The Status of Sex Therapy in Modern Psychology
One of the most controversial treatment categories in the area of sexual dysfunction is that set of therapies referred to collectively as “Sex Therapy”. This form of therapy, as it is currently applied, has its origins in the work of Masters and Johnson from the early 1970s. (Weiderman, 1998) Eschewing the typical psychoanalytical approach to the common complaint of sexual dysfunction, these theorists focused instead upon relatively brief, problem-oriented, and behavioral approaches to the issues. Weiderman, 1998) They focused upon the notion that a vast majority of these problems were initiated by a sexually restrictive or religiously orthodox upbringing. (Weiderman, 1998)
Thus, they approached the problem from a perspective of social-cognitive therapy, rather than that of intrapsychic factors. (Weiderman, 1998) Focusing on performance-anxiety, the goals of this therapy were relief of anxiety and education on sexual matters. (Weiderman, 1998) Helen Kaplan expanded this paradigm by adding a return to psychodynamic analysis as a contingency if the socio-cognitive approach failed. Weiderman, 1998) The therapeutic steps taken in Masters and Johnson’s approach consisted of a number of elements. (Weiderman, 1998) The therapy was couples-oriented, and began with educational sessions regarding anatomy and physiology. (Weiderman, 1998)
The traditional sex therapy paradigm had a male-female team of therapists, so sessions consisted of four individuals. (Weiderman, 1998) Clients would then be guided in a series of guided behavioral exercised designed to stimulate sexual gratification in the absence of anxiety. Weiderman, 1998) As the state of medical research and the nature of complaints from patients have changed since the time of Masters and Johnson, therapists turn increasingly to a biological model of explanation and pharmaceutical treatment of sexual dysfunction. (Weiderman, 1998) While the outcome of the cognitive-behavioral approaches to sexual dysfunction has been historically positive, there is still much dispute as to whether the long-term effectiveness of such treatments merits a complete shift away from long-term psychoanalytical approaches to sexual dysfunction.
Recent examination of results of cognitive-behavior therapy for sexual dysfunction has shown positive results in only about half of the cases. (McCabe, 2000) One of the key elements of this issue is whether the patient in question is male or female. One of the most common complaints among males seeking treatment for sexual dysfunction is the problem of erectile dysfunction. (Wylie, 1997) Some studies have suggested that positive outcomes can be achieved for this disorder in therapy based on short term cognitive-behavioral couples sessions.
Increasingly, the use of prescription medication, such as Viagra, has shown great promise for the treatment of this disorder, suggesting that it is in large part physiological in nature. (Wylie, 1997) A recent trend finds Viagra and similar drugs being prescribed for women who are experiencing certain levels of dysfunction. (Bancroft, 2002) Such an approach is problematic in several ways, all of which highlight the issues regarding gender and sex therapy in general practice, as well as in pharmacological approaches. Bancroft, 2002) A study was recently conducted on the efficacy of the drug Sildenafil on female sexual dysfunction. (Rosen, 2002) For the purposes of this particular study, female sexual dysfunction is limited to the area of hypo-sexuality and female sexual arousal disorder. (Rosen, 2002) The results of this study were mixed. (Rosen, 2002)
Roughly one in four participants reported an increase in arousal and interest as a result of using the drug, and one-third reported clitoral hyperactivity. Rosen, 2002) These results suggest that the use of vasodilators can only address one part of the issues affecting female sexual response. In a physiological sense, the female clitoris is analogous to the male penis, and the vasodilators tend to have comparable effects on those parts of the body. Nevertheless, in females, such stimulation does not lead to a universal reversing of aversion among women, whereas, in men, performance and desire are enhance d on a much more consistent basis. (Rosen, 2002)
One issue that is central to this controversy is that of male-female differences in sexuality. (Bancroft, 2002) The basis of this difference is three-fold. (Bancroft, 2002) The first element is the fact that women have less need for their sexuality to be based on reproductive hormones. (Bancroft, 2002) The second consideration is the notion that female sexual gratification and orgasm are not consistently and well-met by vaginal intercourse (Bancroft, 2002) and the third is that the female propensity to react to social inhibitions to sexual conduct seems higher than that of men.
An interpretation of the variability found in female sexuality in classic studies as compared to that of males is that such variability is a result of social influences that affect female sexuality much more than that of males. (Bancroft, 2002) In short, it appears that some women are more sexual than other women, whereas this variation does not appear within the male population. (Bancroft, 2002) Trends of sexual behavior over the long run also point to significant gender differences. Classic studies show a consistent pattern was that sexual activity in males spikes at puberty, and gradually declines as he ages. Bancroft, 2002) On the other hand, female sexuality seems to increase more gradually, peak later and decline more abruptly than male sexuality. (Bancroft, 2002) These differences suggest a differing role of hormones in reproductive behavior of men and women. (Bancroft, 2002)
Recorded studies in sexual response to testosterone also seem to differ between the genders. (Bancroft, 2002) While testosterone increase invariably leads to increased sexual conduct in males, studies in female behavior have yielded inconsistent and varied results. Bancroft, 2002) A second issue affecting the approach of the use of pharmaceutical intervention for sexual dysfunction in women is the poorly understood nature of the interaction between psychological and physiological elements of sexual dysfunction. (Bancroft, 2002) Because of the lack of hard knowledge on the exact nature of this interaction, predicting the outcome of a pharmacological approach to the issue. (Bancroft, 2002)
The physiological elements of female sexual activity are less clear-cut than those of the male. Bancroft, 2002) As this is the case, it is difficult to predict that a medication that focuses one particular aspect of sexual function in males, such as blood-flow with Viagra, would have comparable and consistent results upon women. (Bancroft, 2002) The final issue that must be addressed is the definition of female sexual dysfunction. (Bancroft, 2002) Male dysfunction is essentially a zero-sum game with respect to the actual act of intercourse. (Bancroft, 2002) The male is either physiologically able, or he is not. The female circumstance is different.
Physiologically, the female body may be “ready” for sexual intercourse at any time, but the level of pleasure, desire, and positive biological results, such as orgasms, varies greatly. (Bancroft, 2002) Thus it becomes harder to identify whether a given condition among female patients is actually dysfunction, or an otherwise recognizable manifestation of circumstances causing a decrease in desire. (Bancroft, 2002) The DSM-IV lists only two types of sexual desire dysfunction, that of hypo-sexuality and sexual aversion. Heiman, 2002) Neither of these have shown themselves to have significant data in support of effective psychological treatment. (Heiman, 2002)The DSM-V also describes Female Sexual Arousal Disorder, which is described in terms of vaginal lubrication and vasorestriction. (Heiman, 2002)
These has been little clinical data exploring whether this disorder can in any way be alleviated by conventional sex therapy. (Heiman, 2002) The area of sex therapy has attempted to grapple with these and other issues with regard to male-female differences. Bancroft, 2002) The formative studies in the field, those of Masters and Johnson proceed on a functional definition of female sexual dysfunction that may be fundamentally flawed. (Bancroft, 2002) The assumption utilized by Masters and Johnson is that female dysfunction is characterized by an inability to achieve orgasm during vaginal intercourse. (Bancroft, 2002)
The problem with this assumption is that subsequent research has shown that most women do not achieve orgasm solely from that activity, requiring other acts of sexual stimulation. Bancroft, 2002) A lack of robust differentiation of gender in the diagnostic language of sexual dysfunction is prevalent despite studies which have shown that these differences are significant and highly relevant to treatment. (Bancroft, 2002) Studies have suggested that women define dysfunction in a different way than men. In one such study, it was determined that 47% of women defined sexual dysfunction as a function of lack of interest whereas only 8% of men held a similar definition.
Even more telling, 68% of men defined the dysfunction as related to an inability to perform sexually from a physiological standpoint, whereas the comparable statistic in women was only 8%. (Bancroft, 2002) These data illustrate that the nature of dysfunction is both poorly understood and not well-differentiated by sex therapists. (Bancroft, 2002) The result of this phenomenon is that socio-cognitive therapy that focuses on the underlying causes within a relationship for the dysfunction is much better received by women than by men. Bancroft, 2002) These differences tend to highlight the underlying question: that of whether a sexual problem aught to be considered a dysfunction. (Bancroft, 2002) This determination has even greater relevance to the prospect of pharmacological treatment. (Bancroft, 2002) An apt analogy might be whether it is appropriate to prescribe a lifetime of anti-depressants to a patient, simply because he or she is going through a few weeks of depression.
It is important to note that the social restraints binding female sexual conduct have been relatively unchanged throughout time. (Farvid & Braun, 2006) Women have traditionally faced a societal expectation of limited sexuality, a stereotype than has been both complicating and self-perpetuating for women historically. (Farvid & Braun, 2006) This notion, as debunked as it may seem by modern sociological information and media, is nonetheless still reinforced by media. Farvid & Braun, 2006) A recent examination of two magazines with high circulation and a preponderantly female audience has illustrated the prevalence of this trend. (Farvid & Braun, 2006)
The “message” of these magazines with respect to both male and female sexuality is still contradictory and extremely pervasive. (Farvid & Braun, 2006) Women who were sexually active and “free” were depicted as empowered, yet women as a group were characterized as seeking or needing a stable relationship with men. Farvid & Braun, 2006). Women in the magazines were consistently depicted as seeking a monogamous, life-long relationship. (Farvid & Braun, 2006) Men, in contrast, were often depicted as a source of stress and negative feelings with respect to women.
This, of course presents a double-edged sword with respect to female sexuality. The magazines create the circumstance of a sexual woman seeking an unattainable perfect mate, while highlighting stress associated with the search for and attaining of the mate. Farvid & Braun, 2006) men’s contributions to these magazines generally consist of advice to the woman as to how to be sexually pleasing to men. (Farvid & Braun, 2006) The constant emphasis on giving men pleasure engenders a feeling of sexual inadequacy among female readers. (Farvid & Braun, 2006) There is an overall lack of variety in described sexual activities, and they focused of vaginal intercourse and simultaneous orgasm as the ultimate goals of sexual encounters.
This singleness of sexual ideals flies in the face of what is known about the nature and causes of healthy female sexuality, such as the notion that vaginal intercourse is not the ultimate cause of female orgasm. (Farvid & Braun, 2006) In spite of the progress made in achieving social equality for men and women in modern society, studies continue to indicate an increased sexual inhibition and decreased sexual excitement in women as compared to men. (Carpenter & Janssen et. al. 008) This suggests one of two conclusions. The first is that women continue to experience sociological pressure that discourages sexual expression. The second is that women simply have a lower baseline for positive sexual experience. (Carpenter & Janssen et. al. 2008) This particular issue has specific implication for socio-behavioral therapy for women. If their decreased desire on an individual basis cannot be attributed to factors of sociology, is questionable if therapy that deals with that issue will be effective.
In the area of eliciting specific sexual response, a tool necessary for therapeutic and data-oriented studies on sexuality in both genders, there has been a measurable difference found between the types of erotic images most effective in attaining arousal across the two genders. (Janssen, Carpenter, & Graham, 2003) Subjective response analysis in one study showed that women prefer erotic images selected by other women, but gave no clear indication of what type, activity or permutation of participants elicited consistently high results among women. Janssen, Carpenter, & Graham, 2003) In yet another area of analysis, research suggests that women are more easily distracted during sexual activity than are men. (Meana & Nunnick 2006) As attention is a key to cognitive function, this finding has therapeutic implications as well. (Meana & Nunnick 2006)
The elements central to distraction for female participants tend also to be related to perceptions of attractiveness of either themselves or their partners, the result of which can be mid-activity revulsion or aversion. Meana & Nunnick 2006) Such aversion could easily be misdiagnosed in therapeutic sessions leading to a faulty process for therapy and other similar complications. (Meana & Nunnick 2006) The ramifications of the phenomena described above point to the complexity of female sexuality and suggest that the standard of treatment of couples-based therapy may miss the underlying issues particularly for women who are complaining of sexual dysfunction. (Daines & Perrett, 2000) First, defining a lack of arousal or interest as a dysfunction, as has been pointed out may not be correct.
The studies outlined above have shown that female dysfunction is hard to define empirically, largely because there is an incorrect understanding in both the scientific and general communities as to what sort of stimulation is sexually gratifying for females. In couples-therapy, although the behavioral elements address arousal and stimulation for the female, the underlying understanding of gender differences is often lost. (Daines & Perrett, 2000) The psychodynamic approach to sex therapy has the advantage of being more holistic in nature.
Assuming the problems are not based solely in physiology, psychodynamics offers a more comprehensive therapeutic basis for treatment. In contrast to the “band-aid” approach of behavior and cognitive therapy, the psychodynamic approach lends itself to a long-term holistic improvement that is far more likely to transcend gender and have a lasting positive effect on sexual function. (Daines & Perrett, 2000) A robust psychodynamic assessment of a problem can result in a more holistic view of the circumstances, causes and possible solutions to the situation. Daines & Perrett, 2000) In couples’s therapy, one or the other of the parties is generally presented as the “client”. (Daines & Perrett, 2000) This initial impression itself tends to skew the assessment framework, especially in an area where the behavior of the other party may be a contributing factor to the manifested disorder. (Daines & Perrett, 2000)
This “couples-oriented” approach helps the pair deal with the issues in an environment removed from blame and singling out, and one that is sufficiently holistic and robust to change the underlying paradigms that are at the root of the dysfunction. Daines & Perrett, 2000) It would appear that in the absence of data concerning human sexuality in general, and female sexuality in particular, the efficacy of cognitive-behavioral therapy will be limited at best. The stimulus-response-type paradigm used to overcome issues in the short term do not necessarily deal effectively with possible underlying issues or pathologies.