Recommendations For Clinical Practice

We would like to end with five questions that may help establish the heart of the problem in women with complaints about reduced or absent arousal and desire.

The first question is whether the client wants to be sexual at all. This question may refer to people that were excluded from Masters and Johnson's studies. These may be people so deeply involved in relational conflict, that they, as Masters and Johnson put it, need legal advice instead of sex and relationship therapy (101). The prognosis for a rewarding sexual relationship, even if all the relational discord was to be resolved, seems to be poor (121). Learning to stop arguing or learning to do that more effectively does not necessarily improve the sexual relationship. For that, as we have argued, situations with positive sexual meanings are a first prerequisite.

The second question refers to the sensitivity of the sexual system. As we have seen, in healthy women problems related to genital unresponsiveness are unlikely. For clinicians who need to rule out that organic etiology is underlying sexual arousal difficulties, or who question genital responsiveness for other reasons, a psychophysiological assessment will provide indispensable additional information.

Next, are there, on the basis of sexual history, positive expectations regarding sex? Are there any sexual rewards? And are these expectations activated in the given sexual situation, and which new sexual stimuli are likely to be sexually rewarding? When there are no or only a few positive experiences, one can try to help women find these experiences. A confrontation with sexual stimuli will probably only be rewarding by the sexually rewarding experience. Our disposition to respond positively to tactile stimulation must become associated with sexual stimuli.

If all these conditions are satisfied and the sexual system is activated, there will be a cascade of events that occur partly automatic and partly on the basis of conscious decisions. Whether we will be sexually active will depend, ultimately, on decisions about the partner, the circumstances, and on ideas about how we want to shape our sexual lives.

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