Week 1 Assignment

Couples

Sexuality Counseling: A Professional Specialization Comes of Age

Stephen Southern1 and Rochelle Cade2

Abstract For individuals and couples experiencing such distress, sexuality counseling, an emerging specialization in professional counseling, may provide relief, understanding, healing, and intimacy. This review attempts to describe the paradigm shifts and key figures in the field, sexuality counseling as a professional specialization, the process of sexuality counseling including assessment, diagnosis and treatment planning, and various roadblocks to intimacy. It concludes with advocacy of the new specialization as a synthesis of trends in sexual health.

Keywords sexuality counseling, sex therapy, sexual dysfunction, brief sex therapy, medical model, New View of women’s sexuality

‘‘When sexual function goes along smoothly, it is usually taken

for granted and given little thought. But if sexual function is a

problem in one way or another, it can be a source of anxiety,

anguish, and frustration that often leads to general unhappiness

and distress in personal relationships’’ (Masters, Johnson, &

Kolodny, 1986, p. 462). For individuals and couples experien-

cing such distress, sexuality counseling may provide relief,

understanding, healing, and greater intimacy.

Sexual issues were addressed in the origin of psychotherapy

with the development of psychoanalysis. Over the years, the study

and treatment of sexual dysfunction and dissatisfaction contribu-

ted to the emergence of a new field, sex therapy. Classic models

for sexual responding were developed through ethnographic and

laboratory research. Advances in medical technology and new

medications led to the medicalization of sex therapy as an exten-

sion of a patriarchal, masculine model of sex. Feminists rejected

the focus on medical treatment of genital responses and advocated

focus on relational and cultural factors. The contemporary sexual

health movement promises to advance integrative approaches to

helping couples with sexual satisfaction and optimal sexual func-

tioning. The convergence of sociocultural factors suggests that

the time is right for a sexuality counseling specialization within

professional counseling. The following overview attempts to

describe the paradigm shifts and key figures in the field, sexuality

counseling as a professional specialization, the process of sexual-

ity counseling including assessment, diagnosis and treatment

planning, and various roadblocks to intimacy.

Emerging Sexualities: Whither Sexual Health

Anecdotal data and expert opinion estimated that 50% of couples and 50% of individuals experience sexual problems

during their lifespan (Masters & Johnson, 1970). Recent

research has confirmed that sexual disorders are common, even

normative in the United States. Data from a large-scale sample

of U.S. adults, aged 18–59, reported prevalence rates for sexual

dysfunction in the past 12 months: 43% for women and 31% for men (Laumann, Paik, & Rosen, 1999). Heiman (2002b)

summarized the results of several studies concluding that

10–52% of males and 25–63% of women in the general popu- lation experience sexual problems. Studies of particular popu-

lations have revealed even higher prevalence rates than those

reported for the general population.

Large-scale epidemiological studies (Bancroft, Loftus, &

Long, 2003; Laumann, Gagnon, Michael, & Michaels, 1994;

Laumann et al., 1999, 2005; Mercer et al., 2003) have con-

firmed that sexual dysfunction in one or more components of

sexual response is commonly encountered in the clinic and the

community. Heiman (2007, p. 89) summarized the prevalence

and epidemiological studies estimating that 63% of women reported some arousal or orgasm problems. Some women

described marked distress with their difficulties in functioning,

while others reported satisfaction with their relationships and

sex lives even though there were some sexual problems.

Rosenbaum (2007) reported that as many as 15% of premeno- pausal women present sexual pain disorders including

1 Department of Psychology and Counseling, Mississippi College, Clinton, MS,

USA 2 Department of Counselor Education, University of Houston-Victoria,

Victoria, TX, USA

Corresponding Author:

Stephen Southern, Department of Psychology and Counseling, Box 4013,

Mississippi College, Clinton, MS 39058, USA

Email: [email protected]

The Family Journal: Counseling and Therapy for Couples and Families 19(3) 246-262 ª The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1066480711408028 http://tfj.sagepub.com

dyspareunia and vaginismus. Lack of interest in sex, including

sexual desire discrepancies in couples, affected 16% of men and 33% of women (Maurice, 2007, p. 187). A total of 35% of men reported at least one sexual problem in the last year (Mercer

et al., 2003).

Although there are problems with the diagnostic criteria for

sexual disorders, as many as 30% of men report concerns with rapid or premature ejaculation (Althof, 2007, pp. 217–220).

Approximately 8% of male respondents reported not being able to achieve an orgasm (Laumann et al., 1999). Rosen (2005)

indicated that prevalence of erectile dysfunction (ED)

increased with age with as few as 7% of men under 30 years of age presenting ED and more than 50% of men older than Age 60. Qualitative research (e.g., Symonds, Roblin, Hart, &

Althof, 2003) established that male sexual dysfunction contrib-

uted to lack of self-confidence, embarrassment, avoidance of

sexual outlet, and fears about losing one’s sexual partner. Sex-

ual problems increase with age; however, worries and concerns

about sexual performance contribute psychogenic and rela-

tional factors to the mix of etiological factors.

Concurrent with increasing use of selective serotonin uptake

inhibitors (SSRIs), such as fluvoxatine (Prozac), for depres-

sion, anxiety, and other emotional concerns, there were com-

plaints of sexual dysfunction, including inability to become

aroused or to experience orgasm. One study (Clayton, Keller,

& McGarvey, 2006) reported that 95.6% of women and 97.9% of men taking SSRIs exhibited impairment in at least one phase of sexual functioning. There are also high rates of

sexual dysfunction in individuals receiving antipsychotic med-

ications (Dossenbach et al., 2005; Olfson, Uttaro, Carson, &

Tafesse, 2005). Generally, sexual dysfunction rates increase

with chronic illness, including diabetes and cardiovascular dis-

ease (Hayes & Dennerstein, 2005; Jack, 2005; Jackson, Rosen,

Kloner, & Kostis, 2006; West, Vinikoor, & Zolnoun, 2004).

Cancer survivors and their partners are especially likely to

experience compromised sexual functioning (Lagana et al.,

2005; Navon & Morag, 2003). Informed and empathic sexolo-

gists have even addressed the sexual needs of terminally ill per-

sons involved in palliative care (Redelman, 2008).

The most recent trend in the emerging field of sexual med-

icine is to define sexual problems in biological terms, reclassify

complaints according to diagnoses that demand medical atten-

tion, develop consensus-based treatment guidelines, and treat

sexual disorders with medications (Jackson et al., 2006; Lewis

et al., 2004; Lue et al., 2004). Based upon the success of silde-

nafil (Viagra) in treating ED, clinicians and researchers have

attempted with some success to reconceptualize female sexual

dysfunction in such a manner that medication is warranted

(e.g., Dennerstein & Goldstein, 2005; Dennerstein & Hayes,

2005; Rosen, 2002). However, feminists are sensitizing profes-

sionals in the field to pitfalls involved with the disease-oriented

‘‘hunt for pink Viagra’’ (Hartley, 2006).

Some sex therapists (e.g., Bancroft et al., 2003) have

responded to medicalization of the profession by asserting that

emotional factors, such as sense of well-being and relationship

with one’s sexual partner, contribute more than genital

functioning to distress about sex. If sexual satisfaction is

dependent upon relational factors (McConaghy, 2004), sex

therapy, which has been since its origin relational in orientation,

has a place in the contemporary treatment of sexual concerns.

Definitions of women’s sexual dysfunctions can be reconsidered

without resorting to overmedicalization. Recommended changes

to classification should take into account contextual factors and

degree of reported distress (Basson et al., 2003). Since there exist

some empirically supported or evidenced-based treatments for

sexual dysfunction (Baucom, Shoham, Mueser, Daiuto, &

Stickle, 1998; Heiman, 2002a, 2002b; Segraves & Althof,

2002), sex therapy will likely be included in emerging integrative

biopsychosocial models of care.

The dominant emerging model for sexuality is a focus on

achieving or maintaining sexual health. Sexual health repre-

sents more than the relative absence of symptoms, duress, or

impairment. Instead, the construct of sexual health takes into

account increasing opportunities to find fulfillment and make

meaning from sexuality.

Sexuality is a central aspect of being human throughout life and

encompasses sex, gender identities and roles, sexual orienta-

tion, eroticism, pleasure, intimacy, and reproduction. Sexuality

is experienced and expressed in thoughts, fantasies, desires,

beliefs, attitudes, values, behaviors, practices, roles, relation-

ships, and so on. Sexuality is influenced by the interaction of

biological, psychological, social, economic, political, cultural,

legal, historical, religious, and spiritual factors (World Health

Organization conference on sexual health, January 2002).

Similarly, sexual health affords a goal or ideal for organizing

various aspects of intimacy in an intentional pair-bond or

relationship.

Sexual health is the integration of the somatic, emotional,

intellectual, and social aspects of sexual well-being, in ways

that are positively enriching and that enhance personality, com-

munication, and love (World Health Organization in Firestone,

Firestone, & Catlett, 2006, p. 11).

Sexual health exists within the individual and is shared by a

loving couple with a supportive community. A sexually healthy

adult expresses one’s sexual preferences, which are congruent

with personal values while respecting the rights of others.

Healthy sexualities may include the absence of genital sexual

activity and reproduction and increase love, intimacy, and joy

in relationships. Sexuality counseling, which takes into account

the developmental significance of individual sexual fulfillment

and opportunities for intimate relationships, is especially well

suited to advance sexual health in the next millennium.

Historical Overview: From Sex Therapy to Sexuality Counseling

Sexuality counseling is a professional specialization in transi-

tion. During a relatively brief modern history of approximately

Southern and Cade 247

40 years, the overall field of sex therapy has experienced major

paradigm shifts. Originally, sex therapy was within the domain

of psychoanalysis, though it was not identified as sex therapy at

the time. Freud and his followers provided psychoanalytic ther-

apy from a psychosexual perspective whereby sexual problems

were viewed as symptoms of neuroses and manifestations of a

deeper conflict in the individual. Problems in psychosexual

development interfered with the unfolding of sexual maturity,

which was signified in the capacity to experience orgasm in

heterosexual vaginal intercourse (Person, 2005). Freud and his

students offered psychoanalysis, a technique that addressed

only indirectly the sexual experiences of patients. His tech-

niques were revolutionary and controversial in Victorian times.

Transference, countertransference, and the development of

insight were the catalysts for change in this theoretical orienta-

tion. The psychoanalytic approach was both cost and time

intensive and was not known for its effectiveness (Kleinplatz,

2003).

Classic Models

Kinsey and colleagues (Kinsey, Pomeroy, & Martin, 1948;

Kinsey, Pomeroy, Martin, & Gebhard, 1953) advanced

knowledge about a wide range of sexual behavior through

sexual history, interview, correspondence, pornography, and

self-exploration through large-scale surveys about sexual beha-

vior in the 1940s. His surveys were the first of their kind and the

data obtained from the surveys allowed Kinsey to draw a distinc-

tion between what society deemed to be normal and what people

actually did sexually (Goodwach, 2005). The published results

of Kinsey’s studies informed professional and lay audiences

about the prevalence of sexual variance in the population.

Masters pioneered hormone replacement therapy and estab-

lished an extensive research program in human sexual func-

tioning. In the laboratory, he monitored physiological

changes during masturbation and intercourse. Later, Masters

developed with Virginia Johnson sex therapy. This therapy was

more short-term in comparison to psychotherapy approaches,

included both partners in a couple, and the therapy was con-

ducted by a male–female cotherapy team to reduce risk of

transference. Masters and Johnson applied their research from

the laboratory to the development of sex therapy techniques

that remain the foundation for treatment of sexual dysfunction

and dissatisfaction. The classics, Human Sexual Response, was

published in 1966, while Human Sexual Inadequacy introduced

sex therapy in 1970. The evolution of the Masters and Johnson

Institute model for sexuality, from laboratory research to brief

conjoint sex therapy has been described in detail (Maier, 2009).

Sex Therapy Ascends

During the 1970s, LoPiccolo and LoPiccolo (1978) and other

behavior therapists applied principles of counterconditioning

to sex therapy techniques. Another notable figure during this

time was Dr. Helen Singer Kaplan who integrated medical

practice, psychotherapy, and sex therapy. Considered a bridge

between psychoanalytic treatment and the more modern

behavioral methods, Kaplan’s model (1974) emphasized the

role of immediate symptoms that the clients were presenting

for treatment (Bradley & Fine, 2009). Kaplan utilized an active

and direct approach to symptoms and if this was met with resis-

tance or was unsuccessful, she would turn to psychodynamic

theory to consider deeper issues. In 1979, Kaplan pioneered

treatment of sexual desire disorders, including couple desire

discrepancies, at multiple causal levels, anticipating popular

systemic and multimodality approaches. She also introduced

medication, especially SSRI antidepressants, as an aid to over-

coming sexual phobias (Kaplan, 1979, 1983, 1987). As sex

therapies emphasized relationships in the healing process, there

was a noticeable increase in mass media attention to the issues

of sexual dysfunction (Bradley & Fine, 2009).

Sexual Explorations

Since the 1980s, popular publications such as Cosmopolitan,

Redbook, and other mainstream magazines published articles

about such topics as orgasm, sexual satisfaction, and ways to

achieve both (Bradley & Fine, 2009). Similarly, self-help

books and non-Western sexual disciplines (i.e., Kundalini yoga

and Kama Sutra) aimed at improving sexual functioning gained

attention and popularity. This mass media attention and cul-

tural changes allowed adults to address their own sexual diffi-

culties and resulted in decreased demand for sex therapy

(Bradley & Fine, 2009).

A decade later, expansion of the Internet contributed to eas-

ily accessible content from sex information to sexual advocacy.

Individuals were free to explore their sexualities and to obtain

information and interaction related to sexual expression. While

ease of access to the Internet hastened the self-help revolution in

sexual health, anonymity, and affordability also contributed to

compulsive cybersex (Carnes, Delmonico, Griffin, & Moriarty,

2004; Cooper, 2004; Cooper, Delmonico, Griffin-Shelley, &

Mathy, 2004; Cooper, McLoughlin, Reich, & Kent-Ferraro,

2002; Cooper, Scherer, Boies, & Gordon, 1999; Southern, 2008).

In the 1990s, the term sexual addiction was coined and the

increased use of Internet-based pornography became more

omnipresent (Bradley & Fine, 2009) fueling sexual variance and

some predatory sexual activity (Carnes et al., 2004). This led to

changes in the nature of clients seeking sex therapy. The propor-

tion of clients with more pervasive and chronic sexual problems

increased while the proportion of clients needing education

dwindled (Wiederman, 1998). Serious sexual problems, resis-

tant to change through education and advocacy, were frequently

associated with a history of sexual abuse or premature erotic

awakening (Schwartz, 1996; Schwartz, Galperin, & Masters,

1995; Schwartz & Masters, 1988; Schwartz & Southern, 1999).

Back to the Future: Recovering Psychodynamics

The role of early sexual abuse has received considerable atten-

tion in sex therapy as well as psychotherapy in general. During

248 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

the 1980s and 1990s, sex therapists were rediscovering the

contributions of psychodynamics to sexual issues. Several contri-

butors integrated sex therapy with object relations approaches

(e.g., Scharff, 1982, 1988; Scharff & Scharff, 1987). Apfelbaum

(1984, 1988, 1989) expressed an ego-analytic model of sex ther-

apy. Schnarch (1991) shifted away from a genital model of sex

therapy toward a dyadic, systems-oriented intimacy model.

Schnarch advanced the concept of the sexual crucible in which

attachment theory, individual psychodynamics, family of origin

issues, marital and family systems perspectives, and spiritual mat-

ters may be addressed in a unifying manner.

Each of the contributions to contemporary sex therapy

employed the ‘‘back to the future’’ approach by incorporating

elements of psychodynamic models to address sexual concerns

in the context of intimacy disorder. Theories have also become

more complex, integrative, or postmodern (Wiederman, 1998).

Schwartz, formerly the director of psychosexual research,

expanded the work of Masters and Johnson Institute to address

a wide range of intimacy dysfunction and trauma-based disorders

(e.g., Schwartz & Cohn, 1993; Schwartz & Southern, 1999).

A recent comprehensive model of sex therapy, exploring aspects

of intimacy dysfunction arising from negative sexual develop-

ment, was built on the structures of the psychotherapy integration

movement.

Firestone and colleagues developed a voice therapy from

depth-oriented psychodynamic therapy to address self-

destructive behaviors, overcome psychological defenses, and

free sexuality. They described in Sex and Love in Intimate

Relationships (Firestone et al., 2006) cognitive–affective–

behavioral techniques for accessing and changing the inner

voices that interfere with the development of intimacy and the

expression of sexuality in loving relationships. Thus, sex thera-

pists employ a broad range of therapeutic approaches and treat-

ment modalities.

Medicalization: Chasing Diseased Dollars

As theoretical approaches and the nature of client issues chan-

ged, so too has the role of medicine in the conceptualization

and treatment of sexual dysfunction. Leiblum and Rosen

(2000) noted the field of sex therapy has been marked by a

trend toward greater medicalization and an increasing empha-

sis upon pharmacological intervention. Recent years have

demonstrated both an increase in the number of medications

available by prescription to address the symptoms of sexual

dysfunction as well as a dramatic increase in media advertising

regarding pharmacological remedies (Bradley & Fine, 2009).

A night of television commercials for Viagra, Levitra, and

Cialis provides ample evidence of the direct marketing of

men’s sexual rehabilitation services. In addition to advertising

pharmacological options for improving sexual functioning,

these commercials normalize older people’s continuing interest

in sex (Goodwach, 2005).

The growing popularity of medical intervention for sexual

dysfunction can be attributed to a number of factors. The

growth of managed health care has contributed to an emphasis

on short-term treatments. Empirically supported treatment

(EST) research has contributed to evidence-based practice

(EBP) in all approaches to therapy. These studies are supported

by the pharmaceutical industry and encouraged by Health

Maintenance Organizations (HMOs; Kleinplatz, 2003). Insur-

ance companies are more likely to reimburse for interventions

provided by urologists and gynecologists than from sex

therapists (Wiederman, 1998). Sociocultural issues may also

promote medical intervention as opposed to therapeutic inter-

ventions for sexual dysfunction. Clients may avoid the social

stigma of a psychological basis of their sexual dysfunction and

sex therapy by seeking medical intervention and pharmaceuti-

cal treatment for their ‘‘medical disorder.’’ Since there exist

some empirically supported or evidenced-based treatments for

sexual dysfunction (Baucom et al., 1998; Heiman, 2002a,

2002b; Segraves & Althof, 2002), sex therapy will likely be

included in emerging integrative biopsychosocial models of

care. The result of these factors is that medical treatments

have been at least tried with virtually all sexual dysfunctions

(Leiblum, 2007; Wiederman, 1998).

Men Like Quick Fixes

Many individuals, especially men, attempt to avoid the

demands of intimacy and true relational therapy by seeking a

self-administered ‘‘quick fix.’’ Men have used desensitizing

gels in misguided attempts to delay ejaculation, rubber bands

and rings to prolong erection and intercourse, and various her-

bal and over-the-counter remedies to recover ‘‘potency’’; all of

which focus solely on the mechanics or hydraulics of sex. Since

male sexuality appears inexorably linked to power through

competition and conquest, it is easy to understand the allure

of sildenafil citrate (Viagra) and other effective medications.

Sexually anxious men could regain their confidence through

administration of the ‘‘little blue pill.’’ In this scenario, it would

be unnecessary to experience vulnerability, communicate one’s

feelings to a partner, or collaborate with another human being

in a course of intimacy-enhancing sex therapy. Viagra may fix

the functioning of the penis but does not fix the functioning of

the relationship, which may come as a surprise to many men.

The medicalization of sex therapy is a trend with much crit-

icism. In the medical model, the person becomes a patient and

is fixed with a procedure or pill by a medical professional

(Sheppard, Hallam-Jones, & Wylie, 2008). Kleinplatz (2003)

criticized the medical model for its emphasis on quantity, per-

formance, and objective measures (e.g., frequency and firm-

ness of erections) as opposed to the quality of sex and

measures of subjective experience (e.g., pleasure, satisfaction,

intimacy). Leiblum and Rosen (2000) warned ‘‘with the suc-

cess of new pharmacological agents, there is an inevitable

focus on biological causes for sexual dysfunction and a ten-

dency to seek simple medical solutions for more complex indi-

vidual or couples’ problems’’ (p. 11). In the most recent edition

of Principles and Practice of Sex Therapy, Leiblum (2007)

expressed the major synthesis of perspectives in sex therapy.

She noted that diagnosis and pharmacological innovations were

Southern and Cade 249

less important than cultural factors, lifestyle choices, and

integrative treatment. Leiblum (2007) concluded that the most

important goal of contemporary sex therapy is

. . . helping our patients achieve a more satisfying relationship

and quality of life using the most effective and least costly

means rather than any predetermined set of objective sexual

criteria (p. 17, italics by author).

Paradoxically, the search for the ‘‘quick fix’’ in the medicaliza-

tion of sex therapy affords opportunities for effective brief

therapies for sexual difficulties (Green & Flemons, 2004).

Victor Frankl, founder of logotherapy, actually began to

describe in the 1940s successful applications of two strategic

techniques for alleviating sexual problems, such as impotence

and frigidity (obviously the old terms with negative connota-

tions): paradoxical intention and dereflection (Frankl, 1978,

pp. 152–158). The techniques involved either prescribing the

symptom or restraining performance, respectively. The author-

itative pronouncement in the Masters and Johnson model of

treatment enlisted a directive that the couple refrain from

sexual outlet while focusing on nondemand sensual pleasuring.

Such directives can contribute to sexual intercourse in approx-

imately 30% of cases. Clearly, clients in logotherapy and sex therapy were anticipating a quick fix in order to resume sexual

interactions.

Expectations of clients, especially in initial interactions with

caregivers, determine the future success of clinical work for

sexual problems (Miller, Donahey, & Hubble, 2004). Rather

than viewing sex therapy clients as resistant, therapists can

help clients obtain good results by joining with their view of the

problem, using the client’s language system to address matters

instead of diagnostic categories, engendering hope and expec-

tancy for beneficial change, planning for between session and

extratherapeutic contributions to change, and taking into

account the client’s stage of readiness for action (Hubble,

Duncan, & Miller, 1999; Miller, Duncan, & Hubble, 1997;

Miller et al., 2004). Stage-specific change strategies focus on

the readiness of the client to become actively engaged in the

change process.

Six distinct stages for change were identified by Prochaska

(1999) and colleagues: precontemplation, contemplation, pre-

paration, action, maintenance, and termination. During the pre-

contemplation stage, the therapist joins with the clients and

provides helpful information. Contemplation involves the

examination of potential costs and benefits of changing or

remaining the same. Stage-oriented sex therapists tailor home-

work exercises to accommodate clients who are just contem-

plating change. The therapist may suggest that clients ‘‘go

slow’’ and ask them to consider ‘‘dangers of improvement’’

(Miller et al., 2004, pp. 32–33). The stage of preparation builds

upon the slow change process introducing values, cultural con-

texts, and relationship factors. Client choices about homework

are respected and the couple engages in relationship building.

Action is the typical focus of sex therapy. In this stage, the

formerly contemplative, well-prepared couple has good

anticipation and expectation for beneficial change. They are

able to complete meaningful homework exercises between

sessions and to share their experiences with the collaborating

therapist. In the maintenance stage, the therapist helps the

couple avoid relapse by anticipating challenges. They may

make plans for ongoing exploration and growth in their sex

lives. Upon termination, the couple is ready to self-direct the

change efforts, but informed of opportunities for booster

sessions and follow-up consultation (Miller et al., 2004).

New View: Women Save Sex Therapy

Women do not want a ‘‘little pink pill’’ to fix their sexual

concerns (Hartley, 2006). Men, who stereotypically seek a

quick fix in which relational issues are bypassed, were easily

influenced by media and pharmaceutical companies to embrace

the ‘‘little blue pill.’’ Interventions such as use of Viagra limit

sex therapy to genital sexual functioning. Feminists in sex ther-

apy and related professions have articulated a New View in

which individual choice, relationship factors, and cultural val-

ues are emphasized.

Tiefer and others rejected the overmedicalization of sex

therapy, articulating instead the New View of female sexuality

(Kaschak & Tiefer, 2001; Tiefer, 2000, 2001, 2002; Tiefer,

Hall, & Tavris, 2002). Social constructionism is the most recent

and promising approach to contemporary sex therapy. As a

postmodern development, A New View of Women’s Sexual

Problems (Kaschak & Tiefer, 2001), a manifesto written by

12 clinicians and social scientists, calls into question the

disease-oriented, diagnosis-dependent, overmedicalized, and

patriarchal model of sex therapy. Tiefer (2000, 2001, 2002),

in particular, has been a persuasive critic of attempts by phar-

maceutical companies to define sexuality in terms of biological

reductionism. The feminist movement implicit in the New

View arose after the success of Viagra in treating male sexual

dysfunction. Subsequently, there was much more attention and

research directed at women’s sexual disorders. However,

Tiefer and colleagues resisted the attempts to find a ‘‘little pink

pill’’ (i.e., female Viagra or another quick fix pharmaceutical)

and ultimately challenged the validity of the disease-oriented

diagnostic criteria of the DSM-IV-TR (American Psychiatric

Association, 2000).

The New View begins with a woman-centered definition of

sexual problems: ‘‘discontent or dissatisfaction with any emo-

tional, physical, or relational aspect of sexual experience

(Kaschak & Tiefer, 2001, pp. 228–229). The New View

emphasizes the social and contextual when attempting to

describe or understand sexual concerns. Causal and curative

factors may occur in one or more of the following categories:

(a) sociocultural, political, or economic factors; (b) partner and

relationship factors; (c) psychological factors; and (d) medical

factors. Even the descending order of the categories helps to

restore balance in contemporary sex therapy. The New View

categories have validity and fit the lived experiences of women

and their partners (Nicholls, 2008). The evolution of the New

View campaign has been described in detail (Tiefer, 2008).

250 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

Postmodern sex therapy will be concerned with the meaning

people make from their sex lives. Solutions to sexual concerns

may be found in one or more systems of intervention, including

the medical model of diagnosis and medication. However,

postmodern sex therapists will resist the dehumanization and

reductionism that diminish human beings to passive consumers

of new technologies and pills. If Viagra killed relationship-

oriented sex therapy, then the New View may resurrect an

inclusive, person-centered biopsychosocial approach to sexual

healing. The New View is the cornerstone of a contemporary,

integrative sexuality counseling.

A Model for Sexuality Counseling

A clinically relevant model for sexuality counseling takes into

account classic approaches, evidence-based practices, medical

advances, and postmodern corrections to the medicalization of

sex therapy. The classic model of Annon (1976) has provided a

basic structure for the provision of sexual health services. His

PLISSIT model outlines the potential levels of intervention for

clinical decision-making. The PLISSIT model is presented

below with special attention to the stages of change in sexuality

counseling (see Miller et al., 2004).

P––Permission to talk about sexuality and sexual issues;

empathy and encouragement; empowerment to make

choices about sexual changes. (This level of the model

seems well-suited to the precontemplation and contem-

plation stages of change.)

LI––Limited information; sex education; exploration and

clarification of gender and sexual myths and stereotypes;

information about prevalence and etiology of problems

as appropriate. (This level corresponds to the contempla-

tion and preparation stages of change.)

SS––Specific Suggestions; particular interventions, includ-

ing medical, psychological, and relational factors unique

to the case; providing contexts of choice and respect for

cultural considerations. (This level of the model

addresses the needs of the preparation and action stages

of change.)

IT––Intensive Therapy; ongoing engagement of the couple

in systematic individual and conjoint services focusing

on relationship dynamics, psychological concerns, and

complex presenting problems. (This level recognizes the

need for in-depth sexual health services to promote

maintenance of treatment gains.)

In a recent textbook, Sexuality Counseling: An Integrative

Approach (Long, Burnett, & Thomas, 2006, p. 18), the PLIS-

SIT model was used to determine who could provide the four

services. Long and colleagues observed that counselors from

marriage and family or mental health counseling training pro-

grams may be equipped by the education and clinical training

to provide Permission and Limited Information. They stated

that Specific Suggestions (i.e., typical sex therapy exercises)

and Intensive Therapy should only be performed by clinicians

whose licenses or specialized training demonstrates advanced

competency in sex therapy or supervision. Otherwise, the

authors recommended that the counselor refer to a sexuality

health care provider who presents in-depth training sufficient

to deal with the intensity of complex cases.

Two physicians (Stevenson & Elliott, 2007) organized treat-

ment recommendations according to the PLISSIT model. They

presented some of the most complex cases involving physical,

psychological, and relational factors affecting sexuality in

couples living with illness. They included most medical and

psychological interventions, including medication and injec-

tion, under the Specific Suggestions heading. Permission and

Limited Information could be provided by a nonspecialist, while

individual and marital/couples counseling and sex therapy

interventions were classified as Intensive Therapy (p. 343).

Clearly, these physicians valued the specialized training and

relational perspective of marriage and family counselors.

Referral to a Sexuality Counselor

Sexuality counseling is a specialty area in professional counsel-

ing, and therefore, it is essential to refer to a clinician with an

appropriate educational background, credentials (e.g., certifi-

cation, licensure) and advanced training and supervision in

sexuality. In addition, the sexuality counselor would require

specialized knowledge of how other clinicians’ interventions

(e.g., treatment of depression, diabetes, cardiovascular disease,

cancer) affect, engender, or exacerbate sexual problems

(Kleinplatz, 2009).

Nathan (1986) defined four levels of expertise on sexual

issues: (a) Level 1: comfort in discussing sexual material

and/or sexuality, (b) Level 2: recognition of sexual problems,

(c) Level 3: evaluation of sexual problems for intervention or

referral, and (d) Level 4: treatment of severe sexual problems.

Many clinicians are too embarrassed, uncomfortable, or wor-

ried about their lack of ability to help their clients with sexual

issues at Level 1 and so they avoid the topic altogether with

clients. Other clinicians may comfortably operate at Level 1 and

Level 2 and then make an appropriate referral for Levels 3 and 4.

Unfortunately, there are a number of well-meaning clincians with

good intentions who try to offer interventions at Levels 3 or 4 but

are simply not qualified.

In a recent study of factors contributing to the readiness of

rehabilitation counselors to address sexuality issues with their

clients, willingness to discuss sexuality was associated with

knowledge of sexuality and comfort with sexuality (Juergens,

Smedema, & Berven, 2009). Addressing even the initial levels

or stages of sexual issues required specialized training and

comfort of the counselor in general with addressing sexual

issues. Another study investigated the current status of practi-

cing clinical psychologists as sexual healthcare providers.

Reissing and Giulio (2010) surveyed 188 professional psychol-

ogists in a metropolitan Canadian city. They found that 60% of clinicians rarely if ever asked their patients questions related to

sexuality. They concluded that the lack of sensitivity and clin-

ical involvement reflected lack of knowledge and comfort

Southern and Cade 251

arising from nonexistent to insufficient training. The psycholo-

gists recommended specialized training in sexuality and ther-

apy techniques within the clinical psychology graduate

curriculum. In addition, they recommended workshops and

continuing education in assessment and intervention tech-

niques to prepare practicing psychologists to deal with the

sexuality issues of patients. Reissing and Giulio cautioned that

psychologists who offer sexuality treatment without adequate

training and supervision could be violating ethical standards

and potentially harming the persons they intended to serve.

Sex counseling and therapy were addressed early in the coun-

seling profession (Masters & Johnson, 1976; Schiller, 1976).

Kilpatrick (1980) summarized what counselors needed to know

about human sexuality. Fyfe (1980) introduced an early training

model for human sexuality counseling. The Association for

Counselor Education and Supervision (ACES, 1990) began to

collect and share sexuality course syllabi and audiovisual mate-

rials. Gray, House, and Eicken (1996) emphasized human sexu-

ality instruction for marriage and family counselor educators.

Humphrey (2000) advocated the study of sexuality counseling

in counselor preparation programs. Harris and Hays (2008) rec-

ommended sexuality education and supervision to help clinical

members of the American Association for Marriage and Family

Therapy discuss comfortably sexual issues with their clients.

Instruction and supervision is human sexuality has been

advocated for over 35 years. Most mental health professionals

lack specialized training and experience; therefore, they are not

adequately prepared to discuss these important life concerns

with their clients. Sexual concerns are common, but the clini-

cian’s lack of information and comfort may interfere with the

disclosure and healing process. Human sexuality should be

addressed in training programs for professional counselors.

Some mental health and marriage and family counselors may

pursue specialized training required to embrace the full range

of opportunities for facilitating sexual health in clients.

Listings or directories of qualified professionals can be

found through organizations such as the Society of Sex Ther-

apy and Research (SSTAR) or American Association of Sexu-

ality Educators, Counselors and Therapists (AASECT).

Sexuality Counseling as a Process

The process of sexuality counseling begins with listening care-

fully to each member of the couple. The attuned sexuality

counselor will facilitate the clients constructing their own story

about their sexual concerns: expressing dissatisfaction, dys-

function, or distress in their own words (see Doan, 2004). The

counselor starts the process of applying lenses from a multicon-

textual perspective (Carter, 1993; Carter & McGoldrick, 1999)

to identify resources and stressors from the individual to com-

munity level, including sociocultural, spiritual, and especially

developmental contexts. The counseling profession has always

valued the developmental perspective in which one looks

beyond present difficulties to possibilities for ongoing growth

and fulfillment. The initial process of joining with the couple

sets the stage for relational assessment and introduction of the

early stages of change.

Nonpatriarchal Assessment: No Hard or Fast Diagnoses

A relational approach sets the backdrop against which other

data may be gathered and evaluated. Flemons and Green

(2007) described the role of the curious observer who moves

among various roles, assessing and participating along the way.

They identified five relationships of particular importance in

the assessment.

1. The relationship between you and your clients.

2. The relationship between your clients.

3. The relationships between your clients and sexuality.

4. The relationship between you and your sexuality.

5. The relationships between your clients and their problems

(Flemons & Green, 2007, p. 130).

The relational approach to formulation reminds the counselor

of the centrality of relationship in sexuality while facilitating

the counselor’s examination of biases, assumptions, and expec-

tations in the intake process. Now the sexuality counselor is

ready to apply the New View.

The New View campaign for rejection of DSM diagnoses

(APA, 2000) and medicalization of women’s sexual concerns

resulted in a friendly, multicontextual framework for classify-

ing sexual problems. The classification framework confronted

the false notion that the sexual experiences of men and women

were basically equivalent. The framework rejected the human

sexual response cycle model of Masters and Johnson (1966,

1970) as the basis for diagnosis according to phase in the cycle.

Finally, the framework challenged the one-size-fits-all treat-

ment bias of medicalization. The working group countered the

focus on genital responses by emphasizing relational and socio-

cultural dimensions. (Nicholls, 2008; Tiefer, 2004).

The New View of Sexual Problems

I. Sexual problems due to sociocultural, political, or economic

factors. (20% of problems according to Nicholls, 2008) A. Ignorance and anxiety due to inadequate sex education,

lack of access to health services, or other social

constraints.

B. Sexual avoidance or distress due to perceived inability to

meet cultural norms regarding correct or ideal sexuality.

C. Inhibitions due to conflict between the sexual norms

of one’s subculture or culture of origin and those of the

dominant culture.

D. Lack of interest, fatigue, or lack of time due to family

or work obligations.

II. Sexual problems relating to partner or relationship (65% of problems).

A. Inhibition, avoidance, or distress arising from

betrayal, dislike, or fear of partner, partner’s abuse

252 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

or couple’s unequal power, or arising from partner’s

negative patterns of communication.

B. Discrepancies in desire for sexual activity or in pre-

ferences for various sexual activities.

C. Ignorance or inhibition about communicating prefer-

ences or initiating, pacing, or shaping sexual activities.

D. Loss of sexual interest and reciprocity as a result of

conflicts over commonplace issues such as money,

schedules, or relatives, or resulting from traumatic

experiences, for example, infertility or the death of a

child.

E. Inhibitions in arousal or spontaneity due to partner’s

health status or sexual.

III. Sexual problems due to psychological factors (8% of problems).

A. Sexual aversion, mistrust, or inhibition of sexual

pleasure due to past abuse, general personality

problems with attachment, rejection, cooperation,

or entitlement.

B. Sexual inhibition due to fear of sexual acts or of their

possible consequences, for example, pain during

intercourse, pregnancy, sexually transmitted disease,

loss of partner, loss of reputation.

IV. Sexual problems due to medical factors (7% of problems).

A. Numerous local or systemic medical conditions

affecting neurological, neurovascular, circulatory,

endocrine, or other systems of the body.

B. Pregnancy, sexually transmitted diseases, or other

sex-related conditions.

C. Side effects of many drugs, medications, or medical

treatments.

D. Iatrogenic conditions (Working Group on a New View

of Women’s Sexual Problems in Tiefer, 2004,

pp. 254–256; retrieved from http://newviewcampaign.

org/manifesto.asp).

The percentages of women’s problems according to the

accounts by women, analyzed by Nicholls (2008), reinforces

the primacy of relational issues in sexual concerns, highlights

the significance of sociocultural factors, and turns upside down

the conventional, patriarchal view of the importance of medical

and psychological contributing factors. Nevertheless, medical

evaluation and diagnosis retain a place in the assessment

process of sexuality counseling.

Traditional Approaches to Assessment and Diagnosis

Assessment and diagnosis of sexual problems frequently

begins by ruling out medical factors or clarifying health

problems and organic contributions. The sexuality counse-

lor should encourage a basic medical screening for clients.

However, the referral to another healthcare professional

should be made only after establishing an adequate rela-

tionship, providing permission and encouragement,

offering accurate information, and completing the multi-

contextual, relational assessment described in the previous

section.

Given the biopsychosocial nature of sexual disorders, an

individual or couple presenting sexual concerns should com-

plete a medical history and physical examination with a

physician or nurse practitioner. If indicated, relevant labora-

tory tests, such as hormonal profiles, can be completed.

Sexual dysfunction may be secondary to a known or undiag-

nosed medical condition and thus is becomes important to

investigate. Psychotropic medications or other medications

are used frequently by patients and the side effects of phar-

macotherapy may include sexual problems. Medication,

such as antidepressants, antipsychotics, and antihyperten-

sives, can cause sexual difficulties. Alcohol, cigarettes,

methadone, and nonprescription drugs, including antihista-

mines and topical vaginal medications, can also cause prob-

lems (Goodwach, 2005). Therefore, it is essential in

contemporary sex therapy practice to insure that patients

consult their family doctors or receive referral to physicians

early in the process. Frequently, it is possible for the sex

therapist and health provider to work collaboratively (South-

ern, 1999).

After health status has been determined and organic contri-

buting factors have been addressed, a comprehensive sex his-

tory should be completed. In their pioneering effort, Masters

and Johnson (1970) completed in-depth sex histories and inter-

views with both members of the ‘‘marital unit.’’ Assessment

culminated in a roundtable discussion before the implementa-

tion of an intervention tailored to the couple’s needs. Kaplan

(1983) also provided a framework for conducting a comprehen-

sive evaluation of sexual disorders, including clinical decision

trees or flow charts. The sexuality history should include the

following domains (see Carter & McGoldrick, 1999; Hertlein

& Weeks, 2009; Iasenza, 2004; Leiblum & Rosen, 1984;

Sternberg, 1986) addressed in individual, conjoint, and

roundtable formats.

1. Current sexual preferences, functioning, and satisfaction

for both partners.

2. Family of origin messages and sexual practices for the

families of both partners (possibly including a sexual

genogram).

3. Spiritual and cultural values for sexual activities (empha-

sizing embodiment and assessing shame).

4. Individual developmental history including childhood,

adolescence, and adulthood (creating safe conditions for

disclosure of abuse experiences).

5. Relationship history including major events (i.e.,

separation, onset of serious illness, pregnancies, and so

on).

6. Effects of contraception, pregnancy, illness, medication,

and the aging process.

7. Current sexual and relationship contexts regarding com-

mitment, intimacy, and passion,

Southern and Cade 253

After obtaining data about each partner’s sexual concerns, the

sexuality counselor integrates the individual presentations and

develops clinical hypotheses related to sociocultural, psycholo-

gical and relational factors in the emerging clinical portrait. In

addition, a thorough clinical assessment establishes the exper-

tise of the sexuality counselor; demystifies the sexual concerns

and reduces shameful avoidance; clarifies the particulars of the

presenting problem; and engenders hope and positive outcome

expectancies for ongoing movement through the stages of

change toward meaningful shared sexuality.

Types of Dysfunction

Although the New View (Tiefer, 1991) has contradicted the

human sexual response cycle identified initially by Masters and

Johnson (1966, 1970), it remains a central organizing construct

for understanding sexual activity, especially heterosexual inter-

course. The classic model for the sexual response cycle was

augmented by Kaplan (1974, 1979, 1983). Dysfunction accord-

ing to phase in sexual response cycle was embedded in the

Diagnostic and Statistical Manual (APA, 2000). Therefore, it

may be useful to understand the more traditional typology

while applying the New View corrections to its excesses and

potential abuses. Particular disorders for males and females

may exist in each of the phases of the sexual response cycle,

which consists of desire, arousal, orgasm, and resolution. Any

of these phase disorders can interfere with pursuit of intimate,

partner-oriented sexual expression. The following classifica-

tion system was derived from training at Masters and Johnson

Institute and the clinical practice perspective of Southern

(1999) and is intended as an aid to problem specification at the

individual level of assessment. Occasionally, there are comple-

mentary disorders presented by couples (e.g., rapid ejaculation

and anorgasmia or preorgasm). The types of dysfunction

depicted in Table 1 represent conditions specific to phases in

the sexual response cycle according to gender.

Goodwach (2005) offers three areas of criticism of the DSM

categories. First, the declassification of homosexuality as a sex-

ual disorder illustrated that diagnoses are not simply medically

based but are influenced by prevailing social mores. Secondly,

treatment based on DSM categories is problematic because

symptom removal in one partner does not necessarily translate

into sexual pleasure and satisfaction for both. And finally, this

nomenclature of sexual diagnoses has become a key contribu-

tor to reductionist thinking in the area of sexual difficulties,

because it does not reflect the complexity of sexuality, sexual

desire, or the intimate relationship.

The potential value of an outmoded, patriarchal, heterosexist

model for the human sexual response cycle (Masters & Johnson,

1966, 1970) and the diagnoses derived from it (e.g., American

Psychiatric Association, 2000; Southern, 1999) is its utility. Most

extant interventions follow differential diagnosis and various

treatments are associated with the particular diagnoses. Two pro-

minent references, Principles and Practice of Sex Therapy (Lei-

blum, 2007) and Systemic Sex Therapy (Hertlein, Weeks, &

Gambescia, 2009), are organized according to traditional

diagnosis of sexual disorder. Interventions were matched with

phase of disorder in a recent textbook, Sexuality Counseling:

An Integrative Approach (Long et al., 2006) for female sexuality

(pp. 101–102) and male sexuality (pp. 126–127). Specific Sug-

gestions and Intensive Therapy (from the PLISSIT model)

address specifically the aforementioned sexual disorders. How-

ever, an integrative model offers a framework for organizing the

ongoing clinical judgment process.

Scaffolding for Sexuality Counseling

Couples are prepared for sequential development of sexual

knowledge, skill, comfort, and meaning by exposure to sufficient

support afforded through the interventions of the sexuality coun-

selor. The framework provided by the counselor provides a tran-

sitional support for construction in process. Expert scaffolding

involves strategies and techniques that activate existing knowl-

edge, provide context and motivation, and introduce new subject

matter. Reviewing media, role playing, asking leading questions,

thinking aloud, and storytelling assist the couple to consider new

possibilities for their sexual relationship.

According to Vygotsky’s (1987) model for scaffolding, the

learner has a zone of proximal development, which is the differ-

ence between what the learner can do without help and what

can be done with help and collaboration. Our model for sexu-

ality counseling is based on the idea that the professional coun-

selor facilitates the sexual development of a couple by

introducing information and interventions that fit the current

zone or level, yet challenges them to move toward greater

self-direction, competence, flexibility, and meaning-making.

Selected interventions seem to fit initial, middle, and final

interventions in sequence (Table 2).

It is beyond the scope of even this lengthy review to describe

in detail the interventions or techniques; however, the afore-

mentioned framework provides direction for additional review.

Table 1. Types of Dysfunction by Sexual Response Cycle Phase

Type of Dysfunction

Phase Male Female

Desire Hypoactive sexual esire Hypoactive sexual desire

Sexual aversion Sexual aversion Sexual desire

discrepancy Sexual desire

discrepancy Sexual compulsion Sexual compulsion Paraphilia Paraphilia

Arousal Erectile dysfunction Sexual arousal disorder Orgasm Delayed ejaculation Anorgasmia/preorgasm

Rapid ejaculation Resolution Pain Pain

Sexual compulsion Sexual compulsion Sexual dissatisfaction Sexual dissatisfaction

Note: Common or typical presenting problems are highlighted in boldface. Pain may be encountered in several phases, depending upon etiology, although the conditions are reported typically during attempts at penetration or following penetration.

254 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

Techniques corresponding to three stages (precontemplation,

preparation, and action) are briefly described in the following

sections with an emphasis upon sensate focus as a core sexual-

ity counseling technique.

Bedtime Stories

The narrative approach to sexuality counseling has wide

applicability starting with the initial intake session, extending

throughout the middle or working stages, and concluding with

the couple’s optimal view of their satisfying sex life (see Doan,

2004). Initially, it is helpful to listen carefully to each member

of the couple as the story of the problem emerges. The extent to

which the couple moves toward a shared understanding of what

is changeworthy may be predictive of the course of counseling

or consultation. Ideally, they will co-construct a story, consist-

ing in a concrete image or vignette, of the problem. The sexu-

ality counselor should possess multicultural competencies and

willingness to join with the lived experiences of the client

couple. It is helpful to be familiar with actual accounts of sexual

experiences and their meanings. Sexuality counselors could be

prepared to receive and share in their clients’ stories by becoming

familiar with such works as Why Women Have Sex: Understand-

ing Sexual Motivations from Adventure and Revenge (and Every-

thing in Between) by Meston and Buss (2009).

A key component of narrative therapy involves externaliz-

ing the problem, in which a problem, formally assigned to a

member of the couple or perceived to exist inside a person, is

characterized as an intruder into the relationship (Doan,

2004; White & Epston, 1990). This permits the couple to col-

laborate in innovating a solution in which a new or preferred

story replaces an old, problematic story. Frequently, couples

use creativity and humor to banish the intruder from the bed-

room. The sexuality counselor helps the couple construct their

new story through careful questioning and understanding

responses with an open mind. Bedtime stories may be sufficient

to move the couple from precontemplation toward revolution-

ary action in which the relationship is transformed.

Sensate Focus: Out of the Head and Into the Bed

The cornerstone of sex therapy from Masters and Johnson Insti-

tute was the assertion that ‘‘Sex is a natural function’’ (Masters

& Johnson, 1970).The goal of direct sex therapy within the

Institute’s model involved removing roadblocks to the natural

expression of sexuality within an intimate relationship.

Although Schnarch (2000) warned that ‘‘first-generation’’

approaches, emphasizing the natural function of sex and the

blockage model of treatment, could lead to pathologizing and

stuckness in individual diagnosis, direct sex therapy

Table 2. Selected Interventions in Sexuality Counseling by Stage

Stage Global Intervention Specific Techniques

Precontemplation Permission to talk about sex Possibility/solution focused therapy approaches Encouragement Joining and empathy Narrative/storytelling approaches Empowerment Relaxation training

Contemplation Sex information/education Internet/media/virtual reality Psychoeducation

Normalizing, reframing Restraining change Paradoxical intention, dereflection

Deconstructing gender New View classification Prevalence and etiology Differential diagnosis

Preparation Sexuality assessment Sexuality history Multicontextual assessment Relationship assessment

Sexual genogram Skills training Courtship recommendations

Sensate focus Action Referral Medical history and physical

Medical intervention Examination Collaboration Medication adjustment

Hormonal therapy Medical/surgical intervention

Intensive therapy Couple therapy Cognitive/voices therapy Psychodynamic therapy

Maintenance Retention Relapse prevention Generalization Intimacy enhancement

Optimal sexual health Termination Celebration Ritual enactment

Follow-up Booster sessions

Southern and Cade 255

intervention is indicated for simple case presentations and to

catalyze issues for ‘‘second-generation’’ intimacy enhance-

ment. Similarly, Tiefer (2004) called into question the assertion

of sex as a natural function in her critique of biology in favor of

choice, turning the medicalization of sexual health on its head.

Sensate focus techniques are still used extensively in sex

therapy and self-help approaches. A recent review of sensate

focus (Weeks & Gambescia, 2009) brings the technique from

its biased, historical context into an enlightened, systemic

approach. They identified nine functions of sensate focus.

1. Help each partner become more aware of his or her own

sensations.

2. Focus on one’s needs for pleasure and worry less about the

problem or the partner.

3. Communicate sensual and sexual needs, wishes, and

desires.

4. Increase awareness of the partner’s sensual and sexual

needs.

5. Expand the repertoire of intimate, sensual behaviors.

6. Learn to appreciate foreplay as a goal start rather than a

means to an end.

7. Create positive relational experiences.

8. Build sexual desire.

9. Enhance the level of love, caring, commitment, intimacy,

cooperation, and sexual interest in the relationship (Weeks

& Gambescia, 2009, pp. 348–353).

These functions shift client perceptions from immediate gains

in sensual experiences toward what is possible in an intimate

relationship.

The shift in perception or focus affords a corresponding

shift from first-order toward more meaningful second-order

change, a characteristic of successful systemic interventions (see

Watzlawick, Weakland, & Fisch, 1974). Second-order change

takes into account the views and biases of the counselor–observer,

whose participation in the process transforms the shared

relationship.

First-order change refers to change within the normal defi-

nitions, understandings, premises, rules, and practices of a

given system . . . . Second-order change is a change of the

premises, definitions, practices, and traditions of a given

system of relationships. It most often represents a counterin-

tuitive stepping out or a reversal of the commonly held ideas

on the nature of the situation and its logical and reasonable

solutions. It has been described as paradoxical or ironic

(Fraser & Solovey, 2004, pp. 194–196).

Sensate focus starts in the body and arrives in the context of the

relationship.

The Masters and Johnson (1970) model for sex therapy

involved intensive treatment of couples experiencing sexual

dysfunction. The treatment would be offered daily over a

10–14-day period by a dual-gender, co-therapy team. Daily

continuity of treatment facilitated removal from environmental

distractions, recovery of courtship experience, and realization

of incremental gains. Over the years, the treatment model was

adapted to include ‘‘weekend intensives’’ and weekly outpati-

ent visits. However, the efficacy of some of the techniques

could decrease with changes in the original format (Masters

& Johnson, 1970; Schwartz & Masters, 1988).

Although the Masters and Johnson Institute model pre-

scribed specific homework exercises for particular types of

sexual dysfunction, there were several common interventions.

Through the authoritative pronouncement (Masters & Johnson,

1970, pp. 287–290), the couple is asked to refrain from sexual

outlet during the initial touching exercises. Shifting the focus

away from the demands of sexual performance enables the cou-

ple to engage in intimate conversation and courtship. Another

common intervention involves the roundtable (Masters &

Johnson, 1970, pp. 57–78) in which the results of assessment

can be discussed while sex education is initiated. A central

component of intensive sex therapy involves the famous sen-

sate focus exercises (Masters & Johnson, 1970, pp. 66–85).

Sensate focus encourages concentration on the here-and-

now sensations involved in intimate, nonsexual contact.

Initially, each member of the couple engages in ‘‘selfish touch-

ing,’’ in which touch is guided by one’s genuine interests rather

than trying to produce a response from one’s partner. If the

partner feels any discomfort or wishes to redirect the one doing

the touching, then that individual places her or his hand on top

of the partner’s hand. This practice, like other techniques in the

Masters and Johnson model, establishes the foundation for sex-

ual self-responsibility. Components of the sensate focus home-

work address such roadblocks as sexual withdrawal and

performance pressure. In this manner, the dissatisfied or dys-

functional individual becomes a participant in ongoing sexual

intimacy, rather than an anxious observer or a dehumanized sex

object.

Sensate focus and nondemand pleasuring encourage sexual

sharing within the context of intimacy. Sexual self-

responsibility contributes to assertion and active involvement

rather than spectatoring (e.g., attempting to observe one’s sex-

ual performance) or passive frustration. Each partner is treated

as the expert of one’s own body. Predictable gender differences

establish that no man will ever understand fully a woman’s

sexuality and no woman can appreciate all the connotations

of a man’s sexual experiences. Some couples may share a

heightened awareness or empathy; however, each member of

an intimate couple is first an autonomous and unique

individual.

The sensate focus homework exercises involve sensual

touching in the privacy of one’s home. Three exercises are typi-

cally completed: breasts and genitals off limits, breasts and

genitals on limits, and full body touching with opportunity for

sexual outlet through self-guided manual stimulation. When

the sensate focus exercises have been completed, the couple

is ready to address particular types of sexual dysfunction or

dissatisfaction through specific techniques. Another technique

that fits the action stage of change involves a psychodynamic

approach called voice therapy.

256 The Family Journal: Counseling and Therapy for Couples and Families 19(3)

Quieting the Voices

Some couples will require in-depth therapy addressing family

of origin issues and current couple conflicts in order to free the

sexual relationship from the pain and shame of the past. Family

of origin issues can be addressed productively in ongoing rela-

tional and individual sessions. Therapy can help the growing

individuals neutralize or counteract the inner voices that inhibit

sexual expression (Firestone et al., 2006). As Schnarch (2000)

demonstrated, sexual desire disorders, especially desire discre-

pancies, function to set limits on the capacity for genuine inti-

macy, given the current levels of differentiation and abilities to

self-soothe.

There are a number of factors, both static and dynamic, that

can contribute to intimacy dysfunction. For some clients,

trauma, especially physical and sexual abuse interferes with

intimacy and sexual functioning. Sex-negative environments

and family-of-origin messages about sex can also influence

sexual functioning and intimacy. According to Weeks (2005):

Some families are silent on the issue of sexuality. Children in

these families sometimes internalize this silence as meaning

that something is bad or wrong with sexuality. The parents do

not help them make sense of relationships or sexuality as they

mature and particularly as they become adolescents and strug-

gle with biological and emotional changes. Other families are

more toxic in the messages they transmit to their children

through their actions and words (pp. 94–95).

Messages received in childhood are internalized and can be

repeated throughout adulthood. Weeks (2005) provides two

examples family of origin messages. The first example is of

women saying their mothers told them that sex was just some-

thing that a woman had to grin and bear because it was her

duty to her husband. Another example is of a sexual lesson

passed from father to son. A man presented with an ED just

a few days after his 40th birthday. His father had made some

reference to the fact that when a man reaches 40 he loses’’it.’’

Family-of-origin messages can also stifle natural expression of

sexual exploration and curiosity. Such expressions have been

associated with punishment or ridicule leaving feelings of

shame and guilt.

Contemporary psychodynamic approaches (e.g., Althof,

1999, 2000; McDougall, 1995; Scharff, 1982; Southern,

2002) recognize the self-defeating and sadomasochistic origins

of many sexual symptoms. The sexual problems fail to

remit and the patients resist change because the symptoms are

overdetermined (i.e., have several remote and recent functions)

and frequently represent best efforts to reenact unfinished

business through the mechanism of repetition compulsion.

According to the psychodynamic perspective, meaningful

change comes slowly after examining patterns of behaviors,

meanings associated with the symptoms, and resistances to

complete homework, such as failing to complete a touching

exercise.

According to Schnarch’s (1991) sexual crucible approach,

based on Bowen’s (1978) model of family systemic

functioning, neither partner will be able to sustain true intimacy

and mutuality until each person differentiates or grows toward

a more resilient sense of self. The sexual crucible helps a cou-

ple mature during a brief, intense exposure to anxieties about

their relationship. By balancing the desire for communion with

another person and the desire to become autonomous, partners

are able to participate in a sexual relationship based on fulfill-

ment rather than a false love based on fear of emptiness.

Firestone et al. (2006) developed a powerful voice therapy

that combines psychodynamic insights with practical cogni-

tive interventions. They articulated a series of questions and

accusations that help to unearth or reveal the unhealthy

messages arising from dysfunctions in the family of origin.

Inner ‘‘voices’’ before, during, and after sex interfere with

sexual functioning and satisfaction (Firestone et al., 2006,

pp. 229–262).

Why would he want to be in a relationship with you?

She is trying to control me.

Your penis is too small.

Your breasts are not like other women’s.

Don’t have oral sex, he’ll be repulsed.

You won’t be able to satisfy her.

He’ll think you are a slut.

You’re hurting her.

She’s too needy.

He’s unreliable.

You always give in; you have no dignity.

How do you know she had an orgasm?

These inner voices can be quieted by confronting and disputing

them in the safe haven or holding environment of the therapy

session.

1. Each partner formulates the problem that he or she believes

is limiting the sexual relationship.

2. Partners give voice to self-critical and negative partner

perceptions.

3. They must contain (typically with the help of a therapist)

the anger or sadness associated with verbalizing the inner

voice.

4. Now the couple is free to explore the origins of negative

cognitions, correcting early mistakes and distorted beliefs.

5. They plan together ways to change behaviors and commu-

nications in order to counteract the old dictates of their

voices and to move toward mutually acceptable goals.

6. They may change contexts and circumstances associated

with maintaining the voices.

7. The couple can expect some strong ‘‘voice attacks’’ as they

move toward sexual fulfillment (Firestone et al., 2006,

pp. 235–237).

Intensive depth-oriented therapies are reserved for cases in

which permission and encouragement, sex information, and

specific suggestions (including the sensate focus exercises) fail

to catalyze the sexual growth process. Intensive psychotherapy

Southern and Cade 257

can be helpful in removing roadblocks that will not budge.

Repeated attempts to use rational problem solving or brief stra-

tegic interventions may be insufficient to help, leading to a

greater sense of hopeless, resignation, and withdrawal.

Removing the Roadblocks: On the Road to Optimal Sexual Health

Sexuality counseling techniques can be used not only to

remove roadblocks linked to specific sexual disorders but also

to strengthen intimacy in committed relationships. After a

shared definition of the problem has been established, the cou-

ple can move away from blame, shame, and guilt and move

toward their goals in sexuality counseling. Couples may choose

to expand sexual scripts or schemas to tolerate change and

embrace innovation in their sexual functioning. Play, including

leisure, loving play, and sexual play can be introduced or rees-

tablished between partners. The ability to express desires and to

explore sexual fantasies and preferences may be part of the

treatment process. Goals can also include time management

and an increase in intimate partner time, challenging family

of origin messages, or making specific behavioral changes in

sexual behavior.

It is possible to identify some aspirations for the life beha-

viors of a sexually healthy adult. The following list was com-

piled by the Sexuality Information and Education Council of

the United States (SIECUS, n.d.).

� Appreciate one’s own body. � Affirms that sexual development may or may not include

reproduction or genital sexual experience.

� Interact with both genders in respectful and appropriate ways.

� Affirm one’s own sexual orientation and respect the sexual orientation of others.

� Express love and intimacy in appropriate ways. � Develop and maintain meaningful relationships. � Avoid exploitative and manipulative relationships. � Make informed choices about family options and lifestyles. � Exhibit skills that enhance personal relationships. � Discriminate between life enhancing sexual behaviors and

those that are harmful to self and/or others.

� Express one’s sexuality while respecting the sexual rights of others.

� Express one’s sexuality in ways congruent with one’s values.

This list of sexually healthy life behaviors affords direction for

the emerging professional specialization of sexuality

counseling.

This overview of sexuality counseling places the specializa-

tion in a historical content and between two competing para-

digms. The original thesis of classic models of sex therapy

converged on a contemporary patriarchal paradigm called med-

icalization. The antithesis of this patriarchal view, in which

male sexual functioning was emphasized, is the New View, a

feminist model reclaiming the centrality of relational and

sociocultural factors in sexual satisfaction. An integrative

sexual health perspective affords the synthesis upon which

the emerging specialization of sexuality counseling may con-

tinue to grow and flourish.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship,

and/or publication of this article.

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