Sexual Performance Anxiety: A New Model (SPA) and CLINICAL Approach (SPA-R)

We all know Sexual Performance Anxiety is a frequent flyer in our clinical rooms. Clients bring it up, and we recognize its impact, but how often do we feel we have a truly comprehensive, actionable framework to address it head-on beyond general anxiety management? While it is strongly linked to sexual dysfunctions, a detailed conceptualization that directly informs how we treat it has often felt lacking.

That’s why I was excited to read a recent paper by David L. Rowland and Paraskevi-Sofia Kirana titled A Theoretical Model for sexual performance anxiety (SPA) and a Clinical Approach for Its Remediation (SPA-R).

What Does the Paper Offer?

1. A Theoretical Model for Sexual Performance Anxiety (SPA) Figure 1:They lay the groundwork by explaining anxiety as a construct, briefly touching on general anxiety/performance models, and then presenting their specific theoretical model for Sexual Performance Anxiety. This model serves as a heuristic, helping us understand the nuances of SPA and the factors mediating and moderating it in sexual situations. The reader is guided through the model with the help of figures that progressively build the framework for better comprehension.
2. A Clinical Approach for Remediation (SPA-R) Figure 2:This is where it gets really practical for us. Directly tied to their theoretical model, they outline a structured 4-phase framework designed for clinical use:
   • Phase 1: Creating a Foundation.This phase focuses on essential client education about anxiety (as a normal emotion), the non-voluntary nature of sexual function, and distinguishing helpful vs. unhelpful coping strategies. This phase also builds the groundwork for trust and understanding.
   • Phase 2: Strategic Mapping.This involves collaboratively exploring and mapping the client’s unique experience with SPA – identifying specific triggers, cognitive appraisals, emotional responses, and behavioural patterns in past/current sexual interactions.
   • Phase 3: Reconstructing the Sexual Experience.Clients begin actively planning and selecting specific coping strategies to manage SPA in real-life situations, moving towards a concrete plan of action.
   • Phase 4: Active Coping in Real-Life Situations.The “training” phase. Clients engage in exposure to anxiety-provoking intimate situations (ideally starting small) while actively using their planned strategies. This phase heavily involves review, reappraisal, embracing acceptance, fostering connection, and gradually moving from conscious control towards more automatic, engaged sexual experiences.

Why Should You Consider Reading This? Key Clinical Takeaways:

The SPA-R approach emphasizes several principles that many of us will find align with effective therapy but structures them specifically based on the SPA model:

• Active Coping:Empowers clients, building on their initiative in seeking help.
• Integrative:Synthesizes effective elements from behavioral, cognitive, attentional, and emotional approaches (and acknowledges pharmacological adjuncts).
• Balanced Focus:Gives equal weight to preparing before a sexual situation (antecedent-focused: education, mapping, reconstructing) and managing during the situation (response-focused: real-life application).
• Acceptance is Key:Stresses acknowledging and accepting emotional discomfort without needing absolute certainty of performance, shifting goals from performance to experience.
• Flexibility:Adaptable for both solo clients and partnered clients (partner involvement is optional, not required). It also respects couple autonomy, avoiding rigid prescriptions like traditional sensate focus, allowing couples to integrate strategies into their existing practices.
• Realistic Expectations:Discusses treatment length (potentially 4-6 biweekly sessions in positive cases, aligning with ~10 for general CBT) and highlights the crucial goal-setting discussion: Are we restoring function, remediating anxiety, or both? It significantly distinguishes between seeking certainty (e.g., via PDE5i) and building safety/security despite uncertainty.

A Stimulus for Our Practice

For clinicians seeking a structured, theoretically grounded, yet flexible approach to help clients navigate the complexities of sexual performance anxiety, this paper offers a valuable roadmap providing concrete steps and principles that can enrich our clinical toolkit.

The authors thoughtfully present their model and approach not as the definitive answer but as a well-reasoned framework intended to stimulate critique, discussion, and further research on this vital topic.

I encourage you to look up Rowland and Kirana’s full paper (it’s open-access) to explore the SPA model and the SPA-R clinical approach in greater detail. Let’s keep learning and refining how we support our clients!

Rowland DL, Kirana PS. A theoretical model for sexual performance anxiety (SPA) and a clinical approach for its remediation (SPA-R). Sex Med Rev. 2025 Mar 27:qeaf012. doi: 10.1093/sxmrev/qeaf012. 

Full text link: https://academic.oup.com/smr/advance-article/doi/10.1093/sxmrev/qeaf012/8097852?login=false