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In the late 1960s and early 1970s, the focus in sex therapy was on behavior change. Sex therapists then usually acted as guides, describing techniques and assigning sensate-focused homework. In the 1990s, the availability of a wealth of new information and procedures, combined with our current understanding of the significance of such factors as family-of-origin issues and patient emotions and cognitions, has brought the practice of sex therapy to a new level of sophistication. Designed as a succinct guide to contemporary sex therapy, this book provides a state-of-the-art, empirically based overview of the most common sexual dysfunctions, and a step-by-step manual
for their assessment and treatment.

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Sexual Dysfunction

The Guilford Press

Chapter One

Interest in sexual behavior increased dramatically in the last two decades. During the 1980s (and continuing to the present), the emergence of HIV and AIDS raised awareness of the health implications of sexual behavior. During the 1990s, there have been highly visible developments in the pharmacological treatment of sexual problems, most notably, the development and marketing of Viagra (sildenafil citrate) for the treatment of erectile dysfunction. Private and publicly supported research promises more pharmacological treatments of sexual problems in the decade to come.

With the launching of Viagra and subsequent worldwide attention, questions were raised about the need for psychological treatments. Doubts about the role of mental health professionals in treating sex dysfunction have been short-lived. Although Viagra alone as treatment has been sufficient for some men suffering from erectile dysfunction, for many others this has not been the case. Viagra has not cured marital and relationship problems, has not corrected myths and misunderstandings (nor has it provided accurate educational material), has not overridden negative sexual messages and sexualtrauma, and has not taught sexual skills (nor how best to create sexual feelings and a conducive sexual environment). No pharmacological agent will substitute for these basic and essential ingredients of enjoyable and fulfilling sexual experiences.

Viagra has had the most impact on primary care physicians, who are the largest prescribers of this medication. Unfortunately, primary care physicians do not typically have the time or skills to screen sexual problems adequately and often prescribe Viagra when nonmedical factors may be contributing heavily to the problem. Viagra "failures" are most likely a result of insufficient psychosocial screening and a purely biomedical approach to a complex, biopsychosocial experience.

A decided benefit of the Viagra craze is that it has legitimized help seeking for sexual problems. With the frequent commercial appearances of former U.S. senator and presidential hopeful Bob Dole (extolling the benefits of Viagra for treating erectile dysfunction), the American public has been given a very powerful message that sexual problems are commonplace and treatable, and there is no need for shame.

Sex is important to people. This is more evident today than at any other time in our history. Our goals in writing this book are (1) to provide a state-of-the-science overview of the most common sexual dysfunctions, and (2) to present an introductory guide to the assessment and treatment of these problems.

This book is intended for health care professionals at various levels of expertise and for both medical and nonmedical disciplines. Accomplished sex therapists may wish to compare their own approaches with ours and may find some interesting ideas described herein. This book is also intended for health care professionals currently in training (e.g., graduate students, medical interns, and residents), or currently practicing but who have little (or no) previous training in the assessment and treatment of sexual dysfunctions. Finally, this book is also intended for practicing physicians (e.g., internists, family practitioners, urologists, and gynecologists) who treat patients' sexual dysfunction complaints and who wish to learn more about the psychological aspects of sexual dysfunction. This book is not intended to replace other types of formal training and should be used in conjunction with supervision from an experienced sex therapist.

We begin in this chapter with an overview of our current understanding of sexual function and dysfunction, and describe our general approach to the management of sexual difficulties. The remainder of the book is divided into two parts and incorporates the most up-to-date clinical and research information available. In Part I (Chapters 2-5), we provide a more detailed discussion of each of the main classes of sexual dysfunction. We focus on definitions and descriptions, prevalence, and etiology. In Part II (Chapters 6-10), we describe our approach to assessing and treating these problems, present seven detailed case histories, and provide information about how you can obtain further training and even establish a practice in sex therapy.

Definitions of Sexual Function and Dysfunction

Controversy and Change

We are educators, clinicians, and researchers. In the context of our teaching and supervision, we often wrestle with the constructs of "normality and abnormality," "health and pathology," and "function and dysfunction." We are thankful that our students and supervisees continually challenge our definitions and help us to remain open-minded and responsive to new information. This is particularly important in a socially sensitive and value-laden field such as human sexuality-a field where popular beliefs about function and dysfunction seem to be quite labile. To illustrate this point, we can use two examples: thinking about masturbation and sexual desire.

In previous times, masturbation received widespread condemnation. For example, in the 18th century, numerous treatises were written describing the physical and mental consequences of masturbation (see Caird & Wincze, 1977; Gagnon, 1977). It was during this time that a particularly well-known Swiss physician, Tissot (1766), published a volume titled Onania, or a Treatise upon the Disorders Produced by Masturbation. Among the many physical and mental disorders purportedly caused by masturbation were failing eyesight, consumption, gonorrhea, hemorrhoids, digestive disorders, melancholy, catalepsy, imbecility, loss of sensation, lethargy, pervasive weakness of the nervous system, impotence, and insanity! Eventually, because of the scientific work of Kinsey and others, more enlightened views about masturbation emerged. Today, in stark contrast, masturbation is prescribed as therapy (e.g., see LoPiccolo & Lobitz, 1972; Zilbergeld, 1999). In fact, it turns out that directed masturbation (see Chapter 7) is a particularly effective treatment for lifelong female orgasmic disorder (see Heiman & LoPiccolo, 1988). (As an aside, we are reminded of the exchange between the Countess and Boris in Woody Allen's movie Love and Death. Countess: "You are a wonderful lover." Boris: "I practice a lot when I am alone.")

Before we rest on our accomplishments, however, we should note that we are not entirely free of 18th-century thinking. It was just a few years ago that Surgeon General Jocelyn Elders was forced to resign her post for suggesting that masturbation might be an acceptable substitute for high-risk sexual behavior! Yes, change has occurred, but there is still room for improvement.

Related beliefs about sexual appetite, desire, and behavior have also changed. Beginning with the writing of the Christian theologian Paul, sexual abstinence and chastity were seen as virtuous. Indeed, those interested in maximizing their spiritual development were required to take vows of celibacy and chastity (Cole, 1956). In the first half of the 20th century, however, scientists began to question whether sexual abstinence was contrary to human beings' basic biological nature (e.g., Parshley, 1933) and potentially harmful. Today, the absence of sexual desire is seen as a clinical disorder that warrants proper diagnosis and treatment. Who knows what the next decade will bring?

We hope that these two examples (from many that we might have selected) serve to illustrate our point: Definitions of sexual function and dysfunction are inevitably influenced by current social mores, values, and knowledge. In the past 10 years, we have noticed an increase in sexual dysfunction research studies from different cultures. Whenever possible, we have incorporated cross-cultural comparisons. As these and other influences change, so too will our definitions of sexual function and dysfunction. Mindful of this caveat, then, we are poised to discuss current clinical definitions.

Current Definitions

Current approaches to define sexual function and dysfunction have been influenced by recent biomedical research and clinical practice. Current thinking suggests that human sexual functioning, for most people on most occasions, proceeds sequentially. This axiom, accepted by most sexologists (i.e., experts in human sexuality), has its formal beginning with Havelock Ellis (1906), who postulated that sexual functioning has two stages: tumescence (i.e., the engorgement of genitals with blood, resulting in erection in males and vaginal lubrication in females) and detumescence (i.e., the outflow of blood from the genitals following orgasm). Ever since, scientist-practitioners have attempted to delineate more precisely the basic biological sequencing of sexual function.

William Masters and Virginia Johnson, household names to most Americans, contributed immensely to our understanding of sexual functioning. During the 1950s and 1960s, they conducted a very extensive (and equally controversial) series of scientific observations of sexual activity with human volunteers. In their 1966 book Human Sexual Response, based upon thousands of hours of careful laboratory research, Masters and Johnson suggested that physiological responding in healthy, well-functioning adults proceeds through four stages: (1) excitement, (2) plateau, (3) orgasm, and (4) resolution. They documented the genital and extragenital physiological changes that typically occur during each of these phases. The model they provided was instructive and elegant.

Yet something was missing. That something was most apparent to those practitioners working with not-so-well-functioning individuals and couples (e.g., Kaplan, 1979; Lief, 1977). Some of these sexually troubled persons complained of an inability to become amorous, a lack of interest in sex, or even an aversion to sexual activity. In the decade following the publication of Human Sexual Response, it became increasingly clear that there was a "stage" preliminary to the excitement phase identified and described by Masters and Johnson. This preliminary stage, subsequently labeled sexual "desire," involved a person's cognitive and affective readiness for, and interest in, sexual activity. Without sexual desire, physiological and subjective arousal, and subsequent orgasm were much less likely to occur.

Subsequent theoretical writing and empirical research have served as the basis for our current understanding of sexual function and dysfunction. Most sexologists agree that healthy sexual functioning comprises three primary stages: desire, arousal, and orgasm. (Each of these terms is defined and discussed further in the coming chapters.) Sexual dysfunction, then, consists of an impairment or disturbance in one of these stages. Although this stage model is somewhat arbitrary in that it identifies discrete stages in what may well be a continuous process, we believe that it provides a useful heuristic from which to conceptualize and discuss sexual health. Not surprisingly, this model is compatible with current diagnostic schemes.

Recognizing Sexual Dysfunctions: The Challenge of Diagnosis

The Current Diagnostic Scheme

Although several diagnostic approaches have been proposed to classify the sexual dysfunctions (e.g., Schover, Friedman, Weiler, Heiman, & LoPiccolo, 1982), the diagnostic scheme that has been most widely adopted for sexual dysfunctions is that contained in the Diagnostic and Statistical Manual of Mental Disorders (hereafter abbreviated as DSM; American Psychiatric Association, 1994). This series of manuals was developed to aid mental health care professionals in the diagnosis and treatment of the so-called "mental disorders." (The first edition of DSM appeared in 1952, and new editions appeared in 1968 and 1980; the third edition was revised in 1987. The fourth edition of DSM was published in 1994 and its text revision-DSM-IV-TR-in 2000.) Although the manual was not developed for sex therapists, it contains diagnostic categories and criteria for the most commonly seen sexual difficulties.

There are nine major diagnostic categories for sexual dysfunction in DSM-IV-TR. These diagnostic categories, depicted in Table 1.1, include the following: hypoactive sexual desire disorder, sexual aversion disorder, female sexual arousal disorder, male erectile disorder, female orgasmic disorder, male orgasmic disorder, premature ejaculation, dyspareunia, and vaginismus. (These terms, and their diagnostic criteria, are described in detail in Chapters 2-5.) All nine of the dysfunctions identified in DSM-IV-TR should be further conceptualized along two dimensions. First, they may be characterized as "lifelong" (also known as "primary") or "acquired" (also known as "secondary"). Second, a dysfunction may be "generalized" (i.e., occurring across all sexual situations and partners) or "situational" (i.e., limited to certain situations and partners). These distinctions are believed to be important with respect to both etiology and treatment.

DSM-IV-TR represented an improvement over previous editions of DSM but is still far from perfect. The primary limitations within sexual dysfunction diagnosis is the inherent subjectivity of criteria in most categories. Terms such as "minimal sexual stimulation" or "normal sexual excitement" leave much to clinical judgment.

Despite limitations, DSM-IV-TR classifications continue to be used in professional journal articles, by most health professionals (from whom referrals may originate), and by insurance companies (for third-party reimbursement). It should be noted, however, that most insurance companies still do not reimburse for treatment of sexual dysfunction. Often, a diagnosis of anxiety disorder or depression is justifiable. Familiarity with DSM-IV-TR categories and criteria is essential.

Sexual Deviations, Dysfunctions, and Dissatisfaction

The DSM diagnostic scheme includes the sexual deviations (i.e., paraphilias), as well as sexual dysfunctions. Paraphilias are disorders in which an individual experiences recurrent and intense sexual urges and fantasies involving either (1) nonhuman objects (i.e., a fetish), (2) suffering or humiliation of oneself or one's partner (i.e., sadomasochism), or (3) nonconsenting partners (e.g., pedophilia, exhibitionism, frotteurism). Assessment and treatment of the paraphilias are not covered in this book. (Interested readers are referred to Kafka, 2000; Laws, 1989; Laws & O'Donohue, 1997; Wincze, 2000.)

However, knowledge of the assessment and treatment of the paraphilias or atypical sexual behavior (that does not meet the criteria for paraphilia) is important for assessment and treatment of sexual dysfunction. Unusual types of sexual preferences or stimulation are at times at the root of sexual dysfunction in both men and women.

Continues...

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Excerpted from Sexual Dysfunction by John P. Wincze Michael P. Carey Copyright © 2001 by The Guilford Press. Excerpted by permission.
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