EMPOWERMENT
A Group Therapy Curriculum
Treating Young Adult Women Experiencing
Female Sexual Interest/Arousal Disorder
Ana K. Jaimes Aragón
Contents
Introduction ...... 1
Participant Criteria ...... 3
Treatment Format ...... 7
Treatment Evaluation Questionnaire ...... 11
Self of the Therapist ...... 14
Session 1: Meet and Greet ...... 15
Handout 1 ...... 27 Handout 2 ...... 29 Handout 3 ...... 30 Session 2: What is Shame? ...... 32
Handout 4 ...... 38 Handout 5 ...... 39 Session 3: Exploring Sexual Shame and FSIAD ...... 41
Handout 6 ...... 51 Handout 7 ...... 52 Handout 8 ...... 54 Session 4: The Social and Psychological Dimensions of Sexual Shame ...... 56
Handout 9 ...... 66 Handout 10 ...... 68 Handout 11 ...... 70 Handout 12 ...... 71 Session 5: Mind-Body Connectivity ...... 72
Handout 13 ...... 77 Handout 14 ...... 79 Handout 15 ...... 81 Session 6: Focusing Attention Attitude ...... 83
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Handout 16 ...... 92 Session 7: Understanding Sexual and Emotional Satisfaction ...... 93
Handout 17 ...... 98 Handout 18 ...... 99 Handout 19 ...... 100 Handout 20 ...... 101 Handout 21 ...... 102 Session 8: Redefining Sexuality and Sex ...... 103
Handout 22 ...... 109 Handout 23 ...... 110 Session 9: Speaking Up About Sexual Concerns ...... 111
Session 10: Reflecting on The Re-Self-Discovery Journey ...... 118
Handout 24 ...... 121 References ...... 122
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Introduction
Sexuality is a continuum comprised of biopsychosocial elements that affect how people experience romantic and sexual feelings towards themselves and others. Awareness about how these biopsychosocial elements affect the sexual psyche permits a person to develop a congruent sexual self-concept. Having a congruent sexual self-concept helps a person navigate interpersonal and intrapersonal intimacy and gain emotional and sexual satisfaction. However, sexuality is a fragile construct easily influenced by psychosocial factors. When sexuality is ensnared by sexual shame, it consumes the capacity for sexual pleasure and sexual interest.
Young-adult women who are in the midst of the developmental phase of exploration and solidifying their sexual identity can feel confused or distressed at the reduced or absence of sexual interest/arousal.
Empowerment is a group-based therapy curriculum tailored towards young-adult women who experience female sexual interest/arousal disorder (FSIAD). The goal of this curriculum is to decrease the impact sexual shame has on young-adult women’s sexual self-concept in order to increase sexual and emotional satisfaction. The impact sexual shame has on the sexual self- concept will be evident by the quality of emotional and sexual experiences with self and/or partner. For women to learn how to navigate sexual shame by exploring various aspects of their sexual self-concept and sexual identity, interventions and strategies within Empowerment are aimed to culminate in healthy sexual practice and lead towards emotional and sexual satisfaction.
Important Note: Regrettably, since most research to date focuses on the female cisgender brain, the Empower curriculum addresses sexual arousal and sexual interest concerns among young cisgender women. This does not mean that LGBTQIA+ people do not express such issues, but
1 that this project chose to centralize sessions on the current body of research that exists around
FSIAD. Diversity consideration sections were included in some sessions of Empower, but it should be recognized that this curriculum may not address issues that may be reported in
LGBTQIA+, BDSM, and polyamorous communities.
Design and Framework of Curriculum
Empower, A Group Therapy Curriculum: Treating Young-Adult Women Experiencing
Female Sexual Interest/Arousal Disorder utilizes narrative therapy, cognitive behavioral therapy
(CBT) and mindfulness. Concepts in narrative therapy assist the facilitator’s conceptualization of
FSIAD and psychosocial issues, while CBT strategies are used to restructure the thought process around FSIAD. Mindfulness concepts are implemented to match to sensate focus phase 1, commonly used in couples therapy. By practicing mind-body connectivity and present-mind awareness the automatic nervous system will calm, enhancing attentive focus on sensations and away from the analytical mind concerning sex.
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Participant Criteria Screening
Group members will be screened using a personal interview method. Using a personal interview method will allow the facilitator to assess appropriateness of treatment for interviewees, as well as suitability for group membership. Conducting a personal interview is an opportunity to inform prospective members about the theoretical framework (handout 1), session content, rules and regulations, and to acquire informed consent and confidentiality agreement. A personal interview also creates an opportunity for the facilitator to build rapport with each prospective member.
Physical and Mental Health
FSIAD can result as a secondary symptom of a psychological diagnosis, medical condition, and medication or medical treatment, thus will involve a multi-disciplinary team
(Kaplan & Horwith, 1983; Aslan & Fynes, 2008). The facilitator should place special consideration to assessing group members medical history during the assessment period to refer group members to an appropriate specialist if needed. In addition to conducting a detailed assessment of group members medical history, the facilitator will assess for clinical co- morbidity. For example, a high comorbidity rate exists between depression and FSIAD (Atlantis
& Sullivan, 2012). In instances in which such comorbidity does occur, the primary diagnoses should take precedence in treatment. That is, if depression and/or anxiety exacerbate FSIAD, depression and/or anxiety should be address prior to starting group therapy to address FSIAD symptoms, since the polythetic diagnostic criteria of FSIAD calls for a complex psychological treatment approach to treat intrapersonal and interpersonal domains (Brotto, 2017).The facilitator may incorporate the PLISST model to address the complexity of FSIAD (Dahlen, 2019).
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Trauma History
Survivors of sexual abuse can regain sexual interest/arousal capacity through a trauma informed treatment that addresses sexual shame (Pulverman & Meston, 2019). However, this curriculum is not trauma informed. Facilitators using this curriculum should take precaution in assessing participant’s trauma history and therapy received to address trauma symptoms.
Individual and couple’s sexual abuse recovery therapy focused in learning healthy sexual intimacy may best suited for survivors to unravel sexual difficulty and trauma (Kleinplatz, 2012;
Kleinplatz, 2001).
Genito-Pelvic Pain/Penetration Disorder
Genito-pelvic pain/penetration disorder can co-occur with FSIAD (Svedhem et al., 2013).
However, women who report pain during intercourse will need further therapy that is focused on the pelvic pain and other comorbid mental health issues prior to entering group therapy. In addition, women experiencing genito-pelvic pain/penetration disorder may benefit from a group with women who are experiencing similar sexual difficulties.
FSIAD Subtypes
In the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American
Psychiatric Association [APA], 2013) four features are listed under each sexual dysfunction: acquired, lifelong, general, and specific. These features should be measured during the screening and assessment process. Although this curriculum focuses on learning a new way to be sexually healthy, assessing for FSIAD features will help assemble proper treatment to address subtype symptoms. Assessing for FSIAD features will also help assemble a group of women who experience similar circumstance and will support each other in their sexual health.
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Asexuality
Asexuality is s a sexual orientation in which an individual experience little or no sexual attraction (Van Houdenhove et al., 2014). Asexual or ace people do not report personal distress about the lack of sexual attraction compared to non-asexual people (Brotto at al., 2010). Rather, ace people report distress when sexual desire is present (Brotto et al., 2010). Ace people seeking therapy may best benefit from services aimed on identity empowerment.
Inclusion Criteria
This curriculum was created to address female sexual interest/arousal disorder (FSIAD) among women ages 21 to 35. According to the DSM-5 (APA, 2013), women must manifest at least three of the following:
1. Absent or reduced interest in sexual activity.
2. Absent or reduced sexual/erotic thoughts or fantasies.
3. No or reduced initiation of sexual activity, and typically unreceptive to a partner's
attempts to initiate.
4. Absent or reduced sexual excitement/pleasure during sexual activity in almost all or
all (approximately 75%-1 00%) sexual encounters (in identified situational contexts
or, if generalized, in all contexts).
5. Absent or reduced sexual interest/arousal in response to any internal or external
sexual or erotic cues (e.g., written, verbal, visual).
6. Absent or reduced genital or nongenital sensations during sexual activity in almost all
or all (approximately 75%-1 00%) sexual encounters (in identified situational
contexts or, if generalized, in all contexts).
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Exclusion Criteria
This curriculum does not include research on physiological and biological changes that affect sexual functioning among women over the age of 35. Women above age 35 who experience FSIAD symptoms may benefit from an age specific group approach where treatment addresses postmenopausal concerns and lifelong FSIAD issues. This curriculum is not trauma informed, therefore women with history of sexual abuse are excluded from the present curriculum. Women experiencing genito-pelvic pain/penetration disorder may report FSIAD symptoms, however, due to the severity and complexity genito-pelvic pain/penetration disorder, this group of women will be excluded from the present curriculum.
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Treatment Format
This structured group curriculum incorporates intrapersonal processing and psychoeducational aspects specifically designed for young-adult women, ages 21 to 35. This group curriculum comprises 5 to 8 group members who will meet weekly for 2-hour long sessions over the stretch of a 10 week period. This curriculum is meant to be used in consecutive order as each session will build upon the previous session objective. In the case a group member missed a session, the group facilitator and group member will schedule an hour of personal therapy prior to the next session.
Rules and Regulations
Rules and regulations are conducted in two parts of the group: during the participant assessment phase and briefly in session one. During the participant assessment phase, a confidentiality agreement and informed consent can be gathered. These documents are best distributed by the facilitator’s agency or created by the facilitator to meet the law and ethical standards of the state in which group therapy is conducted. Rules can be implemented by the facilitator using their own clinical judgement (e.g. attendance, punctuality, and socializing outside of group therapy). The facilitator may also involve the group in generating ground rules to foster a communal environment.
Implementing non-judgmental rules and regulations creates a shame-free environment.
For example, sex educators use the rule “don’t yuck my yum” to encourage group members to adopt an open-minded attitude before rejecting someone’s sexual practice or sex ideology.
Instead of dismissing other group members point of view, members are asked to listen and ask
7 open-ended questions from a curious standpoint. This helps increase understanding between group members and practice compassion.
Group Therapy Space and Equipment
The space to conduct group therapy should be in a large private room which accommodates 5 to 8 group members and the facilitator. If the space is near a shared common area a sound machine may be used. The chairs will be placed in a circle to increase cohesiveness among group members.
The group facilitator will gather materials prior to conducting sessions. Standard equipment includes a large white board and dry eraser markers or projector, writing material, access to internet, and access to a computer or any device with speakers. Homework assignments will require a 5” x 7” journal which will need to be purchased by either the facilitator or group members.
Session Design
There are two parts that make up the design of each session. The first part includes the session objective, materials needed to direct session activities, and suggestions for the facilitator to read before leading the session discussion. The second part outlines the session which is separate into three sections: check-in, discussion, and cool-down. The check-in section provides an opportunity for universality as group members discuss their response to the previous session homework. The discussion section outlines discussion topics and activities that promote shame resilience and sexual self-congruence which are key in reducing shame and increasing sexual and
8 emotional satisfaction. Each task of the session discussion will be conducted within a specific time frame. These times are listed next to each section or activity.
The facilitator will need to thoroughly read through the session plan prior to conducting the session to ensure the session objective, activities, and homework are appropriate for the group. Discussion questions, narrative samples, and handouts are included in the Empower curriculum to help the facilitator lead the session. A pin icon ( ) marks helpful tips for the facilitator.
Session Outline
Lesson Objectives
The lesson objective guides the central theme of the session. Supplies Needed
The supplies needed section lists the supplies needed to conduct activities and/or mindfulness portions of the session. Some activities will require handouts for members to read, therefore, the facilitator will need to gather prints and other material prior to conducting the session. Before Conducting the Session
The before conducting the session portion contains information or statistics helpful to navigate the session objective, discussion, and activities. Check-In
The check-in section of the session is conducted between 15 to 20 minutes, in which group members are asked to discuss journal entry thoughts/responses assigned in the previous session’s homework. Due to time limit, not all group members are required to share. The check-in portion
9 also provides the facilitator an opportunity to evaluate the level of information the group will need. The check-in portion is a time for members to connect with other group members and touch-base with the facilitator.
Discussion
Session Topic
The session topics will be written out on a board or listed off to the group members.
The topics will be the primary focus of the discussion where members will have an opportunity to relate to one another, offer support, and problems are normalized. The session topic will be the psychoeducation piece that is related to the session objective. The facilitator may refer to Before
Conducting the Session section to provide cohesive instructions.
Session Activity
The session activity section includes exercises, therapy questions, narrative samples, and psychoeducational information that will help facilitate discussion. Cool-Down
The cool-down section contains mindfulness technique directed by the facilitator.
Homework
Each session contains a homework assignment and/or journal entry. The homework section may be handed to group members as a document or sent via email.
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Treatment Evaluation Questionnaire
The facilitator will email or hand out the treatment evaluation questionnaire to group members in session five and session ten. The evaluation’s purpose is to: (a) measure effectiveness of treatment, (b) receive feedback on how affective techniques and interventions are, (c) and receive feedback on how helpful group members find the psychoeducation material to be
Sexual Distress
1. On a scale from 1 – 10 (1 – low distress, 10 – high distress) rate the level of sexual
distress you are currently experiencing.
2. On a scale from 1 – 10 (1 – not helpful, 10 – very helpful) rate how helpful have the
interventions been lessen sexual distress.
3. What exercise have you found helpful in between the first session to now for sexual
distress?
4. Which exercise have you found the least helpful for sexual distress?
Sexual Satisfaction with Oneself or Partnership
1. On a scale from 1 – 10 (1 – low satisfaction, 10 – high satisfaction) rate the level of
sexual satisfaction you are currently experiencing.
2. On a scale from 1 – 10 (1 – not helpful, 10 – very helpful) rate how helpful have the
interventions been to increase sexual satisfaction.
3. What exercise have you found helpful in between the first session to now for sexual
satisfaction?
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4. Which exercise have you found the least helpful for sexual satisfaction?
Emotional Satisfaction with Oneself
1. On a scale from 1 – 10 (1 – low satisfaction, 10 – high satisfaction) rate the level of
emotional satisfaction with yourself interest currently experiencing.
2. On a scale from 1 – 10 (1 – not helpful, 10 – very helpful) rate how helpful have the
interventions been increase emotional satisfaction.
3. What exercise have you found helpful in between the first session to now for emotional
satisfaction?
4. Which exercise have you found the least helpful for satisfaction?
Sexual Shame
1. On a scale from 1 – 10 (1 - lowest, 10 – highest) rate the level of sexual shame you are
currently experiencing.
2. On a scale from 1 – 10 (1 – not helpful, 10 – very helpful) how have the interventions
been helpful to navigate sexual shame.
3. What exercise have you found helpful in between the first session to now?
4. Which exercise have you found the least helpful?
Session Feedback
1. On a scale from 1 – 10 (1 – no time, 10 – enough time) how well are the sessions time
managed.
2. If there is a concern around time management, please indicate below to help us better
plan for sessions.
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3. On a scale from 1 – 10 (1 - easy to understand, 10 – having a hard time understanding)
rate the level of clarity with homework assignments.
4. On a scale from 1 – 10 (1 - easy to understand, 10 – having a hard time understanding)
how would you rate the clarity of instructions provided during sessions.
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Self of the Therapist
This curriculum addresses sexual shame as the primary discord which affects the development of a congruent self-concept and sustains FSIAD symptomology. Group members may present viewpoints that differ from the facilitator’s views. Thus, the facilitator is advised to do self-of-the-therapist work. The facilitator’s self-of-the-therapist work may involve recognizing countertransference which affects treatment management. For example, the facilitator’s shame filled values or open-minded approach to sex can affect how the facilitator is conducting the group discussion and how they respond to group members experiences. Self- reflection or personal therapy can help facilitator further explore countertransference reactions and practice culture sensitivity. Although facilitator use language to challenge members shame rooted values instilled by culture expectations, culture values remain an integral part of the participant’s identity (Kleinplatz, 2012). Therefore, the facilitator must remain culturally sensitive to the member’s culture beliefs to ensure therapeutic task work (Kleinplatz, 2012). The facilitator is an important person in group members evolution journey and thus need to practice self-of-the-therapist work.
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Session 1: Meet and Greet
Lesson Objectives
The first session is focused on having group members becoming acquainted, introducing the group framework, establishing the rules and guidelines of group therapy, assessing the baseline of each member’s diagnosis, and gathering measurable information to track therapeutic progress.
The facilitator will talk for most of session to explain the framework of therapy, structure of sessions, and purpose of techniques. The facilitator will have the opportunity to engage group members briefly during the check-in and discussion in session one.
Supplies Needed
• Name Tags
• Pencils/Pens
• Flip Pad/Large Piece of Paper/Dry Eraser Board
• Copies of handout 2 and 3
• Subjective Units of Distress Sheet
• 5” x 7” journal to be use throughout session plan for homework assignment. This may
be provided by the facilitator or purchased by group members.
Create take home folders for group members to keep information and handouts that will
be collected through the 12 sessions
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Before Conducting the Session
Review the DSM-V diagnostic criteria for female sexual interest/arousal disorder (FSIAD) and read through the lesson plans of this curriculum. The first session is focal for the facilitator to establish trust within the group. Group members who express concerns around FSIAD for which answers may not be clear. The facilitator is encouraged to provide an honest reply if information is not available in this curriculum. Make a note of concerns expressed to research outside of session and appropriately address in the next session.
The diversity consideration section within the lesson plan includes asexuality information. This information is to provide or use as a psychoeducational piece with group members if needed. It also provides resources the facilitator can handout to group members.
Check-In
The check-in portion is to initiate participation by having group members volunteer to share journal responses. Due to the time limit of 15 to 20 minutes, not all group members are required to share. However, cohesiveness can be created by facilitating commonality. For example, using phrases such as “who else has had the same or similar concern as (participant name)?” and inviting the participant to share their own experience. The check-in portion of this curriculum also provides an opportunity to evaluate the level of information group members requires based on their common concern. For example, if in session one group members are unclear of the difference between FSIAD and asexuality, the facilitator can dedicate time to briefly address this concern in session one and/or plan to an in-depth session on sexuality.
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For further support in facilitating group therapy check out:
Jacobs, E., Schimmel, C., Masson, R. and Harvill, R. (2016). Group counseling: strategies and skills. (8th ed.). Boston, MA: Cengage Learning
5 Min. Female Sexual Distress Scale (Handout 3)
As group members walk in, have them fill out FSD scale upon arrival, this
will provide the facilitator with a baseline measurement prior to administering
treatment.
5 Min. The Facilitator’s Introduction
Sample Narrative:
“Hi my name is ______. Welcome to the first session of Empower, where
we will explore female sexual interest/arousal disorder (FSIAD), and various
factors that influence and sustain FSIAD. Each of you have chosen to
participate in this 12-week long structure group therapy, which will meet
every other week for 2 hours on (day of week). Before we start the workshop,
I would like to do an ice breaker in order for all of us to get acquainted. After
this, I will give you some information about EMPOWER’s framework, how
sessions will be conducted, work with you to establish some ground rules, and
open a discussion on what you hope to learn during this time. You are free to
ask me questions and share your concerns throughout this session as it will
help me understand your needs and modify lessons as we go.”
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15 Min. Group Members Introduction Round
Conduct an introduction round where each member briefly introduces
themselves (e.g. name, age, gender pronoun), something they enjoy doing on
their free time, and an aspect they love about themselves/day.
These next two sections are optional to include into session one.
These sections can be discussed in-depth with prospective group members
during the personal interview of the screening phase. If the facilitator decides
to include these topics into session one, they will need to decide the amount
of time for review or discussion. Any additional time will need to be either
adjusted into the session plan or addressed with group members
Introducing the Curriculum Theoretical Framework (Handout 1)
Contains research around FSIAD and young-adult women which can be used
as a guide for the facilitator.
Setting up Ground Rules
Please refer to Rules and Regulations under Treatment Format.
Discussion
Session Topic
• How FSIAD Affected Group Members’ Lives
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Session Activity
40 Min. Group Discussion
Sample Narrative:
“Each session will have a check-in and a group discussion. Check-in is
typically 10 to 15 minutes to kick off the session, today is an exception as we
need to get familiar with the group. The time for the discussion portion will
typically be 30 to 45 minutes long but will fluctuate depending on the topic of
the session and participation. With this said, participation is key in making
group therapy work for you and your fellow members, and I would like to
hear each of your thoughts in these discussions. I want to clarify that you are
free to choose when and what you would like to share. For today’s discussion,
I want to know more about you.”
The facilitator can use handout 3 (Female Sexual Distress Scale) or the
questions below to start the conversation on FSIAD
• When FSIAD enter your life, how did it influence you?
• How did FSIAD affect others in your life?
• What was your initial reaction to FSIAD?
• What pushed you to want to find out more about FSIAD?
• Have you met others who encountered FSIAD or similar sexual
difficulties?
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Cool-Down
5 min. Transition into cool-down section
Sample Narrative:
“Thank you for sharing how FSIAD has impacted your life. Let us work
together to address some of the issues presented in the next weeks to come.
We will be transitioning into the cool-down portion of this curriculum.
During the cool-down we will learn techniques that will help the brain calm
down. The cool-down portion will be conducted within 10 to 15 minutes.
Before we go on to the cool-down activity, let’s talk about SUDS.”
10 Min. Subjective Units of Distress (Handout 2)
The facilitator will explain the purpose of tracking Subjective Units of
Distress
(SUDs) throughout group sessions and explain how to use the SUDs sheet.
Sample Narrative:
“Subjective Units of Distress, referred to SUDs, is a tracking log. SUDs
provide insight on how your body is responding under distress versus in a
relaxed state of mind. High levels of distress have been linked to FSIAD;
therefore, it is important to become aware when your body is under distress to
then make a conscious attempt to comeback to a neutral state. When our
minds and body is neutral, we can then focus on what is sexually and
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emotionally satisfying. Being in a neutral state of mind, can also help us
process what is occurring and communicate to others what we would like to
experience.”
Now Let Us Talk About How to Use Suds
Sample Narrative:
“If you look at the SUDs handout, there are date, technique, pre, post, and
comment sections. I will provide you with the name of the technique. Under
pre, you will indicate distress level on a scale of 1-10, 1 is lowest level of
distress and 10 highest level of distress. You will write in your SUDs prior to
doing the exercise. After doing the exercise, under post I will ask you to write
your SUDs. The comments section is to write a brief comment on how this
technique worked for you. Let’s put this to practice!”
15 Min
Mindful Breathing Beginning Exercise
https://ggia.berkeley.edu/practice/mindful_breathing
The mindful breathing beginning exercise contains an example of how to explain breathing to
group members and instructions on how to conduct this exercise. Please refer to the link above.
10 Min. Wrap Up the First Session
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Before ending the first session, the facilitator will introduce the purpose of
therapeutic journaling and homework task.
• Purpose of journaling is to help group members unpack and process
shame filled thoughts/responses during homework assignments.
• Journal entry will be shared during the cool-down of the following
session. Not all group members are required to share.
Sample Narrative:
“I am passing out a 5x7 journal that will accompany you throughout this
journey. Therapeutic journaling is a private reflection/conversation on deep
rooted emotions, reactions, and perceptions of difficult and upsetting life
events. In this group therapy, we will be using journaling as a process of
writing out shame filled thoughts and/or other forms of emotional responses
to personal experiences. Journaling is a part of the homework assignments.
During the check-in portion of the following session members are asked to
share their journal entry response to help unpack and process the occurrence.
Sharing helps create a welcoming environment for shared vulnerability where
group members can relate to each other’s experience. It also helps me
understand what each of you need in this workshop.”
The facilitator should read the homework assignment to evaluate if the facilitator possesses the skill level to deal with material that surfaces (i.e. affairs) from the journal entry. Homework section can be printed or sent via email to group members.
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Homework
People’s muscles often become stiff under a stressful situation or are tense when they have been under stress throughout the day. People sometimes become accustomed to stiffness, which affects their ability to distinguish when they are relaxed versus when they are tense. This is important when it comes to FSIAD because it helps women understand more about their body’s reaction to sexual stimulation. The more women understand about the body’s reaction under stress, the better they can address thoughts, beliefs, values, or other factors that influence such reaction. Practicing body awareness can help reset a woman’s state of mind during sex and help women to communicate with their partners about what is or is not enjoyable. The body scan meditation is an exercise used to promote body awareness, stress awareness, and practice mindful focus.
Body Scan Meditation - 30 minutes https://ggia.berkeley.edu/practice/body_scan_meditation
Journal Entry
Write down any body changes (e.g. body stiffness, anxious movements, breathing) after doing the meditation, then write down thoughts and feelings you believe could have influenced or related to the stiffness/body movement.
Example: After doing the body scan meditation, I noticed my shoulders were up and tense. I have been under stress at home lately because my partner has been wanting to have a date. I
23 think this is where I am carrying anxiety because a date means things will lead to something more, and I am anxious on how to talk to him/her/them.
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Diversity Considerations
A diversity consideration to briefly address in session one is asexuality. Clinicians and
LGBTQ representatives have pointed out that FSIAD diagnostic criteria appears to detail asexuality. Since past editions of the Diagnostic and Statistical Manual (DSM) has listed homosexuality and transsexual as diagnosis, it is no wonder that FSIAD is questionable.
Asexuality is a sexual orientation where the person experiences little to no sexual attraction to another being. The similarities in marked absence of sexual interest/arousal in asexuality and
FSIAD can be problematic. Furthermore, asexuality is among a spectrum of sexual orientations and contains branching ace identities. Research reveals that some asexual people have romantic feeling, blurring the distinction line between FSIAD and asexuality. However, asexuality and
FSIAD are considered two distinct subjects.
One marked difference between asexuality and FSIAD is marked levels of distress for experiencing low or absence in sexual interest/arousal and the desire to regain or obtain this level of functioning. An asexual person on the other hand does not report such levels of distress.
Levels of distress in asexual people are related to interpersonal issues around sexual activity, not necessarily wanting to gain sexual arousal or interest. As De Paulo, writes (2016) the following:
Both [asexuality and FSIAD] are relevant to a lack of interest in sex. The key difference
between such sexual dysfunctions and asexuality is that people with disorders experience
significant personal distress because of their lack of sexual attraction. Asexual do not.
They aren’t worried about their asexuality (except for the disapproval it can bring from
other people) and they are uninterested in seeking professional help to deal with it (paras.
13).
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Dedicating a session to discussing human sexuality can be helpful to women who may not have known they are asexual people. Discussing human sexuality can enlighten to cisgender women about romantic orientation.
Resources about asexuality: https://www.thetrevorproject.org/wp-content/uploads/2017/09/asexuality.pdf
Asexuality an Invincible Orientation by Julie Sandra Decker
Ace & Proud: An Asexual Anthology by A. K. Andrews
Resource on human sexuality: https://www.youtube.com/watch?v=xXAoG8vAyzI
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Handout 1
Female Sexual Interest/Arousal Disorder (FSIAD)
The DSM-5 classifies FSIAD as a female sexual dysfunction. FSIAD is marked by significantly reduced or absence of sexual interest/arousal for at least 6 months (APA, 2013).
FSIAD has been documented as a complex diagnosis as symptoms arises from multiple and interrelated medical, biological, and psychosocial factors. Although treatment and diagnosis for
FSIAD has been difficult to determine (Feldhaus-Dahir, 2009). One third of women in the
United States report having low or diminished sexual interest/arousal (Rosen et al., 2009).
FSIAD Among Young-Adult Women
Young-adult women report an array of sexual difficulties as middle-age women. Here are the percentages of sexual problems reported by young-adult women compared to midlife women.1
SEXUAL PROBLEM YOUNG-ADULT MIDDLE-AGE
WOMEN OR OLDER
AROUSAL 14.1% 16.2%
ORGASM 19.8% 23.1%
SEXUAL SATISFACTION ISSUES 87.6% 23.1%
1 Espitia De La Hoz, Franklin José. (2018). Prevalencia Y Caracterización De Las Disfunciones Sexuales En Mujeres, En 12 Ciudades Colombianas, 2009-2016. Revista Colombiana De Obstetricia Y Ginecología, 69.1, 9-21. 27
Sexual difficulties reported by young-adult women often meet the criteria for a female sexual dysfunction. Here are the sexual difficulties consistently reported by young-adult women.2
SEXUAL PROBLEM YOUNG-ADULT WOMEN
INABILITY TO CLIMAX 86.7%
NO SEXUAL INTEREST/AROUSAL 81.2%
INSUFFICIENT LUBRICATION 75.8%
PAINFUL INTERCOURSE 75.8%
How Does FSIAD Affect Mental Health?
Women between ages 25 to 44, who experience FSIAD, convey various mental health issues such as high personal distress and partner distress (Hendrickx, Gijs, Janssen, & Enzlin,
2016) compounding a negative self-concept (e.g. body-image, self-esteem, self-perception, sexual desirability, and physical attractiveness), and increasing sex avoidance behavior and fear around future intimate relationship (Hendrickx, Gijs, Janssen, & Enzlin, 2016; Quinn-Nilas et al., 2016).
CBT, Narrative Therapy, & Mindfulness
The way we see FSIAD can impact the way we think about ourselves, our body, and our intimate partner(s). Cognitive behavioral therapy (CBT) provides a way to reorganize our thought process around FSIAD and sexuality. Narrative therapy separates the problem from ourselves to help reflect on how this problem affects our life. Mindfulness enhances awareness of thoughts, emotions, and bodily sensations in a nonjudgmental manner. These three therapeutic approaches have been combined to enhance shame resilience and healthy sexual practice.
2 Moreau, C., Ka, A. E., & Blum R.W., (2016). Sexual Dysfunction among Youth: An Overlooked Sexual Health Concern. BMC Public Health 16.1, 1-10. 28
Handout 2
Subjective Units of Distress (SUDS)
From 0 – 10 indicate what is your current distress level?
0 – Not good / 10 – The best
Date Technique Pre Post Comments Mindful Breathing Beginning Exercise
3
3 From Trujillo-Arevalo, A., (2011). Manualized cognitive-behavioral / narrative therapy treatment for children with depressive symptoms. [Culminating Project, California State university, Northridge]. CSUN Scholarworks.
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Handout 3
Female Sexual Distress Scale - Revised
Name ______Date ______
Below is a list of feelings and problems that men and women sometimes have concerning their sexuality. Please read each item carefully and check the box that best describes how often that problem has bothered you or caused distress over the last 4 weeks. Please check only one box for each item and take care not to skip ANY items. If you change your mind, erase your markings carefully.
Please check one box per question.
1. How often did you feel distressed about your sex life? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
2. How often did you feel unhappy about your sexual relationship? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
3. How often did you feel guilty about your sexual difficulties? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
4. How often did you feel frustrated by your sexual problems? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
5. How often did you feel stressed about sex? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
6. How often did you feel inferior because of sexual problems? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
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7. How often did you feel worried about sex? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
8. How often did you feel sexually inadequate? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
9. How often did you feel regrets about your sexuality? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
10. How often did you feel embarrassed about sexual problems? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
11. How often did you feel dissatisfied with your sex life? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
12. How often did you feel angry about your sex? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always
13. How often did you feel bothered by low desire? 0 Never 1 Rarely 2 Occasionally 3 Frequently 4 Always © American Foundation for Urologic Disease, Inc.4
4 From De Rogatis L, Clayton A, Lewis-D’Agostino D, Wunderlich G, Fu Y. Validation of the female sexual distress scale- revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008 Feb;5(2):357-64. 31
Session 2: What is Shame?
Lesson Objectives
Session two will explore how shame affects women’s mental health. The facilitator will introduce the concept of shame and distinguish shame from guilt. The facilitator will use the process of externalization, a narrative therapy technique, to allow group members to consider their relationship with shame. This discussion will set the groundwork for session three, where group members will explore the concept of sexual shame and its relationship with FSIAD.
Supplies Needed
• Name Tags
• Dry Eraser Board, Markers, and Eraser
• Handout 4 and 5
• SUDs sheet
Before Conducting the Session
Unlike guilt, which can be channeled into a productive response, shame has been shown to be a destructive emotion to people’s mental health. Shame has been linked to low self-esteem in women with eating disorders (Woodward et al., 2019); it has been shown to contribute and maintain mental health issues among LGBTQ+ people (Scheer et al., 2020); and shame has also been shown to affect sexual functioning and satisfaction in childhood sexual abuse survivors
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(Pulverman & Meston, 2019). The facilitator may need to read research about shame to discuss the difference between shame and guilt and how shame effects people’s mental health.
Check-In
25 Min. Sharing Thoughts on Session 1 Journal Entry
Group members will share a brief response to the body-scan meditation
homework. This check-in will help the facilitator evaluate each member’s
mind-body awareness. The concept of mind-body connectivity will be further
discussed in session five.
Sample Narrative:
“Hi everyone, I want to check in on how everyone is doing. Last week we
went over so much information about the group and had a discussion on
FSIAD. I also assigned the body scan meditation as homework. For this
check-in I want to go around the room and have each person share a thought
or emotion they experienced when doing the body scan meditation.”
It can be difficult to have participants engage in a discussion for the first check-in. The
facilitator can initiate a discussion by point out a common theme among members stories.
For example, “as I am listening to each of your response, I notice the common theme is
stress. I am wondering when a person carries stress how does it affect their behavior
towards others, themselves, sex?” or “Now that you have learned to practice body
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awareness, I am wondering these same body parts where one carry’s stress, are the same
when it comes to sexual anxiety?”
Discussion
Session Topic
• What is Shame?
• Externalizing Shame
Session Activity
20 Min. Exploring Shame
• Introduce the word Shame
o Have group members define or explain what shame means or
feels like, body sensations associated to shame, other emotions
linked to shame, and situations that trigger shame within the
group member
o Example of a participant response would be:
I know I am ashamed because I mentally curl within myself, I
feel inadequate, bad, unimportant, flawed, incompetent, etc.
20 Min. Brené Brown Definition of Shame (Handout 4)
Introducing this quote can facilitate a discussion on shame filled experiences.
Here are some quote sections to emphasize to begin externalizing shame.
• “The focus is on self and not behavior”
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o This part of the quote indicates that a person internalizes an
experience, an action, or the fail to act so deeply they believe
they are unworthy of connection and love. The focus is on
self-worth as people, rather than the behavior.
o Behavior is flexible, adaptive, and unpredictable as it is reliant
on outside factors (other responses, situation, time)
• “Shame does not lead to positive change”
• Shame is not helpful or productive rather it is destructive to the
self-esteem.
The facilitator may need to distinguish shame from guilt. Here is a simple way to explain
the difference between shame and guilt.
Guilt is connected to remorse and takes responsibility of an action. It tends to focus on
behavior or imagined behavior.
• “I made a mistake” or “I did something bad”
Shame is linked to thoughts of being flawed and unworthy. Shame is often connected to
moral judgement (e.g. dishonorable, improper, wrong) placed on oneself.
• “I am a mistake” or “I am bad”
40 Min Externalizing Shame
In the following externalization activity will allow group members to consider
their relationship with shame.
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• If we picture shame as a thing, how will it look like, sound like, feel
like.
• What would it say to you?
o “nothing you ever do is ever enough”
o “I’ll never make them happy”
• How does it affect your response to others?
o Defensively/reactive anger: “I was just about to do it; you’re
always pestering me!”
o Disassociate or withdraw becoming quiet or mentally curling
into oneself
o Retreat: physically leaving but choosing to ignore
communication about subject
• When and how has shame helped you?
If flight, fight, freeze response is not familiar to group members, the facilitator may want
to revisit this concept in session five, Mind-Body Connectivity. Cool-Down
Research shows that women’s self-esteem is affected by FSIAD (Akhavan et al., 2018). Studies also suggests that shame may exacerbate FSIAD symptoms. Taming Feelings of Shame is a mindfulness exercise in which group members will learn how to become aware of shame, hence building shame resilience. Shame resilience will be discussed with the group in session three.
15 Min. Taming Feelings of Shame with This 10- Minute Practice (Handout 5) - SUDs
https://www.mindful.org/tame-feelings-shame-10-minute-practice/
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Homework FSIAD is a tough issue to navigate and more so when women have negative opinions about themselves. Research shows that women who experience FSIAD report self-esteem and body- image related issues such as feeling less sexually desirable or unworthy of love and affection.
Leaning how shame affects self-perception can help women move closer to a sexually and emotionally fulfilling relationship with themselves.
Self-massage as Emotional Regulation – 20 Minutes
This step by step instructional can be found on: https://www.mindfulcenter.org/cmpblog/self- massage-as-emotional-regulation
Journal Entry
People unconsciously associate body parts with shame-filled thoughts. During this exercise notice which body-parts carry shame? Then write in your journal how the association between the body part and thought was created.
If this exercise brings up a strong overwhelming emotional reaction or triggers trauma please stop the exercise and contact the facilitator or call the National Alliance on Mental
Illness (NAMI) Helpline: 1 (800) 950 – 6264
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Handout 4
Brené Brown’s Definition of Shame
5
5 From Brown, B. (n.d.). Downloads and guides. Brené Brown. https://brenebrown.com/downloads/ 38
Handout 5
Taming Feelings of Shame
With This 10- Minute Practice6
Take a comfortable meditation posture, eyes closed if comfortable. Begin by bringing attention to the body sitting. Attending to the base of the body as it contacts the surface you are resting on. Allowing the jaw to soften, shoulder blades sliding down the back and hands at rest in the lap or on your thighs.
Turn your attention to the sensations of breathing at the level of the belly. Attending to the in breath and the out breath, the rising and falling of the abdomen. Perhaps letting the breath move in and out of the body naturally, as best you can.
And now, gently bringing to mind an experience or memory, a time in which you felt shame. Maybe it was something you did or something that someone else said about you or to you. Whatever it is, turning toward this memory, experience, or situation gently, as best you can, checking in with what thoughts are present, what emotions, and what body sensations.
Without needing to change or fix anything, beginning to explore what is arising or what is here right now.
If there are specific thoughts, as best you can experience them as sensations of the mind, as events that come and go. If there are emotions, naming or labeling them as they make themselves known. Saying to yourself shame is here or fear, anxiety or guilt, whatever it is and staying with these for a few moments.
6 From Rockman, P. (2019 November 28). Tame feelings of shame with this 10-minute practice. Mindful. https://www.mindful.org/tame-feelings-shame-10-minute-practice/ 39
And now, shifting your attention to any associated sensations in the body. Investigate these with friendly interest, getting curious about them, even if they’re unwanted or intense……really getting to know them if this is possible in this moment.
If the sensations are particularly intense or strong, saying to yourself, “this is a moment of difficulty. I can be with this, it’s already here.” If it is helpful breathing into the sensations, expanding on the in breath and softening on the out breath, staying with these sensations as long as they are capturing your attention.
If this is too difficult or feels overwhelming there is always the choice to return your attention to the breath at the belly or to open your eyes, letting go of this practice. Otherwise, continuing with this attention to the sensations in the body…
And now, returning to the sensations of breathing in the abdomen to the rising and falling of the belly with each breath, breathing in and breathing out…
And when you’re ready, bringing attention to the entire body, to any and all sensations, resting here in a more spacious awareness if this is available…
Then gently with this shameful experience in the background now, asking yourself:
Can I let this be as it is?
(It’s already here, after all.)
Can I let it go? (It’s already happened.)
Does it need addressing? Do I have to take an action? If so, what?
Can I shift my attitude, bringing a different perspective to this experience?
And then gently opening the eyes if they have been closed and letting go of this practice…
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Session 3: Exploring Sexual Shame and FSIAD
Lesson Objectives
Session three will focus on sexual shame and its relationship to FSIAD. The facilitator will need to establish a supportive environment to encourage deeper exploration of sexual shame filled experiences. Supplies Needed
• Name Tags
• Dry Eraser Board, Markers, and Eraser
• SUDs Sheet
• Handout 6,7, 8 Before Conducting the Session
Anatomically correct clinical terms should be used to decrease further shame that may occur unintentionally on behalf of the therapist and to restructure how group members view and discuss sex. Using anatomically correct clinical terms may elicit shame within group members but shame needs to be discharged for the facilitator to aid in sexual healing. The slang term exercise was included in this curriculum to permit sexual shame recognition. The facilitator will need to be aware of shame filled reactions to challenge sexual attitudes. However, the facilitator will need to use their clinical judgement on how to address participant discomfort.
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Preparing for The Slang Term Exercise
Slang terms are a sexual-avoidance strategy used to maneuver through sexual shame, but they can prevent congruence (Hastings, 1998). To prevent further shaming, rather than correcting a participant use of vocabulary, the facilitator may approach the slang term with curiosity, such as referring to the slang term with a question. Doing this will allow the facilitator and group members the opportunity to explore what slang provides within a partnership/sexual relationship.
An example of this intervention is when a member uses the word cunt to refer to the vagina as they are asking a question, the facilitator will first answer the question with the clinical term and then respectfully asks if cunt is how they typically describes the vagina. The facilitator can transition into deeper exploration on how slang helps member(s) navigate shame during conversations about sex.
Self-of-The-Therapist Work
During session three’s discussion activities, it is important for the facilitator to explore their own reaction towards slang words or group members attitude on sex. For instance, the word cunt has long held a degrading connotation towards women. Some facilitators may choose to disclose with members about their reaction towards slang. Allowing the facilitator to take responsibility for their reaction. Facilitators are cautioned to not add shame to the client’s experience or becoming focused on their own shame. By having open conversations that debunk old-fashion terminology, views of sex, and sexuality, clients are to make a quicker healing bond between sexuality and self.
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Check-In
25 Min. Sharing Thoughts on Session 2 Journal Entry
Sample Narrative:
“Last week’s homework you had an opportunity to explore where shame
resides within the body. Who would like to start?”
• Tell me more about how the link between shame and (body part)
started?
• May you please share an automatic though you had when massaging
(body part). When did these thoughts start developing?
• How did you react to the negative thoughts (e.g. stopping the exercise,
moved to the next body part quickly, insulted the body part)?
Discussion
Session Topic
• Exploring the Development of Sexual Shame
• Sexual Shame Filled Experiences Related To FSIAD
Session 3 key terms (Handout 8)
The following handout can be helpful for the facilitator to refer to in defining various key terms for the following session activities.
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Session Activity
10 Min. Slang-term Exercise (Handout 6)
The goal of this exercise is to get group members to start acknowledging how
social influences affect sexual attitudes. Rather than having the facilitator
explain how people are socialized to talk about sex, the slang-term exercise is
a social experiment for group members to become pro-active in critically
thinking about their sexual attitude.
30 Min. What is sexual attitude and sexual shame? (Handout 7)
Handout 7 is included as a guide for the facilitator rather than an
informational handout for the client. The facilitator can use the following
questions to navigate the conversation around sexual shame and add
information from handout 7 to the discussion.
Provide the definition to sexual shame
• ask group members if they have ever felt sexual shame during an
intimate or sexual experience?
• If they were to imagine sexual shame as a cousin of shame, where
would it linger on (e.g. body part, situation, a person, an action/touch)
• How does sexual shame influence our response to sex, sexual partners,
or in sexual situations?
It is common for people to develop sex avoidance when sexual shame is persistent. Sex
avoidance and aversion will be explored in session five. If the topic of sex avoidance
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comes up in the group discussion prior to session five handout 14 contains information on
sex avoidance and aversion that can help the facilitator to briefly navigate this
conversation and create questions that will help deeper exploration of sex avoidance
reactions.
30 Min. Sexual Shame Triggers
Refer to Handout 8 to read over the definition for sexual shame trigger.
Continue with the following questions to explore members sexual shame
triggers.
• How do you know that sexual shame is appearing?
• Provide the sexual shame trigger definition which is included in the
terminology for session three found on handout 8 along with other
terms.
Sexual shame triggers can be various social influences If group members are
having difficulty understanding their own sexual shame triggers use the
following questions to evoke a memory that may be connected to sexual
shame.
• Have you ever had an experience where you felt “not extraordinary
enough”?
o When people compare themselves to the ideal attractive person
can trigger body-image shame, which can also contribute to
sexual shame.
• How about a time where you felt “not authentic enough”?
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o There is an expectation to be authentic in sex, especially in
relationships where sex equals love.
o Faking pleasure rather than openly expressing the lack of
interest/arousal to a partner.
• What about “not sexual enough”?
o There are expectations around sexual performance and sexual
functioning, which are concepts rooted in the idea that humans
must physiologically respond to sexual stimulation.
The facilitator can guide the group into a deeper processing level about sexual shame triggers by highlighting common social responses (e.g. giggling, joking, minimizing, ignoring) when discussing shame-filled experiences. For example, the group giggling as members share stories about faking sexual pleasure may indicate that members are uncomfortable with voicing out interest/arousal issues to their partner(s). The facilitator may gently ask: “I noticed we are giggling about faking orgasm, probably because its common. I am wondering what would happen if we sit with our partner and tell them we are having trouble getting aroused or having difficulty in becoming interested in sex?”
The groups response to this question may be, “If I speak up about this my partner will leave” or “verbally stating that I have no interest in sex is acknowledging that something is not right with me.” These are distorted automatic thoughts (i.e. overgeneralization, dichotomous thinking, mislabeling, etc.) or irrational beliefs (perfection-based worth) which the facilitator can restructure by using various CBT techniques (e.g. socratic questioning or const-benefit analysis).
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10 Min. how does sexual shame affect behavior/responses?
This question is introduced in session three to evoke critical thinking on how
sexual shame affects member’s response to sex. Group members and the
facilitator are not expected to pinpoint an answer, instead this idea will be
explored throughout the curriculum.
Sample Narrative:
“First thing I would like to say is thank you for being vulnerable in this
session, talking about sexual shame can be intimidating. Being okay with
vulnerability allow people to gather self-awareness, and with self-awareness
we can gain confidence to use our voice. The answer to the last question I
asked how does sexual shame affect behavior/response? The answer is
complicated because there are a mix of psychological and social component
to sexual shame. We will dedicate session three in developing the answer this
question.”
Consensual and pleasurable sex are important principles to mention in session three
since any young adults are amid of developing healthy sexual practices.
Here are resources to help the facilitator explain consent to group members:
https://www.youtube.com/watch?v=oQbei5JGiT8
https://www.healthline.com/health/guide-to-consent#verbal-and-nonverbal-cues
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Cool-Down
Gratitude can boost mental and physical wellness when expressed to others or privately to oneself (Tabibnia & Radecki, 2018). Gratitude journaling increase satisfaction, decreases anxiety, and activates the medial prefrontal cortex function, which is important for emotional regulation (Tabibnia & Radecki, 2018; Smith et al., 2018). The next exercise will implement gratitude journaling in relation to the sexual self-concept, a concept that will be explored in session four.
15 Min. Writing A Gratitude Letter to Ward Off Sexual Shame - SUDs
Group members will sit down and think of 2-3 things that they enjoy about
their sexual self. This can include an emotional aspect of their sexual life that
brings pleasure, body-part that they find sexually attractive, belief about sex
that has helped them overcome shame.
The facilitator may play calming instrumental music to create a relaxing
ambiance.
Suggestions:
Yurima – River Flows in You (3.08 min)
Yurima – Love me (4.03 min)
Brian Crain – Dreamsong (3.38 min.)
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Homework Brené Brown’s Shame Work Sheet focuses on shame resilience theory. According to Brown
(2006) since shame cannot be eliminated, then women can develop resilience to it, which helps them navigate through shame-filled experiences in a constructive manner. Developing shame resilience allows women to remain authentic, congruent, and grow from their experience.
Brené Brown’s Shame Work Sheet – 30 to 40 minutes file:///C:/Users/anakj/Downloads/ITIWJMreadingguide.pdf
The facilitator will need to print Brené Brown’s Shame Work Sheet for each group member.
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Diversity Considerations
Social influences contribute to the development of belief on sex, premarital sex, extramarital sex, and other sexual behavior. Religion plays a crucial factor in informing sexual practices (Murray et al., 2007) and disclosure of sexual behavior that opposes rigid culture and religious practices (Adamczyk & Hayes, 2012). However, religious practices can vary within ethnic groups who commonly practice that religion and can vary across regions in the world
(Adamczyk & Hayes, 2012). In addition, some religions report more conservative views on sex than other religions (Adamczyk & Hayes, 2012). Other types of social influences such as sex and gender, level of education, level of conservatism was influence permissiveness of sexual attitudes which was correlated to openness to experience and conscientiousness (De Jong et al.,
2012). Interestingly, personality traits we are also influential factors in sexual attitude.
According to De Jong et al. (2012), extroversion has been linked to riskier sexual behavior.
Boundless of research studies have shown that various sexual influences affect sexual behavior and sexual attitudes. Although understanding the social influences on sex can be educational and helpful to group members, facilitators need to be sensitive to group members comfort level when addressing their personal views and beliefs on sex.
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Handout 6
Slang-Term Exercise
The slang-term exercise7 is a social experiment for group members to become pro-active in critically thinking about their sexual attitude
1. On a board create 4 sections with ample amount of space for each section.
2. write out the following words one for each section: breast, penis, vagina, sex
3. Have the group shutout slang term they have heard for each of the words.
4. After filling out all four sections, look at the board together, and ask why we have so
many slang terms to describe these perfectly good terms?
5. After group members provide explanations why socially we have created slang terms for
body parts and sex, transition into exploring sexual attitudes.
Breast Penis Vagina Sex
Titties, Tatas, the The wand, anaconda, Vag, Vajayjay, nether Make love, sleep twins, boobs, cock, dick, ding-a- region, hoo-haw, with…, do it, hook boobies, tits, melons, ling, dingle, dingus, chacha, private part, up, get lucky, get it coconuts, milkers, the dog bone, fuckpole, unmentionables, lady on, get busy, make snuggle pups, the jock, the love stick, business, lady v, lady babies, fuck, shag, girls, pinky and etc. bits, crotch, kitty, screw, bang, bone, perky, tig ol’ bitties cooch, punani, penis nail, get nasty, etc. etc. fly trap, etc.
7 Fields, A. (personal communication, November 19, 2019) introduces the slang-term exercise to MFTs to explore influences on sexual attitude. 51
Handout 7
What is Sexual Attitude and How Does It Work?
Sexual attitude is the beliefs someone has on sex, sexuality, and sexual behavior. A person’s sexual attitude influences a person’s behavior, thoughts, emotions, and reactions.
Sexual attitude includes a numerous of beliefs on different sex topics. For example, a persona can have a different belief on each of these topics: porn, affairs, outercourse, non-sexual touch, monogamy, and celibacy. Some beliefs may be rigid compared to others, and some may possess a rigid sexual attitude overall. However, having a rigid sexual attitude does not mean a person will have a less satisfying sexual and emotional encounter. Understanding one’s own sexual attitude can be helpful in decoding sexual shame triggers. Shame triggers are events or actions that set off sexual shame, therefore stifling sexual satisfaction and emotional satisfaction
What is Sexual Shame?
Sexual shame is an intense emotional suffering in existing as a sexual being with sexual thoughts that may be accompanied with a sense of worthlessness, imperfection, and loss of belonging.
What is the Function of Sexual Shame?
Sexual shame is closely related to someone’s sexual attitude. According to Lichtenberg
(2011) shame acts as a regulatory signal that activates when an ongoing experience of interest- excitement is stifled. What this means is that sexual shame starts to develop when there are multiple negative sexual experiences.
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How Does Sexual Shame Affect Young-Adult Women?
Young-adult women who experience FSIAD report a higher frequency of negative internalize messages, negative self-perception, and develop a fear around initiating physically intimate relationships due to sexual desire and arousal complications. Additionally, women who experience FSIAD report an impairment in body image and feeling less sexual desirability.
These results may be connected to sexual shame that has built or been reinforces by past sexual experiences and partner sexual responses.
How is Sexual Shame Developed?
Sexual shame can stem from having many shame-filled experiences. These experiences can include partner/ex-partners negative responses or early childhood experiences. Sexual shame can also stem from maladaptive thinking. Maladaptive thinking includes having shame-related thoughts (e.g. thinking of past sexual events) in the current situation, which lead to feeling defective or having self-critical thoughts around sexuality (Pulverman & Meston, 2019). The thought process is important when it comes to sexual satisfaction. For example, past experiences, motivational gains, and cognition affect mental sexual arousal (Basson, 2001). Which is foundational in establishing emotional and sexual satisfaction within a sexual event. Other research on schema work and female sexual dysfunction shows that irrational beliefs experienced during sex overwrite the pleasurable sensations (Middleton et al., 2008). Even though sexual shame can stem or be reinforced by negative sexual experiences, restructuring the thought process around sex can create a flexible sexual attitude where healthy sex practice is key to having a sexual and emotional satisfying encounter.
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Handout 8
Session 3 Key Terms
Sex Avoidance: Sex avoidance is the tendency to avoid sex due to negative outcomes related to sexual difficulties during past sexual encounters (O’Sullivan & Majerovich, 2008; Moreau et al.,
2016).
Sexual Attitude: Sexual attitude is the beliefs someone has on sex, sexuality, and sexual behavior.
Sexual Healing: Sexual healing is an intimate process of healing from cultural and personal influences placed on sexuality. (Hastings, 1998)
Sexual Performance Anxiety: Sexual anxiety is a state of uneasiness and is accompanied by psychological distress due to the perceived expectation or pressure to sexually perform physically and/or emotionally.
Sexual Shame Trigger: Sexual shame trigger are events or actions that set off sexual shame, therefore stifling sexual satisfaction and emotional satisfaction. These triggers are informed by a person’s sexual attitude and social influences.
Sexual Shame: Sexual shame is an intense emotional suffering in existing as a sexual being with sexual thoughts that may be accompanied with a sense of worthlessness, imperfection, and loss of belonging.
Shame Resilience: Shame resilience is the ability to recognize shame, practice critical awareness of forces that inform shame triggers, and ability to communicate of impact shame had (Brown,
2006).
Shame: Shame is an intense and painful emotional experience around the idea of imperfection and is accompanied by a sense of worthlessness (Brown, 2006).
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Social Influences: Social influences are demands that exist in a person’s social environment
(e.g. media, religion, politics, family values, social experiences, etc.)
Vulnerability Continuum: Vulnerability continuum is the ability to be aware of issues, events, and perceptions that make a person feel vulnerable.
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Session 4: The Social and Psychological Dimensions of Sexual Shame Lesson Objectives
This session will explore social influences in the development of sexual attitudes. This will challenge group members to look and understand their sexual attitude and its role maintaining sexual shame. After exploring the social dimension of sexual shame, the facilitator can transition into the psychological dimension. This will be done by discussing the sexual self-concept. Supplies Needed
• Name Tags
• Handouts 9 -11
• Dry Eraser Board, Markers, and Eraser
• SUDs Sheet Before Conducting the Session
This session is one the most complicated sessions with the curriculum to break down. Reason for this is there are many bidirectional interactions occurring between the social and psychological dimensions. To make things more complex, sexual shame can have and bidirectional interaction towards facets of these dimension, such as those seen with sexual shame and different features of the sexual self-concept. The facilitator goal is to engage a critical awareness continuum to enhance shame-resilience. Critical awareness continuum is a skill used to enhance awareness of how social and cultural forces shape experiences, and the ability to critically assess personal experiences in the context of those forces (Brown, 2006).
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Two handouts have been included to help the facilitator breakdown the self-concept and its relationship with arousal, and to engage group members in critical awareness.
Self-concept terminology (Handout11)
Self-concept and Arousal (Handout12)
Check-In
25 Min. Sharing Thoughts on Session 3 Journal Entry
Shame resilience will be covered in a later session, thus briefly explore a few
responses to the concepts found within the Shame Resilience worksheet. Here
are some suggested sections of the worksheet that can spark a brief
conversation about shame resilience or shame triggers.
• Shame symptoms
• Identities
• Strategies of disconnecting
Transition session into today’s complex session.
Sample Narrative:
“Last sessions I asked How does sexual shame affect behavior/response?
The answer to this question is complicated because sexuality is
multidimensional. Meaning there are biological, psychological, and social
dimensions to it. FSIAD is also a complex mix of physiological (e.g. bodily
function), social (e.g. social environment), interpersonal (e.g. partner
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interaction or past sexual experience) and psychological (i.e. intrapersonal
dialogue and mental health issues) factors. Sexual shame is the byproduct of
continuous conflicting and negative exchanges between two or more of these
dimensions. This week we looked at the social and psychological dimensions
of sexual shame.”
Discussion
Session Topic
• Social Influences
• Sexual Attitudes
Session Activity
30 Min. Connecting Sexual Shame to Social Influences on Sexual Attitude (Handout 9)
This conversation begins by having group members ponder on how social
influences affect people’s interaction around sex.
• The facilitator may use handout 5 to psychoeducate group members
on the types of social influences exist and have group members
discuss how these inform their personal sexual attitude. Here is a
sample of how this can be created into a quick exercise to facilitate
discussion.
Sample Narrative:
“Last session we explored how sexual shame can be informed or trigger by
various social influences. Social influences are demands that exist in a
58 person’s social environment. I have here a list of social influence subjects, which each of you received, please let me know if you need one. I want you to take 10 minutes and look over the list, and circle which ones are strong sexual shame trigger. After were done and share how this influence shaped and gave power to sexual shame.”
Here are example questions that can be asked:
• What messages do women receive from (social influence) about
sexuality?
• How are women depicted within ______? And how do these
images inform sexuality and sexual shame?
• How do sex expectations in ______affect women’s own
perception of their sexual satisfaction or emotional satisfaction in
sex?
• What messages do women internalize about their sexual
desirability within ______? and how does sexual shame maintain
this link?
• What other social influences maintain what is portrayed in ______
(political interest, culture values, family beliefs, etc.).
Transition to psychological dimension
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After group members have a decent grasp of social influences and sexual
attitude, group members can transition into a discussion of the sexual self-
concept.
Sample Narrative:
“As each of you have shared a situation where social influence formed your
sexual attitude towards sex or sexuality, and these also play a role in sexual
shame triggers, I will have us transition over to understanding the
psychological dimension of sexual shame by exploring the sexual self-
concept.”
30 Min Self-concept sky (Handout 10)
This exercise is to facilitate a discussion on self-concept. The handout
contains information for the facilitator. Self-concept terminology
(Handout11)
• How has sexual shame affected your sexual self-concept?
• Have group members write down three areas and share one
Let’s talk!
Have group members share thoughts on how interrelated social influences and
sexual attitude with the sexual self-concept, and how this may affect their
view of FSIAD.
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Sample Narrative:
20 Min “we discussed the sexual shame, sexual self-concept, social influences and
sexual attitude; and have come to understand they all intermingle with each
other. I am wondering knowing this information how your view of FSIAD
has changed?”
• Do other concepts on the cloud exercise (handout 9) influence how
your reaction or how you cope to FSIAD?
• How about when FSIAD joins you in a romantic/sexual event?
• Sexual shame can complicate things, I am wondering how you would
like to manage sexual shame within the psychological dimension (e.g.
intrapersonal dialogue, self-concepts, emotional response)?
Cool-Down
The meditation exercise that is included, Sensory Awareness Meditation for Beginners
Will walk group members through the five senses to refine awareness. However, this exercise was intentionally included as a grounding technique that group members call use during the homework assignments.
15 Min. Sensory Awareness Meditation for Beginners - SUDs
https://www.theepicself.com/meditation/sex/sensory-awareness-guided-meditation-
for-beginners/
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Prior to ending the session, the facilitator will need to inform group members that the next homework assignments will involve examining the breast and vulva and masturbation. If there is a level of discomfort, the facilitator should invite an open conversation about the group members emotions and perspective. Session five and handout 12 contain helpful information to address concerns around masturbation.
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Homework Examining One’s Own Breast and Vulva Exercise – 30 to 40 minutes Society has told women that the vulva and vagina are dirty, smelly, look weird, and taste weird – but these are not helpful comments to women’s sexual health. Examining one’s own breast and vulva is encouraged. Examining the vulva and breast medically important and has mental health benefit. Examining through explorative touch and masturbating can be beneficial in that it helps form an understanding of how one’s genital is structured. It also further informs women about the sexual shame that is attached to their breast and vulva.
Journal entry Practice mindful awareness of sexual shame. What thoughts/feelings come up? What social influences informs them? How do thoughts change the way you see breast and the vulva?
Rules for this assignment:
You are not allowed to masturbate in this assignment, instead you are asked to look at the
vulva and breast closely from a curious stance.
You may shift the structures around to get to the next step
Steps for the assignment:
✓ Make a date with yourself: schedule yourself some uninterrupted me time
✓ Take a few deep breaths
✓ And look for the following basic genital and breast structures:
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1. Breast: The breast is made of fatty tissue and specialized tissue that produces milk.
2. Areola: is a circle of pigmented skin surrounding the nipple. It contains sebaceous glands that
produce lubrication for the nipple during nursing.
3. Nipple: raised region of tissue, connected to the mammary gland from which milk can be
secreted. The nipple also serves as an erogenous zone. An erogenous zone is highly sensitivity
body part that can produce a sexual response, such as relaxation, thoughts of sexual fantasies,
sexual arousal and orgasm.
4. Mons Pubis: is an area of fatty tissue that rests on top of the pubic bone. It is naturally covered
with pubic hair. This is the area that women are familiar with since it is easily visible when
naked.
5. Vulva: is the external part of the female genital which protects the sexual organs, the urinary
opening, and vagina. the mons pubis splits off into two sections of labia’s
a. Labia Majora “outer labia”: are large, fleshy folds of tissue that enclose and protect the
other external genital organs. The labia majora can vary in color such as brown, tan,
pink, black, red, purple or cream and have hair. The outer labia produce sweat and
lubricants
b. Labia Minora “inner labia”: are the inner labia that have no hair and made of delicate
tissues. This tissue is covered with blood vessels which engorge with blood. This makes
the inner labia swell and become sensitive to stimulation. Some women have larger
outer labia, while others have larger inner labia. The labia are also not symmetrical or
identical. So basically, there is no “normal”, so don’t worry about how yours looks like.
64 c. The Clitoris: follow the line of your inner labia upwards, there you will find a
protruding tissue within a hood. The clitoral hood this is a small flap of skin, or
membrane, that protects the clitoris. Pull back the hood, and you will find the clitoris.
The clitoris can be visible in some women, while in other it may be more hidden. The
clitoris extends within the body, but there is a nub of skin that sits out within the vulva.
The clitoris is made up of a high concentration of nerve endings, which makes it the
most sensitive erogenous zone. d. The Urethral Opening: Right below the clitoris is the urethral opening, which is the
hole pee comes out of. It’s a very small opening, which can be hard to spot. e. The Vagina: the vaginal opening sits further down in some women, and in other may be
closer to the clitoris. The vaginal canal is where any sort of penetration occurs, where
menstrual fluid flows out of, and babies get delivered out of. the vaginal canal is covered
off by your cervix, which opens into the uterus, fallopian tubes, and ovaries. f. The G-Spot: was name after the doctor who discovered it, Grafenberg. The g-spot has
been a highly debated area within the vaginal canal, that is said to create powerful
orgasm, strong arousal, and ejaculation. There is much controversy around the g-spot,
some people swear that it exists while other believe it is part of the inner clitoral
structure. To potentially find the g-spot, insert a finger into your vaginal canal with your
palm facing up. The g-spot is on the front wall of your vagina, the wall closest to the
stomach, not towards the back. It is said to protrude from the side of the wall, it is about
the size of a nickel, it is dense and spongy. If you cannot locate it don’t stress it, this area
has yet to be scientifically backed up to exist.
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Handout 9
Social Influences on Sexual Attitudes
Below are categories of various social influences8 that inform the development of people’s attitudes. Social influences are analyzed within the context of sexual attitude. Sexual attitude refers to the thoughts/feelings that stem from beliefs around sexuality and sexual behavior. A person’s sexual attitude is developed by various social influences, such as those listed below.
Some social influences may be more influential than others. It is worth exploring one’s sexual attitude to understand how they influence sexual behavior and responses to sexual behavior.
Early Family Messages are messages (e.g. verbal or non-verbal cues/reactions and education) received from an early age. For example, not talking about sex, associating sex to marriage and love, beliefs around masturbation (i.e. reactions to an infant/child/teen masturbating), reactions to sexual acts (e.g. flipping the channel or cover the child’s eyes).
Early sexual experiences/abuse are first sexual experiences that occur in a person’s life, such as exposure to porn, first sexual encounter, childhood sexual behavior, and parent’s reaction to sexual behavior.
Religion: This category is to discuss how religion affects a person’s sexual attitude, for example, religious values, beliefs, teachings, religious interactions, etc.
Culture: This category is to discuss how culture affects a person’s sexual attitude, such as gender roles and expectations, family reactions. Culture can influence and be influence by the other social influences, such as the country’s political views can shift cultural values and beliefs
(i.e. political movements) and vice versa.
8 Fields, A. (personal communication, November 19, 2019) discussed how various social influences affect one’s sexual attitude. 66
Media: This category is to discuss how the media affects a person’s sexual attitude. Common message is having unrealistic expectations about sex, where sex scenes involve little to no foreplay and focus on penetration and orgasm. Other media messages are expectations around body-image, personality traits, and sexuality, love and sexual practices, single versus coupled expectations etc.
Politics: This category is to discuss how political views within the person’s social environment and country affects a person’s sexual attitude. This category can influence the level of sexual education a person received. Government policies being passed or debated on will change or reinforce people’s views on sexuality and sexual health.
Medical History includes infections, disease, and disability. other social influences stigmatize sex within the context of infections, disease, and disability which can affect a person’s self-view.
For example, people with a disability is have sex and have romantic relationships yet society ignores, and stereotypes disabled people’s sexuality.
Personality: Freethinking vs. conservative and extraverted vs. introverted. Studies show that personality traits such as extroversion/introversion, level openness, agreeableness, and conscientiousness influence sexual outcomes (e.g. attitudes towards sex, frequency of sexual activity, number of sex partners) (Allen & Desille, 2017; Jong, Pieters & Stremersch, 2012).
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Handout 10
Sexual Self-Concept Sky The illustration shows various features of the self that make up the self-concept. These features include self-worth, body-image, and self-esteem, etc. The sexual self-concept is a feature of the self-concept made up of human sexuality factors (i.e. sexual orientation, gender, sexuality, etc.). Thus, the sexual self-concept is specifically how we see ourselves as a sexual being. Negative emotions, such as shame can affect feature within the self-concept. Those injured features can affect other features and the self-concept overall. For example, low self- esteem can affect body-image, and when the person has not developed enough shame resilience, negative messages become internalize, further damaging and exacerbate self-esteem and body- image issues.
The same cycle occurs for the sexual self-concept with sexual shame. Sexual shame is a type of shame that shows up when sexual behavior/thoughts/feeling occur. When sexual shame shows up it does not only disturb the sexual self-concept, but other features as well. For instance, a person can possess a strong sense of self-confidence but experience sexual shame when talking about sex. Sexual shame can gain power over this person, and start affecting the sexual self- concept, which then affects the level of self-confidence they possess. As Brené Brown points out, since shame cannot be destroyed, people need to learn how to strengthen shame resilience.
Therefore, women have the power to develop their shame reliance to confront shame and sexual shame, they may just need a bit of courage and support.
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Some of the clouds contain concepts that are not part of the self-concept. These are sexual attitude, life experiences, emotional maturity, and personal values. These were included because they are important influencers towards shame and support the development of the self- concept and sexual self-concept. Practicing shame resilience, can help lessen distress when the interaction between features is negatively disrupted.
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Handout 11
Sessions 4 Key Terms
Self-concept is the overarching construct about oneself (i.e. how I see myself, how I think about myself, and how I feel about myself). This concept is comprised of other aspects of the self.
• Sexual self-concept is the idea of how a person perceives and appraises their sexual
behavior, sexual aptitude, and sexual identity.
• Self-esteem is the overall sense of sense of worth and value as a human being. Involves a
variety of beliefs about oneself and aids in appraising one’s character traits.
▪ Self-worth
▪ Confidence
• Body-image is a subjective perception one’s physical self and is accompanied by
emotions and thoughts around that perception.
• Self-schemas are an individualized collection of knowledge-based information about
oneself.
o Self-image is a collection of perceptions of one’s abilities, appearance, and
personality. It is influenced by other’s perception of oneself and the inkling of
how one would like to be seen oneself.
▪ Ideal self
▪ Social self
▪ Sexual self
▪ Past/present self
• Self-view is defined by various sources as the careful consideration and regard towards
one’s own interest.
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Handout 12
Self- Concept and Arousal
According to Basson (2002):
A positive self-view will result in a woman’s processing sexual stimuli into arousal and a
willingness to engage in further activities, which promotes more arousal. A negative self-view
more likely will result in hesitancy, conservatism, and perhaps embarrassment. These feedback
loops continue throughout the sexual experience, fine tuning not only the autonomic nervous
response but also the affect, cognition and mental excitement.(p. 23)
Figure 1. Feedback Loop 9
9 Figure 1. Feedback Loop reprinted from Basson, R. (2002). Women’s Sexual Desire--Disordered or Misunderstood? Journal of Sex & Marital Therapy, 28, 17–28. doi:10.1080/00926230252851168
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Session 5: Mind-Body Connectivity
Lesson Objectives
For this session, the check-in and discussion will occur together. The facilitator will need to process the homework assignment from session four, Examining the breast and vulva in a mirror. Processing the sexual shame that arise during this assignment is important to address deep rotted sexual shame.
Supplies Needed
• Name Tags
• Laptop and speaker
• Dry Eraser Board, Markers, and Eraser
• SUDs Sheet
• Handouts 13 – 15
• Treatment Evaluation Questionnaire – page 14 Before Conducting the Session
Mind-body connection is the idea that the what occurs in the mind such as thoughts, feelings, beliefs, and attitudes affect the body. Furthermore, thoughts and emotions affect brain activity, such as strengthening neural connections and releasing neurotransmitters (e.g. serotonin, dopamine, norepinephrine, etc.). In this session, the facilitator will structure questions around the somatic responses that accompany negative and aversive reactions towards examining the breast
72 and vulva. Then moving towards connecting the questions to thoughts, emotions, or environment. Check-In/ Discussion
60 Min. Here are some issues to discuss regarding masturbation and reactions to
masturbation.
• How is masturbation helpful (Handout 13)
• Aversion response to genitals (Handout 14)
• Disgust reactions
o To navigate a disgust reaction, the facilitator may want to
consider carefully their won reaction to not shame the group
members response. Explaining how disgust is an adaptive
response can give an opportunity to move into discussing
shame.
o Sample Narrative:
“Disgust is a primary emotion that kept our ancestors safe in
their environment, it is an adaptation skill to let us know the
difference between edible food and poisonous food. Disgust is
a response that exist and can also be developed. When disgust
happens, where in the body is it felt?”
o After discussing disgust, relate how disgust is often
accompanied by shame.
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o Example: when disgust happens, this is an indication that
shame is lurking around. What are your thoughts on this?
• Confused or discomfort when there is a physiological response
without sexual interest/ arousal
o Refer to the Fruit Bowl Imagery Exercise
o The importance of mental arousal and sexual motivation are
explored in session six, Knowledge is Power: understanding
sexual and emotional satisfaction.
Questions to explore further into responses or encourage discussion:
• I am wondering what feeling was present before the exercise was
done.
• When emotions are high in other situations, how have you coped?
• How did the body respond before ___ happened?
• I’m wondering what thoughts cross your mind during/before ___?
• Have these reactions occurred before? When, where, with whom?
Session Activity
The two following activities have been included to assist the facilitator in psychoeducating group members on body-mind connectivity. Based on the check-in/discussion, the facilitator will need to decide if how these activities will be personalized to the group members responses
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20 Min. Fruit Bowl Imagery Exercise (Handout 15)
This exercise can be used to explain automatic responses that are initiated by
thoughts and imagined events. This can be helpful when discussing aversion
to sex and genitals or sexual avoidance behavior
• Physiological responses occur even when people do not want the
response to happen. (example: tickling initiates laughter even when
we do not enjoy or want to be tickled.)
▪ Communicating with partners is key to build shame resilience.
How to talk about what feels good and what doesn’t will be
discussed in session nine
• When we want sensations to occur but have intrusive images/thoughts
such as past sexual experience or imagined negative response
(example: a partner comments to leave the shirt on sex, the words
keep replaying, or the person starts to think “I wish he like my body”)
25 Min. Fight, flight, Freeze Response to Shame
There are various ways people respond in shame filled experiences, in session
three and four group members explored deep rooted shame-filed experiences
and processed through them to understand underlying thoughts the maintain
sexual shame. The facilitator can refer to comments or stories shared by
group members to normalize women’s flight, freeze, fight responses. When
these come up in this session, it is important to be mindful not shame group
members reactions, instead ask therapeutic questions and normalize reactions.
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• Reactive or defensive responses can arise from feeling embarrassed or
fear of acknowledging one’s limitation. I am wondering if these
emotions were felt by any of you.
• It is intimidating looking at the vulva or touching one’s breast, in that
moment when you decided to stop, I am wondering where the reaction
stems from?
Cool-Down
15 Min Grounding Meditation - SUDs
https://www.theepicself.com/meditation/personal-growth/beginners-
grounding-guided-meditation-for-beginners/
Homework
Free writing – 10 minutes Free writing is used to process the discussion that occurred in session five. The facilitator may send out or hand out the Treatment Evaluation Questionnaire to gather feedback about group treatment. The Treatment Evaluation Questionnaire can be found under Treatment Evaluation on page 14.
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Handout 13
Masturbation a Form of Healthy Sex
Masturbation is common among women ages 18 to 39 (Herbenick et al., 2010). Masturbation can be a helpful tool to understand the function of various body-parts, learn about pleasure areas (i.e. erogenous zones) and the type stimulation that is enjoyed (Robinson et al., 2011). Mutual masturbation can also enhance mutual pleasure among couples and serves as an education tool in understanding each other’s body, pleasure responses, and boundaries (Kaestle & Allen, 2011).
Masturbation can enhance acceptance of these areas as ones ‘own, learn the mechanical purpose of the structure, and inform pleasurable stimulation.
Sexual Shame and Masturbation
Even though masturbation presents benefits for women’s mental health and couple’s relationship formation, it can be an intimidating and daunting occurrence. Masturbation can elicit feelings of shame such as being disgusted with oneself or feeling awkward due the unfamiliar feeling
(Kaestle & Allen, 2011). However, shame forces women to suppress sexual urges. As Kaestle and Allen (2011) state, “shame led many group members [in the study] to make concerted efforts to control their urges to masturbate” (p.) For example, women who enjoyed masturbation and experienced sexual shame limited the number of masturbations sessions and used secrecy and lying to hide masturbation (Kaestle & Allen, 2011). Women find themselves in a constant tug of war between shame and pleasure. These contradictory and conflicting feelings arise due to society stigmatizing masturbation. Cultural responses to masturbation influenced how women talk about masturbation. Kaestle and Allen (2011) discuss how they witnessed derisive humor, stereotypes, and humiliation within their study to discouraging masturbation and portraying it as
77 taboo. Although masturbation continues to be stigmatized, cultural views are shifting. According to Herbenick et al. (2010), women in the United States are engaging in a diverse range of solo and partnered sexual practices
Masturbation as a Tool to Treat FSIAD
Masturbation and fantasy are tools used in sex therapy to treat orgasmic and arousal/interest difficulties (Robinson, et al., 2011). Engaging women in a discussion about masturbation within group therapy helps them redefine what sex and masturbation mean, which is useful in the development of a healthy sexuality. For example, Robinson et al. (2011) writes about a woman who experienced orgasmic, sexual arousal/interest problems, and has a history of childhood sexual abuse. After undergoing treatment, the individual reported great improvement. She had learn to see other behaviors as sexual and intimate (e.g. holding hands and good communication), identify and pace sexual activity that is enjoyed, set boundaries on those that are not, learn about the type of partner whom she would like to develop a sexual and intimate relationship (e.g. slow, patient, playful, and willing to learn to be sexual together), learned to say no to others, and coming to an acceptance of a difficult reality in regard to the abuse. Overall, masturbation can be a helpful tool to address various sexuality issues.
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Handout 14
Aversive Response to Physical Stimulation of Genitalia
Negative Past Experiences/Abuse studies shown repetitive exposure to negative stimulation can affect arousal. Brom et al. (2015) found that women who were exposed to an erotic image that was paired with a painful electric stimulus experience decrease in physiological arousal to that erotic image. Brom et al. (2015) states that acquired likes and dislikes are hard to dissolve, but these negative conditioned responses can lessen by exploring the subjective reality of the person, altering the pairing with a positive stimulus. Women with history of sexual abuse have been shown to experience a female sexual dysfunction (Pulverman & Meston, 2019). Studies also show that resilience in women with history of sexual abuse is successful in cognitively enhancing emotional responses to aversive pictures compared to women with PTSD after sexual trauma and non-traumatized group members (Brom et al., 2015)
Disgust Reaction
Women show stronger sex-disgust association than men (Grauvogl et al., 2015). Having rigid beliefs that sex and sexual behavior is bad can lead to having a disgust reaction towards the sex and the vagina. According to De Jong et al. (2013) subjective moral trigger disgust reactions.
Meaning, women who have strong belief that sex is immoral, or the vagina is dirty, can have disgust reactions towards them. Having a Disgust reactions does guarantee that person will have a sexual arousal problem (Grauvogl et al., 2015) but disgust can interrupt the development of sexual pleasure and arousal, elicit avoidance of
79 sexual interaction, and trigger reflects sociomoral transgressions (De Jong et al., 2013).
Furthermore, if morals around sex are rigid, they enter a self-perpetuating cycle where disgust becomes a chronic response (De Jong et al., 2013).
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Handout 15
Fruit Bowl Imagery Exercise
This fruit bowl exercise10 is an imagery exercise used to explain how the automatic physiological responses can be set off by images, even when they are imagined, recalled, and unwanted.
1. Have group members imagine a fruit (e.g. mango, watermelon, strawberry, etc.) or any
yummy dish.
2. Describe the fruit or dish in detail by incorporating the senses. Describe texture, color,
flavor, smell, and temperature of the fruit/dish. Group members should salivate while the
image is described.
Sample Narrative:
• “Imagine that you are holding a mango in your hand. As you look at this mango you
notice the red, or yellow, color. You bring it close to your nose to smell the aroma. You
start peeling the mango from top to bottom, very slowly; or you may want to cut it into
four sections with a knife on a wood board. Pay attention to the sound of the peeling or
cutting, the mango juice that begins to drip down. You start to lick your fingers to get a
first impression of the flavor…sweet or perhaps bittersweet. You are finally ready to give
a first bite…MMMM… the flavor melts in your mouth. This can be the best mango you
have ever tried!”
• “Who salivated while imagining the mango?”
• “Something interesting that this exercise shows us is that our brain cannot easily
distinguish from images and reality. The brain saw a mango and sent signals around to
10 From Trujillo-Arevalo, A., (2011). Manualized cognitive-behavioral / narrative therapy treatment for children with depressive symptoms. [Culminating Project, California State university, Northridge]. CSUN Scholarworks. 81 other sections in the brain to produce saliva. Saliva is necessary for digestion; it helps break down nutrients and prevents choking.”
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Session 6: Focusing Attention Attitude
Lesson Objectives
Sensate focus has long been used in couples counseling, and with couples who experience a sexual dysfunction. Phase one of sensate focus often gets little show time because couples are more interested in regaining sexual function. However, in this curriculum much love and attention has gone into mimicking phase one of sensate focus. Group members have engaged in various mindfulness exercise, yet no session has dedicated time to break down the importance of mind-body connectivity. This session will focus on dismantling sexual shame through practicing focus attention attitude, a technique in sensate focus. In addition, the concept of sexual satisfaction versus emotional satisfaction will be introduced to challenge the idea of sexual functioning.
Supplies Needed
• Name Tags
• Handout 16
• Dry Eraser Board, Markers, and Eraser
• SUDs Sheet
Before Conducting the Session
Sensate focus is a sex therapy technique developed by Masters and Johnson. Sensate Focused is structured touching and suggestions that enable inner sexual discovery (Winer & Avery-Clark,
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2014) by refocusing a person’s attention on the present sensory perception rather than goal- oriented behavior (i.e. orgasm and penetration) and emotions. This conscious awareness effort is referred to focusing attention attitude. Winer and Avery-Clark (2014) explains sensation is a reliable measure while emotions or sexual arousal are unreliable forces and/or involuntary.
Check-In/ Discussion
For this session, the check-in and discussion will occur together.
The facilitator will need to prepare group members with the homework assignment for this session, Mindful masturbation. This session will teach focusing attention attitude as the first step to learning one’s own likes, pleasure, sexual and emotional satisfaction.
Session Topic
• Focusing Attention Attitude
• Mindful Touching
• Masturbation Session Activity
20 Min. Focusing attention attitude
Focusing attention attitude is a present-mind awareness used to relax the
automatic nervous system to allow a natural arousal and pleasure response
Here are some key points to discuss:
• Focusing attention attitude refers to conscious effort to redirect
attention to the present sensation rather than emotion and sexual
arousal.
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• Focusing attention attitude is a helpful skill in managing anxiety and
other interruptions that inhibit natural responses (Winer and Avery-
Clark, 2014)
• Natural response means pleasurable sensations subjective to
the person. It is not the physiological response (e.g.
lubrication, labia swelling, vaginal contractions, etc.) during
sexual stimulation.
• Sensation is a reliable measure, while emotions and physical arousal
are unreliable and/or involuntary.
• Example: just because the vagina produces lubrication during
sexual stimulation does not mean that stimulation is enjoyed,
this is an involuntary response, and unreliable in measuring
pleasure.
• To obtain pleasure is to redirect the voluntary attention of trying to
onto the sensation.
Sample Narrative
“Forcing a response to occur can be frustrating and discouraging. Instead of forcing pleasure to happen, focus on the touch. If it feels good to you, then you add that to the bucket of ‘feel good touches’ if the touch is meh or nah then move on to a different form of touch or another area.”
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25 Min. Mindful touching (Handout 16)
Mindful touching is to help group members sharpen their focusing attention
attitude. This is helpful in blocking off negative self-talk and redirect
attention to touch and pleasure awareness. These two will be important to be
familiar with to complete the homework assignment.
Sample Narrative
“This is an exercise that is not focused on sexual touch or increasing arousal.
It is, however, an exercise to increase pleasure awareness. Pleasure is
synonymous with enjoyment, preference, and satisfaction. Society often
associates pleasure to sexual acts, but nonsexual touch or other acts can be
equally enjoyed. We’re going to do an exercise to use focusing attention
attitude and pleasure”
Let’s talk!
Have group members discuss which touch was enjoyable, relaxing, or
amusing.
• What were there initial reaction to touch (e.g. ticklish, giggling,
discomfort, anxious, indifferent)
• Textures, sound, or scents observed when touching different areas of
their hand/arm?
• Which form of touch and on what part was the sensation most
enjoyable?
• Did they notice a shift in response when touch was enjoyed?
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45 Min. Masturbation (Handout 13 in session 5)
This handout is to help cover the discussion about masturbation with group
members. The handout covers the benefits to masturbation, normalizing
sexual shame when masturbating, and how it is a tool to treat FSIAD. The
facilitator and group may need to revisit the topic of masturbation even if it
was discussed in the previous session. The facilitator may expand the
discussion on masturbation to include talk about sex.
Here are some conversation starters:
• How was masturbation talked about in your household?
• When you hear the word masturbation what are your thoughts?
• Have any of you tried masturbation in the past? And if so, what was
your experience?
▪ In this question the facilitator will need to look out for social
influencers or past negative experiences around masturbation.
▪ Example: “I tried when I was younger, but I stopped because it
felt wrong, and after that I never tried again”
▪ The facilitator can ask: I am wondering what made
masturbation feel wrong? What told you that what you were
doing was wrong?
• The facilitator may want to refer to sexual shame and social
influencers that stigmatize masturbation.
15 Min. Sex Education on The Clitoris
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Education on sexual anatomy can be enlightening and intimidating for group members who are experiencing sexual shame around their current state of sexual satisfaction, but exposure to these discussions will move clients to higher awareness about themselves and their body.
Sample Narrative:
“Now that you all had opportunity to learn about the vulva I would like to focus on the clitoris. The reason we will be talking about the clitoris is to evaluate how society talks about the clitoris. I am wondering what you have heard about the clitoris?”
• Vaginal orgasms are depicted as the only form of orgasm a woman
can have. Clitoral orgasm is more common than vaginal orgasm.
• Results from a quantitative study conducted in Finland shows that of
10, 637 respondents, a “third of women (34%) reported that they
usually attained an orgasm via stimulating the clitoris” (Kontula &
Miettinen, 2016).
• Inner parts of the clitoris are involved during vaginal canal
stimulation, and external stimulation of the clitoris does not suggest
stimulation of internal clitoris parts (Buisson & Jannini, 2013).
• Suggested material to use to help explain the clitoris:
o Le Clitoris https://vimeo.com/222111805 - This video is in
French; subtitles will need to be turned on.
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Clitoris 3D models – This model demonstrates the size of the clitoris, and to
explain how it sits within the body. 3D models have been used by other
countries to enrich sex education. Using a model of the clitoris allows women
to have a mental image of what the clitoris looks like, helping them better
understand the sexual anatomy of their body.
Cool-Down
This meditation exercise is to enhance body awareness. Group members will need to lay in a comfortable space. This is helpful for group members to begin practicing attention focus attitude on sensations using their resting body.
15 Min. Body Awareness Meditation - SUDs
https://www.theepicself.com/meditation/personal-growth/body-awareness-
guided-meditation-for-beginners/
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Homework
Mindful Masturbation – Personal time frame set
Before moving onto masturbation, set aside 5-15 minutes to set an intimate setting. Create a warm and inviting space where you feel safe. For some this may be in their bedroom, lying in a comfortable position with candles lit and soft music in the background. While for others, it may be while sitting in a private home lounge. You will decide the setting in which you will feel most relaxed and safe. Prior or during this exercise you may not have the sexual interest or arousal, and that is okay. This is an exercise to practice mind-body connectivity and focusing attention attitude.
Key rules before masturbating:
• When masturbating I want you to focus on touch. Acknowledge anxiety thoughts such as
“am I doing this right,” “this is weird,” or “I can’t believe I am doing this right now.” If
such thoughts arise, refocus on touch
• Focus on pleasure rather than arousal or orgasm
Steps to start off a mindful masturbation session:
1. Start by setting a space that safe, comfortable, and relaxing. Bring in items or an
ambiance that you will enjoy. Music, aromas, or comfy sheets. As you are setting up,
give yourself enough time to explore you space.
2. When you are ready, get into a comfortable position, and allow your body to melt into its
surrounding. Remember the todays exercise is not about masturbation strategies to
achieve an orgasm, instead it is about learning about yourself and touch.
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3. Begin exploring your body, eliminate expectations and should, and instead focus on
sensations that are pleasurable. Just like the mindful touch exercise.
4. Move slow through the exploration, you will decide where you want to start. It may be
tempting to go straight into clitoral and vaginal stimulation, but this is about enjoying the
journey of pleasure.
5. Try different forms of touching on different areas of the body, in different erogenous
zones (like the breast, neck, navel, and thighs) and different parts of the vuvla (like the
labia, the clitoris, the vagina, the vaginal wall)
6. Focus on individual preferences. Notice if one touch feels good on a specific part of the
body/vuvla but not on another, try a different touch, strokes, pressure, and rhythms.
7. It may take some time to get into masturbation, and don’t worry about that. There is no
end goal, only gains. Just explore through masturbation to learn what makes you happy.
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Handout 16
Mindful Touching
Have group members touch different parts of their hand and arm (palm, fingertips, outside/inside arm, fold of the arm) and have them use various forms of touch (rubbing hand together, rubbing fingers, tracing, tapping, sweeping motion, using the fingernails) a few seconds on each part.
1. “We’re first going to start by taking three deep breaths in…you may close your eyes or keep
them open”
2. “Were going to be using different forms of touch on different parts of our arm. As we do this
exercise focus on the type of sensation you are experiencing. If that sensation feels nice,
make a mental note. If it does not try a different touch.”
3. “First let’s start with the forearm. I would like you all to use a stroking touch on the outside
of the forearm… you can use the full hand… or the fingertips …or the nails (15 seconds)
4. Now move onto the inside of the forearm. This time using a sweeping motion with the
finger… switch to a soft scratching motion… a soft fast tapping. Now squeeze different
sections of the inside of the forearm. You can add pressure… or slow down the squeezes (15
seconds)
5. Move up to the palm of the hand. Try softly making a circular motion with the fingertips…
how about tracing the lines on your palm… or scratching sensation with the nails. (15
seconds)
6. Now touch any part of the arm or hand using your fingertips, I want you to focus on the
sensation fingertips is picking up, the sensation can change by the texture or temperature of
the parts. (8 seconds)
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Session 7: Understanding Sexual and Emotional Satisfaction Lesson Objectives
Sexual motivation and mental sexual arousal concepts will be introduced in session seven to normalize the absence or lack of sexual arousal/interest. Psychoeducational information will focus on sexual response variability among women. Supplies Needed
• SUD’s Sheets
• Dry Eraser Board, Markers, and Eraser
• Handouts 17 -21 Before Conducting the Session
Read through sexual motivation and mental sexual arousal handout. The facilitator may need to seek out outside assistance and resources to grasp Basson’s ideology around sexual response, as these concepts are key to normalizing lack of sexual interest/arousal among women with FSIAD. Check-In/ Discussion
For this session, the check-in and discussion will occur together.
The facilitator will need to permit group members the time to process their reaction to session six homework assignment, Mindful masturbation.
Session Topic
• Intimacy-Based Sexual Response Model
• Sexual Motivation and Mental Sexual Arousal Model
• Sexual and Emotional Intimacy
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Session Activity
45 Min. Sharing Thoughts on Session 6 Homework – Mindful Masturbation
Discussion questions:
• Last week the assignment was mindfulness masturbation. I am
wondering how it went. How was it focusing your attention on
pleasurable touch rather than orgasm?
• When you were setting up your space, where there any persistent
thoughts or feelings occurring?
• Explore nervousness: where was that felt in the body, how did
it change motivation to start, coping to do the assignment
• Prior to/during mindful masturbation, was sexual shame trying to join
in?
• What were the triggers? and what was helpful to lessen shames
grip?
• What did group members gain from mindful masturbation?
• How can mindful masturbation sessions help build resilience in their
life?
20 Min. Expectation to Be Sexually Functioning
This exercise is done to explore the unrealistic expectations group members
hold and that affect mindful masturbation.
• Write out: What did I expect my body to do during masturbation?
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• After group members add to the board to answer the first question,
write: what does society expect my body to react during sex?
After the group is done adding to the board, engage group members to ponder
the overlap between the answers, and the differences.
• When women’s expectations are focused on not fitting into social
expectations to be sexually functioning address them.
• I noticed that what we wrote on this board is based on the idea
that our bodies are expected to sexually perform for others.
What are your thoughts?
• As read this board I am wondering if you notice a theme, or a
concept?
20 Min. Sexual satisfaction versus emotional satisfaction
After discussing how social expectations influence the idea of sexual
function, introduce the concept of sexual and emotional satisfaction to help
group members find realistic desires.
• If I say sexual satisfaction is important in a sexual relationship, what
does this mean to you?
o Redefining sex will occur in session 8.
• If I say emotional satisfaction is important in asexual relationship,
what does that mean?
• Various couples learn to have emotionally satisfying sexual
encounters, the goal is to increase emotional intimacy.
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o Couples who learn to focus on pleasurable and satisfying sex
will often focus on the emotional component – that is having
sex to increase intimacy with their partner and with
themselves.
20 Min Basson’s Intimacy-Based Response Model & Sexual Motivation and Mental
Sexual Arousal Model (Handout 18 - 20)
Psychoeducate on how sexual responses works, sexual motivators, and
variability among women. Please refer to handout for detailed information on
these models and concepts. Key terms (Handout 17)
Personal Distress and FSIAD (Handout 21)
Correlation between high distress and multitude of factors (e.g. societal
pressure, sexual experiences, partnership distress, and other facets of life) Cool-Down
Meditation exercise aims to process past emotions to allow group members to embrace newfound emotions. This is helpful for women experiencing FSIAD as they are processing the shift of sexual functioning into sexual and emotional satisfaction.
15 Min. Open Heart Meditation - SUDs
https://www.theepicself.com/meditation/stress-anxiety/heart-relaxation-
guided-meditation-for-beginners/
Homework
Inner Strength Journal entry – 20 minutes for each task
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1. write about an inner strength you possess that has helped call upon when sexual shame
comes in between you and an intimate interaction.
2. Implement this inner strength this week, and then write if this strength was helpful when
sexual shame came in during the new emotional or sexual situation.
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Handout 17
Session 6 Key Terms
Emotional Satisfaction: Emotional satisfaction is the satisfaction or contentment that arises from understanding one’s emotions and conveying emotions in an attuned conversation with another person.
Mental Arousal is subjective mental excitement that utilizes a state of mind within the desired context and stimulus. It employs attentive focus on the sensation that leads to stimulus appreciation and pleasure.
Motivational Force is a term used by Basson to describe how external elements affect mental arousal. These forces are easily influenced by positive and negative sexual experiences, and these experiences are also influenced by multiple internal (intrapersonal) and external
(interpersonal) factors (Basson, 2000).
Responsive Sexual Desire is a responsive state of mind to the expectation of increase intimacy that does not occur spontaneously (Basson, 2000).
Sexual Arousal can be a physiological (e.g. vaginal lubrication, erect nipples, change in breathing) and/or psychological (e.g. mental arousal) response (Flannery, n.d.).
Sexual Satisfaction: Sexual satisfaction refers to experiencing psychological sexual pleasure and emotional fulfilment.
Spontaneous Sexual Desire is an innate biological drive to seek sexual stimuli and facilitates arousal from those stimuli (Basson, 2002). Spontaneous sexual desire is not necessary to be sexually responsive and/or aroused, and not necessary to have pleasurable and fulfilling sex.
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Handout 18
Basson’s Intimacy-Based Sexual Response Model
Basson’s model depicts an interactive cycle between underlying motivators that activate sexual interest, arousal, and desire. Basson’s model incorporates the need for intimacy. It also acknowledges sexual interest/arousal can be responsive or spontaneous and can arise at any point of the cycle. When looking at Basson’s model one can understand there are many external factors that enhance sexual motivation and mental sexual arousal. This signaled that sexual desire and sexual arousal coincided with each other, were susceptible to variation among women, and are dependent on external and internal components. This information was revolutionary because professionals understood that all women do not respond to sexual stimuli the same way and go through a linear sexual response cycle.
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Handout 19
Optional: Clinicians may want to use this image to condense information on how sexual experiences, spontaneous sexual interest, and ability to sexually respond are interconnected and varies amongst women. Facilitators can use figure 2 as an example of how to illustrate Basson’s model of sexual motivation.
Figure 2. Basson’s Model of Sexual motivation11
11 Figure 2. Basson’s model of sexual motivation reprinted from Flannery, F. Z., (n.d.). Taking a closer look at Basson’s model of the sexual response cycle. Sexology International Blog. https://sexologyinternational.com/taking-a-closer-look-at-bassons-model- of-the-sexual-response-cycle/ 100
Handout 20
Sexual Motivation and Mental Sexual Arousal Models Basson’s integrates emotional and physical satisfaction into the cycle as a motivational force to
sexual motivation rather than depicting physiological response as the goal of sex. Basson
clarifies that physiological sexual responses do not reflect how women appreciate a sexual
stimulus or context and may not always reinforce sexual motivation. Rather the motivation to
seek sexual satisfaction lead to maintaining arousal and desire.
Figure 3. The motivational component of women’s desire12
12 Figure 3. The motivational component of women’s desire reprinted from Basson, R. (2000). The Female Sexual Response: A Different Model. Journal of Sex & Marital Therapy, 26(1), 51-65. doi:10.1080/009262300278641
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Handout 21
This image explains how various external factors influence mental sexual arousal, which affect
sexual motivation, sexual interest in FSIAD. Interpersonal issues (e.g. marital/partnership
problems, family problems, parenting issues, etc.), partner’s excitement, and physical response
can directly or indirectly influence mental arousal. Physiological arousal, however, does not
affect mental arousal, but mental arousal does influence physiological response.
Figure 4. A model of women’s sexual arousal13
13 Figure 4. A model of women’s sexual arousal reprinted from Basson, R. (2000). The Female Sexual Response: A Different Model. Journal of Sex & Marital Therapy, 26(1), 51-65. doi:10.1080/009262300278641
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Session 8: Redefining Sexuality and Sex
Lesson Objectives
This session will empower group members by redefining sex as a response of what is pleasurable to them. Participant will also learn about the intimacy-based sexual response model, allowing a conversation to redefine sexual response. Supplies Needed
• Name Tags
• Handout 22 and 23
• Dry Eraser Board, Markers, and Eraser
• SUDs sheet Before Conducting the Session
Eliminate the word foreplay when talking about sex. traditionally sex is split into two categories sex (intercourse) and foreplay; which insinuates that only intercourse is sex. This belief encourages sexual shame around intercourse and outercourse. Check-In
25 Min. Sharing Thoughts on Session 7 Journal Entry
Group members will be asking to share a thought on strengths helped them
tame sexual shame when a sexual or emotionally intimate situation presented
itself.
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Discussion
Session Topic
• Redefining Sex
Session Activity
15 Min. Use Quote to transition discussion to redefine sex and sexuality (Handout 22)
• As we read this quote what stood out for you?
15 Min. Normalizing Sex – Optional
Relevant disclosure of the facilitator’s experience navigating sexual shame
can normalize the difficulty and purpose of using critical awareness
continuum to sexually heal.
Sample Narrative:
“I noticed when I spoke about sex with others, I would use the word coitus,
making love, and fucking. It wasn’t until I had a stranger asked, ‘why don’t
you just say sex?’ At first, I was offended that he wanted to dictate how I
spoke about my body, but I later came to understand that this was shame. I
felt ashamed saying the word sex in public. So, I asked myself why? For the
first time I had to look at shame in the face and talked to it. It had been telling
me that sex is a dirty thing, it is a bad thing, and therefore needs to be covered
up with other words. in my mind a connection was made. Sex is bad, I am
having sex, so I am bad. I was internalizing this message unconsciously. But
sex is not bad, it is normal, pleasurable, and educational; and like any other
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act that involved our body and the body of others, we must practice
responsibility and safety.”
25 Min. Redefining Sexual Response
Engaging group members to share thoughts on the term sexual response will
open a conversation about group members belief on sexual responses and
how it arises in women.
• Write out the term sexual response on a board
• Example of participant response: “Sexual response is a
reaction to something that feels good” and “something women
are supposed to feel during sex or before it”
• Redefine sexual response: a result of what is subjectively sexually
enjoyed by a person.
• include orgasm, vaginal lubrication, moaning, toes curling,
palpitation or other traditional physiological responses
• It also includes somatic sensations - tingles, butterflies, feeling
warm
• Emotions/psychological - feeling love, appreciation, comfort,
safety
• Sexual response can be reached
o through physical touch - caressing, kissing, licking, etc.
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o Can be reached by a pleasurable sexual act - kiss, hug, holding
hands, massage, “flirting” playful teasing, bondage,
blindfolding, vibrators, household items, etc.
• It can be shown by acts of compassion, nurture, love, and care
25 Min Intimacy- Base Model (Handout 23)
This handout explains how intimacy need plays a role in obtaining sexual and
emotional intimacy. The facilitator can use handout 23 to assist with
discussing intimacy needs over physical gratification.
Separating sex into two categories, foreplay and sex, is a sexual shame strategy that
maintains the traditional view of sex (i.e. sex only includes penetration) and supports
heteronormative sex. Eliminating the term foreplay will allow group members to focus on
redefining sex and will restructure how members discuss sex. Below are bullet point
notes that the facilitator can bring up during the conversation and a narrative sample of
how such conversation can be introduced.
• Foreplay is everything that occurred from the last sexual experience to the
next.
o It is not only done before sex to create a physiological response or prepare
someone for penetration
o When sexual healing occurs, kissing, holding hands, skin-to-skin contact
without arousal and genital stimulation will be considered part of sex.
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• Foreplay reinforces heteronormative ideas about sex, an example is the idea that
lesbians cannot have sex because there is no penetration and gay men only have
sex until there is anal penetration.
Example Narrative
“Society often splits sex into two: foreplay and sex. Sex is seen to occur by means of only penetration. Reality is that a person can get great arousal from little stimulation, rather the reciprocal energy (intimacy) creates a pleasurable feeling that contributes to arousal, and sexual and emotional satisfaction. There is little to no need for physical stimulation and penetration. So, let’s review; (a) foreplay is everything that occurred between the last sexual experience to the next. This includes non-sexual acts and non-sexual behavior (b) sexual response is a result of subjective pleasure (c) sex are actions that contribute to sexual satisfaction, mental arousal, and emotional satisfaction (d) arousal varies from among women, include mental sexual arousal, and is influences by psychological and interpersonal factors.”
Cool-Down
This meditation increases body awareness to manage stress and fear which can be helpful for women who experience FSIAD. It teaches women to focus on relaxing the body rather than emotion.
15 Min. Mindfulness Meditation for Stress and Fear - SUDs
https://www.theepicself.com/meditation/fear/mindfulness-meditation-for-
stress-and-fear/
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Homework
Who was sexual shame then and who is it now? Journal Entry – 30 minutes
1. Recall a time when sexual shame started to develop and what/whom reinforced sexual
shame’s influence in your sexuality (e.g. sexual intimacy attempt, sexual thought,
sexuality question, etc.).
2. Now, think about how sexual shame may come up in the future.
3. How will you interact with it this time around? Has sexual shame change its appearance?
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Handout 22
“It is time we saw sex as the truly sacred art that it is. A deep meditation, a holy communion and a dance with the force of creation.” — MARCUS ALLEN
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Handout 23
Basson’s Intimacy-Based Sexual Response Model 2
This model was directly taken from Basson’s work around intimacy. According to
Basson (2000), women’s sexual response stems from intimacy needs rather than just physical sexual gratification, and sexual responses may be maintained through rewards and gains that are not strictly sexual. Thus, intimacy is a driving force for mental sexual arousal.
Figure 5. Alternative model of Female Sex Response Cycle. 14
14 Figure 5. Alternative model of Female Sex Response Cycle reprinted From Basson, R. (2001). Using a Different Model for Female Sexual Response to Address Women's Problematic Low Sexual Desire. Journal of Sex & Marital Therapy, 27(5), 395-403.
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Session 9: Speaking Up About Sexual Concerns
Lesson Objectives
Discussing sexual concerns with a partner can be difficult. This session will focus on providing tools to group members on how they can discuss their sexual concerns with a partner. Supplies Needed
• Name Tags
• Handout 24
• Dry Eraser Board, Markers, and Eraser
• SUDs Sheet Before the Conducting Session
Conducting couples works without the other partner present can present challenges, however, remembering that the person in front is sharing their own truth can help the facilitator focus on who is present. Before conducting this session, the facilitator can benefit from revisiting couples therapy approaches, such as Gottman therapy and emotionally focused therapy.
Here is a refresher on Gottman: https://www.gottman.com/blog/manage-conflict-the-six-skills/ Check-In
25 Min. Sharing thoughts on Session 8 Journal Entry
Explore the responses to the questions in journal entry.
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• Who is sexual shame and how did it look like at the beginning of
therapy?
• How would you like your interaction with sexual shame look like if in
the future it comes up?
• Has sexual shame changed its appearance in the now?
Discussion
Session Topic
• Navigating Sexual Issues with a Partner/ Partners
• Managing Conflict
Session Activity
45 Min. Navigating sexual issues with a partner
This section will provide group members tools to bring up sexual issues
• I am wondering if each of you has experience a disagreement with a
partner. How did you get through it? What happen to the relationship
after?
o If group members used communication to get through a
disagreement, ask further clarification on the interaction.
▪ what occurs to them when their partner is expressing their
concern?
▪ How does the partner react to their response or when the
group members are expressing their concern?
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o If partners ignore each other (i.e. stonewall) ask further
information about the group members assumptions and
perspective, and the after effect on the couple.
▪ It sounds like it is hard on you when your partner shuts
down. I am wondering when that happens what are the
thoughts that come up?
▪ It sounds like you are trying to make sense of the
situation when you shut down, I am wondering how do
you both end up resolving the situation?
• Stone walling can be a coping mechanism when emotionally
overwhelmed. Stepping to the side to process disagreements and
discussion are healthy, but it can be assumed as indifference and
personalized, such as “he/she doesn’t care about me.” Here is a
resource to read more on stone walling:
https://www.betterhelp.com/advice/relations/stonewalling-ways-to-
deal-with-it/
30 Min. Managing conflict
The facilitator may need to normalize disagreement, and then normalize
disagreements about sex. Normalizing can be a way to reassure group
members that they are not alone in feeling embarrassed, ashamed, and fearful
about the reactions they will receive when talking about sex to their partner,
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Sample Narrative:
“Disagreement is normal, all couples do it and can get through it by using listening and communication skills. Disagreement is healthy for relationship growth. People don’t stay the same throughout their lifetime, and we should not expect them to, this also means relationships need to change, to adjust to the people within it. It is okay to have disagreements about sex as well.
Couples who talk about sex openly tend to be emotionally and sexually satisfied. What are your thoughts on that?”
• What are your thoughts on why couples choose to stay in sexually and
emotionally unsatisfying relationships?
o Often couples avoid conflict
▪ ward off feeling negative emotions (vulnerability)
▪ fear it will damage the relationship and placing value
on the relationship over their own wellness.
▪ hurting their partners feelings and would rather keep it
to themselves.
• Shame playing a role in bringing up a discussion with their partner
o There is vulnerability that comes with opening-up about sexual
concerns. Shame can deter someone from talking about sex,
especially if both partners hold rigid beliefs around sex
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Using Gottman six skills of conflict management can help prepare group
members on starting up conversations:
https://www.gottman.com/blog/manage-conflict-the-six-skills/
Cool-Down
This meditation exercise will be done in pairs. This is an exercise that promotes mindful conversation between partners. By learning this technique group members will learn a different way of to communicate challenges with their partner.
15 Min. A 10-Minute Meditation on Love Connection- SUDs
https://www.mindful.org/a-10-minute-meditation-love-practice/
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Diversity Considerations There is more research interest on LGBTQ couples, thus improving the quality of therapy services mental health clinicians provide. Although there is a long way to go in diversifying results and studies in sex therapy, the little information within the field of research can help facilitate conversations about sexual concerns among LGBTQ couples. A current study on same- sex and different-sex marriages shows that marital strain is linked to psychological distress in both same-sex and different-sex relationships, however women in different-sex marriages are more reactive to marital strain than women of same-sex marriages (Garcia & Umberson, 2019).
Garcia and Umberson (2019) states this result can be that “same-sex couples are more egalitarian, engage in fluid gender dynamics and script, and emphasize power disparities less than different-sex couples” (p.1265). Which indicate that LGBTQ couples engage in healthier conversations compared to heterosexual couples. However, marital strain and sexual difficulties do occur among LGBTQ couples, and mental health clinicians and researcher should continue to expand and diversify findings.
Lesbian couples
Researchers have gathered that lesbian women practice sexual desire alignment and accurate perception of partner’s sexual preferences and responses (Paine et al., 2018).
Furthermore, lesbian couples place emphasis on emotional congruence, intimacy, equality, and derive pleasure from tender and sensual activities (e.g. kissing, hugging, and caressing) (Paine et al., 2018). research reveals that lesbian women draw from marital norms when sexual changes occur dues to age. In other words, sex decreases with age in order to manage distress (De Jong &
Reis, 2015). According to Hall (2001) lesbian couples tend to work cooperatively to overcome obstacles that impede progress in their relationship and are open to seek out therapy to work
116 through psychological aspects. Hall (2001) advices that metal health clinicians working with lesbian couples on sexual concern focus on forging new accounts (e.g. updated versions of their love story in which they explore what it means to be a normal, healthy, loving, partner) rather than focusing on the sexual problems. Furthermore, Hall (2001) suggest “facilitators need to be conversant with the traditional stories many lesbian partners use to certify their togetherness”
(p.282). Thus, facilitators using this curriculum to address sexual shame and FSIAD issue among young-adult lesbian women ought to seek resources that will inform treatment on how to discuss sexual issues with their partner.
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Session 10: Reflecting on The Re-Self-Discovery Journey Lesson Objectives
This session will serve as reflection of the overall therapeutic journey. Group members are encouraged to share gains and what they will continue to work on as well as the Clinician summarizing and highlighting main points during the discussion section. Then, group members will be asked to fill out a three-question survey to gather information on ways to improve the group. Clinician will check on unresolved issues and offer additional support. Supplies Needed
• Name Tags
• Paper and Pencils
• Female Sexual Distress Scale – handout 3 of session one
• Treatment Evaluation Questionnaire – page 14
• Handout 24
• SUDs Sheet Check-In
20 Min. Check-in will include a going over past breathing exercise and SUD’s
As discussed in the meet and greet, session1, group members have been
tracking their SUDs to cool-down exercises. This is informative to the
facilitator and the client to understand what exercise work best to alleviate
distress levels.
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20 Min. Administer the Female Sexual Distress Scale (Handout 3 of session 1)
On the last session of group therapy, group members will need to fill out
another FSDS to obtain a measure for sexual distress and compare results to
the baseline measure gathered in session one.
15 Min. Treatment Evaluation
This can be mailed to group members to acquire information about how
effective treatment was in decreasing sexual shame to increase sexual and
emotional satisfaction.
Additional support for unresolved issues
This will include local couples or family therapy within the members
residence, unless otherwise specified by the group member.
Here are some national resources to include:
1-800-799-7233 National Domestic Violence Hotline
1-800-273-8255 National Suicide Prevention Lifeline
1-800-662- HELP SAMSAH National Helpline
Discussion final session will include assessing gains of this curriculum, feedback, administering assessment tool and conducting a farewell exercise.
The facilitator may handout the Treatment Evaluation Questionnaire to gather feedback about group treatment. The Treatment Evaluation Questionnaire can be found under Treatment Evaluation on page 14.
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Session Activity
45 Min. Good and Evil compassion exercise (Handout 25)
This exercise calls forth shame filled sentences such as “I am always
criticizing others; I am a terrible person” and group members empowered
each other by repeating compassionate sentences. This is a symbol of support
within the group of people and compassion within oneself.
Congratulations party!
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Handout 24
Good and Evil, a Compassion Exercise15
1. participant take six strips of paper each. Write three Negative Messages or beliefs on
three of the paper strips; i.e. You're dumb, you're ugly, etc. Write three Powerful,
Positive Responses to the messages on the other three paper strips; i.e. I have confidence
in my abilities. I'm proud of the way I look.
2. Form two rows of three standing opposite each other. Let group members choose if they
want to be in the "Good" row or the "Evil" row. A participant gives one of his Negative
Messages to each person in the "Evil" row. He gives the corresponding Powerful,
Positive Response paper to the person in the "Good" row that is facing the "Evil"
side. The participant stands between the first pair as they read the messages on the sheets
and try to influence the participant using ad lib sentences. The "Evil" person extends her
arm out to block the participant from passing.
3. Example - Evil: "You're really dumb. You are always so slow. Why don't you ever
understand anything?" Good: "I'm proud of my abilities. I may not be perfect, but I'm
exactly who I need to be." Participant listens to the two sides and finally chooses the
"Good" side by repeating the Powerful Positive Response and pushing past the "Evil"
person's arm block. Participant repeats process with next pair until finished with all three
pairs. Repeat for each person.
15 McNiff, S. (n.d.). Group activities. Expressive therapist. http://www.expressivetherapist.com/group-activities.html 121
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