Sexual Psychology – Critical Reflection #4 – Due Fri 12/3

THE STATE OF SEX RESEARCH IN MFT AND FAMILY STUDIES LITERATURE: A SEVENTEEN-YEAR CONTENT

ANALYSIS

Adam C. Jones, Natalie C. Johnson, Sydney Wenglein, and Sara T. Elshershaby Texas Tech University

The ability to conceptualize and treat sexual problems has been widely accepted as a crucial skill to master the MFT training. However, clients’ sexual relationships are often ignored by clinicians because of a lack of experience or training, or personal discomfort. In this content analysis, we review sex and sex therapy research within MFT and family studies journals since the turn of the century. Of the 13,919 articles published within the 15 journals, 137 focused on sexuality or sex therapy. The articles were divided into five themes: sexual and relational health, sexual diversity, treatment and contributors of sexual dysfunction, sex therapy practices, and sexual education and development. Implications for clinical practices, sex therapy integration, and future research are discussed.

LITERATURE REVIEW

Understanding sex within the scope of relationships is a crucial aspect of relational therapy. Current trends in sexual dysfunction treatment suggest that sexual problems are closely and recip- rocally linked to relationship satisfaction, as older, behavioral or medical models often ignore the larger role that a couple’s relationship plays in sexual functioning and satisfaction (Metz & McCarthy, 2007). Understanding how to treat sexual problems and dysfunctions within relation- ships is a valuable and crucial skill for marriage and family therapists.

The Relational Etiology of Sexual Problems Because of the complex etiology of sexual problems, clinicians that are skilled in utilizing a

systemic perspective are often uniquely qualified to address sexual problems (Johnson & Zuccarini, 2010; Metz & McCarthy, 2007). As many as forty-five percent of couples experience sexual prob- lems problem at any given time (Laumann, Paik, & Rosen, 1999). These sexual problems are most prevalent in men and women between the ages 40–65 (Laumann et al., 2005; Shifren, Monz, Russo, Segreti, & Johannes, 2008). Numerous components of sexual desire and relationship satis- faction are significantly related within the context of relationships, regardless of potential issues such as; perceived power differentials in relationships, number of children, or pregnancy (Brezs- nyak & Whisman, 2004; del Mar S�anchez-Fuentes, Santos-Iglesias, & Sierra, 2014; Witting et al., 2008). Several studies have outlined that poor conflict resolution skills in couples may be a cause or result of sexual problems (Metz & Epstein, 2002). Those who are worried about the future of their relationship often have greater difficulty maintaining an erection or reaching orgasm during sex (Laumann et al., 2005).

In response to this clear link between sexual and relational functioning, there have been clear efforts in the field of sex research to emphasize the importance of integrating a systemic, relation- ship perspective in treating sexual dysfunctions (Kleinplatz, 2015; del Mar S�anchez-Fuentes et al., 2014). Sex therapy treatments have widely been moving in the direction of a more integrative

Adam C. Jones, MS, Marriage and Family Therapy Program, Texas Tech University, Lubbock, TX; Natalie C.

Johnson, MS, Texas Tech University, Lubbock, TX; Sydney Wenglein, MS, Texas Tech University, Lubbock, TX;

Sara T. Elshershaby, BS, Texas Tech University, Lubbock, TX.

Address correspondence to Adam C. Jones, Marriage and Family Therapy Program, Texas Tech University,

P.O. Box 41250, 79409-1250, Lubbock, Texas; E-mail: [email protected]

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Journal of Marital and Family Therapy 45(2): 275–295 doi: 10.1111/jmft.12344 © 2018 American Association for Marriage and Family Therapy

model of treatment that focuses more on relationship factors than medical treatments (Metz & McCarthy, 2007). The “good-enough sex” model encourages an integrative approach that acknowledges the role that sex and intimacy plays in relationships and focuses primarily on finding pragmatic sexual solutions, rather than focusing on perfect sexual functioning (Metz & McCarthy, 2007). While the field of sexual treatment and research has moved to more adequately integrate relationships, the MFT and family studies fields have done little to integrate sex therapy into rela- tional therapy.

Many MFTs may fail to integrate sex therapy into their relational treatment because they assume that helping partners improve trust and communication, without directly addressing the sexual issues, will allow for sexual issues to resolve themselves (Johnson & Zuccarini, 2010). How- ever, the one recent study may challenge this assumption (Jones, Robinson, & Seedall, 2017). The study found that couples’ problem-solving communication processes directly influenced relation- ship satisfaction, but not sexual satisfaction; while only sexual communication processes predicted sexual satisfaction. This indicates that the integration of sexual communication skills, distinct from other types of problem-solving communication, into couples’ work is essential in improving sexual relationships (Jones et al., 2017). This finding suggests an important paradigm shift from the assumption that improving general communication skills will automatically translate into improved sexual relationships. Relational therapists should assess for both sexual and relational problems and integrate both into their treatment and intervention of couple issues.

Lack of Sexual Discussion in MFT Practice Despite this clear etiological link between relationship and sexual issues, many therapists in

the field shy away from engaging in conversations about sex with their clients due to their own feel- ings of incompetence or discomfort (Harris & Hays, 2008; Reddick, Heiden-Rootes, & Brimhall, 2017). In a study of various health and mental health professionals, 90% of participants felt that addressing sexual issues in treatment was important, yet 86% reported having little training in addressing sexual issues and 94% were unlikely to discuss sexual issues with their patients (Haboubi & Lincoln, 2003). Timm (2009) identified several reasons why clinicians do not discuss sexuality with their clients. These reasons included a lack of training in sexual treatments, self of the therapist issues; a division of disciplines between sex therapy and couples therapy; and a gen- eral reluctance or disregard for this topic. However, a therapist comfort level with sexual content has been found to be among the greatest predictors of therapists’ initiation of sexuality-related dis- cussions with their clients (Harris & Hays, 2008).

In a study of MFTs, Harris and Hays (2008) argued that when clinicians ignore client sexual- ity and sexual components of health, they potentially increase the risk for negative client outcomes. They observed that education, supervision, experience, and knowledge are each associated with therapists’ comfort level in discussing sexuality with their clients (Harris & Hays, 2008). Therapists with more education and supervision were more likely to initiate sexuality discussions with clients. It is important, therefore, to examine the standards, sources, and resources available to marriage and family therapists, which promote this education, supervision, experience, and knowledge.

Current State of Sex Therapy in Marriage and Family Therapy Education and Training Examining the training and exposure to sex therapy practices that are available to MFTs may

provide greater insight into how to best aid therapists in being comfortable discussing client sexual- ity and aid professionals in their own ability to navigate sexual discussions. There has been little research done on the current state of sex therapy education and training in the field of marriage and family therapy. Recently, Zamboni and Zaid (2017) attempted to address the gap in this litera- ture by conducting a study on how human sexuality is implemented into MFT programs by sur- veying 69 MFT program directors. They found that having a sexuality curriculum was highly valued among program directors. At least one sexuality course was required within all participat- ing programs. Although a sexuality course was required, most of those courses had a strong emphasis on diversity and sexuality, while topics on general human sexuality, sexuality develop- ment, sexuality as a dynamic of relationships, or sexual issues/concerns appeared to be focused on less, if even at all (Zamboni & Zaid, 2017). Although the field of MFT places a strong importance of looking at all issues through a culturally diverse lens, it is important that core topics on human

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sexuality, as well as sexual well-being are not overlooked by educators and the curricula within these programs.

There is currently no standard for sex therapy training across programs. Yet version 12 of the COAMFTE accreditation standards does require some competency in understanding sex therapy practices and human sexual development. Although sex therapy is listed as a competency in the COAMFTE Foundational Curricula, time spent within the curricula on the subject of sex therapy, as well as sexuality, is not suggested nor regulated. Therefore, there could be a wide range of MFT programs who differ in the amount of time spent on the education and training of sex therapy and/ or sexuality. Zamboni and Zaid (2017) also found other gaps within MFT sexual health education by concluding that there are barriers to advancing sex therapy competency in MFT graduate pro- grams, including the fact that there are “few MFT faculties with expertise in human sexuality and marginalized sexual health topics” (p. 1).

The Need for Research in Improving Clinical Practice and Establishing the Field Because many do not receive advanced training in sexual treatments during their clinical edu-

cation, they are often left to receive this knowledge of sexual treatments through research and other avenues of continuing education. Yet the extent of available literature to practicing clinicians has only recently been explored. In 2014, the Journal of Marital and Family Therapy compiled a virtual issue on the topic of sex therapy, where they re-published 6 articles (from 1972 to present) with a specific focus on sex therapy and couple sexual relationships. Guest editor Katherine M. Hertlein discovered that the few articles presented lacked a focus on sexuality through a systemic lens, and instead focused on “how the couple system responded to an individual sexual problem– specifically, articles on sex addiction, previous sexual abuse, or the experience of living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), etc.” (Hertlein, 2014, p. 3). Sexual problems and concerns may certainly impact a couple’s functioning directly; yet, what has been noticeably disregarded in the literature are “the specific ways in which such concerns may manifest sexually and how they are treated” (Hertlein, 2014, p. 3). With little literature available to clinicians on the treatment of sexual concerns the improvement of sex therapy practices in the field remains stagnant, which potentially perpetuates the avoidance of sexual issues.

By utilizing a systemic lens in the ways in which we intervene with sexual partners, marriage and family therapists have numerous opportunities to begin developing adaptations of theories that have already been integrated into the field for decades (Weeks & Gambescia, 2015). In order to better establish the unique position and paradigm within the realm of sexual treatment, this study aims to understand what work is being done in fields that typically espouse systemic theories in their research. While there may be many MFT family studies researchers who publish sex research in sex journals, there is a need to establish the benefits of a systemic paradigm in sexual treatment. Over the past few years, excellent contributions in the systemic practice of sex therapy have been presented in other literature (e.g., Weeks, Gambescia, & Hertlein, 2015), we examined the state the literature within peer-reviewed research journals. Though MFT and family studies are separate fields, family studies research is closely related to the MFT field and oftentimes informs the work of MFT researchers. Advancing the study of assessment, diagnosis, and treatment of sex- ual concerns and dysfunctions may validate the unique treatment approach of MFTs, provide more opportunities for expanding therapy practices, and promote positive changes within relation- ships.

Purpose The purpose of this study was to conduct a content analysis of the types of sexual research that

is being published in the most relevant MFT and family studies journals since the turn of the cen- tury. The last comprehensive review of literature on sexual relationships within family studies research observed the trends in sexual research through the 1990s (Christopher & Sprecher, 2000). The authors of that article examined literature addressing sexual behavior, sexual satisfaction, and sexual attitudes within the confines of committed relationships, but did not address sex therapy practices or training. Unfortunately, a thorough examination of sex research from the paradigm of family research has not been conducted since. Since that time, there have been significant changes in sexual attitudes (Keleher & Smith, 2012), sexual behaviors (Mercer et al., 2013; Twenge,

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Sherman, & Wells, 2017), and sexual technology (Malcolm & Naufal, 2016), each of which have an influence on relationships (Capogrosso et al., 2013; Twenge et al., 2017).

In this study, we explore how sex research within the MFT and family studies fields have responded to these changes. Our review of the current state of sex therapy training and education is an attempt to explore the quality and quantity of research focused on topics related to sex ther- apy or sexual relationships. We did so to highlight the areas in which there appears to be a lack of integration between the MFT and sex therapy field, such as general sex education and training. In a manner similar to other content analyses (e.g., Blumer, Hertlein, Smith, & Allen, 2014; Parker, Chang, & Thomas, 2016), we determined the extent to which sex research is being published and what themes emerged in the topics and analyses of these articles. Lastly, we examined some of the publishing trends of these articles in order to present them in such a way that the strengths and gaps in the literature would be beneficial to future research.

METHOD

Design The approach for the study was descriptive in nature. We based our approach to the analysis

on other similar analyses in the past (Blumer et al., 2014; Parker et al., 2016; Seedall, Holtrop, & Parra-Cardona, 2014) to analyze the frequency that topics related to sex therapy or sexual relation- ships are discussed in peer-reviewed MFT/Family studies journals. By using a systematic process, a content analysis identifies and analyzes patterns and themes within various types of content using a unique coding process that focuses mostly on identifying characteristics of the content (Bauer, 2007). The research questions guiding the analysis were as follows: “how often are sexuality and sex therapy topics the focus of MFT and family studies research?” “What are the most relevant clinical implications from sex research in MFT/family studies journals over the past 16 years?” “What advancements have been made in integrating couple and sex therapy?” and “What method- ological approaches are used to approach the topic of sexuality in MFT/family studies journals?”

Sample Our sample consisted of all published peer-reviewed articles from 15 prominent MFT/family

studies journals that were published from the years 2000–2016. As a content analysis of sex research had not been conducted in MFT journals previously, we chose to look at articles since the turn of the century to adequately analyze trends and have a more complete picture of the state sex research. Sex research journals were not included in the study as the primary focus of the study was to observe the sex research being published in journals where the primary focus is on couple and family relationships. The list of journals was similar to other content analyses published in JMFT in recent years (Blumer et al., 2014; Hartwell, Serovich, Grafsky, & Kerr, 2012; Seedall et al., 2014) and included the following: American Journal of Family Therapy, Contemporary Fam- ily Therapy, Couple and Family Psychology, Families, Systems, and Health, Family Process, Family Relations, Journal of Couple and Relationship Therapy, Journal of Family Issues, Journal of Family Psychology, Journal of Family Psychotherapy, Journal of Feminist Family Therapy, Journal of Mar- ital and Family Therapy, Journal of Marriage and the Family, Psychotherapy: Theory, Research, and Practice, and The Family Journal. There was a total number of 13,919 articles between these 15 journals prior to the searching, sorting, and coding procedures.

Searching Procedures Our analysis began with three of the researchers searching marriage and family therapy and

family studies journals starting in 2000, through the end of 2016. The group members searched only peer reviewed articles where the primary focus of the article was couple sexual relationships or sex therapy. An electronic copy of all the articles was obtained by the four-person research team [AJ, NJ, SW, SE]. Each researcher was trained in how to conduct the searches effectively, and then carried out the searches independently. The articles were managed using an online citation sharing software (Zotero, Roy Rosenweig Center for History and New Media, Fairfax, VA, USA) to which each researcher saved their citations and a copy of each article. Each researcher conducted

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searches for 8 journals, with all searches being conducted twice for each journal, in order to ensure that each article and citation was obtained in the software.

The searches of the MFT/family studies journals used the search terms “sex therapy” and “sexual” to find articles covering the broad range of topics. The search term “sexual” was selected over “sexuality,” “sex,” or other words to avoid confusion with articles addressing biological sex, and to capture a broader range of articles than those including the word “sexuality” (“sexual-inter- course,” “sexual relationships,” etc.). Searches were done through our university’s library system, primarily using Ebscohost and Sage search functions. The 15 MFT/family studies journals included a total of 13,919 articles. Our search yielded 840 total results. Only peer-reviewed articles were included in the sorting process. Before the sorting process began, any book reviews, letters to/ from the editor, articles that weren’t peer-reviewed, were removed from our search totals and the citation software. All duplicate articles from the combined searches were merged to produce a total of 658 MFT/family studies articles. See Table 1 for the breakdown of search results by journal.

Sorting and Coding Procedures Phase one. After all articles had been collected, the research team developed criteria for sort-

ing and selecting articles that met our criteria. For the MFT/family studies journals, each researcher read through the titles and abstracts of each of the initial pool of articles to find articles where the primary focus of the article was sexuality in relationships (monogamous or nonmonoga- mous), sexual problems, or sex therapy. Articles that did not address these criteria were removed. For example, articles relating to sexual orientation, sexual abuse, or sexual infidelity where the focus of the article did not address the sexual relationship were excluded. Articles addressing treat- ments for sexual problems, as well as sex therapy techniques, interventions, or approaches were included in the final criteria. Articles that addressed sex therapy treatments for individual sexual dysfunction were also included, as sexual problems in individuals are most often treated in the con- text of a relationship (Metz & McCarthy, 2007).

Three of the researchers completed the initial sorting process (NJ, SW, & SE). All articles for each journal were sorted through by two separate researchers, and any articles where there was dis- agreement was discussed with the group and decided upon. The first author (AJ) came on as a fourth researcher at this point to review the included and excluded articles and ensure that all arti- cles were sorted properly in order to minimize subjectivity. The result of this sorting process pro- duced a total of 144 articles between the 15 journals (For a complete list of the reviewed articles, please click on the link at the bottom of the article).

Phase two. After relevant articles were selected, all 144 articles were divided among the four researchers and read through in their entirety. Summaries were created for each of the articles to provide a synopsis of key terms, methodological approaches, analyses performed, major findings, and clinical implications of the study. Through the process of reading the articles, 7 more articles were excluded after further review showed that they did not fit our original inclusion criteria, resulting in a final coded total of 137 articles that met our sorting criteria.

Phase three. After all articles were read through and summarized accordingly, the research team met together to develop themes surrounding the topical subjects of the articles. The team began the coding process together by coding the first 25 articles to ensure that each person under- stood the process of developing themes. Each of the team members then completed the theme development process on their own. The team met and discussed their individual themes together, and final overall themes were then decided on as a group.

The final themes of the content analysis included (a) sexual and relational health, (b) diversity, (c) sexual dysfunction, (d) sex therapy practices, and (e) sexual education and development. Once the themes were decided upon by the group, each of the articles was assigned to the theme that most closely addressed the main purpose of the article. This assignment to themes was done inde- pendently by each researcher through a voting process. Any items that did not accrue a majority of votes from the four researchers (at least 75%), were discussed between the group until a majority vote was achieved. Likewise, any articles that could have been assigned to two or more themes were discussed by the group and assigned to the most appropriate theme. There was high agree- ment between the researchers for each theme during the original voting process: sexual dysfunction (98%), education and development (94%), sexual and relational health (88%), diversity (88%),

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sex therapy practices (83%). After finalizing the assignment of articles into major themes, the searching, sorting and coding analysis of sex research within MFT journals was completed.

FINDINGS

The primary goal of the article was to provide a descriptive analysis of sex research within MFT and family studies journals. To do so, we observed the frequency of sexual topics discussed, the methodological approaches used in the research, and the most relevant clinical implications of that research. The frequency, sampling characteristics, methodology, and clinical implications were observed to provide clinicians and researchers with a better understanding about how to best

Table 1 Summary of Search Results by Journal

Journal name Databases used

Search terms used

Total # of journal articles

Total # of search results

Total # of articles sorted

Total # of articles coded

American Journal of Family Therapy

Ebscohost “Sexual” “Sex Therapy”

550 63 3

42 5

Contemporary Family Therapy

Ebscohost “Sexual” “Sex Therapy”

589 35 1

34 10

Couple and Family Psychology

Ebscohost “Sexual” “Sex Therapy

130 13 0

13 6

The Family Journal Sage Publishers

“Sexual” “Sex Therapy”

702 31 0

21 16

Family Process Ebsochost “Sexual” “Sex Therapy”

739 48 2

48 7

Family Relations Ebscohost “Sexual” “Sex Therapy”

921 41 0

19 3

Families, Systems, and Health

Ebscohost “Sexual” “Sex Therapy”

894 30 0

6 0

Journal of Couple and Relationship Therapy

Ebscohost “Sexual” “Sex Therapy”

386 65 13

66 15

Journal of Family Issues

Sage Publishers

“Sexual” “Sex Therapy”

1,171 14 0

14 3

Journal of Family Psychology

Ebscohost “Sexual” “Sex Therapy”

2,709 85 0

82 12

Journal of Family Psychotherapy

Ebscohost “Sexual” “Sex Therapy”

498 48 20

45 22

Journal of Feminist Family Therapy

Ebscohost “Sexual” “Sex Therapy”

315 64 3

44 9

Journal of Marital and Family Therapy

Ebscohost “Sexual” “Sex Therapy”

814 69 6

45 9

Journal of Marriage and Family

Ebscohost “Sexual” “Sex Therapy”

1,550 144 0

138 19

Psychotherapy Ebscohost “Sexual” “Sex Therapy”

1,951 41 1

41 1

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approach sexual treatments, and what ways MFT and family studies researchers may best con- tribute to the extant literature.

Out of a total 13,919 articles within the 15 journals, there were 137 articles where the focus of the article was sexuality in relationships or sex therapy (less than .01%). Of the articles that were found, sorted, and coded, 54 focused on research relating to sexual and relational health (39%), 25 focused on diversity issues (18%), 18 on sexual dysfunction (13%), 24 on sex therapy practices (18%), and 16 on sexual education and development (12%). These five major themes each contained various subthemes to further illustrate which types of articles were coded into the major themes. Articles in the “sexual and relational health” included anything focused on medication (five articles), relationship factors (i.e., housework, satisfaction levels, relational processes; 25 articles), technology (six articles), infidelity (one article), sexually transmitted infections (two articles), other individual factors (i.e., childhood sexual abuse, personality, addiction, body image; 15 articles), and how they directly impact sexual relationships. Articles focused on diversity issues covered topics such as gen- der (six articles), sexual minorities (i.e. LGBTQ couples or nonmonogamous relationships; 10 arti- cles), spirituality and religion (one article), and racial or ethnic factors on sexual relationships (8 articles). Our theme of treatment and contributors of sexual dysfunction included 14 articles focused on treatment, and four articles focused on contributing factors. Articles in our sex therapy practices theme included ten articles focused on theoretical approaches and integration with couples therapy, six on assessment and diagnosis, two on specific sex therapy interventions, and six articles that focused on the education and training of sex therapists. Lastly, the education and development theme consisted on six articles focused on geriatric or aging couples, two on sexuality in young adulthood, two on sexual education, and six on general sexual development.

Summary of Article Types and Sample Characteristics Each of the 137 articles was coded by their type of methodological approach to studying sexu-

ality. Tables 2 and 3 provide a breakdown of article types by frequency and by journal. Each arti- cle was sorted into one of five categories including: quantitative, qualitative, mixed methods, theoretical/intervention, and review of literature. Theoretical/intervention articles were the most common article type (61 articles, 45%). Theoretical and intervention articles included those that outlined new theoretical approaches to conceptualizing or treating sexual dysfunctions. Any arti- cles that suggested the treatment approaches without providing empirical evidence for the approach were considered intervention articles, rather than reviews of literature. Those articles that addressed the most recent literature but did not provide treatment suggestions were consid- ered reviews of literature (5 articles, 0.04%). A little more than half of the articles employed any type of empirical approach. There were 51 articles that used quantitative methods to explore sexu- ality (37%), 19 that used qualitative analyses (14%), and one that used a mixed-methods approach (<0.01%).

The sampling characteristics of the included articles were also coded in our analysis. The authors coded the empirical articles (qualitative, quantitative, and mixed-methods) for each sam- ple’s inclusion of various races/ethnicities, relationship types (i.e., monogamous/

Table 2 Summary of Article Types and Methodologies Used in Sex Research within MFT and Family Studies Journals

Article types Number of articles

Qualitative 19 Quantitative 51 Mixed-methods 1 Review of Literature 5 Theoretical/Intervention 61 Articles used 137

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nonmonogamous), sexual orientation, participants from outside the United States, and clinical participants. Table 4 indicates the number of articles that indicated each these categories. The table only includes articles that specified the sample characteristics listed above.

Table 3 List of Article Types and Methodologies Used in Sex Research, Organized by Journal

Journals Article types (Listed from most- to least-frequent)

American Journal of Family Therapy

Theoretical/Intervention (3); Quantitative (1); Review of Literature (1)

Contemporary Family Therapy Theoretical/Intervention (4); Quantitative (3); Review of Literature (2); Qualitative (1)

Couple and Family Psychology Quantitative (4); Qualitative (2) The Family Journal Theoretical/Intervention (16) Family Process Qualitative (2); Theoretical/Intervention (3);

Quantitative (2) Family Relations Qualitative (2); Quantitative (1) Journal of Couple and Relationship Therapy

Quantitative (7); Theoretical/Intervention (6); Qualitative (2);

Journal of Family Issues Quantitative (3) Journal of Family Psychology Quantitative (11); Qualitative (1) Journal of Family Psychotherapy Theoretical/Intervention (19); Review of Literature (2);

Quantitative (1) Journal of Feminist Family Therapy Theoretical/Intervention (7); Qualitative (2) Journal of Marital and Family Therapy

Qualitative (3); Quantitative (3); Theoretical/ Intervention (2); Mixed Methods (1)

Journal of Marriage and the Family Quantitative (13); Qualitative (4); Review of Literature (1)

Psychotherapy: Theory, Research, Practice, and Training

Theoretical/Intervention (1)

Table 4 Description of Sample Characteristics of the 71 Empirical Articles that Were Coded

Sample characteristic Number of articles Percent of total (Out of 71 Articles)

Articles with a majority of non-White participants 9 13% Articles with monogamous individuals/couples 12 17% Articles with nonmonogamous individuals 3 4% Articles with heterosexual individuals/couples 41 58% Articles with LGBT individuals/couples 11 15% Articles with international samples 12 17% Articles with clinical samples 5 7%

Note: The numbers in this table indicate only articles that identified the race, relationship type, sexual orientation, and origin of the sample. Many articles did not indicate information above and were not included in the table. If the information above was not included in the article, it was not included. If articles compared multiple types of populations, the article was included in both categories. For example, if an article compared monogamous and nonmonogamous couples, the article was counted in both the monogamous and nonmonogamous categories.

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Clinical Implications Through our content analysis, we outlined the clinical implications of the empirical articles

within the 137 coded articles. To effectively do this, we created a table that provides a comprehen- sive summary of the clinical implications affiliated with each theme (see Table 5). In articles that addressed sexual education and development, diversity, and sexual or relational health, the clinical implications focused on a broad range of topics including: relational traits that tend to be associ- ated with good sexual relationships, suggested interventions for couples therapy, awareness around diverse relationship issues, the impact that various demographic differences or sexual prob- lems will have on the therapeutic process, and the importance of addressing self-of-the-therapist issues surrounding sex, gender, and race. However, within these themes, few studies provided direct implications for sex therapy or the treatment of the sexual relationship. Many of these arti- cles came from family studies journals that did not focus on therapeutic intervention.

Within the two remaining themes, treatment and contributors of sexual dysfunction and sex therapy practices, many article authors provided direct implications for the assessment, diagnosis, and practice of sex therapy. These studies, although limited in number, promote an integration of the sex therapy and couples therapy fields, and provide clinicians with reliable and helpful ways in which we can begin closing the preexisting gap.

Table 5 Summary of Clinical Implications of MFT and Family Studies Research, Organized by Theme and Subtheme

Category Clinical implications

1. Sexual/ Relational health

Medication Use - Clinicians should support both partners and consider the sexual needs of women when treating sexual erectile dysfunction (Askew & Davey, 2004).

Maintenance/Housework/Relationships - Clinicians need to consider a variety of behaviors that can increase/maintain excitement in intimate relationships (Malouff, Mundy, Galea, & Bothma, 2015). - Therapists can help couples increase intimacy by spending more time together and negotiating changing gender expectations (Reynolds & Knudson-Martin, 2014). - Therapists need to consider couple strategies for increased sexual desire in intimate relationships (Ferreira, Fraenkel, Narciso, & Novo, 2014). - Consider sexual restraint as a factor for increased relationship out- comes (Busby, Carroll, & Willoughby, 2010). - Clinicians should consider perceptions of sexuality as a factor con- tributing to overall relationship satisfaction (Hernandez, Mahoney, & Pargament, 2011). - Contribution of housework by male partners can increase sexual fre- quency and satisfaction in heterosexual relationships (Johnson, Galambos, & Anderson, 2016). - External stressors and lack of dyadic coping are associated with lower sexual activity and satisfaction (Bodenmann, Atkins, Sch€ar, & Poffet, 2010). - Clinicians should consider how sexual satisfaction can contribute to long-term relationship satisfaction (Fallis, Rehman, Woody, & Pur- don, 2016).

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Table 5 Continued

Category Clinical implications

- Therapists need to give attention to caring and loving behaviors in relationships as predictors to increased positive sexuality (Charny & Asineli-Tal, 2004). - Clinicians should consider the relationship between marital duration and extramarital sex as contributors to relationship satisfaction (Liu, 2000). - Lower sexual frequency is associated with lower relationship out- comes in cohabiting couples than married couples (Yabiku & Gager, 2009). - Clinicians should consider cohabitation as a predictor of poorer rela- tionship quality (Sassler, Addo, & Lichter, 2012). - Clinicians should consider contextual factors and attitudes regarding gender and sexual permissiveness (Kraaykamp, 2002). - Therapists should consider depression as a predictor of relationship satisfaction among older couples (Scott, Sandberg, Harper, & Miller, 2012). - Clinicians should consider the role of the sexual relationship in romantic relationships and how neuroticism can impact the marriage (Daspe, Sabourin, Lussier, P�eloquin, & Wright, 2015). - Risky sexual behaviors from husbands increases the risk of wives being exposed to STIs (Hall, Fals-Stewart, & Fincham, 2008). - Clinicians should consider the negative impact child sexual abuse may have on sexual satisfaction in relationships (Vaillancourt-Morel et al., 2016). - Extreme levels, both high and low, of neuroticism predicted poorer sexual satisfaction, but low-to-moderate levels predicted higher sexual satisfaction (Daspe et al., 2015). - Gay couples who parent children report higher levels of commitment to their partners, while simultaneously reporting lower sexual satisfac- tion due to less time for relationship maintenance (Huebner, Mandic, Mackaronis, Beougher, & Hoff, 2012). - Compared to nonvictims, newlywed women with a history of child- hood sexual abuse experience sexual re-victimization in marriage, which may increase trauma symptoms (DiLillo et al., 2016). - As those with ambivalent attachments also experience lower sexual satisfaction, it is important for clinicians to take a thorough assess- ment of attachment history for clearer conceptualization of sexual problems (Clymer, Ray, Trepper, & Pierce, 2006).

HIV/STI’s - Ongoing discussions with gay couples and HIV infection are impor- tant in facilitating healthy communication and needs recognition (Palmer & Bor, 2001). - Therapists should consider adolescent marital perceptions to gain a better understanding of sexual behaviors and risks of HIV/AIDS (Clark, Poulin, & Kohler, 2009).

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Table 5 Continued

Category Clinical implications

- Couples with children are more likely to use condoms than married couples with fewer or no children (Cordero-Coma & Breen, 2012).

Technology and Cybersex - Clinicians should consider Internet sexual activities as having a high impact on intimate relationships (Parker & Wampler, 2003). - Training programs need to consider cybersex in relationships as pre- dictors of relationship satisfaction (Goldberg, Peterson, Rosen, & Sara, 2008). - Acceptance of sexting practices in relationships is viewed more posi- tively by same-sex relationships compared to heterosexual relation- ships (Hertlein, Shadid, & Steelman, 2015).

Infidelity - Clinicians should consider infidelity across different-sex and same- sex couples to better help couples cope with the negative effects of infi- delity on intimate relationships (Leeker & Carlozzi, 2012).

Other Individual Factors - It is important to consider contextual factors such as obesity when working with bariatric clients as individuals or part of a couple or family system as it can impact intimate relationships (Moore & Cooper, 2016). - Clinicians should assess for a variety of factors of aggression to bet- ter understand violence in relationships (Marshall & Holtzworth- Munroe, 2002). - Therapists need to consider their own biases when working with cou- ples reporting childhood sexual abuse as a contributor to therapy effectiveness (Anderson & Miller, 2006). - Clinicians should address women’s body esteem with both partners to potentially increase marital satisfaction (Holt & Lyness, 2007). - PTSD correlates with lower marital satisfaction, increased verbal aggression, and lower sexual satisfaction for individuals who were prisoners of war (Dekel & Solomon, 2006). - Couples therapy can increase communication and problem solving in relationships where the woman is a survivor of childhood sexual abuse and currently in recovery (Trute, Docking, & Hiebert-Murphy, 2001). - Diary reports indicated that husband’s depression levels mediated the amount of discussion of sexual intimacy, leading to greater use of angry expressions and depressive expressions by both husbands and wives (Papp, Goeke-Morey, & Cummings, 2013). - Compared to nonvictims, newlywed women with a history of child- hood sexual abuse experience sexual re-victimization in marriage, which may increase trauma symptoms (DiLillo et al., 2016). - Body image issues are not a “female problem” only, positive body image is an important predictor of sexual satisfaction for both males and females (Holt & Lyness, 2007). - Supportive partners may aid in a woman’s recovery from a hysterec- tomy, however partners may lack information about how the surgery may impact the sexual relationship (Askew & Zam, 2013).

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Table 5 Continued

Category Clinical implications

2. Diversity Race/Ethnic Factors - In a focus group of African American women, most indicated being dissatisfied with the quality and quantity of sex education provided by their caregivers, which, they felt, contributed to barriers to inti- macy in relationships (Rouse-Arnett & Dilworth, 2006). - Clinicians should be aware of how sexual values and attitudes of African American women are often negatively influenced by their experiences with sexuality education, religious institutions, and healthcare providers (Rouse-Amett, Dilworth, & Stephens, 2006). - Clinicians working with Chinese women should understand that the local sex ratios influence women’s likelihood of sexual activity, pre- marital sexual intercourse, having been forced into sex, and testing positive for an STI’s. (Trent & South, 2012). - Clinicians who work with Indian clients should be aware of the cul- tural norms in the region. Local male-to-female sexual ratios in India are positively and significantly associated with likelihood that women will marry prior to age 16 and have experienced forced sex (Trent, South, & Bose, 2015). - Early sexual initiation can be influenced by both family structure and change. For White women, early sexual initiation was associated with increased family transitions. For Black women having resided in a single-parent residence during adolescence was associated with early sexual initiation (Wu & Thomson, 2001). - Socioeconomic status influences the likelihood of sexual practices.In Kenya, income was positively associated with the likelihood of safer sex (Luke, Goldberg, Mberu, & Zulu, 2011).

Sexual Minorities - While men and women both value romantic love, women valued love, faithfulness, and lifelong commitment. Also sexual minorities value faithfulness and lifelong commitment less than heterosexuals. (Meier, Hull, & Ortyl, 2009). - Contrary to many assumptions about women in relationships with younger men, minority women (other than those who are black) and lower-income individuals are most likely to engage in an age–hypoga- mous relationship. Most of these relationships are long-lasting and result in marriage (Alarie & Carmichael, 2015). - Non-monogamous gay men were more “out”, had more sexual part- ners, and lower levels of dyadic attachment than monogamous gay men, but did not differ with monogamous men in terms of sexual fre- quency, sexual satisfaction, relationship satisfaction, and attachment styles (Bricker & Horne, 2007). - Those in nonmonogamous relationships can experience healthy and happy relationships, but there is evidence to suggest that non-mono- gamy may create some vulnerability to long-term stability (Whitton, Weitbrecht, & Kuryluk, 2015). - Lesbian couples experience similar levels of sexual activity and satis- faction to heterosexual and gay couples, and report fewer and

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Table 5 Continued

Category Clinical implications

different types of sexual problems than heterosexual women (Meana, Rakipi, Weeks, & Lykins, 2006).

Gender - The emotional work around negotiating sexual behaviors in relation- ship can take a toll on the relationship, women often times try to change their feelings about sex, however many couples successfully navigate this emotion work (Elliott & Umberson, 2008).

Spirituality/Religiosity - Those who pledge sexual abstinence before marriage are much more likely to remain abstinent until marriage than those who do not and are more likely to restrict pre-marital sex to their future spouse (Uecker, 2008).

3. Treatment & Contributors of sexual dysfunction

Treatment of Sexual Dysfunction - When working with Vulvar Vestibulitis syndrome (VVS)It is impor- tant for the therapist to create a treatment plan that includes many unique things including: treating the couple, rather than just the woman experiencing VVS; helping the couple develop a broader sex- ual style that encourages alternative ways of sexual intercourse which cause less vulvar pain; helping couples develop a shared understand- ing of treatment and of themselves as a couple; and finally, helping couples locate appropriate physicians, information, and resources about VVS (Connor, Robinson, & Wieling, 2008). - The wives of hypersexual men may not display psychopathology or problematic personality traits, however, they are significantly more distressed about their marriages than those without hypersexual hus- bands (Reid, Carpenter, Draper, & Manning, 2010)

4. Sex therapy practices

Sex Therapy Training - Sexual knowledge, education, and clinical experience are all impor- tant predictors in helping therapists feel more competent and com- fortable in addressing sexuality with clients (Harris & Hays, 2008).

5. Education and development

Aging - Couple’s with higher levels of sexual satisfaction tend to have higher quality marriages and less marital instability over time (Yeh, Lorenz, Wickrama, Conger, & Elder, 2006). - Incongruent experiences of marital sex are a source of conflict between husband’s and wives of midlife couples, however couples in later life tend to have more congruent experiences of marital sex (Lodge & Umberson, 2012). - Clinicians should explore sexual inactivity between older married persons and their partners and should also assess attitudes on whether or not they intend or want to engage in sexual activity in the future (Karraker & DeLamater, 2013).

Sexual Development - Helping families understand the importance of older sisters roles as confidants, sources of support, and mentors to reduce adolescent sex- ual risk behaviors and promote healthy sexual development and romantic relationships (Killoren & Roach, 2014). - Creating awareness among therapists on contextual factors, such as social class and racial differences, and the formulation of sexual

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DISCUSSION

In this study, we analyzed a large time period across a broad range of journals to capture sig- nificant trends in sex research within MFT and family studies literature. Given the importance that sexuality plays within couple relationships it was surprising to find how little sex has been the focus of MFT and family studies literature (less than 0.01%). These 137 articles that were published in 15 journals across the span of 17 years, yields an average of 8 articles published about sex each year, or 0.5 articles per journal per year.

In presenting the types of research articles available within the field, we identified a lack in empirical research about sex. Of the 137 articles, little more than half (51%) utilized some form of qualitative, quantitative, or mixed methods approach to studying sex. There were a substantial number of theoretical articles that proposed effective sexual treatments without any empirical backing, the majority of which (35 articles) were published in two of the journals (the Journal of Family Psychotherapy and the Family Journal). We do not wish to de-value the theoretical articles that have been written, but we hope to highlight the need for quality empirical data to develop and validate the theoretical work that has been presented.

Of the empirical articles, most of the studies used small, convenience samples. The samples also consisted of a majority of white (87%) and heterosexual (58%) individuals or couples. Because several studies did not report the sexual orientation of their participants, it is anticipated that many more of the studies included only opposite-sex couples. Furthermore, only twelve arti- cles indicated receiving any or all participants from outside the United States. As a result, many of the clinical implications of these studies can only be applied to the white/heterosexual/U.S. popula- tion. We encourage future researchers to consider the need for research with diverse populations. Advancing the knowledge base in these areas will provide clinicians with more treatment consider- ations for culturally competent practice. Because norms around sex-related topics may vary widely

Table 5 Continued

Category Clinical implications

relationships, that affect the premature dissolution of these relation- ships among young people (Sassler, Michelmore, & Holland, 2016).

Young Adulthood - By learning about and understanding the young adult clients’ lan- guage, therapists can help these clients create new meanings and new stories about their relationships in a way that makes sexual and romantic relationships less confusing (Banker, Kaestle, & Allen, 2010). - Promoting parental communication about sex can potentially decrease the likelihood of making sexual decisions that one will regret (Allen, Husser, Stone, & Jordal, 2008).

Sexual Education - Helping families understand the importance of parental involvement and shared decision-making in relationships for sexual risk reduction in young women (Kogan, Simons, Chen, Burwell, & Brody, 2013). - The success of sexual risk reduction interventions may be attenuated by sexual traumas histories and comorbid mental health issues. (Wyatt, Loeb, Williams, Zhang, & Davis, 2012). - Promoting condom use and mutual masturbation as a safe sex prac- tice was effective in increasing condom use in Peurto Rico (P�erez- Jim�enez, Seal, & Ronis, 2014).

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from culture to culture, it is important for clinicians to be knowledgeable in how to navigate con- versations about sexuality.

With the increasing cultural acceptance of nonmonogamous (Shernoff, 2006) and same-sex relationships (Keleher & Smith, 2012), surprisingly little has been done to identify the best treat- ment practices when working with sexual minorities. Our study yielded 3 empirical articles that addressed the sexual relationships of sexual minority groups. Nonmonogamous relationship con- stellations are not uncommon to clinical settings, and the current body of literature provides an inadequate foundation for systemic training and treatment. As a result, these populations may have unique challenges that often go unaddressed or unnoticed by their clinicians. Family studies researchers may also benefit and serve this population by researching the unique attributes of satis- fying and pleasurable sexual relationships of sexual minorities. However, the fact that all six arti- cles were published within the last 10 years may be some sign, though small, that this research is becoming more popular and pertinent to the MFT and family studies fields.

Of the 71 empirical studies, five included clinical samples, most of which were singular case study analyses. No randomized trials of sex therapy treatments or sex therapy process studies have been presented in the MFT and family studies literature. Researchers may benefit these fields by concentrating their efforts on integrating medical records data, specific sampling within a given participatory community, and process research of sex therapy treatments into their work. Researchers may consider the possible benefit in collaborating with other disciplines in producing quality sexual interventions. By advancing the clinical research of sex therapy practices, MFTs and family studies researchers can strengthen the empirical support of the systemic paradigm they employ.

Within the analyzed literature, there was an overall shortage of articles on sex therapy from these journals (24 articles, 18% of the 137 articles discussing sex). Within those 24 articles, only four specifically discussed how to train MFTs in giving sex therapy. As the MFT field continues to move toward the integration of marriage and family therapy with other medical professions, sys- temic and integrative therapists may be among the best qualified to handle the complex and chal- lenging treatment of sexual dysfunctions. Being able to identify the bio-psychosocial and spiritual components that all contribute to sexual problems has repeatedly been shown as crucial to treat- ment success (Hughes, Hertlein, & Hagey, 2011). It is important to be able to train MFTs to recog- nize and conceptualize sexual problems within an integrated treatment paradigm to provide adequate treatment (Hughes et al., 2011). Due to the lack of sex research in MFT and family stud- ies journals, it may be important to teach clinicians how to consider and access research from other disciplines that may in form their sex-related therapy work.

Integration of Couples and Sex Therapy There have been multiple efforts made in the field of sex research to emphasize the importance

of integrating relational factors into the treatment of sexual dysfunctions, moving away from the medicalization of sexuality (Metz & McCarthy, 2007). There were several articles in our search that spoke to the integration of couples and sex therapy (Hertlein & Weeks, 2009; Johnson & Zuccarini, 2010; McCarthy, 2001; Tambling, 2012; Trepper, Treyger, Yalowitz, & Ford, 2010; Yarhouse, 2008). Many of these articles spoke directly to the integration of sex therapy within already estab- lished MFT models (e.g., Emotionally Focused Therapy, Solution-Focused Brief Therapy). While these articles provide excellent suggestions for treatment, there are still no empirically validated studies that show the beneficial outcomes of MFT approaches when treating sexual disorders.

Within our search, we found a total of five articles that addressed the theoretical integration of couples and sex therapy. When thinking about how exactly clinicians can begin moving toward the integrative paradigm of sex and marital therapy, Hertlein and Weeks (2009) argue that the frameworks informed by Sternberg’s (1986) triangular theory of love, the intersystem approach (Weeks, 1994), and the theory of interaction (Strong & Claiborn, 1982) offer therapists a way to both independently and comprehensively attend to the sexuality and couples’ issues that occur in the therapy room by implementing a sequence of collective and collaborative interventions. Sex therapy then becomes a framework for therapists to begin synthesizing “knowledge about couples therapy, sex therapy, medical therapy, psychology, and knowledge about larger systemic contexts” into the treatment of sexuality and sexual dysfunctions (Hertlein & Weeks, 2009, p. 46).

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McCarthy (2001) argues that while the couples’ therapy field is growing, it appears that its counterpart in the field, sex therapy, is becoming stagnant. Within the training, research, and prac- tice of couples’ therapy, sexuality remains a minor focus. Couples’ therapists, therefore, typically avoid questions with their clients around sex and sexuality “because of fear of invasiveness, bound- ary violation, and eliciting sexual feelings in the therapist or client” (McCarthy, 2001, p. 47). McCarthy (2001) suggests that couples’ therapist can begin integrating sex therapy into the field through consultation and supervision with a sex therapist. The sex therapist can train a couple’s therapist in the integration of sex therapy by following the PLISSIT Model (Annon, 1976). The four levels of intervention include: permission giving, limited information, specific suggestion, and intensive sex therapy. McCarthy (2001) discusses the fact that not all clinicians are capable or will- ing to practice sex therapy, however, they should be giving clients the permission to view sexuality as a shared pleasure that is a positive, integral part of self, and marriage, as well as being able to confront the myths that clients have about sexuality.

Other contributions to the theoretical integration of couples and sex therapy go a step further into looking at how specific systemic approaches (Solution Focused Brief Therapy, Feminist Fam- ily Therapy, and Emotion Focused Therapy) can be integrated with sex therapy in the treatment of sexual dysfunctions and disorders (Daniels, Zimmerman, & Bowling, 2003; Johnson & Zuccarini, 2010; Trepper et al., 2010). By utilizing the main components of SFBT, such as a positive, inter- connected, and strength-based approach, Trepper et al. (2010) believes, that in combination with medication and other behavioral skills, a comprehensive form of treatment could be extremely valuable to client goals being met. Similarly, Daniels et al. (2003), outline the benefits of using a feminist perspective in sex therapy. By integrating a feminist perspective, clinicians can address some of the sexual disadvantages that both men and women experience as a result sexual myths and socialization. Within this integrative approach, the authors outline several sexual disadvan- tages of cultural, sexual myths that can be useful to discuss with clients.

Johnson and Zuccarini (2010) develop a view of sexual functioning that is complementary of attachment theory and the process of emotion focused couple therapy (EFT). Within the article, healthy sexual functioning is placed in the context of attachment and a “safe emotional connec- tion” (Johnson & Zuccarini, 2010, p. 6). Simultaneously, Johnson and Zuccarini (2010) define a couple’s distress and sexual problems as a threat to their attachment and emotional connection. By viewing a couples’ sexual functioning through an attachment lens, Johnson and Zuccarini have provided the field of marriage and family studies with a greater understanding of how an empiri- cally validated approach such as EFT can be adapted to address sexual issues within the couple system.

Limitations One potential limitation in doing a content analysis is the possibility of not finding relevant

content. We made every effort to find all relevant articles, yet it is certainly believable that there was human error in the process. It is also possible that more search terms may have yielded more search results. We also recognize that this analysis does not provide a comprehensive look at all MFT and family studies research. There are journals that focus on sex and marital therapy that were not included in the analysis because of our decision to not include sex research journals (e.g., Journal of Sex and Marital Therapy). There may be many articles on the subject within those jour- nals. Also, there may be many MFT and family studies researchers that publish their sex research in other journals and may have affiliations with other sex-related organizations. Furthermore, researchers may also consider publishing sex research in other journals that are found in more interdisciplinary databases. We also do not know how many articles were submitted to these jour- nals, therefore our analysis may not comprise all of the research being done. Lastly, there may also be other journals that may have a greater amount of research on sex than the journals that were reviewed in this research.

CONCLUSION

Overall, while the field of sex therapy is making important efforts to recognize the influence of the relational context in which sexual problems occur, the field of relationship studies, MFT and

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family studies has largely failed to acknowledge the role that sex plays in maintaining, promoting closeness, healing, and perpetuating relationships. Sexual problems often reflect and exacerbate relational conflict, anxieties, insecurities, and communication (Johnson & Zuccarini, 2010).

The results from this study revealed the unique opportunity researchers have to strengthen the research base of sexuality and sex therapy within MFT and family studies research. Despite this surprisingly small amount of research, it may certainly be the case that many MFT and family studies researchers that are publishing their sex research in other journals. However, the small amount of literature in these MFT and family studies journals may be indicative of a long list of short-comings including, little inter-disciplinary collaboration between our fields, inadequate training of sex therapists, discomfort in addressing sexual topics, or difficulty in researching sexual relationships. Researchers in these fields have the unique opportunity to strengthen the practice of integrative and systemic therapies, enhance the training and capabilities of clinicians, and discover important treatments of sexual problems. Furthering sex research may have lasting impacts for future generations in a world of evolving relationship patterns and sexual behaviors.

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SUPPORTING INFORMATION

Additional Supporting Information may be found in the online version of this article:

Data S1. Analyzed References.

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