Models For Treating Sexual Dysfunction Sex Therapy

Sex therapy theory and technique were derived from the pioneering works of both Masters and Johnson (1) and Kaplan (2). Initially Masters, a gynecologist, used an innovative 2 week, mixed-gender, co-therapy team, quasiresidential approach.

Sex therapy rapidly morphed into weekly sessions provided within a solo MHP's office based practice. Treatment continued to emphasize "sensate focus exercises" and the reduction of performance anxiety. By the 1980s, sex therapy reflected a cognitive-behavioral theoretical bias, while typically utilizing Masters and Johnson variations, such as Kaplan's, four phase model of human sexual response: desire, excitement, orgasm, and resolution (1,4,5). The models were not necessarily linear and causes could become effects. For instance, an ED might cause diminished desire. However, generally speaking, sex therapy was and is, the diagnosis and treatment of disruptions in any of these four phases and/or the sexual pain and muscular disorders. These dysfunctions occurred independent of each other, yet they frequently clustered.

Sex therapy was based on the development of a treatment plan conceptualized from the rapid assessment of the immediate and remote causes of SD while maintaining rapport with the patient (6,7). The sex therapist assigned structured erotic experiences carried out by the couple/individual in the privacy of their own homes. These exercises were designed to correct dysfunctional sexual behavior patterns, as well as positively altering cognitions regarding sexual attitudes and self-image. This "home play" modified the immediate causes of the sexual problem, allowing the individual to have mostly positive experiences and created a powerful momentum for successful treatment outcome. Interventions aimed at correcting or challenging maladaptive cognitions were incorporated into the treatment process (8). The individually tailored exercises acted as "therapeutic probes" and were progressively adjusted until the individual or couple was gradually guided into fully functional sexual behavior (4,6). However, each dysfunction had its own cluster of immediate causes. Certain exercises were typically used with a particular dysfunction. For example, almost all men with premature ejaculation (PE) were taught the "stop-start" technique, because failure to recognize and respond properly to sensations premonitory to orgasm, characterized that syndrome.

Patients might be single or coupled. The single patients were seen alone, but their new sexual partner might join them in treatment, once an ongoing relationship was formed. Couples were usually seen conjointly, however, during the evaluation phase of treatment, they were typically seen alone for at least one session of history taking. Other individual sessions were reserved for management of resistance where it may be more strategic to discuss the obstacles to success privately. To facilitate the success of this rapid approach, individuals/ couples at times needed to explore other aspects of their relationship and/or intrapsychic life. Nevertheless, establishing sexual harmony typically remained the primary focus. Despite the concrete goal orientation, the therapeutic context was humanistic, emphasizing good communication, intimate sharing, and mutual respect.

Sex therapy was an "efficacious" treatment for primary anorgasmia in women, some erectile failure in men, and was "probably efficacious" for secondary anorgasmia, ... , vaginismus in women and PE in men (9). Clinical experience supported efficacy in treating hypoactive sexual desire, sexual aversions, dyspareunia, and delayed orgasm in men (9). Despite its potency, there were and are drawbacks to this approach, particularly from a cost-benefit standpoint. Although considered as a "brief treatment" within a mental health context, it typically required many appointments with a trained specialist and a high degree of motivation on the part of the patient. Historically, healthcare systems have discarded labor intensive, expensive approaches once "easier" and more rapid alternatives were available. Sex therapy receded as a treatment of choice during the 1990s, as medical and surgical approaches performed by urologists established hegemony over the treatment of ED, in particular. The pinnacle of this transition was reached during 1998, with the launch of sildenafil.

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