Sexual Dysfunction

Although sexual dysfunctions have been treated by a wide array of different therapies, this entry concentrates on the most commonly used techniques in sex therapy. Until the 1960s, the predominant approach to the treatment of sexual dysfunction was psychoanalysis. Sexual problems were viewed as symptoms of emotional conflict originating in childhood.

Cognitive-behavioral psychologists have long taken issue with the psychoanalytic approach. They believe that a person can be emotionally healthy and still have sexual difficulties. Maladaptive sexual functioning is learned, they believe, and it can be unlearned without extensive probing into a client's past.

Masters and Johnson's approach. The treatment program that William Masters and Virginia Johnson developed is a two-week process, conducted by a man and a woman. Both partners in the couple seeking treatment are given a thorough medical examination and interviewed by the therapist of the same sex, followed by an interview with the other therapist. All four people (the couple and the two therapists) then discuss treatment goals.

Masters and Johnson recommended the use of both a male and a female therapist to provide a "friend-in-court" for the client of the same sex. They stressed the treatment of specific symptoms rather than extensive psychotherapy aimed at determining potential underlying, unconscious sources of difficulty.

Kaplan's approach. Helen Singer Kaplan (1974) developed an approach to sex therapy that combined some of the insights and techniques of psychoanalysis with behavioral methods. Her approach begins at the surface or behavioral level, and probes more deeply into emotional conflicts only if necessary.

Many sexual difficulties stem from superficial causes. If a sexual difficulty is rooted in a lack of knowledge, for example, information and instruction may be all that are needed to treat it. If the trouble is of recent origin, a series of guided sexual tasks may be enough to change patterns of response. If deep-seated emotional problems exist, the therapist may use more analytic approaches to help clients obtain insight into the less-conscious aspects of their personality. This last approach has been designated as psychosexual therapy to distinguish it from sex therapy.

Nondemand pleasuring and sensate focus. In exercises involving nondemand sensate focus, the clients initially avoid sexual intercourse. In fact, couples are forbidden to engage in any sexual activity until the therapist instructs them to do so. Over the course of treatment, they receive homework assignments that gradually increase their range of sexual behaviors. Initially, only kissing, hugging, and body massage may be allowed.

The partners are instructed to take turns in the roles of giver and receiver as they touch and caress each other's body. When playing the role of giver, the person explores, touches, and caresses the receiver's body. In applying this technique, called nondemand pleasuring, the giver does not attempt to arouse the receiver sexually. In an exercise called sensate focus, the receiver concentrates on the sensations evoked by the giver's touch on various parts of the body. In these exercises, the giver's responsibility is to provide pleasure and to be aware of his or her own pleasure in touching. The receiver's role is to prevent or end any stimulation that he or she finds uncomfortable or irritating by either telling or showing the partner his or her feelings.

The next step is to engage in nondemand breast and genital caressing while avoiding orgasm-oriented stimulation. If the partner or the person who is experiencing sexual difficulty becomes highly aroused during this exercise, that partner may be brought to orgasm orally or manually after completion of the exercise.

Other sexual behaviors are gradually added to the clients' homework. Successive assignments may include nongenital body massage, breast and genital touching, simultaneous masturbation, penile insertion with no movement, mutual genital manipulation to orgasm, and, finally, intercourse.

Masturbation training. Most treatment programs for orgasmically inhibited women include training in masturbation, particularly if the woman has never had an orgasm. This approach is used mainly in cases of primary orgasmic dysfunction and female hypoactive sexual desire. In this approach women are encouraged to learn about their bodies and relax to the point where they can experience orgasm.

The approach most commonly employed for premature ejaculation is the squeeze technique (Masters and Johnson 1970). The partner circles the tip of the penis with the hand. The thumb is placed against the frenulum on the underside of the penis, while the fingers are placed on either side of the corona ridge on the upper side of the penis. When the man signals that he is approaching ejaculation, his partner applies fairly strong pressure for three to five seconds and then stops with a sudden release. The partner stimulates his penis again after the sensations of impending ejaculation diminish, usually within twenty to thirty seconds. Typically, the man is told that he should not try to control his ejaculation but should rely instead on the squeeze technique. The entire process is usually repeated twice per session before ejaculation is allowed.

Some couples prefer to apply the squeeze technique as close as possible to the base of the penis rather than the tip. This variation has the advantage of being easier to do during intercourse, but for some couples it does not work.

Numerous other therapy formats and techniques are sometimes used in conjunction with the foregoing approaches to the treatment of sexual dysfunctions. For example, for women who have primary or secondary orgasmic dysfunction, group therapy is effective and less expensive than individual therapy (LoPiccolo and Stock 1986; McCabe and Delaney 1992).

Various approaches involving surgery and mechanical approaches, hormones, and drugs have been used in the attempt to treat sexual dysfunctions. The fact that most of these treatments have been developed for male sexual difficulties probably reflects the cultural emphasis on male sexual performance. In general, before permitting these kinds of treatment, the client should make sure no other type of treatment is effective for him and obtain a second opinion.

Surgical procedures, including implants, have been used in the treatment of erectile dysfunction. There are two basic types of plastic or silicone implants. One is a semirigid rod that keeps the penis in a constant state of erection but can be bent for concealment under clothing. The other type of silicone or plastic (polyurethane) implant an inflatable device surgically implanted under the skin of the penis; to achieve erection, the man presses a pump implanted in the scrotum. The pump forces fluid from a reservoir put under the abdominal muscles into cylinders implanted in the penis. Complications of this method include infection and mechanical failure. Follow-up studies of prosthesis recipients and their partners have indicated that they were generally satisfied with the choice to have the surgery.

The vacuum pump has been used as a nonsurgical method to treat erectile difficulties. The penis is inserted into an acrylic tube while a hand-held vacuum pump draws blood into erectile tissue. A rubber band holds the blood in place for up to thirty minutes.

Hormone administration, principally testosterone, has been used for years to treat erectile dysfunctions. If the problem is not due to hormone deficiency, however, hormones can increase sexual arousability without improving performance, which can result in further deterioration of the client's condition. Testosterone treatment also increases the risk of coronary thrombosis, atherosclerosis, and cancer of the prostate.

The use of testosterone-estrogen pills, creams, and gels have been used to try to increase women's sexual desire. It is unlikely that these medications are helpful except, perhaps, for women with abnormally low levels of testosterone and without other complicating factors (e.g., anxiety, stress, guilt, or anger at partner) that are inhibiting their sexual response. Research is badly needed on the effectiveness of this approach as well as possible side effects. For example, the dosage level is presumably important; high levels of testosterone might increase sexual desire in some women, but they also would tend to masculinize women, producing unwanted body hair and the like.

A number of drugs can create pharmacological erections through injection into the penis by relaxing the smooth muscle of the corpora cavernosa. They appear to be most useful for men with irreversible biological erectile dysfunction. The client can be taught to inject the drug himself. Erection usually occurs within ten minutes and lasts about two hours. There is some risk with this treatment, which has a number of side effects such as penile scarring, priapism, cardiac irregularities, and changes in the liver with long-term use.

A recent drug, sildenafil citrate, approved by the Food and Drug Administration in 1998, is taken orally as a pill. Sildenafil is marketed as Viagra. Used by men who have erectile difficulties, it is taken one hour before the man wants to have an erection and the erection can last for up to four hours following administration. Unlike other treatments, Viagra does not work unless the person is experiencing sexual arousal. It works by blocking an enzyme that allows blood to flow out of the penis.

Irwin Goldstein and his colleagues (1998) reported in a study of 532 men that 70 percent of all attempts at sexual intercourse with an erect penis were successful for men taking Viagra, whereas only 22 percent of attempts were successful when men were administered a placebo. Other studies have shown the effectiveness of Viagra for men with erectile dysfunction. Viagra's effectiveness for women with sexual arousal difficulties has been more mixed but there has been less research conducted with women.