TO practice safe sex always

1. Mr. Siba karmi
M. Phil in PSW
CIP, Ranchi

2.  INTRODUCTION
 SEXUALITY: AN OVERVIEW
 SEXUAL DYSFUNCTION AND DEVIATIONS
 APPROACHES TO SEX THERAPY
 FORMAT OF SEX THERAPY
 THERAPUTIC TECHNIQUES
 CULTURE - BOUND SYNDROMES
 CONCLUSION
2

3. “Sex is a natural function.
You can’t make it
happen, but you can
teach people to let it
happen.”
-William Masters
“If sex is such a natural
phenomenon, how come
there are so many books
on how to do it?”
-Bette Midler
3

4.  The sexual nature of human beings is unique
and display complex sexual behaviors. We
create ideas, laws, customs, fantasies, and art
around the sexual act.
 “Sexual health is the integration of the somatic,
emotional, mental and social aspects of sexual
being, in ways that are positively enriching and
that enhance personality, communication and
love (World Health Organization).
4

5. Sexuality is a general term for the feelings and behaviors
of human beings concerning sex. The term sex is used to
refer the biological designation of being either male or
female. Gender role is a wide assortment of expectable or
appropriate thoughts, feelings, and behaviors of males
and females; this is specific to socio- cultural
environment. Gender identity is referring to our self –
awareness of our maleness and femaleness, this may
involve the degree to which our biological characteristics
and our gender role are commensurate.
5

6. Excitement phase -thoughts play a major
role in excitement phase. Heart rate
and blood pressure gradually
increase throughout the excitement
phase. It includes penile erection in
the male and vaginal lubrication and
enlargement and breast changes in
the female.
The plateau phase- with continued erotic
stimulation, further physical changes
occur along with the individual’s
perception of growing sexual
pleasure. It includes the slight
retraction of the clitoral shaft and
glands in females and slight increase
of penis in males.
6

7. The orgasm phase- the sudden release of the tension
that built up during the plateau phase is an orgasm.
The resolution phase-the person has a sense of
relaxation and well-being after orgasm. Women’s
body returns to its pre excitement state and the penis
return to its unstimulated appearance.
7

8. 1) Desire phase –This model distinguishes between desire
as a psychological issue and physical first stage of
response in Master and Johnson.
2) The excitement phase
In this stage, vasocongestive responses of the pelvis and
genitalia are prominent. It includes generalized whole
body increase in muscular tension, modest increase in
heart rate, blood pressure and respiration rate
3) The orgasm phase
The third stage of Kaplan’s model is orgasm and
resolution phase is not included in her model.
8

9.  Lack or loss of sexual desire- loss of sexual desire is the
principal problem and is not secondary to other sexual
difficulties, such as erectile failure or dyspareunia.
 Sexual aversion and lack of sexual enjoyment- in
sexual aversion, prospect of sexual interaction with a
partner is associated with strong negative feelings and
produces sufficient fear or anxiety that sexual activity is
avoided. In lack of sexual enjoyment, sexual response
occurs normally and orgasm is experienced but there is
a lack of appropriate pleasure.
 Failure of genital response- in male erectile disorder,
the principal problem is erectile dysfunction, i.e.
difficulty in developing or maintaining an erection
suitable for satisfactory intercourse. In female sexual
arousal disorder, the principal problem is vaginal
dryness or failure of lubrication.
9

10.  Orgasmic dysfunction – in this disorder, orgasm either
does not occur or is delayed and this is more common in
women more than men.
 Premature ejaculation- the inability to control
ejaculation sufficiently for both partners to enjoy sexual
interaction. In some cases, ejaculation may occur before
vaginal entry or in the absence of an erection.
 Nonorganic vaginismus- spasm of the muscles that
surround the vagina, causing occlusion of the vaginal
opening. Penile entry is either impossible or painful.
 Nonorganic dyspareunia- is the pain during sexual
intercourse and occurs both women and men.
 Excessive sexual drive- men and women may
occasionally complain of excessive sexual drive as a
problem in its own right. It usually occurs during the
late teenage.
10

11.  Transsexualism is a desire to live and be
accepted as a member of the opposite sex.
 Dual- role transvestism is the wearing of
the clothes of the opposite sex for part of
the individual’s existence in order to enjoy
the temporary experience of membership
of the opposite sex. No desire for a
permanent sex change or surgical
reassignment.
 Gender identity disorder of childhood is
characterized by a persistent and intense
distress about assigned sex, together with a
desire to be of the other sex in early
childhood. There is a persistent
preoccupation with the dress and/or
activities of the opposite sex and/or
repudiation of the patient’s own sex.
11

12.  Fetishism is defined as the reliance on some non-
living object as a stimulus for sexual arousal and
sexual gratification.
 Fetishistic transvestism- the wearing of clothes of
the opposite sex principally to obtain sexual excitement
 Exhibitionism is a recurrent or persistent tendency to
expose the genitalia to strangers (usually of the
opposite sex) or people in public places, without
inviting or intending close contact and the act is
commonly followed by masturbation.
 Voyeurism is a recurrent or persistent tendency to look
at people engaging in sexual or intimate behaviour
such as undressing.
 Paedophilia is the sexual preference for children,
usually of prepubertal or early pubertal age.
 sadomasochism is a preference for sexual activity that
involves bondage or the infliction of pain or humiliation
12

13.  Sexual maturation disorder is the individual suffers
from uncertainty about his or her gender identity or
sexual orientation which causes anxiety and depression.
 Egodystonic sexual orientation is the gender identity or
sexual preference is not in doubt but the individual
wishes it were different because of associated
psychological and behavioral disorders and may seek in
order to change it.
 Sexual relationship disorder is the gender identity or
sexual preference abnormality is responsible for
difficulties in forming or maintaining a relationship
with a sexual partner.
13

14. Pursuing sexual partners and consummating a
sexual interaction can become a compulsive and
uncontrollable behavior pattern similar to drug
addictions. There is a addiction cycle that
describes four stages 1) preoccupation2)
ritulization3) compulsive sexual behavior4)
despair. Some discussions point out the
similarity between sexual addiction and
paraphilia.
14

15. Ancient India, China, Greece and
Rome all had sex literatures and
ancient India had a rich tradition
of eroticism. ‘kamasutra’ and
‘Vedas’ are the examples of
Indian tradition of eroticism and
pleasure was described mainly
from male point of view. Foucault
argued that India and other non –
western people enjoyed sex as an
erotic sensibility, but the western
society was restricted to scientific
discourse. 15

16.  Sigmund Freud advocated that sexuality began in
infancy, not at puberty, and it was intrinsically linked to
the development of personality. Freud’s libido theory
(1905) explains sexual impulses as instinctive drives
which built up and demanded expression and
relief(pleasure principle). Actions of erogenous zones
would bring the child into conflict with his parents
(external reality), and the resulting frustrations and
anxieties. Freud advocated sexual symptoms as simply
manifestations of deeper conflict in the individual and
need long –term treatment targeted the underlying
neurotic and characterological difficulties. Transference
and counter transference and the development of the
insight were used as the catalyst for changing the
conflicts. 16

17. Henry Havelock Ellis - sex as a natural human instinct
and challenged the notion that masturbation caused
illness, insanity and depravity. He argued that
homosexuality was inborn and could not be treated as a
vice. He suggested that female sexuality as more
passive, elusive and complex than male sexuality, and
need for extensive foreplay, including cunninlingus.
Kinsey conducted the first large –scale surveys of sexual
behaviour in the United States and published a book,
Sexual Behaviour in the Human Male. According to
Kinsey, sexual behaviour was rigidly policed by
moralists, the church and the law.
17

18. Masters and Johnson revolutionized the treatment of
sexual problems with behaviorally oriented
interventions to treat specific symptoms. They
pioneered the idea of couple therapy for sexual
difficulties. They also identified women as equal to
men in their abilities to enjoy sexual experience and
proposed four phases of human sex response cycle.
The main contribution is that sex therapy was
constructed around measurable and physiological
responses. This approach helped to establish the
legitimacy of the sex therapy.
18

19. Dr Helen Singer Kaplan introduced a new sex
therapy and advocated that symptomatic relief
could be obtained by adding brief
psychodynamic therapy to deal with current
conflicts. She experimented with various
treatment formats and also introduced
medication, especially SSRI antidepressants, as
an aid to overcoming sexual phobias.
19

20.  In the mid -1980s, pharmacological approaches were
emerged for male sexual dysfunction. But mode of
treatment was changed into medical treatments
including sophisticated penile implants, penile
injections, intraurethral inserts and drugs like Viagra
and Aswagandha. Low –dose antidepressants
prescribed for treatment of premature ejaculation.
Testosterone and other hormone therapies were
recommended to treat both men and women for sexual
aversion or lack of desire and Viagra is the starting
treatment for erectile difficulties. Some professionals
suggest surgical procedures to increase the size of the
vaginal openings and treat sexual pain disorders.

20

21.  Society’s myths about sex
 Interpretation of religious traditions and sexual
dysfunctions
 Sexual dysfunctions and later life
 Race and ethnicity
 Interpersonal problems and sexual dysfunctions
 Lack of sexual information
 Lack of domestic privacy
 Psychological problems and the development of
sexual dysfunctions
 Sexual assault and/ or abuse
21

22. Common sexual behaviors
 Sexual fantasies- individual either recalls erotic sexually
stimulating episodes that occurred in past or imagines
sexually arousing situations.
 Masturbation is a self-stimulation of the genitals to produce
sexual excitement and pleasure.
 Communication regarding sex-good sexual communication
between partners is an important part of any sexual
relationship.
 Foreplay or shared touching implies that it always precedes
sexual intercourse. Kissing, touching and oral -genital sex are
considered to be the common foreplay behaviors. Some
people like to perform oral sex on each other at the same
time.
 Afterplay is defined as whatever a couple does immediately
following a sexual interaction
22

23.  The Man- on-Top Position-This is also called the ‘male
superior position’. The man is lying face –to-face on top of his
female partner.
 The Women –on –Top Position-A women sits or squats on
her partner who lying on his back. Her knees might be bent
with the tops of her feet in contact with the bed and the
female can control the angle, rate and depth of the penile
penetration.
 The Lateral Entry Position-This is also called side – to- side
position, in which the couple lies on their sides facing one
another.
 Rear Entry Intercourse-This position is also called ‘doggy
style’. A couple cannot see each others’ faces during the
penetration. The woman support herself on her hands and
knees while the man kneels behind her.
 Heterosexual Anal Intercourse-It is asexual variation not a
sexual deviation. If the women have lost her vaginal
muscular tone, it can be a pleasurable alternative.
23

24.  Role and guidelines -Evaluate the client’s problems in depth,
translate for, and represent fairly the member of distressed
marital unit of the same sex. The male therapist can provide
much more information relating to male –oriented sexual
function for the wife of the marital unit and female –oriented
function is best expressed by the female therapist, e.g.; it is
difficult to elicit reliable material from sexually dysfunctional
male by the interview of a female therapist.
 Dual sex therapy teams-Laboratory experience supports the
concept that a more successful clinical approach to problems of
sexual dysfunction can be made by dual- sex teams of therapists
than by an individual male or female therapist. A dual –sex
therapist team may avoid the disadvantage of interpreting patient
complaint on the basis of male or female bias.
 Initial stages sex therapy-Usually therapist allows one hour for
history taking and initial assessment. This information is
necessary for two purposes. 1) To determine the mode of therapy
2) to determine the need of physical examination.
24

25. History taking and assessment -Sex history taking is a
structured one with chronological framework. It
includes life –cycle influences, sexually oriented
attitudes, feeling, expectations, experiences,
environmental changes and practices.
Check list for sexual history taking
 Precise nature of the sexual problem
 The history of the sexual problem
 The nature of the general relationship
 Psychiatric history
 Medical history
 Contraceptive history
 Attitudes to the sexual problem and possible treatment
25

26.  Sensate focus is a progressive stage exercises
 First stage- preferably two sessions –in first session one member
will be the active partner and second session the same member will
be the passive partner. Mutual touching is not encouraged in the
first stage. One member of the couple touches the partner’s body,
but not allowed to touch the genitals or breasts of the passive
partner. The active partner will do what he or she wishes in the way
of touching. But he may not try to guess what the passive partner
would like. The purpose of the touch is not to be erotic. It will
establish an appreciation of touch sensations by both the touching
partner and the partner being touched. In second session, the
couples switch roles. In these two sessions, communication should
minimum and with the exception of the person being touched. This
non-demand, non intercourse sexual pleasuring help the clients
relax and know more about what they find sexy and exciting.
26

27.  Second stage- the touching partner is allowed to touch the
breasts and genitals of the partner. The passive partner is
instructed to move the active partner’s hand to those areas
that are most excited when touched. A hand riding technique
can be used. One partner places his or her hand on top of
other’s hand. It may indicate more or less is desired, a faster
or slower pace is desired or the hand should move to another
place. This non-verbal communication will be effective in this
exercise.
 Third stage-it involves mutual touching but intercourse and
orgasm are discouraged.
 Fourth stage-after several days of sensate focus exercises the
couple gradually assumes to the female- top-position. If the
couple learned the concepts of sensate focus exercise then
intercourse is allowed. Otherwise sensate focus exercises will
continue.
 Fifth stage – this successful performance will be generalized
into other positions. This self assurance makes it easy for a
couple to proceed sexual intercourse with fully aroused.
27

28. it stands for permission, limited information,
specific suggestions, and intensive therapy.
Permission involves validating the patient’s
thoughts, emotions and sexual activities. In
limited information therapist gives the
information that they can use to gain a better
understanding of their problem. After that
therapist gives specific suggestions related to
the problem, e.g , sensate focus. In intensive
therapy, the client explores any psychological or
social difficulties that may affect their sexual
life.
28

29. Sexual desire disorders
 disorder react to the prospect of sexual interaction
with severe anxiety and may have psychosomatic
reactions including irregular heart beat, dizziness,
and trouble breathing. Therapists first clarify these
issues and choose the appropriate therapeutic
strategy.
 Identify the Interpersonal and/or emotional
difficulties that make sex unfulfilling and identify the
performance anxiety.
 These people frequently averse to certain sexual
behaviour and should stop participating in those
behaviour that cause distress.
 Therapist encourages the couple to avoid intercourse
for a significant time (2months or so) and the couples
can explore other avenues of physical intimacy
without anxiety and fear. This will be a big relief to
the couple and having sex without having
intercourse may actually make the initially
unpleasant activity appears more interesting and 29

30.  People with low sexual desire learn to enjoy the pleasures
from masturbation; it may be used as a rehearsal for
interpersonal intimacy. Therapist often gives advice to use
vibrators for self exploratory exercises and gradually they can
enjoy an enhanced sense of sensitivity to physical and
interpersonal sexual stimuli. Sometimes massage offers a
chance to share sexual interaction in a non demand and non
intercouse situation.
 Sensate focus technique will help with these patients.
Patients can caress one another while talking about their
feelings and giving their partner gentle suggestions and
encouragement.
 Finally the couple can understand that there is no ‘right’ and
‘wrong’ way to share physical intimacy and subsequently
performance anxiety diminishes significantly.
30

31.  Therapist must know the client’s sexual value system
 Then patient has to discover or acknowledge what they find
sexy. Approach those goals in small steps and will be
rewarding and enjoyable to the client. Sensate focus exercise
will be effective in approaching these goals in a progressive
manner.
 Couple begins with caressing or massages not involving
their genitals or women’s breasts.
 Progress to genital and breast touching
 Eventually engaging in intercourse and couple is encouraged
to enjoy the feeling of the penis being contained in the
woman without any pelvic thrusting. If they have always
been anxious about being a good lover, then it will be a
difficult sexual exercise. It may feel unusual for a man to
enter his partner and then hold it.
 Progress to intercourse without orgasm and mutual gentle
pelvic thrusting is recommended. But the couple is informed
that orgasm is not the part of this exercise. These exercises
will give sexual self –confidence and lessen performance
anxiety.
31

32. Anorgasmia
 To examine the women’s sexual value system to
determine what she finds sexy and exciting.
 Visual or prose erotica or video tapes are used to
stimulate sexual thoughts and feelings and to
develop sexual fantasies.
 Encourage to use vibrators to stimulate clitoral
area during the masturbation or intercourse to
increase the intensity, consistency and
controllability of sexual stimulation.
 It is important for the client and therapist to learn
to appreciate the nature of the orgasmic
experience based on the words used to describe it.
32

33.  Masturbation training as combination of relaxation
techniques and self stimulation homework assignments can
be effective in the treatment of anorgasmia. Studies reveal
that women can more easily and regularly have orgasms
during masturbation than sexual intercourse. Counseling, sex
education, and improved body awareness are also included
in the treatment. Women who had undergone masturbation
training were more likely to have orgasms during sexual
interaction with partner.
 Coital alignment technique is an intercourse position with a
slight variation on the man – on –top position and one of the
reasons is that during intercourse clitoris doesn’t receive
much stimulation in most of the common positions. In this
coital alignment technique, partner moves his entire body
forward so that the top of his penis may more directly
stimulate his partner’s clitoris during pelvic thrusts.
33

34. Start – stop technique
This method was first proposed by James Semans in 1956 and popularized
by Masters and Johnson in his book ‘Human Sexual Inadequacy’. It
involves genital stimulation until a man becomes erect, then interruption
during which he begins to lose his erection, and then continued
stimulation with the recurrence of his erection. These exercises teach a
man the feeling associated with building sexual tension, and also he can
lose and quickly regain his erection. This will lead to greater sexual self
confidence and self control.
34

35. Coronal squeeze technique
In this technique, the man lies on his back with leg spread
apart and the man’s pelvis more or less in partner’s lap. After
that she initiates manual genital stimulation until the man
attains a firm, full erection and at that time she grasps penis
in a special way. She will be putting her thumb on the
frenulum (underside of the penis) and her first and second
fingers on both sides of the coronal ridge. She applies firm
pressure for 3 or 4 seconds in his penis. This will lead to an
immediate loss of the desire to ejaculate and temporary
decrease in the firmness of penis. She again manually
stimulates the penis until he obtains a full erection and then
applies the squeeze technique. This will go for prolonged
stimulation of a man’s penis without ejaculation.
35

36. Basilar squeeze technique
The man’s partner or the man himself applies firm
pressure to the base of the penis. The advantage is
that man can easily do it himself and apply pressure
to the base of the penis during intercourse. He will
get more control over the timing of the ejaculation.
36

37.  Use the same stimulation techniques until the man attains an
erection and repeating the process a few times. The man can feel the
erection without ejaculating.
 Again the woman stimulates his penis until he becomes erect and
this time she assumes the female –on-top position. Gradually
inserting his penis inside her vagina and hold it completely still.
The man can experience the feelings of penile containment without
the immediate desire to ejaculate. This will lead to increase his
feelings of control and confidence.
 Most of the men with premature ejaculation still feel a desire to
ejaculate, immediately after the penis entered the vagina. At this
time, he will communicate this to her with words or gesture and
she raises herself and applied squeeze technique. This again
diminishes the desire to ejaculate.
 She again inserts the penis into her vagina before penis becomes too
soft. She engages in slow and gentle pelvic thrusting.
 Over a number of days, the client begins to feel self confidence and
self control and can generalize to other intercourse positions.
37

38.  Find out the man’s sexual value system to
determine what he finds sexy and exciting
 Female partner has to stimulate her partner’s
penis manually.
 Once he attains an erection then the female
assumes the female –on –top position and insert
his penis into her vagina.
 At this time she immediately begins vigorous
pelvic movements. This will be sufficient for
ejaculation.
 At the beginning of therapy ejaculation may not
happen and then he should withdraw his penis
and female partner can do the technique again.
 Over a number of days, the client begins to feel
self confidence and can generalize to other
intercourse positions. 38

39.  Use of surgical lubricant to make
vaginal penetration more comfortable
 Assuming female –on- top position that
will help her to control the angle, rate,
and depth of penile penetration.
 Careful use of dilators- She may
lubricate with the smallest
circumference and then gradually
inserts into her vagina.
 Relaxation exercises and sometimes
hypnosis will help the client
 Vaginismus is often associated with a
history of sexual abuse or assault and
more focused psychological therapies
are needed.
39

40.  Psychodynamic approaches to therapy for paraphilias-
Freud believed that neurotic patients repress their
unconscious conflicts and that lead to paraphilic behaviors.
Therapist can uncover those conflicts. Psycho-dynamic based
group therapy will be effective in paraphilic treatment.
Cognitive – behavioral approaches to therapy for the
paraphilias
 Self –control techniques
People can acquire will-power and self control when they are
reinforced for desired behaviour. Techniques called ‘thought
–shifting’ and ‘thought- stopping’ can be very effective in an
individuals attempt to distract him- or herself when engaged
in deviant thoughts, fantasies, and urges. These are willful
strategies in which an individual practices deliberately
changing the focus of their thoughts or stopping them
altogether.
40

41. Stress management
 If the person can be taught techniques to control,
minimize, and eliminate stressors, ultimately they will
successful in refraining from becoming obsessed with
deviant thoughts. These techniques can be used to help
people assess the reality of ideas and threats that in fact
may be entirely irrational. Many cases the clients are
taught relaxation techniques that allow them to remain
calm and focused when they feel stressed by
provocative environmental stimuli. Stress management
techniques must be both emotion focused and problem
focused.
 Cognitive restructuring
Therapist can help their clients to identify rational and
distorted thought patterns and eliminate these counter
productive mental habits. After cognitive restructuring
the client may diminish the significance of their
behaviors.
41

42. Social rehabilitative techniques
 Clients may receive systematic
instruction in learning to better assess the
impact of their emotions and actions on
others. The paraphilics need to learn
better skills concerning sexual
communication and various socially
acceptable ways of initiating and
maintaining intimate relationships with
an appropriate partner. The client may
be asked to model or role play different
scenarios that have in the past
precipitated erotic thoughts and
fantasies.
 Sex education
It is noted that parphilics have very little
knowledge about human sexuality and
human sexual arousal and response. This
may be a major contributing factor in the
development and expression of the
deviant sexual behaviour.
42

43.  Aversive techniques for treating paraphilias-researchers
attempted to treat sexual deviations through the use of
electrical shock paired with pictures depicting paraphilic
behaviors. The result of this study revealed that aversive
conditioning procedure was relatively ineffective in
diminishing sexual arousal.
 Biological/ medical approaches to the treatment of
paraphilias –Some researchers believe that paraphilias are
best understood as an obsessive –compulsive continuum.
One such investigation (Kruesi et al, 1992) studied the effects
of antidepressant agents on the intrusive nature of paraphilic
thoughts, fantasies and urges. Subjects received daily doses
of antidepressants - clomipramine and desipramine - that
have been effective in the treatment of obsessive compulsive
disorder and seemed to diminish the severity of paraphilic
preoccupations when compared with the pre-treatment
reports.
43

44.  Dhat – it is a folk diagnostic term used in India to refer to
severe anxiety and hypochondriacal concern associated with
the discharge of semen, whitish discoloration of urine, and
feelings of weakness and exhaustion.
 Koro - this refers to an episode of sudden and intense anxiety
that the penis (in women the vulva and nipples) will recede
into the body and possibly cause death. This is reported in
South and East Asia.
 Management-emphatic listening, non confrontational
approach, reassurance and correction of erroneous beliefs,
along with the use of placebo, anti -anxiety and anti
depressant drugs will be effective in the treatment of dhat
syndrome. Psycho education, sex education, relaxation
techniques including biofeedback and culturally informed
cognitive behavior therapy are also included in the
management of culture bound syndromes.
44

45. We are surrounded by sexuality.
It is an inevitable factor in human
life and a major component in
couple relationship. But many
people are suffering from sexual
dysfunctions and other sexual
problems. There are several
methods to tackle the hurdles.
Professional approach of a
therapist and co operation of
clients – these are determining
factors of the success of sexual
therapies. Otherwise sex is not
so sexy anymore.
45

46. 46
“sex is a complete
therapy in itself when
done in the right
sense”
THANK YOU