The client with sexual dysfunction may or may not define the problem directly; if, for example, the woman is the partner experiencing major dissatisfaction with her relationship, for any one of a number of reasons, she purposely may obscure her basic personal antipathies by describing gross sexual irregularities on the part of her partner. Sometimes when it is the man who wishes to end the relationship, he often employs the pressure of partial sexual withdrawal, or even complete sexual refusal. At this point, therapy is sought solely to justify condemnation of what is termed the mate's unfair, inadequate, or wrong sexual behaviour.
Actually, the incompatibility that brings the couple to the therapist usually is not primarily of sexual origin. Sexual incompatibility may well be the secondary result of relationship disagreement over such problems as money, relatives, or child care. Such areas of dispute easily may undermine any poorly established pattern of sexual adjustment. Frequently, withholding of sexual privileges is used as punishment in retaliation for true or fancied misdeeds in other areas. The complaint should be attacked directly and with a sense of urgency. Otherwise, permanent impairment of the relationship may be inevitable.
The need to acquire accurate and detailed sexual histories is basic to determining the type and the degree of sexual problems.
Sexual histories must reflect accurately details of early sexual training and experience, family attitudes toward sex, the degree of the family's demonstrated affection, personal attitude toward sex and its significance within the relationship, and the degree of personal regard for the relationship partner. While the actual nature of the existing sex difficulty may be revealed during an early stage of history-taking, the total history, as it discloses causation and subsequent effect, provides the basis for the most effective means of therapy.
The first step in the two-interviewer approach to diagnosis and treatment has been to see the man and woman together as a complaining unit during the initial interview. Procedures and philosophies are explained to them. If the couple desires to continue after the concepts have been outlined, they are separated for individual interview but only after each partner is assured that similar background material will be covered simultaneously by the two interviewers.
The knowledge that both members of the couple are undergoing similar interviews, that essentially the same background material will be investigated, and that all areas of professed concern will be probed in depth, produces an atmosphere that encourages honest reporting and an unusual amount of client attention to detail. Finite details of past and present sexual behaviour may be obtained during the initial interview. Encouraged by a receptive climate, controlled, brief questioning, and a non-judgmental attitude, the client is just as free to discuss the multiple facets of sexual dysfunction, for example, a homosexual background, as he might be to present the specific details of a chronic illness in a medical history. It should be noted particularly that in the process of acquiring a detailed sexual history, the usual basic physical and social histories of medical and behavioural significance also are recorded.
For the rapid diagnosis and treatment of sexual incompatibility, a man-female therapy team approach involves the male relationship partner being interviewed first by the male member of the therapy team. Simultaneously, material from the female partner of the involved relationship unit is acquired by the female member of the therapy team. Prior to the second investigative session, members of the therapy team exchange pertinent details of the couple's reported sexual distress.
During the second session the female partner of the complaining couple is re-interviewed by the male member of the therapy team. Meanwhile, the man is evaluated by the female therapist. At the third interview, the therapy team and the relationship couple meet to review the positive features of the earlier interview sessions and to discuss in detail the active degree of the sexual incompatibility.
THE THERAPEUTIC PROCESS
Once the background of the individual couple's sexual imbalance has been defined, and the clinical picture explained to their satisfaction and understanding, a discussion of therapeutic procedure takes place.
In general terms, the psychotherapeutic concepts and physiologic techniques employed to attack the problems of anorgasmia and erectile dysfunction are explained without reservation. Specific plans are outlined for the therapeutic immediacies and a pattern for long-range support is described. With this specific information available, a decision must be reached as to whether the couple has sufficient need or interest for active participation in the therapeutic programme.
A decision obviously is based not only on a joint evaluation of the quality of the relationship and the severity of the sexual distress, but also on a review of the individual abilities to co-operate fully with the programme. If doubt exists, on the part of either member of the investigative team or either partner of the sexually incompatible relationship unit, as to real interest in remedial techniques or ability to co-operate fully as a couple, the couple is directed towards other sources of clinical support.
Since the two major sexual incompatibilities are anorgasmia in women and erectile dysfunction in men, treatment for these problems will be discussed in detail.
Two major
types of erectile dysfunction countered in men are:
(1) Failed erection. Penile erection cannot be achieved.
(2) Inadequate erection. Full penile erection either cannot be achieved
or, if accomplished, is maintained fleetingly and lost, usually without
ejaculation.
Note. Premature ejaculation - ejaculation before, during, or immediately after penetration - is not a form of erectile dysfunction, but is discussed here due to the similarity of therapeutic approach.
Impotence: once the possibility of spinal cord disease or certain endocrinological problems, such as hypogonadism or diabetes, have been eliminated, the total history should be scrutinized for the omnipresent signs of psychogenic origin for the specific type of male erectile dysfunction reported.
In the case of the man with failed or inadequate erection, history-taking should stress the time-table of symptom onset. Has there always been difficulty, or is loss of erective power of recent origin? If recent in origin, what specific events inside or outside the relationship have been associated with onset of symptoms? Are there any masturbatory difficulties ? Is there a homosexual background of significance?
Further questioning should define the man's attitude towards his sexual partner. Is there rejection not only of the relationship partner, but also of other women? Are the female partner's sexual demands in excess of his levels of sexual interest or ability to comply? Is there a sexual disinterest that may have resulted from the partner's physical or personal traits, such as personal habits or chronic alcoholism?
In the case of a client with premature ejaculation, questions should be concentrated in a different area. Does this rapid ejaculatory pattern date from the beginning of his sexual activity? Has he been exposed to prostitute demand for rapid performance during his teenage years? Does he think of the female sexual role as purely one of service to male demand?
Actually, the fundamental therapeutic approach to all problems of erectile dysfunction is one of creating and sustaining self-confidence in the client. This factor emphasizes the great advantage in training the woman to be an active member of the therapeutic team. All pertinent details of the anatomy, physiology, and psychology of man erectile dysfunction should be explained to her satisfaction. The rationale of treatment, together with an explanation of the specific stimulating techniques most effective in dealing with the specific type of erectile dysfunction distressing her partner must be made clear to her.
In the early stages of treating failed or non-erective erectile dysfunction, it is wise to avoid emphasizing the demand that intercourse be the end of all sexual play. Frequently, the man's inability to meet just such a repetitive female demand is already one of the primary factors in his erectile dysfunction. Some men find release from fear of performance when they are given to understand that sexual play need not necessarily terminate in intercourse. They are then able to relax, enjoy, and participate freely in the sexually stimulating situations created by their partners to a point where erection does occur. After several such occasions of demand-free spontaneous erections, the men may even initiate and complete the sexual act. This casual sexual intercourse may well be the beginning of release from their chronic or acute failed or non-erective erectile dysfunction.
In most cases, manual penile manipulation varying in degree of intensity and duration probably will be necessary, This controlled penile stimulation must be provided by his previously trained female partner. The man with inadequate erection syndrome should be exposed to long and regularly recurrent periods of manual stimulation in a sensitive, sexually restrained, but firmly demanding fashion.
In the opposite vein, the man with the difficult problem of premature ejaculation should be manually stimulated for short, controlled periods with stimulation withheld at his own direction as he feels ejaculation is imminent. The shaft of the penis should be well lubricated to reduce skin sensation. This technique will fail frequently and ejaculation will occur. However, the couple should be encouraged to return to the technique repetitively until the man's obviously improved control leads to the next therapeutic step. This will be sex in the female superior sexual position, which can later be changed to a non-demanding sideways sexual position. These progressive control techniques emphasize the relationship approach to the problem of sexual inadequacy and from here on psychogenic support and the co-operation of the woman certainly will reclaim many of those men who were formerly inadequate sexually.
From a therapeutic point of view, the maximal meaning of the word should indicate no more than a prevailing inability or subconscious refusal to respond sexually to effective stimulation. A woman is not necessarily lacking in sexual responsiveness when she does not experience an orgasm. Therefore, the achievement of orgasmic response should not be considered the objective of sexual gratification for the responding female.
Unhappily, many women, unable to achieve an orgasmic level of sexual response in the past have been labelled frigid. The free use of this term frequently does great psychological damage. Anorgasmia is a term that should be employed to avoid adding shame, and/or fear of inadequate performance to whatever other psychological problems a woman may have.
It is true that there are a number of women who experience a persistently high degree of sexual arousal, but, for various reasons, are not able to achieve a satisfactory orgasm. In evaluating this problem, initial exploration should be concentrated in two areas of psychosexual withdrawal. The first is to determine the presence or inability to respond to effective sexual stimulation. The second is to define the possible existence of sexual incompatibility caused by misunderstandings resulting from a difference in the sex tension demands of the relationship partners.
Three positive indications of female psychosexual problems can be developed by careful history-taking:
(1) Attitude towards sex and its significance within the relationship.
(2) Attitude to the relationship partner.
(3) Fear of pregnancy.
In investigating the attitude towards sex, existing negative concepts should be
pursued by careful interview techniques. Questioning should explore early sexual
training and experience, exposure to lack of demonstrated parental affection,
history of same-sex experience, if any, and/ or any traumatic sex-oriented
incidents that might have affected natural sexual responsiveness.
When exploring the area of personal regard for the relationship partner, the female partner's disinterest or lack of co-operation with the consulting therapist may be an interesting clinical symptom of itself. When essential indifference towards a relationship partner has been exposed, the existence of a basically unwanted relationship or relationship undertaken without intelligent preparation or emotional maturity is a real possibility. Perhaps, in these cases, referral to a relationship counsellor or undertaking relationship counselling in the more general frame of reference is in order, rather than concentrating on the sexual aspects of the problem.
When there is any indication of fear of pregnancy the therapeutic approach is obvious. Actually, satisfactory results are ordinarily more easily achieved in pregnancy-phobia situations than in either of the other two areas of psychosexual withdrawal. After the background of the female's sexual unresponsiveness has been established, and the couple has accepted the conclusions presented during the diagnostic sessions, therapy may begin. Female sexual responsiveness may well depend upon the successful orientation to the following framework of therapeutic approach:
(1) The possibility of anatomic or physiologic abnormalities that can contribute to varying shades of discomfort during intercourse should be eliminated. Explanation of male and female sexual anatomy, directly if necessary, should be accomplished.
(2) Affirmation that sexual expression represents an integral basis for sharing within the relationship should be emphasized.
(3) A mutually stimulating sexual pattern should be developed and adapted to the individual psychosocial backgrounds of the relationship partners.
(4) Gentleness, sensitivity, and technical effectiveness in the male partner's approach to sexual encounter should be encouraged.
(5) Emphasis should be placed on the fact that female orgasm is not necessarily the be-all and end-all of every sexual encounter.
With regard to pelvic abnormalities, it might be noted that a history indicating actual pain or any other physical displeasure during sex play or intercourse certainly suggests the need for an adequate physical examination. If physiological variants, such as pelvic endometriosis, causing severe, recurrent discomfort during intercourse with deep penile penetration are revealed, subsequent medical and / or surgical adjustments may be indicated. However, it should be noted that sometimes the simple clinical expedient of teaching the couple proper positioning for sex may remove the female partner's discomfort.
A high percentage of psychologically based problems for women begin as the result of rejection of, or ignorance of sexual positions by either or both relationship partners. The therapist may also be called upon to provide reassurance as to the propriety of variants of stimulating sexual behaviour. Clients who are sexually incompatible as the result of the woman's or man's total lack of sexual experience before relationship are seen occasionally. Moreover, many women have been taught that only certain specifics of sexual stimulation or certain sexual positions are acceptable. These women do not readily accept any deviation from what they consider "right and proper," regardless of the interests of their relationship partners.
Teaching the sexually unfulfilled woman and her partner the basic rudiments of sexual anatomy may be extremely important. Many men, however experienced in intercourse, are unaware of the importance of adequate techniques for clitoral area stimulation. Few are aware that it is the gentle friction of the mons area or of the clitoral shaft rather than the clitoral glans that provides the most effective stimulation for the female partner. Moreover, many women as well as men are not aware of the basic physiology of sexual response and of the fact that physiological orgasm takes place within the vagina and clitoris, regardless of where sensation is perceived by the woman or initiated by the man.
In the development of a mutually stimulating sexual pattern it is important that the couple's move towards maximal female sexual responsiveness should be accompanied by the woman asking for such things as: specific sexual preferences, desired zones of erogenous stimulation, choice of coital positioning and, particularly, stating that her orgasm is near. The couple must be taught to consider moments of individual preference for sexual encounter. Experimentation with varieties of time, place, and sexual techniques should be made in order to achieve the necessary mood conducive to the female's successful sexual response. It is well to bear in mind that the two basic deterrents to female sexual responsiveness are fatigue and distraction.
The item in the therapeutic framework emphasizing gentleness and sensitivity needs little elaboration. But it should be noted that the man's approach - his ability to project both security and affection to his partner - may be an absolute essential to any improvement in the woman's sexual responsiveness. A re-evaluation of the man's attitudes towards sex and towards women may be as important to the progress of therapy as the attention paid to his education in specific sexual techniques.
The second major area to be explored with the couple is the possible difference in the degree of basic sexual tension demonstrated by the woman as opposed to that indicated by the man. In analysing this area, it should be emphasized that an impression of low-level female sexual demand should only be established in relative comparison to a higher libido partner. A lower level of demand does not necessarily connote either inability to respond adequately to effective heterosexual stimulation or homosexual tendency.
Yet, when such a divergence in sexual interest is encountered, there are inevitable misunderstandings between the relationship partners. In some cases there may be a conscious sexual withdrawing by the lower-response partner, developing from a sense of personal inadequacy or from a wish to punish what is considered as excessive demand. Conscious sexual withdrawal also may develop from a deep resentment or a sense of rejection felt by the partner wishing a higher degree of sexual participation.
The couple's understanding and acceptance of a difference in sexual tension demand is far more important than its causation and the determination of a specific spouse role-playing. A higher level of demand may well belong to either partner. This is evident in relationships between younger partners as well as in many relationships between older individuals. Feelings of sexual inadequacy, distrust, or withdrawal may be corrected by education of each person to the other partner's individual, highly personal, sexual requirements.
Thereafter, the problem becomes one of adjusting acknowledged differences in sexual desire to a mutually accepted plan for effective release of the higher level of demand. It has been noted frequently that the relief of inhibitions of the lower-tension partner (once the relationship unit problem is understood) may be marked by a more receptive, or even increased willingness to participate in sexual activity; even though there is no permanent elevation of the lower-level partner's own sexual tensions.
The advice of the initially consulted therapist frequently will be the most important step in relief of relationship sexual problems. The therapist's forthright guidance and initial reassurance, whether he refers his clients to other professionals or treats them himself, provide the best foundation for the solution of problems of sexually incompatible relationships.