Relationship Counselor and Clinical Sexologist Dr. Martha Tara Lee of Eros Coaching spoke on "Dealing with Female Sexuality" at the Malaysian International Scientific Congress of O&G (MISCOF 2018) on 29 July 2018 at Kuala Lumpur, Malaysia. bout Dr. Martha Tara Lee Dr. Martha Tara Lee is Relationship Counselor and Clinical Sexologist of Eros Coaching. She is a certified sexuality educator with AASECT (American Association of Sexuality Educators, Counselors, and Therapists) as well as certified sexologist with ACS (American College of Sexologists). Martha holds a Doctorate in Human Sexuality, Masters in Counseling, Certificates in Sex Therapy, Practical Counselling and Life Coaching, as well as two other degrees. She was recognised as one of ‘Top 50 Inspiring Women under 40′ by Her World Singapore in July 2010 and ‘Top 100 Inspiring Women by CozyCot Singapore in March 2011. Subscribe so you don't miss a thing! http://www.ErosCoaching.com Social media links https://www.facebook.com/eroscoaching https://twitter.com/drmarthalee https://www.linkedin.com/in/leemartha Programs Ready Get Sex Go http://www.eroscoaching.com/rgsg Sex Jumpstart http://www.eroscoaching.com/sex-jumpstart Tongue Twisters http://www.eroscoaching.com/tongue-twisters Sex Possible http://www.eroscoaching.com/sex-possible Clean and Clear http://www.eroscoaching.com/clean-and-clear Books Orgasmic Yoga: Masturbation, Meditation and Everything In-Between https://www.amazon.com/Orgasmic-Yoga-Masturbation-Meditation-Between/dp/1515118193 Love, Sex and Everything In Between https://www.amazon.com/Love-Sex-Everything-Between-Martha/dp/9814484199/ref=reg_hu-rd_add_1_dp From Princess to Queen http://www.eroscoaching.com/queen

1. Dealing with
Female Sexuality
Malaysian International Scientific
Congress of O&G (MISCOG 2018)
26-29 July 2018
Kuala Lumpur, Malaysia

2. DR. MARTHA TARA LEE
Relationship Counselor & Clinical Sexologist
• Doctorate in Human Sexuality
• Masters in Counselling
• Masters in Public Policy and
Management
• Bachelor of Arts (Comm)
• Cert in Sex Therapy
• Cert in Practical Counselling
• Cert in Life Coaching

3. • The need to talk about sex
• Sexuality Models
• Sexual Dysfunctions
• What can help
AGENDA

4. • Personal embarrassment
• Lack of knowledge re: clinical relevance
• Ignorance re: who, when, how, or what
to ask
• Concern re: not knowing how to answer
questions
• Concern re: becoming
aroused/uncomfortable
• Concern re: appearing
seductive/intrusive
• Uncertainty about legal issues
• Time constraints
WE DON’T ASK
BECAUSE OF…

5. Why Do Medical and Mental Health
Care Professionals Need to
Understand Sexual Problems?
Sexual problems have
an adverse effect on
interpersonal
relationships and the
quality of life.

6. Nicolosi A et al. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual
attitudes and behaviors. Urology 2004;64:991-997.
SEX IS IMPORTANT TO PATIENTS
In a survey of over
27,500 people in 29
countries, the majority
of male (83%) and
female (63%)
respondents described
sex as “extremely”,
“very”, or “moderately”
important in their lives.

7. 1. What qualities and behaviors do health
care professionals consider in determining
sexual health?
2. How do we support patients in identifying
their sexual needs and aspirations?
3. How do our personal beliefs and
experiences inform or interfere with this
aspect of our work?
VALUES

8. SEXUAL RESPONSE CYCLE

9. FACTORS MODULATING SEXUAL
FUNCTIONING

10. • Hypoactive Sexual Desire
Disorder
• Sexual Arousal Disorder
• Sexual Aversion Disorder
• Female Orgasm Disorder
• Sexual Pain Disorder
▪ Dyspareunia
▪ Vaginismus
Female sexual
interest/ arousal
disorder
Genito-pelvic
pain/penetration
disorder
DSM-5 FEMALE SEXUAL
DYSFUNCTIONS

11. Frigidity
Inhibited Sexual Desire Disorder -
DSM-3
Hypoactive sexual desire disorder
- DSM-3-R
Female sexual interest/ arousal
disorder - DSM-5
A NAME IS JUST A
NAME?

12. Causes of Female Sexual Dysfunction
Desire:
Psychological factors
Emotional or physical distress
Menopause, decreased hormone levels
Medications (including antidepressants and anxiolytics, antihypertensive agents)
Arousal:
Psychological factors
Trauma or surgery
Medication (including antidepressants and anxiolytics, antihypertensive agents)
Orgasm:
Emotional or sexual abuse
Decreased hormone levels
Trauma or surgery
Medications (including amphetamines, antipsychotics, antidepressants and
anxiolytics, antihypertensive agents)
Sexual Pain:
Psychological factors
Infection
Endometriosis
Medications that cause decreased vaginal lubrication

13. • Sexual dysfunctions (except substance-/medication-induced
sexual dysfunction) now
– Require a duration of approximately 6 months
– More exact severity criteria
• Subtypes for all disorders include only
– “Lifelong vs. acquired” and
– “Generalized vs. situational”
• Two subtypes were deleted:
– “Sexual dysfunction due to general medical condition” and
– “Due to psychological versus combined factors”
MORE ON DSM-5

14. Masters level clinicians, Psychologists and Medical
professionals, academics, Physical Therapists,
hypnotherapists etc all provide sexuality-related services
Requires these characteristics:
• Self-knowledge
• Professional judgment
• Ability to monitor and manage own reactions
• Willingness to research new perspectives, practices
and identities
MULTI-DISCIPLINARY FIELD

15. • Background information
• Chief Complaint
• History of Chief Complaint
• Sexual Status
• Masturbatory Status
• Medical Assessment
• Psychiatric Assessment
• Sexual History
• Family History
• History of Relationships
• Current Relationship
• Summary and Feedback
EVALUATION OF
SEXUAL DISORDER

16. • The immediate cause of desire
disorders manifest in the
patient’s avoidance of sexual
feelings, sexual thoughts and
fantasies.
• Does not initiate sexual activity.
• Not responsive to partner’s
initiation of sexual activities.
SEXUAL DYSFUNCTIONS
Female sexual interest/arousal disorder

17. Five factors must be considered during assessment and
diagnosis of female sexual interest/arousal disorder given that
they may be relevant to etiology and/or treatment:
1) Partner factors e.g. partner’s sexual problems, partner’s
health status;
2) Relationship factors e.g. poor communication, discrepancies
in desire for sexual activity;
3) Individual vulnerability factors e.g., poor body image,
history of sexual or emotional abuse), psychiatric comorbidity
(e.g. depression, anxiety), or stressors (e.g., job loss,
bereavement;
4) Cultural/religious factors e.g. inhibitions related to
prohibitions against sexual activity; attitudes toward sexuality;
and
5) Medical factors relevant to prognosis, course, or treatment.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), American Psychiatric
Association

18. Reported prevalence rates for female orgasmic problems
in women vary widely, from 10% to 42%, depending on
multiple factors (e.g., age, culture, duration, and severity of
symptoms) (Graham 2010); however, these estimates do
not take into account the presence of distress.
Only a proportion of women experiencing orgasm
difficulties also report associated distress (Oberg et al.
2004). Variation in how symptoms are assessed (e.g., the
duration of symptoms and the recall period) also influence
prevalence rates (Mercer et al. 2003).
Approximately 10% of women do not experience orgasm
throughout their lifetime e(Laumann et al. 1994).
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), American Psychiatric
Association

19. • Distraction
• Performance anxiety
• Negative sexual beliefs or
misconceptions
• Ignorance about genital
sensitivity/poor technique
• Anxiety about “letting go” – need
to control
• Lack of trust, feelings of safety
• High religiosity negatively
correlated with orgasm; high
education positively correlated
with orgasm.
FACTORS ASSOCIATED WITH
ORGASMIC PROBLEMS

20. • History of Sexual Abuse/Trauma
• Early abandonment by an important male figure
(Fisher, 1973)
• Current relationship dissatisfaction (Mah & Binik,
2001)
• Partner’s lack of understanding of woman’s sexual
preferences and need for particular kind of
stimulation
• Partner’s dysfunction – Premature ejaculation,
Erectile dysfunction
FACTORS ASSOCIATED WITH
ORGASMIC PROBLEMS

21. 1. Clitoral
2. Vaginal
3. G-spot
4. AFE-spot (Anterior fornix
erogenous zone Dr. Chua Chee
Ann)
5. Cervical
6. Nipple
7. Anal orgasm
8. Blended
9. Ejaculatory
10. Multiple
TYPES OF ORGASMS

23. 9% did not have orgasms during
intercourse
Herbenick, D., Fu, T. (., Arter, J., Sanders, S. A., & Dodge, B. (2017). Women's Experiences With
Genital Touching, Sexual Pleasure, and Orgasm: Results From a U.S. Probability Sample of Women
Ages 18 to 94. Journal of Sex & Marital Therapy, 44(2), 201-212. doi:10.1080/0092623x.2017.1346530
18.4% of women reported that vaginal
penetration lone was sufficient for
orgasm
36% indicated that, while clitoral
stimulation was not needed during
intercourse, orgasms were enhanced
36.6% reported clitoral stimulation was
needed for orgasm during intercourse

24. SEXUAL FUNCTION ASSESMENT
TOOLS FOR CLINICIANS
1. Relationship Assessment Scale https://goo.gl/fJhFmH
2. Female Sexual Function Index https://goo.gl/vgf7Wv
3. Female Sexual Distress Score – Revised https://goo.gl/jWqqY2
4. PISQ-12 - New Patient Pelvic Organ Prolapse/Urinary
Incontinence Sexual Function Questionnaire
https://goo.gl/DZ3s5N
5. PISQ-31 - A New Instrument to Measure Sexual Function in
Women with Urinary Incontinence or Pelvic Organ Prolapse
https://goo.gl/2VrkRC

25. Sex is
painful for
1 in 10
women
The study also found
that among the 1,708
women who surveyed
as not sexual active,
over two per cent said
they avoided sex
altogether because
they found the act
painful or were afraid
of feeling pain.
Mitchell, K., Geary, R., Graham, C., Datta, J., Wellings, K., Sonnenberg, P., … Mercer, C. (2017).
Painful sex (dyspareunia) in women: prevalence and associated factors in a British population
probability survey. BJOG: An International Journal of Obstetrics & Gynaecology, 124(11), 1689-
1697. doi:10.1111/1471-0528.14518

26. The population
prevalence is
estimated to vary from
3 to 18% globally, 2
and lifetime estimates
range from 10 to 28%
Painful sex was
reported by 7.5% of
sexually active women,
of whom one‐quarter
experienced symptoms
very often or always,
for ≥6 months, and
causing distress.
Mitchell, K., Geary, R., Graham, C., Datta, J., Wellings, K., Sonnenberg, P., …
Mercer, C. (2017). Painful sex (dyspareunia) in women: prevalence and associated
factors in a British population probability survey. BJOG: An International Journal of
Obstetrics & Gynaecology, 124(11), 1689-1697. doi:10.1111/1471-0528.14518

27. About 5-47% of the
population suffer
from vaginismus
and it is not race-
specific.
Nusbaum MR, Gamble G, Skinner B. et al. The high prevalence of
sexual concerns among women seeking routine gynecological care. J
Fam Pract. 2000;49(3):229–32
In Malaysia, the
prevalence of sexual
pain disorder is more
than 60% among
patients in primary care.
Sidi, H., Puteh, S.E., Abdullah, N., & Midin, M. (2007). ORIGINAL
RESEARCH—EPIDEMIOLOGY: The Prevalence of Sexual Dysfunction
and Potential Risk Factors That May Impair Sexual Function in
Malaysian Women. The Journal of Sexual Medicine, 4(2), 311-321.
doi:10.1111/j.1743-6109.2006.00319.x

28. Research findings in Iran
showed that the most
common sexual
dysfunction (in infertility
treatment) was orgasmic
disorder (83.76%) and
the rate of sexual desire
disorder, dyspareunia and
vaginismus were 80.7%,
67.7% and 76.7%
respectively.
More than 50%
of cases
reported
decreased
frequency of
coitus after
diagnosis of
infertility.
Tayebi, N., & Ardakani, S. (2009). Incidence and Prevalence of the Sexual Dysfunctions in Infertile
Women. European Journal of General Medicine, 6(2), 74-77. doi:10.29333/ejgm/82644

29. 1. Kegels
2. Intention - Heart-genital
connection
3. Movement - Pelvic lift/ tilt
4. Breath
5. Sound
6. Fantasy
7. Sensate Focus
USEFUL PRACTICES

30. • Frequency
• Duration
• Intensity
KEGEL EXERCISE

31. Stage 1
–Without genital touch
Stage 2
–With genital touch
Stage 3
–Go with the flow
SENSATE FOCUS

32. The treatment of vaginismus is designed to
extinguish the conditioned spasm of the
muscles surrounding the vagina by
means of systematic in vivo
desensitization
(gradual dilation of the spastic introitus).
OBJECTIVE OF VAGINISMUS
TREATMENT

33. Systematic desensitisation methods have produced
success rates of 90-95%.
Vaginismus is thought to be more prevalent in
younger women, women with negative attitudes
towards sex and those with a history of sexual abuse
or trauma.
Jeng, C., Wang, L., Chou, C., Shen, J., & Tzeng, C. (2006). Management and Outcome of Primary Vaginismus. Journal of Sex &
Marital Therapy, 32(5), 379-387. doi:10.1080/00926230600835189

34. • Mid 20s – 30s
• Virgins/ “Good girls”
• Had 1 or 2 boyfriends
• Sex not talked about at home/ with
friends
• Lack of sex education
• Religion/ Strict upbringing
• Not comfortable with her body
• May also have never masturbated/
had orgasm
GENERAL PROFILE

35. • Psychotherapy
– Including Couples Therapy
• Hypnotherapy
• Behavioral Therapy
– Systematic Desensitization
– Systematic Vaginal Dilation
• Somatic/ Body-based work
VAGINISMUS TREATMENTS

36. • Session 1: Overview + Kegels
• Session 2: Three More Exercises
• Session 3: Sex Education
• Session 4: Sexual communication
MARTHA’S TREATMENT

37. Session 1:
• Fear of penetration
• Slow progressive steps
• Lemon/ Lime - feeling in
vagina
• Vagina most sensitive
at 1st 1/3
MESSAGE

38. LINK BETWEEN PAIN VS. PLEASURE

39. LINK BETWEEN PLAY VS. PRACTICE
SESSIONS

40. V + P = PV
BREAKING SEX DOWN

41. THREE CYCLES OF AROUSAL

42. Session 2: Getting in
touch with your body
• Anal breathing
• Bridge (Angle of
vagina)
• Heart-vulva
connection
• Sexual positions
MESSAGE

43. Session 3: Sex ed slides
• Sex is great, fun,
wonderful
• We are made for sex/
pleasure
Session 4: Sexual Communication
• Importance of Communication
• Giving, Receiving, Absorbing,
Allowing
• Giving/ Receiving Feedback
MESSAGE

44. TO UNDERSTAND WHAT IS SEX

47. • Code Words
– Red, Yellow, Green
• Open Ended Questions
• Closed Ended Questions
• Scale 1 to 10
COMMUNICATION

48. • Enjoying being close
to each other
• Touching and
stroking
• Kissing
• Massaging
• Talking
• Holding hands
FOCUS ON SHOWING YOUR FEELINGS FOR
ONE ANOTHER IN OTHER WAYS BY

49. https://sexualityresources.com/sites/default/files/documents/VR%20pamphlet%2017.pdf

50. 1. Moisturize and massage your genital tissues.
2. Maintain pelvic floor strength.
3. Take sexual ownership.
4. Regularly schedule orgasms.
5. Make more time for sex.
6. Expand the ways of having sex.
7. Get professional help
MORE TIPS FOR WOMEN

51. 1. Sex Is Bigger Than Any Body Part
2. Even If You’re Afraid To Ask — Ask
3. Don’t Wait, Act Now
4. You Are Not Alone
5. Don’t Give Up
TAKEAWAYS

52. We need:
Self knowledge
Facts
Options
Techniques
Honesty

53. Mitchell, K., Geary, R., Graham, C., Datta, J., Wellings, K., Sonnenberg, P., … Mercer, C. (2017). Painful sex (dyspareunia) in women:
prevalence and associated factors in a British population probability survey. BJOG: An International Journal of Obstetrics &
Gynaecology, 124(11), 1689-1697. doi:10.1111/1471-0528.14518
Nicolosi A et al. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology
2004;64:991-997.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), American Psychiatric Association
Herbenick, D., Fu, T. (., Arter, J., Sanders, S. A., & Dodge, B. (2017). Women's Experiences With Genital Touching, Sexual Pleasure, and
Orgasm: Results From a U.S. Probability Sample of Women Ages 18 to 94. Journal of Sex & Marital Therapy, 44(2), 201-212.
doi:10.1080/0092623x.2017.1346530
27-question survey to 1,053 people (Jan 10, 2010 - Nov 12, 2011) sponsored by Loveology University
Nusbaum MR, Gamble G, Skinner B. et al. The high prevalence of sexual concerns among women seeking routine gynecological care. J
Fam Pract. 2000;49(3):229–32
Sidi, H., Puteh, S.E., Abdullah, N., & Midin, M. (2007). ORIGINAL RESEARCH—EPIDEMIOLOGY: The Prevalence of Sexual Dysfunction
and Potential Risk Factors That May Impair Sexual Function in Malaysian Women. The Journal of Sexual Medicine, 4(2), 311-321.
doi:10.1111/j.1743-6109.2006.00319.x
Tayebi, N., & Ardakani, S. (2009). Incidence and Prevalence of the Sexual Dysfunctions in Infertile Women. European Journal of General
Medicine, 6(2), 74-77. doi:10.29333/ejgm/82644
Jeng, C., Wang, L., Chou, C., Shen, J., & Tzeng, C. (2006). Management and Outcome of Primary Vaginismus. Journal of Sex & Marital Therapy, 32(5),
379-387. doi:10.1080/00926230600835189
Website:
Anterior fornix erogenous zone. (2018, May 3). Retrieved from https://en.wikipedia.org/wiki/Anterior_fornix_erogenous_zone
The Most Important Sexual Statistic. (2009, March 16). Retrieved from https://www.psychologytoday.com/us/blog/all-about-sex/200903/the-most-
important-sexual-statistic
Vaginal Renewal Program. Retrieved from https://sexualityresources.com/sites/default/files/documents/VR%20pamphlet%2017.pdf/ accessed date (July
7, 2018)
Bibliography

54. Thank you!
Dr. Martha Tara Lee, D.H.S.
Clinical Sexologist
Eros Coaching Pte Ltd
Website: www.eroscoaching.com
Email: drmarthalee@eroscoaching.com