Contemporary Sex Therapy

Skills in Managing Sexual Problems

Cate Campbell

• Editorial: Routledge
• Año: 2020
• ISBN:
  9781000036381
• Edición: 1
• Categoría: Psychologie
• Categoría: Psychische Gesundheit in der Psychologie

Contemporary Sex Therapy explores modern sexuality, its expression and problems, and some of the uniquely twenty-first century issues facing sex therapists and society as a whole. Seeking solutions to these and other common sexual and relationship problems, the book provides a practical, sensitive and modern approach, which tackles the complexities of contemporary relationships, identity, love and sex.

A comprehensive, stepped approach to psychosexual therapy is offered, demonstrating how to tackle blocks to sex and intimacy as well as providing an understanding of how and why they develop. Loss of desire, sexual pain anderectile and orgasm difficulties are seen within the context of modern life and relationship dynamics, so that comprehensive and realistic solutions are more readily enabled. The book looks at significant issues such as sexual consent, sexual and gender identity, sexual trauma and culture, as well as the more recent challenges of porn-related sexual dependency, chemsex, female genital cutting and technology. Throughout, the emphasis is on recognising and meeting the specific obstacles and needs of a wide diversity of relationships and experiences, providing a vast toolbox to appropriately address contemporary sexual issues.

Established sex therapists, as well as students, will benefit from the book's modern approach which focuses on each partner's experience, avoiding outcome and response anxiety entirely and appreciating the range of pressures experienced by modern couples. Relationship therapists and couples themselves will also be motivated by new ideas and explanations, which often challenge existing intuitive understanding to produce nuanced and effective solutions to improve sex and intimacy.

Chapter 1

History and philosophy of psychosexual therapy

There is evidence that ancient civilizations around the world used forms of sex therapy which were not just concerned with sexual problems, but also with sexual enhancement and pleasure seeking (Niak, 2017). However, from around the fifth to the fifteenth century, Western sexual behaviour became dictated by religious ideals which exercised social control. It was insisted that sex was for reproduction only, and that sex solely for pleasure was both aberrant and bad for health. Health increasingly took over as the rationale for sexual proscription from the sixteenth century, as medicine became more professionalised (Atwood & Klucinec, 2007). Women’s health, in particular, was bound to their sexuality and reproductive potential rather than their sexual pleasure. Just being a woman has historically been seen as a cause of neurosis. The root of the word ‘hysteria’, for instance, comes from the Greek hystera, meaning ‘womb’. From the days of the ancient Greeks to the present, female hormones and the womb itself have been thought to affect women’s mental health. At one time it was even thought the womb could move around the body, afflicting organs and mood on its way (Adair, 1996).

As industrialisation took hold in the West, sex became as subject to market forces as everything else (Foucault, 1990), albeit sometimes obliquely. From the mid-nineteenth to early twentieth century, for instance, French physicians promoted the idea that women’s routine was too sedentary and that they needed exercise to prevent physical, mental and sexual health problems. Recognising the importance of women’s role in servicing the family, and thereby keeping the workforce afloat, they were encouraged to be as active as possible, taking on more strenuous household tasks, such as chopping logs (Quin & Bohuon, 2012). For girls and young unmarried women, sports were imported from England with the intention of preparing them for healthy childbearing and rearing. That they readily took to activities such as cycling and riding then created the problem that they were mobile and often, therefore, out of sight. Ultimately, swimming, cycling and horse riding – all of which somewhat challenged modest dress – were medically banned during menstruation. No other justification for control was available as the exercise did, indeed, promote fitness and enhance mood.

In the nineteenth century UK women were expected to service men’s sexual appetites, but not to experience the same desires and pleasures as men. Towards the turn of the century a medically trained social reformer named Henry Havelock Ellis began championing women’s rights, including sexual rights (Ellis, 2012), claiming that women could enjoy sex given sufficient appropriate stimulation. So outrageous were his ideas that his writing could only be seen by doctors until 1935 (Goodwach, 2005a). Many years ahead of his time, he normalised practices such as oral sex and masturbation, as well as homosexuality, and researched transgender issues, influencing many future practitioners, including Freud.

Gender

Ellis truly was transgressive as, for example, he questioned a binary approach to gender. Gender difference had become much more important in the eighteenth century, once again as medicine and science sought empirical evidence to explain the world. Certainly, ‘proof’ was offered to bolster power differentials, and ‘expert’ opinions were respected even in the absence of evidence. The gender dichotomy developed alongside racism; for instance, the hugely influential German psychiatrist Richard von Krafft-Ebing (1886) claimed women from – what he defined as – more primitive races than Europeans showed less gender difference. Before and since, the search to define a gender binary has failed, despite exploration of promising anatomical, genetic, hormonal, gonadal and neurological possibilities (Sanz, 2017). Indeed, the more a definitive explanation of gender has been sought, the more elusive it has become. While one in 2000 of us has been classified as anatomically – that is, genitally – ‘intersex’, there are also multiple versions of human biology which make it no simple matter to assign gender in other ways, while genital and gonadal anatomy is often so ambiguous that assigned gender has merely been a matter of parental choice (Associated Press, 2005).

Knowing and enacting gender has been of varying importance in different cultures and at different times. Nevertheless, even ancient societies emphasised social/sexual characteristics as indicative of good enough masculinity/femininity (Berry, 2013). Erectile failure in ancient Rome and Greece, for instance, was not just enthusiastically treated with the currently popular concoction, but prophylaxis was employed to avoid this misfortune. This becomes more understandable in relation to the idea that, at the time, and for centuries afterwards, physical adversity was associated with metaphysical or spiritual malady, including as punishment for some sort of unsociable thought, deed or aspect of temperament. Once science began to replace mysticism as the dominant authority on sex, from the eighteenth century, sexual behaviours other than straight intercourse were vilified. Krafft-Ebing made a living from pathologising sexual behaviours and creating fear about sexual response and mere thought, never mind behaviour. Perhaps this explains why adequate masculine gender performance has so much significance even now; we have become habituated to the idea that any lack, however minimal or blameless, is a cause for shame.

The twentieth century

The theories of Sigmund Freud in the early twentieth century ushered in a different approach to sexual problems, which he viewed as the root of most internal conflict. Human instincts, including drives related to procreation and pleasure, were thwarted by social convention, Freud asserted (1905/2016), and this conflict was at the root of much psychological distress. This related to issues such as resolution of the Oedipus complex, the incest taboo and penis envy, which became the focus of treatment for most psychological complaints, while sexual issues themselves weren’t directly addressed.

It wasn’t until the mid-twentieth century that interest began shifting to physical sexual problems. However, research and ‘treatment’ focused entirely on pathology rather than enhancement, with the emphasis on deviation rather than normality, but without any clear idea of what ‘normal’ was (Atwood & Klucinec, 2007). This meant practitioners were looking for extremes of behaviour or arbitrarily applying norms. Researchers like Alfred Kinsey and Masters and Johnson sought to determine people’s actual sexual behaviour rather than pursuing fairytales about what they ought to be doing or what was deemed ‘right’. The research by Kinsey and colleagues (1948) involved thousands of people and demonstrated the wide variety of sexual behaviour being enjoyed, often covertly. This was highly important at a moralistic time when aversion therapy was being employed to treat ‘perversions’ like masturbation and, particularly, homosexuality, which the American Psychiatric Association still considered treatable until the 1990s.

The physiology of erotic pleasure finally became the focus of scientific research when physician William Masters and his assistant, Virginia Johnson, brought sex into the laboratory, painstakingly measuring the effects of their subjects’ arousal. Though Masters began his work investigating sex workers, of the approximately 700 subjects that were studied, few were not white, middle-class and well-educated. Yet the context of the research cohort was, at the time, entirely irrelevant.

Masters and Johnson’s (1966) research set out to determine what happens to the body during sex, establishing stages of sexual response from arousal, through a plateau phase and orgasm to resolution, when the body returns to its homeostatic state. Though they promoted male and female sexual response as analogous and linear, they revolutionised the thinking of the time, asserting the role of the clitoris and debunking Freud’s idea that ‘vaginal’ orgasms reflected ego maturity. Having also identified the common sexual problems people experienced, Johnson realised that the behavioural interventions of practitioners like the South African psychiatrist Joseph Wolpe (1958) could potentially be used to treat what Masters and Johnson now termed ‘sexual dysfunctions’. Using relaxation and a hierarchical progression through a series of challenges to an individual, Johnson hoped patients would be able to overcome sexual anxiety through the gradual desensitisation which Wolpe was using successfully.

At about the same time, scepticism was growing about the efficacy of psychoanalysis, which was seen to take too long to achieve results and to have poorer outcomes than other interventions. This interest in other approaches was heavily influenced by the now contentious work of psychologist Hans Eysenck (1952) who reviewed the effectiveness of therapeutic modalities, finding Freudian psychotherapy fared worst. Since Eysenck was, at the time, using behavioural therapy at the Maudsley Hospital, he wasn’t unbiased. Nonetheless, behavioural interventions gained in popularity and Masters and Johnson’s (1970) treatment advice offered a cognitive behavioural (CBT) approach, introducing systematic desensitisation through ‘sensate focus’. They also sometimes used – mainly female – sexual ‘surrogates’, who stood in for partners under their direction. However, this controversial approach never gained general momentum and remains within the domain of specialist sex workers, primarily helping disabled clients.

Helen Kaplan-Singer (1974) elaborated Masters and Johnson’s CBT approach, including psychodynamic attention to the antecedents of couples’ sexual problems, which she saw as a symptom. She later (1979) discussed a triphasic sexual response cycle, involving desire, arousal and resolution, which inevitably contributed to the idea of low or absent desire as abnormal. US psychiatrist Harold Lief was also interested in desire disorders, suggesting that low testosterone may be responsible for loss or lack of sexual interest. He also acknowledged the role of psychological, relationship and contextual issues, however, setting up and encouraging sexual awareness and education as part of medical training.

Sexology

Sexology as a discipline was developing around the world in the second half of the twentieth century, not always fully embracing the Masters and Johnson approach. In Eastern Europe, where sex therapy tended to be a state-funded, multidisciplinary offering, for instance, women were sometimes taught how to have ‘vaginal’ orgasms, the rationale being that this was what they wanted (Wislocka, 1978). The concept of empowered women with access to the workplace, contraception, childcare and sexual satisfaction sounds ideal. However, priests were often members of the multidisciplinary sexology team, and women were encouraged to pursue sexual satisfaction in tandem with domestic responsibility, with the ideal of stable marriage and family at the heart of the project (Košciaňska, 2014). Thus, while Western sexual emancipation was overtly linked to the economy and the commodification of sex and the body, in the Eastern Bloc the economy still benefited as stable families contributed to the workforce, reducing the need for state aid.

The 1970s

Not everyone interested in learning about sex had an economic motive. The Hite Report (Hite, 1976) into female sexuality exploded popular understanding around women’s sexual response and interests. US graduate student Shere Hite had collated more than 3,000 questionnaires from women which made public the – then – shocking ‘secret’ that women often faked their climax to comply with Freud’s myth that penetrative sex was responsible for ‘mature’ female orgasms. So much male hostility had greeted the idea that female orgasms were all ‘clitoral’ in origin, and that a minority of women experienced orgasm through penetration alone, that when Masters and Johnson presented this to the medical community they were forced to play down their findings. Hite’s work made it possible for women to share their experiences and realise there was nothing wrong with them if penetrative sex didn’t always, or ever, result in orgasm. Practically overnight, women began seeing themselves as entitled to sexual pleasure, as female sexual needs became increasingly normalised and encouraged. More effective and available contraception, and liberalising of attitudes towards sex in the 1960s and 70s, led to more sex positive discourses, so that many couples were becoming less inclined to automatically tolerate sexual difficulties.

In the UK, the Institute of Psychosexual Medicine was established in 1974, initially just for the medical profession but now for all practitioners who routinely examine their patients, such as nurses and physiotherapists. The emphasis of treatment is on the patient’s reaction to a physical genital examination which offers information about their comfort with their bodies, ability to relax and to manage an unusual situation. Practitioners don’t take a history but hope to create a safe environment in which the patient feels able to speak about their problems freely. Attention is paid to the relationship between practitioner and client, including the transference. This provides a helpful additional layer to the practitioner’s clinical skills – an adjunct to their medical offering rather than replacing it.

The term ‘psychosexual’ was adopted by UK sex therapists in general. The British Association of Sexual & Relationship Therapy was formed at around the same time, as a specialist organisation for sex therapy practitioners, applying professional standards and accrediting individuals and training. These days known as the College of Sexual and Relationship Therapists (COSRT), its members are not primarily medically trained but come from a wide range of disciplines, including counselling and psychotherapy, sexual health, psychiatry, nursing and midwifery, and medicine.

US psychologist Jack Annon’s (1976) PLISSIT Model, discussed further in Chapter 3, provided a structure for the exploration of sexual concerns. Davis and Taylor (2006) proposed an EX-PLISSIT Model which emphasised the consent stage of the process, which they felt was often skipped. Stepped approaches like this fit well with modern PST, where therapeutic need can be gradually assessed while therapeutic intent is present from the beginning.

Medical approaches

The 1980s saw an even greater shift towards medical solutions for sexual problems, with vasodilator injections, vacuum pumps, hormones and surgery now being offered to treat erectile difficulties. Among other medical interventions, antidepressants were used to combat early ejaculation, while vaginal stretching and relaxation exercises, physiotherapy and surgery were applied to combat vaginismus. On the face of it, both psychoanalytical and bio...