinson Table 2. (Continued).

Study SampleTreatment sessionsFollow-up (months) Treatment(s) Outcome Dyspareunia (from vulvar vestibulitis) Bergeron et al. (2001) 78 1.8 (CBT) 2.3 mo (bf) 6 1. Group CBT Complete relief or improvement: 39% GCBT, 36% biofeedback, 68% surgery 2. EMG biofeedback 3. surgery (vestibulectomy) Danielsson et al. (2006) 37 1.4 mo (bf) 2.4 mo (cream) 6,12 1. EMG biofeedback Both signiﬁcantly improved pain threshold quality of life, and psychosexual functioning, no diﬀerence between treatments 2. topical lidocaine McKay et al. (2001) 29 Monthly evaluations 4–6 EMG biofeedback 69% became sexually active; 89% negligible or mild pain ter Kuile and Weijenborg (2006)67 12 1–3 weeks Group CBT Signiﬁcantly less coital pain and vaginal tension Sexual and Relationship Therapy277 of PsycINFO and EBSCOhost were searched using the terms ‘‘hypoactive sexual desire’’, ‘‘sexual arousal disorder’’, ‘‘female orgasmic disorder’’, ‘‘inorgasmia’’, ‘‘vaginismus’’, ‘‘dyspareunia’’, ‘‘female sexual dysfunction’’, female sexual disorder’’, ‘‘treatment’’ and ‘‘intervention’’. Case studies were excluded, as were those that did not describe the treatment in enough detail to warrant inclusion.

Sexual desire disorders Hypoactive sexual desire disorder (HSDD) is considered one of the most diﬃcult sexual disorders to treat psychologically given its complexity and relatively poor prognosis (Kaplan, 1979). According to the DSM-IV-TR (APA, 2000), HSDD is deﬁned as a persistent deﬁciency or absence of sexual fantasies and desire for sexual activity causing marked distress. Although psychological processes have long been assumed to be the core of HSDD, within the past decade medical interventions such as testosterone therapy have gained momentum (e.g. Davis et al., 2008). Despite promising medical interventions, B/CB treatments are employed to help women regain a sense of sexual desire given motivational and emotional factors contribute to HSDD.

Traditionally, a lack of desire is seen as avoidance related to anxiety toward sexual intimacy (Kaplan, 1979) or a result of relationship problems (Verhulst & Heiman, 1988). The goal of B/CB treatments is to alter the way women feel, think and approach sex by addressing anxiety and negative cognitions/attitudes.

While outcome research is limited, the few studies that have demonstrated positive outcomes consist of treatment modalities using systematic desensitization (including sensate focus exercises) and cognitive-behavioral therapy (CBT) (see Table 2).

Sensate focus, much like other forms of systematic desensitization, is a set of exercises aimed at gradually introducing sexual touching and stimulation into a relationship over the course treatment. Proceeding through graded exposure steps that move from non-sexual to sexual allows women to acquaint themselves with sexual pleasure within the conﬁnes of a safe environment and open communication.

Hurlbert (1993) sought to determine whether orgasm consistency training in addition to a standard CB program was more eﬀective than the CB intervention alone. Included were 39 women who completed either the standard CB or multimodal treatment. At the three-month follow-up, women who received the combined treatment reported greater sexual desire, arousal and sexual assertiveness than women in the standard group. These gains were maintained at the six-month follow-up with the addition of greater sexual satisfaction. Overall, both groups of women had positive increases in their sexual desire, yet there were added beneﬁts for women in the combined treatment.

Another study conducted by McCabe (2001) focused on a CB treatment addressing inhibitive cognitions and behaviors as well as partner communication and sexual skills to decrease anxiety related to sexual performance. Forty-three women reported low sexual desire pre-treatment. Post-treatment, the number of women reporting low desire decreased to 29. While not exceptional, results suggest that CB interventions may be helpful for increasing sexual desire.

The most well-controlled study thus far of HSDD employed a short-term, CB group format with both a treatment and wait-list control group (Trudel et al., 2001). Seventy-four couples were randomly assigned and evaluated at pre-treatment, 278R.D. Stinson post-treatment and two follow-ups. Couples assigned to the treatment condition engaged in weekly group sex therapy sessions focused on examining the dysfunctional cognitions related to hypoactive sexual desire. Results showed a decrease in symptomology and increases in overall cognitive, behavioral and marital functioning. Seventy-four percent were considered improved at post-treatment and held steady at 64% three-months and one year later. At post-treatment, 28% judged they were completely symptom-free; this rose to 31% at three-month follow-up and ended at 38% at the one-year follow-up. Based on these results, CB approaches should be considered treatment options for women with HSDD.

Sexual arousal disorders Sexual arousal disorder is diﬃcult to study given that it often does not occur independent of other sexual dysfunctions (Segraves & Segraves, 1991). According to the DSM-IV-TR (APA, 2000), female sexual arousal disorder is deﬁned as the persistent or recurrent inability to attain, or maintain until the completion of sexual activity, an adequate lubrication-swelling response of sexual excitement, which causes marked distress. Much like desire disorders, B/CB interventions have been considered helpful for treatment (see Table 2).

The McCabe (2001) study discussed previously also included women with sexual arousal problems. Pre-treatment, 18 women reported sexual arousal diﬃculties.

After the ten-week CB intervention, eight women continued to report diﬃculties.

With more than half of the women reporting treatment gains, this suggests that CB interventions are even better suited to arousal problems than HSDD. However, note that many women have multiple sexual dysfunctions. Thus, the results cannot be interpreted as independent from one another.

Another study targeted at overcoming arousal problems was conducted by Morokoﬀ and Heiman (1980). They used both a clinical and non-clinical sample comprised of 11 women each. Both groups engaged in ﬁve erotic stimulus conditions pre- and post-treatment. The clinical sample, however, engaged in 15 sessions of CB intervention between pre- and post-treatment, while the non-clinical sample did not.

At pre-treatment, both groups had similar physiological responses to erotic stimuli, but subjective reports of sexual arousal were higher in the non-clinical group. After the clinical sample received therapy, both groups had similar genital responses and reports of subjective arousal. The authors concluded that treatment for inhibited arousal should target cognitive and emotional experiences instead of only the physiological responses of the body.

Orgasmic disorders Female orgasmic disorder (or inorgasmia) is the most studied of all female sexual dysfunctions; outcome research dates back decades. Thus, we are aware of more eﬃcacious treatments for this sexual disorder than any other. Behavioral and cognitive-behavioral treatments for lifelong (or primary) inorgasmia are considered ‘‘well-established’’ and eﬃcacious and treatments for acquired (or secondary) inorgasmia ‘‘probably eﬃcacious’’ (Heiman, 2002; Heiman & Meston, 1997).

According to the DSM-IV-TR (APA, 2000), female orgasmic disorder is the persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase, causing marked distress.Sexual and Relationship Therapy279 Behavioral and cognitive-behavioral treatments have been the methods of choice for treating female inorgasmia and include directed masturbation, sensate focus, systematic desensitization and CB therapy in multimodal treatment combinations (see Table 2). Generally, the ability to orgasm is drastically improved with B/CB treatment.

Lobitz and LoPiccolo (1977) employed a behavioral approach to increase orgasm. A masturbatory program was used in conjunction with a time-limited behavioral program involving both partners. Based on classical conditioning, in vivo graded exposure (systematic desensitization) was used to decrease performance anxiety and introduce orgasm to participants. Clients were instructed to focus on erotic stimuli they found arousing during intimate activity with their partner and, once aroused, masturbate to orgasm. Thus, sexual arousal and orgasm became paired with sexual activity with their partner. Treatment gains were maintained after six-months. All primary inorgasmic women remained orgasmic while three out of nine secondary inorgasmic women maintained orgasmic functioning.

Riley and Riley (1978) also employed directed masturbation. Fifteen patients underwent a conventional approach (sensate focus and supportive psychotherapy), while twenty experienced masturbatory training in addition to the conventional approach. Post-treatment, 90% of women in the directed masturbation group had attained the ability to orgasm by any means, while 53% in the conventional approach had attained the same ability. Also, 85% in the combined approach were able to orgasm during intercourse by any means while 47% in the conventional approach had attained the same ability. At a 12-month follow-up, all women had maintained the ability to orgasm.

In her study of CB interventions for sexual dysfunctions, McCabe (2001) included women with inorgasmia. Pre-treatment, 36 women were inorgasmic. After the program aimed at decreasing anxiety through addressing inhibitive cognitions and behaviors, six women continued to report the inability to orgasm. This level of improvement was the best across all sexual diﬃculties suggesting orgasmic diﬃculties are responsive to CB interventions.

In general, outcome research for B/CB treatments of female orgasmic disorder show that women can learn to shift self-induced orgasm to sexual situations involving an intimate partner.

Sexual pain disorders Sexual pain disorder treatments are frustrating given the physiological and psychological mechanisms responsible are not yet fully understood. However, it is believed that both physical and psychological components are involved and should be part of a multidimensional treatment (Basson et al., 2004). What makes diagnosis and treatment more complicated is the fact that dyspareunia and vaginismus overlap (de Kruiﬀ, ter Kuile, Weijenborg, & van Lankveld, 2000). Some researchers even question them as sexual dysfunctions (Binik, Bergeron, & Khalife, 2007).

Despite our limited understanding of vaginismus and dyspareunia, B/CB treatments have been studied (see Table 2). Perhaps complicating things further is contention over what should be considered the goal of treatment. Most researchers use vaginal penetration as evidence of treatment success (e.g. McKay et al., 2001; van Lankveld et al., 2006), while others posit treatment success should encompass other forms of sexual pleasure (Basson et al., 2004). 280R.D. Stinson Vaginismus According to the DSM-IV-TR (APA, 2000), vaginismus consists of a recurrent involuntary spasm of the outer third of the vaginal musculature that interferes with intercourse causing distress or interpersonal diﬃculty. An international committee (Basson et al., 2004) recommends a more comprehensive deﬁnition including ‘‘phobic avoidance, involuntary pelvic muscle contraction and anticipation/fear/ experience of pain’’ (p. 30) be used.

Treatment is generally systematic desensitization with graded dilators, sex therapy, cognitive restructuring, education and relaxation training despite limited controlled research. Outcome studies that include B/CB treatments for vaginismus show promising results (see Table 2).

Schnyder, Schnyder-Luthi, Ballinari and Blaser (1998) compared in vivo versus in vitro desensitization with vaginal dilators. Treatment sessions were continued until symptoms abated. After an average of six sessions, 98% were able to engage in intercourse. Although 50% still experienced some pain, they reported satisfying sexual experiences. At follow-up, 50% reported their vaginismus had disappeared while 47% said symptoms had greatly improved.

Another research group (ter Kuile et al., 2009) treated 10 women with exposure therapy. At post-treatment and one- and twelve-month follow-up, 90% were able to successfully engage in intercourse. While a small sample size, the success rate from only three therapy sessions demonstrates impressive gains.

A large controlled study conducted by ter Kuile and colleagues (ter Kuile et al., 2007; van Lankveld et al., 2006) compared group cognitive-behavioral therapy (GCBT) with bibliotherapy and wait-list controls. Treatments consisted of psycho- education, behavioral exercises and cognitive restructuring among others. At post- treatment, results indicated that the two treatments showed superiority over wait-list controls (14% success versus 0%; van Lankveld et al., 2006). At each follow-up the percentage of success continued to increase, suggesting treatment gains were ongoing. Those who were successful at achieving intercourse showed signiﬁcantly less fear of sex and were more able to accept non-penile penetration (ter Kuile et al., 2007).

Dyspareunia Dyspareunia is deﬁned as recurrent or consistent pain associated with sexual intercourse causing distress or interpersonal diﬃculty. Treatments include biofeed- back, medications, CB therapy and surgery among others. The etiology appears to be both psychological and physiological, yet recent studies have focused on vulvar vestibulitis (provoked vulvar pain) as its cause.

Investigations by ter Kuile and Weijenborg (2006) and McKay and colleagues (2001) show promising results for B/CB treatments. Electromyographic (EMG) biofeedback was taught to 29 women. After four to six months of use, over two- thirds reported increased sexual activity and 89% reported greatly reduced pain (McKay et al., 2001). Alternately, GCBT was used with 67 women and after 12 sessions participants reported signiﬁcantly less vaginal pain and tension (ter Kuile & Weijenborg, 2006).

Danielsson, Torstensson, Brodda-Jansen and Bohm-Starke (2006) compared a topical cream with EMG biofeedback. After treatment completion and atSexual and Relationship Therapy281 two follow-ups, women reported signiﬁcantly improved pain thresholds and psychosexual functioning. They found no signiﬁcant diﬀerence between the two treatment regimens.

In the most well-controlled study, Bergeron and colleagues (2001) compared GCBT, EMG biofeedback and surgery. All participants reported decreased pain.

Complete relief and improvement was experienced by about one-third of the GCBT and EMG biofeedback groups versus two-thirds of those obtaining surgery.

However, it should be noted that the surgery group did not include those who had been assigned, but dropped out not wanting surgery.

When addressing sexual pain, it is important to remember that these disorders are multi-dimensional and inﬂuenced by a multitude of factors including behavior, aﬀect, cognition, relationship dynamics and medical status (Binik, Bergeron, & Khalife, 2007). Assessment must explore each of these areas and treatment must address each component contributing to women’s sexual pain.

Discussion The studies reported here suggest that B/CB interventions are helpful for treating sexual diﬃculties. It is disheartening, then, to see eﬃcacy research not keeping pace with its need. With so many women experiencing sexual dysfunction, and so few seeking treatment, it suggests the psychological ﬁeld must do more to instill hope in individuals that their troubles can be successfully addressed. In fact, female sexual dysfunction seems to have become normalized. Data from the Global Study of Sexual Attitudes and Behaviors (Moreira et al., 2005) showed that 75% of women thought sexual diﬃculties are normal with aging, 68% were waiting for it to go away and 54% did not think their doctors could do much to help.

There are several things our profession must do to ensure continued progress for the treatment of female sexual dysfunctions:

.Support the testing of medical interventions. The current push for medical/ pharmacological treatments cannot be resisted. Interventions such as medica- tions, topical creams and surgery all have potential beneﬁt. Further research regarding their contribution to combating female sexual dysfunction should be continued in order to discover new treatments and establish their safety and utility. Developing eﬃcacious medical treatments will provide more options for women who seek help.

.Increase controlled trials for psychological interventions. The development and improvement of psychological interventions seems to have stagnated since the medicalization of sexual dysfunctions. Several psychological professionals ﬁnd this concerning (Rosen & Leiblum, 1995). It can be argued that mental health and medical professionals do clients a disservice by suggesting and prescribing medical interventions without also emphasizing the underlying psychological cause of their problems. Not all clients desire medical treatment and such treatments are sometimes inappropriate. Also, in order to provide the best psychological service, we must continue seeking empirically supported treatments for all dysfunctions, not just orgasmic diﬃculties.

.Understand multi-dimensional problems require multi-dimensional solutions.

Much like other psychological disorders, medical and psychological interven- tions together may be the best prescription for sexual disorders. This requires 282R.D. Stinson treatment teams consisting of at least a psychologist and physician. Using a biopsychosocial model for conceptualization and treatment provides the best care.

.Incorporate recently developed psychological interventions. While therapies consisting of systematic desensitization, sensate focus and cognitive restructur- ing have demonstrated utility, recent developments in areas such as mind- fulness (e.g. Brotto, Basson, & Luria, 2008) are helpful too. Since traditional psychological approaches are not always successful, it is worth talking with clients about trying newer alternatives based in cognitive and behavioral frameworks.

.Let clients deﬁne ‘‘dysfunction’’ and ‘‘success’’. Sexual behavior is a complex system involving multiple processes. The current dichotomy of functional versus dysfunctional sexual health is problematic. Wincze and Carey (1991) suggest sexual functioning should be considered to occur along a continuum of satisfaction and this view should be highly attractive to mental health professionals who deal with the complexities of the human experience. We should work with our clients collaboratively to determine treatments that meet their individual sexual needs and circumstances. Eﬃcacious CB treatments, which encourage modifying not only sexual behavior, but also the thoughts, feelings and beliefs about intimacy that may negatively impact sexual satisfaction, help the profession do this.

Notes on contributor Rebecca Stinson is a doctoral student in counseling psychology at The University of Iowa and holds a Master of Education degree from the University of Missouri-Columbia. She researches the connections between gender and sexuality.

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