What is Sexual Dysfunction, and How Does it Differ from Occasional Sexual Difficulty?
Occasional sexual difficulties are universal and most people will experience them temporarily and intermittently in the course of their normal sexual lives. These include: lack of sexual interest or desire; problems with erection or arousal; rapid, delayed or absent orgasm; and sexual pain. If these occur every now and then, they are usually the result of a situational problem, like consuming too much alcohol. Most people shake them off with little problem.
Sexual dysfunctions, on the other hand, are longer lasting, occur more often, and result in much more emotional and relationship distress. They meet specific criteria as described in the recently published DSM-5 (2015) that include occurring 75–100% of the time and having a duration of at least six months.
What Are the Causes of Sexual Dysfunctions?
Sexual dysfunctions can be caused by a number of factors. Although we will be emphasizing the psychosocial, it is important to consider the biomedical variables at the beginning of the therapy evaluation. Masters and Johnson emphasized the psychological, relationship, lifestyle, and cultural nature of what they believed to be the cause of the majority of sexual dysfunctions. However, they also said, “There is never any excuse for treating a physiological dysfunction as a psychological inadequacy” (Masters & Johnson, 1970, p. 53). It is extremely important, while identifying the factors that contribute to sexual dysfunctions, not to fall victim to either/or thinking. Both/and analysis is critical. Sometimes, as therapy and Sensate Focus progress, a sexual dysfunction that at first seemed to be caused by something medical (e.g., erection difficulty associated with a spinal cord injury) begins to improve. The body responds to Sensate Focus in spite of the medical problem as underlying psychological, relationship, and other sociocultural factors are addressed.
Sometimes it is not possible to identify the main issues involved in a sexual dysfunction during the early phases of assessment. It is important to keep an open mind, reminding clients that Sensate Focus is not only helpful for treating the sexual problem but also for determining what is contributing to or maintaining it. As Sensate Focus continues, factors that were not apparent at the beginning become more obvious.
Sometimes a reported sexual dysfunction is not the problem in need of treatment. For example, erection disorders may actually hide a problem with rapid ejaculation. Sometimes the presenting sexual dysfunction is not a dysfunction at all. A couple may bemoan a desire disorder when the partners are actually experiencing differences in their preferences for the frequency of sexual activity, neither of which falls under clinically diagnosable conditions.
Here are five of the most important areas to consider when looking at sexual dysfunctions.
Since the concept of sex as a natural function points to the importance of underlying biomedical processes, it is logical to initiate assessment by looking for biomedical factors. These may include any condition or medication that affects endocrine (hormonal), cardiovascular (blood flow) or neurological (nerve conduction) functioning in the pelvic region. These conditions may be the result of: chronic illnesses (e.g., diabetes, hypothyroidism); prescribed, non-prescribed medications or “street” drugs; and/or medical interventions (e.g., radiation or prostate surgery).
Individual issues include the client’s overall psychological functioning (e.g., anxiety, mood disorders, trauma) as well as negative views of self, body, or sex. It is important to take a look at the client’s distracting thoughts and feelings, especially those having to do with the sexual concern. Examining the client’s sexual experience, techniques, preferences, awareness of these preferences, and knowledge about sexuality in general is also important. Historical issues include childhood neglect or abuse, and differing attachment styles (such as anxious or avoidant patterns).
Partner and Relationship Factors
It is always important to consider the partner’s possible impact when looking at clients’ sexual dysfunctions. These include the partner’s illnesses, sexual dysfunctions, performance expectations, and responses to the sexual problems. Evaluating the partners’ psychological functioning, and the partner’s willingness to participate in therapy is vital. Understanding the partner’s subjective experiences of his or her own sexual and relationship history, and the meaning placed on the presenting sexual dysfunctions, are also imperative.
Relationship distress may add to sexual dysfunctions. Conversely, relationship problems can be the result of sexual dysfunctions. Feelings of rejection, frustration, and inadequacy can lead to less positive feelings about partners, less frequent shows of affection, unhelpful or absent communication, and less quality time spent together. All of these may contribute to lowered satisfaction with intimacy in general and sexual intimacy in particular. Dealing with communication problems, power struggles, and unresolved conflicts and resentments in the relationship may not resolve the sexual concerns. However, failure to deal with them certainly won’t resolve the sexual concerns. Addressing relationship issues is essential for laying the foundation for working on the sexual dysfunction.
A topic that is sometimes overlooked in the evaluation of sexual dysfunctions is the effect of other demands on the individual’s or couple’s time. What are the professional or job responsibilities? How stressful are these? What about the impact of children, relatives, and others? Is involvement with parents an issue? The main purpose of looking at these is to clarify the amount and quality of time the partners have to devote to themselves and to their relationship. Other stressors may include: job or personal losses; lack of exercise; overeating; and habits that contribute negatively to the client’s overall physical and psychological health.
It is essential to review the effect that family of origin, social, and religious factors have on sexual functioning. Although most clinicians assess the impact of these variables on women in terms of their constraining effects, and on men in terms of their pressuring effects, it is so important not to presume that the opposites aren’t also significant factors. Taking a look at the extent and nature of the sexual values, scripts, and misinformation affecting each partner is necessary.
All of this suggests that there are a number of factors contributing to a sexual dysfunction including a new area of interest – environmental toxins (Reddy, 2016). However, the exact causes may be unclear even by the end of the evaluation. Interestingly enough and quite often, clients progress regardless of whether all the original etiological factors have been identified. Sometimes the clinician needs to initiate therapy to determine what is actually causing the problem. As noted, Sensate Focus is useful for teasing out these variables.
An example of this might be the low desire client who reports no obvious causes of the sudden loss of interest. Even the results of the medical evaluation may be negative. It is often helpful to begin Sensate Focus to identify the contributing causes of the dysfunction. Usually by the time the couple has moved to Sensate Focus with breasts, chests, and genitals on limits (described later on), the most significant individual and couple issues contributing to the sexual dysfunction become apparent.
Another example is when a woman who reports taking a medication for anxiety due to stress at work has her first reported difficulty with orgasm. The partner responds in a strong, negative way. This only adds to the woman’s orgasmic concerns when the couple approaches the next sexual encounter. Then the woman has more difficulty being orgasmic. It is not too long before this pattern is established. What might have begun as a stressful work and medication-related difficulty becomes a much larger, psychological and relationship problem leading to dysfunction.
How Are Sexual Dysfunctions Evaluated and Treated?
Sex therapy begins with a thorough assessment of these medical, psychological, relational, cultural, and lifestyle factors that might impact sexual functioning. Here are some ways to do this.
A thorough medical examination by a primary physician or a sexual medicine specialist (e.g., endocrinologist, pelvic floor specialist, trained gynecologist or urologist) is often recommended to add to the interview process and treatment itself. Understanding the interaction between medical and psychosocial factors requires looking at medicines, hormones, and health issues in addition to doing therapy. Although we are leaving an analysis of biomedical factors in sexual dysfunctions to other sexological experts, we do not want to ignore the need for their assessment as part of a thorough evaluation and treatment program.
Most sex therapy evaluations begin with, and are devoted primarily to, taking a formal, detailed, self- and partner-report history (Althof, Rubio-Aurioles, & Perelman, 2012). Appendix A is a sample sexual history interview form that may be helpful. If the clinician is following Masters and Johnson’s original protocol, the evaluation usually begins with both partners being seen together to review past and present therapy and current therapy goals. It includes examining the relationship dynamics, individual strengths, and motivation of both partners.
The initial couple’s session is followed by the individual psychosocial evaluation, referred to as history-taking. This involves between one and three sessions for each partner. Additional history-taking sessions can be included as needed.
The focus during the history-taking is on individual psychological concerns such as identifying anxiety, depression, psychosis, substance abuse, trauma, and beliefs about any physical challenges. These problems make short-term therapy difficult and may indicate the need for medications or other types of treatments. Other important issues include attachment styles, family of origin, relationship and sexual history, and the partners’ perceptions of one another and of the presenting problem(s). The history-taking
is structured to develop material within a chronologic framework of life-cycle influences, which reflects sexually oriented attitudes and feelings, expectations and experiences, environmental changes and practices. History-taking certainly must provide information sufficient to define the character (etiological background, symptom onset, severity and duration, psychosocial affect) of the presenting sexual dysfunctions. Equally important, history-taking contributes knowledge of the basic personalities of the … partners and develops a professional concept of their interpersonal relationship adequate to determining (1) changes that may be considered desirable, (2) personal resources and the depth and health of the psychosocial potential from which they can be drawn, and (3) [relationship]-unit motivation and goals (what the … partners actually expect from therapy).
(Masters & Johnson, 1970, p. 24)
The most important aspect of the individual history-taking is what is referred to as phenomenological evaluation, or what Masters and Johnson referred to as an assessment of the clients’ sexual value system. It is important for clinicians to understand how clients actually experience within themselves and within their psychosocial situation whatever they are describing. They need to understand how clients subjectively experience their sexuality, dysfunction, sexual relationship, and sexual background. What does the problem mean to them? What value do they put on the problem? How do they feel about it? What emotions are triggered by the problem? What thoughts do they have about it? The emphasis is not so much on what actually or “factually” has happened or is happening outside of themselves. It is not about passing judgment on the experience as good or bad, right or wrong. The emphasis is, quite simply, on how whatever happened or is happening comes across to each client, how the client takes in and processes the experiences. An understanding of this sexual value system is critical for making sure that the treatment is sensitive to each client’s core sexual values and experiences.
The most helpful attitude clinicians may adopt during the individual history-taking is one of treating “the individual as a whole person … When taken out of context of the total being and his environment, a ‘sex’ history per se would be as relatively meaningless as a ‘heart’ history or a ‘stomach’ history” (Masters & Johnson, 1970, p. 23). Out of the psychosocial sexual history emerges each client’s sexual value system, “derived from sensory experiences individually invested with erotic meaning” and “reinforced by years of psychosocial adaptation” (Masters & Johnson, 1970, pp. 24–25).
Some clinicians add intake surveys to this formal history. To gather information on female desire, arousal, and orgasm dysfunctions, Cynthia Graham (Graham, 2010) and Lori Brotto and her research team (Brotto et al., 2010) suggest using the following inventories: Golombok-Rust Inventory of Sexual Satisfaction (GRISS); Brief Index of Sexual Functioning for Women (BISF-W); Sexual Desire Inventory (SDI); Derogatis Interview for Sexual Functioning (DISF); Female Sexual Function Index (FSFI); Sexual Function Questionnaire (SFQ); Female Sexual Distress Scale (FSDS); Sexual Interest and Desire Inventory (SIDI); Hypoactive Sexual Desire Disorder (HSDD) Screener; Female Sexual Distress Scale-Revised (FSDS-R); and Women’s Sexual Interest Diagnostic Interview (WSID).
Collecting information on sexual desire, erectile dysfunction, and orgasmic concerns in men, including hidden variables, can be simplified by using the International Index of Erectile Function (IIEF) and the Male Sexual Health Questionnaire (MSHQ) as well as the GRISS and FSFI (Meana & Steiner, 2014; Perelman, 2014; Rosen, Miner, & Wincze, 2010).
Once the history-taking and inventory use have been completed, clients are invited to a roundtable session. There are three main aspects to the roundtable.
During the roundtable session, therapists share their understanding of the etiological and maintenance factors contributing to their sexual and relational difficulties, and suggest the treatment plan for these concerns. This is done together with the clients’ feedback as the planning and implementation of sex therapy and Sensate Focus is always an ongoing and joint effort between participants and therapists.
Although understanding the couple’s full individual and relationship history and current concerns underscored their work, the focus of Masters and Johnson’s original, intensive Sensate Focus approach emphasized only those factors that had immediate impact on the sexual problem. The goal of sex therapy and Sensate Focus is to do as much but no more than necessary to resolve the concern.
As a result of the history-taking sessions and other evaluative techniques, therapists and clients work together to create the therapeutic format. Here are some questions to consider:
Will Sensate Focus be Used Together With, Before, or After Medical Treatment?
Many clients seek out medical interventions such as medications, surgeries, physical therapy, and other medical resources before seeing a sex therapist. They come to therapy when these solutions have not worked or when partners come to agreement that they prefer non-medical interventions first, or in combination with medications. As sex therapists, we believe in listening to the client’s values while advising them of their options. We believe in utilizing a collaborative approach that involves medical intervention along with sex therapy in most cases.
Will Therapy be Short Term and Intensive or Longer Term and More In-Depth?
Short-term, intensive therapy (for example, having therapy sessions more than one time a week) works best if clients have a difficult time carving out time for their relationship at home, if one or both partners travel a lot for work, if the relationship is in severe crisis, or if they live some distance from the therapist’s office. The advantage of the short-term, intensive approach is that results are usually experienced more quickly. However, longer-term, weekly, or bi-weekly treatment is more practical for most clients and clinicians. The advantage of the less frequent, longer-term program is that the skills learned in therapy are already being worked into the clients’ regular lives while they are engaged in sex and relationship therapy. Intensive, short-term treatment usually has to be combined with a re-entry period during which clients have to address working their skills into their daily routines. However, this can usually be handled with later booster sessions when the clients revisit skills learned during the intensive treatment program.
Will Therapy Include One or Both Partners?
“Treatment is sometimes divided into two phases: treatment when there is no partner and later resumption of treatment when [clients] establish a new relationship” (Althof, 2014, p. 125). Individual sex therapy and Sensate Focus is appropriate when there is no partner or when the partner is either unwilling or unable to come to the therapist’s office. It can also help when there is an element of the sexual dysfunction that is best suited to individual intervention (e.g., in the case of Vaginismus where self-Sensate Focus and initial insertion of dilators may best be handled individually).
In general, it is difficult to use Sensate Focus effectively unless both partners participate in therapy at least at some point. Obviously, it is impossible to use the Sensate Focus couples techniques without having both partners. However, perhaps the most important reason to consider including both partners in sex therapy and Sensate Focus has to do with Masters and Johnson’s revolutionary treatment idea that it is not so much either partner that represents the client in therapy as it is the relationship that is the client. Regardless of which partner presents as the identified client, both are affected by the sexual difficulty and each is critical to resolving it.
Some clinicians have suggested that Masters and Johnson focused on the symptomatic partner rather than on the couple’s relationship. This is difficult to understand in light of their description of sex therapy and Sensate Focus. In fact, they stressed that failure to include both partners is to ignore “half the problem” (Masters & Johnson, 1970, p. 3).
There is no such thing as an uninvolved partner in any [relationship] in which there is some form of sexual inadequacy … Isolating [either of the partners] in therapy from his or her partner not only denies the concept that both partners are involved in the sexual inadequacy with which their … relationship is contending, but also ignores the fundamental fact that sexual response represents (either symbolically or in reality) interaction between people.
(Masters & Johnson, 1970, p. 2)
Do One or Both Partners Need Individual Therapy for Another Issue Before or During Sex Therapy?
Sometimes one or both partners may come to therapy with significant sexual or psychological issues that require individual sessions or separate individual therapy either before or during the implementation of sex therapy and Sensate Focus. This is most appropriate when one or both partners experience a serious problem that might interfere with Sensate Focus if it is not addressed. These conditions include clinical depression, bipolar disorder, psychosis, substance abuse, severe personality disorders, and/or a history of trauma or neglect, among others. Individual therapy may be recommended for partners who are in chaotic or toxic relationships.
However, Sensate Focus itself is such a powerful diagnostic and therapeutic technique that its very implementation may not only reveal psychological concerns of which clients may be unaware but also may have a stabilizing and progressive effect on the issues the individual and couple are experiencing. This means that not everything has to be entirely copasetic with either the individual partners or with the relationship before Sensate Focus is initiated. Sensate Focus may even serve as a useful technique for helping individuals and couples with non-sexual problems.
Should Clients Engage in Relationship Therapy?
Couples often ask whether or not they should have separate conjoint or relationship therapy before or during sex therapy. Even within the field, there is contention about the juxtaposition of relationship and sex therapy. In fact, sex therapy actually is, to a large extent, couples therapy. We are aware of the interactional nature of sexual and relationship issues. Whether the presenting problem began with relationship or sexual problems, both aspects of the couple’s interaction are inevitably involved. In addition, many clients come to sex therapists after a successful couples therapy experience that has improved the relationship but not solved the sexual problem.
Will a Dual-Sex Therapist Team Be Involved or One Therapist?
Masters and Johnson famously invented the use of dual-sex therapy teams. However, this practice has fallen out of favor for a variety of reasons. Dual therapist teams may often help tremendously with sex therapy and Sensate Focus particularly if one or both partners have a preference for this approach or have a history that requires the development of a particularly strong transference with a same- or opposite-sex therapist. However, in most outpatient settings, a dual therapy team may not be available or practical. In our experience, if clients are encouraged to verbalize any discomfort or bias they experience with the single therapist approach, the Sensate Focus process usually moves along smoothly with only one clinician involved.
Important Attitudes and Skills
Once the format has been determined, several crucial attitudes are often introduced in this roundtable meeting. Without these, it is difficult to move forward in the initial phase of sex therapy and Sensate Focus.
The first of these attitudes is a clinical, neutral, Gestalt-like, mindful here-and-now approach both inside and outside the bedroom. This focuses on the present and as little as possible on the past (“This never worked before!”) or future (“Will this work?”). The reason for this? Simple: No one can do anything about what has happened in the past or is going to happen in the future. The focus is on what can be in the now.
The other critical attitude introduced during the roundtable session is radical self-responsibility. It is identical to the attitude suggested by the Dalai Lama: “Do not let the behavior of others destroy your inner peace.” This reinforces the idea that no matter what is going on with the partner, clients are responsible for managing their responses and following through with the suggestions. “Gradually, the partners comprehend their role in creating barriers to intimacy rather than focusing on a symptomatic partner” (Weeks & Gambescia, 2009, p. 342). It also helps clients to focus on their own experience of the touch rather than on what they think is going on with the partner. Too often clients, like all of us human beings, are likely to focus on what the other person is doing or not doing. In the case of Sensate Focus, this results in not following through with the touching sessions “because my partner didn’t initiate when it was her turn,” “because my partner didn’t seem to be in the mood,” “because my partner didn’t move my hand away,” “because my partner didn’t seem to be focusing on sensations,” or “because my partner said he wanted to do something else during the session.” Not only does an attitude of radical self-responsibility diffuse projections of blame and get around unproductive interactions between the partners, but it also helps clients focus on that over which they have control (their own thoughts and behavior) and reinforces the first attitude above of here-and-now mindfulness.
Other Self-Management and Relationship Skills
In addition to the introduction of mindful and self-responsible attitudes, other self-management and relationship skills may be offered as needed. These include: communication skills; identifying, accepting, and managing feelings; negotiating differences; creative problem-solving; quality couple time; and using the partner as a resource. These are necessary to create, revive, and/or sustain a secure relational environment conducive to change.
The most important feature of the roundtable session for the purposes of this manual is the introduction of Sensate Focus 1. This is the subject of the next chapter. Not only is this the therapeutic centerpiece and primary modality through which sexual difficulties are more fully understood and addressed, it is also one of the aspects of the Masters and Johnson approach that has most influenced the field of sex therapy. It is a powerful way to move the didactic information offered during the therapy session out of the office and into the experiential context of the couple’s bedroom. This, after all, is the purpose of sex therapy.