Sensate Focus in Sex Therapy

Male HSDD is a new category in DSM-5. It is diagnosed when a man regularly and over time does not experience sexual or arousing thoughts or fantasies and has a lack of desire for sexual activity. Men diagnosed with HSDD may not initiate sexual activity or are generally unreceptive to partner initiation. Masturbation and sexual activity with a partner may take place but only infrequently. Merely having low sexual desire does not suffice for a diagnosis of HSDD because, as with other sexual dysfunctions in the DSM-5, the lack of fantasy/interest must cause distress to one or both partners. The diagnosis must be made in consideration of the man’s age and sociocultural background. It does not simply reflect a difference in level of interest between the man and his partner. This difference in level of interest is more accurately described as desire discrepancy. As with other dysfunctions, the problem must persist or be intermittent for six months. A man with a lifelong lack of fantasy and interest but who also identifies as asexual would not be given this diagnosis.

Until recently, Male HSSD was considered rare and few men presented with it for sex therapy. But now studies suggest that this diagnosis occurs in approximately 15–25% of the male population across the lifespan and is particularly common in older men. As many as 41% of men aged 66–74 years experience HSDD. Besides age, the other factors that must be considered when working with HSDD are general health, the difference between sexual interest and sexual desire, the degree to which the individual or partner experiences distress in response to the level of desire, and the duration of the problem. Perhaps reflecting cultural or religious factors such as inhibitions and prohibitions against sexual activity, the DSM-5 reports that while 12.5% of men of Northern European descent report low desire, 28% of men 40–80 years of age, of Southeast Asian descent, report it.

Cases of HSDD usually fall into one of four categories:

(1)HSDD with significant biomedical involvement;

(2)HSDD without biomedical involvement;

(3)lack of desire for sex with a current partner – sexual desire is being fulfilled otherwise; and

(4)lack of desire for sex with a current partner – sexual desire is being suppressed.

(Meana & Steiner, 2014, p. 49)

There is another source of HSDD that is often overlooked and to which Meana and Steiner (2014) refer as the “hidden” contributors. These include a past history of erection concerns about which the HSDD client may not be entirely aware, or may be unwilling to share early in the Sensate Focus process. Additionally, it is important to assess the role of a history of ejaculatory problems (either early or delayed). Clients may have developed a protective, secondary, and presenting complaint of lack of desire. This is often associated with repression of sexual fantasy in response to, and as a deflection away from, these earlier sexual difficulties about which the client may be uncomfortable. When clients are uncomfortable discussing the erectile or ejaculatory history hidden behind the HSDD, sometimes an individual assessment session, as opposed to a conjoint session, may help tease this out. Alternatively, sometimes when clients are uncomfortable discussing their erectile or ejaculatory history underlying the HSDD, the opposite is true: a conjoint history-taking session or a history-taking session with the other partner alone, may be much more helpful as the partner is more likely to provide accurate information about this hidden contributor. This is an example of why taking both an individual history as well as the history of the partner is so critical. It is important for sex therapists to be aware of these potentially hidden factors during both the sex history and also during the processing of Sensate Focus sessions. As noted, Sensate Focus itself can be a powerful diagnostic procedure, revealing underlying contributors to sexual difficulties that clients are unprepared to reveal during the sex history.

In order to accurately assess these four, the clinician must take a detailed history of the client’s medical situation, including the medications he is taking, alcohol use or abuse, and the use of illicit drugs. Medical conditions that involve the kidneys, cardiovascular system, central nervous system, and a history of cancer must be evaluated. Most important, however, is a consideration of the endocrine system, especially whether there is a presence of hypogonadism, hyperprolactinemia, thyroid disorders, and diabetes. All of these conditions may affect the level of testosterone in the blood stream that, in turn, may affect the level of a man’s desire. However, except in cases of hypogonadal disorder, the role of testosterone in male desire is not entirely clear: “There … may be a critical threshold below which testosterone will affect sexual desire in men and above which there is little effect of testosterone on men’s desire” (DSM-5) (American Psychiatric Association, 2015, p. 442).

In our experience, most of the other factors associated with Male HSDD do not easily fit in the formal DSM-5 criteria for diagnosis. Among the most important are partner and relationship factors. These include the build-up of anger and resentment over: perceived partner criticism; power struggles; partner’s sexual issues; and partner’s health limitations, among other issues. These also include determining whether the HSDD client is fulfilling needs for sexual release by means other than those involving his partner. This may include masturbation, pornography, extra-relationship affairs, or alternative sexual interests. Additionally, assessing the partner’s attraction for the HSDD client is critical. However, when the HSDD client attributes his dysfunction to factors such as “My partner has gained weight,” it is important for the clinician to consider the possibility that this is not the primary issue. Instead, it may be a more culturally acceptable way for the client to explain his lack of interest.

The HSDD client must also be evaluated for individual psychological factors such as depression, anxiety, childhood neglect, or emotional or sexual trauma. These men have a higher incidence of depression and anxiety. They may also be experiencing reactions to changes in sexual responsiveness due to age or resulting from medical procedures such as prostate surgery.

Environmental stressors impacting the HSDD client, as well as his partner, may include job loss, family concerns, bereavement, or workaholism. Cultural or religious factors such as inhibitions and prohibitions against sexual activity need to be examined. Men with HSDD often come from backgrounds where emphasis was placed on both emotional restraint and also on the negative aspects of sexual expression, often contributing to a deep sense of shame about sexuality.

Specific Treatment Modifications of Sensate Focus for Male Hypoactive Sexual Desire Disorder

Clinicians are much more likely to regard female clients as susceptible to low sexual desire and may overlook the significance of the changes necessary to work with HSDD men. Presuming that the medical and health contributors, if any, have been eliminated or adequately addressed, Sensate Focus with HSDD men begins with readjusting their expectations.

In initial sessions, self-Sensate Focus opportunities may be suggested. During these, the HSDD client is guided to focus on the sensations provided by his own body. He begins touching himself mindfully from head to toe, avoiding at first any areas of his body that represent something sexual for him. Eventually he will include these areas into his self-touch.

Either to help with the educational process or simply because of the HSDD man’s anxieties about his sexual appetite, he may respond best to having some individual sessions prior to or together with couple’s Sensate Focus. This is particularly true when the richness of the client’s fantasy life is in question. Many HSDD clients feel ashamed of the fact that they perceive themselves as less masculine because of their limited fantasy life, and they may need education and support for this issue. It is important to remember that even though expectations are that men know what stimulates them, any particular male client may not necessarily be aware of this.

Fantasies and Visual Sensations

If the client is not channeling sexual tension away from the relationship by fantasizing, or by reading or watching erotic material in order to fantasize, or by zeroing in on the visual sensations he might find stimulating, he may actually be encouraged to cultivate these as means for enhancing his sensorial involvement. He is urged to spend between 10 and 15 minutes a day, six days a week, recollecting or creating imagined scenarios, or using visual or written materials he thinks once were, or might become, stimulating. This, of course, presumes that he and the partner are both agreeable. The emphasis, as with couple Sensate Focus, is on his sensory experience in the moment, without judgment or expectation. Every time he finds himself distracted by demanding thoughts, he refocuses on sensations in the moment.

It is important to make a comment here about visual sensations. Since visual sensations provide many men with additional gateways into arousal, encouraging men with HSDD to consciously attend to these may be helpful. Just as with touch sensations, many people are not aware of the different categories of visual sensations. While touch sensations may be defined as temperature, pressure, and texture, visual sensations include color, shape, shading (dark or light), and the combination of these three to suggest movement. Making these dimensions concrete can be of great assistance not only to men with HSDD but to men experiencing other sexual dysfunctions as well.

However, while cultivating his sensory and imaginal repertoire, the man with HSDD is discouraged from masturbating to orgasm to this fantasy or visual material unless he has an extremely limited fantasy life, or such limited awareness of what absorbs him sensorally, that doing so would be therapeutic. If the client has never or rarely masturbated, he may need support for self-Sensate Focus before he engages with his partner. This may involve mindfully focusing on tactile or other sensory experience that helps focus him on his physicality. It may include the use of fabrics he finds absorbing, or vibrator stimulation to intensify the sensations.

Education About the Cultural Portrayal of Men

Whether done in individual sessions or sessions with the partner, it is important to educate HSDD clients about the unrealistic portrayals of male sexual prowess in movies and especially in pornography. Men are not always ready for sex, at “the drop of a bra” as William Masters was fond of saying or, as we have experienced with Gay men, at “the sight of a crotch.” The waxing and waning of sexual desire must be normalized. As with all clients, they must also be offered support and hope that their concerns can be addressed.

Spontaneity

Educating the HSDD man about over-valuing spontaneity is another important consideration. With these clients, almost more than any other, it is critical to inform them how unrealistic it is to expect that spontaneous sexual interest will occur in the context and daily routine of a long-term committed relationship.

Female Sexual Interest/Arousal Disorder

When couple’s Sensate Focus is initiated, HSDD men are encouraged to participate on a regular basis with no more than 72 hours (preferably 48 hours) separating the opportunities. Frequency is emphasized over the length of individual sessions; it is the regularity of contact that is most important for building sexual tension. Scheduling the sessions is frequently helpful because often clients who experience HSDD may be more controlled, structured individuals and they respond well to planning ahead. Scheduling the sessions can also alleviate the problems associated with relegating touching to times when energy is likely to be lowest, for example, late at night.

It is often important to have the HSDD client initiate the Sensate Focus sessions at least in the beginning of treatment. This is also diagnostic because if he does not initiate there is much grist for the therapeutic mill in terms of the resistances he is experiencing, and how to manage them.

Additionally, scheduling sessions can assist with problematic relationship dynamics. It can ease timing problems associated with pressured physical contact in response to the partner’s frustrations over not having had sexual contact for a long period of time. “One partner insists on having his or her ‘needs’ met, and the other reacts to this insistence by withdrawing. The more the latter withdraws, the more the former demands, and vice versa” (Meana & Steiner, 2014, p. 52). This dynamic may show up in Sensate Focus as it did in their previous attempts to address the problem.

Another relationship concern is the man’s feeling empowered to have greater control over not only the timing of, but also the specific activities associated with, Sensate Focus. Many men with HSDD experience themselves as having little input into the sensual contact they have with their partners, or are concerned that the input they would like to have will not be well received. For example, one client reported that he would like to have some coverings over the lamps in the room during the Sensate Focus sessions. This might seem like a little detail; however, not only did it mean a lot to him in terms of feeling more empowered but also he had never shared this with his partner. It opened the floodgates for many more conversations about their sensual interchange.

If, either through the history-taking or the Sensate Focus sessions, it becomes apparent that a major source of the client’s difficulties is concern about ejaculatory control or erection response, the changes that are suggested below in the sections on Premature Ejaculation and Erection Disorders can be incorporated into the Sensate Focus activities for the HSDD client. Actually, the emphasis is on treating the primary etiological factor, namely, the Early/Delayed Ejaculation or the Erection Disorder, and then the avoidance of sexual contact evidenced by the HSDD client will likely decrease.

Women diagnosed with FSIAD must meet three of the following six criteria:

Female Sexual Interest/Arousal Disorder (FSIAD) is a new composite DSM-5 category that combines the previous diagnoses of Hypoactive Sexual Desire Disorder and Female Sexual Arousal Disorder from the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV-TR) (American Psychiatric Association, 2003). This change was made, in part, because research indicates that desire may follow rather than precede sexual activity for a number of women (Basson, 2002a; Basson, 2002b; Carvalheira, Brotto, & Leal, 2010).

1.Interest in sexual activity fails to emerge during a sexual encounter;

2.There are reduced, or there is an absence of, fantasy, sexual or erotic thoughts;

3.There is a lack of initiation or reduced initiation or receptivity to sexual activity;

4.The woman experiences reduced pleasure or sexual excitement during sexual activity;

5.There is an absence of or reduced sexual interest/arousal in response to sexual cues (e.g., written, verbal, visual, etc.); and/or

6.There is a reduction in or absence of genital or other sexual sensations.

Despite the fact that, by definition, sexual dysfunctions must result in distress for one or both partners, there is little emphasis in the publications on FSIAD about this characteristic when it comes to the female client (Brotto & Luria, 2014). However, it has been our experience that for treatment to be successful the woman, herself, must ultimately claim her own interest in treatment for herself, not simply to avoid relationship distress.

Lack of sexual desire is the most common and distressing sexual complaint of women, particularly, but not exclusively, of younger women. However, since FSIAD is a new diagnosis, there are few studies that suggest its prevalence. Preliminary results hint that anywhere from 10.2 to 40.6% of women aged 16–44 experience problems with sexual interest or desire, depending on whether it is measured as existing from one month or six months (Mercer et al., 2003).

FSIAD clients may seek help as a result of partner pressure or because they, themselves, are distressed about their lack of interest. Brotto and Luria suggest that FSIAD presents in three major ways: “I’ve lost my libido,” or women who have difficulty becoming interested before or during sex but would like to regain their desire; “It takes a long time for me to get sexually excited,” or women who do not experience desire before physical contact but who, after some longer-than-preferred amount of time, are able to become aroused; and “I would be content if we never had sex again!” or women who are not interested before or during sex, and who have little interest in regaining their desire (Brotto & Luria, 2014, p. 18). Women in this last category are often encouraged to come to therapy by their partners.

In a number of studies … a weak correlation between lower levels of estradiol and decreased sexual desire has been found by some … but not by others … Despite long-held popular beliefs, population-based studies have shown minimal or no correlation between testosterone levels and sexual desire in women.

As with Male HSDD, it is critical to take a detailed history of the client’s medical situation. Conditions that are believed to affect desire and arousal in women are circulatory, musculoskeletal, central nervous, and endocrinological, including low estrogen and testosterone levels. However, the specific nature of these effects is complex and confusing. For example, with regard to endocrine considerations,

(Brotto & Luria, 2014, pp. 24–25)

Nonetheless, all of these systemic concerns should be considered.

In our clinical experience, the pairing of lack of sexual interest with lack of physiological response is rare except in cases that are hormonal, that result from clinical depression and/or anxiety, or that are a response to medication or a medical condition. A medical factor, such as having radiation, chemotherapy, or removal of her uterus, can obviously have an impact on a woman and not just from the medical procedure itself. For some, these may have significant sexual, psychological, and relationship effects in addition to anything physical that results. This has to be acknowledged and Sensate Focus needs to be reframed in terms of what can now be done rather than what was previously possible.

Somewhat more common in our experience than the pairing of the lack of sexual interest with the lack of physiological response in the absence of a medical issue is reduced or modified pleasure in sexual response, and the perception that there is an absence of sexual response to effective stimulation. The first reflects the importance of looking at relationship dynamics. More important than hormonal issues for most women are their feelings about their partner and the relationship. For example, a woman who might report a reduced or modified experience of sexual pleasure paired with loss of desire may be one who has repeatedly had sexual relations with a partner to avoid or resolve tension in the relationship (something we refer to as service organization sex), leading to feelings of resentment. Clearly, conflictual relationship dynamics like these may have negative effects on sexual desire and responsivity. Relationship difficulties that threaten security and fidelity need to be evaluated. Ironically, as Esther Perel (2007) has reminded us, one of the main contributors to a loss in sexual interest and arousal can be an excess of security and familiarity; the very ingredients that go into making a relationship erotic in the beginning (novelty, unpredictability) may erode as the realities of what makes a long-term relationship work (stability and commitment) become evident.

The absence of sexual response to effective sexual stimulation often suggests the importance of exploring sociocultural issues. For example, the partner of an FSIAD client may see the woman’s sexual response (nipple erection, areola swelling, lubrication, sex flush, rhythmic vaginal contractions, etc.) while the woman, herself, remains unaware of her own reactions. The results of a study by Chivers and Daily (2005) is interesting in this regard. Both men and women were shown six videos of both human and non human sexual activity. The women were found to be physiologically aroused to all 6 vignettes as measured by blood flow to the genitals but they did not necessarily report subjective arousal. It was theorized that one reason was that subjects repressed their awareness of their own physiological arousal, or were unwilling to report it, as a result of sociocultural pressures not to be aroused to certain sexual stimuli. It comes as no surprise that these sociocultural factors have a significant impact on sexuality in general, and its development and expression in women in particular. The results of a study by Robbins et al. (2011) suggest that while 62.6% of 14-year-old boys and 80% of 17-year-old boys masturbate, only 43.3% of 14-year-old girls and 58% of 17-year-old girls engage in self-stimulation.

Another, more biological interpretation is that the physiological response to sexual stimulation may be a physical protective mechanism to avoid trauma to the body during rape.

Yet another factor to explore for women who are unaware of or unwilling to report observable arousal comes from a trauma-informed perspective. A sexual trauma survivor who experiences or suppresses physiological arousal during sexual assault or abuse may develop dissociation or repress awareness of their current responses in order to defend against shame or guilt.

The influence of cultural norms on FSIAD women is no more apparent than in the negative images these clients so often have about their bodies. The relation between negative body image and low sexual desire is well documented. The perceived failure to achieve socially approved standards for physical attractiveness is regarded as one of the two most powerful psychological contributors to hypoactive desire disorder in women. This highlights the significance of evaluating both sociocultural and psychological factors.

The other most common factor contributing to FSIAD has to do with environmental stressors: many FSIAD women are overwhelmed by myriad responsibilities they have fulfilling their professional, domestic, relationship, and social roles. They are often either mentally or physically exhausted, or both. Research on women working at home, women working both at home and at a job, and women working both at home and at a career indicated that especially women who are involved in careers while also holding down the fort at home are much more likely to experience decreased sexual desire (Avery-Clark, 1986). It is difficult to feel sexually interested or aroused, or even be aware of these even if they are present, when you are so preoccupied with obligations that you have no time to pay attention to these experiences.

Specific Treatment Modifications of Sensate Focus for Female Sexual Interest/Arousal Disorder

Despite being an advocate of sexual science, when it comes to FSIAD, Kathryn Hall suggests that it may be the case that, as yet, “Sexual medicine has little to offer women in terms of enhancing their sexual desire and pleasure” (2016, p. 390). Therapy usually moves quickly to psychological and relational interventions.

In cases in which the woman is not experiencing personal distress by her lower interest or arousal, and is coming to therapy as the result of partner pressure, the first treatment concern is to assist the woman with finding her own motivation for working on the issue. Without this, treatment success is highly questionable.

We must remember that some women have never or rarely spent time exploring their bodies, cultivating fantasies, and learning what is of interest and arousing to them. The purpose of Sensate Focus with FSIAD women is to help with all these issues. Sensate Focus strategies with these clients usually involve the women either exploring their bodies alone at first in terms of what absorbs their attention, or involving the partner in the exploration. If clients choose to do the touching by themselves, self-Sensate Focus involves mindfully connecting to tactile or other sensory experiences to help ground them in their physicality. It may also include sensory-oriented baths, massages, vibrator stimulation, and physical exercise. Clients are offered sexual information and suggestions for focusing on the sensations provided by their bodies as they begin touching themselves from head to toe as best they can, but avoiding breasts and genitals at first. Eventually clients include their breasts and genitals into the touch. They are encouraged to have one session a day, six days a week, for approximately 10–20 minutes. The emphasis, as with couple’s Sensate Focus, is on the physical, sensory experience in the moment, without judgment or expectation, and refocusing from distractions onto the touch sensations.

Fantasies

The development of a rich source of sexual fantasies is another Sensate Focus adjunct with FSIAD clients. Using any literature from romance novels to poetry, and experimenting with visual images, the woman is encouraged to spend some time daily focusing on this part of herself. While men often devote a considerable amount of time in their adolescence and early adulthood to cultivating their interests and fantasies (often paired with self-stimulation), women are less likely to do this. In fact, they may be discouraged from exploring what they find physically and imaginally absorbing especially when their sociocultural or religious family of origin is conservative.

Sensate Focus is initiated following or along with self-discovery and fantasy enrichment. The woman moves her partner’s hand away if anything is uncomfortable, and uses positive handriding to practice communicating what she might like to explore in that moment. It is important to have the couple slow down so that they can educate themselves and each other about what may be absorbing and ultimately, in Sensate Focus 2, stimulating.

When the couple’s Sensate Focus is initiated, and depending on the individual and/or partner dynamics, the client with FSIAD is usually the initiator of the Sensate Focus touching sessions. This is especially the case if she is the member of the couple who has engaged in sexual activity mainly to service her partner. Although the goal is to have the FSIAD client eventually alternate with the partner when it comes to initiating the Sensate Focus sessions, this does not have to be the case at the beginning of Sensate Focus. This is because the FSIAD client may need a number of sessions before she can feel the empowerment of initiating, touching and being for her own interest. A helpful analogy is suggesting that just because one partner is hungry does not mean that both must have a full course meal. All that each partner owes the other is to sit down to the table of the Sensate Focus exercises.

Either the FSIAD partner may decide to stop the session after her portion of the touching has been completed, or she may decline to engage in Sensate Focus at the other person’s initiation. This allows her greater comfort and practice when being touched and touching for her own interest. However, she is then to re-initiate that same session at her own behest at some later point. Both partners, but particularly the FSIAD partner, respond best to the suggestions if they have the option of declining or stopping any particular Sensate Focus opportunity. In these cases it is important for the therapist to help the woman pace her initiation and involvement instead of the partner being the one to do this.

Erectile Disorder

Erectile Disorder (ED) is defined as the regular and repeated inability to achieve or maintain erections that are firm enough for insertion during partnered sexual encounters. A diagnosis must meet one of the following three criteria:

1.A notable difficulty obtaining an erection;

2.A distinct difficulty maintaining an erection once it has been obtained; and/or

3.A marked decrease in the firmness or rigidity of the erection.

The diagnosis is not given if erection concerns are occasional or if they do not create distress for one or both partners in a relationship. As with all other sexual dysfunctions, the erectile concern cannot be more appropriately traced to a different sexual dysfunction (e.g., secondary to Rapid Ejaculation), and it cannot be only the result of factors such as substance abuse or prescribed medications.

ED is present in approximately 10% of men under 35 years of age, and can occur in as many as 50% or more of men over the age of 60. It is susceptible to age and to medical and psychological factors.

ED can be generalized or it can also be situational, occurring only with a particular partner, with certain types of partners, in long-term relationships but not in short-term interactions, in certain environments, and under the influence of certain kinds of stressors. A common presentation is men who can have erections with self, partner, or oral stimulation but who lose it at insertion or immediately thereafter. This is especially true in men who experience an erection and attempt to use it immediately over concerns for its loss. ED may also be associated with a previous history or another sexual issue, most often an ejaculatory, problem.

As with Male HSDD, there may be a hidden, or primary, sexual cause of ED that is not at first reported. Research has shown that a history of some other sexual dysfunction may be associated with as many as one-third of cases of erectile insecurity. Particularly in older men, a history or the presence of delayed or absent ejaculation may contribute.

Erectile Disorders may be primarily biomedical or psychogenic in nature. Often there is significant interaction. Even if medical factors are the initial cause, the individual’s psychological confidence and his relationship are sometimes so negatively affected as to contribute further to the disorder and even maintain it autonomously. As mentioned, factors contributing to ED vary, and a multidisciplinary evaluation is critical (Metz & McCarthy, 2004). Both individual self-report and partner observations are taken into consideration. Other physiological procedures such as nocturnal penile tumescence and rigidity measures may be helpful but are used much less frequently than prescribed medication.

In medical terms, ED is not only especially affected by cardiovascular difficulties (hypertension, hypercholesterolemia) but can actually be an early indicator in younger men of impending cardiovascular problems (Rosen, Miner and Wincze, 2014). Other medical factors include endocrine (diabetes, low testosterone, hypothalamic-pituitary-gonadal axis disturbances) and lower urinary tract problems.

The psychological status of any man presenting for treatment of ED should be evaluated. Important factors include the degree to which the client is affected by performance anxiety associated with concerns about erections, and spectatoring that involves observing the state of engorgement. These are the two most common psychological factors. They are the two distracting thought patterns that make it difficult to focus on sensory absorption during sexual interaction.

Both the man’s and the partner’s level of knowledge about erections needs to be assessed. While many people have a sophisticated understanding of the physiology and response patterns of male arousal, many do not, and no assumptions should be made about the extent of their knowledge on the subject. For example, few people are aware that the erection response, even in fully functioning men, regularly comes and goes over a period of time. In the absence of fears of performance and spectatoring that result in anxiety, penile engorgement will return at its own natural rate and rhythm.

Men who have experienced sexual abuse are susceptible to ED. This may be the direct result of the abuse itself. Or it may be the result of the intense shame often experienced by men in a culture that recognizes the possibility of women being sexually abused but that places a special stigma on men being the subject of abuse.

The relationship of any man presenting with ED should be evaluated. Interpersonal factors may include hostility between partners. Partner factors may include the experience of pain with intercourse. Others factors include the willingness, or lack thereof, of either the partner or the man himself to incorporate oral or manual stimulation into the physical interactions. The possibility of sexual variation, including oral and manual stimulation, removes pressure from intercourse as a necessity. Determining the partner’s level of cooperation with variation can be critical. Additional partner dynamics might be an inhibited partner who will only engage in sexual interactions with the lights off when visual stimulation may be critical for the man especially if he is older.

The degree to which the man with ED may be experiencing gender identity or sexual orientation concerns also needs to be evaluated. This may reflect sociocultural influences. Some men may have entered into traditional marriage and family situations as a result of social pressures when, in fact, they are not comfortable with the gender identification or sexual orientation they present to others. Other cultural and religious factors include a history of negative messages about sexual expression that contribute to shame and guilt. Although body image is often considered when taking the history of a female client, it should not be ignored when evaluating men with ED. Cultural pressures on men to adhere to certain standards of appearance are becoming nearly as intense as those experienced by women. Gay men have been confronting these pressures for a long time, but heterosexual men are increasingly subjected to them as well.

Additionally, situational stressors encountered through work, relationship, and home life should not be neglected in the assessment, and neither should lifestyle patterns associated with alcohol, prescription and street drugs, smoking, exercise, and obesity.

Specific Treatment Modifications of Sensate Focus for Erectile Disorder

The effects of ED may be devastating for the individual as well as for his partner. Clients often come in for therapy feeling very discouraged. Many have already tried medications that worked initially but less so over time. It is important to begin Sensate Focus as quickly as possible in most of these cases.

Medications

Sensate Focus treatment strategies for men with ED follow the usual prescribed hierarchy with the following changes. Depending on the client and partner, some sex therapists will begin treatment with the addition or maintenance of PDE-5 inhibitors such as sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra), eventually discontinuing it as clients experience spontaneous erections with their partners and increased confidence. With the build-up of sexual tension engendered with Sensate Focus, these spontaneous erections, especially morning erections, are reassuring and signal the degree to which anxiety and pressure have been factors in the erectile difficulties.

Expanding the Sensory Experience

When the couple begins Sensate Focus with breasts, chest, and genitals on limits, the partner is guided to move away from the penis when it becomes engorged. The partner may move to touching other parts of the body, then return regularly to genital touch, and then move away again. This redirects the focus of attention away from engorgement and onto a more full-bodied approach.

During the Sensate Focus sessions, it is not uncommon for a man who has been experiencing satisfactory engorgement with breast and genital touching to experience difficulty when partner astride, genital-to-genital is suggested. To manage this it is important for the therapist to explicitly state that no engorgement is needed for this exercise and that focus is to remain on tactile sensations. However, due to cultural expectations (“I should have an erection!”) and the concomitant anxiety, many men either lose engorgement or do not experience engorgement during the initial stages of this exercise. When the partner is playing with his or her genitals against those of the man with ED, the partner may experience a burst of arousal and even be orgasmic, despite the ED client’s non-engorged penis. The effect of actually experiencing that engorgement is not essential for the partner’s sexual response cannot be underestimated. It does much to dispel the ED client’s performance anxiety.

Another suggestion that can help allay the participant’s performance apprehension is having the partner do the inserting when the time becomes appropriate. The client with ED is instructed to leave the inserting to his partner, maintaining his focus on the tactile sensations. The client’s partner is in a much better position to gauge the firmness of the client’s engorgement, gauge when she (or he) is ready for insertion, and knows where the penis goes.

Another modification for men with ED is to encourage refocusing their visual attention on some aspect of their partner’s body they find interesting. As noted in the section on Specific Treatment Modifications of Sensate Focus for Male HSDD, it can be helpful to encourage the client to expand his sensation repertoire by focusing on the shape, shading, color, and motion offered by visual sensations. When experiencing penile spectatoring the ED man might attend to the shape of the swell of his partner’s breasts, or on different tints of the partner’s skin. Alternatively, the ED partner may be encouraged to focus on visual imagery in the form of a fantasy if this is within the couple’s sexual value system.

Code Word

Most couples grappling with ED are familiar with the experience of sensing when the ED partner is experiencing increasing performance anxiety. Often this results in stopping the touching, mechanically going through the motions of the touching, or falling into a goal-oriented, demanding mindset of working deliberately at it. In order to manage this, couples are encouraged to agree on a positive code word that is verbalized by the man when he experiences a rise in anxiety. When he says the code word, both partners change their positions and actions while continuing to touch. This suggestion gives both partners something different to do to override their pattern of helplessness and discouragement in the face of anxiety associated with absent erection or diminished engorgement.

Understanding Erection Responses

As suggested in the ED assessment section, many people are not aware that erection responses ebb and flow even in the most functional men. It can be helpful to both partners to provide information about the fact that, in the absence of anxiety about whether or not an erection will occur or be maintained, penile engorgement will return according to its own natural rate and rhythm.

Paradoxical Injunction

An additional technique that drives home this understanding about how erection responses wax and wane naturally is to suggest that the ED client gain and lose engorgement on purpose in the presence of his partner. This can be done before and/or during insertion. If this is done during insertion, the partners remain quiet and intentionally allow the engorgement to diminish. These experiences serve as a paradox: the very thing that is feared is assigned and, since sexual responsiveness is a natural function, conscious attempts to prevent it are more likely to produce it, at least in time. In younger men, this quiet insertion with loss of engorgement may take some time to accomplish. Once partners know the erection will return, the anxiety associated with fears of losing the erection will decrease.

Female Orgasmic Disorder

Although approximately 6–15% of women who experience orgasmic difficulties report achieving orgasm too quickly, this is not included under the DSM-5 classification system for FOD.

Female Orgasmic Disorder (FOD) is the inability to experience an orgasm in most, if not all, sexual opportunities. It is also defined as experiencing a reduced intensity of orgasmic sensation in most, if not all, sexual opportunities. This reduced intensity of sensation is new in DSM-5 and reinforces the fact that orgasm is not an all or nothing experience for women. The new diagnostic criteria include both physiological alterations AND the subjective experience of intensity. This is because, unlike male orgasm, female orgasm has no externally irrefutable signal.

Even more so than with FSIAD, publications on FOD frequently fail to emphasize women’s own experience of orgasmic concern, or lack thereof, in the diagnosis of the dysfunction. However, as the prevalence statistics below indicate, women, themselves, are often not particularly distressed by what others may label as their orgasmic difficulties.

Depending on which research you examine, FOD impacts between 3 and 41.2% of women. The fact that only between 3.4 and 14.4% of these women report their low or absent orgasmic response as distressing suggests the need for further clarification. FOD appears to be the second most common sexual dysfunction presented by women after FSIAD.

Lack of orgasmic release can be a lifelong problem or a recent one. It can be a generalized condition, or related to certain types of stimulation, circumstances, or partners. For example, some women have never achieved an orgasm by any means with self or partner although they may have done so in their sleep state (somnus orgasm). However, for the majority of women with this concern, masturbating to orgasm is not a problem when using finger stimulation of the clitoris, rubbing against the bed or another object, squeezing the legs together rhythmically, or using imagery or toys such as dildos and vibrators. Many women, especially younger ones with less partner experience, may seek help for having orgasms when their partner is involved. Some are able to be orgasmic with oral or other stimulation with a partner, but not with insertion, and they hope to experience an orgasm with intercourse.

Menopausal women report somewhat greater difficulty achieving orgasm. They discover the changes occurring with aging, such as vaginal dryness and atrophy causing pain, may preclude insertion or diminish their responsiveness.

The experience of orgasm is extremely variable from woman to woman and differs in intensity for the same woman from occasion to occasion. What we know is that most women require stimulation of the clitoris to be orgasmic with or without intercourse. There is no single approach to orgasmic release that suits all women all the time.

Most often, orgasmic difficulties are the result of a number of factors, and the focus is on working with more than one of them. Therefore, a multifactorial evaluation is necessary. Medications, including some cancer medications and many of the anti-depressants, may be culprits. Between 30 and 60% of women on these medications are orgasmically affected by them (Montgomery, Baldwin, & Riley, 2002). Other medical variables impacting orgasmic release include radiation treatment, spinal nerve damage, chronic or progressive medical conditions (thyroid conditions, diabetes, multiple sclerosis), and include surgeries (e.g., pelvic nerve damage from radical hysterectomy). In the case of women who have hysterectomies, some of them may have previously focused on contractions of the cervix or uterus and, if so, they may report a diminished or absent orgasmic response.

Orgasmic difficulty may be influenced by psychological and learning factors as well. One of the most important ones to assess is the specific manner in which the woman has attempted to bring herself to orgasm in the past. Detailed information is critical because individual preferences vary tremendously. Additional factors for consideration may include:

1.General sexual inhibition;

2.Low self-esteem;

3.Lack of familiarity with one’s body;

4.Serious concerns about one’s body and its appearance;

5.Anxiety or depression;

6.Fear of loss of control or vulnerability;

7.Personality factors (e.g., introversion, inhibition, emotional dysregulation, hesitation in engaging in new experiences);

8.A history of neglect, or emotional, physical or sexual abuse; and

9.Pregnancy concerns.

For many women, the inability to shift out of the analytic, task-oriented mindset that is useful for meeting responsibilities, and into the sensorially-oriented experiential mindset is a major factor. When clinically significant mental illness appears to be the primary cause of orgasmic dysfunction, a DSM diagnosis of FOD is not made.

Other individual contributions to FOD that are in need of evaluation include the extent to which the woman has cultivated her subjective experience of sexuality and her comfort level with this. For example, many women with orgasmic and other sexual difficulties do not allow themselves to fantasize or even think about sex very often. They infrequently engage themselves in any form of sensual appreciation. When they are involved in sex, they may also try to consciously make orgasm happen which only makes it less likely to occur.

Partner factors may also be relevant. These include partner health status, concomitant sexual problems (e.g., rapid ejaculation), or poor partner technique. The latter may dovetail with relationship factors that also need to be explored, such as poor non-verbal or verbal skills between the partners. However, current research suggests that it “is not clear whether the communication problems were a cause or an effect of the orgasmic difficulties” (Graham, 2014, p. 98).

A variety of other relationship variables may require assessment. Lack of quality time, lack of privacy, and lack of general relationship skills (e.g., conflict resolution), power inequities and the associated build-up of resentments, and discrepancies in sexual interest that may have contributed to one partner’s pressuring the other for sex and/or orgasm, may all be factors in FOD. Severe relationship distress that includes emotional, sexual, or physical abuse clearly may be related factors.

Sociocultural and religious expectations may also affect sexual responsivity alone and/or with her partner. The manner in which a woman is raised to think about and develop her sexuality can have a tremendous impact on whether she grows up with deeply ingrained barriers to arousal and orgasmic release, or whether she has learned to integrate her sexuality into her growth as a person. For example, because of sociocultural and religious values, some women are highly responsive by themselves but have difficulty being orgasmic with a partner because she is so focused on the partner's experience. Additionally, some women have not been permitted or willing to engage in masturbation. Research suggests that there is a positive correlation between women who masturbate before marriage and their ability to be orgasmic with their partners.

Finally, lifestyle stressors, such as excessive works hours, job loss, care of elderly relatives and young children, and bereavement must be evaluated. These may be powerful influences.

Specific Treatment Modifications of Sensate Focus for Female Orgasmic Disorder

Medications

There are a number of biomedical strategies that may be considered before trying Sensate Focus or while working with these procedures. For example, if the woman is on an SSRI antidepressant or birth control, and if this is suspected to be contributing to the orgasmic difficulties, a change in medication may be helpful. As yet, there are currently no pharmacological medications or treatments for anorgasmic women that have been approved (Graham, 2014). Medications such as sildenafil, estrogen, testosterone, tibolone, and a variety of nutritional supplements have not produced reliable results.

Sensate Focus strategies for women who have never achieved orgasm by any means (except in sleep) begin with education about their own bodies through self-touch Sensate Focus exercises. Following procedures developed by Dodson (1996), and Heiman and LoPiccolo (1988), these are initiated with Directed Masturbation (DM) techniques. These include education about orgasmic experience, the use of Kegel exercises to strengthen Pubococcygeal (PC) muscle control, and self-Sensate Focus.

For women who have reduced sensation due to neurologic or medical procedures, medications or illnesses, or for any woman experiencing FOD, the development of fantasy with reading material and visual images can be very helpful. For women who have had a hysterectomy and had focused on the pleasurable sensations of uterine contractions during orgasm, teaching them to refocus on other parts of the body in contraction can be very productive. The intense use of a vibrator can be valuable, particularly if the more powerful type is incorporated into the touching. Unfortunately, apparatuses, such as the Eros clitoral therapy device, have not shown to be consistently effective with anorgasmic women.

The Sensate Focus techniques themselves involve the woman’s learning to receive and give themselves clitoral stimulation at the same time they are exploring pelvic body alignment (the coital alignment technique, or CAT). Here the client focuses on touch sensations while discovering different ways in which she can shift her pelvis to obtain more effective clitoral stimulation. This usually includes manual touch, partner touch, genital-to-genital contact, or by other means. For example, using a smaller vibrator along with insertion may be very helpful.

Once the woman has learned how to be orgasmic by herself, she works on communicating her new awareness and needs to her partner. Couple Sensate Focus may begin at the same time as self-Sensate Focus or afterwards.

Sensate Focus techniques for women who want to be orgasmic with partner insertion or intercourse often begin with educating both the woman and her partner about the fact that orgasm with intercourse is often the most challenging way for women to become orgasmic with a partner. Many couples are not aware that many women are not regularly or easily orgasmic with insertion only. They usually need additional clitoral stimulation. This often comes as a surprise.

Longer and more varied pre-Sensate Focus exploration periods, mixed with surprises, can also aid the couple. One of the ways of making the experience more varied is to start and stop intercourse using a varied and teasing approach. There is no eleventh commandment that says once there is insertion, thou shalt not change the activity.

Premature (Early or Rapid) Ejaculation

Premature, Early, or Rapid Ejaculation (PE) has been defined in the DSM-5 (2015) as a persistent or recurrent pattern of partnered penetration that results in undesired ejaculation within one minute of insertion in 75% or more of sexual intercourse occurrences. The three criteria are: “(1) a short ejaculatory latency; (2) a lack of perceived self-efficacy or control about the timing of ejaculation; and (3) distress and interpersonal difficulty (related to the ejaculatory dysfunction)” (Althof, 2014, pp. 113–114).

Emphasis is placed not only on the duration until ejaculation but also on the psychosocial impact that PE has on the man, his partner, their sexual relationship, and their relationship in general. While alluding to PE occurring in non-vaginal penetration, the DSM-5 offers no specific duration criteria.

Self-report investigations suggest that PE affects 20–30% of men. However, since self-report measures do not necessarily meet formal diagnostic standards, the actual prevalence may be somewhat lower, perhaps as low as 1–2%. Although PE has long been considered a dysfunction more common to younger men, recent research suggests that this is not necessarily the case and that it does not necessarily diminish with advancing age.

It is not uncommon for acquired PE to be associated with erectile insecurity, especially in older men. In these cases, PE may result from conditioning that is associated with efforts to ejaculate before the loss of erection. In these cases, erectile insecurity may be the primary difficulty and focus of treatment.

PE may present as either lifelong or acquired. Men who have lifelong PE have always experienced ejaculatory control problems. Men with acquired PE develop ejaculatory control problems following a period of control. Lifelong PE is two times more common than acquired. Some men struggling with lifelong PE may suffer from a biological susceptibility to the dysfunction, the specific physiology of which has yet to be entirely determined.

PE can present as either situational or generalized across partners and situations. Many men will not meet the formal DSM-5 criteria and may last longer with partnered insertion, but the couple may identify Early Ejaculation as a problem in their sexual relationship because they would like a longer period of intercourse. Some men have no difficulty delaying ejaculation with self-stimulation or with partner manual or oral sex but cannot delay ejaculation with partner insertion.

PE can have a tremendous negative effect on the relationship. These men more often than not avoid sexual interactions with their partners or hesitate to form new sexual relationships. They report concerns about their partner’s being unfaithful and about lower satisfaction with all aspects of relationship intimacy.

As with other sexual difficulties, many factors must be evaluated when assessing PE (Metz & McCarthy, 2003). The initial one is whether the dysfunction is lifelong or acquired, because the former is more likely to suggest a biological vulnerability not infrequently associated with serotonin functioning. In these cases, SSRIs (e.g., Prozac and Zoloft) can be helpful, especially in the absence of significant individual and/or relationship difficulties. Other medical factors that occur less often but that are important to consider include genetic predispositions, endocrinological concerns, increased penile sensitivity associated with nerve transmission disorders, and prostatitis. For example, PE may include a complex and as yet poorly understood relationship among depression, serotonin, and thyroid functioning. Althof asserts, “50% of men with hyperthyroidism had PE and, when successfully treated, the prevalence of PE fell to 15%” (2014, p. 118). An additional medical-related issue in need of further study is drug use and particularly withdrawal from opiates.

Psychological factors associated with PE include:

1.Anxious feelings of a phobic, conflictual, or anticipatory nature;

2.Early experiences where importance was placed on ejaculating quickly (e.g., concerns that the parents would come home);

3.Lack of sensory awareness of the level of sexual excitement;

4.Embarrassment about the difficulty;

5.Hostile feelings towards the partner coupled with passive-aggressive expression of this hostility; and

6.Excessive narcissism and an associated lack of concern for partner satisfaction.

Information also needs to be gathered about the man’s knowledge of performance anxiety. Although fears of performance aren’t usually associated with the original PE experience, they often contribute to the continuation of the problem. Once the man loses his ability to manage his ejaculation, and also loses his sexual confidence in general (about two-thirds of PE men do), this anxiety becomes a distraction from sensory awareness of his level of arousal, and he is even more likely to ejaculate quickly. Once this pattern is in place, the man has little or no voluntary control over his ejaculatory response.

Assessing the partner’s awareness of the involuntary nature of the ejaculatory response pattern is also critical. Often the beliefs of the partner that the man with PE can exert control over his ejaculation if he wanted to and if he cared about the partner are sources of partner emotional pain and sexual frustration. Partners may respond with low desire and a lack of willingness to become sexually involved. This is especially the case if there has been no sexual release offered by other means or if the partner values having release only with insertion. The lack of ejaculatory control and the partner response may both contribute to the problem. Assessing the partner’s willingness to participate in techniques for learning delay is critical.

Women are … angry with their partners with PE because they do not feel that their concerns have been genuinely “heard” by the men nor that they are unwilling to “fix” the problem. Men likewise believe that their partners do not understand the degree of frustration and humiliation that they routinely experience. This disconnection between the men and their partners is the basis for considerable relationship tensions.

(Althof, 2014, p. 121)

In addition to these client and partner issues, it is important to evaluate lifestyle stressors the couple is confronting. For example, hurried sexual interactions are a problem. This may happen when the couple is living with children, relatives, or even a guest, any of whom may knock on the bedroom door at any minute. It would also include long working hours and limited time together, all of which can affect the frequency of intercourse, the amount of time devoted to touching before intercourse, the length of time needed for the man’s partner to reach orgasm with insertion as desired, the partners’ responses after ejaculation, and the man’s awareness of his level of arousal.

Specific Treatment Modifications of Sensate Focus for Early Ejaculation

Medications

Some couples may choose pharmacological intervention, especially several of the SSRIs, prior to or in conjunction with Sensate Focus. These medications are known to delay ejaculation in many men.

Education

Sensate Focus treatment for Early Ejaculation begins with educating clients about the sexual response cycle and the two-stage model of ejaculation: the point of ejaculatory inevitability when the man knows he is going to ejaculate but hasn’t yet done so; and ejaculation proper when semen is actual expelled.

Individual Sessions: Stop-Start, Squeezes, and more

Clients experiencing PE may be invited initially to practice Sensate Focus sessions while alone, tuning into the tactile sensations. This is instead of returning to their familiar pattern of attempting to delay ejaculation through numbing themselves (e.g., with alcohol) or distracting themselves from the sensations (e.g., using negative imagery). During these self-stimulation sessions they are asked to practice at least one of several ejaculatory control techniques. The first approach is often Seman’s Stop-Start Method (1956). Clients are asked to self-stimulate until they can feel their arousal moving up quickly, stop for a few seconds, resume until they can feel their arousal moving up quickly again, stop for a second time, re-stimulate, and then allow themselves to ejaculate on the third or a subsequent opportunity. They are reassured that some loss of engorgement is to be expected but will return with re-stimulation.

Instead of distracting himself with negative imagery, the client is encouraged to do the very opposite, to become ever more attentive to how aroused he is, and to practice stopping well before reaching ejaculatory inevitability. The goal here is twofold. The exercises assist him in reconditioning the ejaculatory response and also teach him to become increasingly aware of his level of arousal. Nonetheless, if the client waits until the point of ejaculatory inevitability to stop, he is invited to appreciate the ejaculation as it occurs instead of trying to stop it at that point (an impossibility). He is then encouraged to continue practicing mindfulness with regard to his arousal and to cease stimulation well before ejaculating.

An additional focus is to encourage him to tune into his PC muscles intermittently to check the degree of tension he is experiencing with anxiety and higher levels of arousal and to practice releasing them. By intentionally squeezing these muscles in a paradoxical fashion, tightening them, and then letting them go, he can check and correct tension being held in the pelvis. He will likely interpret this letting go as relaxation because of the difference between the tension associated with intentionally tightening the PC muscles, and the letting go of this tension. He will further interpret this sense of release (relaxation) as his making progress because no longer will his PC muscles be in the taut state that is indicative of impending orgasm. In order to arrive at a less tense state that counters ejaculation, he is also encouraged to take in a deep breath and release it as he lets go of the tension in his PC.

During the self-stimulation Sensate Focus sessions, clients may be encouraged to try two other types of squeezes. These are referred to as the Coronal and the Basilar squeezes (see Illustrations 7.1 and 7.2). Although the Coronal Squeeze in particular is the essential squeeze used for treating PE when the partner is also involved, and while it is more effective in this context, both it and the Basilar Squeeze can be initiated during the self-stimulation sessions (Puppo, 2013). It must be initiated at the early stages of self-stimulation and must be applied periodically, approximately every one or two minutes. The use of these two squeezes, both including the partner and by the PE client himself, is described in detail in the next section on Couple Sessions. However, when the Coronal Squeeze is used in the individual sessions, the PE client obviously applies the Coronal Squeeze himself rather than having the partner do it, and he uses different finger placements.

As the client reports better latency with manual stimulation, additional suggestions are offered, such as the use of powder, oil, or lotion to create a slicker, more-stimulating surface. A masturbatory sleeve may also be useful for providing a stimulating middle step between self-contact with the hand and insertion with the partner. Masturbatory sleeves are flexible tubes made with one or two openings and an inner surface that feel more like a vagina or anus than does a hand. These can offer clients a chance to practice more with the stop/start technique and also to build additional confidence and control.

Couple Sessions: Stop-Start, Squeezes, and more

The next step may involve incorporating the partner into the treatment. Some sex therapists begin with this couple’s phase, including the partner in all parts of treatment. Some therapists emphasize the Coronal and the Basilar squeezes while others focus on the Stop-Start method.

The couple sessions follow the usual Sensate Focus protocol with partners engaging in the my turn/your turn touching with breasts, chest, and genitals off limits. As soon as they move to including the genitals into the contact, and at the moment that the partner has first contact with the PE client’s genitals, he or she applies the Coronal Squeeze quickly and very firmly (see Illustration 7.1). The partner does this by placing his or her thumb on the centerline of the frenulum on the under side of the penis, and positions the index and middle fingers directly opposite the thumb, just above and below the center line of the coronal ridge, on the upper side of the penis. The partner applies the squeeze suddenly, with very firm pressure, counting silently, “One thousand one, one thousand two, one thousand three,” and then releases the squeeze abruptly. It is very important that the fingers are directly opposed to each other down the midline of both the upper side and underside of the penis, and not off on the sides of the penis, and that the squeeze is applied very firmly. Otherwise, the PE client may experience the contact as stimulating rather than as interrupting the ejaculatory response.

7.1Coronal Squeeze

One of the advantages of implementing the Coronal Squeeze during couple sessions is that the partner’s applying it is more effective than when the client applies it himself. This is because of the element of surprise. The nervous system of the man experiencing PE has time to anticipate the squeeze when he is applying it, even if only by a fraction of a second, whereas he does not have time to anticipate it when the partner applies it. Therefore, when the partner applies it, the penile nerves associated with ejaculation are interrupted just that much more abruptly. This speeds up the ejaculatory reconditioning process.

If the Coronal Squeeze is used by the PE client himself during self-Sensate Focus sessions, the man is directed to put his index and middle fingers on the frenulum on the under side of the penis and to position his thumb directly opposite of these, just below the coronal ridge on the upper side. He also applies the squeeze suddenly, with a very firm pressure, counting to himself, “One thousand one, one thousand two, one thousand three,” and then releases the squeeze abruptly. He then continues to self-stimulate, applying the squeeze again as before. The Coronal Squeeze reduces the urgency to ejaculate. He then continues to self-stimulate, applying the squeeze again as before.

There is another squeeze that the PE client can apply during both the couple sessions and individual sessions. This is the Basilar Squeeze (see Illustration 7.2). The Basilar Squeeze should be applied only after the PE client has achieved some degree of ejaculatory control with the Stop-Start method and the Coronal Squeeze, and/or during the individual, self-Sensate Focus sessions after he has obtained some degree of ejaculatory control. When this squeeze is used in the couple sessions, it first involves the partner’s wrapping his or her hand around the base of the penis (where it joins the body) and, just as with the Coronal Squeeze, squeezing it very firmly, counting silently for three seconds, and then suddenly releasing. At some point when sufficient ejaculatory control has been achieved, the PE client can take over applying the Basilar Squeeze especially just prior to insertion.

7.2Basilar Squeeze

When the Basilar Squeeze is used by the PE client himself during individual sessions, he applies it just as he does with the Coronal Squeeze except in this case at the base of the penis rather than at the coronal ridge. He applies the squeeze suddenly as he feels his level of arousal increasing, counting to himself as he also does with the Coronal Squeeze, and then abruptly releasing.

The Stop-Start method is also very effective when used in the couple sessions with PE clients and their partners. They begin with the partner touching the man with PE while the man directs stopping and starting with both hand stimulation and later the Stop-Start technique with insertion. The couple may use a code word that is said when the man’s arousal is increasing, and then both stop moving.

The touching sequence, regardless of whether the Stop-Start, Coronal Squeeze, and/or Basilar Squeeze techniques are applied, then follows the usual hierarchical steps of Sensate Focus. After there has been touching with breasts, chests, and genitals off limits, the next step is having them on limits, then mutual touching, and then partner astride. The partner applies the Coronal Squeeze just prior to insertion and, initially, insertion takes place without movement. If the Basilar Squeeze technique is used, the client squeezes the base of the penis prior to insertion. All of this is accompanied by the Stop-Start technique and the Basilar Squeeze with movement. With heterosexual couples, the partner astride position is recommended because of the greater ejaculatory control it usually provides.

As partners of clients with PE are often frustrated, it is helpful to discuss options for their own release before or after the Sensate Focus suggestions, if they would like. This may include liberally involving the PE client, or partners can provide themselves with release on their own.

Delayed Ejaculation

Delayed Ejaculation (DE) is a condition in which men, even in the presence of sufficient stimulation, find it “difficult or impossible to ejaculate and experience orgasm. This diagnosis requires distress about the symptom(s), adequate sexual stimulation, and a conscious desire to achieve orgasm” (Perelman, 2014, p. 139).

Men who have never ejaculated by any means (primary DE) are extremely rare. Men who have acquired delayed ejaculation, especially after age 50, represent perhaps 8–15% of the male population.

DE is most common during intercourse with a partner. Despite the capacity and the desire to ejaculate, some clients report that they can eventually ejaculate with a partner but only after lengthy and vigorous stimulation. Some describe giving up after a prolonged effort as a result of discomfort on their own part or on the part of their partner. While episodic ejaculation difficulties are not uncommon as men age, men with DE often report ejaculation having been a problem at all ages.

Many men with DE have no difficulty with erections or ejaculating in a reasonable time while masturbating, especially when alone. Some have no difficulty ejaculating in the presence of their partners while masturbating or with manual or oral stimulation by their partner, but cannot do so during vaginal or anal intercourse.

For some couples, delayed or absent ejaculation is not an issue. It does not meet diagnostic criteria until the couple desires to become pregnant. At this point it represents a diagnosable problem for one or both partners. For other couples, each partner may experience him- or herself as inadequate and the sexual encounter as unfulfilling as a result of the ejaculatory problem. Sometimes partners of men with DE attribute the problem to themselves because of feeling unattractive, rejected, or unlovable.

Other psychological factors that affect ejaculation include worries about body image (Perelman & Rowland, 2006) and a preference for sex by themselves (Apfelbaum, 2000). Perelman has reviewed the literature and identifies three factors that are strongly associated with DE: a high rate of masturbation (three or more times per week); a distinctive masturbatory pattern that is difficult for a partner to replicate (such as using extreme thigh pressure); and “a disparity between the reality of sex with a partner compared with preferred sexual fantasies during masturbation” (Perelman, 2014, p. 141).

There are multiple factors that contribute to the onset and continuation of DE. A variety of medical, psychological, relationship, and cultural contributors to the problem must be fully assessed.

Medical factors contributing to DE include: hormonal deficits, especially having to do with androgen levels; diabetic neuropathy; prostate cancer treatment; the ingestion of 5-alpha reductase inhibitors for enlarged prostate or hair loss; any illness or surgery that interferes with the pelvic nervous system; penile desensitization particularly with aging; and anti-depressants such as SSRIs. Perelman and Rowland (2006) suggest that the primary cause of DE may be a combination of the individual man’s neurological predisposition, producing a range of ejaculatory latency across men, and of a variety of factors operating in any particular encounter, producing a range of ejaculatory latency for each individual man in different situations. Some men with DE report a history of bladder shyness. Anxiety may contribute to other biomedical-related etiologies.

On the psychological level, any emotional state that inhibits the orgasmic reflex can affect ejaculation. This includes feelings of anxiety and attentional distraction, both of which can shift the man’s focus away from the very stimulation on which he needs to focus to be orgasmic. Kaplan and early psychodynamic theorists also suggested that internal psychological conflict might be associated with DE. The intrapsychic strife may be connected to a fear of pregnancy, relationship involvement, hostility towards the partner, resistance to pleasure, fears of castration, and even sadistic impulses towards partners, among others. Other theorists have suggested that the anxieties and attentional distractions are associated with poor communication about the desired type of stimulation and other sexual needs (Masters & Johnson, 1970; Perelman, 2014). This is one reason it is so important to ask during the assessment about whether the man tells his partner in detail about the way he prefers to be stimulated.

As a result, some clinicians suspect that the growing use of online pornography may affect delayed or absent ejaculation with a partner. However, this is currently a controversial theory.

When it comes to relationship issues, resentment and hostility that have built up within the context of the couple’s sexual and non-sexual interactions require consideration. This is particularly true when there is pressure to, or fears of, conceiving (Althof, Rubio-Aurioles, & Perelman, 2012). It is not uncommon for more introverted or reserved men who are apprehensive about expressing their feelings to displace their resentments onto their sexual interactions, unconsciously or subconsciously conditioning themselves to withhold ejaculation.

Family beliefs about sex, and cultural and religious conservatism, can also influence the development of DE (Masters & Johnson, 1970). Any environment that reinforces a negative perception of sexual expression, and especially ejaculation, increases the likelihood of delayed orgasm.

Specific Treatment Modifications of Sensate Focus for Delayed Ejaculation

As there is currently no medical procedure that aids the treatment of DE, therapy moves immediately to Sensate Focus.

Much like the treatment of pain and penetration disorders, the treatment of DE may begin with the client spending individual time prior to initiating couple’s Sensate Focus, time devoted to everything but self-stimulating to orgasm. He is asked to stop his regular self-stimulation habits and encouraged not to orgasm until he is able to ejaculate with his partner. Sensate Focus self-exploration is suggested with three goals including helping him identify the specific touch and fantasy stimuli: he finds most arousing; that parallel what he would like to find stimulating with his partner; and that he already does find stimulating with his partner. The man experiencing DE identifies the type of stimulation he requires to ejaculate with a partner in terms of degree of pressure, speed, or location of touch. The characteristic that is most common among men who confront DE is lack of adequately arousing stimulation. This is often the case because men tend to stimulate themselves more vigorously and with greater pressure whereas their partners, especially female partners, may stimulate them less intensely and with lighter pressure using their own frame of reference for preferred stimulation pressure.

During these self-Sensate Focus opportunities, the DE client initially spends time focusing on touch sensations that are most absorbing, with the understanding that ejaculation is not the goal. He is directed to stop short of orgasm as this not only removes the demand pressure for ejaculating but also begins retraining his self-stimulation triggers to approximate those he would like to experience with his partner. If his grip has been significantly firmer than the sensations of vaginal or anal stimulation can possibly replicate, he is asked to use a lighter touch.

Stimulation and Code Word

The next step is to desensitize the ejaculatory response to partner interaction in a step-wise fashion by having the couple initiate touching with breasts, chest, and genitals off limits, and then moving them on through the Sensate Focus hierarchy. During this involvement with the partner, the man learns to stimulate himself and ejaculate in his partner’s presence. The next successive approximation is to have him learn to ejaculate with his partner providing part or all of the skin-to-skin contact. Then the couple cooperates with insertion just as ejaculatory inevitability (the first stage of male orgasm) approaches.

All this time, the client communicates to his partner the type of stimulation he finds most effective, non-verbally if possible but also verbally if necessary. The partner is asked to stimulate vigorously and, if the client experiences himself being distracted by old, inhibitory thoughts, he uses a previously agreed-upon code word, much as do the clients with ED, to suggest a change in position and/or the type of stimulation he receives from his partner.

Fantasy and Other Helpful Techniques

Unlike other clients with sexual dysfunctions, men with DE are encouraged to focus on whatever sensory stimulation they find absorbing and arousing, including not just touch sensations but also visual sensations, fantasy, verbal communication, bodily movement, and anything else that will facilitate their becoming mindfully absorbed in the experience with their partners.

Much as with FOD, the importance of varied stimulation from a number of sources with elements of surprise cannot be overemphasized. For example, stopping and starting intercourse rather than staying the course once insertion begins may provide the extra stimulation needed.

Additional therapeutic adjustments may include PC exercises to tone and provide release of overly tense PC muscles, and deep breathing techniques to help stimulate calming, parasympathetic responses.

Genital Pelvic Pain Disorder (Dyspareunia) and Penetration Disorder (Vaginismus)

1.Difficulty and pain with insertion or touch to the affected area;

Genital Pelvic Pain Disorder and Penetration Disorder include pain of various intensities occurring in different locations in the genital pelvic area. This pain occurs most often when there are attempts to touch the painful area but it can even occur when touch is merely anticipated. Included in this diagnosis are Vulvodynia, a burning pain for which there are no apparent or obvious physical findings, and Vaginismus, the reflexive spasms in the outer third of the vaginal barrel that are an intensification of normal, voluntary muscles guarding the vaginal opening in anticipation of pain, fear, or anxiety, or manifesting as a phobic response. Despite the fact that the DSM-5 and other definitional schemes emphasize pain with insertion, we are also going to include difficulty and pain not necessarily associated specifically with insertion or thoughts about insertion. With this in mind, common characteristics include:

2.Anxiety just thinking about the potential of pain with insertion or touch to the affected area; and/or

3.The defensive reflex of a spasmodic tightening of the pelvic floor muscles during attempts at insertion, touch to the affected area, or thoughts of touch to the affected area.

Genital Pelvic Pain Disorder (Dyspareunia) is present in approximately 15% of women in North America. Penetration Disorder (Vaginismus) prevails in somewhere between 0.4 and 6.0%. The rates are higher in areas of the world where there is a lack of adequate sex education and much sexual inhibition. Vaginismus is often undiagnosed or misdiagnosed by medical professionals and therapists alike, especially in its mild to moderate forms.

There is little information on its occurrence in transgender populations or related to anal pain in Gay populations. However, recent research includes the possibility that men may also experience Genital Pain and Dyspareunia (Bergeron, Rosen, & Pukall, 2014).

Genital Pelvic Pain Disorder and the pain associated with Penetration Disorder are often described as burning, cutting, shooting, or throbbing. The pain may be felt around the entire vulva, just at one spot, at the vaginal opening, or deeper within the vagina. It may be present throughout insertion or just at the beginning, during urination, during a gynecologic exam, or when the client is attempting to use tampons.

Sometimes the Dyspareunic or Vaginismic client experiences pain at the beginning of insertion and it diminishes as she continues with intercourse. Other women experience so much distress that insertion is impossible and must be stopped. Sometimes the pain continues for a time even after attempts at intercourse have ended.

There is also variability in the type of sexual interest and responsiveness reported by those with Genital Pelvic Pain or Penetration Disorders. Some report experiencing a satisfactory sex life, especially with Vaginismus, and come for therapy only when they want to conceive and are unable to do so. Others report experiencing an almost phobic response to any attempts at, or thoughts about attempts related to, sexual activity of any type.

Both partners may come for therapy without being aware of the specific Dyspareunic or Vaginismic nature of the sexual dysfunction. Instead, they may present as a case of lack of desire, disorder, unconsummated sexual relationship, and even ED (later determined as having developed secondarily as a reaction to the pained partner’s distress).

Early puberty and pain with first tampon use, vulvovaginal and urinary tract infections, early and prolonged use of oral contraceptives, nociceptor proliferation and sensitization, and lower touch and pain thresholds … Recurrent yeast infections can cause persistent vulvar pain … Abnormalities of the [pelvic floor muscle] while at rest, including hypertonicity and poor muscles control, hypersensitivity, and increased mucosal sensitivity, may close the vaginal hiatus and thus interfere with penetration. Women may also exhibit a defensive reaction of the PFM [pelvic floor muscle] during attempted vaginal penetration. A vicious cycle involving the pain and further muscle dysfunction makes it difficult to identify cause and effect and is complicated by the involvement of psychosocial factors.

Dyspareunia and Vaginismus may be a result of biomedical problems and these usually need to be ruled out first. In addition to the effects of aging (decreasing lubrication, thinning of the vaginal walls), surgery, and treatments for infertility, chronic illnesses, and cancer, biomedical factors may include

(Bergeron, Rosen, & Pukall, 2014, p. 161)

Other etiological factors may include environmental sensitivities and allergies. Particularly in the case of Vaginismus, pain experienced during the first attempt or attempts at insertion, pelvic exams, and infertility treatment can contribute significantly to the onset of the disorder.

Other individual and psychological factors include a history of physical or emotional abuse, and sexual trauma that may increase the likelihood of genital and pelvic distress as much as four- to six-fold. In general, low self-esteem and developmental immaturity are reported as positively correlated with pain or penetration dysfunctions. Anxious or somatizing personality styles or disorders, where there is a tendency to catastrophize about physical distress and pain, are often associated with a greater likelihood of suffering Genital Pelvic Pain or Penetration Disorder. This is also true of those who fear losing control in response to pain, or who channel anxiety into physical distress.

There are a number of interpersonal factors that may contribute to Genital Pain and Penetration Disorders. These include poor sexual technique, partner pressure, and lack of partner support. The Dyspareunic person who feels compelled to engage in sexual activity in order to avoid negative consequences in the relationship, or who believes they are not psychologically or physically ready for sexual activity, has a higher likelihood of developing pain-related dysfunctions.

As with most other dysfunctions, situational stressors that include overwhelming family and work responsibilities contribute to the increased likelihood of experiencing Dyspareunia or Vaginismus. Cultural factors, like belief in the painful loss of virginity, are also associated with the development of these disorders. Vaginismus, in particular, is more common in sexually conservative cultures.

Specific Treatment Modifications of Sensate Focus for Genital Pelvic Pain (Dyspareunia) and Penetration Disorder (Vaginismus)

The most important part of any sexual pain treatment is that the client must experience herself as being in total control of the experience. This begins with a detailed medical exam by a well-trained gynecologist or pelvic floor specialist, conducted to confirm the diagnosis and identify biomedical problems. The person conducting the examination prepares the client carefully, reassuring her that there will not be any vaginal penetration, that she can ask for a pause or to stop at any time, that she will be engaged throughout, and that she is encouraged to provide feedback during the exam.

Psychosocial factors contributing to the disorder may also have to be addressed. These include clinically significant problems including a history of trauma, affective disorders, severe couple’s conflict, and the partner’s individual and/or sexual issues.

Medical Treatments

Some clients may choose an exclusively medical treatment approach such as the use of topical applications, oral or vaginally administered anti-anxiety medications, Botox, or surgery. Clients may also elect pelvic floor specialists and biofeedback training. Neither of these approaches precludes the use of a coordinated intervention that also includes sex and relationship therapy.

The Sex Therapy Approach: Education, Individual Sessions, Fingers, and Dilators

Most sex therapy with Genital Pelvic Pain/Penetration Disorders begins with sexuality education emphasizing the role of the pelvic floor muscles in the pain disorder, and the role of the fear–avoidance loop. In the case of Vaginismus, mindfulness training coupled with the use of the woman’s own fingers or a set of graduated dilators in a systematically desensitizing fashion is usually suggested. The client may use the dilators by herself in combination with pelvic floor training, and also with increased awareness of her PC muscles.

When it comes to Sensate Focus proper, treatment usually begins with the Dyspareunic or Vaginismic client’s initially engaging in daily touching sessions by herself, focusing on tactile sensations as usual. This might be likened to pairing systematic desensitization treatment with in vivo exposure therapy during which the client is encouraged to confront and manage her fears, and become desensitized to them as she slowly moves up a hierarchy of increasingly anxiety-provoking experiences. These sessions are paired with mindfulness training to manage the anxiety in which the client practices returning her attention to the tactile sensations as well as to her breathing. This sometimes takes place in the bath and may be followed by genital self-discovery. Before any attempts at inserting a finger or dilator, the client may be encouraged to let go of her anxious tension using PC practice, orgasmic release, deep breathing, and/or guided imagery.

Next, she practices insertion with her fingers and/or vaginal dilators in order to further desensitize her anxieties around contact and insertion. This begins with the smallest finger or dilator or, if these are too large, with just the tip of a Q-tip. It is lightly placed near her vaginal opening or close to the perineum. It is suggested she contract, or tighten, her PC muscles as much as she can, counting silently to herself, “One thousand one, one thousand two, one thousand three” and then letting go of the pelvic tension. She does this three times in a row, then takes a 10-second break, then does another set of three 3-second contractions, takes another break, and then does a third and final set. She practices these sets of three 3-second contractions three times, for a total of nine PC muscle-tightening/releasing repetitions.

The client practices these sets of three 3-second contractions as long as she needs to in order to feel comfortable, or at least less uncomfortable, with having her finger or the dilator in this position. A good indicator of when the client is ready to progress is when she comes into therapy reporting feeling bored or uninterested in the sessions rather than anxious.

The next step is to repeat this sequence of three 3-second contractions as the woman moves in small increments closer to inserting either her little finger or the smallest dilator into her vagina. She then attempts another group of three sets of three 3-second contractions. Slowly and in a step-wise fashion, she moves closer to inserting the finger or dilator with each group of contractions, and is strongly encouraged when removing her finger or the dilator to take as many steps as she took inserting. Sensing her new control, she is less likely to set off any unwelcome and painful contractions.

When the client has managed her avoidance and moderated her anxiety, she is encouraged to move on to the next larger dilator. She will have greater confidence in her ability to experience insertion without pain when she has traced the circumference size of her partner’s glans or partner’s dildo and knows that she has been able to comfortably insert a dilator matching this circumference size.

It bears repeating that the client is always in complete control in terms of placement, depth, and moving on with the next largest finger or dilator, all in supportive collaboration with her treating professional. The client is encouraged to practice all of these skills at least once if not twice a day for six out of seven days a week and for as many weeks as it takes until she reports feeling less fearful and is catastrophizing less often about insertion. The time frame required for working in individual sessions can vary tremendously from client to client.

Having said all of this in terms of the procedures, variations are sometimes helpful. For example, couple’s Sensate Focus during which the woman is orgasmic might actually precede and then be followed by the woman’s exploring by herself or in the company of her partner with finger or dilator insertion. This is because her arousal and orgasmic response may help her feel connected to her partner, less anxious, and less physiologically tense.

Partnered Sensate Focus suggestions are given shortly after the Vaginismic client begins feeling less uncomfortable with the self-insertion process and is ready to engage in a couple’s experience. Suggestions often then follow the usual hierarchical steps and lead to the non-demand, sensory-oriented atmosphere that may further help the client let go of her tension. However, the woman may, after practicing by herself for a period of time, decide to include her partner in her own touching sessions prior to beginning the couples portion of Sensate Focus. This can be left up to her.

When formal couple’s Sensate Focus begins, after genitals are on limits in the touching, and perhaps after she has been orgasmic, the woman inserts either her finger, her partner’s finger or, more likely by this time, the smallest graduated dilator. Then she slowly alternates tensing and letting go of her PC muscles around it, and holds it inside for a time. Later the client can practice slowly moving the dilator while in the presence of the partner. The partner can be involved in holding, touching, and being supportively present. As her comfort level increases, the client can use larger fingers and/or increasingly larger dilators.

Some women prefer not to use their fingers or a dilator in the partner’s presence and to proceed to female astride. They can then play outside the vaginal opening, tensing and releasing the PC muscles while being touched by the partner until they feel ready to move back onto the penis and slowly insert using the skills practiced with the dilator or their largest fingers. Her next step is experimenting slowly with movement and depth, again, staying focused on temperature, pressure, and texture, and changing her action if she experiences any discomfort.

Before doing any inserting, the woman is encouraged to practice the skills she has mastered in the individual finger or dilator sessions. She tightens her PC muscles three times in sets of three 3-second contractions. Then she lets go of the contractions, inserts fingers, the dilator, or her partner’s penis a little further to whatever degree she would like, and then continues the process. If pain occurs, she is encouraged not to grin and bear it. Instead, she breathes, contracts her PC muscles even more tightly and paradoxically than they are already, and removes the penis, finger, or dilator systematically, in a step-wise fashion, so as to avoid triggering any defensive contractions.

As an addition to the systematic desensitization provided by the use of finger, dilator, or penile insertion during Sensate Focus, treatment of Genital Pain and Penetration Disorders is even more effective when coupled with anxiety management and cognitive-behavior therapy skills that address catastrophizing, pain hypervigilance, and negative self-judging affective and thought patterns, among others.

LGBTQ, Sex and Gender Variant, Kink, and Non-Monogamous Clients

For the most part, Masters and Johnson developed their model for Sensate Focus with heterosexual couples. Although the original research on male and female sexual response published in Human Sexual Response (1966) was carried out with identified Gay, Lesbian and heterosexual individuals and couples, a complex and sophisticated understanding of sexual orientation and gender fluidity had barely been articulated at that time.

Over the past four decades, since the publication of Masters and Johnson’s original Sensate Focus protocol, most clinicians have recognized the vastness of, and variation in, human sexual expression. Hall and Graham (2014), Iasenza (2010), Leiblum and Rosen (2007), and Nichols (1982) have offered excellent reflections and research findings on these subjects. These clinicians and investigators have moved from a model of sexual deviance to one of sexual variation. In general, “members of sexual minorities now seek sex therapy not for help in changing or accepting their orientation but for help improving their sexual satisfaction” (Nichols, 2014). The old, rigid categories for labeling individuals in terms of sexual orientation, gender identification, and non-mainstream sexual interests have begun to fall away.

The initialism LGBTQ refers to Lesbian, Gay, Bisexual, Transgender, and Queer and/or Questioning. It acknowledges that many individuals do not fit comfortably into neat sexual categories. It is associated with other descriptions such as sex and gender fluid, sex and gender variant, kinky, and gender nonconforming, among others, in an effort to capture the non-binary, intersecting, and versatile nature of gender identification, sexual orientation, and expression. Research suggests that these groups of clients, particularly bisexual women, are more likely to express sexual interests that are not considered mainstream. These may include:

1.Bondage and discipline, dominance/submission, and sadomasochism (BDSM);

2.Unconventional sexual practices, concepts, identities, and fantasies;

3.Alternative relationships (multiple sexual and romantic partners, or polyamory); and

4.Open relationships (sometimes referred to as ethical non-monogamy).

(Barker & Langdridge, 2010; Richters, de Visser, Rissel, Grulich, & Smith, 2008)

Even so-called conventional sexual interests are more fluid than has been previously appreciated. We have witnessed the sometimes inclusion of BDSM play into what are considered mainstream practices since the publication of the best seller, Fifty Shades of Grey (James, 2011). Not surprisingly, research findings on the sex lives and sexual difficulties of minority and non-traditional individuals and couples are even more limited than the results on heterosexuals with conventional sexual interests. With these qualifications in mind we will proceed to describe the most common sexual difficulties of Lesbian and Gay couples, and make suggestions for modifications in Sensate Focus that may be helpful. We will follow with a few comments on work with transgender clients and other sexual minorities.

Lesbian Sexuality

Depending on which findings you consider, somewhere between 2 and 8% of women identify as Lesbians and/or Bisexual. Bailey and his colleagues (2016) suggest that the prevalence is probably less than 5%. Even though this is less than what the average American guestimates (as high as 25%), it is still a sizable portion of the population and clinicians are increasingly receiving requests from Lesbian couples for sex therapy.

Specific Treatment Modifications of Sensate Focus for Lesbian couples

The most common sexual complaint of Lesbian women is their own or their partner’s lack of sexual desire despite the absence of major conflicts, and in the presence of both good communication and physical affection. The initiation of sex seems to be particularly susceptible. Some of the first researchers to explore Lesbian sexual patterns suggest that Lesbians have less frequent sexual encounters than other partnerships (Blumstein & Schwartz, 1983). The term “Lesbian death bed” has been coined to describe the loss of sexual frequency in these long-term relationships. Women in Lesbian relationships may differ from heterosexual women in that their sexual interest may more often follow rather than precede sexual interaction (Basson, 2000).

Nevertheless, other researchers have discovered that while sexual encounters between Lesbians may be less frequent and less genitally focused, they include more sensuality and last for longer periods of time (Iasenza, 2002). Still others have identified Lesbians as being: more frequently orgasmic in their sexual encounters; less likely to have sex just for their partner’s sake when they themselves are disinterested; less likely to report pain disorders; and less likely to have sexually transmitted infections (Nichols, 2014). Lesbian sexual relationships also appear to be characterized by the enduring eroticism of butch/femme identities, the exploration of gender dynamics, and their egalitarian nature (Lev & Nichols, 2015). This egalitarianism, together with the associated intense emotional and sexual connection between the partners, may result in a sense of symbiosis. The mystery that can add an extra and elemental spark of eroticism to their sexual relationship may be absent (Nichols, 2014).

Experts who work with Lesbian couples report that, for the most part, they do not significantly alter Sensate Focus procedures or instructions when working with Lesbian couples. In a personal communication (March 31, 2016), Suzanne Iasenza, a specialist working with Lesbian and Queer clients, suggests, “Because the goal is the development of presence instead of the achievement of a particular physical act (‘being’ vs. ‘doing’)” there is no need to change the Sensate Focus activities when working with Lesbian as opposed to heterosexual couples.

Low Desire

The treatment of low desire in Lesbian women is similar to its treatment in heterosexual women. In an effort not to repeat information that has already been presented, please refer above to the section on Female Sexual Interest/Arousal Disorder (p. 68).

Genital-to-Genital Contact

As with all couples, the Lesbian couple’s goals and preferred sexual practices are to be considered when suggesting a hierarchy of touch suggestions. In creating the Sensate Focus hierarchy, the only routine change that usually needs to be made has to do with the genital-to-genital contact. The couple may decide what position they would like to assume in this step. Is one of the partners going to be on top rubbing her mons area on the mons area of the other partner? Or would assuming a side-by-side scissoring position be preferable?

Insertion

The next issue to be considered is insertive sexual contact. Do they practice insertion of any kind? If not, would they like to? If so, would they prefer insertion using their fingers? Would they rather use a strap-on or a dildo? When Sensate Focus moves from resolving a sexual dysfunction (Sensate Focus 1) to enhancing the relationship (Sensate Focus 2), is oral sex something they would like to experience or with which they have difficulty?

Gay Male Sexuality

As with women and the Lesbian population, Gay men are thought to make up somewhere between 2 and 8% of men, most likely right around 5% (Bailey et al., 2016). Gay couples are similarly interested in resolving sexual dysfunctions and cultivating sexual optimization, and are increasingly knocking on the door of sex therapists.

While Gay couples practice anal sex less often than oral sex or mutual masturbation, and while Gay couples who do practice it do not necessarily include it in every sexual encounter, when they do report sexual difficulties associated with anal sex it often has to do with disagreements over the role of insertee (top) vs. that of the inserter (bottom). Another difficulty therapists may encounter is aversion to anal sex or painful anal sex, sometimes associated with sexual trauma. One increasing concern among this population is the rising rate of HIV transmission (Center for Disease Control and Prevention, 2015). This has led to harm reduction techniques, including serosorting. Serosorting involves identifying the status of possible partners before engaging in unprotected anal sex and using PrEP, a controversial antiretroviral drug, in small doses while HIV negative.

Gay male couples, like Lesbian couples, are more similar to all other couples than they are different. However, they do seem to report a lower rate both of Premature and Delayed Ejaculation as well as fewer concerns with out-of-control or problematic sexual behavior. This is despite the fact that research findings also suggest Gay men experience a higher overall rate of sexual dysfunction in general, and ED in particular (Bancroft, Carnes, Janssen, Goodrich, & Long, 2005; Sandfort & de Keizer, 2001). They also report a higher number of consensual non-monogamous relationships and a higher overall number of casual sex partners and sexual frequency than heterosexual men or women.

Specific Treatment Modifications of Sensate Focus for Gay Couples

Much as with Lesbian couples, sex therapist Joe Kort suggests that he does not significantly alter Sensate Focus procedures or suggestions when working with Gay as opposed to heterosexual couples (personal communication, March 31, 2011). Sex therapy for Gay couples is individualized and directed towards their goals as well as incorporating their sexual preferences. One of the Sensate Focus modifications includes the choice of positions for the genital-to-genital contact. These may include kneeling on the bed while facing one another, or lying face-to-face, or some other position.

Another modification with Gay couples has to do with the treatment of ED. In using Sensate Focus with heterosexual ED couples, the female client goes astride her partner, directs the genital-to-genital contact, and does the inserting when she is ready and when she knows there is sufficient engorgement for her partner to be ready. As a result, the client with ED does not have to be concerned about the insertion. For Gay couples who practice anal sex, this is obviously not the case. It can be somewhat more difficult to replicate this non-spectatoring approach if the ED client is the top or inserter. In these instances, including additional practical suggestions for gaining and losing engorgement may be helpful for managing fears of performance. Sensate Focus modifications for Gay couples may emphasize directing attention to visual sensations. These alterations may include an emphasis on visual sensations especially when spectatoring their own arousal.

In cases of rapid ejaculation, one important modification is the position for touching with chest and genitals on limits. It is important for the person being touched, even if he feels somewhat vulnerable, to stay in the position where he is lying down on his back, facing towards the ceiling, and lying in between his partner’s outspread legs rather than sitting up in front of his partner to allow application of the Coronal Squeeze.

Bisexuality, Pansexuality, and Other Orientations and Identities

In recent years there has been more acceptance of bisexuality, pansexuality, and asexuality among others as valid sexual orientations, especially among younger age groups. Studies seem to point to the likelihood that bisexuality is more common among women than men, with three times more women identifying as bisexual as opposed to Lesbian (Gartrell, Bos, & Goldberg, 2012). These figures may be somewhat skewed because they rely on self-identification rather than sexual behavior or fantasy. They also may not include the category of heterosexually identified men who have sex with men (MSM) but who may not consider themselves bisexual.

According to sex therapist Margaret Nichols, Ph.D., “many self identified bisexuals are also transgender, ‘kinky,’ or polyamorous” (2014, p. 325). This requires the clinician to be informed, comfortable with, and sensitive to these diversities, or be prepared to refer clients to clinicians who are. One of the more common concerns in couples in which one partner is identified as bi- or pansexual is the fear that the partner will decide to become involved with a partner of the alternative gender. This raises the ongoing concern that this partner will decide he or she is more heterosexual or Lesbian or Gay than originally suspected and the fit between the couple may evaporate.

Specific Treatment Modifications of Sensate Focus for Bi- and Pansexual Couples

Bisexual and pansexual partners, regardless of gender or other identifications, have not been sufficiently studied to determine what, if any, sexual dysfunctions or difficulties they experience that are different from heterosexuals, Lesbian, or Gay identified clients. There do not appear to be any significant changes in Sensate Focus suggestions for this population unless gleaned from the client history-taking sessions and in consideration of the clients’ goals.

Transgender or Gender Queer Couples

Transgender people can be a rewarding population with which to work in sex therapy. They represent the most recent chorus of minority groups seeking inclusion, legal protection, social justice, and access to health and mental health care.

Specific Treatment Modifications of Sensate Focus for Transgender Clients

The research on transgender and gender queer individuals is exceedingly limited (Colebunders, De Cuypere, & Monstrey, 2015). What we do know, however, is that gender refers to one’s personal sense of maleness, femaleness, or gender fluidity/variance. This personal sense is related in complex fashion to self-concept and is not simply compliance to gender roles (how one is expected to live out his/her gender identity) or sexual orientation (the type or person to whom one is currently sexually attracted, if any). There is an increasing acceptance of the fact that there is much variation in gender identities beyond the conventional male/female dichotomy. In fact, the author of a recent publication encourages professionals to educate their trans clients that accepting their trans identities and bodies as they are without using hormones or surgical intervention may also be a valid way for them to proceed (Sieber, 2012).

Within the population of transgender-identified people, a subset has recently been identified as persons who may also be diagnosed on the Autism Spectrum. The most non-binary gender-identified individuals may be people who are on the Spectrum and who also identify as trans (Kristensen & Broome, 2015).

Trans-identified individuals who are seeking gatekeeping services for genital alignment surgery consult many sex therapists. However, since the subject of this manual is the use of Sensate Focus, we are not going to go into detail about medical transitioning. Instead, we are going to focus on working with clients who are already transitioning or have completed transition. We are going to discuss the adaptations of Sensate Focus that are helpful for these couples. Information on the guidelines for professionals working with transition can be obtained by visiting the website of the World Professional Association for Transgender Health at www.wpath.org.

In the last three decades, the age at which many trans-identified individuals come forward with gender-related concerns has dropped considerably. The significance of this is that fewer grow to adulthood without making their transitions, and fewer marry and have children, only later to identify as transgender. This has reduced the number of heartbreaking scenarios that used to play out in our offices whereby life partners had to grapple with whether or not to stay together in modified relationships or change their own sexual orientation.

Much like therapy with cisgender couples, sex therapist Suzanne Iasenza (2010) describes the use of Sensate Focus with transgender clients as primarily cultivating a state of mindfulness. She does not modify Sensate Focus significantly when working with this population.

Male-to-Female Trans Clients

Despite treating fewer couples that must wrestle with these difficult decisions, male-to-female trans individuals on hormones still present with sexual difficulties in their relationships. This is usually associated with desire difficulties. While the trans client may experience changes in desire as an extremely meaningful and even enjoyable female rite of passage as well as a relief from the tyranny of testosterone and ego dystonic erections, their partners may not be so enthusiastic. Sometimes partners process the loss of sexual interest and capacity as disturbing if only because the change is not of their own choosing.

In situations where both partners desire an increase in sexual interest and sexually connected involvement, Sensate Focus can be a useful medium to reduce goal-oriented attitudes, increase sensual interaction, fuel sexual thoughts and feelings, and aid the discovery of sexual relating and release with which they are more psychologically comfortable. Just as with addressing interest and arousal in non-trans women, self-Sensate Focus, fantasy development and other enrichment techniques can be useful.

The structure of the Sensate Focus hierarchy depends on the trans client’s view of her body. While some pre-op male-to-female trans people are comfortable with genital stimulation, erections, and insertion, others are not. Some prefer to have their genitals secured and covered at all times; others are at ease with rubbing mons areas together for stimulation rather than being touched directly. The critical issue here is that the therapist must work in a collaborative fashion with the trans client and her partner to determine what is most helpful for that particular couple. Additionally, the therapist needs to encourage the partners to negotiate how the non-trans partner will provide and be provided release as desired.

Female-to-Male Trans Clients

The number of people transitioning from female-to-male has recently equaled that of the previously more common male-to-female trans individuals (Beemyn & Rankin, 2011). Two-thirds of these individuals first identified as butch Lesbians. A number of investigations suggest that these transmen are blending sexual orientation and gender identity into more varied and non-binary identities. Those under 40 are identifying themselves more as gender queer. They report having a more fluid sense of their gender, sexual attraction, and orientation. They also are less conventional in their transitioning expectations and desires: they are not automatically heading towards hormone replacement or genital surgery.

The most common sexual difficulties presented by female-to-male trans clients, besides the ones that come to light during the self-discovery and transitioning process itself, can be the trans client’s higher sexual drive and interest, often a byproduct of testosterone treatment. Previously well-matched couples, especially couples that are now transmen and their cisgendered female partners, may find themselves at odds over sexual frequency. This may result in loss of sexual desire by the cisgendered female partners. As a result, these couples are best treated by using Sensate Focus in a way that mirrors its use with clients troubled by FSIAD. The same can be said if the cisgendered partner is male. In this situation Sensate Focus would be used in a way that reflects partners’ experiencing Male HSDD.

Kink

Kink is considered engagement in unconventional or non-traditional sexual activities, concepts, fantasies, or scenarios in order to increase sexual arousal and intimacy between partners. In contrast to vanilla or straight sexual behavior, Kink derives from the sense of change in direction, or bend, in sexual behavior and preferences.

People of all sexual orientations and walks of life practice kinky or unconventional sex. They may participate once in a lifetime or make it a lifestyle. They may even be unaware of the moniker and yet practice it in the privacy of their bedrooms, or they may be fully identified with the lifestyle in the public arena. One study suggests that heterosexual men and women are the least likely to practice Kink activities as defined by bondage and discipline, dominance and submission, and sadomasochism (BDSM), and bisexual men and particularly women are most likely. Nonetheless, somewhere between 12 and 55% of these populations have either restrained someone or been restrained for sexual arousal. Between 4 and 36% have received or inflicted pain for pleasure (Breyer, Smith, Eisenberg, Ando, Rowen, & Shindel, 2010).

Specific Treatment Modifications of Sensate Focus for Kink Clients

Kink may include fetishism, BDSM, sexual objectification, and a host of very specific sexual interests currently categorized as Paraphilic Disorders in the DSM-5. In recent years people in the Kink community have begun to question the appropriateness of including these categorizations as diagnostic criteria in the DSM-5 since, just as Gay and Lesbian people used to be included in this classification system, they may represent a normal variation in sexual interest and not as a diagnosable abnormality, especially under circumstances of consent.

In a personal communication (March 29, 2016), Margaret Nichols, Ph.D., who specializes in work with the Kink community, suggests that there is no need to modify the specific Sensate Focus procedures and suggestions when working with kinky clients. Neil Cannon, Ph.D., LMFT, another sex therapist familiar with the Kink community, concurs. He advises that the changes in Sensate Focus with clients from the Kink community often have not so much to do with the actual process of the touching opportunities, that is, not so much with changes in the actual positions, pacing, or activities. For the most part, clinicians using Sensate Focus with Kink clients follow the standard protocol. Instead, most alterations have more to do with the applications of Sensate Focus. Sensate Focus may be used as a bridge to help these clients when they are at an impasse in their intimate relationships, or with common sexual dysfunctions. Sensate Focus can serve as a confidence booster that reassures the client. Sensate Focus can also be used to help Kink couples slow down their sexual activity.

What follows is an example of using Sensate Focus as a transitional bridge with a couple that presented for therapy and was engaging in BDSM practices including a female partner who was submissive and who also suffered from Dissociative Identity Disorder. All of the partner’s personalities were adult except for one that was a nine-year-old girl. The clients were concerned because they believed that BDSM play with the “young” girl violated the definition of consent. The couple not only started to disengage from BDSM sex but also from non-BDSM, mainstream sex. With this couple, Sensate Focus was used to help them re-engage first in non-BDSM sex and then as a transition for helping them back to BDSM that no longer included playing with the nine-year-old female alter.

With another couple, BDSM activities had been labeled as problematic because they had come to dominate their sex life. They had stopped having non-BDSM sex altogether. The male partner subsequently developed erectile problems when the couple tried to engage in non-BDSM sex and was feeling increasingly vulnerable. Because the couple still wanted to savor non-BDSM sex, Sensate Focus was implemented to help the partner with ED manage the anxiety-provoking distractions associated with his erections in this context. The Sensate Focus protocol, attitudes, and skills were identical to those used to help non-Kink partners resolve erectile dysfunction. However, they served not only as a transitional tool but also as a significant confidence enhancer and a way of slowing the sexual activity down. This provided more opportunity for exploring the varied sensual connection they could experience with each other.

Consensual, Non-Monogamous Couples

Consensual non-monogamy is the open agreement between two people that they are not going to be sexually exclusive with one another. In an article entitled, What Psychology Professionals Should Know About Polyamory (based on a paper presented at the 8th Annual Diversity Conference in March 1999 in Albany, New York), one researcher states,

While openly polyamorous relationships are relatively rare … there are indications that private polyamorous arrangements within relationships are actually quite common. Blumstein and Schwartz … noted that of 3,574 married couples in their sample, 15–28% had an understanding that allows non-monogamy under some circumstances. The percentages are higher among cohabitating couples (28%), lesbian couples (29%) and gay male couples (65%).

(Weitzman, 1999, p. 312)