Sexual-Incapacity Therapy

Edward A. Tyler
 e-Book 2015 International Psychotherapy Institute

From American Handbook of Psychiatry: Volume 5 edited by Silvano Arieti, Daniel X. Freedman, Jarl E.
Dyrud

Copyright © 1975 by Basic Books

All Rights Reserved

Created in the United States of America

Table of Contents

Sexual-incapacity Therapy

Definitions

Examination of the Sexually Incapacitated Patient

Specific Therapeutic Goals

Therapeutic Techniques

Sensate-Focus-Oriented Therapy

Conclusions

Bibliography
 SEXUAL-INCAPACITY THERAPY
Therapeutic measures for human sexual incapacities are as old as

recorded history. Documentation usually appeared in vignettes concerning

persons of status, fame, or notoriety (Hastings, 1963; Johnson, 1968; Taylor,

1954; Taylor, 1900). These persons were almost exclusively males, since,
until this century, women were defined as having low or no sexual (Gibbons,

1923), intellectual, or achievement drives. In contrast, the potency and virility

of men was believed to be positively correlated with their bravery, leadership

ability, competence as soldiers, influence with the gods, etc. Known or

rumored impotence in a king or tribal leader could lead to his being expelled,

killed, or replaced. Not only were leaders supposed to produce heirs, but crop

failures, poor hunting and fishing harvests, lack of rain, losses in battle were
often attributed to a male leader’s impotence or lack of virility. It was

believed that a witch or the devil could cast a spell of impotence on a man.

The witch was believed to use such devices as an invisible ligature around the

base of the penis of the afflicted male. With this etiology, the logical treatment
was to destroy the hapless woman accused of being the guilty witch.

As recently as the first part of the twentieth century, the Christian world

subscribed to a moralistic etiology (Taylor, 1900). It was believed to be God’s

punishment or, at least, a deserved consequence of sexual excesses such as

masturbation (self-abuse [Pullias, 1937]), "excessive" sexual excitement

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during courtship, "excessive" coitus, "unnatural" prolongation of coitus (for
the alleged greater gratification of the female), "abnormal" coital positions,

and sexual activities with lascivious females. "Therapies" were prescribed by

priests (penances), mystics (love potions), and by physicians (advice and

pharmaceuticals). In 1900, an authoritative book (Taylor, 1900)

recommended that "the first indication is to determine what is the morbid

factor and when discovered to treat it on general medical principles . . . some

benefit may follow the judicious installation of strong nitrate of silver solution
into the prostatic urethra. . . . In some cases much benefit is produced by the

ingestion of a combination of atropine and strychnine. . . . Quinine in three

grain doses given three times a day, particularly in combination with

strychnine, and in very atonic cases with atropine is sometimes of marked

beneficial affect. . . . A preparation composed of various animal extracts,

known as phospho-albumen acts as a decided sexual tonic in some cases. . . .

Chloride of gold and sodium administered in the form of pills in doses of one-
twentieth of a grain, three times a day, have been vaunted by several authors

of having marked aphrodisiac power," and so on. Almost every imaginable

"witch’s brew" and magic "love potion" as well as innumerable physical

manipulations of the penis, perineum, prostate, testicles, and rectum were

tried without notable or predictable success.

From the early nineteen thirties until the mid-sixties, psychodynamic

psychotherapy became the treatment of choice (Condrau, 1960; Deutsch,

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 1965; Ferenczi, 1956; Flick, 1969; Freud, 1955; Glen, 1968; Moore, 1964).

Results were neither impressive nor consistent. Insight and/or acceptance of

one’s incapacities were acceptable outcomes of therapy. During the sixties,

Masters and Johnson (1968; 1970) reported on a technique that offered a

significantly high and predictable rate of success in improving the sexual

interest and performance of sexually incapacited women and men. About the

same time there were reports (Brady, 1966; Dengrove, 1967; Haslam, 1965;
Rachman, 1961) of successful therapy using the behavior-therapy techniques

of Wolpe and Eysenck. These two therapeutic regimes have some common

objectives that will be discussed later.

Definitions

Before discussing specific therapeutic principles, objectives, techniques,

and outcomes, it is necessary to operationally define such constructs as

sexual incapacity, assumed etiologies, and acceptable therapeutic outcome.

Sexual Incapacity

Sexual incapacity cannot be measured by any objective or observable

tests, scales, or examinations. The diagnosis must be made whenever a

patient presents with a subjective complaint of failure to meet her/his1 own

and/or her partner’s sexual-behavioral expectations. The problems about

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which patients complain are most commonly one, more, or all of the five
listed below:

1. Female—infrequent or complete absence of orgasms.

2. Male—impotence, the inability to obtain or maintain an erection.

3. Male—premature ejaculation, prior to or almost immediately after

the penis is introduced into the vagina (Salzman, 1954).

4. Female and/or male—infrequent or complete lack of desire for

sexual activity on the part of one or both partners.

5. Male and/or female—disgust, fear and/or anxiety at the thought of

participating in sexual behavior.

These problems are frequently selective, being experienced primarily or

exclusively only in sexual transactions:

1. With a specific person (spouse, fiancé, primary partner, etc.).

2. With a specific class of relationships (i.e., marital partner only,

pickups only, obese partners only, nice girls only, etc.).

3. In specific places (i.e., in automobiles, on a beach, in the living

room, in the bed, etc.).

4. Under specific conditions (only when drinking, only when fatigued,

only when angry, only when playing a passive role, etc.).

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 The problems may be partial, complete, sporadic, or total and of long or

short duration. Typically, once an individual experiences a sexual-response

problem, she begins to predict the problem will recur every time a sexual

response is desired or required. This fear that failure in sexual response will

occur becomes as incapacitating as the inadequate response itself. The

isolated, partial, or sporadic symptoms typically increase in frequency and

severity with time unless the patient is given prompt, adequate reassurance,
education, or the needed therapy.

The above description may seem too constraining to some readers. It is

operational for this article only. It does not address itself to such questions as:

(a) Is monogamy or having multiple partners the biological norm for human

sexual transactions? (b) Should we utilize a descriptive (i.e., telling it like it is)

or a prescriptive (i.e., telling it like it ought to be) norm to measure human

sexual behavior? (c) Are love and/or legal sanction (marriage) an essential
part of adequate sexual response? (d) Is homosexuality a life style or a sexual

maladjustment needing therapy? (e) What about wife swapping, swinging,

incest, masturbation, sadomasochistic sex, transvestism, transsexualism, etc.?

These are not trivial issues on the contemporary human sexual scene, but are

more philosophical than therapeutic at this time in human history (Marmour,

1971).

Etiology

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 Predominantly, patients complain of their behavioral failures to meet

their own expectations for adequate sexual performance and enjoyment

(Gutheil, 1959; Peterson, 1961; Wahl, 1967). Patients are problem- not

diagnosis- oriented. They hurt and they seek to be relieved rather than

classified and labeled. Wershub (1959) reports that approximately 5 percent

of all sexual-inadequacy complaints have an etiology that is, in part or totally,

related to structural, biochemical, and/or physiological disorders. These

physical problems should be competently investigated whenever there is

good reason to suspect their presence. Listed below are some of the more

common structural, biochemical, and physiological causes of human sexual

incapacity (Hastings, 1963):

Male (Wershub, 1959):

1. neurological lesions (Wershub, 1959)

a) destruction and/or transection of the sacral spinal cord and the

cauda equina and parasympathetic plexuses

b) high lumbar sympathectomy when ganglions below the twelfth

dorsal nerve on both sides are removed

2. diabetes Mellitus (Chokyu, 1965; Wershub, 1959)

3. Alcoholism (Levine, 1955)

4. drug addictions (narcotic, amphetamines [Bell, 1961; Wershub,

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 1959])

5. heavy-metal poisoning

6. peyronie’s disease

7. lerichie’s syndrome

8. calcification of the vas deferens (frequently diabetic also)

9. frolich’s syndrome

10. phimosis

11. hydrocoele

12. varicocoele

13. crytorchidism

14. orchialgia

15. priapism

16. elephantiasis

17. sebaceous cysts scrotum

18. prostatectomy

19. perineal trauma

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 20. congenital anomalies (absent, concealed, adherent or double
penis, hypospadias, episadias, anorchidism, sexual
infantilism)

21. transsexual surgery

22. climacteric (Browning, 1960; Wershub, 1959)

23. aging

Female (Roen, 1968):

1. congenital defects (absent or infantile vagina or clitoris)

2. perineal trauma

3. pubococcygeus muscle relaxations and lacerations (Kegel, 1952;

Roen, 1968)

4. clitoral adhesions (Clark, 1968; Roen, 1968)

5. atrophic changes after menopause

6. painful infections of vagina

7. pelvic inflammatory disease

8. cysts of labia

9. massive or painful tumors of the genitalia

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 10. painful rectal disease.

Routine investigation of each of the above in every patient presenting

with a chief complaint of sexual inadequacy is an expensive and inconvenient

disservice to the patient. The yield is low and the patient with the diseases

listed above usually presents first with symptoms of his primary disease. The
patient suffering only from a behavioral, sexual- inadequacy problem can

become conditioned, by an overzealous search, to believe that there is some

remote, as yet undiscovered, structural-biochemical-physiological problem

that accounts for his sexual incapacity. Until this nonexistent physical
condition is discovered, he refuses the treatment that can successfully

influence his problem.

Overwhelmingly, human sexual-incapacity problems that are presented

by patients are the consequences of: (1.) faulty learning; (2.) inadequate

knowledge; (3.) inexperience; or (4.) anxiety. Only a therapy program

addressing itself to these defects has any chance of consistent success.

American child-rearing patterns are eminently suited to the

development of sexual-incapacity symptoms. The adolescent female is taught

to attract males, exhibit sexiness, and participate in sexually arousing petting,

up to a point. She is further taught that it is her job to "cool it" when she

experiences a high level of excitement because he won’t stop unless she does.

When she learns her lesson perfectly, she grows up to be a non-orgasmic

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 woman. Her complaint is expressed as "I get very excited sexually, but when I
feel like I am almost there, I just go numb and lose all my sexual feeling."

The adolescent male is warned not to get caught in the act, by catching
VD or by impregnating a nice girl. It is implied simultaneously that he is

lacking in masculinity if he doesn’t seduce a few females. He cannot be caught

if he is unable to have an erection, and is less likely to be caught if he only has

a "quickie." Anxiety about being caught on the one hand, and fear of not

performing like a stud on the other set the stage for the male symptoms of

prematurity and impotence.

Since sexual-incapacity symptoms so frequently are specifically related

to the sexual interaction between the presenting patient and her primary

partner, most successful therapy programs focus on the therapy of both

sexual partners and their relationship rather than attempting to treat only the
individual who initially complains (Masters, 1970). At times partners’

complaints appear to be reciprocal; as one improves, symptoms appear in the

other unless both are in a therapy program together. Brody’s successful

treatment of 65 percent of 105 females without treating their partners is a

notable exception (Brody, 1972).

Acceptable Therapeutic Outcome

The only acceptable therapeutic outcome is one in which the patient’s

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 behavior has changed in the direction of her own stated expectations. The
patient initially needs help in explicitly defining her own sexual expectations.

Occasionally, she needs help in modifying her expectations into some that are

more realistic than those which she brought with her to the therapist.

"Insight" without behavioral change cannot be considered an acceptable

outcome of sex therapy. Insight with behavioral change is attractive, but is

probably of insignificant value to the patient. Knowing why and being able to

construct an interrelated etiological-therapeutic model is very important to

the researcher. Knowing how to cause a lasting change in the incapacitating

behavior is more important to the therapist. The therapist’s primary

responsibility is to help her patient attain a therapeutic result acceptable to

the patient. Sex therapists must decide, before starting with their patients,
whether they are primarily therapists or primarily researchers. By first

setting up measurable relevant objectives against which the therapeutic

outcomes will be measured, therapists can contribute to their own and others
knowledge. Having an attractive, internally consistent, abstract model,

designing a therapy to fit the model, and explaining away unsuccessful

therapeutic outcomes contributes nothing.

Examination of the Sexually Incapacitated Patient

History Taking

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 Diagnosis and treatment are more dependent on the patient’s history

(Hastings, 1963; Masters, 1970) than the physical or laboratory findings.

Therefore, a detailed problem-oriented story of the way in which the patient’s

sexual behavior doesn’t meet her expectations is essential. However,

obtaining the needed history doesn’t require any special techniques or

outlines. The data should describe the symptoms, their frequency and

duration, their consistency, the specific circumstances or factors under which

symptoms occur, vary, or are absent. It is also important to know whether the

symptoms occur with all partners and with all forms of stimulation (genital,

oral, manual, self-induced as well as partner induced). If the patient has had

any therapy, the type, duration, and outcome should be documented. None of
this data base is different from the kinds of data appropriately collected on

any medical problem.

Since therapists are trying to change the behavior of their patients, the
more a therapist learns about her patients’ life styles, personal traits and

habits, problem-solving patterns, anxiety levels, life goals, ambitions, values,

and fantasies, the better. It is usually valuable to have a gestalt of a patient’s

total behavioral functioning, but this is especially important when the

therapeutic goal is to change behavior.

Eliciting the history is more dependent on a therapist’s comfort with

human sexuality and her breadth of knowledge about the wide range of

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 human sexual behavior than on any special interviewing techniques or
gimmicks (Lash, 1968; Tunnadine, 1970; Tyler, 1968).

Physical Examination

A general physical examination with thorough observation of the genital

anatomy is indicated routinely. The examiner is looking for congenital

defects, scarring, local infections, degenerative changes, and unusual size. It is

perfectly acceptable for the sex therapists to do their own physical

examination within the limits of their competence (Hartman, 1970).

When a specific organic disease from the above etiological list is

suspected, appropriate physical examinations, and laboratory and x- ray

studies must be included. Consultations should be requested when these

examinations are beyond the sex therapist’s level of competence in the

diagnosis and/or management of these diseases.

Specific Therapeutic Goals

Regardless of the therapy strategy or procedures one utilizes, it appears

that there are three specific goals. They can be met by any of the following
commonly used techniques: (1) reducing anxiety; (2) extinguishing old

incapacitating sexual behavior patterns; and (3) conditioning to respond to

biological sensual cues (Hartman, 1970; Kegel, 1952; Pullias, 1937).

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 1. Before attempting anything else, the therapist must reduce the

amount of anxiety that the patient feels about her past and current sexual

behavior, performance, and attitudes. It is the author’s opinion that the

patient usually experiences this sexual anxiety in two forms: shame-and-guilt

anxiety, and performance anxiety. Shame-and-guilt anxiety is more commonly

seen in persons who had rigid moral or religious upbringing, who are

compulsive, who have a general discomfort with messy or "dirty" activities

and are uncomfortable with physical and emotional intimacy (e.g., touching

another individual). Performance anxiety is more likely to be found in

persons who are competitive, ambitious, physically perfectionistic, and

intellectually sharp. A combination of both is seen in persons who try to

reduce shame and guilt by turning any performance into work. They believe

it’s acceptable to participate in pleasurable activities as long as one really

works at it.

Tranquilizing drugs (Freyhan, 1961; Greenberg, 1965; Haider, 1966)

are not the therapy of choice in managing these sexual anxieties. A more
effective strategy is a therapy based on the principle that therapists are

authority figures and members of the "establishment" who have more

humanistic and permissive attitudes on sexuality than the patients have

encountered in their past. These authority figures are open to and not fearful

of their patients’ sexuality. These less fearful and more permissive

authoritative figures convey in gesture, manner, tone of voice, and content

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that it is okay, it is normal and it is not immoral to have sexual feelings, sexual

thoughts, and sexual desires. They approve open, honest inquiry and

communication about sexual matters between the patient and themselves,

patient and friends, patient and potential sexual partners. They encourage the
patient to explore and define her sexual expectations. They are not alarmed

or judgmental when the patient’s desires, expectations, and moral values

appear to be in conflict. The patient’s anxiety about her sexual behavior,

desires, and attitudes is far more effectively reduced by the therapist’s gestalt

of overall comfort and tolerance about human sexuality than by a relatively

uninvolved or even apprehensive exploration of the patient’s past as

practiced by many traditional psychotherapists.

2. Old patterns of sexual behavior that have not worked in the past need
to be extinguished to make the patient more receptive to learning new, more

effective patterns. As long as the older, familiar patterns are still available,

one tends to repeat them even when these are relatively unsatisfactory. This
is particularly true when the patient feels anxious and/or there are no visible

alternative patterns of sexual behavior. The initial goal was to reduce anxiety.

The reduction of anxiety makes it easier for the patient to avoid returning to

her old patterns. Not using the old unsatisfactory pattern reduces the anxiety
even more, and both make the patient more receptive to learning new

patterns not visible or attainable in the past. Interference with the patient’s

continued use of her old patterns creates a vacuum and helps to motivate the

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learning of new acceptable substitutes that evoke less anxiety and incapacity.

An effective way to interrupt the older patterns is to make a "contract" with

one’s patients that, while undergoing therapy, they will refrain from any

sexual activity other than that discussed with and prescribed by the therapist.
Masters and Johnson (1970) simply inform their patients that they are not to

have any intercourse until the therapists believe they are ready. It is obvious

that both the patients and their therapists must have a great deal of
confidence in the therapist’s ability if they are to agree to such a "contract" as

no intercourse until it is prescribed by the therapist.

3. Conditioning the patient to listen to (i.e., pay attention to and respond

to) her own human, biological-sensual cues is the final step. Most patients

who are performing sexually in a way that does not meet their own
expectations find themselves trying to will an orgasm, erection, or sexual

desire. They substitute conscious cortical control for a spontaneous response

to proprioceptive-sensory input from the sensual areas of their own bodies.

In contemporary society we have discouraged physical exploration of one’s

own body and tender (as distinguished from competitive and/or violent)

physical contact with each other. This has encouraged using cerebration and

fantasy to deal with stimuli, desires, and temptations that are taboo. Many
modern humans have learned to suppress their biological-sensual cues. Since

this inhibition is a taught and learned phenomenon, it can be unlearned. To

improve sexually the patient must be taught to listen and respond to her

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genital, sensual, proprioceptive information and not permit this input to be

overruled by "logical," "rational," cortical controls (Masters, 1970). Lidz says

(1968):

The proper carrying out of the sexual act and the enjoyment of it involves
an ability to give way to the irrational, the timeless, the purely animal in
one: it includes a loss of individuality in a temporary fusion with another.
It contains the potentiality of leaving behind the tensions of civilization as
one loosens the bonds to reality to float again in the purely sensuous. Here,
one needs to be unabashed by the nakedness of impulse and drive, by
recrudescence of the infantile and the revealing of much that one has
sought to hide from others. The woman in particular requires a capacity to
rescind control and give way before an ecstasy that threatens to
overwhelm and annihilate her by its very intensity. The sexual act contains
a definite and direct relationship to infantile relatedness to the mother,
with a renewed interest in sucking, in odor, in skin eroticism; and a
reawakening of old forbidden desires to explore and play with orifices. So
very much that has been learned needs to be undone; much that has been
hidden and long repressed and kept unconscious but that haunted dreams
and masturbatory fantasies needs to be released to permit sexual intimacy
and enjoyment and to allow fulfillment rather than provoke shame and
guilt. The very good sexual adjustment demands such abilities to reverse
the socialization process—and yet to permit the individual to be secure in
the feeling that the regression and reversal will only be temporary and not
reclaim the self. [p. 424]

The therapeutic strategy can now be seen as a combination of: (1)

reducing the patient’s guilt and performance anxiety by authoritative

permissiveness, education and reassurance; (2) reducing the anxiety still

further by interfering with the old patterns that originally had been shaped

by the anxiety and ultimately became a source of anxiety as well; (3) creating

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 a temporary vacuum to stimulate motivation for learning new patterns, and
(4) teaching the patient to respond more spontaneously to her own

biological-sensual stimuli.

Low anxiety is optimal for predictable learning. One learns during a

state of high anxiety, but what will be learned is less under the control of the

teacher (i.e., therapist). When the new patterns to be learned are offered in
such a graduated form that the patient never experiences a rapid rise in

anxiety and experiences a small but constant measure of success, what is

learned not only increases the patient’s competence but reduces the

reappearance of performance anxiety. In both behavior therapy (Lazarus,

1969) and Masters and Johnson sex therapy(Masters, 1970), attention is

given to introducing small but graduated changes, starting in areas the

therapist predicts are unlikely to evoke anxiety. Progression is paced, to

continue to hold anxiety to a minimum, as the patient is encouraged to move

closer and closer to functioning sexually in a biologically natural way.

Therapeutic Techniques

At the present time, sexual-incapacity-therapy regimes, strategies,

techniques, and gimmicks are almost as numerous as the number of

therapists (Cooper, 1969; Diamond, 1968; Faulk, 1971; Klemer, 1965; Wahl,

1967). Most therapists identify themselves as using some specific technique

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described by a well-known therapist. However, most of these are self-trained.
Typically, they use an ill- defined blend of their own psychotherapeutic skills

with things they have read or heard that other therapists utilize in sex

therapy. Too few keep records suitable for audit or reporting in the literature.
Most devote only a small percentage of their time to sex therapy, and so any

given patient is likely to find herself being shifted back and forth from sex

therapy to marital counseling to individual psychotherapy.

Therapists carefully trained in behavior therapy have applied these

simple, behavior- modification techniques to the complex of behaviors

involved in human sexual interactions (Dengrove, 1967; Haslam, 1965;

Holroyd, 1970; Jones, 1972; Kraft, 1967). Both behavior-modification

therapists and Masters and Johnson oriented therapists have the overall
objective of producing a change in the patient’s sexual behavior. There are

differences in their strategies, techniques, and theoretical models. The other

large group, psychodynamic psychotherapists, accept insight and

understanding as a major objective (Hummer, 1966). They, therefore, use

significantly different strategies and techniques. Another strategy is the use of

mechanical devices [Russel, 1959] (such as vibrators, penile splints, artificial

vaginas, etc. [Lowenstein, 1941]), pharmaceutical agents (hormones

[Andersen, 1958; Borelli, 1967; Margolis, 1966; Seid, 1962], vitamin E,

psychotropic agents [Kiev, 1968], anesthetic ointments), dietary fads (raw

oysters, raw eggs, wheat germ, etc.) and surgical procedures (Deutsch, 1965;

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 Lash, 1968; Lydston, 1908; Pearman, 1972). These are used independently or

in combination with other therapies. Even direct personal instruction via

coitus with the therapists has been recommended.

Variables Influencing Outcome

It now appears that a wide variety of therapeutic strategies and

procedures utilized have been influential or coincidental with favorable

outcomes. However, serious evaluation of the efficacy of these various

therapeutic efforts has been difficult. No well-defined criteria have been

established to determine something as simple but essential as how to

differentiate between severe cases needing intensive, skilled therapy and

mild cases that might have resolved spontaneously or with brief reassurance

and accurate information from minimally skilled, warm, tolerant humans

with some professional status and credibility. It is the author’s observation

that choosing a particular procedure seems less important than the

therapist’s belief that she knows what she is doing will work (Tyler, 1968).

Another significant variable is how much suffering the patient is

experiencing from her sexual incapacity problems at the time she seeks

therapy. It seems more logical, as well as humane, to conceptualize this as the

level of positive motivation toward relief rather than a resistance against

change. Oversimplified, the question is whether the patient hurts enough to

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seek out a therapist who is confident, available, and affordable, and to trust
this therapist enough to allow her sexual behavior to be shaped. Additionally,

since therapy is directed at the sexual partners, both must be at a similar level

of motivation at the same time.

The personality of the therapist is frequently stated to be a crucial factor

in any therapeutic procedure. Psychiatric resident applicants are frequently

evaluated, sometimes elaborately, in an effort to screen out those believed to

be poorly qualified. The specific behavioral objectives of residency training

for which they are found unqualified is not usually spelled out.

More rarely are evaluations conducted with the goal of "screening in"

those with specific characteristics desirable in a therapist. Screening in is very

important in both self-selection and training-program selection for sex

therapists.

Without presuming to set the inclusive criteria, it is useful to describe

the characteristics observed in a variety of therapists who devote a significant

amount of their time treating sexual incapacities.

1. They are careful listeners.

2. They are persistent history takers.

3. They are more problem-oriented than diagnosis-oriented.

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 4. They help patients conceptualize and define their own sexual
expectations.

5. They do not push their own values on their patients as better,

healthier, or more "normal" (Tyler, 1973).

6. They are aware of and tolerant of a wide range of human sexual

behavior.

7. They openly convey warmth, concern for, interest and involvement

in, their patients’ sexual discomforts and disabilities.

8. They do not hesitate to be firm, directive, and authoritative (not

authoritarian).

9. They experiment—i.e., do what "feels right" at the moment.

10. They pay close attention to immediate feedback and modify their
techniques, strategies, and communications immediately, as
the feedback indicates.

It is worth repeating that this list does not pretend to be a complete or

prescriptive guide for selecting sex therapists. It is a description of those

characteristics common to several sex therapists who have some consistent

degree of success in their sex-therapy practices.

Behavior Therapy

The specific techniques of behavior-modification therapy are

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 adequately described in Chapter 15 of this volume and will not be repeated
here. The same basic techniques are applied to changing the unacceptable

sexual behavior (Dengrove, 1967; Haslam, 1965; Holroyd, 1970; Jones, 1972;
Kraft, 1967; Lazarus, 1963). A given therapist may elect to use some of the

"sensate-focus" exercises used by the Masters and Johnson disciples, and/or

the role-playing, confrontation techniques used by encounter-group leaders.

Psychotherapy

The strategies and techniques used in psychotherapy are adequately

described elsewhere in this volume. These are less homogeneous than the
behavior therapies. These are also likely to be applied unmodified to the

patient’s sexual problems. The amount of emphasis on the patients’

understanding of their basic psychological problems, "working through" of

their conflicts and accepting the therapists’ theoretical premises (Spiegal,

1967), is highly variable from therapist to therapist. The therapist’s comfort

with human sexual behavior and her definition of what is "normal" are much

more critical factors in psychodynamic psychotherapy than they are to the

more ritualized behavior therapies (Marmour, 1971). A given

psychotherapist may selectively introduce some of the sensate-focus

exercises (Masters, 1970) and encounter-group techniques but, as a rule, is

less comfortable with these. Psychotherapists have usually been

indoctrinated to be nondirective, unrevealing of how they feel or what they

American Handbook of Psychiatry Vol 5 27

 are experiencing, and not to touch their patients. It is difficult to prescribe

sensate-focus exercises or to utilize encounter-group techniques without

directing, revealing, or touching. When therapists do not routinely use these

in their clinical practices, they are initially unsure and hesitant when
introducing them in sex therapy. The end result is that they remain

uncomfortable as sex therapists or begin to introduce similar techniques in

their therapy of other patients. This is usually good if they are comfortable
and open about these modifications of their therapy techniques. It is usually

bad when they feel guilt about "betraying" their teachers and the theories on

which their previous therapeutic techniques have been based.

Hypnosis (Mirowitz, 1966)

Hypnotic therapy is discussed in Chapter 12 of this volume. These

techniques are also applied directly to sexual-incapacity symptoms by

suggesting relaxation and loss of inhibition in responding to sexual arousal.

Hypnosis may be used independently or in combination with any of the other

therapies discussed in this chapter.

The Masters and Johnson Approach

Masters and Johnson have developed a human, sexual-inadequacy

therapy (1970) that has popularized a broad awareness of the problem and

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 has offered the most consistent therapeutic success. This "sensate-focus"
approach is presently the therapy of choice among the majority of

practitioners who deal with sexual incapacity problems and as such deserves

a more detailed presentation.

Sensate-Focus-Oriented Therapy

The basic concept of sensate-focus-oriented therapy is that the person

with sexual problems is not paying attention to and responding to her own

natural, biological-sensual cues. Therapy is directed toward freeing the

patient to become capable of experiencing the pleasurable and exciting

sensory stimuli from her genital anatomy. When this is accomplished, it is

believed that these formerly sexually incapacited persons will be

permanently able to experience and respond to their own sexual needs

without incapacitating symptoms.

A few sex therapists have been trained by Masters and Johnson, but

most sensate-focus sex therapists use their own version of the technique.

Although variations do exist in the details of the therapeutic attack as

employed by different therapists, the similarities are sufficiently widespread

to warrant an attempt to extract the basic principles upon which the

therapeutic strategies and techniques are based.

Most therapists focus on the therapy of a sexual unit rather than an

American Handbook of Psychiatry Vol 5 29

individual. A sexual unit may be defined as a married couple, an engaged
couple, or an individual and her primary sexual partner. Masters and Johnson

reported on the use of successful surrogate partners when no natural primary

partner was available. Therapy is usually conducted in joint interviews with

both partners always present.

Coequal male-female co-therapy teams are said to be the ideal model

(Masters, 1970). Unless the therapists are equal in each other’s and their

patients’ eyes, male and female co-therapists add little except cost. Too often

a chauvinistic male therapist brings any female he can find into the therapy

session and appoints her to be his "cotherapist." She has little background to
understand what is taking place, little or no status in either the patients’ or

the male therapist’s eyes and presents a model of male- female inequality to

the patient couple. Even two equal co-therapists have to work at presenting
themselves as a team not dominated by either the male or the female. This is

most likely to occur when each is comfortable with her or his own and each

other’s sexuality. Verbal encountering to clarify their interpersonal

relationship with each other is often helpful.

Therapy typically starts with a long detailed history (Hastings, 1963;

Masters, 1970). This serves three purposes: (1) establishing communication;

(2) understanding most of the patients’ sexual patterns of behavior, attitudes,

needs, fantasies, and expectations; and (3) exposing the therapists’ sexual

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attitudes and tolerance level to the patients.

Following this a contract is negotiated (Masters, 1970). The therapists

share their understanding of the problem with the patients and a therapeutic

plan is agreed upon. In addition to cost, duration, and appointment frequency

the "contract" includes such items as: availability of therapists beyond the

regularly scheduled appointments, how much control of the patients’ sexual

behavior by the therapists will be required, how much homework is

indicated, whether therapy will be limited to sexual behavior or also include

counseling about other personal, interpersonal, and marital problems.

Reassurance and support, which have been developing, are now more

strongly reinforced. The overall message conveyed is, "I, your therapist, do

understand your sexual problems, accept where you are, and am willing and

able to help you. I am an authority figure who is more knowledgeable,

understanding, and permissive of your sexuality than other authority figures

you have known in your past. You are human beings with your own sexual
expectations, which I now understand and will respect."

Effective communication skills between the sexual partners have usually

deteriorated and therapy moves along more smoothly when therapists focus

on this problem early (Lederer, 1968; O’Neil, 1972). Effective communication

may be verbal, para- verbal, or nonverbal, but is always characterized by

American Handbook of Psychiatry Vol 5 31

messages that are equally clear to the sender and the receiver. Sexual
communications are most clear when they deal with the "here and now"

rather than the past or the future, are statements concerning "where I am,"

"what I am experiencing," inquire rather than accuse, assume, predict, or

guess the partner’s motives, wishes, or needs, and are not distortions of
reality. The therapist may choose to end the first session with the patient

couple by inviting them to try this style of communication for a week before

proceeding to work on the sexual behavior itself. Most couples who agree to
try this have been moderately successful. They report a reduction in their

hostility, their anxiety, and their misunderstanding of each other’s messages.

Estimation of motivation for change is necessary. This is less important

in the two-week concentrated program offered by Masters and Johnson than

in the variations that employ one or two appointments weekly. The latter
strategy is quite dependent on the patients’ willingness to spend time doing

the prescribed homework. When the couple can’t find time for thirty minutes

of uninterrupted sensate- focus exercises at least every other night, therapy

should be discontinued until the patients can arrange their schedules.

Availability by phone is desirable when the therapists choose a once or

twice weekly interview strategy. It is the author’s experience that the phone-
call availability is rarely abused. Mandatory delay of feedback until the next

scheduled appointment allows a bad situation to get worse and slows down

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progress when things are going well.

The homework is a sine qua non for successful sex therapy (Masters,
1970). It consists of carefully prescribed, reciprocating body-massage

exercises. The couple is instructed to spend an uninterrupted thirty to forty-

five minutes on this activity at least every other night. They take turns at

"pleasuring" and "being pleasured by" each other. The primary objective is for
each to develop her or his own sensate-focus awareness without moving

ahead fast enough to develop incapacitating anxiety. Additionally, each has an

opportunity to learn that pleasuring can be as exciting as being pleasured

(Masters, 1970).

The couple is instructed to lie nude beside each other on a bed in a

lighted room and relax. When they feel somewhat relaxed, pleasuring starts

with gentle massaging of non-eroticized areas of the receiver’s body. By

random selection one has been assigned the role of giver only and the other of

receiver only. Halfway through the exercises they will change roles. It is felt
that initially concentrating on only one role maximizes awareness and

proficiency in that role. Much later blending of the two roles alternately or

simultaneously will be a matter of personal preference.

The giver is in charge of what is given as long as pressure is not put on

the receiver to respond with anything other than what the receiver is

American Handbook of Psychiatry Vol 5 33

spontaneously experiencing. The goal is to develop an awareness of
experiencing the sensory stimuli generated from one’s own body being

touched and from touching one’s partner’s body (Hollender, 1969).

Premature demand for sexual performance either from oneself or one’s

partner evokes anxiety and interferes with learning to pay attention to one’s
own pleasurable sensory cues.

A few nights to a week later the receiver is allowed to indicate

preferences in the kind and location of the massaging that is preferred. This is

a learning exercise in which the patients teach one another what they have

learned about themselves while in the receiving role. Each also learns what
pleases the other, and the importance of keeping each other informed. When

they do not aggressively make specific demands, both become less fearful of

being neglected or of being overwhelmed by the demands of the partner.

Many sexually incapacitated persons do not like to touch "messy,"

"dirty," "sticky," "slimy," substances, i.e., normal vaginal secretions or semen.

Therefore, at this stage, hand lotion is introduced in the massaging exercises

(Masters, 1970). Any "clean," "sterile," water-soluble hand lotion will suffice.

It should be used in sufficient quantities as to be experienced as "messy" but

paired with the already pleasurable sensation of being massaged.

Next the constraint of limiting the massages to non-eroticized areas of

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the partner’s body is removed. This is prescribed when the therapists believe
the couple can experience sensual arousal without significant anxiety. Now

the goal becomes developing awareness of sensual stimuli originating in one’s

body rather than that originating primarily in one’s head (Kegel, 1952;

Masters, 1970). This may be a particularly difficult phase for the less
incapacitated partner if she or he is highly aroused sexually but constrained

from having sex relations because of an earlier contract with the therapists.

The couple is reassured that a spontaneous orgasm is acceptable, but

pressuring oneself or one’s partner is not. Since the receiver can control how

much stimulation she or he accepts and the giver can decide how much she or

he is willing to offer, the chance for making anxiety provoking demands is

minimized. Independently, or with the help of the therapists, the couple may
negotiate to allow the over-aroused individual to masturbate for relief.

When the couple is sufficiently comfortable with experiencing sensual

arousal, they are permissively encouraged to experiment with experiencing a

full sexual response, dependent primarily on body, not head, stimulation

(Masters, 1970). Initially, this should be experienced by one in the receiver

role only. Manual stimulation for this first full sexual turn on is least likely to

tempt the previously incapacitated person to return to the older

unsatisfactory sexual patterns. However, the therapists must use their clinical
judgment about when to prohibit, permit, or encourage oral-genital or
genital-genital stimulation. In either case, the previously sexually

American Handbook of Psychiatry Vol 5 35

incapacitated person should be allowed to satisfy herself before trying to

satisfy her partner. Learning how to recognize, sort out, and spontaneously

respond to sensual body stimuli is necessary before one can effectively

participate in simultaneously giving and receiving sexual responses.

After both partners are able to experience desire, arousal, pleasurable

excitement, and orgasm when in a receiver role only, the constraint on

intercourse is removed. The therapists should help the couple select a time,

place, and set of circumstances least likely to evoke anxiety or fear of failure.

The couple must be reassured that lack of complete success at this point
doesn’t mean starting all over again. It is helpful to supportively remind them

how far they have already come. Anything that reduces the anxiety of the

couple seeing this as the "final exam" is helpful. Demanding good

performance of themselves or each other now will have the same

counterproductive effect it had in the past.

A failure, even after weeks or months of satisfactory sexual

performance, may panic one or both partners into making a self-fulfilling

prophesy of a return of the old sexual incapacity.

Interviews, during the sensate-focus homework exercises, are used to

explore, clarify, instruct, educate, reassure, praise, support, and maintain the

patients’ enthusiasm. Primarily, discussions focus on sexual behavior, but,

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from time to time, exploring some other aspect of the couple’s interpersonal
relationship may facilitate their ability to interact sexually. Nonverbal

encounter-group techniques and role playing can be effective in helping the

couple recognize and/or express themselves when verbal communication

becomes garbled or blocked. However, therapists who are themselves

uncomfortable when interacting with their patients nonverbally will find it

difficult to convince their patients to participate.

Sex education is valuable for some patients who have very limited

information and very little ingenuity. When they become free enough to

experiment, they have no models or guidelines. Reassuring information,

reading materials, pictures, models, and movies can be used to stimulate

discussion. These are offered permissively and as possible patterns the

patients may want to consider for themselves. Setting up a competitive

situation must be actively avoided.

When the primary symptom is premature ejaculation rather than male

impotence or a non-orgasmic female, an addition to the above techniques is

indicated. Medication (Gibbons, 1923), hypnosis, and psychotherapy have

been used, but techniques specific for the symptom (Ahmed, 1968, Masters,

1970) offer more consistent success. The best-known technique was

described by Semans (1956) and is called the Semans squeeze technique.

Vandervoort (1972) has published an illustrated booklet describing its use.

American Handbook of Psychiatry Vol 5 37

 Oversimplified, the male recognizes his pre-ejaculatory inevitability and
informs his partner. She grasps the head of his penis between her thumb and

fingers hard enough to hurt. His urge to ejaculate and some of his erection

disappear. Sexual activity is resumed and the steps above repeated as

frequently as necessary. Over time, the male is conditioned to last longer

before ejaculation.

A more humane approach also involves the active, willing cooperation

of the partner (Hirsh, 1951). She lightly strokes the penis until he experiences

prejaculatory inevitability. He indicates this state, and she stops. A minute or

two later when the inevitability feeling has passed, she resumes stroking the

penis and the process is repeated several times. Masters and Johnson report

that this technique can increase duration after intromission from a few
seconds to several minutes. The strategy is to increase the male’s tolerance

for experiencing genital stimulation without adding to his mental excitement

and anxieties. Most males spontaneously prescribe the reverse of this for
themselves trying to avoid all stimulation until the moment of vaginal entry.

This means relying primarily on intellectual and fantasy stimulation to obtain

and maintain their erections.

Conclusions

The therapy of human sexual incapacities is a mixed bag at the time of

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this writing. The syndromes of sexual problems are ill-defined and vague or
operationally defined and arbitrary. The "diagnostic" categories are not well

related to specific etiologies, pathologies, prognoses, or therapeutic regimes.

Therapies are loosely structured, vary from therapist to therapist, and the
model, principles, or strategies are rarely identified. Treatment is most likely

to be aimed either at specific symptoms or at overall improvement in the

patients’ psychological adjustment.

On the positive side, human sexual functioning has become a legitimate

concern of those offering health-care services. The newness and as yet poorly

defined diagnostic categories make this group of human maladies more

patient-oriented than is the case in more traditional medical care. It is

accepted that sexual incapacity can only be diagnosed subjectively by the

patient herself. This potentially gives the patient options in deciding how

much and what treatments she will accept, since the patient defines her own

incapacity in terms of a variance from her personal expectations for her own
sexual health. In offering the patients these kinds of "diagnosis" and "therapy"

options, human sexual health care is more advanced than other areas of
health care.

Preventive measures are still poorly understood. The role of sex

education in prevention of sexual-inadequacy problems is still very

controversial (Vincent, 1968). The August 25, 1969, AMA News reported,

American Handbook of Psychiatry Vol 5 39

"When most of the emotion is stripped away, the basic views of the
proponents and opponents of sexual education are these: the former hold that

sex education courses are designed to answer the ‘whys’ of children’s

questions about family life, physiological development and its relationship to

the society in which they live. It’s taught in a clinical, detailed manner which

allows students to make their own moral judgments. Opponents hold that sex

education courses are really ‘how to’ courses that teach mechanics of

intercourse without morals attached to it." Both are partly right. Courses
should he designed and delivered to do what proponents aim for, but

frequently they are so poorly conceived and/or delivered as to accomplish

what the opponents claim. Even when the moral aspects are stripped away,
hunch rather than data relates sex education to better sexual functioning.

Most sex therapists believe reassurance about the normality of sexual

feelings plus accurate information about patterns, varieties, and frequencies

of sexual behaviors, the existence of recreational as well as procreational sex,

the relationships between sex, love, and marriage, the relationships between

menstruation, menopause, old age, and sexual behavior should be readily

available to all humans as they need it. Our current divorce rate and the

frequency of sexual incapacities and marital discord suggest that a better

preparation for sexual roles is needed before humans reach adulthood. When

parents become comfortable with their own sexuality, their children can

obtain most of the sex education they need from their own parents in their

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 own homes. Parents need to: (1) encourage their children to be curious about

any and everything known to mankind; (2) offer their children a model of two

adults who are involved, intimate, and not afraid to show affection for each

other; and (3) help their children understand that it’s okay to pursue pleasure
as a positive goal rather than as something only experienced by breaking the

rules.

Basically, this prescription assumes that young humans who are

allowed to experience reality as it occurs become those best able to recognize

and deal with reality as they grow older. Sexual functioning is a significant
part of human reality. As humans become better able to deal with their sexual

reality, the need for therapy of sexual incapacities will decrease.

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Notes

1 Hereafter in this chapter "her," "she," and "herself" will be used arbitrarily to avoid the repetitive,
clumsy use of "her/him," "she/he," "herself/himself."

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