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Sex therapy is an approach to the treatment of sexual problems. Results of psychophysiological studies of sexual responses in sexually functional subjects, in the 1960s, allowed gynecologist William Masters and psychologist Virginia Johnson to develop a therapeutic format for the treatment of sexual inadequacy. Apart from organic causes, sexual problems may be attributed to interpersonal diﬃculties and to problems with emotional functioning. Masters and Johnson were convinced that ‘adequate’ stimulation would result in sexual response in an engaged partner. Adequate stimulation feels good, is rewarding, and facilitates focus of attention on those feelings. Originally, adequate stimulation in therapies was restricted to behaviors comprising the classical heterosexual foreplay, coitus, and orgasm sequence. This criterion for adequate stimulation has been abandoned because of the rich diversity in sexual practices that exist in the real world.
Masters and Johnson hypothesized that fear of failure, and as a consequence becoming a spectator of one’s own feelings, is the most important cause for sexual inadequacy. They devised a very ingenious procedure to assist people in becoming engaged in feelings of sexual excitement. Three important steps were speciﬁed. In the ﬁrst step people learn to accept that mutual touching feels good. In this step demands for sexual performance, and anxieties related to such demands, are precluded by an instruction not to touch genitals or secondary sex characteristics (e.g., breasts). When the ﬁrst step leads to acceptance of positive bodily feelings, the second step demands including genitals and breasts in mutual touching and caressing. Masters and Johnson have suggested some variations to accommodate speciﬁc sexual problems (e.g., premature ejaculation, erectile problems). The second step has to result in the physiological signs of sexual excitement—vaginal lubrication in women and erection of the penis in men. In the classical sequence the ﬁrst and second step prepared for the third step which consisted of coital positions, again with variations, and stimulation through coitus to orgasm. Although coitus may be relevant from a reproductive point of view, it is not always and certainly not the only way to experience the ultimate pleasures of sex.
1. Desire, Excitement, And Orgasm
Masters and Johnson, on the basis of their psychophysiological studies, proposed a model of sexual response consisting of three phases: an excitement phase, an orgasm phase, and a resolution phase. The excitement phase and orgasm phase may be recognized as the second and third step of the classic treatment format. When other therapists began to apply Masters and Johnson’s format it became clear that many patients do not easily engage in interactions prescribed by the sex therapy format. Apparently, an initial motivational step was missing. People who hesitate or avoid intimate interactions may lack desire, which often means that they do not expect the interaction to be rewarding. In 1979 Helen Kaplan proposed adding a desire phase, preceding the three phases speciﬁed by Masters and Johnson. Since Kaplan’s proposal it has become clear that the prevalence of lack of desire is considerable. With hindsight most people accept that lack of desire must be the most important sexual problem. It is a problem for the individual who does not arouse desire in his or her partner. In most instances, not feeling desire is in itself unproblematic, but lack of sexual desire may become a problem in the relationship.
Sex therapy was a fresh and new treatment. Sexual problems were openly discussed, there was no time-consuming delving into past conﬂicts, and there were suggestions for a direct reversal of symptoms of sexual failure. Masters and Johnson preferred working with couples because the interaction within the couple often contributes in important ways to the sexual diﬃculties. Other therapists have oﬀered treatment to individuals and to groups of individuals or couples.
An alternative to Masters and Johnson’s therapy format is the mimicking of normal sexual development through the use of masturbation. This has been an important step for many women, especially those who missed this aspect of discovery of their own sexuality. In this approach people learn to induce sexual excitement through masturbation to eventually apply this ‘skill’ in interaction with a partner.
Some approaches developed from behavior therapy and rational emotive therapy focused on performance anxiety and fear of failure. Others used interventions from couple and group therapy. It is fair to say that nowadays almost all approaches to sexual diﬃculties incorporate elements from the Masters and Johnson sex therapy format.
2. Sexual Dysfunctions In Men
2.1 Diagnostic Procedures
The aim of the initial clinical interview is to gather detailed information concerning current sexual functioning, onset of the sexual complaint, and the context in which the diﬃculty occurred. This information gathering may be aided by the use of a structured interview and paper-and-pencil measures regarding sexual history and functioning. An individual and conjoint partner interview, if possible, can provide additional relationship information and can corroborate data provided by the patient. The initial clinical interview should help the clinician in formulating the problem. It is important to seek the patient’s agreement with the therapist’s formulation of the problem. When such a formulation is agreed upon, the problem may guide further diagnostic procedures.
Many men with erectile dysfunction may be wary of psychological causes of their problem. Psychological causes seem to imply that the man himself is responsible for his problem. This may add to the threat to his male identity that he is already experiencing by not being able to function sexually. Considering the way a man may experience his problem, it can be expected that it will not be easy to explain to him the contribution of psychological factors. A clinician knowledgeable in biopsychosocial aspects of sexual functioning should be able to discuss the problem openly with the patient. Dysfunctional performance is meaningful performance in the sense that misinformation, emotional states, and obsessive concerns about performance provide information about the patient’s ‘theory’ of sexual functioning. When contrasting this information with what is known about variations in adequate sexual functioning, it is often clear that one cannot but predict that the patient must fail. For the clinician a problem arises when, even with adequate stimulation and adequate processing of stimulus information according to the clinician’s judgment, no response results, either at a physiological or a psychological level.
At this point, a number of assessment methods aimed at identifying diﬀerent components or mechanisms of sexual functioning may be considered. In principle, two main strategies may be followed: In the ﬁrst, although a psychological factor interfering with response cannot be inferred from the report of the patient, one can still suspect some psychological factor at work. Possibly the patient is not aware of this factor, thus he cannot report on it. Eliminating this psychological inﬂuence may result in adequate response. The second strategy applies when even with adequate (psychological) stimulation and processing, responding is prevented by physiological dysfunction. Physiological assessment may then aid in arriving at a diagnostic conclusion. The biopsychosocial approach predicts that it is inadequate to choose one of these strategies exclusively. The fact that sexual functioning is always psychophysiological functioning means that there may always be an unforeseen psychological or biological factor.
2.2 Psychological Treatments Of Sexual Dysfunctions In Men
2.2.1 Approaches To Treatment. The most important transformation of the treatment of sexual dysfunctions occurred after the publication of Masters and Johnson’s (1970) Human Sexual Inadequacy. First of all, they brought sex into the treatment of sexual problems. Before the publication of their seminal book, sexual problems were conceived as consequences of (nonsexual) psychological conﬂicts, immaturity, and relational conﬂicts. In most therapies for sexual problems sex was not a topic in the therapeutic transactions. There were always things ‘underlying,’ ‘behind,’ and ‘besides’ the sexual symptoms that deserved discussion. Masters and Johnson proposed to attempt directly to reverse the sexual dysfunction by a kind of graded practice and focus on sexual feelings. If sexual arousal depends directly on sexual stimulation, that very stimulation should be the topic of discussion. Here the second important transformation occurred: A sexual dysfunction was no longer something pertaining to an individual; rather, it was regarded as a dysfunction of the couple. It was assumed they did not communicate in a way that allowed sexual arousal to occur when they intend to ‘produce’ it. Masters and Johnson thus initially considered the couple as the ‘problem’ unit. Treatment goals were associated with the couple concept: The treatment goal was orgasm through coital stimulation. This connection between treatment format and goals was lost once Masters and Johnson’s concept was used in common therapeutic practice. People came in for treatment as individuals. Male orgasm through coitus adequately fulﬁlls reproductive goals, but it is not very satisfactory for many women because they do not easily achieve orgasm through coitus. What has remained over the years, since 1970, is a direct focus on dysfunctional sex and a focus on sexual sensations and feelings as a vehicle for reversal of the dysfunction.
What Masters and Johnson tried to achieve in their treatment model is a shift in their patients’ focus of attention. Let us look at one of Masters and Johnson’s interventions to elucidate this point. People with sexual dysfunctions tend to wait and look for the occurrence of feelings, instead of feeling what occurs—hence, the spectator role. Their attention is directed towards something that is not there or does not exist, which is frustrating. In simplest form, Masters and Johnson propose to redirect attention by using the following steps: ﬁrst of all they manipulate expectations by instructing the patient about what is allowed to occur and what is not. It is explained to the patient that nonsexual feelings are to be accepted as a way to accept sexual feelings later on, and therefore sexual areas are excluded in the initial homework tasks. From a psychological point of view this manipulation is ingenious; it directs attention away from sex—when you feel a caress on your arm it may be pleasant but (now) it is not sexual—however, at the same time, it deﬁnes sexual feelings as feelings in ‘sexual areas.’
To attain a direct approach of sexual function numerous variants of couple, communication, and group therapy have been used. Rational emotive therapy has been used to change expectation and emotions. To remedy biographical memories connected with sexual dysfunction, psychoanalytic approaches have been used as well as cognitive behavior therapy approaches. There are speciﬁc interventions for some dysfunctions; for example, premature ejaculation has been treated with attempts at heightening the threshold for ejaculatory release (stop–start or squeeze techniques).
Recently, as a spin-oﬀ of research into cardiac vascular smooth muscle pharmacology, drugs have become available which act by relaxing smooth muscles in the spongiose and cavernous structures in the penis. This relaxation is necessary to allow blood ﬂow into the penis, thus causing an erection. Some of these drugs (e.g., sildenaﬁl—Viagra ) support the natural neurophysiological reaction to sexual stimuli. Others act locally in the penis without sexual stimulation. To slow down speed of ejaculation in men with premature ejaculation SSRIs (serotonin selective reuptake inhibitors) seem to be helpful.
Smooth muscle relaxants like sildenaﬁl are helpful in older men when less naturally occuring transmitters are available. Men with vascular or neurodegenerative diseases (e.g., diabetes, multiple sclerosis) may also beneﬁt from the use of smooth muscle relaxants. Although these drugs are very eﬀective, they do not help every man with erectile problems.
Pharmacological treatment for erectile disorder may be an important step in restoring sexual function. Most couples will need information and advice to understand what they may expect from this treatment. For many it will not bring the ﬁnal resolution of their relationship problems. In addition to drug treatment they will need some form of sex therapy or psychotherapy.
2.2.2 Validated Treatments For Male Sexual Dysfunctions. It has been diﬃcult to get an overview of treatments for sexual dysfunctions because any proposal about how to approach dysfunctions was valid. This has changed through the introduction of criteria for validated or evidence-based practice by the American Psychological Association (APA). From the timely review by O’Donohue et al. (1999) of psychotherapies for male sexual dysfunctions it appears that the state-of-the-art is far from satisfactory. Following the criteria of APA’s Task Force, they found no controlled outcome studies for male orgasmic disorder, sexual aversion disorder, hypoactive sexual desire disorder, and dyspareunia in men. For premature ejaculation and for erectile disorder there is evidence for the usefulness of psychological treatment. But eﬀects are limited and often unstable over time.
Although the evidence-based practice movement should be ﬁrmly supported, unqualiﬁed support would be disastrous for the practice of the treatment of sexual problems. The care for patients with sexual problems must be continued even without proof according to the rules of ‘good clinical practice.’ The sensible clinician will learn to be very careful about any claims concerning either diagnostic procedures or treatments.
3. Sexual Dysfunctions In Women
3.1 Diagnostic Methods
Similar to the procedures in men, initial interviews should help the clinician in formulating the problem and in deciding whether sex therapy is indicated. Since sexual problems can be a consequence of sexual trauma it is necessary to ask if the woman ever experienced sexual abuse. An important issue is the agreement between therapist and patient about the formulation of the problem and the nature of the treatment. To reach a decision to accept treatment, the patient needs to be properly informed about what the diagnosis and the treatment involve. Dependent on the nature of the complaint, the initial interviews may be followed by medical assessments. In contrast to the assessment of men, the psychobiological assessment of women’s sexual problems is not well developed.
3.2 Psychological Treatments Of Sexual Dysfunctions In Women
3.2.1 Approaches To Treatment. Similar to men, the treatment of sexual dysfunction in women contains many elements from Masters and Johnson sex therapy. As noted before, an important addition, especially in women, is the use of masturbation to discover their own sexuality.
Low sexual desire is generally treated with sensate focus exercises to minimize performance pressure, and communication training. In the treatment of sexual aversion the focus is on decreasing anxiety, the common core of sexual aversions. Behavioral techniques, like exposure, are most commonly used.
Treatment of sexual arousal disorder generally consists of sensate focus exercises and masturbation training, with the emphasis on becoming more self-focused and assertive in asking for adequate stimulation.
For the treatment of primary (lifelong) anorgasmia there exists a well-described treatment protocol. Basic elements of this program are education, self-exploration and body awareness, and directed masturbation. Because of the broad range of problems behind the diagnosis of secondary (not lifelong) and situational anorgasmia, there is no major treatment strategy for this sexual disorder. Dependent on the problem, education, disinhibition strategies, and assertiveness training are used. It is important to identify unrealistic goals for treatment like achieving orgasm during intercourse without clitoral stimulation.
For dyspareunia (genital pain often associated with intercourse), there are multiple possible somatic and psychological causes. A common picture is vulvar vestibulitis, pain at small inﬂamed spots at the lower side of the vaginal opening. However, often there is no clear organic cause for the pain. Treatment should be tuned to the speciﬁc causes diagnosed and can vary from patient to patient. Behavioral interventions typically include prohibition of intercourse, ﬁnger exploration of the vagina, ﬁrst by the woman, then by her partner. Sensate-focus exercises may be used to increase sexual arousal and sexual satisfaction. Pelvic ﬂoor muscle exercises and relaxation training can be recommended in case of vaginismus or a high level of muscle tension in the pelvic ﬂoor.
Treatment of vaginismus commonly involves exposure to vaginal penetration by using dilators of increasing size or the women’s ﬁngers. Pelvic ﬂoor muscle exercises may be used to provide training in discrimination of vaginal muscle contraction and relaxation, and to teach voluntary control over muscle spasm.
Pharmacological treatment of sexual disorders of women is just beginning. Smooth muscle relaxants have been used in women to ameliorate sexual arousal and as a consequence hypoactive sexual desire. It appears that drugs like sildenaﬁl produce smooth muscle relaxation and increased genital blood ﬂow, but they have no eﬀect on the subjective experience of sexual response. In women with subphysiological levels of testosterone—mainly in the postmenopause—testosterone patches appear to have an eﬀect on mood, energy, and libido.
3.2.2 Validated Treatments For Women’s Sexual Dysfunctions. Reviews of treatments for sexual dysfunctions in women following the criteria for validated or evidence-based practice have been published (O’Donohue et al. 1997, Heiman and Meston 1997, Baucom et al. 1998). Heiman and Meston conclude that treatments for primary anorgasmia fulﬁl the criteria of ‘well-established,’ and secondary anorgasmia studies fall into the ‘probably eﬃcacious’ group. They conclude with some reservations that vaginismus appears to be successfully treated if repeated practice with vaginal dilators is included in the treatment. Their reservations are due to a lack of controlled or treatment comparison studies of vaginismus. All authors conclude that adequate data on the treatment of sexual desire disorder, sexual arousal disorder, and dyspareunia is lacking.
Although the evidence-based practice movement deserves support, care for patients with sexual problems must be continued even without proof according to the rules of ‘good clinical practice.’
4. Future Directions
Sex therapy bloomed in the 1970s and 1980s, but reviews of evidence-based treatments suggest that developments stagnated and very few new studies have been undertaken. The recent shift to biological approaches will continue, at least for a while. Viagra and testosterone patches will shortly be followed by more centrally acting drugs (e.g., dopamine agonists). The search for drugs has provoked a wide range of studies into the biological basis of sexual function. This work inspires behavioral and cognitive neuroscience studies, which may provide a framework and new tools to better understand sexual emotions and sexual motivation.
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