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Journal of Family Psychotherapy, 20:95–111, 2009 Copyright © Taylor & Francis Group, LLC ISSN: 0897-5353 print/1540-4080 online DOI: 10.1080/08975350902967218
WJFP0897-53531540-4080Journal of Family Psychotherapy, Vol. 20, No. 2-3, April 2009: pp. 1–27Journal of Family Psychotherapy
What Every Sex Therapist Needs To Know
What Every Sex Therapist Needs To KnowJ. Ridley
JANE RIDLEY Private Practice, West Berkshire, United Kingdom
This article outlines both the personal attributes and the knowledge base required by aspiring sex therapists. It focuses on the intercon- nected and interdependent nature of sexuality. The complex concept of social norms, a brief introduction to diagnosis and prevalence of sexual difficulties, the anatomy and physiology of sex, and the sexual response cycle are covered. Areas that are controversial or are currently being debated are identified, including concerns over the medicalization of sexuality and male/female differences. No attempt is made to cover the material in detail except to note their significance. Issue regarding therapy are left to other articles.
KEYWORDS sex therapist, sexual response cycle, sexuality, sexual behavior
INTRODUCTION
If you are considering training as a sex therapist today it is essential that you are a resilient and flexible person, nevertheless able to be firm about your own and others’ boundaries. You will constantly learn new aspects of your- self, your motivation, your sexual orientation, moral and social code, and your prejudices and excitements. Paradoxically, this means you will simulta- neously be developing and changing.
You may often explore with clients an unfamiliar world that provokes in you ideas, feeling, and fantasies that have been strangers to you; guilt or shame may become more familiar, as will sexual and other powerful feel- ings. Being open to monitor your reactions must become part of you and your daily work. Allowing yourself to learn and to respond to the clients’ world with empathy and without judgment will be stretching and enriching.
Address correspondence to Jane Ridley, Orchard Lodge, Sfichen’s Green, West Berkshire RG 8954, UK. E-mail: janeridley@tandj77.demon.co.uk
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A central aspect of becoming a sex therapist is your own curiosity, open- ness, and preparedness to learn, without prejudice.
Your openness must also encompass the clients’ reactions, attitudes, feelings, or fantasies toward you. Your age, dress, ethnicity, voice tone, choice of language, social or religious attitudes, likes and dislike, and preju- dices will be observed, noted, and judged by your clients. Since you rapidly become part of the client’s system, how you are perceived by clients will influence the outcome of your work together.
In the process of becoming a sex therapist, there is much to learn and understand. Concepts such as what is normal sexual behavior or how to define and understand sexual difficulties or dysfunctions are central. A clear knowledge of the anatomy and physiology of male and female sexuality, the sexual response cycle, and the impact of life events and ageing upon sexuality must be understood within an historical context and that of the individual, couple, family, or social network, as well as their ethnic or reli- gious affiliations. Physical and mental health, the use of drugs or alcohol, domestic violence, previous sexual or emotional abuse, and traumatic expe- riences all have an impact upon the individual’s sexual life. Specialist knowledge and skills may need to be learned to work with these client groups. Evidence from research and evaluative studies is constant emerging that may affect how one understands or approaches aspects of human behavior and must be constantly monitored and responded to.
Disentangling the interaction between organic, physical, individual, interrelational, social, or environmental factors can make you feel part of a tangled boundaryless web. However, the development of skills depends upon an awareness of the complex interaction between the physical and organic aspects of sexuality and the individual’s internal and external psy- chological world as well as the social network surrounding the individual or couple. Thinking and working systemically greatly facilitates this process. It is essential to use supervision to explore not only what is happening to cli- ents, but also what issues are being raised for you. Regular supervision will become an essential routine (Giami, 2001; Mann, 1997; Ridley, 2006).
Historically, therapy has developed down separate theoretical routes (Ridley, 2006). More recently there has been a movement toward an integra- tive approach enabling therapists to select, from the rich range of theoretical options, the approach most suited to each particular client. Crowe and Ridley (2000) describe a hierarchy of alternative interventions (ALIs), which offers the therapist guidelines on why and when to choose which approach and when it may be useful to move up or down the hierarchy during ther- apy to an ALI. Weeks and Hof (1994, 1995) developed the intersystem approach for this purpose. Clarity about the therapist’s use of theory and the ability to move between theories is an essential skill. “A good postulate here is; fire your theory before you fire your client, or your client fires you” (Weeks et al., 2005, p. 9). (See also Chapter 3, The Intersystems Approach).
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Throughout this journal issue the intersystems approach is used when assessing the impact upon the individual’s sexual function, the interplay between his or her psychological makeup and the interpersonal and social environment she or he inhabits. This parallels Crowe and Ridley’s model for assessment.
As sex therapists learn more about clients, difficult moral or legal issues can arise. Conflict between loyalty to the client, or client confidentiality, may seem at odds with society’s requirements. Knowing the limits of ther- apy and working within the professional codes of practice and the legal framework are essential and challenging (AAMFT, 2001; BASRT, n.d.). Sex therapists do not work outside the legal and social framework of the country (even though, occasionally it may feel that way). Working together with other professionals and knowing the limits of sexual therapy, when to seek help from other coprofessionals, and when to refer on are basic require- ments. Working together with psychiatrists, doctors, social workers, proba- tion, prison, or other welfare agencies then becomes a support for both therapist and client.
These personal attributes and rich knowledge base are essential requirements for the sex therapist who wishes to learn the intervention skills described throughout this journal issue and developed during clinical practice under professional supervision.
SEXUALITY AND SEXUAL BEHAVIOR
Social Norms
Human survival depends upon the physiological fact that, for the next gen- eration to be conceived, men and women must have sexual intercourse, however brief (in vitro fertilization, IVF, is now available to a select few). Societies have developed different ways of coping with this powerful and necessary creative force. Within a multicultural society at the beginning of the 21st century, one is faced with a multitude of social, religious, or ethnic practices affecting the individual, couple, or family. Any attempt to under- stand what is seen as “normal” sexual behavior must take account of this rich context.
Gender and gender issue such as whether lesbian, gay, bisexual, or transsexual have similar experience of sexuality as heterosexual men and women; whether men and women’s approach to sex is different will affect the way sexuality is understood (Basson, 2002; Komisaruk, Beyer-Flores, & Whipple, 2006; Ridley, 1999).
In 1973 the American Psychiatric Association ceased to consider homo- sexuality as pathological. “It is hard to overestimate the impact of this deci- sion. First declaring homosexuals as ‘normal’, or at least as normal as heterosexuals, undermined laws, civil commitment procedures and the
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practice of therapy itself” (Nichols & Shernoff, 2007, p. 393). The legal acceptance of gay, lesbian long-term relationships through the Civil Partner- ships Act (2004), implemented December 5, 2005, questions previous approaches to sexuality and sexual behavior within Britain.
Kinsey and coworkers (1948, 1953) were among the first to study and publish material regarding the sexual behavior of Americans between 1938 and 1952 and opened up sexual behavior as an appropriate area for study. Newport (1997) examining the concept of norms wrote, “The concept of a norm is mysterious because it refers to a concept which exists ‘out there’ as part of culture, but is something which generally, unlike laws, for example, is never written down or codified formally” (p. 1). He continues
Survey research provides an excellent mechanism for social scientists to use to analyse a society’s norms. If 80% of the members of a society agree that certain behaviour is appropriate in a given situation, then it can be hypothesised that this represents a fairly widely shared norm. If only 20% agree, the behaviour is more appropriately characterised as deviant, rather than normative (p. 1).
Newport wrote of the tension that exists between the basic sex drive and culture’s attempts to control or channel “this amazingly powerful instinct.”
The tensions, described by Newport (1997) are seen clearly between generations. Regarding premarital sex, 71% of the over 65s said premarital sex was wrong, while for 75% of the 18 to 29 year olds it was not wrong. Six percent of the over 65s and 50% of the 18 to 29 year olds had lived together before marriage. Seidman and Rieder (1994) examined sexual behavior in more detail by reviewing American surveys and analyzed the 1988–1990 General Social Survey, which indicated that most American males have had intercourse by 16 to 17 years of age, and females by 17 to 18 years of age. The majority of 18 to 24 year olds have multiple serial part- ners; the 25 to 59 year olds being relatively monogamous.
Regarding extramarital relationship, surprisingly perhaps, both older and younger Americans had a similar view, 79% said it is always wrong for a married person to have sexual relationships outside marriage. Only 3% said it is not wrong at all. However, when examining what people actually do, 80% of the public said that 50% or more married have com- mitted adultery.
In relation to extramarital relationships in Britain, Wellings, Field, Johnson, and Wadsworth (1994) wrote “Disapproval of extramarital sexual relationships extends to all age groups. . . . There is no clear age related trend in these data” (p. 249). They urge that, “care needs to be taken here in distinguishing attitudes from behaviour. Disapproval of behaviour does not mean that people refrain from it. Adultery is still one of the most widely cited grounds for divorce in Britain. But, practice aside, the principle of
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monogamy is held in very high regard” (p. 249). Physical sexual exclusivity may be more important to women than to men, although paradoxically men may expect their partners to be faithful to them (Ridley, 1999; Wellings et al., 1994). Hence a paradoxical difference occurs between what may be seen as social norms and individual behavior.
In contrast, Nichols and Shernoff (2007) believe that little should be taken for granted “including the two-gender system, the assumption of het- eronormality, and romantic views like the belief that monogamy and high sex drive are compatible” (p. 381).
Heterosexual/Homosexual Issues
The Gallup Poll Review (Newport, 1997) states, “Americans have a complex set of attitudes about homosexual relations . . . 52% say that homosexuality should not be considered an acceptable alternative lifestyle” (p. 3) with 59% indicating that homosexual behavior is morally wrong. As we have seen within the United Kingdom although since December 2005 there is legal acceptance of civil partnerships, there is little consensus among religious or political leaders. However, 25% of adults have had heterosexual anal inter- course, and up to 20% of adult men report they have had a homosexual experience: 1% to 6% reported such an experience during the previous year.
Attitudes to sodomy, usually defined as anal or oral copulation with a member of the same or opposite sex, continue to vary from country to country. Much of the resistance to the acceptance of anal or oral sexual contacts between consenting adults in private tend to come from church organizations or affiliations. Both American and British data indicate that around 25% of heterosexual couples have had anal intercourse, and suggest that, “oro-genital contact may be experienced by increasing proportions of those who have not yet had vaginal intercourse . . . as a risk reduction strat- egy in the face of AIDS” (Wellings et al., 1994, p. 157). It is noteworthy that “stimulating the rectum, could add to the quality of orgasm” for women and may account for the “experience of orgasm in men receiving mechanical stim- ulation of the prostate during anal intercourse” (Komisaruk et al., 2006, p. 78)
This is one of many aspects of sexual behavior raising problems of acceptance within the framework of norms. If not normal then how are these behaviors to be understood, as problems, variations, or dysfunctions? The boundaries are often blurred (Popovic, 2006).
Professional organizations can also be at odds with what society accepts. Paraphilias for example, as defined by the American Psychological Association (APA) are “recurrent intense urges and sexually arousing fanta- sies involving either non-humans, or the suffering or humiliation of oneself or one’s partner, and even children or consenting adults” (2000, p. 566). This behavior “must cause clinically significant distress or impairment in social,
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occupational, or other important areas of functioning” (p. 566). Are we therefore to assume that unless there is clinically significant distress, paraphilias can be placed within the normal spectrum of human behavior?
The Ageing Population
By the year 2030, nearly 20% of people in the United States will be 65 years or older (Bradford & Meston, 2007), a trend that is not restricted to America, as worldwide adults 60 and over are the most rapidly growing population (World Health Organization, 2002). Many myths and misconceptions inhibit the understanding of the norms of sexual needs and desires of this popula- tion (Hodson & Skeen, 1994). Contrary to some myths the sexual life of the older couple may slow down but continues into late age. It is understand- ably dependent upon factors such as the availability of a partner, illness, and the impact of some medications. Changes that do occur affect men and women slightly differently.
Although erectile functioning tends to decline from mid life into old age erectile failure is not inevitable. Typical changes include a delay in gaining a full erection, less rigidity of the erect penis, a lessening of sensitiv- ity of the penis, and fewer erections during sleep (Wespes, 2002). The orgasmic responses may change taking longer to achieve orgasm with a less forceful ejaculation and less volume of semen (Schiavi, 1999).
For women, we may again see a difference between desire and arousal, as there seems to be a steep decline in sexual desire (DeLamater & Sill, 2005) but sexual satisfaction may remain higher in older women than in men (AARP, 2005). The lining of the vagina thins, and vaginal lubrication and engorgement of the clitoral and vaginal tissues is slower and less robust; these features usually follow the menopause with the consequent loss of estrogen. As a result there may be an increased risk of vaginal pain, urethral irritation, and urogenital infections (Society of Obstetricians and Gynaecologists of Canada, 2004). Myths about sexuality and ageing and a lack of awareness of the needs of the older person, can intervene detrimen- tally to the development of a therapeutic alliance.
Sexual Abuse, Rape, Domestic Violence
Until the 1960s sexual abuse of girls by males or females and its impact on sexuality was rarely discussed (Jehu, 1979, 1989). Greater awareness, often through clinical experience, enabled the issue of the abuse of males to be raised. Within the context of a discussion about norms, what does this mean? Was sexual abuse seen as an acceptable aspect of family life until the 20th century? Do rape and domestic violence fall into this same category? Genital mutilation is illegal within Britain but is still performed within some British cultural groups and is often understood as a necessary
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religious or “circumcision ritual.” Such dilemmas are part of becoming a sex therapist.
Tiefer (2002) questions robustly the way sexuality has been understood and corralled by “experts who know a lot about the body mechanics rather than those who understand learning, culture and imagination” (p. 134). She prefers to understand sex as an aspect of human potential, but its interpreta- tion within each society as a social construct. She also wonders whether sex is a talent such as music or mathematics and writes, “to insist that everyone is equally talented at sex is fraudulently democratic” (p. 156). Her view of normality is challenging and well worth thinking through. For the sex thera- pist working with clients whose norms are not their own requires a sensitiv- ity, which is respectful of the client, without being overwhelmed.
DIAGNOSIS AND PREVALENCE OF SEXUAL DIFFICULTIES
The Diagnostic and Statistical Manual of Mental Disorders text revision (DSM-IV-TR, American Psychiatric Association, 2000) is used worldwide for diagnosis and treatment of both male and female sexual difficulties. Its validity is currently questioned. There is increasing disagreement about the prevalence of sexual problems and an intelligent debate is developing regarding what constitutes a sexual problem or dysfunction. Komisaruk et al. (2006) drawing from the National Health and Social Life Survey (NHSLS, 1999) indicate that 43% of women and 31% of men in the United States are affected by sexual problems. However, the researchers did not ask about the level of distress, now seen as a defining characteristic.
Kaplan (1995) focused specifically on desire disorders within a clinic population said, “38% of the 5,580 patients with diagnosed sexual disorders whom we say between 1972 and 1992 met the criteria for sexual desire disorders” (p. 10), an upward trend fueled possibly by the ageing popula- tion and the impact of AIDS. Orgasmic problems are again dependent upon the individual’s level of distress. A nonrandom sample of couples found that 63% of the women reported arousal and orgasmic problems although they were happily married, and 85% said they were happily married (Frank, Anderson, & Rubinstein, 1978).
DSM IV-TR (American Psychiatric Association, 2000) includes within it dyspareunia and vaginismus. Binik, Meana, Berkeley, and Khalife (1999) argue cogently that these are not sexual problems but problems of pain and fear of pain and should be treated as such. Low or absent desire in men is also being debated, as is the issue of rapid ejaculation (previously called premature ejaculation; Althof, 2007). There is little information regarding delayed ejaculation, the prevalence rates ranging widely from 1% to 10% (Spector & Carey, 1990) with a possible increase with age. Erectile dysfunction is considered to be a common and distressing aspect
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of male sexuality with possibly 50% of the over 60s expressing concerns (Rosen, 2005).
In 2003 a second consensus conference reviewing DSM-IV-TR (American Psychiatric Association, 2000) recommended that instead of a single diagno- sis of female sexual arousal disorder there should be four. Those that are primarily physical, primarily subjective, combined physical and subjective arousal disorder, and a newly defined arousal disorder that of persistent geni- tal arousal. The diagnosis of male sexual disorders has not been formally reas- sessed but is likely to occur particularly in the areas of what constitutes rapid or premature ejaculation.
ASSESSMENT IN THE ABSENCE OF GREATER CLARITY
A thorough assessment and proper diagnosis of the client, or client system, is essential. It is the basis of the treatment plan and therapeutic approach chosen. The present discussions are invigorating, if occasionally confusing. For the new recruit into sex therapy a wonderful opportunity is now avail- able to be aware of the diagnostic criteria and the discussions encircling them. More importantly, to recognize the individuality of the client(s) and be less focused on medicalizing sexuality and develop a therapeutic alliance that respects the uniqueness of each individual seeking help.
THE ANATOMY AND PHYSIOLOGY OF SEXUALITY
An appreciation of the anatomy and physiology of sexuality is necessary. Undue emphasis has led to a mechanistic view of sexuality, largely resulting from Masters and Johnson’s approach to their material and subsequent interpretations. An emphasis upon the context and complexity of sexuality helps to avoid this. Sexuality cannot be separated from the total context within which the individual or couple inhabits. Their social, religious, ethical, community, and familial systems and individual makeup, will all have an important influence upon their understanding of and response to sexuality. The meaning given to dancing, music, eating, clothing, scents, setting, and ambiance; the meaning of a glance; the movement of a hand; or the wiggle of a bottom will all have a personal and social context within which the individual or couple respond. The anatomy and physiology of the individual must be set and understood within these interconnecting systems.
Exploring the Web, it is clear that young people are searching for factual information. See for example the Teen Sex Guide (2006) at Students.com, which describes the male genitalia in detail, and www.bygirlsforgirls.org, which is dedicated to providing helpful information of the female sex
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organs to girls who are interested in knowing the makeup of their bodies.
This is good factual information but the focus is on the genitalia. What is missing is any attempt to describe the total person; see Kaplan (1975), where there are no anatomical drawings of genitalia. Focus on the genitalia ignores the importance of the skin as the largest erogenous zone, and other areas of sensitivity such as the potential tenderness of the breasts, around the mouth, under the nails, or the inner thigh. Clients can be encouraged to learn about their uniqueness by mapping their own or their partner’s body and experiencing their own erogenous zones.
Individuals are highly affected by life experiences; inappropriate sexual touching in childhood of the breast, for example, may make the breast a “no go” area because of the association, however repressed. The position of the light, odors, sounds, and music may all have powerful positive or nega- tive associations, which may affect the responsiveness of the individual to touch or sensuality. Unless these are seen as powerful aspects of the sensual or sexual experience, much will be missed by the therapist.
Paradoxically, sex therapists must have a good understanding of anat- omy and physiology and the sexual response cycle, since many clients are poorly informed and can often be helped by a simple explanation of how the body works. It is important to have sufficient knowledge to identify when a physical examination or referral to a specialist may be necessary, for physical or medical reasons. Understanding the impact of ageing or illness upon the sexual relationship are part of the sex therapist’s daily tasks. Bancroft (1990, currently being updated), is still one of the better resource books for a more complete picture.
THE SEXUAL RESPONSE CYCLE
Masters and Johnson’s (1966) study of human sexual response is a landmark in the understanding of male and female sexual responses, built upon by succeeding clinicians and researcher. They set the direction that sex therapy would travel for many years. How they presented their material and succeeding professionals interpreted the research may be responsible for overemphasizing the physical to the exclusion of others. Nevertheless, their research formed the basis for ongoing work and is worth considering in some detail.
The Four Phases and Two Physiological Changes
Masters and Johnson (1966) divided up the sexual cycle into four specific phases, through which the individual progresses from excitement, to plateau, orgasm and finally resolution. Significantly they described this as a
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“purely arbitrary design” (p. 7), which “is inadequate for evaluation of finite psychogenic aspects of elevated sexual tensions” (p. 7). Women are described as “having the response potential of returning to another orgas- mic experience from any point in the resolution phase” which they describe as the “multiple orgasmic expression” (p. 65). Although aware of male– female differences, these tend to get lost in their excitement at discovering “similarities, not the differences” (p. 8) between the male and female sexual response cycle. These differences are now being addressed (Basson, 2007; Ridley, 1999).
Masters and Johnson described the sexual responses as the result of two principal physiological changes: increase in blood flow to various parts of the body (vasocongestion) and an increase in muscle tension (myotonia). Detailed physiological changes in the female or male were noted as they moved through the phases of the cycle.
Male/Female Similarities and Differences
Masters and Johnson (1966) are at pains to emphasize that the clitoris and the penis are anatomically similar, but the clitoris does not respond as quickly as the penis to stimulation whether direct or indirect, and this is an error in thinking about female sexual responses. Additionally, they chal- lenge the notion of the clitoris having an erection paralleling the male erec- tion. The clitoris is described “as a unique organ, since no such organ exists within the anatomic structure of the human male” (p. 45). The different rates of excitement and engorgement between male and female responses are emphasized, and the need for the clitoris to be stimulated to enable female orgasm. The vagina was studied with similar intensity.
In describing the female orgasm Masters and Johnson emphasize three key areas that interact upon the female orgasm, the physiological, psycho- logical, and sociological. Sociologically, they do recognize that female orgasmic attainment never has achieved the undeniable status afforded the male ejaculation. They predict that the human female now has an undeni- able opportunity to develop realistically her own sexual response levels.
The male sexual arousal cycle, as described by Masters and Johnson, is simpler than the female’s. Again the four phases of excitement, plateau, orgasmic and resolution phase are noted. The whole body, as with the female, shows physical evidence of sexual tension, following the two basic patterns—first widespread vasocongestion and second myotonia, both widespread and specific. The male orgasm and ejaculation, is described using three areas as with the female, of physiologic, psycho- logic, and sociologic. They comment that sociological pressures have played a trick upon the two genders; fears of performance in the female have been directed toward gaining an orgasm and in the male toward erection.
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An important contribution of Masters and Johnson was their detailed study of the impact of ageing upon sexuality. Crucially they were able to challenge the myths of the death of sexual activity with age but describe a slowing down of the sexual arousal system and accompanying minor changes. Their work focused exclusively on the functions and dysfunctions of the genitalia. They identified erectile and ejaculatory problems for men and women with problems relating to penetration and orgasm. These became categories established within the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III, American Psychiatric Association, 1980). This had the two-fold impact of having sexual problems taken seri- ously, while emphasizing the medical and physical aspects as dominant.
The Significance of Desire
Kaplan (1975, 1995) challenged Masters and Johnson’s focus on the genita- lia adding the crucial dimension of sexual desire. She believed, as a result of her clinical experience, that Masters and Johnson had missed this essential element and thus ignored sexual problems relating to desire. As a result hypo- active sexual desire (HSD) disorders were included in DSM–III (American Psychiatric Association, 1980). She believed that “the pathological decrease of these patients’ libido is essentially an expression of normal regulation of sexual motivation gone awry” (Kaplan, 1995, p. 3).
Kaplan’s treatment approach included erotic techniques and their accom- panying emotional impact upon the client/couple. She was concerned about the unconscious conflicts, fears, and desires that she felt may cause or exacer- bate sexual difficulties and are evident within the therapeutic process between clinician and clients/patients. Kaplan draws attention to the “wider psychic matrix of which sexuality is an integral and beautiful part” (p. 7). Her contribution added greatly to the understanding of the emotional and social aspects of sexuality. Paradoxically, the inclusion of hypoactive sexual desire as a disorder within DSM-III added significantly to the medicalization of female sexuality.
The Analytic Contribution
The psychoanalytic field has tended to take a very separate perspective on female and male sexuality, within which a fascinating and often fierce dia- logue continues (Bassin, 1999). Students should be aware of these debates and their impact on theories regarding female and male development. Karen Horney (Bassin, 1999) aptly describes the skeleton around which such dialogues rage.
Seen from the analytic perspective she lists the growing boys ideas, as follows: naïve assumptions that girls as well as boys possess a penis; realization of the absence of the (female’s) penis; belief that the girl has
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suffered punishment, which also threatens him: the girl is regarded as infe- rior; the boy is unable to imagine how the girl can ever get over this loss or envy; and the boy dreads her envy.
She then lists ideas about the development of the female as follows: for both sexes it is only the male genital which plays any part; sad discovery of the absence of the penis; belief of the girl that she once possessed a penis and lost it by castration; castration is conceived of as the infliction of punishment; the girl regards herself as inferior, penis envy; the girl never gets over the sense of deficiency and inferiority and has constantly to master afresh her desire to be a man; and the girl desires throughout life to avenge herself on the man for possessing something that she lacks. Concepts such as penis envy or the castrating woman, from the psychoanalytic field have entered popularly accepted wisdom.
The Complex Female
An intense and fascinating debate is occurring, largely in America regarding the complexity of female sexuality. Beverly Whipple has carried out detailed research into the nature of the female orgasm, best summarized in Komisaruk et al. (2006). Emphasis is placed upon women being asked about the level of distress they experience, as this is now believed to be a key component in the diagnosis of sexual disorder. They also challenge the linear sequence derived from the Masters and Johnson four phases of excitement, plateau, orgasm, and resolution and believe it to be “unhelpful is assessing and managing women’s sexual problems and disorders” (p. 64). Basson (2002) and Basson et al. (2003) seek to redefine the nature of female sexuality. “Now nearly four decades later, we know that sexual interest, motivation, arousal and pleasure are triggered and experienced quite differ- ently by men and women” (p. 6; Leiblum, 2007).
Following a consensus conference in 2003 new recommendations are that, whereas DSM-IV-TR (American Psychiatric Association, 2000) lists only one term for female sexual arousal disorder, there should be four, which are those that are primarily physical, those that are primarily subjective, combined physical and subjective disorder, and a newly defined arousal problem that of persistent genital arousal in the absence of sexual desire (Basson, 2007). While emphasizing the complex nature of female sexuality, the determina- tion that these difficulties should be included within DSM-IV-TR inevitably adds further impetus to the medicalization of female sexuality.
The Dual Control Model for Men
Bancroft and colleagues (2005) have sought to clarify the nature of male sexuality. A concept of an inhibitory factor that operates against an excita- tory factor, the dual control model provides a useful theoretical model with
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which to examine male sexuality, in particular erectile difficulties. It is worth remembering that Masters and Johnson noted in 1966 that “Penile erection may be impaired easily by the introduction of asexual stimuli” (p. 201). Within this model the sexual inhibition/sexual excitation scales (SIS/SES) are used (Janssen, Vorst, Finn, & Bancroft, 2002a, 2002b). The propensity for sexual inhibition, due to the threat of performance failure (SIS I), or the propensity for sexual inhibition, due to the threat of performance conse- quences (SIS II), is measured. The propensity for SES is also measured.
According to this theoretical model, sexual arousal, including genital response, depends upon both an active excitation response plus reduction of inhibitory tone together with the relative absence of inhibitory response to the sexual situation. Further research is obviously necessary, but the con- cepts of an inhibitory system that may work against the excitatory system certainly resonate with clinical experience.
Gender differences are now recognized regarding intimacy needs; fear of or need for intimacy, closeness/distance, emotional/practical, and other differences within a partnership are now understood to affect the individual or couples experience of their sexual life (Popovic, 2005; Ridley, 1999). Sexual preferences being lesbian, gay, and bisexual are increasingly encom- passed as part of the rich spectrum of personal and interpersonal sexuality (Davies & Neal, 2002) although much is still needed to be done.
Overemphasizing the Medical Aspects of Sexuality
An overemphasis upon the physical and medical aspects of sexuality can develop in both the client and practitioner (Hart & Wellings, 2002; Tiefer, 2002). When sexual difficulties are viewed as an illness or physical, it is easiest to seek a medical solution rather that examine aspects of personal or interpersonal life that may contribute. The arrival of Viagra and similar drugs has provided such an opportunity (Ashton, 2007; Finger, 2007); additionally many men’s sex lives have also been improved. Paradoxically when using a drug personal or interpersonal difficulties may be highlighted and then addressed. A search for a similarly drug for women is underway and at the same time a call to resist the medicalization of women’s sexuality (Tiefer, 2002).
An important area, however, is that of the impact of illnesses both mental and physical, which are real and do need to be treated medically. Illnesses such as depression, diabetes, or heart problems can have a seri- ous impact upon the quality of life including the sexual life. Equally, essential medication can treat the illness but may impact negatively upon sexual abilities. Working with clients to find an appropriate balance between these conflicting elements requires an ability to take seriously the physical and medical circumstances faced by each client (Gill & Hough, 2007).
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CONCLUSION
Before embarking upon a career as a sex therapist, you may want to ask yourself if you can accept the personal and professional challenges you will face. Wanting to help is not good enough. A sound wide spectrum knowl- edge base must be learned during which your value system and prejudices will be challenged. You will need to be open to new experiences while retaining the ability to be both flexible and boundaried. Examining your own emotional and sexual responses under supervision will become part of your regular routine. Understanding the multi-layered interaction between the inner/outer world of the client, client system, and the wider social con- text will involve you setting aside previously held perspectives. Knowing the limits of one’s knowledge and skill will mean that seeing advice or referring on to other specialists may be necessary. Being prepared to ques- tion attitudes to what is normal, to value others whose way of life is differ- ent to your own, to learn from good research and evidence-based practice, to practice within the law, however complex, and to cowork with medical and psychiatric specialists while continuing to value the whole person can test us all, but these are essential requirements of a sex therapist.
REFERENCES
AAMFT. (2001). American Association for Marriage and Family Therapy Code of Ethics. Retrieved July 13, 2007 from http://www.aamft.org/resources/LRMPlan/ Ethics/ethicscode2001.asp.
AARP (2005). Sexuality at mid-life and beyond: 2004 update of attitudes and behav- iour. Retrieved July 13, 2007 from http://www.aarp.org/research/family/ lifestyles/2004_sexuality.html.
Althof, S. E. (2007). Treatment of rapid ejaculation. Psychotherapy, pharmacother- apy, and combined therapy. In S. Leiblum (Ed.), Principles and practice of sex therapy (4th ed., pp. 212–240). New York: Guilford.
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