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Sex Therapy: Advances in Paradigms, Nomenclature, and Treatment
Stanley Althof, Ph.D.
Objective: The author reviews the historical paradigms that have inﬂuenced the treatment of sexual problems, changes in the diagnostic nomenclature, and recent innovations in sex therapy. Methods: The author reviews the literature and provides expert opinion. Results: The author gives a historical overview of how theoretical models of understanding human sexuality have inﬂuenced treatment, describes the changes in sexual dysfunction nomenclature, and focuses on the combined medical and psychological treatment of sexual dysfunction. Conclusion: Sex therapy continues to evolve with new paradigms and deﬁnitions for understanding and diagnosing sexual problems and innovative methods of treating sexual problems.
Academic Psychiatry 2010; 34:390 –396
Received October 12, 2009; revised January 1 and February 2, 2010; accepted February 10, 2010. Dr. Althof is afﬁliated with the Department of Psychiatry at the University of Miami Miller School of Medicine in West Palm Beach, Florida. Address correspondence to Stanley Althof, Ph.D., 1515 N. Flagler Dr., Suite 540, West Palm Beach, FL 33401; Stanley.Althof@case.edu (e-mail). Copyright © 2010 Academic Psychiatry
hanges in the ﬁeld of sex therapy are occurring on many levels, including theoretical paradigms, diagnostic nomenclature, treatment interventions, research methodology, assessment measures, development of effective and safe medications, and leadership. We have witnessed transformations in the theoretical paradigms that shape how we think about sexual problems from the classically psychoanalytic to more integrated medical and psychological models. Similarly, treatment interventions have evolved from traditional, ofﬁce-based, individual, group, or couples’ psychotherapy to combining medical and psychological treatments in the ofﬁce or providing treatment over the Internet. In terms of leadership there has been a “changing of the guard” from primarily mental health clinicians to primarily urologists, gynecologists, and primary care specialists. In the 1980s and 1990s, specialized sexuality training centers and programs ﬂourished within academic departments of psychiatry. Today, there are no centers located within departments of psychiatry. This article will review the historical paradigms that have inﬂuenced the treatment of sexual problems, changes in the diagnostic nomenclature, and recent innovations in sex therapy. Depending on the deﬁnition of the sexual disorder, the methodology utilized, and the geographic region, prevalence estimates for sexual problems vary widely. Taking the most conservative estimates, 9% of women suffer from hypoactive sexual desire disorder, 5.1% from female sexual arousal disorder, and 4.6% from female orgasmic disorder (1). In men, prevalence of premature ejaculation is approximately 22%, and the prevalence of hypoactive sexual desire disorder is around 15% (2, 3). Erectile dysfunction is highly age dependent, with prevalence estimates of less than 10% for men younger than age 40 and increasing to more than 40% in men older than age 60 (3). These statistics and the effect of sexual dysfunctions on an individual’s and couple’s quality of life support the need for
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psychiatry’s involvement in research, teaching, and clinical care of individuals with sexual problems. Sex Therapy Sex therapy is a specialized form of psychotherapy that draws on an array of technical interventions known to effectively treat male and female sexual dysfunctions (4). Treatment generally follows the principles of short-term psychotherapy, with the therapist and patient(s) focusing on speciﬁc issues in an individual, couples, or group format. While employing traditional psychotherapeutic techniques such as support, interpretation, confrontation, cognitive reframing, and homework, sex therapy also incorporates technical interventions, such as sensate focus to diminish performance anxiety, stop-start to help patients with premature ejaculation, directed masturbation for anorgasmia, and insertion of dilators paired with relaxation for sexual pain disorders. Psychosexual evaluation goes beyond the conventional mental status examination to examine the patient’s or couple’s sexual history, current sexual practices, relationship quality and history, emotional health, and contextual factors inﬂuencing their lives (e.g., having young children, chronic illness, ﬁnancial concerns). Usually a thorough psychosexual, developmental, and medical history is taken to identify past or current experiences, illnesses, surgery, and medication that may be contributing to the presenting sexual or emotional problem (e.g., past sexual trauma, an oversexualizing parent, diabetes, antidepressant medication). The evaluation seeks to identify all the predisposing, precipitating, maintaining, and contextual factors in the patient’s or couple’s life (5). Historical Contexts and Evolving Paradigms The ﬁrst attempts to describe and classify sexual disorders began with Richard von Krafft-Ebing and his Psychopathia Sexualis (6), which inﬂuenced medical and legal practice for more than 75 years. Observational studies and data quantifying normal and abnormal sexual behaviors were cataloged and ultimately led to the seminal contributions of Ellis (7) and Kinsey et al. (8, 9). Historically, treatments of sexual dysfunctions have been based on prevailing ideologies. Before 1950, psychoanalytical concepts guided clinicians in their understanding and treatment of sexual problems. Sexual symptomatology was linked to constellations of unresolved, unconscious, conﬂict(s) (e.g., oedipal conﬂict, castration anxiety, female immaturity, excessive narcissism, unconAcademic Psychiatry, 34:5, September-October 2010
scious need to debase women) occurring during speciﬁc developmental periods (10 –12). In the late 1950s, the behavioral perspective gained ascendancy. Interventions were modeled after classical conditioning and assumed that the dysfunction was a learned (conditioned) anxiety response. The guiding principle of behavior therapy was to extinguish the anxiety or performance demands that interfered with normal sexual function (13, 14). For example, sensate focus, a series of sensual touching exercises, gradually guides couples to savor sexual touch while extinguishing performance anxiety. Other examples include the stop/start method to treat premature ejaculation and using vaginal dilators and relaxation for vaginismus (15, 16). In 1966, Masters and Johnson (17) reported the ﬁrst results of laboratory observations of male and female sexual arousal and orgasm. Initially they described the physiology of these phases of functioning (arousal, orgasm, and resolution), and later they highlighted the deleterious inﬂuence of performance anxiety (the fear of future sexual failure on the basis of previous failures, which can contribute to all sexual dysfunctions), the effect of relationship factors, and the signiﬁcance of biological factors on the development of sexual dysfunctions (18). Their work foreshadowed the later integration of medical and psychological interventions. Today we have placebo-controlled, randomized studies that demonstrate the negative effect of one partner’s sexual dysfunction on the other’s sexual function and the positive effects of treating dysfunction in both the patient and partner (19). Masters and Johnson’s and Lief’s (20) four-step linear model of sexual response was linear and sequential (Lief added the desire component to the three-step model of arousal, orgasm, and resolution). Alternatively, Basson (21, 22) postulated an intimacy-based circular model of sexual desire for women: women begin lovemaking from a standpoint of sexual neutrality, arousal precedes desire, and that the motivation for lovemaking is emotional intimacy as well as emotional and physical satisfaction. Two studies (23, 24) have tested the validity of the Masters and Johnson model versus the Basson model; it remains too early to conclude which model should prevail. The neo-Masters and Johnson era was heralded by the publication of Helen Singer Kaplan’s book The New Sex Therapy in 1974 (25). She integrated psychoanalytic theory with Masters and Johnson’s cognitive behavior understanding of sexual dysfunction. Distinguishing between recent and remote etiological causations, she recomhttp://ap.psychiatryonline.org 391
mended behavioral approaches for the former and reserved traditional psychodynamic methods for the latter. Throughout this period, the etiology of sexual dysfunction was conceptualized in binary terms—it was either psychogenic or organic. This binary model simpliﬁed treatment planning, especially for men with erectile dysfunction. For example, men diagnosed with psychogenic erectile dysfunction were referred for sex therapy, men deﬁcient in testosterone received hormone replacement, and men with other organic conditions were referred for penile prosthesis. Over time, a third category, mixed erectile disorder, evolved to account for those patients with both psychological and organic factors. Yet “mixed” conveys a static rather than interactive and changeable concept. Disease conditions often change, as do psychological issues. These shortcomings led to the development of the biopsychosocial model, a dynamic and additive model that captures the ever-changing inﬂuences of biology and psychological life (26 –32). Regardless of the precipitating causes, changes in biological and psychosocial domains occur over time. This model encompasses both the psychological life of the patient, the effect of the dysfunction upon the partner and couple’s sexual life, and the ﬂuctuating inﬂuence on sexual function of life style, medication, surgery, and disease. Additionally, the biopsychosocial model enables stepwise treatment recommendations into all three domains. By incorporating these issues into a global assessment of sexual problems, one arrives at a more accurate and comprehensive understanding of what predisposes, precipitates, and maintains the dysfunction. The late 1980s and 1990s ushered in the era of biological discovery, identifying some of the biological underpinnings of sexual dysfunction and the negative effect of life style, aging, disease, medication, and surgery. These ﬁndings ultimately led to the introduction of phosphodiesterase type 5 inhibitor (PDE5i) drugs to treat erectile dysfunction. These medications have dramatically altered the treatment for erectile dysfunction. Physicians have a simple, efﬁcacious, and safe intervention that restores potency in approximately 50 –70% of treated men (34, 35). One might conclude that psychotherapy for erectile dysfunction is an obsolete and antiquated intervention, but given the medication discontinuation rates hovering around 60%, psychotherapy as an adjunct to pharmacotherapy is more relevant than ever. Psychosocial factors may interfere with the use of efﬁcacious treatments (36). Another theoretical paradigm, the dual control model, was set forth by Bancroft and Janssen (37), who believed that simultaneous excitatory and inhibitory systems oper392 http://ap.psychiatryonline.org
ate in parallel and account for both sexual function and dysfunction. They further divided inhibition into two independent dimensions: threat of performance failure and threat of performance consequences. Diagnostic Nomenclature The ﬁrst edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) appeared in 1952 (38). Although it included a section on sexual deviations, sexual dysfunctions were absent. DSM-II was published in 1968 and strongly inﬂuenced by psychoanalytic notions (39). It included two sexual diagnoses: impotence and dyspareunia (painful intercourse). Signiﬁcant changes appeared in DSM-III, published in 1980 (40). Homosexuality was removed from the diagnostic nomenclature and replaced by ego-dystonic homosexuality. Additionally, DSM-III included these sexual dysfunction diagnoses: inhibited sexual desire, inhibited excitement (refers to male and female arousal disorder), inhibited female orgasm, inhibited male orgasm, premature ejaculation, functional dyspareunia and functional vaginismus. In 1987, DSM-III–R removed ego-dystonic homosexuality and added sexual aversion (41). DSM-III-R reﬂected the changing social, political, and scientiﬁc attitudes and the inﬂuence of Masters and Johnson’s and Lief’s four stage sexual response cycle. DSM-IV and DSM-IV-TR changed the names of several dysfunctions and redeﬁned others (42, 43). The following sexual dysfunction diagnoses appear in DSM-IVTR: hypoactive sexual desire disorders for both men and women, sexual aversion disorder, male erectile disorder, female sexual arousal disorder, female orgasmic disorder (redeﬁned in terms of requiring adequate stimulation and high arousal before making the diagnosis), premature ejaculation, male orgasmic disorder (delayed ejaculation), dyspareunia, and vaginismus. Perhaps the most signiﬁcant change from DSM-III to DSM-IV-TR was the inclusion of distress and interpersonal difﬁculty as essential constructs in diagnosing sexual dysfunction. DSM-IV-TR was criticized as being a heterosexist and phallocentric model of sexual behavior. Intercourse was considered the reference standard for many of the diagnoses (44). In response, two consensus conferences comprising a multidisciplinary group of European and North American experts in women’s sexuality were convened in 1998 and 2003 (45, 46) and offered several recommendations on deﬁnitions of female sexual dysfunctions. The Consensus Conference recommended that hypoactive
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sexual desire disorder be renamed women’s sexual interest/ desire disorder. It proposed including sexual receptivity into the diagnosis of hypoactive sexual desire disorder and added absent motivation for sexual behavior to the previous criterion list, which included absent or diminished sexual interest and absent sexual thoughts and fantasies. Female sexual arousal disorder moved away from an exclusive focus on genital arousal (lubrication) to also consider the woman’s subjective experience of arousal and was partitioned into three diagnostic entities: subjective arousal disorder, genital sexual arousal disorder, and combined genital and subjective arousal disorder. Women’s orgasmic disorder was amended to incorporate the need for sufﬁcient sexual stimulation where, despite the report of high sexual arousal/excitement, there is either lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation. Regarding sexual pain disorders, the committee suggested including noncoital sexual pain in the dyspareunia deﬁnition. Finally, the group recommended that persistent sexual arousal disorder, deﬁned as spontaneous, intrusive, and unwanted genital arousal (e.g., tingling, throbbing, pulsating) in the absence of sexual interest and desire, be provisionally included in the diagnostic nomenclature (44). Binik et al. (47, 48) have cogently argued for the reclassiﬁcation of sexual pain disorders to genital pain disorders. They contend that the pain is not sexual per se and should be treated like other pain disorders. Although genital pain disorders can interfere with sexual function, Binik et al. urge a focus on the pain, not the function with which it interferes. The deﬁnition for premature ejaculation has also undergone revision. The criterion set for premature ejaculation promulgated in DSM-IV-TR is persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it; the disturbance causes marked distress or interpersonal difﬁculty and is not due exclusively to the direct effects of a substance. The DSM-IV-TR deﬁnition was criticized for being authority based, excessively vague, and reliant on the subjective interpretation of the clinician (49). In 2008, the International Society for Sexual Medicine convened an expert panel that redeﬁned premature ejaculation as
a male sexual dysfunction characterized by ejaculation which always or nearly always occurs prior to or within about 1 minute of vaginal penetration, and the inability to delay ejaculation on all or nearly all vaginal penetrations, and negative personal conse-
quences, such as distress, bother, frustration and/or the avoidance of sexual intimacy.
The panel concluded that insufﬁcient published, objective data propose an evidence-based deﬁnition of acquired premature ejaculation (49). One ﬁnal note on classiﬁcation concerns comorbidity. DSM-III and IV were heavily inﬂuenced by the concepts of Masters and Johnson and Lief, who proposed the linear, sequential, four-stage model of sexual response. Comorbid sexual dysfunctions were generally not diagnosed in men or women. However, population studies demonstrated that it was not uncommon for women to complain of more than one sexual dysfunction (50). Men, to a lesser degree, also reported experiencing more than one dysfunction. Clinicians were urged to select one diagnosis as primary and the others as secondary, and treatment interventions would initially target the primary diagnosis.
Innovations in Sex Therapy Examples of innovation in sex therapy include incorporating mindfulness techniques for women with complaints of low sexual desire and arousal (51, 52), using the Internet to provide psychological treatment (53, 54), and psychological interventions for women with genital pain (55, 56). Although not treatment innovations per se, advancements in developing validated patient report outcomes are also worthy innovations. Many were initially underwritten by the pharmaceutical industry to test the efﬁcacy of speciﬁc interventions. However, some patient report outcomes could just as easily assess the efﬁcacy of psychological treatment interventions for sexual problems. To assess the efﬁcacy of erectile dysfunction interventions, the International Index of Erectile Function is the gold standard (57). The Index of Premature Ejaculation is also an excellent measure that evaluates interventions (58). The Female Sexual Function Index, in concert with the Female Sexual Distress Scale—Revised measure, is helpful in diagnosing and measuring efﬁcacy of interventions for female sexual dysfunction (59, 60). I believe that combination medical and psychological therapy ranks as the top innovation. Clearly this is not a new innovation to psychiatry—for years it has been the standard of care for depression and employed in treating childhood anxiety, schizophrenia, and posttraumatic stress disorder (61, 62). However, combination therapy is relatively new to sex therapy. It addresses the relevant biological, medical, and psychosocial issues that predispose, precipitate, and maintain sexual dysfunction and is the natural evolution for the biohttp://ap.psychiatryonline.org 393
Academic Psychiatry, 34:5, September-October 2010
psychosocial model. Combining medical and psychological interventions harnesses the power of both treatments to enhance efﬁcacy, increase treatment, and relational satisfaction, and decrease patient discontinuation (63). Combination therapy also provides patients with rapid symptom amelioration, thereby “jump starting” the treatment process. Psychological intervention alone may be time consuming and costly and fail to yield rapid symptom amelioration. Conversely, medical treatments for sexual dysfunction are narrowly or mechanistically directed at sexual function and fail to address salient psychosocial issues. The majority of combination therapy studies have focused on treating erectile dysfunction and combining sildenaﬁl with various psychoeducational interventions, such as a 90-minute psychoeducational meeting, weekly group psychotherapy, and infrequent individual counseling (64 – 69). Studies have also combined intracavernosal injection or vacuum pump therapy with psychological intervention (70 –72) with results leading to improved efﬁcacy of the medical intervention, decreased discontinuation of treatment, and improved sexual satisfaction over medical therapy alone. Given the interrelated biological and psychological etiologies of female sexual dysfunctions, it is likely that combination medical and psychological therapy will ultimately signiﬁcantly beneﬁt women. No female sexual dysfunction drug has been approved in the United States, although Intrinsa (a testosterone patch) has been approved in Europe for hypoactive sexual desire disorder. It would be naive to expect a tablet, patch, or cream targeted at a sexual symptom to rapidly reverse the dysthymia, anxiety, and/or interpersonal problems that often accompany female sexual dysfunctions. Similarly, although no medications are approved for premature ejaculation in the United States, selective serotonin reuptake inhibitors (SSRIs) have been effectively used. Combining SSRIs and psychotherapy could offer signiﬁcant beneﬁts (73). Teaching men, especially those with acquired premature ejaculation, methods to monitor their arousal and delay ejaculation may improve the efﬁcacy of the SSRI. Combination therapy for premature ejaculation also targets interpersonal issues and the psychosocial effect on the man and/or the partner. Before uncritically accepting combination therapy, more research is warranted. To be convincing, such studies should be controlled comparisons of a medical intervention alone versus medical intervention plus some form of psychotherapy. Validated patient report outcomes should assess differences in efﬁcacy, and data regarding discontinuation should also be captured.
Conclusion Schover and Leiblum (74) wrote about the stagnation of sex therapy in 1994 and criticized clinicians for failing to develop innovative sex therapy techniques. Others believed that with the introduction of the safe and effective PDE5i drugs, sex therapy would wither away. On the contrary, sex therapy seems very much alive and continuing to evolve, as is evident in the development of new theoretical paradigms, advances in the deﬁnitions of male and female sexual dysfunction, and the introduction of new treatment interventions that require further assessment. Psychiatry seems to have marginalized the treatment of traditional sexual dysfunctions. For instance, psychiatrists account for only 2% of all the PDE5i prescriptions written, which led drug companies to strategically stop marketing these agents to them. This is surprising given that many of the medications psychiatrists routinely prescribe lead to decreased sexual function. There is a great deal that mental health clinicians can offer individuals and couples with sexual dysfunction. Little exposure to sex therapy during training sends a signal that sexual life is not within the province of psychiatry. Residents and other trainees require supervision to assist them in learning treatment techniques for sexual dysfunction. It is genuinely surprising that interns and residents tend to ignore/bypass the sexual issues of patients they are treating for other disorders. This lack of enthusiasm is also reﬂected in the paucity of grand round presentations on sexuality in academic departments of psychiatry. We need to do more to interest our colleagues and students to bring sexual therapy back into the mainstream of psychiatry, perhaps by offering to present mini-courses/seminars on sexuality topics as part the training curriculum; presenting the results of our research to interested colleagues; and developing interdisciplinary training experiences for psychiatric residents.
Dr. Althof has provided full disclosure from several public and private sources that are available upon request.
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