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Sex therapyis a therapy is a psychotherapeutic approach that addresses concerns of sexual feelings, sexual functions and intimacy. Treatment of sexual dysfunction, such as non-consummation, premature ejaculation, erectile dysfunction, low libido, unwanted sexual fetishes, sexual addiction, painful sex, or a lack of sexual confidence, assisting people who are recovering from sexual assault, problems commonly caused by stress, tiredness, and other environmental and relationship factors. Sex therapists assist those experiencing problems in overcoming them, in doing so possibly regaining an active sex life. It can be helpful to people of all ages regardless of age, gender, or sexual orientation. Psychologists provide sex therapy, in addition to social workers, physicians or licensed therapists who have obtained post-graduate training in the handling of issues related to sex and relationships. The American Association of Sex Educators, Counselors and Therapists (AASECT) is an organization that oversees clinical training for a sexual health practitioner to become a certified sex therapist (CST).

Description

Sex therapy became mainstream in 1970. Since then sex therapy is a specialty within the fields of psychology, psychiatry, and medicine. Certified sex therapists are required to have at least “90 hours of course work covering such basics as the history of sexology; knowledge of sex research and literature; the anatomy and physiology of sexual response; developmental and sociocultural, and medical factors affecting sexually transmitted infections and prevention issues; sexual abuse and its consequences; sexual orientation; and sexual minorities”. Ethical principles are important to all forms of therapy, but especially in sex therapy for the vulnerability related to sex. Ethical principles include respect for diversity in values, sexual orientation and gender. Individual or couple psychotherapy may be offered. It is important to note that each person’s biopsychosocial vulnerabilities that may increase a risk of sexual dysfunctions in one person may not in another person. Reasons that men and women are motivated to enter sex therapy are quite different. It is more common for men to seek sex treatment for problems with sexual performance, compared to women who are more motivated to seek sex treatment for expressing concerns relating to sexual feelings.

History of Western Approach

Before the 20th century sex was not spoken about in public reflecting societal norms and beliefs of the time. It was not until this time that key figures transformed our thinking about sex.

Sexual Modernism

Henry Havelock Ellis (1859-1939)


 * A physician, Henry Havelock Ellis, emphasized that sex was natural to humans and instinct also that it could be enjoyable.  Ellis challenged Victorian England beliefs; he did not agree that masturbation caused illness and insanity .  Ellis felt that stressors and repressive circumstances contributed to sexual dysfunction.

Magnus Hirschfeld (1868-1935)


 * German physician,Magnus Hirschfeld, founded the Institute of Sexual Science, one of the very active institutions for sex research located in Berlin. Hirschfeld was interested in problems associated with sexuality and the relationship that was associated with sexual problems and taboos as well as trauma.

Sigmund Freud (1856-1939) 


 * From Freud’s psychoanalytic theory, sexual problems were usually resulted from unresolved conflicts in childhood relating to attachment and tension involving parents . Freud’s Stages of Psychosexual Development consisted of 5 stages: oral, anal, phallic, latent and genital.  Freud theorized that for a male in each of these stages, failure to move through them, in addition having an unresolved Oepidal desire could result in a psychosexual disorder .  Thus, one of his greatest contributions to sexuality was how sexuality is vital to personality .  During the first half of the 20th century psychiatrists used the psychoanalytic model while addressing sexual dysfunctions.  Men who presented sexual dysfunctions during this time were treated using the psychoanalytic model.

Sexual Freedom Movement

William Masters (1915- 2001) & Virginia Johnson (1925- 2013)-


 * It was not until the 1940s and early 1950s that the highly controversial work of Alfred Kinsey  began to describe and categorize normal sexual behavior.  Kinsey’s work influenced Dr. William Howell Masters, a gynecologist and Virginia Eshelman Johnson, a psychologist.  Together they revolutionized the field of human sexuality ).  In 1970, they published Human Sexual Inadequacy, which discussed sexual disorders and treatments.  The clinical work was based on reports of the human body’s physiological responses to erotic stimulation (Human Sexual Response 1966).  This publication illustrated four phases called the human sexual response cycle: excitement, plateau, orgasm, and resolution, after the body returns to the pre-excited state .  Sexual dysfunctions were then defined as any inappropriate response during the sexual response cycle .  These dysfunctions were generally attributed to a range of psychological causes including performance anxiety  .  Consequently, sexual dysfunctions were added to the Diagnostic and Statistic Manual of Mental Disorders (DSM).  Masters & Johnson believed that sexual performance was natural, however negatively influenced by sociocultural attitudes and, specifically related to sexually restrictive or religiously orthodox upbringing .  If treatment was sought and treated properly with psychotherapy, the sexual problems would be reduced .  Another important contribution by Masters & Johnson is that they were able to challenge myths regarding sexuality decreasing with age . This continues to be challenged today in Western society.

Helen Kaplan (1929-1995)


 * An American sexologist, Helen Kaplan, used Masters & Johnsons techniques combined with Freudian techniques and developed her idea of “new” sex therapy.  Kaplan felt that the first step in treatment for sexual dysfunctions, required cognitive behavioral therapy for immediate relief, followed by the usage of psychoanalytic techniques that target deeper issues, such as, resistance to treatment .  Additionally, Kaplan replaced the human body’s physiological responses to erotic stimulation done by Masters & Johnson with desire, excitement, and orgasm.

Specific Techniques for Specific Conditions

Sex therapists treat patients with desire, arousal, performance, and satisfaction issues. They also treat patients who have experienced sexual trauma or abuse, or who are struggling with gender identity or sexual orientation issues, fetishes, sexual pain or sexual compulsions/addictions.

Sexual dysfunctions

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; The American Psychiatric Association, 2013) classifies various sexual dysfunctions as delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature ejaculation, substance/medication-induced sexual dysfunction, other specific sexual dysfunction and unspecified sexual dysfunction. Sexual dysfunctions are a multifarious group of disorders that are typically differentiated by a “clinically significant disturbance in a personal ability to respond sexually or to experience sexual pleasure” with a minimum of 6 months duration. These disorders can be organized into four categories: sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders.

Male Sexual Dysfunctions

Male sexual problems typically have 3 elements: functional impairment, low-self esteem, resulting in suffering negative consequences. In order to diagnosis sexual dysfunctions there have been numerous diagnostic tools that help supplement a clinical interview and diagnosis. Men can benefit from sex therapy for an assortment of reasons. It is recommended for men who have a biogenic sexual dysfunction or for an individual whose sexual dysfunction is due to anxiety and may prefer a drug free approach, but it can also be combined with pharmacological therapy. Primarily, it is appropriate for men who want to have a more sexually satisfying relationship.

Delayed Ejaculation


 * The DSM-V diagnostic criterion for Delayed Ejaculation is a “marked delay in or inability to achieve ejaculation (Criterion A)” . The typical goal used to treat delayed ejaculation is to stimulate higher levels of psychosexual arousal resulting in an orgasm during sexual experiences.  In sex therapy masturbatory training is common.  An example of masturbatory training could involve masturbating with thoughts of sexual fantasy to increase arousal.

Erectile Disorder


 * The most common sexual dysfunction is erectile dysfunction. Lewis found that in the United States, ED has affected as many as 30 million men and “approximately 5-50% of all men depending on their age group” (as cited in Rowland, 2012 p. 45).  The DSM-V diagnostic criteria for Erectile Disorder are “the repeated failure to obtain or maintain erections during partnered sexual activities (Criterion A)” .  The PLISSIT model is helpful in sex therapy for treating ED.  Some clinicians also choose to use integrative therapy.  Integrative therapy is helpful in treating ED for the following process elements as suggested by Rowland (2012), developing a patient/therapist relationship; expressing empathy, genuineness, and positive regard; developing motivation to change; identifying ED-related affects, cognitions, and behaviors; and supporting self-efficacy .  Seeking sex therapy to help with ED for psychogenic/relationship issues has produced high satisfaction rates of 50-70% that maintain treatment for 12 months or longer.

Premature ejaculation


 * The DSM-V diagnostic criterion for Premature Ejaculation includes “a persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it” . Treatment in sex therapy includes a behavioral technique called start-stop, described by Helen Singer Kaplan in How to Overcome PE (1989).  This technique involves the patient who is directed to masturbate in private and attempt to stop when the moment of ejaculatory inevitability (MOEI) occurs.  When the feeling of ejaculating subsides the patient will then start masturbating again.  This occurs 3 times, allowing ejaculation on the 4th time .  Another form of treatment is the squeeze technique.  The squeeze technique involves squeezing just below the head of the penis right before ejaculation occurs; this helps to give more control over ejaculation .  Results suggest premature ejaculation has the best behavioral treatment.

Male Hypoactive Sexual Desire Disorder


 * Male hypoactive sexual desire disorder, previously known, as Hypoactive Sexual Desire has been made exclusive to males in the DSM-V. The diagnostic criterion in the DSM-V is considered if there is “persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity.  The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual’s life” .  Treatment can vary in which it may include biomedical approaches, or perhaps a combination of counseling dealing with general stressors, or focusing on relationship and sexual stressors (Rowland, 2012 p. 38) .  In relation to sexual dysfunctions addressing stressors is critical, because stress is known to increase adrenal cortisol in the body, resulting in a decrease in testosterone levels .  Low testosterone levels can cause a decrease in sexual thoughts or desire.  Examining and alleviating these stressors with therapeutic help can increase testosterone, without prescription medications.  A biomedical approach would be taken if after laboratory testing, results indicate a deficiency or abnormal level of hormones.  For example, if an abnormal level of testosterone were present, testosterone therapy is the next step if desired by the patient .  If a biological abnormality is not the cause, psychosexual therapy is recommended.  If it is due to general stressors, one or both partners may be included. Likewise, if it is due to issues in the relationship, counseling for both partners is beneficial for a renewed sexual desire.  Treatment can focus on addressing the following factors, conflicts, understanding their partner’s needs, adjusting behaviors or cognitive processes and developing communication between partners.  The goal is to improve sexual intimacy and interest within the relationship.

Female Sexual Dysfunctions


 * Female sexual dysfunctions are categorized into 4 different categories: low libido, difficulty attaining sexual arousal, inability to experience orgasm, and pain during sexual intercourse . It is estimated that 40-45% of adult women suffer from some form of female sexual dysfunctions.  The most common among women are dysfunctions involving orgasm and desire .  It is important to note that little is written about female sexual dysfunctions, compared to male sexual dysfunctions.

Female Orgasmic Disorder


 * Female Orgasmic Disorder is new in the DSM-V, making it exclusive to females, previously known as Orgasmic Disorder in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; text rev.; DSM-IV- TR; APA, 2000). The DSM-V diagnostic Criterion A for Female Orgasmic Disorder is characterized by “difficulty experiencing orgasm and or markedly reduced intensity of orgasmic sensations” .  Treatment for this in sex therapy might include directed masturbation.  The behavioral exercises are done at home in private.  Each session is done for an hour each day, and a diary is kept to record behaviors and feelings during each exercise.

Female Sexual Interest/Arousal Disorder


 * Sexual Desire and Arousal Disorders were combined in the DSM-V to Female Sexual Interest/Arousal Disorder, making it exclusive to females. DSM-V Criterion A includes “lack of, or significantly reduced, sexual interest/arousal” .  Treatment of this in sex therapy may include any of the following interventions: hormonal therapy, treatment of a specific dysfunction, anxiety reduction, treatment of depression, increasing sensory awareness, improving the relationship, enhancing sexual/sensual experiences, facilitation of erotic responses, or dealing with intrapsychic conflicts.

Genito-Pelvic Pain/Penetration Disorder


 * Genito-Pelvic Pain/Penetration Disorder is new to the DSM-V, it merged DSM-IV categories of vaginismus and dysparenuia since the disorders were highly comorbid and difficult to differentiate. The diagnostic criteria for Genito-Pelvic Pain/Penetration Disorder according to the DSM-V in criteria A consists of “four commonly comorbid symptom dimensions: 1) difficulty having intercourse, 2) genito-pelvic pain, 3) fear of pain or vaginal penetration, and 4) tension of the pelvic floor muscles” .  Sex therapy may use a combination of effective treatments to help such as, explanation and education on sexual techniques, addressing couple factors, relaxation due to anxiety, reassurance, desensitization, and addressing unresolved traumatic experiences if necessary .  Dyspareunia is commonly caused by inadequate vaginal lubrication.  If it is not due to various infections, or other diseases such as endometriosis, lubricants may be suggested.  Vaginismus is commonly caused by a “fear of vaginal penetration and is often related to a history of assault or abuse” .  Treatment focuses on any abuse or assault that may have occurred in the past.

Other applications of sex therapy and further treatments for sexual

Sexual problems in victims of sex abuse


 * Individuals who have suffered sexual abuse in childhood or adolescence often develop problems concerning sexual desire and arousal and may experience a phobia of sex, guilt or disgust when touched, feeling emotionally distant, or have disturbing sexual thoughts or fantasies resulting in arousal dysfunctions or desire dysfunctions . In incest victims fear of sex, arousal dysfunctions, and desire dysfunctions were the most common .  Treatments by sex therapists use cognitive behavioral therapy to gradually rebuild sexual relationships by attempting to make victims of sex abuse feel safe, but hope to make sex feel safe and enjoyable.

Sexual disorders associated with physical illness


 * Chronic illness can impact an individual on all phases of sexual response and pleasure resulting in negative effects on the relationship and sexual satisfaction . Unfortunately, many medications used to treat chronic illness, may have a negative impact on sexual functions.  Additionally, an altered body image accompanied by psychological distress can limit an individual’s sexual satisfaction for one or both partners in the relationship.  For example, an altered appearance and bodily function due to surgical procedures as well as medical treatments (amputation, mastectomy, or hair loss) or psychological distress related to anxiety, loss of self-esteem, grief, and depression is often associated with chronic illness.  While these examples may not affect certain couples that easily accept limitation, others may not react the same and any alteration of sexual function within the relationship can precipitate a significant emotional crisis.

Sexual problems with alcoholics


 * Alcohol abuse often causes sexual problems in both sexes, but especially men, in whom erectile dysfunction, low sexual desire and ejaculatory problems are common . Fahrner (1987), studied sexual dysfunction in male alcoholics.  The study concluded that sexual dysfunction is common among male alcoholics.  Fahrner also suggested treatment facilities should begin to care of sexual dysfunctions in the usual treatment program.

Classic Models

In all models, psychosexual and psychological histories are one of the most important assessments that impact sexual dysfunctions. Psychological histories are critical to identify psychological disorders such as depression or anxiety. Most important is a psychosexual history. This evaluation is one of the first steps in helping to assess sexual dysfunctions (Woodland 30).

Masters & Johnson Approach


 * In 1970, Masters & Johnson introduced sensate focus, a technique used to elevate a variety of sexual problems such as erectile difficulties or orgasmic disorders, by highlighting the focus on sensations .  Sensate focus is an exercise that occurs in steps that both partners participate in together.  Today, there are different variations of this model, but generally speaking it focuses on re-establishing communication between partners and to enable each partner to play the dual role of giving pleasure to and getting pleasure from the other partner .  The exercise will only work if both partners agree to refrain from sexual intercourse, causing couples to shift their focus on sensations received from the physical touch of their partner from head to toe.  The goal is for partners to  “… learn to heighten their awareness of a broader range of stimuli that include all of the senses” .  As discussed in the “The Uses & Benefits of “Sensate Focus” exercises by De Villers & Turgeon, 2005, Masters and Johnson (1970) “proposed that removing intercourse would make sex less goal orientated resulting in a decrease in performance anxiety and cognitive distractions that are associated with many sexual difficulties” .  Depending on each couple, at discretion of the therapist verbal communication is not encouraged, unless it causes pain, becomes uncomfortable or it needs to stop.  Verbal communication is encouraged after the exercise is completed.  The first stage consists of partners taking turns touching the other, but avoiding breasts and genitalia.  Slowly moving into further stages, hopes to feel more in touch with their own sexual desires as well as their partners and feeling emotionally closer to each other.  In addition Masters & Johnson introduced directed masturbation, which has been elaborated by LoPicollo and Lobitz (1972) and transformed again by Barbach (1974) for use as a group treatment with women without their partners.  The model by LoPicollo and Lobitz described by Both & Laan (2009), is a 9 step program done in the privacy of the home that addresses the following basic elements: education about female sexual response and spectatoring, visual and tactile self-exploration and body awareness, directed masturbation, and sensate focus (p. 262).  Using the model discussed by Both & Laan, many positive improvements have been reported.  For example, positive thoughts of body awareness, enjoyment in sex, and sexual arousal were noted.

The PLISSIT Model Approach


 * Developed by Jack Annon  in 1976, the  PLISSIT  mode of sexual counseling is an acronym for Permission, Limited Information, Specific Suggestions, Intensive Therapy .  Each represents four levels ranging from simplest to more complex levels of intervention.  This approach allows physicians to treat sexual issues up to their level of expertise and comfort and refer the patient elsewhere if necessary.

Permission


 * Individuals are given permission to speak about their sexual concerns by reassuring the patient they are accepting, non judgmental and actively listening. This becomes highly therapeutic to individuals, because they are reassured a space that they are able to talk about their sexual concerns, behaviors, thoughts, or fantasies with out being judged.  This helps if in past the patient was too embarrassed to discuss or were never comfortable discussing it with others.  The therapist assures the patient that their experiences are normal as long as it is not harming anyone else or themselves.  This creates an environment that the patient feels they are able to be honest.  For example, an individual may feel guilty and anxious because of masturbating .  By reassuring the act of masturbating is normal, creates an environment that allows the patient to express himself or herself freely.

Limited Information


 * Limited information involves giving patients information or different resources about their concerns in a limited manner. This includes clarifying any information that is incorrect and providing them with factual information.  Many patients benefit from this level of intervention .  For example, correcting the patient if they are misinformed about certain facts.

Specific Suggestions


 * Specific Suggestions may include suggesting relationship counseling in addition to sexual counseling. Sensate focusing would be an example of specific suggestions or using lubrication for vaginal dryness.

Intensive Therapy


 * Invasive Treatment is the last step and that would refer a patient for individualized therapy for a long-term intervention from a certified sex therapist, gynecologist, or urologist.

Cognitive Behavioral Therapy Approach


 * Based on the assumption that sexual dysfunctions such as performance or anticipation anxiety are the result of anxiety, CBT is used in the treatment of sexual dysfunction to provide changes in thinking and beliefs that affect how an individual behaves towards sex. Changing beliefs and behavioral strategies related to sex and performance can improve the quality of the patients’ sex life, reduce anxiety, and create positive sexual attitudes .  The behavioral aspect includes relaxation techniques, which can help anxiety related to sex and improve quality of sex life.  CBT in sex therapy can help someone explore those reasons and change their thoughts related to sex ).  CBT in this setting can be time limited to usually 12-20 sessions, and emphasizes sexual exercises in between sessions .  In the treatment of sexual dysfunctions, CBT has positive outcomes.

Psychoanalytic Approach


 * The psychoanalytic  approach primarily works through conflicts that are believed to have originated in childhood.  As Bergler and Fenichel discussed, sexual dysfunctions are viewed as “a symptom that expresses a pathological process in personality development; a developmental arrest is thought to result from castration fantasies, guilt over wishes for gratification with father, and unconscious fears” (as cited in Heiman, 2007 p. 94).  As mentioned previously, anxiety is often suggested as the cause of sexual dysfunction.  Heiman (2007), uses an example of a nonorgasmic woman who may have low self-esteem, may very project those feelings on to her husband, perceiving everything he does as controlling .  During treatment in psychoanalytic approaches, understanding defense mechanisms and childhood experiences is central to resolving sexual dysfunctions.

Intersystems Approach


 * The term “intersystems” describes how individual and system theories interact in our lives. Integrating various factors of physiology, psychology, culture and social situations, to understand and treat sexual problems.  Developed by Gerald Weeks in 1986, the framework has 5 components each is examined and plays a part in the creation of the sexual problem: individual, biological, and medical; individual and psychological; dyadic relationship; family of origin; and society, culture, history and religion.  First, biological reasons are assessed.  In terms of medical concerns or medications to treat other problems may contribute to problems in sexual function.  Second, the individual and psychological makeup of a person is examined.  Areas include personality, psychopathology, intelligence, temperament, developmental stages and deficits; attitudes; values; and defense mechanisms.  If a patient has guilt about particular sexual activities, this could impact desire.  Third, in the dyadic relationship, fears; communication; or negative feelings about each other could affect the sexual dysfunction .  Fourth, family of origin is examined, because one of the places people learns about sexuality is by the way their family exhibits and treats sexuality.  Someone, whose family does not discuss sexuality openly, may have feelings certain sexual feelings are bad .  Lastly, the environment the individual or couple is in has an impact on sexual problems.  These reasons are critical in assessing sexual problems because these influences can shape someone’s “beliefs, customs, and values around sexuality and sexual expression” .  This approach is most common in modern sex therapy.

 Criticism 

As noted by Rowland (2012), all models naturally have liabilities. For example, they might focus on specific elements of sexual response while omitting other areas. A major flaw of sexual dysfunctions often put people into categories of functional (normal) and dysfunctional (abnormal), where in reality it happens along a continuum, which many approaches, models or definitions fail to do. Existing models and diagnostic criteria are heteronormative with the assumption of penetrative sex as the main goal, behavioral and biomedical models exclude same sex and gender issues. For example, genito-pelvic pain/penetration disorder, assumes that vaginal penile sex is the ultimate goal, based on heteronormative assumptions. This may not be true for some women regardless of sexual orientation, and thus not being a problem for them. Another criticism of sex therapy is that, homosexual individuals who have specific concerns of sexual function may be excluded from existing models and criteria of sexual dysfunctions. As a result, a broader understanding of sexual disorders is needed.

 Society & Culture 

Sexuality in different cultures is a complex and dynamic concept that is often contradicting with other cultures and maybe within the same culture, involving sexual values, beliefs, traditions, and norms. It is important for sex therapists to understand and know the culture in which where the patients personal sexual belief system and gender intersect. Societal discourse that only ablebodies, specifically, those who are not elderly, disabled, suffering from a disease or who have had surgery are the only ones to have the potential to be sexual, is false. The stigma around this has caused numerous problems. Social effects of chronic illness include the myth that disabled, or ill individuals are unlikely to develop sexual relationships. In addition, the association society has made with the elderly and sex; those who increase in age decrease in sexual functions. Often, elderly couples suffer from various chronic illnesses, which as mentioned previously, other considerations could be the availability of a partner or medications could cause a decrease in sexual activity. It is important to note and differentiate that that it is not due to age, but maybe the illness is to blame. Overcoming sexual stereotypes from society and culture is crucial when dealing with sexual issues. Likewise, doctors need to be more sensitive to patient’s sexual orientation, sometimes talking about sex with a doctor may require an individual to talk about their same-gender sexual practices, putting that individual in a vulnerable position. If an individual had a negative experience due to this reason it has ever lasting effects, not only on the patient but also on numerous levels.