Sex therapy: clinical approaches and effectiveness

Sex Therapy

The efforts in the form of behavior modification with a view to solve the problems in sexual interactions are known as sex therapy. Sex problems most common in the present environment affect the couples in their sex lives and adversely reflected in their sexual behavior. Sexual behavior is any activity inducing the sexual arousal in solitary or between two persons or in a group. The human sexual behavior is influenced by the inherited sexual response patterns as a means of ensuring reproduction and by the societal restraint and influences exerted on the individual in expression of sexuality. (Clellan; Frank, 1951)

It is realized that social taboos, culture and immaturity of social sciences have brought considerable impediment in research in the field of human sexual behavior and until recently the scientific knowledge base was restricted only to a few of the individual case histories studied by European writers such as Sigmund Freud, Havelock Ellis, and Richard, Freherr Von Krafft-Ebing. In early 20th century two major institutes on sex studies were existed. The Nazis destroyed during 1933 the Institut fur Sexualwissenchaft in Berlin that was established in 1897. The American sexologist Alfred Charles Kinsey at Indiana University in Bloomington began the Institute for Sex Research in 1938 which was later named as Kinsey Institute for Research in Sex Gender and Reproduction for undertaking the study of human sexual behavior. The findings of the Institute still constitute most comprehensive data in finding out the sex problems and problems in sexual behavior. (Cutler; McCoy; Friedmann, 1998)

It is customary to classify the human sexual behavior on the basis of the number and gender of the participants. On the basis of the number of the participants the sexual behavior may be termed as issolitary and socio-sexual. The issolitary behavior arises out of the participation of only one individual and the socio-sexual behavior arises out of the involvement of more than one person. The socio-sexual behavior taking into consideration the gender of participants may be heterosexual behavior or homosexual behavior. (Clellan; Frank, 1951) In homosexual activity the participants are of same gender and heterosexual behavior involves participants of the different gender. The socio-sexual activity may also create the possibility of both heterosexual and homosexual activities simultaneously when the number of participants is more than two. (Lever; Kanouse; Rogers; Carson; Hertz, 1992)

The unusual sexual activities in both the cases of solitary and socio-sexual categories may be grouped as deviant behavior. These behaviors even though cannot be judged from moral point due to different social acceptances in different societies yet are regarded as abnormal activities and cause of many of the sex problems. (Adler; Adler 2003) Issolitary sexual behavior gives rise to self-masturbation that refers to the self-stimulation with a view to causing sexual arousal and sexual climax. Mostly, the masturbation is done in private and sometimes as a practice for facilitating socio-sexual relationship. It is generally beginning at or before puberty and are common among the young males. It is commonly regarded as physically harmful. It cannot be set aside as an immature behavior, for sometimes it also common among the adults those are deprived of socio-sexual opportunities. (Marcus; Francis, 1975)

The psychological significance of the masturbation differs from person to person according to their views on its approval. Some regards it as guilt, some regard it as release from tension with no emotional content and for others it is simply a source of pleasure to be enjoyed for its own sake. (Marcus; Francis, 1975) The evidence of orgasm in sleep sometimes occurs in issolitary behavior. The nocturnal emissions sometimes occur in males and the females experience orgasm in sleep as well seems a compensatory phenomenon for the individual being deprived of the sexual activity. Another example of issolitary behavior includes sexual arousal not necessarily leading to sexual activity with another person. Exposure to sexual stimuli seeing attractive persons, sexual themes, are under this category. The response of the adolescents is most acute in these cases. Gradual advancement of the age makes them learn to maintain a balance between suppression of these arousals, which has tremendous adverse psychological and physical impacts and with free expression in fear of social difficulties. (Clellan; Frank, 1951)

The common form of socio-sexual behavior is heterosexual behavior between only one man and one female. The heterosexual behavior some times begins in childhood out of curiosity in form of showing or examining genitalia. (Worthington, 2003) Engagement of children in sex play is get pleasure. The sex play becomes dating during the adolescence, which is socially encouraged. Involvement of physical contact during dating also results in sex arousal. Petting, hugging, kissing and generalized caresses of the body involving genital simulation are general sexual behavior during dating and sometimes regarded as a preliminary to coitus. (Shelley, 1981) Depending upon the marital status of the participants the coitus is looked upon differently by the society. The premarital coitus is condemned in majority of the societies while martial coitus is regarded as an obligation. Extramarital coitus especially, by wives is condemned like anything. (Nichols, 1988)

However, leniency of the societies is seen more often towards extramarital coitus by males than that of females. The extramarital coitus is interpreted by their spouses as an aspersion on their own sexual adequacy, a loss of affection and a source of social disgrace. (Nichols, 1988) The most abnormal form of socio-sexual behavior is homosexuality. It is described as sexual interest in members of one's own sex. (Bell; Weinberg; 1978) Lesbianism is indicated by female homosexuality. It is variously been tolerated, punished and banned in different cultures. The Judeo-Christian as well as Muslim cultures generally professed homosexual behavior as sinful. Modern developments have changed the ideas against homosexuality as a result of increased political activism and due to confusion in regarding homosexuality as a variant of normal human behavior or psychologically deviant behavior. (Cruikshank, 1985)

The lenient approval of homosexuality is seen with its declassification by the American Psychiatric Association, as egosyntonic homosexuality a form of mental illness. The psychologists leveled various theories on its origin regarding it as a form of mental illness. Richard Von Krafft Ebing, the 19th century psychologist traced its origin to the hereditary factors. Sigmund Freud viewed it as a result of conflicts of psychosexual development. (Committee on Adolescence, 1993) The Kinsey Institute of Sex Research viewed homosexuality as a frequent pattern in adolescence among both males and females. In some cases there is evidence of situational homosexual activities. (Evelyn; Wieringa, 1999) Prisons for example in absence of opportunities for heterosexual contract give rise to the heterosexual contact.

Abnormal sexual behavior give rise to many sexual problems which may be classified as physiological, psychological and social origin. There are few sexual problems caused by the physiological deficiencies such as diseases of deficiency in genital developments or neurophysiologic deficiencies governing sexual response. By-products of other pathological injuries may some times give rise to sexual problems. Cardiovascular conditions, vaginal infections, etc. may create disturbances in sexual activity. However, most of the sex related problems caused by physiological deficiencies are solved through medication and surgery. Sex problems caused by psychological factor are mostly common in its occurrence. Generally, the psycho-sexual problems are caused by the socially induced inhibitions, maladaptive attitudes, ignorance and social myths. (Muehrer, 1995)

Different medias such as magazines, marriage books, cheap sexual folklores prescribe ideals of good sex as rapid erection, protracted coitus, simultaneous orgasm etc., non-fulfillment of these ideals always give rise to psychological anxiety, guilt and feeling of inadequacy etc. (Margolies, 1994) Premature ejaculation is considered to be a common psycho-sexual problem mostly among the young males, which is sometimes due to the excessive tension of sexually deprived male. (Kaplan, 1989) In males under 40 the erectile impotence is always viewed as a psychological problem. It is found that the fear of being impotent puts the male in a self-perpetuating problem of impotency and overcome only after successful act of coitus. Sometimes impotence is due to disinterest in sexual partner, fatigue, intoxication which is regarded as occasional impotency. (Kaplan, 1979)

The inability to ejaculate in coitus termed as ejaculatory impotency is of psychogenic origin and associated with traumatic experiences. (Purvis, 1992) Vaginismus, Dyspareunia are some of the psycho-sexual problems faced by the females. The neuro-physiological differences often cause disparity in sexual desire. Problems also occur due to psychological fatigue due to growing disinterest in sexual behavior with a particular partner. Anorgasmy, lack of femal orgasm is another psychological problem. Treating methods of anorgasmy include removing of inhibitions, teaching of coital techniques, orgasm inducements through non-coital methods. Psycho-sexual problems are also caused by lack of free communication between the partners about the facts that contribute or do not contribute to one's pleasure.

The sex problems as believed by some of the patients are solved by medications. But this is a wrong conception. Medication solves only the problems caused due to physical factors which are only a negligible fraction of 15 to 20%. However, most of the problems as seen are due to psychological factors like performance anxiety, fear of failure, guilt, poor self-esteem, poor interpersonal communication, sexual ignorance etc. (Mangan, 1992) These problems are rectified by sex therapy. Sex therapy involves administration of some of the structured sexual tasks to the couple at the therapist's office. The couples practice the methods so prescribed successfully at home after understanding it fully, thereby rectifying the inhibitions that affects sexual response. Techniques developed by the Americans William Masters and Virginia Johnson during 1960s are most frequently used by the therapists. (Leiblum; Raymond, 1989)

The sex therapist mainly brings remedies with the non-organic problems affecting the sexual lives including premature ejaculation, impotence and other forms of sexual dysfunction. Therapists resort on exercises emphasizing inflicting and attaining sensual pleasures in order to overcome the anxieties about sex. Sex therapy may also involve specialized treatments against the specific sex-related problems. The basic principle of sex therapy lays emphasis on the fact that the sufferer is not the individual partner but the entire marital unit. In order to resolve the problems, therefore, participation of both the spouses is of prime importance. Deep rooted marital problems some times are associated with psychological problems and sexual problems. In these cases marital therapy and psycho therapy are to be resorted to conjointly for successful remedy. Success in the field of sex therapy however, depends upon the response of the patients, their openness and allowing the doctor to decide suitable methods. (Everett & Nichols, 1986)

The problems of infertility are dealt in first by investigating the problem. The tradition and culture of the society may some times result in stigmatism of the women, taunting and triggering off of a lot of negative emotions by the family peers, blaming of the spouses to each other for inability to conceive, pressures for frequent sexual activity causing diminished spontaneity etc. (Stigger, 1983) Sometimes men equate their sexual ability with becoming father of a child experiencing anxiety and depression. Often menstrual flow in women signals lack of success in achieving a pregnancy. These problems are regarded as psycho-sexual problems and mostly are self perpetuating. Counteracting the diminished sexual desire, impotence in men, and lack of orgasm in woman gives successful result in these directions. (Covington, 1992)

Many attempts by the doctors and religious leaders have been made in the directions of curing homosexuality. In earlier periods the desire to cure in this line mainly stemmed out of the societal discomfort of having love with same sex and had no pathological implications. (Whittam, 1977) Many theories have been advanced in late 19th centuries in this direction. They are Prostitution Therapy, Marriage therapy which involves continuous association with virtuous women and study of abstract sciences. (Sperry, 1991) Cauterization at the nape of the neck and lower dorsal and lumbar regions is prescribed by the Dr. William Hammond as a therapy against homosexuality. Castration and ovary removal is also practiced in pre-Hitler world against this. To remain Chaste is prescribed as a therapy against homosexuality. (Comment: Integrating psychoanalytic and behavior therapy, 1981)

John D. Qackenbos of New Hampshire propounded the curing of unnatural passions like nymphomania, masturbation and gross impurity through hypnosis. Dr. Louis Max of New York University supported Aversion Therapy in 1935 observing that considerably higher electric shocks diminished the value of the stimulus for homosexuality. Edmund Berger regarded homosexuality as a kind of psychic masochism and supported psychoanalytical theories for curing the homosexuality. Radiation treatment, Hormone Therapy, Lobotomy, Beauty Therapy for lesbians, Psycho-religious therapy etc. are several methods and approaches employed against Homosexuality. (Paul; Robert; & Rountree, 1991)

Several theories have been advanced for counteracting the sexual problems. The theories so advanced are classified as Psychoanalytic, Behavioristic, and Humanistic. Sigmund Freud, Adler, Carl Jung, Horney, Harry S. Sullivan, Erik Erikson, Erich Fromm, Eric Berne, Thomas Harris are major contributions in the field of psychoanalytic therapy. J.B. Watson, B.F. Skinner, Joseph Wolpe, William Glasser regarded as the father of reality therapy, James Dobson propounded major concepts in Behavioristic approaches towards sex therapy. Similarly, the contributions of Carl Rogers regarded as the father of client centered therapy, Abraham Maslow, Viktor Frackl, Rollo May, Seward Hiltner, Mowrer, Fritz Peris Albert Eris helps development tools in the field of Humanistic approach to sex therapy. (Paul; Robert; & Rountree, 1991)

Many therapies are being resorted to come across the psycho-sexual problems. Adlerian Psychotherapy resorts to encouragement, activation and infusion of new lifestyle among the sufferers through relationship, analysis and action methods. Analytical Psychotherapy uses a symbolic approach for guidance and encouragement through dreams, fantasies in order to result in increased awareness and bring symptomatic relief. Behavioral therapy modifies daunted stimulus response through cognitive, motor and emotional responses. Client Centered Therapy involves practice of participative and emphatic listening allowing client to freely vent his or her feelings. (Everett, & Nichols, 1986)

The therapist practicing Eclectic Psychotherapy selects the appropriate approach from the available therapeutic spectrum and uses as per the need of the patient. Encounter psychotherapy applies methods of self-awareness, self-responsibility, awareness of the body, attention to feelings etc. The therapist practicing Experiential Psychotherapy establishes a felt sense within their patients to resolve the problem. Existential Psychotherapy is based on the rationale that understanding of underlying conflict is essential to identify their deficiencies in dealing with the problems. Francine Shapiro developed the Eye Movement Desensitization and Reprocessing method that help the client process through traumatic memories of the events in the past that locked the nervous system and produced psychological problems. (Fenell; Weinhold, 1989)

The Gestalt Therapy involves harmonious and self disclosing confrontation of disharmonious elements through personal participation. Hypnotherapy involves intense focusing of attention upon specific inner or outer stimulus that soothes depressions, uncovers memories. Narrative therapy involves narration of negative stories of shame, isolation and powerlessness with individuals, couples and families creating integrated stories of growth shared struggle and purpose. Non-directive therapy counseling resorts to heeling of problems by ventilating the same and allowing him to find a conclusion. Psychoanalysis therapy lays emphasis on unconscious and dynamic forces in psychic functioning. Reality Therapy presents the individual at his own identity. Somatic psychotherapy takes into account the bodily experiences of using breath, sensory awareness, movement etc. In exploring the causes of the problem. (Everett, & Nichols, 1986)

Testosterone Replacement Therapy to counteract sexual problems arising out of deficiency in testosterone is a recent development in the field of human sexuality that is aimed at production and maintenance of physiologic serum concentrations of the hormone and its active metabolites without significant side effects or safety concerns. Couples Therapy is resorted to when people think that their relationship is good but needs some extra stimulus in order to make it better. The couple therapy involves introduction of the therapist as an objective third party that the family friends and acquaintances can not replace in its objectivity thereby finding out the wrong in the relationship and its solutions. The importance of the therapist lies in its objective and he never takes sides whatever may be contradictions. The therapist also helps in deciding the existence of future of the relationship. (Kaplan, 1987).