Eric C. Krohne Ph.D. (Auth.)-Sex Therapy Handbook_ a Clinical Manual for the Diagnosis and Treatment...

8/18/2019 Eric C. Krohne Ph.D. (Auth.)-Sex Therapy Handbook_ a Clinical Manual for the Diagnosis and Treatment of Sexual …

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SEX THERAPY

HANDBOOK


2/111

SEX

THERAPY

HANDBOOK:

A Clinical

Manual for the

Diagnosis

and

Treatment

of

Sexual Disorders

Eric C. Krohne, Ph.D.

M T ~ L l M I T E D

International Medical Publishers


3/111

Published

in the

UK and Europe by

MTP Press Limited

Falcon

House

Lancaster,

England

Published

in the

US by

SPECTRUM

PUBLICATIONS,

INC.

175-

20

Wexford

Terrace

Jamaica,

N.Y.

11432

Copyright .'9

1982

Spectrum Publications, Inc.

Softcover reprint of the hardcover 1st edition 1982

All r ights reserved. No part of this book may

be reproduced in any form, by photostat ,

microform, retrieval

system,

or any other means

without prior

written

permission

of the copyright

holder

or

his

licensee.

ISBN 978-94-011-9666-6 ISBN 978-94-011-9664-2 (eBook)

DOl 10.1007/978-94-011-9664-2


4/111

Dedication

To

my

teachers

Richard

Sewell &

Gotthard

Eberle


5/111

ACKNOWLEDGEMENTS

I wish to

express

my

appreciation to

Peter Jager,

Ph.D.,

who

offered

direction and encouragement while

much

of

this

material was

being gathered for inclusion in my doctoral dissertation. I am

also

indebted to

Doctors

Masters and Johnson, and to their

publisher,

Little,

Brown Co., as well

as

to

Farrar, Straus Giroux, Inc. ,

for

allowing certain copywritten

material

to be reprinted in

this text.

Takey Crist, M.D., Walker Kirker, M.D.,

and

Jeanne Kirker,

R.N.,

M. N . , generously provided me with

previously

unpublished clinical

material,

as did John Turner, M.A.,

who

sketched

the

clinically

descriptive

illustrations.

Connie Rhodes deserves

particular acknowl

edgment for having

typed, retyped, and

re-retyped the manuscript

often

working late

into

the

evening

and

on

weekends. Finally, I am

grateful

to

Paul Williams,

M.D.,

and Takey Crist, M.D., for their

tutelage and

friendship.

September 1,

1980

Jacksonville, N.C.


6/111

CONTENTS

I.

I I

AN

HISTORICAL

REVIEW

OF SEXUAL PATHOLOGY

AND TREATMENT

The

Story

of Onan

The Thirteenth Century

The Nineteenth

Century

The

Twentieth

Century

The

Psychoanalysts

The

Behaviorists

The new sex therapists

THE HUMAN

FACTORS

IN SEX THERAPY

The

Therapist

Sexual comfort and

discomfort

The

Dysfunctional

Patients

The focus of therapy

The Therapist /Patient

Relationship

The

clinical/therapeutic

relationship

1

1

1

2

7

7

8

9

11

11

11

12

13

13

14

I I I THE

PSYCHOPHYSIOLOGY OF

HUMAN

SEXUAL RESPONSE

5

Sexual

Psychophysiology

Theory

Research

Human Sexual Response: Classical

Description

Excitement

phase

Plateau

phase

Orgasmic

phase

15

15

15

16

16

16

16


7/111

IV.

V.

Resolution phase

Sexual

Response Pattern:

Theoretical

Alternatives

Biphasic

sexual

response

Triphasic

sexual

response

SEXUAL FUNCTION AND DYSFUNCTION

Adequate and Inadequate Sexual Functioning

Sexual adeq uacy

Sexual

inadequacy

Identification

/Classification of

Sexual Dysfunctions

Psychosexual Dysfunctions: Male

Impotence

Primary

impotence

Secondary impotence

Premature ejaculation

Primary premature

ejaculation

Secondary premature

ejaculation

Retarded ejaculation

Primary and secondary retarded ejaculation

Psychosexual Dysfunctions: Female

Orgastic dysfunction

Primary orgastic dysfunction:

Preorgasmia

Secondary orgastic dysfunction

Dyspareunia

Primary

dyspareunia

Secondary dyspareunia

Vaginismus

Primary vaginismus

Secondary vaginismus

General sexual dysfunction

Primary general

sexual

dysfunction

Secondary general sexual dysfunction

PROCEDURAL OPTIONS

FOR

THE DIAGNOSIS AND

TREATMENT OF SEXUAL DISORDERS

DIAGNOSIS

Differential Diagnosis

Diagnostic terminology

Diagnostic format

18

18

18

20

21

21

21

22

22

23

23

23

23

23

24

24

25

25

25

25

26

26

26

26

27

27

27

27

28

28

28

29

29

29

29

29


8/111

VI.

Diagnostic Procedures 30

The sexual

history

30

The

medical evaluation 31

The

mental

status

evaluation

32

Diagnostic

conclusions and implications for

treatment 33

TREATMENT 34

Sex

Education

and Counseling 34

Sex

education 34

The sexual information examination 35

Psychotherapy 38

Relationship

counseling

39

Sex

Therapy 39

The

psycho therapeutic /experiental approach 39

The

sensate focus,

"pleasuring," exercise 40

Non-genital

pleasuring

40

Genital

pleasuring

40

Reactions 41

Rationale 41

Variations in the clinical

application

of therapeutic

options

42

THE APPLICATION OF

PROCEDURAL

OPTIONS FOR

THE DIAGNOSIS AND TREATMENT

OF

SEXUAL

DISORDERS

Impotence

Diagnosis

MALE SEXUAL DYSFUNCTIONS

Sexual history

Medical

evaluation

Psychiatric

/psychological evaluation

Diagnostic conclusions

Treatment: Sex Education and Counseling

Sex

education

Sexual

information

examination

Psychotherapy

Relationship counseling

Treatment: Sex Therapy

Prohibitions and prescriptions

Sensate focus

45

45

45

45

45

47

47

48

48

48

49

50

50

51

51

51


9/111

Extravaginal

ejaculation

52

Vaginal

containment

52

Intravaginal

ejaculation

52

Results

of

Treatment 52

Premature Ejaculation 53

Diagnosis 54

Sexual

history 54

Medical evaluation

55

Psychiatric

/psychological

evaluation

55

Diagnostic

conclusions

56

Treatment: Sex

Education and Counseling

56

Sex

education

56

Sexual information examination

56

Psychotherapy 56


56

Treatment:

Sex

Therapy 57

The

start-stop

technique

57

The

squeeze technique

58

Results

of Treatment

60

Retarded

Ejaculation

60

Diagnosis

60

Sexual

history 60

Medical

evaluation

61

Psychiatric /psychological

evaluation

62

Diagnostic

conclusions

62

Treatment:

Sex Education and Counseling

62

Sex education

62

Sexual information

examination

62

Psychotherapy 63


63

Treatment:

Sex

Therapy 63

Prohibitions

and prescriptions 63

Progressive desensitization and

directed

masturbation

64

Procedural variations 65

Results of Treatment 65

FEMALE SEXUAL DYSFUNCTIONS 65

Orgastic

Dysfunction

65


10/111

Diagnosis

Sexual

history

Medical

evaluation

Psychiatric

/psychological evaluation


Treatment:

Sex Education

and

Counseling

Sex

education


Psychotherapy

Relationship

counseling

Treatment:

Sex Therapy

Prohibitions

and

prescriptions

Directed masturbation

Sensate focus exercise

Non-coital

orgasm

Coital

orgasm

Bridge

maneuver

Results

of

treatment

Dyspareunia

Diagnosis

Sexual history

Medical

evaluation

Psychiatric /psychological evaluation


Treatment:

Sex Education and

Counseling

Sex

education

Sexual information

examination

Psychotherapy


Treatment:

Sex Therapy

Prohibitions

and prescriptions

Non-genital pleasuring

Genital pleasuring

Coitus

Results

of

treatment

Vaginismus

Diagnosis

Sexual history

66

66

67

68

69

69

69

70

70

70

70

71

71

71

71

72

72

72

73

73

73

74

74

74

75

75

75

76

76

76

76

76

77

77

77

77

78

78


11/111

VII

Medical evaluation

Psychiatric /psychological

evaluation


Treatment: Sex

Education

and Counseling

Sex education


Psychotherapy



Prohibitions

and

prescriptions

Dilatation

Self

-

dilatation

Dilatation by partner

Sensate focus pleasuring

Penile penetration

Coitus

Results

of

Treatment

General Sexual Dysfunction

Diagnosis

Sexual

history

Medical

evaluation

Psychiatric /psychological evaluation



Prohibitions and prescriptions

Non-genital

pleasuring

Genital pleasuring

Non-demand

coitus

Coitus

Results of

treatment

CONCLUDING THERAPY

Brief Treatment

Patient satisfaction

Consistent sexual response

Extended Treatment

Inconsistent sexual response

Patient dissatisfaction

78

78

79

79

79

79

80

80

80

80

80

81

81

81

81

81

81

82

82

82

83

83

83

84

84

84

84

85

85

85

87

87

87

87

88

88

88


12/111

Continued treatment

88

Follow-up Treatment

89

Short-term follow-up

89

Long-term

follow-up

89

BIBLIOGRAPHY

91

INDEX

99


13/111

SEX THERAPY

HANDBOOK


14/111

CHAPI ER 1

An Historical Review

of

Sexual Pathology and

Treatment

THE STORY

OF ONAN

Some early

sexual authori t ies

viewed

man's

sexual behavior

from a

re1igio-phi1osophica1

frame

work which saw

the physical

and

biological func

t ions of the

sex

act

as being

secondary

to the

spiritual/moral issues involved.

''Normal''

sexual

functioning

was

that which

corresponded

to certain

religious or

spir i tual principles; "abnormal"

or

improper sexual

functioning

was

that

which

divert

ed from

these

rules or

traditions.

Thus,

we

have

the story of Onan (Genesis 38:8-10), who is

re

ported to

have

ejaculated

improperly,

"spill ing

his seed on the ground"

rather

than impregnating

his

brother 's

widow

as required by

Jewish

law.

Interest ingly,

Onan's contemporaries interpreted

his

behavior

as a voluntary contraceptive act -

ei ther coitus

interruptus

or masturbation

(Noonan,

1966). The Biblical

narrative suggests that this

improper and immoral sexual

behavior

angered the

Hebrew

god,

who

took

Onan's

l i f e

in retr ibution.

(Onan certainly paid a

high

price for what might

actually

be

one

of the

f i r s t

recorded

sexual

dys

functions

- -

premature

ejaculation prior to vagin

a l

penetration,

an involuntary act .)

THE

THIRTEENTH

CENTURY

Later, the Western thinker

Thomas

Aquinas

continued th is

moral

tone in

his

sexual

commentar

ies

by refining the

classical philosophical

con

cept of

Natural

Law. On

his terms,

man's sexual

behavior

was

proper

so long

as

the goal was con

ception - -

which

he believed to

be

the natural

outcome

of coitus.

However,

because

man's moral

1


15/111

2 SEX THERAPY

HANDBOOK

Notes :

nature

was seen as corrupt (concupiscent), his

sexual desires were often thought to be

unnatural

and inappropriate - -

especially

when directed

toward

recreation (fruitio) rather than

procrea

tion.

Thus,

for

'fttomas

Aquinas,

proper,

normal,

and

natural

sexual functioning

took

place when

the

sex

act was

intended for conception; al l

other

acts ( i . e . ,

those not

intended solely for concep

t ion) were unacceptable due to thei r

"unnatural"

self-indulgent

character (Aquinas, 1947).

THE

NINETEENTH CENTURY

By the eighteen hundreds some medical author

i t ies were beginning to concern themselves with hu

man

sexual

behavior.

Like thei r predecessors, they

too believed that some sexual problems were

just

functional,

precipitated

by

such

things

as

immod

erate l ibidinal

desires:

Over-indulgence (sic)

in

intercourse •••

is

sometimes

the

cause

of barrenness;

this is usually puzzling to the in ter

ested parties, inasmuch as the

prac

tices which,

in

thei r opinion,

should

be the source of numerous

progeny,

have

the

very

opposite effect.

By

greatly

moderating thei r

ardor, this

defect may be

remedied.

[Light and

Life,

p. 251].

Undoubtedly, this

rather superficial perspec

t ive

was due

not

only to

the

medical

practi t ioners '

inadequate theoret ical understanding of the

sub

ject but also to the primitive cl inical

procedures

of the period. For example, masturbation was seem

as a degenerative

act ,

certain

to

end with the in

dividual

to

complete

physical and

emotional

col

lapse. Note,

in

th is

regard,

both

the

limited di

agnostic

rationale as well as the

innocuous thera

peutic

suggestions contained in the

following ex

ample:

General Symptoms: The

effects

of

•••

self-pollution •••

appear in

many

forms

In some

cases,

the only complaint

the patient wil l make on consulting you

is that

he

i s

suffering under

a kind of

continued

fever. He

wil l probably

present

a

hot,

dry skin with

something of

a

hectic

appearance. 'fttough al l the

ordinary

means

of arresting such symptoms have been

t r ied, he i s

one

the bet ter .

The sleep seems to be irregular.


16/111

HISTORICAL REVIEW 3

and unrefreshing - - restlessness during the

early

part

of the night and

in

the advanced

stages---profuse sweats

before

morning.

There is

also

frequent start ing in

the

sleep.

from

disturbing

dreams. The

char

acter ist ic

feature

i s

that

your

patient

a l-

most

always

dreams of

sexual

intercourse.

This

i s

one

of

the

ear l iest , as well as

most

constant

symptoms.

When i t

occurs most

frequently, i t is

apt to be

accompanied

with pain. A gleety

discharge

from the ure

thra

may also

be

frequently discovered,

es

pecially

i f

the patient is examined when at

stool

or

after

urinating.

Other common

symptoms are nervous headaches, giddiness,

ringing in the ears,

and a

dull pain in

the

back

of the head. I t

is frequently the case

that

the

patient suffers

a

st iffness

in

the

neck, darting

pains in

the forehead,

and

also weak eyes are

among

the

common

symp

toms.

Treatment: [The

patient

should be

instructed

to]

•••

sleep in

a

hard bed,

and

rise early and

take

a sponge bath

in

cold

water every

morning.

Eat l ight suppers and

refrain

from eating

late

in the evenings.

Empty

the bladder

thoroughly

before re t i r

ing,

bathe

the spine

and hips

with

a

sponge

dipped

in

cold

water.

Never

sleep

lying on the back

Avoid a l l

blghly

seasoned food and

read good

books and

keep the mind

well

e ~

ployed. Take regular and

vigorous

outdoor

exercise every day.

Avoid a l l coffee, tea, wine, beer,

and al l alcoholic

liquors.

Don't use

to

bacco,

and keep the bowels

free.

Prescription

- -

Ask

your druggest

to

put you up

a good

Iron

Tonic and take

i t

regularly according

to

his

directions.

[Light

and

Life, p.

457].

As medical science became more sophisticated,

so did

physicians'

understanding

of

sexual be

havior

and

functioning. Unfortunately,

the

ac

curacy of their

understanding did

not

always

i ~

prove proportionately to their

increased sophis

t ication. The 1866 text , A Treatise on the

Prin

ciples

and

Practices of

MediCine,

Diseases

of

Women

and

Children and Medical

Surge 'Y,

by W.

Paine,

M.D. (Dean of the Faculty, the Philadelphia

Notes:


17/111

4 SEX THERAPY HANDBOOK

Notes: University

of

Medicine and

Surgery),

is such a

case. However,

these

notations are of interest

because they i l lus t ra te not

only

the

application

of

the

medical

category

of

disease to

what had

classically

been

considered moral

problems,

but

also

because

in

them

we

see

the

advent

of

clinical

procedures, including chemotherapy and cauteriza

t ion,

for the treatment of

sexual

problems.

One

does wonder, though, about Paine's choice of sex

ual

"pathologies"

requiring

treatment; and

i t

is

interesting

that

he includes both functional (or

psychosexual) problems in the same chapter

with

gonorrhea, balanit is , and syphilis - - perhaps in

dicating

the

possibili ty of

a lingering

moralism

behind

the

"clinical judgments" relat ing to

sperllUl

torrhoea,

masturbation, nymphomania, and

sa tyr

iasis .

Spermatorrhoea

By spermatorrhoea is understood

involuntary loss of semen. The most

frequent

cause of

th is

diff iculty is

self-abuse;

although i t may

be pro

duced by everything that tends to ex

ci te the

urino-genita1

organs;

hence.

i t

may be induced by constipation,

ascaris in the rectum,

hemorrhoids,

str ic ture of

the urethra, excessive

venery,

frequent

use

of mercurials,

and the

habitual

use

of spirituous

liquors.

Symptoms:

I f

spermatorrhoea

be

associated

with

any considerable loss

of semen,

it

is followed by nervous

debili ty and

i r r i t abi l i ty ;

constipa

t ion; dyspepsia; disturbed

sleep;

despondency; hypochondria; epilepsy;

mental iner t ia ; and insanity.

Treatment: There

are but

few

diseases

where

so

much

quackery

has

been resorted to as

in the manage

ment of

this affection. Unprinci

pled

physicians

are

in the habit of

extorting

large

sums of money from

patients

of

th is

class under

false

pretenses. The treatment consists

in

removing the cause;

hence, i f

pro

duced by masturbation, the patient

should be informed

of the

fact, and

the practice prohibited.

The bowels

should

be

regulated, and

i f parasites

infect

the

rectum, they should be

removed. The stOllUlch should

be kept

in

a healthy condition, and

frequent


18/111

HISTORICAL

REVIEW 5

baths and l ively company

enjoined.

In

addition

to the general bathing, the

genital organs

should

be showered

in

cold water once or

twice

a

day.

The

specific

remedies

that

have

proved

of

the greatest

value

in

this disease,

are gelsemin, camphor,

lupulin,

strychnin, viburin,

ergot,

canthoa

rides, and

phosphorous. These

may

be

caused

ei ther

separately, or in such

combinations as the circumstances re

quire.

The topical applications con

s i s t

in

cauterizing the urethra by

means

of

Lallemand's porte caustique;

and the introduction of bougies, lub

ricated with an

ointment

of hydrastin.

Quinine, iron, and general tonics

also

have

a

favorable

influence

on

this dis

ease.

Masturbation

I t can

hardly

be denied that there

are few

habits

that are more prevalent

or pernicious

in

thei r effects than

mas

turbation. There i s scarcely a

prac

t i t ioner

of any considerable experience

and observation, who

has

not

observed the

frequency

in

which i t

led

to spermator

rhoea

and

nymphomania,

with

a l l

thei r

terr ible

consequences. From the

s i -

lence which

has

been

observed by med

i ca l writers

and

teachers

relat ive

to

these

diseases, and

the

extensive

prac

t ice of

i t at

this

period,

we infer

that

ei ther

the subject has been grossly

ne

glected,

or

that masturbation

is

alarming

l yon the increase. The

practice

of se l f

pollut ion, when

at

f i rs t resorted to,

has

but slight

impression

upon the const i

tution; but, i f continued

for

a few

months,

or years,

a t

least ,

i t

produces

not only an abnormal condition

of

the

sexual organs,

which results in nymph

omania or spermatorrhoea, but

affects

the nutri t ious

functions, and lays

the

foundation for scrofula,

phthisis , and

insani ty, besides so

enfeebling

the

general forces of the body as to predis

pose

the sufferer to many other mala

dies.

Symptoms: The symptoms

of

mas

turbation

are

physical and in tel

lectual

debili ty,

i r r i table

and

va

ci l lat ing dispositon, dyspepsia,

con

st ipation

of the bowels, dry and husky

Notes :


19/111

6

SEX THERAPY HANDBOOK

Notes :

skin, scanty and

high

colored urine,

cold

hands

and

feet ,

and an

i rregul

ar

and

capricious

appetite.

I f the

male abandons the

practice

in this

condition

of the

system,

i t

will

soon

be

followed by

involuntary

discharge of semen. At f i r s t th is

will

occur

at

night during lasciv

ious dreams, but

in

time i t

will

occur during

defecation

and mictu

ri t ion. In this

event

there

will

be

atrophy of the

tes t icles ,

cold and

shrivelled

condition of the

penis,

together with impotency.

Or

i f

the

impotency

is

not complete, the erec

tions of

the

penis will be feeble,

and

almost

immediately

followed

by

emissions. In

the

female,

where

the

practice

is abandoned, there will be

an i r r i t abi l i ty of the nervous system,

a tendency to

i rregulari ty of

the

menses, leucorrhoea, prolapsus

uteri ,

and

in

many

cases, frequent

ovarian

excitement

and

discharge of the ovule.

I f the disease be protracted, the

parts become weak, relaxed and

cold,

and the patient averse to sexual in

tercourse.

Nymphomania

Nymphomania is a

disease of

fe

males, consisting

of

an

i r res is t ib le

desire for sexual intercourse. I t

more frequently

occurs

in those of a

nervous, i r r i table habit; or

of

a

dark, scrofulous, or tuberculous con

st i tut ion.

I t

i s produced by mastur

bation; the reading of lascivious

books; high,

stimulating

living;

an

absence

of physical and mental

e ~

p10yment; par t ies , gay company;

uter ine

and

vaginal

i r r i ta t ion;

h e ~

orrhoids.

and

the presence

of

para

s i tes in the

rectum. In

the major

i ty of

cases,

this condition is never

made manifest by

the patient; but

in

others,

the feelings of

modesty

are

overcome,

and

she gives

vent to the

most

obscene

expressions, and i ~

modest

and

disgusting

manifestations.

I t

may

amount to

absolute

insani ty, or

only an i r r i table and passionate con

dition

of the mind;

while in

other

cases,

the

patient

seeks

to

sat iate

her

morbid

passion by sexual commerce,

or

self-abuse.

I t soon, however,


20/111

HISTORICAL

REVIEW

7

undermines the constitution, producing

an

i r r i tab le condition

of the

bowels

and digestive

organs, disorganization

of

the blood, tuberculous degeneration,

haemoptysis,

deranged

menstrual func

t ions, leucorrhoea,

lumbago, constipa

t ion,

melancholy, pulmonary consumption,

and death.

Treatment: The

treatment

consists

in

removing the cause, invigorating

and

toning

the stomach and bowels, hot

si tz baths,

cold

vaginal injections,

and the cauterizing

of

the cl i tor is

with argenti nitras,

in cases

where

the

disease

has been

produced by mas

turbation. Senecin

and gelsemin, in

the

proportion

of

two

grains of the

former

to one-tenth of

a

grain

of the

la t ter , two

or

three times a

day, ex

erts a

specific

influence

over

the

disease, and I

have

cured many

bad

cases

with

i t . Quinine,

iron,

and

crypipedin,

also

exert

a

favorable

impression.

Satyriasis

Satyriasis i s an

insatiable de

sire

for

sexual

intercourse.

This

is

a

species

of nervous

disease produced

by a disordered condition

of

the

cerebellum, caused

by

alcoholic

drinks,

high l iving, excessive

ven

ery, and

a large

development

of

the

base

of

the brain. I t can be

cured

by a low

diet , frequent shower

baths,

physical

out-door labor, ice-bags to

the cerebellum,

a

hard bed,

and hop

pillows

[Paine,

1866, pp. 919-

921]4

THE TWENTIETH CENTURY

The

Psychoanalysts

Apparently the general

thrust

of

medicine's

sexual theories and clinical procedures contin

ued

in

much these same ways

for

the next several

generations, leading

one

physician,

Wilhelm

Reich,

to say

in March of

1919, "Perhaps it is

the

moralism

with

which the

subject

is approached

that disturbs me"

(Reich.

1975. P. 18). Later.

however,

after

psychoanalytic training,

Reich

lef t

the

practice of

general

medicine

for

psy

chiatry

and sex research:

Notes:


21/111

8

SEX THERAPY

HANDBOOK

Notes :

One

has to

be

familiar

with th is

atmosphere in

the

fields of sexology

and

psychiatry

before

Freud to under

stand the enthusiasm

and

rel ief which

I fel t when I

encountered

him.

Freud

has

paved

a

road

to

a

clinical

under

standing of

sexuality.

He showed

that adult sexuality

proceeds

from

stages of sexual development in child

hood.

I t

was

immediately

clear: sex

uali ty and procreation are not the

same. The words

"sexual"

and

"geni

tal" could

not be used

interchange

ably.

The

sexual

experience comprises

a

far

greater realm than the genital

experience, otherwise

perversion

such

as pleasure in coprophagy, in f i l th ,

or

in

sadism could

not

be

called

sex

ual.

Freud exposed contradictions

in

thinking and brought

in

logic and order.

[Reich, 1975, p. 25]1

As Reich stated

so

clearly, with Freud sexual

theory

expanded

to include

every

sphere of human

activity.

He developed new

perspectives from

which

to

view human sexuality

(psychoanalytic

theory), as well as techniques

(psychoanalytic

psychotherapy) for

the

clinical application

of

therapeutic

principles. In

his

terms,

man's

sex

drive was seen

as

a natural

characteris t ic of

hu

man

behavior, and sexual diff icul t ies or abnormal

i t ies

were identified

as pathological, requiring

treatment. In short ,

not only

did

Freud develop a

comprehensive theory

of

l ibido, but

he also pre

cisely spelled out

how

psychoanalysts should ob

serve and understand the behavior of the patient

so they

could

guide their patients (usually

through lengthy and expensive therapy) toward an

appropriate

adjustment.

The Behaviorists

Working from a

quite

different

perspective,

psychological

researchers from

the

behavioral

schools had, by the la te

nineteen-fift ies and

six

t i es ,

begun

theoretical formulations

and

clinical

experimentation in the area of human

sexuality.

They hypothesized

that

sexual dysfunctions were

conditioned responses to

anxiety-provoking

sexual

stimuli which could

be

treated

by reversing

or

"deconditioning" the individual

through systematic

desensitization techniques (e .g . , Wo1pe, 1958,

1969;

and

Lazarus, 1963). The

results

of thei r

lQuoted with

permission of Farrar,

Straus

& Giroux.


22/111

HISTORICAL

REVIEW

9

experiments were

quite

positive, often

with bet ter

than

a 75% success rate

in

correcting psychogenic

sexual disorders (Seagraves, 1976);

this

was

usu

al ly

achieved in

only a fraction of the time re

quired

by

classical

analysis.

The New Sex Therapists

Paralleling and

systematizing the

experimen

ta l developments of these

behaviorists

and

others

(e .g . , Robie, 1925, 1927;

Kelly,

1930, 1953; and

Semans, 1956) was the cl inica l work of Masters

and Johnson (Human Sexual Response, 1966; Human

Sexual Inadequacy, 1970) whose

pioneering

achieve

ments are virtually responsible

for

making

sex

therapy

into

a contemporary

health

care specialty.

They viewed nonorganica11y based

sexual

dysfunc

tions

as

learned disorders

precipitated

(primar

i ly)

by

sexual ignorance,

performance anxiety,

and poor

communication between partners. This

understanding caused them to develop short-term

treatment programs

consisting

of

directive psy

chotherapy,

communication

t ra ining,

sex

education,

and

a type

of

systematic (in vivo) desensitiza

tion through a

series of sensate

focus exercises

(Franks

and

Wilson, 1974).

Closely following

the lead of Masters and

Johnson

is

the work of Hartman and Fithian

(Treatment

of

Sexual

Dysfunction, 1972),

who

in

corporate much of the former's methodology

into

a "bio-psycho-socia1"

diagnostic/treatment for

mat.

This approach uses

psychological test ing

to achieve a

sexual diagnosis

as well

as

the phys

ical examinations so

characteris t ic

of Masters

and

Johnson; i t also structures treatment

around

behavioral tasks and

sex

education,

while de-em

phasizing - - without

to ta l ly discounting

- - psy

chotherapy

and/or

relat ionship counseling. This

l a t te r factor

has led

at least one

prominent sex

therapist (Ellis, 1975) to suggest

that

while

Hartman and

Fithian

are "highly

creative," the ir

treatment

procedures

are superficial ( i . e . , most

ly

"diversionary") and

as

clinicians, they are

prone to

"risk-taking."

Such

cri t icism notwith

standing, many

therapists

who

have

been

trained

by Hartman

and

Fithian continue to employ

the

bio-psycho-socia1 approach

on

a regular and (sup-

posedly) successful

basis

thus placing i t a-

mong the major approaches in modern sex

therapy.

In 1974 Helen Kaplan published The New Sex

Therapy

wherein she described a therapeutic

schema which t ied

together the

directive-behav

iora1-educative

orientations

of

Masters

and

Johnson/Hartman and Fithian and the dynamic

theories

of the psychoanalysts.

~ r o m

th is

Notes :


23/111

10 SEX THERAPY

HANDBOOK

Notes:

perspective

sex

therapy

begins

with

the "new"

ra

pid treatment approaches; but cl inica l interven

t ion may also occur at

deeper

levels (via

inten

sive

individual

and/or

conjoint

psychotherapy) so

as

to modify those

intrapsychic

or relat ional con

f l ic ts that may

also

be

involved in

the sexual dis

order.

Here,

then, beginning

with

the

analytical the

ories of Freud and continuing

on

through

the

exper

imentations of

the

behaviorists and the procedural

formulations of

Masters

and Johnson,

to

the

new

pervasive psychotherapeutic

approach

of Helen

Kaplan,

i s

seen

the evolution

of modern

sex

thera

py.

From a lengthy analytical

treatment

by singu

lar ly trained experts, sex therapy (which had been

only a sub-category) developed into a new cross

disciplined specialty:

the

short-termed

cl inica l

treatment of

psychosexual

dysfunction.


24/111

CHAPTER 2

The Human Factors in Sex

Therapy

TIlE TIlERAPIST

Ideally, a l l clinicians practicing sex

ther

apy will

have

had extensive t raining in

counsel

ing theories and procedures. This i s advantageous

because.counse1ing ski l ls are just as important

in the

treatment

of psychosexual dysfunctions as

they are when

doing

individual psychotherapy,

conjoint marriage

counseling,

or anyone of

the various types of group therapy

(cf.

Sager,

1975). As a matter of fact, depending on the

circumstances, sexual "counseling"

or

"therapy"

(terms

often used

interchangeably) may require

any or

al l

of these counseling

modalities, so

the more experienced

and

capable clinicians

are, the more l ikely

i t

i s that they

will

be

able

to respond adequately to the

sexual problems

that are presented in cl inica l practice.

Sexual comfort and discomfort

In addition to the

usual

sk i l l s required

of most counselors, sex therapists must also be

comfortable

with sexual

issues.

Primarily th is

means

that

they

must

be

comfortable with

thei r

own sexuality. I f th is most

basic requirement

cannot

be met, i t is doubtful that

they

will

perform

competently as

sex therapists

(cf. Reed,

1976). After a l l ,

how

can counselors encourage

masturbation,

as has been the classical

proce

dure with pre-orgasmic women, i f they feel

guilty

about or are unable to masturbate

them

selves?

A common place for the cl inic ian 's

d i s c o ~

fort with sexual

material

is

to

be

seen in the

area of

vocabulary.

Often

patients

describe

their problems in the vernacular; the sexually

'1


25/111

12


Notes:

anxious therap is t

typical ly feels the need to

"correct"

these terms, t rans la t ing them

in to

"acceptable" cl in ical (s ter i le) language. Un

fortunately

these

"cl in ical t ranslat ions" may

make

pat ien ts

feel

unclean,

raise

thei r

anxiety,

and make it

even

more diff icu l t for them to dis

close relevant material

for

fear of making another

"dir ty"

c01l'D1lent. A

less

anxious therapist

would

attempt

to use a vocabulary tha t is comfortable to

the

pat ients , questioning

thei r

choice

of

terms

only

when those words were too vague to be mean

ingful .

(Such might be the

case

when a \


26/111

The

focus of

therapy.

Depending

on the

circumstances. therapy

may focus ei ther on the

dysfunctional

individual

or

on the sexual relat ionship wherein the problem

occurs. Sex therapy regularly focuses on the

dysfunctional individual in cases of personal

anxiety.

such as with

many

preorgasmic

women

(cf.

Barbach.

1975).

With other

types

of

sexual prob

lems.

where the dysfunction

i s

believed

to

stem

from

the

pat ient ' s sexual

relat ionship (secondary

orgasmic dysfunction.

dyspareunia or

vaginismus

of

sudden

onset. e tc . ) .

the therapeutic focus

is

on the couple's interaction - - and both persons

should enter therapy

on a

joint basis.

In

cases where

the

dysfunction is a reaction

to

problems

or

att i tudes

within

the

relationship,

the inadequ3cy i s approached by treating the re

lat ionship through techniques not unlike those

classically used in marital therapy. In

other

circumstances,

sexual dysfunctions

may

be symp

toms

of chronic

sexual

anxieties that

only

pre

sent themselves within

the

relationship, having

their

origins elsewhere ( in childhood. sexual

ignorance.

etc . ) . These

anxieties are often

treated

successfully with simple sex education.

When

this

is

not

suff ic ient .

the dysfunctional

patient

may require individual psychotherapy in

addition

to

the couple's

relat ionship

counseling

and the jo int performance

of

prescribed

behav

ioral

tasks.

In short ,

some

sexual

problems can

b ~

t reated on an individual basis. However. because

sexual dysfunctions

usually

surface within

a re

lationship, i t is often necessary to treat

the

couple rather than just the individual presenting

the

dysfunctional

symptoms.

Variations

on the

focus of sex therapy will be made la te r in th is

text.

THE THERAPIST/PATIENT RELATIONSHIP

In

t reat ing

psychosexual

dysfunction. the

therapeutic

task

requires

that

the

therapist

and

the

sexually anxious patient(s} develop

a

rela

tionship that

wil l

allow for and

encourage

enough self-disclosure

so that

the patient(s}

can work toward identifying and

resolving

the

anxiety

that

is

precipi ta t ing

the

sexual

problem.

This type

of interchange is

not jus t

"clinical

interaction" between

individuals . but

rather

i t is to be a genuine sharing between patient(s)

and

advocate/mediator

(the

therapist)

within

a

relationship based on support and acceptance.

HUMAN FACTORS 13

Notes:


27/111


Notes:

The clinical therapeutic relationship

Naturally, a

formal

clinical relationship

(with al l

of

i t s

professional

and legal dimensions)

begins by virtue of the fact that the therapist

and

the

patients

have

started

working

together

in

a clinical sett ing. However, a

genuinely

thera

peutic

relationship (wherein

healing occurs) be

gins

only

af ter a mutual bond of t rust and respect

has

developed that wil l support

the

patients in

the

risking

of

self-disclosure that

precedes

al l

authentic

behavioral

change. Hopefully,

th is

bond

will be established early

in

the

relationship;

i

deally,

i t will star t during the

taking

of

the

history

so

that the

clinician will have an

accu

rate view of the pat ient ' s sexual

development

and

intimate

relationships.

Should

the therapeutic

relationship

not

be

established

th is

early,

the

history.

or part of i t . may

need

to be retaken.


28/111

CHAPTER 3

The Psychophysiology of

Human Sexual Response

SEXUAL PSYCHOPHYSIOLOGY

The "new"

or

directive sex therapies,

as

characterized

by the writings of Masters

and

Johnson

(1966,

1970), Hartman

and

Fithian (1972),

and Helen Kaplan (1974b), incorporate elements of

the psychodynamic therapies (the use of insight,

individual and

relationship

counseling, etc . ) and

behaviorism

(especially

desensitization,

condition

ing

techniques,

and

educational

procedures) with

the ir own research findings and treatment perspec

t ives to formulate

strategies for

the short-term

treatment

of

psychosexual dysfunction.

The basis

for this new approach has

been

Masters

and Johnson's

classic

laboratory studies

in

the

area of

human

sexual response.

Their findings

(1966)

contributed

the

essential phenomenological

description of hu

man

sexual

psychophysiology that

serves

even today

as the foundation for the

cl inica l

understanding

of sexual

function

and

dysfunction.

Research

The

f i rs t sc ient i f ica l ly rel iable

studies of

human

sexual behavior

were conducted under

the

di

rection of

A. Kinsey (1947,

1948

and

1953), but

these were limited to a sociological perspective

and derived

to ta l ly

from interrogation.

Masters

and

Johnson, on the other hand, undertook psycho

physiological

studies

that

sought

to describe the

pattern of human

sexual

response

on the

basis

of

direct observation and

recorded

physiologic var i

ables.

Their

1966 text

pictures

both

the

male and

female

sexual

responses as intensifying reactions

to

sexual

stimuli

which

they

arbi t rar i ly

divided

into four specific phases:

1) excitement,

15


29/111


Notes:

2)

plateau,

3) orgasm, and 4) resolution (Figs.

1 and 2 p. 17). This division

provided Masters

and Johnson

with

an effective framework wherein

they

could thoroughly

detail the

variations

and

changes

in

the

sexual

response

cycle (1966, p. 4).

Human Sexual Response: Classical Description

Excitement phase

Either erotic fantasy

or

tact i le stimulation

can

produce

penile erection

in

the human male.

When th is happens there is a lengthening of the

urethra,

both testes elevate within the

scrotal

sac,

and

there is

considerable tensing and thicken

ing of the

scrotal integument.

Females

usually

evidence

a mucoid

transudate

(a lubricating

f luid)

in the vagina

within

th i r ty

seconds of

satisfactory

somatic

or

psychic

stimu

lation.

This

sexual

tension

brings

on a

vascular

engorgement that produces a swelling in both the

glans

and

the shaft of the

cl i to r i s .

Nipple erec

tion

and

enlargement, and an

increase in

breast

size also result from

this

stimulation. In and

a

round the

outer

vagina,

the labia minora swell and

the labia majora tend to f latten. Inwardly, the

vaginal barrel

extends

and expands.

Plateau

phase

I f effective sexual

excitement

continues, the

diameter of the male's corona glans

(the

"head" of

the penis) increases somewhat,

and the

testes

swell and

continue

to

elevate. Some fluid

from

the

Cowper's gland may

also

be

emitted

from

the

penis at this time.

In

the

female,

the

v a ~ i n a l engorgement which

began

during the excitement phase continues during

plateau. This brings on a shrinkage of the outer

third of the lumen which allows the vagina

to

ac

tually

"grip"

even

a

very small penis during

pene

t rat ion.

The uterus moves upward within the pelvic

area

as the vagina expands with continued vasocon

gestion. The

previously elongated cl i to r i s then

begins

to

shrink and retreat

from

the vaginal open

ing, and the

labia minora

undergo a noticeable

"reddening." At this point

orgasm

is impending i f

adequate stimulation continues.

Orgasmic

phase

Males usually become

aware that orgasm is im

minent

as they

feel

the

ejaculate collect in

the

prostat ic

urethra; however, the orgasm actually

begins only when the periurethral musculature


30/111

PSYCHOPHYSIOLOGY 17

Male and Female Sexual

Response

Cyc1es

1

I

RGASM

I

PLATEAU

I

Figure

1:

I

ORGASM

PLATEAU

ABC

Figure 2:

R fractory

PIT od

The male sexual

response

cycle.

\

I

1:xI

10

IE

1-1

10

,Z

I

I

(e)

The female sexual

response cycle.

1. Since the male sexual response varies only in

duration, a

single pattern

(Fig.

1)

is de

scriptive of thei r

response

cycle. Females,

on the

other

hand,

vary in

both intensity and

duration;

therefore, three

simplified

patterns

(Fig. 2)

are used to

describe their typical

response. The

sexual

response

cycles

shown

above are taken from Masters and Johnson

(1966, p. 5>., and are used with the ir permis

sion, and with permission of their publisher,

T

i t"t"1

P

.. ,"'n 1. r."

Notes :


31/111


Notes:

undergoes

a series of involuntary contractions.

Similarly, ejaculation

results

from a

series of

rhythmic

contractions of the

urethral bulb and

the

penile

urethra.

During

orgasm

the

female undergoes

a

series

of

contractions

involving

the

muscles

of the outer

third of the

vagina. Deeper

within the pelvis ,

the uterus also contracts

rhythmically.

Both men and women note that orgasm

causes

an

increase in

pulse, respiration and

blood pressure.

The "sex flush" (the

reddening

reported during

plateau)

also

spreads and becomes more intense

during th is experience.

Resolution phase

Following orgasm

the male quickly

loses his

erection. This

happens

in two stages: in the

f i rs t stage penile size decreases

rapidly

but in

completely;

in

the second stage the

penis

returns

slowly

to i t s normal size. The testes and scrotum

then drop to thei r original

position;

pulse, blood

pressure, and respiration soon return to normal;

the sex flush quickly disappears.

After orgasm the man goes through a refrac

tory period wherein he is

unable

to become r e s t i ~

ulated. This period varies in duration from person

to person - -

usually

taking

longer

as

the

individu

a l ages.

Within

half an

hour

af ter her

orgasm

the wom

an 's

areolae, cl i toris , uterus, and vaginal

barrel

shrink

to thei r original

size.

Unlike the male,

however, the female

does not

experience refraction,

and she

is

capable of another

orgasm

almost immedi

ately.

SEXUAL RESPONSE PATTERN: THEORETICAL ALTERNATIVES

Biphasic Sexual

Response

Helen

Kaplan

has repeatedly

(1974a,

1974b,

1975

and 1976) pointed

out her

bel ief that

Masters

and

Johnson's quadriphasic

model wrongly implies

that the human

sexual

response is

an

orderly se

quence of a unitary and inseparable

event.

Ini

t ia l ly (1974a, 1974b,

and

1975) she was of the o

pinion that a biphasic

pattern

- - unlike that of

Masters

and Johnson

in

that i t included the entire

sexual

response

cycle(s) in

just

the

excitement

and

orgasm

phases

- - more accurately described

sex

ual

psychophysiology

(Fig.

3,

p.

19:

"Sexual

re

sponse

i s

••• actually a well

coordinated

sequence

of two discreet

physiologic

responses: erection


32/111

PSYCHOPHYSIOLOGY

19

Human Sexual

Response:

Kaplan's

View

l

Figure 3: Biphasic sexual response (male and female).

OUl ation

of Stimulation

Figure 4: Triphasic sexual response (male

and

female).

Duration

of Stimulation

1. Figures

3

and

4

i l lus t rate

Kaplan's contention

that

the sexual

response cycle

i s

a

sequence

of discreet

psychophysiologic responses.

Note s :


33/111

20


Notes :

and

ejaculation in

the

male,

and analogously,

lubrication-swelling and orgasm

in

the female"

(1974a, p. 126).

Triphasic Sexual Response

Later (1976,

1977 and 1979) Kaplan expanded

her view

to

include

a

(pre-excitement)

desire

phase.

This f inal, t r iphasic

scheme (Fig.

4,

p.

19)

was theoret ical ly

an

improvement

over both

the classical model of Masters and Johnson,

and

her

own

ear l ier (biphasic) description,

in

that

i t allowed for the incorporation of various sexu

al

appetites

(hyperlibido, hypolibido,

etc . )

within the sphere of human

sexual

responses

- -

a

move she calls "entirely consistent

with

a

psy

chophysiologic

theoretical

orientation"

(1976,

p. 84). Unfortunately,

however,

in

the

absence

of

ei ther confirming

psychophysiologic

studies

or

other

supporting

cl inical

evidence,l neither

Kaplan's biphasic nor t r iphasic descriptions of

the

sexual

response

cycles have been

shown to be

more accurate or more

useful than

that

previous

ly offered by Masters

and

Johnson, and neither

has become widely

accepted

in sex therapy

cir

cles.

lKaplan admits (1977)

that

her psychophysi

ologic

descriptions of the male/female sexual

re

sponse

cycles

are

unsupported

in studies on

hu

mans, and her final tr iphasic construct

i s simp

ly

a ' ~ y p o t h e s i s •••

based

on fragments of cl ini

cal

evidence

and

animal

experiments

and by

analo

gy

with

the physiology of other human appetites"

(p. 4).


34/111

CHAPTER 4

Sexual Function and

Dysfunction

ADEQUATE

AND

INADEQUATE

SEXUAL

FUNCTIONING

Sexual Adequacy

Researchers and therapists have

been unable

to

clinically determine or universally agree

upon

what consti tutes

normal

or

adequate

sexual func

t ioning.

Lazarus

(1969,

p.

53). however,

offers

a

definit ion of sexual adequacy that is applic

able

to and

operable within

most

theoretical

and/

or

cl in ical

perspectives.

In

his

terms,

sexual

adequacy is

"the

abi l i ty to

obtain

and maintain

a

sufficient degree of sexual

arousal so as to

derive

pleasure from

the sex

act

and contribute

to

the

enjoyment

of

one's

partner , f inal ly lead

ing

to orgasmic re1ease.,,1 (This

suggests that

an

adequate

sexual response closely

resembles

the

psychophysiologic response pattern described

by

Masters

and

Johnson.) Interest ingly, Lazarus

does

not

s ta te the

types

of behavior, or describe

the

techniques

by

which this pleasure

is

to

be

a

chieved,

leading one

to

infer that the

way

sexu

al pleasure is obtained

is

to

be determined

by

the needs and

desires

of the individuals concerned.

I Lazarus

,

requirement of orgasmic release

is

the

only controversial element in his

defini

tion.

Most

therapists recognize that orgasmic

response

is

not necessarily

a

personal goal

of

every

person, in every sexual relat ionship, al l

the time.

Therefore, on occasion,

one may

choose

to

modify

this

part of the definition

i f i t is

not applicable to the needs

or goals of the

pa

t ient(s)

involved.

21


35/111

22

SEX THERAPY

HANDBOOK

Notes :

Sexual Inadequacv

A

sexual

response that fai ls to meet the ex

pectations of

either

partner is often

- -

though

not

always

accurately

- -

termed

"inadequate."

Oc

casionally

the

sexual response of any person can

be variously impaired, affecting both performance

and one's subjective evaluation of those experi

ences. When such

an

impairment

actually

interrupts

or significantly changes an individual 's normal

sexual

response cycle, i t

i s termed a sexual

dys

function.

l

At other times.

however. the

supposed

"inadequacy" is

simply the result of unrealistic

expectations that cannot be

fulfi l led. In

these

cases

the problem

l ies with

the

inappropriate ex

pectations,

rather

than

with

the psychophysiology

of the sexual

response cycle.

IDENTIFICATION/CLASSIFICATION

OF

SEXUAL DYSFUNCTIONS

Unfortunately there

is

no universally

accept

ed method or rationale for the clinical identif ica

t ion of human sexual disorders,

and

although

various

systems of

classification

have been recommended

(Croft, 1976; Kaplan 1974a; and O'Connor,

1976;

e tc . ) ,

none

has been broadly

applied

in the pro

fessional l i terature, and no single formulation

has come

into

general cl inica l use. In fact , a

thorough review of the sex

therapy

l i t e ra ture

re

veals

that

sexual dysfunctions

are

most

often

iden

t i f ied simply

by

the

psychophysiologic symptoms

they

exhibit (Hartman

and

Fithian, 1972: Masters

and

Johnson,

1970;

Meyer, 1976; Zussman and Zussman,

1976; etc. ) and then they are often

grouped

accord

ing to

the gender

of

the

patients wherein they oc

cur

- -

when that designation is

essential to ,

or

characteris t ic of,

the disorder.

lSexual dysfunction can be termed ei ther

primary

(when the impairment has always existed)

or seCondary (when i t

occurs after

a period of

sexual

adequacy). Situationally

precipitated

im

pairments

are

considered

secondary

dysfunctions

since

they

follow a

period

of

adequate

sexual

functioninR.


36/111

FUNCTION

AND

DYSFUNCTION

23

PSYCHOSEXUAL

DYSFUNCTIONS:

MALE

Impotence

A male

is

considered

sexually

impotent

when

he cannot obtain

or maintain

an erection of the

penis suitable

for vaginal penetration

1

and

pleasurable coitus (Meyer,

1976).

Primary impotence

Males who have experienced

sat is fac

tory coitus, with

orgasm,

are conisdered to

be

suffering from primary impotence. This is the

case

even though

they

may

relate

a history of sa t

isfactory masturbation to orgasm. The American

Medical Association (1972) notes

that

primary im

potence

is

usually not

precipitated

by

any

single

factor, but

rather, i t is often attributable to a

cluster of

influences

such as family environment,

peer

relationships,

negative

maternal

influences,

religious

bel iefs , homosexual contacts, and se1f

devaluation following

negative

experiences

with

prosti tutes. Furthermore,

i f

the

f i r s t unsucces

fu1 coital

attempt i s t ied to trauma,

an

on-go

ing pattern of fai lure

may

develop.

Secondary impotence

Erecti le

diff icul t ies

arising

af ter

a

period

of adequate sexual functioning comprise

the

cate

gory of

secondary

impotence. Anxiety i s the most

common

et iological factor in this sexual dysfunc

t ion,

even though drugs, alcohol,

diabetes,

and

diffuse

arteriosclerosis may be occasionally in

volved. O'Connor and Stern (1972) suggest that

complaints

of inconsis tent

or select ive potency,

par t ia l or infirm

erection,

and/or

reactive

im

potence

(e.g. ,

following a 14 point drop in the

Dow

Jones

average)

are

a l l descriptive of second

ary impotence.

Premature

ejaculation

TWo different

cr i te r ia are

frequently

ap

plied when distinguishing between

"fast"

or

"quick" ejaculation and

premature

ejaculation.

One

factor used

by

many

clinicians

in

establ ish

ing that an ejaculation

i s

actually

premature,

is the

amount

of time required, after sexual

lMasters and Johnson (1970) make

an

in ter

esting observation regarding penile penetration.

On

their terms i t is not necessary that the penis

successfully

penetrate

a

vagina;

rather,

they

sug

gest

that

any successful intromission,

either

het

erosexual or homosexual,

designates

potency - -

on

Notes:


37/111

24 SEX

THERAPY HANDBOOK

Notes:

stimulation begins, before the male ejaculation.

O'Connor (1976)

reports

that

an

ejaculatory delay

of 1-1/2 - 2

minutes, after

vaginal

penetration,

cannot

be considered premature.

Some

other

cl ini

cians

feel,

however. that the number

penile/

vaginal

thrusts that

take place before

ejaculation

occurs

is

the distinguishing factor in premature

ejaculation. O'Connor and

Stern

(1972)

and

O'Connor

(1976) note that an ejaculatory delay of more than

ten

thrusts

is not premature.

Jon

Meyer (1976),

on the other hand, suggests

that

an

ejaculation

any

time prior to, or during, the f i rs t

fifteen

thrusts

is

premature.

1

Primary premature ejaculation

Fast ejaculatory responses are frequently a

problem

for

young

males

who

have

not

yet learned

techniques for delaying thei r

ejaculations.

Most

often,

however, these "quickies" are not

of dys

functional

proportions. This being the

case, pri

mary

premature ejaculation

is not a common problem.

Secondary premature

ejaculation

Premature ejaculation i s almost always

3 sec

ondary development.

That

is to

say, i t

is a sexu

al ly

dysfunctional

behavior that is precipi ta ted

by situational factors and reinforced by repeti t ion.

1

In Meyer's terms i t

is

also a

premature e

jaculation when the

ejaculation happens

during fore

play ( i f both

partners

had

Intended

to

continue

on

to coitus)

and/or

when the ejaculation occurs

dur

ing, or jus t before, vaginal penetration.


38/111

FUNCTION AND DYSFUNCTION 25

Retarded ejaculation

This psychophysiologic disorder,

which was

earl ier termed "ejaculatory

incompetence"

by

Masters and Johnson (1970), has been defined by

Helen Kaplan (1974b, p. 316)

as

a

"specific

inhibi

tion of

the

ejaculatory

reflex." Jon Meyer (1976)

portrays retarded ejaculation as a

profoundly

slow

ejaculatory response during coitus which, in some

males,

is characterized by a

complete

inabili ty

to

ejaculate intravaginally - -

with the mastur

batory

response

usually not affected.

1

J.F.

O'Connor (1976)

feels

that this dysfunction is

clinically established when a male

cannot

ejacu

late within

45 minutes after

vaginal

penetration.

I t was originally reported

(Masters

and

Johnson,

1970)

that

retarded

e.1aculation

was a

very

rare condition. This impression was la ter

confirmed by

O'Connor and

Stern (1972)

who

re

ported

that retarded

ejaculation

occurred only

once

in every

15,000

males.

Since then, however,

Kaplan (1974b) and O'Connor (1976) have re-exam

ined this phenomenon and both have concluded that

i t is more prevalent

than

previously

thought.

Primary and

secondary

retarded

ejaculation

Masters and Johnson (1970)

note

that retar

ded

ejaculation presents

i t se l f

in

both

primary

and

secondary forms;

and

while

Helen Kaplan agrees

that, in i t s secondary form,this dysfunction

is

not

uncommon, she

suggests that

primary

retarded

ejaculation

is

only rarely encountered in cl in i

cal practice. Thus, i t seems

safe

to conclude

that this sexual disorder

is

most often

brought

on by

si tuational

factors and

maintained as

a

learned or conditioned response.

PSYCHOSEXUAL DYSFUNClIONS:

FEMALE

Orgastic

Dysfunction

Perhaps the most widely recognized

sexual

disorder

in women has been the inabi l i ty to a

chieve

orgasm. At

one

time this was referred to

IHelen

Kaplan (1974b)

notes

that

there

are

cases

of

more severe inhibition

where

the

man

cannot ejaculate in the presence of a

woman -

even with masturbation. Even

in

these cases, how

ever, the masturbatory

ejaculation

i s usually not

affected

i f he

is allowed complete

isolat ion

from females.

Notes:


39/111

26 SEX THERAPY

HANDBOOK

Notes:

as "fr igidi ty ,"

but the pejorative nature of that

term (which was supposed to

designate

only

an in

hibit ion

of the orgastic component of the female

sexual

response cycle) has led to i t s being

re

placed in the clinical nomenclature.

"Orgastic

dysfunction"

or

"non-orgasmia" are the terms

most

often applied.

Primary

orgast ic

dysfunction:

Preorgasmia

Women who

have

never

experienced

orgasm by

any means (masturbation, cunnilingus, coitus,

etc. )

evidence

primary

orgastic

dysfunction. Because

a l l

healthy women

with normal anatomy

are - - theo

ret ical ly

- -

potentially

able to experience orgasm,

those with

primary symptoms might more accurately

be termed

"preorgasmic"

since

their

in i t ia l

orgas

mic

response

s t i l l

awaits

them.

Secondary

orgastic dysfunction

I f orgast ic dysfunction occurs af ter a per

iod of orgasmic response, i t i s considered a

sec

ondary disorder. As Kaplan (1974b)

has

pointed

out,

secondary

orgastic dysfunctions may be either

absolute or si tuational . When

the

woman

cannot

a

chieve

orgasm

under

any circumstances, the dis

order

i s absolute;

i f

she cannot reach climax

on

some occasions,

but

she can on others, i t i s a s i t

uational

orgastic

dysfunction.

Dyspareunia

Painful coitus may be either

organic

or psy

chological in origin,

and

i t may present i t se l f as

either a primary or secondary dysfunction.

Rubin (1968) reports that

about

one-fifth of

a l l the women

who

have been

treated

surgically

for

prolapse of the uterus experience a

loss

of feel

ing

or pain

during

coitus as a result of those

procedures.

Jeffcoate

(1967) notes a 30% incidence

of

apareunia

and

dyspareunia

subsequent

to

combin

ed

anterior

and posterior colporrhaphy. Masters

and Johnson

(1970) have found that vulvovaginitis,

endometriosis,

and

pelvic infections

can

also

bring

on painful intercourse.

Primary dyspareunia

As a primary

disorder dyspareunia

may origin

ate

as an

anxiety reaction to a woman's f i r s t

ex

perience of intercourse. Other causes, such as an

intact

hymen, may cause

pain

during her f i rs t sex

ual experience,

and

the

anticipation of

more

pain

on

subsequent

occasions may keep her from

adequate

sexual

functioning

thereafter.


40/111

FUNCTION

AND

DYSFUNCTION

27

Secondary dyspareunia

Emotions or

physical trauma

may precipi ta te

secondary

dyspareunia.

For example, a woman's

occasional anger toward her sexual partner may

interrupt

her

normal sexual response

cycle,

caus

ing

inadequate

vaginal

lubr ication, result ing in

painful intercourse. Episiotomy scars and

changes in the size of the

vagina

following hys

terectomy

are also

common

causes of secondary

dyspareunia.

Vaginismus

An involuntary

spasm of

the

perivaginal

mus

culature (specif ical ly,

the sphincter

vaginae

and levator

ani

muscles), which

happens

whenever

an

attempt

at

vaginal

penetration

is

made,

i s

termed

vaginismus. This reflex (conditioned re

sponse) of the muscles surrounding

the

vaginal

opening

makes

penetration

very

diff icul t or

vir

tual ly impossible.

On

those occasions

when

vaginal penetration

is accomplished,

the

woman

experiences

l i t t l e ,

i f

any,

sexual

excitement (O'Connor,

1976)

and

the

result ing coital ac t iv i t ie s are

not

pleasurable

for her. As

with

orgastic dysfunction, however,

she

must

not be

automatically

designated

"fr ig id ."

Indeed,

Kaplan (1974b)

correctly

points

out

that

"many

women who seek treatment for vaginismus are

sexually responsive.

They

may

be

orgastic

on

c l i tora l

stimulation,

enjoy sexual play,

and

seek

sexual contact - - as long as this does not lead

to

intercourse" (p.

412 -

413).

Primary vaginismus

This involuntary muscular response

is not

limited to

sexual act ivi ty;

when the precip i ta t

ing anxiety is present, vaginismic

symptoms

will

present themselves whenever vaginal penetration

is

attempted. This

means

that

some women

have

never been able

to undergo a

pelvic examination or

use

a tampon

because this disorder sometimes sur

faces

ear ly in

l i fe .

Secondary vaginismus

Relational

problems, sexual

anxiety,

severe

dyspareunia, and/or sexual trauma, e tc . ,

can

bring

on secondary

vaginismus. Fortunately,

however,

both primary and secondary vaginismus are rare

disorders (Kaplan,

1974b) and

some

sex therapists

have

never

been

called

upon

to

t rea t

them.

Notes:


41/111

28


Notes:

General sexual dysfunction

A female

who i s essent ial ly devoid of sexual

feelings is

said to

suffer

from

general sexual dys

function. Typically

she

does

not

desire sex,

and

derives no sexual pleasure from erotic stimulation.

In many instances she will exhibit l i t t l e , i f any,

vaginal

lubr ication

or swelling, but

she may

s t i l l

engage in

sexual

act iv i ty due to concern for her

sexual

partner . On

the other hand,

she

may active

ly avoid any

type

of sexual

contact, even though

she

knows that

the marital relationship

wil l

suf

fer as

a result .

Primary general sexual dysfunction

A

woman who has

never experienced

sexual

ex

citement,

or

erot ic

p 1 ~ e

with

any

partner ,

in

any

s i tuat ion ,

displays the primary

symptoms

of

this disorder. Psychological, organic, and/or s i t

uational

factors may be

involved.

Secondary general sexual dysfunction

A

woman who presents the

symptoms

of general

sexual

dysfunction, having previously responded

ad

equately to

sexual stimulation,

is

said

to have

this

secondary disorder.

Sometimes these

women re

sponded well

to premarital pett ing, but

they

be

came

dysfunctional

when

the sexual

stimulation

es

calated

to coitus.

Other

women

may

be dysfunction

al only in specif ic si tuations, or for

isolated

periods of time.


42/111

CHAPTERS

Procedural Options for the

Diagnosis and Treatment

of

Sexual Disorders

DIAGNOSIS

Different ial Diagnosis

Diagnostic

terminology

A

sexual

problem

i s

cl inica l ly

designated

a sexual dysfunction when

i t

disrupts,

or evi

dences

a disruption in, an

individual 's sexual

response cycle. A

sexual dysfunction can

be

ei ther

par t ia l

(an occasionally interrupted or a

chronically

weakened response)

or

complete (a

total interruption). Those that have always ex

isted are considered primary, while others that

occur after a

period

of sexual adequacy,

or

s i t

uationally,

are termed

secondary.

Dysfunctions

are termed psychosexual

or

psychogenic when

Eric C. Krohne Ph.D. (Auth.)-Sex Therapy Handbook_ a Clinical Manual for the Diagnosis and Treatment...

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Transcript of Eric C. Krohne Ph.D. (Auth.)-Sex Therapy Handbook_ a Clinical Manual for the Diagnosis and Treatment...