All psychological disorders present challenges to therapists, and sexual dysfunction is no exception. However, it is unique because of the variety of the disorders that are encompassed by the term and the prevalence rates of the disorders. A recent epidemiological study found overall rates for sexual dysfunction in men and women were 31% and 43%, respectively (Laumann et al., 1999), highlighting a need for effective treatments for sexual problems. This chapter will focus on the evolution of theory and practice in sex therapy. Each sexual dysfunction will be addressed separately, with a specific focus on the most current and empirically supported treatments available to remedy each problem.
Each sexual dysfunction is characterized by the stage of the sexual response cycle that is affected and is defined by a change in sexual functioning that causes distress to the individual and interpersonal difficulties (American Psychiatric Association, 1994). William Masters and Virginia Johnson (1966) first described the stages of the sexual response cycle. These stages consist of the desire phase where one feels the urge to have sex, the arousal phase where one has increased physiological excitement such as higher heart rate and blood pressure, the orgasm phase where reflexive muscle contractions occur in the pelvis, and finally the resolution phase where the body returns to its pre-arousal state. Sexual dysfunction can occur in any of the first three stages of the sexual response cycle but does not occur in the latter phase.
Desire disorders consist of hypoactive sexual desire and sexual aversion (American Psychiatric Association, 1994). Hypoactive sexual desire results from a person having little or no interest in sex or in engaging in sexual activity. However, when sexual activity does occur, the person does not experience emotional distress. Contrarily, people who experience sexual aversion feel negative emotions, such as disgust or fear, when they engage in sexual activity at the insistence of a partner.
Disorders that occur during the arousal phase of the sexual response cycle are female sexual arousal disorder and male erectile dysfunction (American Psychiatric Association, 1994). Sexual arousal disorder is diagnosed in women when there is an inability to maintain lubrication of the vagina or genital swelling. Erectile disorder is diagnosed when there is a failure to obtain or maintain an erection until completion of sexual activity.
Finally, disorders that occur during the orgasm phase of the sexual response cycle are female orgasmic disorder, male orgasmic disorder, and male premature ejaculation (American Psychiatric Association, 1994). Female and male orgasmic disorders are described as a complete absence of orgasm or a delay in the experience of an orgasm during sexual activity. However, though female orgasmic disorder is relatively common, it should be noted that male orgasmic disorder is quite rare among cases seen for sexual dysfunction. It is much more common for a man to present for sex therapy due to premature ejaculation. This disorder is difficult to define, but it is generally classified as a male reaching orgasm with minimal stimulation and before he or his partner want it to occur usually prior to or shortly after entry of the penis into the vagina.
There are two sexual disorders that cannot be defined by the stage of the sexual response cycle in which they occur. These problems are labeled as sexual pain disorders. Dyspareunia is genital pain that is experienced during sexual intercourse, and vaginismus is defined by involuntary contractions of the outer third of the vagina so that entry of the penis or another object such as the finger cannot take place (American Psychiatric Association, 1994).
There are certain overarching themes that each treatment approach supports when explaining the causes of sexual dysfunction. The manner in which sexual dysfunction is addressed in psychoanalytic theory dates back to Sigmund Freud's (1905/1965) writings on personality development. These writings stressed that sexual dysfunction results from a person failing to progress through the oral, anal, and phallic stages of psychosexual development into the genital stage by not resolving the oedipal complex. A healthy transition through these stages occurs when the child is able to progress through the oedipal conflict by behaving like and identifying with the same sex parent. If a person did not progress through the stages and resolve the oedipal conflict, s/he would experience sexual dysfunction in some form in adulthood. Therapy that was insight oriented was recommended in order to aid the client in resolving past issues regarding sexuality.
Current psychodynamic therapy incorporates both Freud's early ideas as well as more modern ideas. Some psychodynamic therapists focus treatment on making unconscious inhibitors of sexual functioning conscious through the course of therapy, while stressing that it is not only important to understand the sexual functioning problem but also the individual's personality development and defense mechanisms that may inhibit change (Rosen, 1982). This treatment relies on the patient to be the motivating person behind change without relying on specific behavioral training techniques. Other psychodynamic therapists use not only psychodynamic techniques, such as working through transference, but apply behavioral or pharmacotherapeutic techniques to best aid the client (Gabbard, 2000). This approach to diagnosing and treating sexual dysfunction relies heavily on the therapist to examine the client's presenting problem and prescribe the treatment method thought to have the best results (Gabbard, 2000). Psychodynamic therapy for the treatment of sexual dysfunction is practiced by a small percentage of psychotherapists and is not supported by the majority of research on sexual disorders.
Behaviorists challenged the psychoanalytic view of sexual dysfunction. Early behaviorists believed that sexual dysfunction resulted from anxiety (Wolpe, 1958). Behaviorists stressed that anxiety inhibited sexual arousal in some way, or was, at the very least, incompatible with arousal. They used systematic desensitization to remedy the problem. The client would be taught relaxation therapy techniques. While practicing these techniques, the client would visualize a self-made hierarchy of sexual behavior. When this process was mastered, the client would then engage in the sexual behaviors while still practicing the relaxation techniques. Although this technique provided help for some clients experiencing sexual dysfunction, it was unsatisfactory for solving many sexual disorders.
Masters and Johnson (1970) expanded the behavioral focus to include early experiences as contributors to sexual dysfunction. They stressed the need for anxiety reducing therapeutic techniques as well as helping the client to learn sexual stimulation procedures. Specific sexual behavior training came in the form of sensate focus, which outlines certain techniques to aid the couple in overcoming anxiety that contributes to sexual dysfunction.
With the advent of the cognitive-behavioral approach, therapy for those with sexual dysfunction was expanded to include a client's cognitions regarding sexuality. Albert Ellis (1962) introduced the idea, but it was expanded upon by later theorists and researchers. Some cognitive factors that may contribute to sexual dysfunction are gender identity conflicts, fears of having children, depression, or religious orthodoxy.
One final general area that has contributed to the current state of knowledge about treating sexual dysfunction is the research on systemic couples therapy. Couples therapists believe that sexual dysfunction experienced by one partner is the result of or is perpetuated by the interactions of the couple. It was first stressed by systemic therapists that sexual dysfunction caused great distress to both members of the couple. More recently, theorists propose that the disorder may also serve some helpful functions within the couple's relationship (LoPiccolo, 2002). According to this perspective, the sexual dysfunction exists in the relationship because it serves a purpose, and helping the partner to overcome his or her problem serves to change the balance in the relationship. This shift, if not monitored by the therapist, can contribute to other problems in the marital dyad. Certain systemic problems that can serve to maintain a sexual disorder are lack of trust, fear of intimacy, power imbalance in the relationship, and an inability to reconcile feelings of love and sexual desire (LoPiccolo, 2002).
Female sexual arousal disorder is often seen in conjunction with orgasm or desire problems. One study showed that 14% of women in the general population report lubrication difficulty (Laumann et al., 1999), but this problem is known to increase in postmenopausal women (Rosen et al., 1993). There is more information available about female orgasmic disorder, and as many as 24% of women experience orgasm difficulty at some time (Laumann et al., 1999). Women can experience either primary (global and lifelong) or secondary (situational and/or not lifelong) orgasmic dysfunction. The former term refers to women who have never had an orgasm, while the latter term refers to women who have infrequent orgasms or can have orgasms only in certain conditions. It should be noted that in order to achieve orgasm, a woman must be able to sustain arousal over time. Because the specific etiology of female sexual arousal disorder is linked so closely with orgasmic dysfunction, the conceptualizations for the disorders will be combined.
Early psychoanalysts believed that a woman who had successfully entered the genital stage would have vaginal orgasms (Freud, 1905/1965). Present psychodynamic therapists believe in order to best address female orgasmic disorder, the issues of anxiety and conflict within the relationship must be reconciled (Rosen, 1982). It is not necessary that the woman be able to progress to the vaginal orgasm, but it is important that she understands herself in relation to her partner in order to be able to attain orgasm. For example, this woman, through examining her feelings about her partner and past relationships, can learn important insight into why she is unable to reach orgasm with her husband. It may be that she internalized negative feelings associated with being close to people for fear that they will hurt her and is now acting these feelings out with her husband.
Present day cognitive-behavioral therapists apply the general ideas of the theory in order to address sexual functioning. The cognitive-behavioral therapist will interview the client to find out the cognitions that may be interfering with her ability to achieve orgasm. The therapist then prescribes cognitive techniques to change these problematic thoughts as well as behavioral techniques to aid the woman in becoming orgasmic (LoPiccolo and Lobitz, 1972).
Systemic couples therapists traditionally view sexual dysfunction as a reflection, cause, or effect of other nonsexual issues that are problematic in the couple's relationship (Whitaker and Keith, 1981). All couples therapy relies upon both members of the couple dyad to participate in therapy. Masters and Johnson (1970) were two of the first researchers to rely upon both members of the marital dyad for changing a sexual dysfunction. Others (e.g., Schnarch, 1991) expanded this idea giving both members of the couple specific duties to perform to help the woman achieve orgasm.
Although all the therapies described have been utilized to treat female arousal and orgasmic disorders, the most support for treating this problem is an integrated approach to therapy. This integrated approach looks to tenets of cognitive-behavioral and systemic therapy as well as any physiological or medical factors that may contribute to the problem (LoPiccolo and Lobitz, 1972; Heiman and LoPiccolo, 1988). In order to best assess the client's problems in any or all of these areas, the initial interview is paramount. The therapist who practices integrative therapy will meet with the couple together and then each member of the couple separately to ensure that all the information relevant to treatment is gathered.
The case conceptualization would continue by getting a thorough orgasmic history. The couple should be asked questions about what they have tried to aid the woman to have an orgasm. It is important to find out information about their expectations about sex and how often or during what activities a woman ‘should’ have an orgasm. The therapist should gather information on areas of family of origin learning history, cognitive factors, relationship factors, and any operant issues in daily life, such as day to day stress, that may contribute to the problem. The therapist should also make sure that the woman has had a gynecological exam to rule out or diagnose any problems that may interfere with her ability to achieve orgasm.
The spastic contractions associated with vaginismus are reported by as many as 12–17% of women who present for treatment at sex therapy clinics (Spector and Carey, 1990). Women presenting with vaginismus can have primary vaginismus where the spasms occur in any type of situation or secondary vaginismus where the spasms may occur only when penetration of some type may occur (Rosen and Leiblum, 1995). Some psychodynamic therapists view vaginismus as a means women use to either reject their role in a relationship with a man or as a physical manifestation of a fear of being violated by a male (Kaplan, 1974). Others stress the importance of factors that coincide with the beliefs of many cognitive-behavioral and systemic couples therapists (Gabbard, 2000). For example, problems such as sexual fears or a history of sexual abuse are thought to contribute to vaginismus. Therapists who adhere to this modern view of the problems contributing to vaginismus will use not only dynamic techniques to aid the client but also behavioral techniques deemed relevant (Gabbard, 2000).
Cognitive-behavioral therapists associate the spastic contractions with a fear response that may be caused by a real or imagined instance where vaginal penetration could occur (Masters and Johnson, 1970). It has been found that sexual fears and phobias as well as a history of sexual abuse are associated with vaginismus (Leiblum, 2000). Vaginismus, in this view, is due not to physical problems but due to psychological problems experienced by the woman. The cognitive-behavioral therapist helps the woman to deal with these negative associations and teaches her other techniques to stop the vaginismus.
Couples therapists conceptualize the disorder similarly to the cognitive-behavioral therapists. Couples therapists believe, as in other sexual disorders, that both partners are crucial for success. As in female orgasmic dysfunction, it is thought that the vaginismus may serve to take the focus from another problematic area of the couple's relationship (Whitaker and Keith, 1981). Couples therapists would then conceptualize the problem as not only the vaginismus but the couple's relationship, and they look to the couple's relationship as a whole in order to find where to best intervene.
An approach that integrates some aspects of all of these therapies is most often used for understanding the contributing factors to vaginismus. A thorough history should be taken and vaginal exam given to ensure that the problem is vaginismus and not related to a physical problem (LoPiccolo and Stock, 1986). Once this has been established, the therapist identifies which factors contribute the most to the present problem. The therapist will often combine tenets from cognitive-behavioral therapy, such as relaxation techniques, to help the woman to gain control over the spasms. Leiblum notes that in most cases of vaginismus, some therapy must be performed to have the couples discuss any fears about penetration or any problems that have arisen due to the couples inability to have intercourse. She goes on to describe some cognitive contributors to vaginismus. These include erroneous ideas about the size of the vagina and the changes that the woman's body undergoes during arousal that differentiate it from the normal unaroused state. Because this process can be very difficult, especially for the woman with primary vaginismus, it is important that the therapist be flexible with the prescribed techniques. Helping the client to relax and trust the therapist is essential in aiding the woman to be able to address her vaginismus.
The diagnosis of dyspareunia is given to women who describe pain during intercourse. It is often difficult to differentiate from vaginismus because many women who complain of vaginismus also complain of pain (Leiblum, 2000). Pain during intercourse has been shown to be experienced by 7% of women in one national sample (Laumann et al., 1999) and as many as 10–15% of women reporting for outpatient treatment (Rosen et al., 1993). This makes dyspareunia a likely problem for a sex therapist to treat.
Psychoanalytic writings do not address the idea of dyspareunia in great depth. However, it is thought that the same types of factors that can contribute to any sexual dysfunction are relevant for dyspareunia. These include the failure to progress through the stages of the sexual response cycle adequately, unresolved feelings about sexuality, guilt about sexuality, or any sexual traumas (Rosen, 1982). Additionally, treatment will consist of dynamic as well as possibly behavioral interventions (Gabbard, 2000).
Cognitive-behavioral therapists take a similar view to dyspareunia as they do to vaginismus. Although the presence of a physical problem contributing to the pain the woman is experiencing is recognized (Steege and Ling, 1993), it is believed that much of the problem can be dealt with by using standard cognitive-behavioral techniques. As it is the case that many women who are treated for dyspareunia by surgical means have some lingering problems (Schover et al., 1992), cognitive-behavioral techniques are very useful to aid in completely remedying the problem. Therapists using these techniques believe that the client's fears about pain during intercourse can continue even when there is no more physical problem. The therapist will use specific behavioral and cognitive techniques in order to help the woman overcome any lingering problems associated with the dyspareunia.
Couples therapy addresses dyspareunia in much of the same way it addresses other sexual dysfunction. Couples therapists will rely on both members of the dyad to be present for therapy. They conceptualize the problem as being sustained by the interactions of the couple and look to change these interaction patterns to help aid the woman in overcoming the pain she experiences during genital contact.
A modern integrated approach to understanding dyspareunia takes into account multiple factors that can contribute to dyspareunia. A thorough history taking is again prescribed where the client's pain is described by the location, quality, types of activities that elicit the pain and the length of time the pain lasts, as well as other factors; furthermore, it is important to understand what brought the woman to treatment as well as her coping strategies for dealing with the pain over time (Binik et al., 2000). Because cases of purely psychogenic dyspareunia are rare, there are not specific therapies outlined for this. However, there is reported success in using tenets of cognitive-behavioral therapy outlined for arousal and orgasmic dysfunctions to treat women with dyspareunia (Bergeron et al., 2001).
Males who present with erectile disorder have problems obtaining or maintaining an erection. This problem has been found to affect 5% of the general population in one epidemiologic study (Laumann et al., 1999) and is most common in older men. Psychodynamic therapists currently view erectile disorder as resulting from a variety of conflicts and anxieties about intimacy and sexuality. It is also thought that the erectile problem may stem from arousal toward or guilt about some deviant sexual fantasy (Rosen, 1982). In each case, the unique convergence of this set of anxieties and conflicts must be understood along with behavioral and pharmacologic interventions in order to best aid the client.
Cognitive-behavioral therapists look to help the client uncover what ideas he possesses that can serve to perpetuate the erectile problem and look to behavioral techniques that will help to restore functioning. Some general cognitive distortions that are common to erectile failure have to do with unrealistic expectations about the man's sexual abilities. Also, a lack of knowledge about the changes that take place in older men regarding erectile response (i.e., slower response, need of more direct stimulation, longer refractory period after ejaculation, and an inability to ejaculate during intercourse every time) occurs (Schover, 1984). This may lead to added distress and anxiety experienced by the male, which also contribute to erectile failure (LoPiccolo, 1992). It is also important to gauge the amount of sexual stimulation the man is currently getting as well as the woman's preferences for sexual gratification as it may not depend on the man obtaining an erection.
Couples therapists rely on many methods used by the aforementioned therapies. They too would take a thorough history encompassing the couple's views about sexuality and the male's sexual response. They would focus on issues pertinent to how the couple is affected by the erectile problem, what has been tried to remedy the problem, and what the couple's expectations about sexual functioning are.
The most common treatment for male erectile disorder involves an integrative approach combining pieces of the cognitive, behavioral, and couples therapy models as well as treatment with Sildenafil citrate (i.e., Viagra). Current therapists stress the importance of the potential for both psychological and physiological problems that contribute to erectile dysfunction (Carson et al., 1999). For this reason, even when it seems that the problem is due mainly to psychogenic factors, it is necessary for the client to have a physical examination. As indicated in the section on cognitive-behavioral therapy, there are many cognitive factors that can contribute to erectile problems and exacerbate prior problems that have occurred with erectile functioning. It is also important to take a thorough history to gauge any individual, relationship, family of origin, or operant factors that may contribute to the erectile dysfunction (LoPiccolo, in press). Some indications that organic causes may be contributing to the erectile disorder include the presence of adequate manual or oral stimulation that do not help to produce an erection and no serious relationship factors accompanying the problem. The assessment of erectile dysfunction can be measured by self-report inventories or by physiological measures such as the recording of nocturnal penile tumescence.
Premature ejaculation is the most commonly reported sexual dysfunction in males. One study reported 21% of men in the general population had rapid ejaculation problems (Laumann et al., 1999). Psychoanalytic therapists do not believe there is necessarily one explanation for rapid ejaculation (Kaplan, 1974). However, it has been suggested that premature ejaculation could be due to problematic masturbation practices combined with sexual fears such as being overwhelmed by sexual excitement (Rosen, 1982). Most psychodynamic therapists today view an integrated approach that includes psychodynamic understanding and behavioral intervention as optimal (Gabbard, 2000).
Cognitive-behavioral therapy views rapid ejaculation as a problem that can be solved with behavioral training. In fact, the most successful therapy used for premature ejaculation was devised by Semans (1956) and modified by Masters and Johnson (1970). This therapy is based upon the idea that the man who is rapidly ejaculating can control this process by learning certain behavioral techniques that monitor his sexual excitement as well as by increasing his orgasm threshold.
Couples therapists believe that the partner of the man who is experiencing premature ejaculation plays an important role in helping the man to stop or limit his rapid ejaculation. The integrative postmodern model illustrates this idea well (LoPiccolo, 2002). Because the woman has been frustrated by her partner's rapid ejaculation and has often been silently suffering, it is important to include her in therapy. The integrative model suggests that the woman will more happily participate in the behavioral techniques outlined by Semans (1956) and Masters and Johnson (1970) if she is receiving immediate returns on her hard work. That is, the man and his partner should agree upon a time when she will also be able to experience sexual pleasure apart from the time when she is helping him with his therapy. As always, it is important to include in therapy the systemic couple issues that may serve to impede therapeutic progress.
Males who experience inhibited ejaculation are rare in clinical populations. However, the problem of inhibited ejaculation is more often seen in homosexual men (Wilinsky and Myers, 1987). Psychoanalytic therapists believe that inhibited ejaculators are stopping themselves from having an orgasm for reasons ranging from a hatred of or disgust for women (Kaplan, 1974) to early childhood conflicts that were not fully resolved and inhibit the man from fully letting go and experiencing orgasm (Rosen, 1982). Whatever the reason for the presenting problem, it is thought that this dysfunction can be difficult to treat due to the many confounding factors that contribute to the disorder.
Cognitive-behavioral therapists view male orgasmic disorder similarly to female orgasmic disorder (LoPiccolo and Stock, 1986). The aim of treatment is to decrease anxiety, increase arousal or desire, and help the client to deal with any conditioning factors that may have contributed to the current problem.
Couples therapists would look to the relationship to see what factors may be contributing the orgasmic disorder. This is best illustrated by the integrative model that includes systemic issues in the treatment of inhibited ejaculation. The model treats male orgasmic disorder by reducing performance anxiety and ensuring adequate stimulation (LoPiccolo and Stock, 1986). The integrative model also notes that in certain cases, neurological disorders may be contributing to the dysfunction. It is important that all possible contributing factors be taken into consideration when devising the best treatment for the client.
Both men and women can experience low sexual desire and aversion to sex. Although women report both disorders at greater rates than men, it has been found that 22% of women and 5% of men endorse low desire in the general population (Laumann et al., 1999). Low sexual desire and aversion to sex are viewed by psychoanalytic therapists as resulting from unresolved sexual issues as well as issues of anxiety about the relationship and what it would mean to the person to have sexual desire. Cognitive-behavioral therapists believe that it is important to help the client identify any negative thoughts they have about sex or sexuality that contribute to their desire to not have sex (LoPiccolo and Friedman, 1988). The cognitive-behavioral therapist will then use this information in structured cognitive exercises as well as behavioral techniques.
Lastly, systemic couples therapists stress the importance of identifying that the client presenting for therapy may be reluctant to overcome the problem if s/he feels as though s/he is being treated as the bad person or there are systemic issues contributing to the problem (LoPiccolo, 2002). For this reason, it is important to identify these issues and use them to help therapy rather than hinder it. Systemic therapists also stress the importance of recognizing the disorder as a way in which the relationship functions rather than focusing on the aspect of the sexual dysfunction (Schnarch, 2000).
As in the other sexual disorders described, the most common treatment for either disorder is an integrated approach. It combines the use of the cognitive and behavioral techniques as well as the systemic issues that serve to keep the disorder present in the relationship. It relies on education about sexual desire and the fact that all humans do have a sex drive. LoPiccolo (2002) notes that therapy should stress that this is a loss to the person to not have a sex drive and that it is not a choice that the person consciously made. It should be stressed to the client that therapy can help to remedy the situation. However, in cases of sexual aversion, it is very important to deal completely with the cause of the aversion. In some cases the aversion may be due to sexual assault as a child or adult. In these cases, it is recommended that using techniques described by Courtois (1988) for survivors of child sexual abuse or Foa (1997) for survivors of rape be used. Therapy for the desire disorder or aversion to sex should follow treatment for the sexual abuse. Courtois outlines a therapy that includes traumatic stress, feminist, and family systems models to address the incest directly. She uses cathartic exercises such as body awareness and saying goodbye, cognitive restructuring, and many other techniques that allow for the client to progress through treatment. Foa utilizes cognitive-behavioral techniques such as cognitive restructuring and in vivo exposure to address the client's problems stemming from rape.
There is no controlled outcome research that examines female arousal disorder specifically, but the research on orgasmic disorder can also be applied to female arousal disorder because of the closely linked nature of the disorders. Early research showed that masturbation provided the best method for helping women achieve orgasm (Masters and Johnson, 1966). Research also supported the notion that the more the vaginal muscles are used and strengthened by exercises, the more likely it is that a woman has increased genital sensation and orgasm (Kegel, 1952). These findings helped contribute to the integrative approach in dealing with female orgasmic disorder (LoPiccolo and Lobitz, 1972). This treatment method can be used in an individual or couples therapy format. Using this treatment method, one study showed that 95% of 150 women were able to reach orgasm due to their own masturbation, 85% were able to reach orgasm due to partner stimulation, and 40% were able to reach orgasm during intercourse (LoPiccolo and Stock, 1986). Another study showed that when compared with sensate focus (Masters and Johnson, 1970) combined with supportive therapy, the integrative approach helped more women to attain orgasm (Riley and Riley, 1978). The self-help book that outlines the same integrative approach (Heiman and LoPiccolo, 1988) has also been shown to be effective in aiding women to overcome orgasmic disorder (Morokoff and LoPiccolo, 1986).
The above research supports the idea of an integrated approach for treating female orgasmic disorder. Treating women with secondary orgasmic dysfunction can be more difficult. One study found that using the integrative approach with secondary inorgasmic women did not significantly help the woman to increase her experience of orgasm with genital caressing by a partner or during intercourse (McGovern et al., 1975). It is suggested from this and other research that a treatment method focusing more on general marital difficulties combined with sex therapy is more appropriate for these women.
Group therapy is another treatment modality that has been used to treat women with orgasmic dysfunction. Research has supported that directed masturbation training in a group therapy format resulted in a 100% success rate of women being able to achieve orgasm (Wallace and Barbach, 1974). Another study found that group therapy worked better for women under 35, but partner understanding and cooperation was a key factor in aiding the women in achieving orgasm (Schniedman and McGuire, 1976).
Research on vaginismus is not as prevalent as research on orgasmic dysfunction in women. A recent review found that there are few studies that compare the available treatments for vaginismus (Heiman, 2002). However, there is some research available on the efficacy of treating women with vaginismus. In a review of the literature on sexual dysfunction, LoPiccolo and Stock (1986) concluded that research on using dilator insertion to aid the woman in overcoming her vaginismus is equally effective whether it is performed by the client or a gynecologist.
Outcome research has shown support for both dilator insertion techniques as well as general sex therapy techniques. Specifically, Hawton and Catalan (1986) used sex therapy techniques derived from Masters and Johnson (1970) as well as dilator insertion to aid women with a diagnosis of vaginismus. Treatment included both the woman and her partner. The findings supported an 80% success rate for those women who completed therapy. Success was aided by the couples’ motivation to be in therapy and relationship before therapy. Future research should focus on comparison studies to test the efficacy of different treatment models for overcoming vaginismus. To date, there are no such studies.
Unlike other sexual disorders, dyspareunia involves a definite physical problem that is contributing to the pain. The most common problem associated with dyspareunia is vulvar vestibulitis (i.e., inflammation of the area between the labia minora) but other conditions such as poor lubrication and vulvar atrophy can contribute to dyspareunia (Binik et al., 2000). Treatment for dyspareunia often involves a medical procedure (i.e. usually vestibulectomy), but research supports therapeutic techniques whether they are delivered with or without the surgical procedure (Bergeron et al., 2001).
A recent study has the best evidence for treatment efficacy. Bergeron et al. (2001) assigned clients to one of three treatment conditions, including group cognitive-behavioral therapy, surface electromyographic feedback (sEMG), and vestibulectomy. Treatment success was measured by less pain, better sexual functioning, and good psychosocial adjustment. For those who participated in the cognitive-behavioral therapy, 40% of the women showed significant improvement. The women who underwent vestibulectomy had a 65% success rate, and 30% of women in the sEMG condition showed significant improvement. This study shows some support for the success of different treatments of dyspareunia, but more research, including randomized controlled studies, is needed to gauge effectively the best types of treatment for women presenting with pain disorders.
Although Viagra has become a prevalent treatment for erectile dysfunction, psychotherapeutic techniques are often important to best aid treatment outcomes. However, research involving psychotherapeutic techniques for erectile dysfunction is mixed. Most therapy involves the man and his partner, but there has been some research on men who present for treatment without a partner. Using a group therapy format focusing on sexual attitude change, masturbation exercises, and social skills training, it was found that the men showed improved self-esteem and sexual satisfaction when compared with a wait-list control group; however, there was only a trend toward improvement in erectile functioning (Price et al., 1981). Another study using different group therapy techniques showed significant improvement in erectile functioning for those who participated in therapy as opposed to the wait-list control group (Kilmann et al., 1987).
Research on therapy involving couples is more prevalent. Educational procedures for older men with erectile disorder have been shown to help improve sexual knowledge as well as frequency and satisfaction of sex (Goldman and Carroll, 1990). In another study, general sex therapy techniques outlined by Masters and Johnson (1970), helped 68% of males presenting with erectile disorder showed some improvement during therapy (Hawton and Catalan, 1986). This same study also supported factors such as good communication by the couple and high motivation for therapy to be helpful in achieving and maintaining change. Other research has suggested contributing factors to erectile dysfunction, but there are no controlled studies evaluating the efficacy of these ideas for treating clients. Specifically, it has been suggested that anxiety is not the main contributor to psychogenic erectile problems but cognitive distortions or performance demands may be more important (Rosen, 2000). It has also been suggested that support from the client's partner surrounding issues of sexuality is an important factor in effecting change (LoPiccolo, in press). However, no research to date has examined these factors in the influence of erectile dysfunction.
The standard treatment procedures for premature ejaculation are outlined by Semans (1956) and Masters and Johnson (1970). In his initial research, Semans (1956) reported long-term gains for 15 men he had treated with the pause technique. Masters and Johnson (1970) reported success rates of 90% for men treated with the pause and squeeze combined procedure. Other research has shown improvements in premature ejaculation for men participating in cognitive-behavioral as well as retraining programs (Kilmann and Auerbach, 1979). Another study, using standard treatment for premature ejaculation, including partners, found that 65% of men who completed treatment showed some improvement in increasing time to ejaculation (Hawton and Catalan, 1986). However, it has also been shown that the long-term benefits of the pause and squeeze technique are not as good as the initial outcomes (D'Amicis et al., 1985).
Research is lacking on the efficacy and effectiveness for treating male orgasmic disorder. Masters and Johnson (1970) reported that when using their standard sex therapy techniques, 14 of 17 men treated for orgasm difficulties were able to attain orgasm during some form of stimulation. Hawton and Catalan (1986) used these same therapeutic techniques and were able to achieve some success with one of five men being able to mostly overcome his orgasmic dysfunction.
Other research has presented case studies outlining successful treatment for male orgasmic dysfunction. One study combining play therapy (e.g., using paradox, reframing, assigning games for homework between the man and his partner) with cognitive restructuring techniques showed improvement in men's ability to attain orgasm due to partner stimulation (Shaw, 1990). LoPiccolo and Stock (1986) suggest that male orgasmic disorder should be treated similarly to female orgasmic disorder. Because it is thought that male orgasmic disorder may stem from medical or surgical conditions complicating the ejaculatory response (LoPiccolo and Stock, 1986), research involving medical interventions is also important for understanding what types of treatment are effective for this disorder. However, to date, there have been no randomized controlled studies examining the efficacy of the procedures outlined for treating male orgasmic disorder.
The disorders of low sexual desire and aversion to sex are treated similarly. Studies that have examined treatment efficacy have focused on cases of low sexual desire. However, there are no randomized control studies that provide definitive evidence for the efficacy of any specific treatment. There is support for treatment approaches that include cognitive, behavioral, and systemic interventions.
One study, using a general sex therapy format outlined by Masters and Johnson (1970), supported the use of the treatment for women with low desire (Hawton and Catalan, 1986). Specifically, they found that 56% of women who completed treatment were able to overcome or mostly overcome their desire problems. Another study evaluated the efficacy of the treatment model that is outlined by LoPiccolo and Friedman (1988). Specifically, the research supported the use of the model for increasing the frequency of sex and marital and sexual satisfaction (Schover and LoPiccolo, 1982). Other research involving low sexual desire involves case studies and techniques that have not been empirically validated.
The standard treatment used for women with female arousal and orgasmic disorder was first described by LoPiccolo and Lobitz (1972) and was later made into a guided self-help book (Heiman and LoPiccolo, 1988). A video is also available that was produced by The Sinclair Institute in consultation with LoPiccolo (1993) that goes through the treatment step by step. The treatment program follows a nine-step model. In the first step, the woman is taught to examine her genitals with a mirror. The goal is for the woman to not only become more familiar with her genitals, but to also become more familiar and accepting of all aspects of her body.
The second step follows with exploring the whole body not just visually but with touch. Women who have global lifelong anorgasmia may experience touching their genitalia for the first time during this step. The third step involves touching the erogenous zones that are present in the body. The woman is encouraged to use lotion or oils to increase the pleasurable sensations. Step 4 involves focusing on those areas of pleasure that were uncovered in step 3. These areas often include the breasts, labia, inner thighs, and clitoris. Step 5 continues this process by encouraging the woman to continue with her pleasurable exploration but to focus on intensely stimulating these areas while using erotic fantasies, explicit literature or photographs.
A woman may reach orgasm during step 5. However, if she does not, step 6 often helps the woman to overcome other inhibitions she has about attaining orgasm. A first task prescribed during step 6 involves role-playing what the woman thinks it would be like to have an orgasm. The therapist should encourage the woman to greatly exaggerate achieving orgasm. It is thought that by doing the role-play the woman will no longer feel inhibited to actually achieve an orgasm.
A second task that is prescribed during this step is to educate the woman about orgasm triggers. It should be noted that these are helpful if performed during a high state of arousal, but can actually serve to hinder the arousal level if performed prematurely. The most effective of these triggers involves taking a breath, tipping the head far back, and pushing down with the diaphragm without letting any air escape. A final technique that is introduced to the woman at this time is the use of a vibrator.
In step 7 the woman demonstrates to her partner how she can bring herself to orgasm. In order to make this step more comfortable for the woman, it is encouraged that the partner first demonstrates how he likes to touch himself. Step 8 follows with the woman teaching her partner how to stimulate her. She should guide his hand and talk to him about what feels good to her. In step 9, the woman and her partner are encouraged to try different positions for intercourse, which allow for direct stimulation of the woman's clitoris to help in achieving orgasm.
While this is the standard program for women who experience global lifelong anorgasmia, the treatment must at times be modified to aid women who have situational orgasmic dysfunction. In the example that follows, the treatment is described in a modified manner for a woman who experiences situational orgasmic dysfunction.
LoPiccolo (in press) describes the case of Helen. Helen and Bob appeared for therapy after 14 years of marriage. Helen is 37 years old. Her presenting complaint was that she is unable to experience orgasm with Bob. She further explained that she does have orgasm when she masturbates alone. Helen began to masturbate at about age 9. Initially, this masturbation was just pressing her thighs together and squeezing her nipples. By her early teenage years, Helen began to lie face down, with her ankles crossed. One hand squeezed and caressed her nipples, while the other caressed her stomach. She pressed her thighs together while she rocked and arched her body on the bed. Helen and Bob explained that they tried caressing her clitoris, without effect. They also tried having him present while she masturbated, which effectively prevented her from becoming aroused. They even tried including her masturbation into their lovemaking. Helen had been masturbating in this way, at a frequency of one to as much as three times per week, for more than 20 years at the time that therapy began.
As a first step in achieving stimulus generalization, Helen was asked to masturbate in the same way as usual except uncross her ankles. Once orgasm was occurring easily in this way, a second change was made. This was to have Helen turn over and lie face up rather than face down while masturbating. Once Helen was able to achieve orgasm in this position, Helen was told to place her fingers on her clitoris and labia as she performed her thigh pressure. At first Helen reported that this caused her to lose arousal, so she was instructed to switch back to thigh pressure only to regain her arousal. After a few sessions using this procedure, she was able to reach an orgasm.
Next, Helen was asked to caress her genitals while using her thigh pressure masturbation. She was again instructed to switch back and forth between thigh pressure only and caressing if she began to lose her arousal. After orgasm was achieved in this manner, Helen was asked to spread her legs apart. She was to alternate between caressing her genitals only and adding thigh pressure when necessary to the genital caressing. When she was about to achieve orgasm, Helen was instructed to spread her legs and use the orgasm triggers without thigh pressure. Helen was able eventually to achieve orgasm by clitoral stimulation without any thigh pressure.
The next steps involved Bob. Assessment had not revealed any couple systemic issues in this case, but having Bob in the room while Helen was trying to achieve orgasm was difficult for her. Bob showed Helen how he was able to masturbate to orgasm, but each time Helen masturbated with Bob present, she was able to experience arousal but not orgasm. Because a new pattern of orgasmic response had already been established for Helen, switching back to thigh pressure masturbation was not recommended. Instead, first Bob then Helen role-played the exaggerated orgasm response. However, Helen still did not achieve an orgasm.
At this point Helen made a suggestion. Helen stated that she would like to masturbate using genital caressing only with Bob holding and kissing her as they had been doing. However, after she was aroused she wanted Bob to leave the room to allow her to masturbate alone. Once she began to have the orgasm, she would call out to Bob, and he would be able to enter the room, and for the first time ever be able to see her having a real orgasm. This procedure worked, and Helen and Bob were able successfully to overcome Helen's orgasmic dysfunction.
As was illustrated in the case example, the client and the therapist must work together to achieve the best treatment protocol. Because Helen and Bob had tried clitoral stimulation to no avail on their own, it was important for the therapist to not re-prescribe a treatment approach that was destined to fail. The standard protocol for orgasmic dysfunction was modified so that Helen gradually switched from her thigh pressure masturbation to masturbation while stimulating her clitoris. This resulted in successful treatment for Helen's situational orgasmic dysfunction.
The standard treatment for vaginismus involves the insertion of dilators of increasing size into the vagina (LoPiccolo and Stock, 1986; Leiblum, 2000). The treatment described here also involves gaining control of the pelvic muscles through practice procedures (LoPiccolo, 1984). Treatment focuses on the goal of helping the couple to be able to have intercourse.
It is first recommended that a thorough history is taken to best diagnose from where the vaginismus stems. The woman begins treatment by learning to gain control of all of her muscles. However, the most relevant muscle for treating vaginismus is the pubococcygeal muscle. Deep muscle relaxation is taught to the client. This is followed by exercises that contract and relax the pubococcygeal muscle. These exercises aid in the insertion of the dilators.
The woman is then given dilators that progress in size to insert into her vagina. The woman is asked to spend 30 minutes or more a night practicing the insertion of the dilator. Once a dilator has been successfully inserted and feels comfortable to the woman, she is allowed to move to the next sized dilator. Once the woman has successfully inserted all the dilators, her partner is encouraged progressively to insert the dilators into her vagina. The final stage of treatment involves intercourse. First, the woman's partner lies passively on his back while the woman kneels above him and gradually inserts his penis. The therapist should stress the need for effective stimulation of the woman in order to encourage the connection between sex and pleasure. Once the woman is able to insert the penis fully, she is encouraged to move while she is on top. Later he can move too, and finally they can try different positions when the woman is comfortable with the change.
The treatment for dyspareunia often involves both medical and psychological aspects. It is often the case that women with dyspareunia undergo a surgical procedure called a vestibulectomy, which corrects the vulvar vestibulitis responsible for the pain the woman is experiencing (Binik et al., 2000). However, therapy is often a necessary follow-up to aid the woman in overcoming any residual problems (Schover et al., 1992).
The therapy that is recommended combines treatment procedures specified for female arousal and orgasmic disorders (Bergeron et al., 2001) as well as vaginismus. After diagnosing the contributing factors, techniques involving relaxation, focusing specifically on the pubococcygeal muscle, as well as education about the woman's body are used. Other procedures involve identifying factors that contribute to arousal and dilator insertion to achieve successful intercourse. For specific procedures see the sections on female arousal and orgasmic disorders and vaginismus.
Male erectile disorder can involve psychological, neurological, vascular, and hormonal problems (Carson et al., 1999). Because there are a multitude of factors that can contribute to the problem, both psychotherapeutic and medical interventions are used to treat the problem. Medical procedures used to address erectile disorder are implantation of a penile prosthesis, use of a vacuum erection device, injection with medication, vascular surgery to remove blocked arteries or remedy other problems, and the use of Sildenafil citrate (i.e., Viagra). For a review of these procedures see LoPiccolo (1998) and Rosen (2000); however, the use of Viagra in conjunction with therapy for erectile dysfunction will be addressed.
The introduction of Viagra for the treatment of erectile disorder has significantly affected therapeutic procedures. Viagra was introduced to the public in 1998. Since then, it has become widely prescribed in the treatment of erectile dysfunction. It is highly effective in men with organic, psychogenic, or mixed impairments resulting in significantly better effects than a placebo (Shabsigh, 1999). Because Viagra works by physiologically aiding the man to get an erection when there is sexual stimulation present, the man is more easily able to overcome his performance anxiety. Viagra is a highly effective treatment for erectile disorder when the assessment indicates its use.
It is often the case that psychotherapy is used along with Viagra to best aid men with erectile dysfunction. The standard psychotherapeutic treatment for erectile disorder involves reducing anxiety and increasing the amount of sexual stimulation the man is receiving. It is indicated for couples who have cognitive, behavioral, or systemic problems that contribute to the erectile disorder. During the first phase of treatment, the anxiety the couple or individual feels about sexual intercourse is discussed. A standard treatment for helping to reduce the anxiety felt by the male is sensate focus (Masters and Johnson, 1970). Sensate focus consists of instructing the client to relax, enjoy the sensual massage, and not to expect to get an erection. LoPiccolo (in press) points out that in this day of ‘pop’ psychology procedures, sensate focus does not always work to reduce anxiety because the man then gets anxious about not feeling relaxed enough to get an erection.
An alternative way to help the man to reduce his anxiety comes from his partner reassuring him that her sexual gratification is not dependent upon him having an erection. If the partner can stress to the man that she enjoys the orgasms she receives due to his manual or oral stimulation of her genitals, this will greatly reduce his performance anxiety. Sometimes, however, it is not as easy for the woman to make this statement. It is important to examine the woman's reasons for her sexual gratification being so dependent upon her husband's erection, and, if possible, resolve these therapeutically to aid the man's performance anxiety. Some reasons that a woman may not be satisfied by sexual acts other than intercourse may include age-related stereotypes about a male's role, lack of experience with other manners of love-making, or religious ‘taboos’.
Increasing the amount of direct stimulation of the penis is often another important factor in remedying erectile disorder. If a man has some organic impairment, simply reducing his anxiety about getting an erection will not result in an erection. Also, as erectile disorder is more common in aging men, and the erection response is more dependent upon direct stimulation as a man gets older, it is important to educate the client and his partner about appropriate stimulation of the penis. If couples have used direct stimulation before, it is stressed that it needs to take place for a longer period of time in order for the man to maintain an erection. For couples who are reluctant to use direct penile stimulation, this issue needs to be dealt with therapeutically looking at any relationship or history variables that may contribute to the reluctance.
The standard treatment for premature ejaculation involves techniques developed by Semans (1956) and Masters and Johnson (1970). Treatment begins by using the pause and squeeze technique during manual stimulation of the penis. If the man masturbates regularly or does not have a partner, he can do the technique by himself. However, the procedure is also recommended with a partner. First, the man's partner is instructed to stimulate his penis manually. The man is instructed to gauge his sexual arousal during this process. When he reaches a high level of arousal, about a 6–8 on a scale of 10, he is to instruct his partner to stop. They wait until the man's level of arousal has decreased and repeat the procedure up to four more times before allowing the man to ejaculate.
Masters and Johnson (1970) added to this procedure the squeeze technique. Directly after the couple pauses from stimulating the man, the penis is to be squeezed firmly at the point where the head of the penis joins the shaft. This technique helps in reducing sexual arousal at a quicker rate and should then be followed by the pause. When the pause and squeeze technique results in less rapid ejaculation for the man, the couple is instructed to do the procedure during intercourse.
There are some special factors to keep in mind during treatment. If a man has a low frequency of sex and/or masturbation, it can be helpful to increase the frequency of either in order to help decrease time to ejaculation. Also, it is sometimes found that the partners of men presenting with premature ejaculation are reluctant to participate in therapy. In these instances, it is helpful to set aside times when the man is in charge of performing pleasurable activities for his partner to increase her desire to participate in therapy (LoPiccolo, in press). This usually results in the woman cooperatively participating in therapy.
Although men presenting with male orgasmic disorder often have a neurological or physiological problem associated with their inability to attain orgasm (Rosen, 1991), there are psychological treatments available. Generally, male inorgasmia is treated similarly to female inorgasmia (LoPiccolo and Stock, 1986). Treatment procedures involve, first, addressing cognitive issues that may contribute to inorgasmia. Some common issues include anxiety about performing, fear of having children, not being sexually attracted to a partner, or issues of power and control in the relationship.
Next, it is important to address the amount and type of stimulation that the man is getting during sexual activity. It is often necessary to increase the types of stimulation applied directly to the penis. Manual or oral stimulation can be added during foreplay to increase the man's arousal level. Also, as many men presenting with male orgasmic disorder have some neurological or physiological complicating factors, men are taught orgasms triggers, such as bearing down while holding their breath and throwing their head backwards. Another treatment factor that can aid in orgasm is the use of a vibrator, specifically used around the scrotum or perianal area.
The disorders of low sexual desire and aversion to sex can be especially hard to treat. They rely on the therapist's skill to engage the client so that he or she does not feel that therapy is only for the benefit of the partner's sex life. One way to begin to engage the client and his or her partner at the start of therapy is to have them make two lists of possible gains and losses if therapy is successful, one pertaining to the relationship and one pertaining to the individual (LoPiccolo, in press). It may also be necessary to help the client redefine the problem and educate the client on the sexual drive (LoPiccolo, in press).
Therapy can then begin with the program for low sexual desire outlined by LoPiccolo and Friedman (1988). The model is a four-stage program. The first stage, affectual awareness, focuses on the emotions involved with having sex. As most clients deny that they have any negative feelings toward sex, the therapist disputes this stressing the biological evidence for a sex drive and reasons that can interfere with being aware of this drive. The lists the clients made of gains and losses of acquiring a sex drive can be helpful during this stage of therapy.
The second stage, insight, involves the client gaining an understanding of what first contributed to the low sex drive and what has maintained this condition. The third stage of therapy involves different cognitive and systemic techniques to help the client deal with the initial contributing factors and negative emotions associated with sex. Systemic techniques are then used to help the client and his or her partner deal with the maintaining or current causes of the low drive.
The final stage of therapy, drive induction, involves behavioral interventions. The client is asked to start noticing external cues to become aware of his or her sex drive. At first, the person may be asked to keep a ‘desire diary’ where s/he keeps track of instances when they notice sexually relevant clues (e.g., movie scenes). As therapy progresses the person may be asked to write erotic fantasies. Furthermore, tasks to enable the low drive client to become aware of and enjoy sensual rather than sexual pleasure are important. Both partners must agree that any sexual activity initiation must be verbal. Once that is agreed upon, the low drive client is asked to identify sensual activities (e.g., kissing, dancing) that s/he would like to do with his or her partner. Once these activities have been identified, the low drive person is encouraged to take the lead in initiating any of the sensual behaviors.
The clients are then trained to initiate sexual activity in different ways than before. First the low drive patient role-plays how his or her partner had initiated sex in the past that resulted in a negative or hurtful emotional response. Next the client demonstrates how s/he would prefer the partner to initiate sex. The partner is then asked to role-play the client refusing to make love in a way that was hurtful in the past. Next, the partner is to role-play an acceptable way for the partner to turn down an invitation to make love.
The sexual activities being participated in by the couple up to this point depend on the couple. However, for clients who experience sexual aversion, therapy tends to take more time. Often clients who feel an aversion to sex know what this emotion stems from. More time is spent, often, during stages 2 and 3 of therapy to work through these negative emotions and thoughts. In the most severe cases, the aversion is the result of sexual abuse either as a child or adult. If this is the case, the therapies outlined by Courtois (1988) for child sexual abuse survivors or Foa (1997) for rape survivors are recommended.
Two challenges that are relevant to all sexual disorders are an unwillingness of one member of the couple to work on the problem or an ongoing affair. If, during the initial interview, it is brought forth that one member of the couple is unwilling to work toward remedying the problem or one member is having an affair, this must be dealt immediately. If one member of the couple does not want to put forth the effort to work on the problem, the therapist should stress that this may not be the best time for the couple to be in therapy. If it is revealed that one member of the couple is having an affair, the spouse that is having the affair must be told that s/he must stop the affair or at least stop it for the duration of therapy. If the spouse will not agree, the therapist must reconvene with both spouses and explain that therapy cannot continue to address the sexual dysfunction because, it seems to the therapist, there are other marital problems that need to be addressed before the therapy can be helpful (LoPiccolo, in press).
Some clients present with special cases of orgasmic dysfunction that rely on the therapist to be able to change subtly the treatment model to best aid the client and her partner. These special cases include reaching orgasm only through the use of a vibrator or through some form of thigh pressure masturbation. Modification of the model for women who use thigh pressure masturbation was demonstrated in the case of Helen and Bob. For those women who can obtain an orgasm only through the use of a vibrator, they are encouraged to stop the use of a vibrator completely and start the treatment protocol beginning with the first step.
Another challenge to the therapist treating orgasmic dysfunction and arousal disorders is the notion that all women must have an orgasm during intercourse. In fact, many women do not have orgasms during intercourse, and this failure to achieve orgasm is often due to a lack of direct stimulation of the clitoris during coitus. If orgasm can be achieved during manual or oral stimulation and is satisfactory to the woman, this should be regarded as a therapeutic success.
A main challenge to the therapist treating vaginismus and/or dyspareunia is the differential diagnosis of the disorders. Because the disorders are so similar, it is often hard for the treating therapist to ensure that s/he is following the best procedure to aid the client. It is also difficult to ensure that clients are getting the best treatment available because there seem to be both psychological and physiological factors that complicate the situation. It has been suggested that to understand better the pain disorders described by women, the disorders should be reconceptualized as genital pain disorders that can interfere not only with sexual activity but also any penetration that affects the genitalia (Binik et al., 2000). Because there are no controlled outcome studies examining the effectiveness of any medical or psychological interventions for the disorders, therapists must use the current classification system that is available to best treat their clients.
Two main challenges in treating erectile dysfunction come from age related issues and the increased medicalization of treatment. Many people who present for treatment of erectile dysfunction are older. Engaging the partner in treatment can be especially hard in an older couple. It is often seen that the women in these relationships were raised with the idea that real men do not need help to get an erection. It is important to spend time thoroughly educating the clients about the erection response and what can be expected now and as the man continues to age.
Another challenge to the therapist treating erectile dysfunction can come from Viagra. One problem occurs if the man has low sexual desire. If he does not want to be having sex, but the pill makes him get an erection, he will avoid taking the pill. This can then lead to other marital problems, including fights about him not taking his pill. Another contraindication for the use of Viagra occurs when the systemic problems of the couple's relationship are the only problems contributing to the erectile failure. It is important for the therapist treating erectile disorder to take all of these factors into consideration when recommending treatment for the client.
The main challenge for the therapist treating premature ejaculation presents in the form of maintaining long-term treatment effects. Research has shown that the immediate benefits of treatment are helpful, but over time, many men return to their pretreatment conditions (D'Amicis et al., 1985). One way to remedy this problem is to ensure that during therapy the clients return to their previous frequency of sexual activity while continuing with the therapeutic techniques (LoPiccolo, in press). This helps to ensure that when the clients leave therapy, the results that were shown were not just artifacts of the higher frequency of sexual activity initiated during treatment.
Male orgasmic disorder is so rarely seen in sex therapy clinics, that having a client with this disorder is a challenge in itself. There are many recommendations about how to treat this problem, but there is no clear research on what works with these clients. As with erectile dysfunction, the partners of these men may challenge the need for the client to have different forms of stimulation to aid in the ejaculation response. It is important to work with the clients in educating them about what is currently known of the dysfunction, and trying different techniques in order to find what will best help the client to reach orgasm.
The main challenge to the therapist treating low sexual desire and aversion to sex is the complex psychological issues that accompany these problems. Treatment is usually longer term than most other sex therapy (LoPiccolo, in press). It often takes a long amount of time to work with the client on the negative feelings s/he associates with sexual activity. It is also hard to engage the client in therapy because these clients do not necessarily want to regain or gain a desire for sexual activity. They may believe that their partners will be the ones mainly benefiting from the therapy because the end result will be them getting what they want (i.e., sex). For these reasons, the initial stage of therapy, affectual awareness, is paramount in order to identify potential issues that the client may use to later hinder therapy.
The field of sex therapy continues to be encroached upon by the many medical treatments. There is often more funding available to study the effects of different drugs on sexual problems than on therapy for sexual problems. However, researchers are cautioning the increased medicalization of treatment for sexual dysfunction (e.g., Bancroft, 2002). This chapter illustrates that for all sexual dysfunctions, a therapeutic component helps to remedy the problem. Psychotherapy for sexual disorders utilizing cognitive, behavioral, and systemic techniques is most effective. Therapies for female orgasmic disorder and premature ejaculation are well established in the literature. Therapies for desire disorders, erectile disorder, male orgasmic disorder, and pain disorders all show support for remedying the existing problems. In the future, it will be important for researchers and therapists to focus on what types of treatment work best for clients. As some disorders have greater influence from physiological factors and some have greater influence from psychological factors, treatment could be matched to best aid the client.