Title: FACILITATING SEXUAL HEALTH: INTIMACY ENHANCEMENT TECHNIQUES FOR SEXUAL DYSFUNCTION , By: Southern, Stephen, Journal of Mental Health Counseling, 10402861, Jan99, Vol. 21, Issue 1
Technological advances afford opportunities for reclaiming sexual functioning, even among individuals with chronic illness or devastating injury. However, medical advances cannot insure that sexual outlet will facilitate intimacy in a committed relationship. Sex therapy, based on the pioneering work of Masters and Johnson, addresses dysfunction in an essential relational context. This article provides an overview of treatment strategies for promoting sexual health.
As we move toward the 21st century, technological advances afford opportunities for nearly everyone to enjoy a satisfying sex life. For example, individuals with devastating spinal cord injuries can learn to reclaim the experience of orgasm, which can be verified by PET and MRI findings, even in the absence of genital sensation (Whipple, Gerdes, & Komisaruk, 1996). Recently, the introduction of an oral medication for erectile dysfunction (sildenafil citrate or viagra ) provided hope for thousands of men and their partners, yet catalyzed the recurrent debate regarding the benefits and limitations of a quick fix for sexual problems (Bancroft, 1990; Tiefer, 1986). Breakthroughs in technology and advances in medicine cannot insure that sexual outlet will facilitate intimacy in a committed relationship.
This statement represents the cornerstone of sex therapy pioneered at Masters & Johnson Institute. The goal of any effective treatment of sexual dysfunction involves removing the roadblocks to the natural expression of sexuality within an intimate relationship. These roadblocks may be organic or psychogenic. Yet, ultimately, sexual health should be defined in the context of facilitating intimacy in an ongoing relationship.
Intimacy is a core component of love. The word intimacy has depth in its very meaning. It was originally derived from the Latin intimus meaning “inner” or “inmost.” The French intime signifies “deep, fervent, ardent.” The Italian intimo means “close” or “innermost.” The derivation of intimacy indicates there is an internal, emotional experience by which each partner is drawn close to the other. Sexual intercourse is a powerful symbol of the loving embrace of intimacy.
When individuals experience difficulty in sexual functioning, they tend to avoid opportunities for physical and emotional closeness (McCarthy, 1997; Moret, Glaser, Page, & Bergeron, 1998). Sex therapy techniques can be used not only to remove roadblocks linked to specific sexual disorders, but also to strengthen intimacy in committed relationships. Although the “medicalization” of sexual dysfunction treatment has resulted in underemphasis of dyadic issues (Ackerman & Carey, 1995; Tiefer, 1986), classic models of sex therapy (e.g., Kaplan, 1979; Masters & Johnson, 1970) and more contemporary approaches (Barbach, 1997; Rosen & Leiblum, 1995; Schnarch, 1997; Schwartz & Masters, 1988) focus on the centrality of couple intimacy enhancement. In the case of erectile dysfunction, sex therapy outcome has been associated with improvement in dyadic communication, expression of affection, and support for partner adjustment (Hawton, Catalan & Fagg, 1992).
The purpose of this article is to provide a brief overview of intimacy enhancing treatment approaches for selected sexual dysfunctions. Some attention is devoted to recent advances in sexual medicine. However, the present overview is offered to counterbalance the medicalization of sexual health by emphasizing the importance of relational intimacy in disrupting syndromes of sexual dysfunction.
If intimacy is the goal of sexual health, then the relationship is the major unit of analysis in the assessment or treatment of sexual dysfunction (Hirst & Watson, 1997; McCabe, 1997; Masters & Johnson, 1970). In the 1970s, when the profession of sex therapy was growing rapidly in acceptance, roadblocks to natural sexual functioning were viewed almost exclusively as emotional or relational in nature. Ninety percent of sexual dysfunction cases were treated as psychogenic in origin (Kaplan, 1983; Wincze & Carey, 1991). Today, etiology in most cases is determined to be organic, primarily because enhanced technology permits the identification of subtle anatomical and physiological features It is likely that almost all cases of sexual dysfunction involve mixed etiology with psychogenic and organic factors (Burvat, Burvat-Herbaut, Lemaire, Marcolin, & Quittelier, 1990; Kaplan, 1983; Kellett, 1995). Although medical treatments are available, they do not necessarily address psychogenic factors or automatically contribute to intimacy. Thus, sex therapy remains an important component in the assessment and treatment of sexual dysfunction in men and women.
Assessment of sexual dysfunction involves ideally a treatment team committed to facilitating sexual health in an intimate relationship. Sexual medicine clinics (Kellett, 1995; Melman, Tiefer, & Pedersen, 1988; Renshaw, 1988; Verma, Khaitan, & Singh, 1998) include physicians and mental health professionals who possess specialized training and experience in the diagnosis and treatment of sexual problems. According to the sexual health model, there are two domains of assessment–the individual and the relationship (McCabe & Cobain, 1998). Some cases of sexual dysfunction seem to be related primarily to individual factors (e.g., vascular erectile dysfunction), while other cases are clearly relational in nature (e.g., sexual desire discrepancy). There are emotional and biological features among the many individual and relational factors in sexual dysfunction.
Comprehensive evaluation of sexual dysfunction can be tailored to the presenting problem. Particular disorders for males and females exist in each of the phases of the sexual response cycle, which consists of desire, arousal, orgasm, and resolution.
The types of dysfunction identified in the table include some conditions described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (American Psychiatric Association, 1994). The table includes some types or classifications recognized in clinical sexology practice (e.g., Kaplan, 1983; Wincze & Carey, 1991). The various dysfunctions may be considered either primary (lifelong) or secondary (reflecting an acquired problem often caused by another condition). In addition, some of the types are generalized, occurring across sexual situations and partners, or situational, applying only to particular settings or partners.
Each of the types of sexual dysfunction has specific diagnostic criteria. The types can be briefly described as follows. Hypoactive sexual desire refers to persistent or recurrent lack of sexual fantasy or desire for sexual activity. Sexual aversion includes persistent or recurrent avoidance of sexual outlet due to distress associated with potentially sexual stimuli. In some relationships, there is a significant difference in desire for sexual outlet, leading to frustration or discomfort for one or both partners. Sexual desire discrepancy is encountered frequently in marital and sex therapy (Beck, 1995; Kaplan, 1979; Lobitz & Lobitz, 1996; MacPhee, Johnson, & van der Veer, 1995; Schwartz & Masters, 1988; Southern, 1985).
Sexual compulsivity is a term coined by the Masters & Johnson Institute to account for hyperactive sexual fantasy and behavior, which produces adverse physical, emotional, and social consequences (Carnes, 1983, 1996; Cooper, 1998; Schwartz, 1996). The general domain of sexual compulsivity may contain paraphilias, or conditions in which sexual interest and preferred or exclusive sexual outlet is associated with a variant or unusual object, partner, or activity (e.g., cross-dressing or transvestic fetishism) (Abel & Osborn, 1992; Abel & Roleau, 1995; American Psychiatric Association, 1994; Moser, 1992). Any of the desire phase disorders can interfere with pursuit of intimate, partner-oriented sexual expression.
Erectile dysfunction includes a number of conditions in which there is difficulty attaining or maintaining sufficient erection (e.g., 70% of full erection) for penetration. The rigidity of erection varies significantly over time and may be affected by a number of situational and chronic conditions. Thus, it is useful to relate the condition to inability or difficulty in completing satisfying intercourse. There are hormonal, neurological, and vascular causes of erectile dysfunction (Burvat et al., 1990; Rowland & Slob, 1995). In addition, performance anxiety and “spectatoring,” or becoming a worried observer of sexual functioning, contribute significantly in the etiology of erectile dysfunction. This condition has been called impotence, a term with many negative and shameful connotations. Sexual arousal disorder occurs in the female when there is difficulty with lubrication or vasocongestion of the labia and clitoris. Similar to erectile dysfunction, female sexual arousal disorder may be associated with hormonal, vascular, and neurological conditions (Palace, 1995; Read, 1995). Labels such as “impotence” and “frigidity” are seldom used in professional settings; however, they are still in common usage in the general public.
Orgasm phase disorders are caused by organic and psychogenic factors. Problems with orgasm (including retrograde ejaculation in which semen is directed into the bladder rather than the urethra) may be secondary to diabetes. Inhibition of orgasm is a side effect of some medications, especially Prozac (fluoxetine hydrochloride) and other serotonin reuptake inhibitors (Ashton, Hamer, & Rosen, 1997; Seagraves, 1998). While arousal phase disorders are linked primarily to stress and anxiety, disorders of orgasm can be conceptualized as difficulty in “letting go” or facilitating the pleasurable sensations of the plateau stage of arousal. Orgasm is a reflex that will occur after an individually determined level of mental and physical stimulation. Individuals who try to maintain excessive control over the environment may have trouble experiencing orgasm (Anderson & Cyranowski, 1995; Byrne & Schulte, 1990; Heiman & LoPiccolo, 1988; Rosen & Leiblum, 1995).
Delayed ejaculation refers to difficulty in attaining orgasm, especially in the context of partner-oriented sexual activity (Apfelbaum, 1989). Some males have never experienced a climax (i.e., ejaculatory incompetence). Other males believe that they climax too quickly. The determination of rapid ejaculation (usually called “premature ejaculation”) almost always involves subjective estimates from the male and his partner about the desired duration of intercourse. Thus, relational factors play a critical role in the assessment and treatment of this dysfunction (McCarthy, 1994; Spector & Carey, 1990).
Only 40% to 50% of females are regularly orgasmic during intercourse (Masters & Johnson, 1970). The “missionary position” or “male superior” position seems to be ill-suited for stimulating the female. Many women are at least situationally anorgasmic, depending upon certain setting and partner variables. If a woman has never experienced an orgasm by any means, then she may have inhibited female orgasm. The current popular term for the condition is “preorgasmic,” suggesting that every woman has the right to realize this natural sexual function (Heiman & LoPiccolo, 1988).
Few classification systems include resolution phase disorders. Yet, if sexual compulsivity is accepted as a valid dysfunction, then it is clear that this condition extends into the resolution phase of the sexual response cycle. Ordinarily, when a male experiences ejaculation, he loses much of his erection and additional stimulation of the penis is considered neutral or aversive. Masters and Johnson (1966,1970) described the refractory period in which there is a gradually increasing period of time (or latency) between the last climax and arousability or interest in another sexual outlet. While females have the potential for multiple orgasms, in general, there is an identifiable period of time in which additional stimulation is not wanted.
The resolution period is also important in terms of bonding or attachment between loving partners (Anderson & Cyranowski, 1995; Lobitz & Lobitz, 1996). According to the sexual health model advocated in this article, in which intimacy is the primary goal, the resolution phase affords opportunity for sharing physical and emotional closeness, warm communication, and mutual respect. Whenever sex is mechanical, compulsive, or abusive, there is no intimacy. For example, the resolution of sexual intercourse may feel like one partner has used the other for masturbation. Sexual health should take into consideration the emotional components of loving partners. Intimacy dysfunction refers to a class of conditions in which sex is solitary, compulsive, or abusive to oneself or one’s partner.
Pain may occur at any point in the sexual response cycle. Obviously, pain is incompatible with pleasure and intimacy in the ongoing sexual experience. Dyspareunia occurs in both males and females. The condition is associated with pain or discomfort in the genitals, which may be a function of organic or psychogenic factors (Meana & Binik, 1994; Steege & Ling, 1993). A related conditions in females, vaginismus, involves involuntary contraction of the circumvaginal muscles such that penetration is difficult or impossible. (Read, 1995). Vaginismus is encountered among survivors of sexual abuse (Leiblum, Pervin, & Campbell, 1989). In fact, much sexual dysfunction in males and females can be related to neglect or abuse in childhood, including lack of sex information, sex negative attitudes, and poor family boundaries (Kinzl, Mangwerth, Traweger, & Biebl, 1996; Kinzl, Traweger, & Biebl, 1995; Sarwer & Durlak, 1996; Wilsnack, Vogeltanz, Klassen, & Harris, 1997).
As individuals learn more about natural sexual functioning, they are able to make sexual choices that foster intimacy in committed relationships. Advances in medical treatment and technology afford opportunities for all couples to realize sexual fulfillment. When there are difficulties in sexual functioning, a comprehensive evaluation, including input from both partners, is indicated. Physicians should complete a history and physical examination, including laboratory testing as indicated, to rule out disease states and medication side effects in the pathogenesis of sexual dysfunction (Kaplan, 1983; Morley & Kaiser, 1993). Urologists and gynecologists are trained generally to address male and female sexual complaints, respectively. In recent years, some physicians have devoted themselves to specialty practice in sexual medicine (Kellett, 1995; Melman et al., 1988; Verma, Khaitan, & Singh, 1998). Mental health professionals who have specialized training in sexual health are equipped to complete an assessment tailored to the particular presenting problem and the dyadic issues of the couple (Ackerman & Carey, 1995; Rosen & Leiblum, 1995; Wincze & Carey, 1991). A treatment plan that addresses organic and psychogenic etiology, including individual and relational factors, can be constructed.
Masters and Johnson (1966,1970) demystified sexual functioning and encouraged couples to seek help. Before 1970, sexual dysfunction was treated by psychiatrists and mental health professionals as symptoms of underlying emotional problems. Today, sex therapists from many disciplines, who have specialized training in the assessment and treatment of sexual problems, offer interventions which remove roadblocks to the natural expression of sexuality in an intimate relationship.
Masters and Johnson began in 1959 their revolutionary program for treating sexual problems. They worked only with couples (originally “the marital unit”) because each case of sexual dysfunction was considered relational in nature. They found that roadblocks to natural sexual functioning were primarily psychosocial (Masters & Johnson, 1970).
With advances in technology, it is clear that organic factors are frequently involved in the etiology of sexual dysfunction (Feldman, Goldstein, Hatzichristou, Krane, & McKinley, 1994; Palace, 1995). For example, vascular problems are major contributors to erectile dysfunction (Burvat et al., 1990; Rowland & Slob, 1995). However, the pioneering model of Masters and Johnson Institute never focused of the causes of individual problems. Rather, the male and female co-therapy team worked with couples to help them overcome relational and emotional roadblocks to intimacy. When intimacy is restored, the natural sexual response is facilitated. In addition, Masters and Johnson offered specific homework exercises to address particular concerns in the sexual response cycle, especially problems arising during arousal or orgasm.
The Masters and Johnson (1970) model for sex therapy involves intensive treatment of couples experiencing sexual dysfunction. Ideally, treatment is offered daily by the co-therapy team over a 2-week period (usually 10 to 12 days). Daily continuity and removal from typical distractions of work and home set the stage for optimal progress. Nevertheless, variations on the Masters and Johnson model include the “weekend intensive” and once weekly outpatient visits. The efficacy of the therapy decreases with changes from the original model, however (Masters & Johnson, 1970; Schwartz & Masters, 1988).
Although the Masters and Johnson model prescribes homework for particular types of sexual dysfunction, there are several common interventions without regard to the specific presenting problem. Initially, the couple is asked to refrain from sexual outlet. This “authoritative pronouncement” (Masters & Johnson, 1970, pp. 287-290) enables the couple to focus on intimate communication without the demand to be sexual. Another common intervention involves the “roundtable” (Masters & Johnson, 1970, pp. 57-78), in which the results of assessment are discussed and sex education is provided. The next step in intensive treatment incorporates one of the most famous interventions in the Masters and Johnson model, “sensate focus” (Masters & Johnson, 1970, pp. 66-85).
Sensate focus encourages concentration on the subtle sensations involved in intimate, nonsexual contact. Initially, the breasts and genitals are “off-limits,” fostering a sensual experience without preoccupation with sexual performance. Each partner takes turns, engaging in “selfish touching,” which is touch guided by one’s interests rather than trying to do anything to or for one’s partner. If the partner feels any discomfort or wishes to redirect the one doing the touching, then that person places his or her hand on top the partner’s hand. This “handriding” is a tool, like other techniques in the Masters and Johnson model, for realizing sexual self-responsibility. Various components of the sensate focus homework address roadblocks having to do with sexual demand, performance pressure, and “spectatoring,” or becoming an anxious observer rather than a participant in sexual functioning.
While Masters & Johnson (1970,pp. 342-360) reported success rates as high as 97% for rapid ejaculation and 80% across all male and female sexual dysfunctions, their model and research have been criticized (Reynolds, 1977; Tiefer, 1991; Zilbergeld & Evans, 1980). However, the Masters and Johnson Institute model (Masters & Johnson, 1970; Schwartz & Masters, 1988) has been for decades the guiding conceptual and clinical paradigm in sex therapy (Rosen & Leiblum, 1995). The core components of sex therapy, including nondemand sexual pleasuring, have been supported in several studies (Hawton et al., 1992; Hirst & Watson, 1997; Rosen & Leiblum, 1995; Sarwer & Durlak, 1997; Wylie, 1997).
Overall, increasing comfort and pleasure relax away anxiety previously conditioned over many frustrating sexual experiences. The sensate focus exercises, which move from nongenital exploration to nondemand sexual outlet through touch, provide opportunities to reclaim open communication and sensuality. Consultation with the couple includes recommendations for rekindling romance and enjoying intimacy.
With the completion of sensate focus exercises, the couple is ready to pursue techniques targeted at specific forms of sexual dysfunction. Using the classification scheme constructed for this article (see Table), it is possible to describe some specific interventions for selected sexual dysfunctions according to phases in the sexual response cycle.
Hypoactive Sexual Desire
Hypoactive sexual desire (HSD) involves recurrent lack of sexual fantasy or interest in sexual activity. Although HSD occurs in both males and females, women most often present this dysfunction (Anderson & Cyranowski, 1995; Beck, 1995). HSD may be primary, in which a person never developed an interest in sex, or secondary to other problems or concerns. The condition may be pervasive and generalized or situational, relating only to particular partners, settings, or activities. For example, an individual may experience lack of desire for one’s partner due to suppressed anger and chronic marital discord, yet retain some sexual desire for an idyllic encounter with another person. Similarly, individuals who have atypical, especially nonpartner-oriented preferences (e.g., a paraphilia such as fetishism) may have a marked disinterest in sex with one’s available spouse (Moser, 1992). HSD must also be differentiated from medical conditions such as endocrine problems and mental disorders, including depression (Kaplan, 1979; 1983).
Following a careful differential diagnosis, it is possible to tailor treatment to the needs of the particular person. Whenever possible the partner should be included in the intervention because of the obvious relational antecedents and consequences in HSD (Heiman, Epps, & Ellis, 1995; MacPhee et al., 1995). In the typical presentation, a woman develops HSD after a long period of marital dissatisfaction. She may feel unsupported and misunderstood. Often her husband persists in making sexual demands, although they have little communication and genuine intimacy. She cannot emotionally say “Yes!” to sex because she is unable to say “No.” Her HSD develops in response to suppressed or unexpressed anger in the context of the power imbalance in the marriage (Schwartz & Masters, 1988; Southern, 1985).
Treatment involves communication and negotiation skills training for the couple (including “I language” assertion, originally developed by Virginia Johnson); sensate focus, to remove the demand for sexual outlet; and encouragement of sexual self-responsibility, by focusing upon the woman’s preferences for the marital sexual relationship (Masters & Johnson, 1970). In the more complicated cases of primary HSD, the woman will likely need a period of individual consultation to learn about sex and acquire the ability to fantasize and associate pleasure with erotic cues and sensations. In some cases, testosterone, the male sex hormone, may be prescribed to increase the female’s level of desire (Beck, 1995).
Erectile Dysfunction
Erectile dysfunction is the most common sexual problem presented in sexual medicine clinics (Kellett, 1995; Melman et al., 1988). Yet, the problem has likely persisted for some time before the anxious, performance-oriented male “acknowledges his failure” and seeks help. Sexual dysfunction and other problems of daily life are often maintained by the words and images used to describe the difficulty. The “impotent” male who has lost his masculine power becomes preoccupied with the normal variations in penile tumescence. By focusing on slight losses of erection and anticipating a “failure,” he strengthens irrational expectations and contributes to increasing anxiety, which steals the blood flow to the penis. While many cases of erectile dysfunction include organic factors (e.g., vascular disease), the syndrome of increasing performance pressure and anxious self-observation contributes significantly to the couple’s distress and avoidance (McCarthy, 1997; Masters & Johnson, 1970).
Interventions for erectile dysfunction usually include some attention to the cognitive distortions and negative self-evaluations that maintain sexual dysfunction. While it may come as a surprise to some individuals, an erect penis is not a requirement for satisfying sex. Zilbergeld (1978) delineated the “myths of male sexuality,” which are based on a hypermasculine, fantasy model of sexuality which constrains both partners. The myths that a man must orchestrate sex in which he is “hard as steel” and “lasts all night” contribute to erectile dysfunction. The initial steps in treatment for this problem include education about limitations of stereotypical gender roles and disputation of irrational beliefs concerning sexuality (Barbach, 1997; McCarthy, 1994, 1997; Zilbergeld, 1978).
Sex therapy for erectile dysfunction builds on the relaxing experience of sensate focus. By the third set of sensate focus exercises, the couple has learned that satisfying sexual outlet can be realized through genital touching in an intimate, romantic context. An erection is not needed for sexual satisfaction. Gradually, the focus is shifted to containment of the soft penis in the vagina, followed by gentle thrusting of the penis with the female astride. The therapeutic exercises are graduated to desensitize conditioned anxiety and promote sense of hope or accomplishment (Masters & Johnson, 1970).
There are several other methods for treating erectile dysfunction. Medical management includes oral medication (e.g., the long-awaited viagra , or sildenafil citrate, a smooth muscle relaxer), urethral suppository (MUSE or alprostadil), vacuum pump, intracavernosal injection (e.g., Caverject), vascular surgery, and penile prosthesis (Ackerman & Carey, 1995; Morley & Kaiser, 1993). Even herbal treatments such as yohimbine have been used to treat problems with erection (Guirguis, 1998). Mental health treatments include hypnotherapy, relaxation training, strategic or paradoxical intervention, and cognitive-behavior therapy. All of these methods have merit (Ackerman & Carey, 1995; Rosen & Leiblum, 1995). Needs of the particular case identified through a comprehensive assessment should determine the treatment approach. However, each case should be considered relational in nature since the partner is affected or the capacity for partner-oriented intimacy is at risk (Barbach, 1997; Read, 1995).
Rapid Ejaculation
Rapid ejaculation is a sexual dysfunction that is based clearly on relational expectations. The common term, “premature ejaculation” signifies the relational origins of a rapid climax. “Premature ejaculation” indicates that the male has climaxed before producing through intercourse an orgasm for his partner. Obviously, this perspective engenders considerable performance pressure, which in turn potentiates rapid ejaculation. This problem can be solved through a combination of cognitive therapy and therapeutic touching exercises. The intervention is tailored to the severity of the presenting problem (e.g., the most severe case involves ejaculation before intromission) (McCarthy, 1994; Masters & Johnson, 1970; Spector & Carey, 1990; Zilbergeld, 1978).
The couple learns that satisfying sex is not a linear progression from touch (sometimes called “foreplay,” implying a focus on intercourse) to mutual orgasm. Instead, either partner may experience a climax through nondemand pleasuring. In addition, the male’s ejaculation need not terminate the touching opportunity. “Start-stop touching” (also labeled “brinkmanship”) is a major intervention for treating rapid ejaculation (Zilbergeld, 1978). In this method, the male is brought to the point of ejaculatory inevitability through touch during the plateau stage of the sexual response cycle. The partner then stops stimulation, reducing the likelihood of the orgasmic reflex and providing time for the male’s relaxation. Masters and Johnson (1970) recommended the squeeze technique, in which either the corona of the glans penis or the base is squeezed by the partner to delay ejaculation.
Anorgasmia
The treatment of anorgasmia in females has some similarities with therapy for rapid ejaculation(Anderson & Cyranowski, 1995; Masters & Johnson, 1970). In both cases, there is an emphasis upon learning to recognize cues that one is moving through the plateau phase toward orgasm. In addition, individuals are encouraged to relax and assume sexual self-responsibility in touching. The anxiety-provoking demand for orgasm in intercourse is neutralized through sex education and cognitive therapy. Anorgasmia (formerly called “frigidity” in the sexist model that focused on female responsiveness to male initiation) is treated as “preorgasm” in contemporary sexual therapy (Heiman & LoPiccolo, 1988). Every woman has a right to discover and express her unique sexuality, including orgasm when she desires to have one.
Preorgasmic women learn how to facilitate sexual responses through self-touching, fantasy enhancement, and graduated desensitization exercises with a partner (Barbach, 1997; Palace, 1995). Since male-superior (”missionary position”) intercourse is not a optimal form of stimulation for most women, the preorgasmic woman and her partner experiment with other forms of stimulation, such as the use of a vibrator (Heiman & LoPiccolo, 1988). During the individual component of treatment, she is encouraged to “let go,” or experience fully the increasing excitement. One of the interventions for this component is “role play orgasm,” in which the female is asked to simulate a full-body orgasm, sometimes after viewing an instructional videotape. During the couple component of treatment, they are asked to move from sensate focus, through experimentation with various positions and forms of stimulation, to facilitation of orgasm with the partner present. When the woman is able to experience predictably her climax, then a “bridging” technique is enlisted to transfer the potential for orgasm to partner-oriented stimulation during penetration (Barbach, 1997; Heiman & LoPiccolo, 1988; Masters & Johnson, 1970).
Sexual Compulsivity
The last two types of sexual dysfunction, sexual compulsivity and vaginismus, represent relatively rare problems, frequently emerging from untreated sexual abuse trauma (Kinzl et al., 19%; Kinzl et al., 1995; Leiblum et al., 1989).The other types of dysfunction overviewed in the present article need not be caused by any underlying psychodynamics. Sexual compulsivity (also known as “sexual addiction”) is most prominent in males who have suffered sexual abuse or severe disruption of psychosexual development. The developing “lovemaps,” used by victimized males to organize their thoughts and experiences related to eroticism (Money, 1986), tend to exclude intimate, partner-oriented sexual outlet in favor of repetitive, unusual, and exploitative forms of sex. The motivation for sex is not pleasure or sensuality. Rather, the nonsexual functions of sex are exaggerated. Mood altering sexual outlet is used to manage stress, ward off depression, express anger, or bolster a fragile ego (Carnes, 1983,1996; Cooper, 1998; Schwartz, 1996).
Treating sexual compulsivity requires individual and relational interventions designed to disrupt replay of sexual trauma (Schwartz, 1996). In many cases, masturbatory excesses have conditioned variant sexual arousal. By assessing the topography or nature of the sexual arousal pattern through self-report or biofeedback (i.e., penile plethysmography), it is possible to then transfer arousal from unwanted or deviant targets to desired partner-oriented outlet (Abel, Huffman, Warberg, & Holland, 1998). Treatment also involves confronting cognitive distortions, typically in group therapy (Abel, Osborn, Anthony, & Gardos, 1992; Carnes, 1983) Other components in the treatment package involve work with the “sex addict” and the “co-addictive” partner (Schneider & Schneider, 1996). The couple examines boundaries or limits to behavior as well as family-of-origin dynamics that contribute to communication difficulty and intimacy avoidance (e.g., Carries, 1983). Sex therapy interventions are used gradually to increase vulnerability, safety, and security.
Vaginismus
The treatment of vaginismus also emphasizes the intentional facilitation of vulnerability. However, the interventions are primarily behavioral, rather than intrapsychic in nature (Read, 1995; Rosen & Leiblum, 1995). Vaginismus involves the involuntary contraction of the pelvic muscles making penetration difficult, painful, or impossible. The etiology of this condition is psychosocial, primarily in traumatic sexual experiences (Leiblum et al., 1989). Yet, “dyspareunia” or pelvic pain that is untreated conditions vaginismus as the couple continues to suffer through attempts at intercourse (Meana & Binik, 1994). Treatment of vaginismus is a microcosm of the sexual therapy model. The couple abstains from sexual outlet, engages in sensate focus or touching opportunities, learns to associate genital touching with relaxation and pleasure, and desensitizes anxieties associated with demanding, performance-oriented sexual activities. Treating vaginismus usually includes specific desensitization exercises. For example, dilators or digits of increasing circumference are introduced by the female into the vagina. Muscular tension and anxious dread are relaxed away in the safe setting afforded by sexual therapy consultation (Masters & Johnson, 1970; Read, 1995).
The emergence of viagra (sildenafil citrate), a simple oral medication for erectile dysfunction, has generated in recent months considerable media attention, making it a good case in point for concluding remarks. viagra produces smooth muscle relaxation and inflow of blood to the corpus cavernosum of the penis, potentiating erection when there is adequate sexual stimulation (Pfizer, 1998). It is less invasive than previous medical interventions such as surgical implantation of a penile prosthesis, injection of medication into the spongy tissue of the penis, or placement of medication via urethral suppository (Ackerman & Carey, 1995; Morley & Kaiser, 1993). Treatment of erectile dysfunction with viagra is reasonably safe, although patients who use nitrates such as nitroglycerine could experience a hypotensive crisis (i.e., dangerously low blood pressure) if they take the medication (Pfizer, 1998).
viagra was well tolerated in clinical trials; however, some men experienced side effects, including headache, upset stomach, visual effects (color tinge), and blurred vision (Pfizer, 1998). The side effects were so mild that few patients decided to discontinue the medication. viagra is effective in producing erections sufficient for sexual activity in 67% to 75% of cases (Pfizer, 1998), an outcome comparable to other medical treatments and sex therapy interventions (Ackerman & Carey, 1995; Guirguis, 1998; Hawton et al., 1992; Masters & Johnson, 1970; Morley & Kaiser, 1993; Rosen & Leiblum, 1995).
Many of the 30 million men in the United States who suffer with erectile dysfunction will benefit from the increasing availability of viagra (Pfizer, 1998). However, viagra is not the “magic pill” or “quick fix” that some will expect or demand (Bancroft, 1990; Tiefer, 1986). Most cases of erectile dysfunction involve physical, psychosocial, and dyadic contributing factors (Burvat et al., 1990; Kaplan, 1983; Kellett, 1995; Masters & Johnson, 1966, 1970; Rosen & Leiblum, 1995). Pfizer (1998) acknowledged in its educational materials that stress, depression, performance expectations, and avoidance must be taken into consideration. Males who present psychogenic erectile dysfunction are more likely to demand rapid medical interventions that may exclude their partners (Kaplan, 1983; Masters & Johnson, 1970). Yet, effective treatment involves improving communication and enhancing intimacy with one’s partner (Barbach, 1997; Hawton et al., 1992; Masters & Johnson, 1970).
The worst case scenario for treatment with viagra (or any medical “quick fix”) involves a physician providing samples or prescribing the medication, then sending the anxious, performance-driven male home to solve his sexual problems. Frequently, the couple has withdrawn from one another. They do not touch or even talk. The female partner may blame herself for the absence of her husband’s response or initiation. The present author is already seeing cases where the male has secretly taken viagra , awaiting a sexual encounter that does not occur. Similarly, having the potential for erection does not insure that the partner is available or their sexual activity is satisfying. Successful treatment of erectile dysfunction and other sexual problems must involve some attention to intimacy enhancement. Pfizer (1998) included in their educational materials, which could be viewed by the male and his partner, remarks from Dr. Gerald R. Weeks, a marital and sex therapist. Dr. Weeks (Pfizer, 1998, pp. 9-11) recommended some activities for improving the relationship and enhancing intimacy. In referring to the roadblocks to sexual health, he noted, “no treatment for ED will make these barriers magically disappear” and “Your relationship needs to be a priority at times” (Pfizer, 1998, p. 11).
Safe, effective medical interventions such as treatment of erectile dysfunction with viagra remove roadblocks to natural sexual functioning and create opportunities to reclaim intimacy in relationships. Use of viagra will be the beginning of a process intended to cultivate emotional and physical closeness in thousands of couples, not the end of an anxiety-driven pursuit to remove a sexual symptom. Although sex therapy lacks definitive research findings and well-established theory (Reynolds, 1977; Rosen & Leiblum, 1995; Weis, 1998), the classic model of Masters and Johnson (1966,1970), with its emphasis on nonsexual touching and open communication, promises to help the field go back to the future.
Technological advances in the 1990s have facilitated careful assessment and reliable treatment for most cases of sexual dysfunction. Specific interventions have been developed for particular types of dysfunction. However, sexual problems evolve in the relational context. Conditioned anxiety, performance pressure, and sexual misconception are common among couples who present for treatment. They would like to regain the natural sexual function. They would also like to enhance the communication and romance in their relationship. Assessment and treatment of sexual dysfunctions should begin with medical examination. Then, sex therapy interventions offered by skilled clinicians can restore intimacy, while removing psychosocial roadblocks to optimal sexual functioning.
Sigusch (1998) discussed a neosexual revolution in which diversification in intimate relationships overcomes the banalization, dissociation, and medicalization of sexuality. Hacker (1990) described a transition from the old norms to the new sexual values of the 1990s in which pleasuring, without the demand for intercourse, heralds a path to caring, respectful behavior between men and women. Perhaps D.H. Lawrence best captured the heart of the “new” sexual health emphasis upon intimacy enhancement in his poem “Wedlock” (de Sola Pinto & Roberts, 1978).
How I love all of you! Do you feel me wrap you
Up with myself and my warmth, like a flame round the wick?
... I spread over you! How lovely your round head, your arms,
Your breasts, your knees and feet! I feel that we
Are a bonfire of oneness, me flame flung leaping round you,
You the core of the fire, crept into me. (p. 245)
Legend for Chart:
A - Phase
B - Types of Dysfunction Male
C - Types of Dysfunction Female
A
B
C
Desire
Hypoactive Sexual Desire
Sexual Aversion
Sexual Desire Discrepancy
Sexual Compulsivity
Paraphilia
Hypoactive Sexual Desire
Sexual Aversion
Sexual Desire Discrepancy
Sexual Compulsivity
Paraphilia
Arousal
Erectile Dysfunction
Sexual Arousal Disorder
Orgasm
Delayed Ejaculation
Rapid Ejaculation
Anorgasmia
Resolution
Sexual Compulsivity
Intimacy Dysfunction
Sexual Compulsivity
Intimacy Dysfunction
Pain[*]
Dyspareunia
Dyspareunia
Vaginismus
[*] Pain may occur in several phases, although these conditions
are frequently encountered during attempts at penetration.
Ackerman, M. D., & Carey, M. P. (1995). Psychology’s role in the assessment of erectile dysfunction: Historical precedents, current knowledge, and methods. Journal of Consulting and Clinical Psychology, 63, 862-876.
Abel, G. G., Huffman, J., Warberg, B., & Holland, C. L. (1998). Visual reaction time and plethysmography as measures of sexual interest in child molesters. Sexual Abuse: Journal of Research and Treatment, 10, 81-95.
Abel, G. G., & Osborn, C. (1992). The paraphilias: The extent and nature of sexually deviant and criminal behavior. Psychiatric Clinics of North America, 15, 675-687.
Abel, G. G., Osborn, C. A., Anthony, D., & Gardos, P. (1992). Current treatment of paraphiliacs. Annual Review of Sex Research, 3, 255-290.
Abel, G., & Roleau, J. L. (1995). Sexual abuses. Psychiatric Clinics of North America, 18, 139-153.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Anderson, B. L., & Cyranowski, J. M. (1995). Women’s sexuality: Behaviors, responses, and individual differences. Journal of Consulting and Clinical Psychology, 63, 891-906.
Apfelbaum, B. (1989). Retarded ejaculation: A much-misunderstood syndrome. In S. R.
Leiblum & R. C. Rosen (Eds.), Principles and practice of sex therapy: Update for the 1990s (pp. 168-206). New York: Guilford Press.
Ashton, A. K., Hamer, R., & Rosen, R. C. (1997). Serotonin reuptake inhibitor-induced sexual dysfunction and its treatment: A large-scale retrospective study of 596 psychiatric outpatients. Journal of Sex and Marital Therapy, 23, 165-175.
Bancroft, J. (1990). Man and his penis: A relationship under threat? Journal of Psychology and Human Sexuality, 2, 6-32.
Barbach, L. (1997). Loving together: Sexual enrichment program. Bristol, PA: Brunner/Mazel.
Beck, J. G. (1995). Hypoactive sexual desire: An overview. Journal of Consulting and Clinical Psychology, 63, 919-927.
Burvat, J., Burvat-Herbaut, M., Lemaire, A., Marcolin, G., & Quittelier, E. (1990). Recent developments in the clinical assessment and diagnosis of erectile dysfunction. Annual Review of Sex Research, 1, 265-308.
Byrne, D., & Schulte, L. (1990). Personality dispositions as mediators of sexual responses. Annual Review of Sex Research, 1, 93-117.
Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: Compcare.
Carnes, P. J. (1996). Addiction or compulsion: Politics or illness? Sexual Addiction and Compulsivity, 3, 127-150.
Cooper, A. (1998). Sexually compulsive behavior. Contemporary Sexuality, 32, 1-3.
de Sola Pinto, V., & Roberts, E W. (1978). D. H. Lawrence: The complete poems. New York: Penguin Books
Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Krane, R. J., & McKinley, J. B. (1994). Impotence and its medical and psychosocial correlates: Results of the Massachusetts male aging study. Journal of Urology, 151, 54-61.
Guirguis, W. (1998). Oral treatment of erectile dysfunction: From herbal remedies to designer drugs. Journal of Sex and Marital Therapy, 24, 69-73.
Hacker, S. S. (1990). The transition from the old norm to the new: Sexual values for the 1990s. SIECUS Report, 18, 1-8.
Hawton, K., Catalan, J., & Fagg, J. (1992). Sex therapy for erectile dysfunction: Characteristics of couples, treatment outcome, and prognostic factors. Archives of Sexual Behavior, 21, 161-175.
Heiman, J. R., Epps, P. H., & Ellis, B. (1995). Treating sexual desire disorders in couples. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical handbook of couple therapy (pp. 471-495). New York: Guilford.
Heiman, J. R., & LoPiccolo, L. (1988). Becoming orgasmic: A sexual growth program for women. New York: Prentice Hall.
Hirst, J. F., & Watson, J. P. (1997). Therapy for sexual and relationship problems: The effects on outcome of attending as an individual or as a couple. Sexual and Marital Therapy, 12, 321-337.
Kaplan, H. S. (1979). Disorders of sexual desire. New York: Brunner/Mazel.
Kaplan, H. S. (1983). The evaluation of sexual disorders: Psychological and medical aspects. New York: Brunner/Mazel.
Kellett, J. (1995). Functions of a sexual dysfunction clinic. International Review of Psychiatry, 7, 183-190.
Kinzl, J. F., Mangwerth, B., Traweger, C., & Biebl, W. (1996). Sexual dysfunctions in males: Significance of adverse childhood experiences. Child Abuse and Neglect, 20, 759-766.
Kinzl, J. F., Traweger, C., & Biebl, W. (1995). Sexual dysfunctions: Relationship to childhood sexual abuse and early family experiences in a nonclinical sample. Child Abuse and Neglect, 19, 785-792.
Leiblum, S. R., Pervin, L. A., & Campbell, E. H. (1989). The treatment of vaginismus: Success and failure. In S. R. Leiblum & R. C. Rosen (Eds.), Principles and practice of sex therapy: Update for the 1990s (pp. 113-140). New York: Guilford Press.
Lobitz, W. C., & Lobitz, G. K. (1996). Resolving the sexual intimacy paradox: A developmental model for the treatment of sexual desire disorders. Journal of Sex and Marital Therapy, 22, 71-84.
McCabe, M. P. (1997). Intimacy and quality of life among sexually dysfunctional men and women. Journal of Sex and Marital Therapy, 23, 276-290.
McCabe, M. P., & Cobain, M. J. (1998). The impact of individual and relationship factors on sexual dysfunction among males and females. Sexual and Marital Therapy, 13, 131-143.
McCarthy, B. W. (1994). Etiology and treatment of early ejaculation. Journal of Sex and Marital Therapy, 20, 5-6.
McCarthy, B. W. (1997). Chronic sexual dysfunction: Assessment, intervention, and realistic expectations. Journal of Sex Education and Therapy, 22, 51-56.
MacPhee, D. C., Johnson, S. M., & van der Veer, M. M. C. (1995). Low sexual desire in women: The effects of marital therapy. Journal of Sex and Marital Therapy, 21,159-182.
Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston, MA: Little, Brown & Co.
Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. New York: Bantam Books.
Meana, M., & Binik, Y. M. (1994). Painful coitus: A review of female dyspareunia. Journal of Nervous and Mental Disease, 182, 264-272.
Melman, A., Tiefer, L., & Pedersen, R. (1988). Evaluation of the first 406 patients in a urology department based center for male sexual dysfunction. Urology, 32, 6-10.
Money, J. (1986). Lovemaps. New York: Irvington Publishers.
Moret, L. B., Glaser, B. A., Page, R. C., Bargeron, E. F. (1998). Intimacy and sexual satisfaction in unmarried couple relationships: A pilot study. The Family Journal: Counseling and Therapy for Couples and Families. 6, 33-39.
Morley, J. E., & Kaiser, F. E. (1993). Impotence: The internist’s approach to diagnosis and treatment. Advances in Internal Medicine, 38, 151-168.
Moser, C. (1992). Lust, lack of desire, and paraphilias: Some thoughts and possible connections. Journal of Sex and Marital Therapy, 18, 65-69.
Palace, E. M. (1995). A cognitive-physiological process model of sexual arousal and response. Clinical Psychology: Science and Practice, 2, 370-384.
Pfizer. (1998,May). The new facts of life. [Videotape and brochure, HX728F97]. (Available from Pfizer U.S. Pharmaceuticals, 235 East 42nd St., New York, NY 10017-5755).
Read, J. (1995). Female sexual dysfunction. International Review of Psychiatry, 7(2), 175-182.
Renshaw, D. C. (1988). Profile of 2,376 patients treated at Loyola Sex Clinic between 1972 and 1987. Sexual and Marital Therapy, 3, 111-117.
Reynolds, B. S. (1977). Psychological treatment models and outcome results for erectile dysfunction. Psychological Bulletin, 84, 1218-1238.
Rosen, R. C., & Leiblum, S. R. (1995). Treatment of sexual disorders in the 1990s: An integrated approach. Journal of Consulting and Clinical Psychology, 63, 877-890.
Rowland, D. L., & Slob, A. K. (1995). Understanding and diagnosing sexual dysfunction: Recent progress through psychophysiological and psychophysical methods. Neuroscience and Biobehavioral Review, 19, 201-209.
Sarwer, D. B., & Durlak, J. A. (1996). Childhood sexual abuse as a predictor of adult female sexual dysfunction: A study of couples seeking sex therapy. Child Abuse and Neglect, 20, 963-972.
Sarwer, D. B., & Durlak, J. A. (1997). A field trial of the effectiveness of behavioral treatment for sexual dysfunction. Journal of Sex and Marital Therapy, 23, 87-97.
Schnarch, D. (1997). Passionate marriage: Sex, love, and intimacy in emotionally committed relationships. New York: W.W. Norton.
Schneider, J. P., & Schneider, B. H. (1996). Couple recovery from sexual addiction/compulsivity: Results of a survey of 88 marriages. Sexual Addiction and Compulsivity, 3, 111-126.
Schwartz, M. F. (1996). Reenactment related to bonding and hypersexuality. Sexual Addiction and Compulsivity, 3, 195-212.
Schwartz, M. F., & Masters, W. H. (1988). Inhibited sexual desire: The Masters and Johnson Institute treatment model. In S. R. Leiblum & R. C. Rosen (Eds.), Sexual desire disorders. (pp. 229-242). New York: Guilford Press.
Seagraves, R. T. (1998). Antidepressant-induced sexual dysfunction. Journal of Clinical Psychiatry, 59, 48-54
Sigusch, V. (1998). The neosexual revolution. Archives of Sexual Behavior, 27, 331-359.
Southern, S. (1985). Hypoactive sexual desire: A cognitive model. Journal of Sex Education and Therapy, 11, 55-60.
Spector, I. P., & Carey, M. P. (1990). Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Archives of Sexual Behavior, 19, 389-408.
Steege, J. F., & Ling, F. W. (1993). Dyspareunia: A special type of chronic pelvic pain. Obsterics and Gynecology Clinics of North America, 20, 779-793.
Tiefer, L. (1986). In pursuit of the perfect penis: The medicalization of male sexuality. American Behavioral Scientist, 29, 579-599.
Tiefer, L. (1991). Historical, scientific, clinical and feminist criticisms of “the human sexual response cycle” model. Annual Review of Sex Research, 2, 1-23.
Verma, K. K., Khaitan, B. K., & Singh, O. P. (1998). The frequency of sexual dysfunctions in patients attending a sex therapy clinic in North India. Archives of Sexual Behavior, 27, 309-314.
Weis, D. L. (1998). Conclusion: The state of sexual theory. Journal of Sex Research, 35, 100-114.
Whipple, B., Gerdes, C. A., & Komisaruk, B. R. (1996). Sexual response to self-stimulation in women with complete spinal cord injury. Journal of Sex Research, 33, 231-240.
Wilsnack, S. C., Vogeltanz, N. D., Klassen, A. D., & Harris, T. R. (1997). Childhood sexual abuse and women’s substance abuse: National survey findings. Journal of Studies
