Sex Therapy - Famous Therapies

I became a sex therapist in the mid-1970s because I was impressed with how well standard sex therapy techniques were able to help people overcome embarrassing problems such as difficulty having an orgasm, painful intercourse, premature ejaculation, and impotence. The use of sex education, self-awareness exercises, and a series of behavioral techniques could cure many of these problems within a matter of only several months. I noticed that as people learned more about the sexual workings of their bodies and gained confidence with their sexual expressions, they would also feel better about themselves in other areas of their lives.
But there were always a number of people in my practice who had difficulty with sex therapy and the specific techniques I gave them as "homework." They would procrastinate and avoid doing the exercises, would do them incorrectly, or, if they could manage some exercises, would report getting nothing out of them. Upon further exploration I discovered that those clients had me major factor in common: a history of childhood sexual abuse.

Besides how they reacted to standard techniques, I noticed other differences between my survivor and nonsurvivor clients. Many survivors seemed ambivalent or neutral about the sexual problems they were experiencing. Gone was the usual sense of frustration that could fuel a client's motivation to change. Survivors often entered counseling because of a partner's frustration with the sexual problems, and they seemed more disturbed by the consequences of sexual problems than by their existence. Margaret,1 an incest survivor, tearfully confided during her first session, "I'm afraid my husband will leave me if I don't become more interested in sex. Can you help me be the sexual partner he wants me to be?"

Many of the survivors I talked with had been to sex therapists before, with no success. They had histories of persistent problems that seemed immune to standard treatments. What was even more revealing was that survivors kept sharing with me a set of symptoms, in addition to sexual functioning problems, that challenged my skills as a sex therapist. These included --

Considering their sexual histories, touch problems, and responses to counseling, I quickly realized that traditional sex therapy was horribly missing the mark for survivors. Standard treatments such as those described in the early works of William Masters, Virginia Johnson, Lonnie Barbach, Bernie Zilbergeld, and Helen Singer Kaplan often left survivors feeling discouraged, disempowered, and in some cases, retraumatized. Survivors approached sex therapy from an entirely different angle than other clients did. Thus they required an entirely different style and program of sex therapy.

Over the course of the last 20 years, the practice of sex therapy has changed considerably. I believe many of these changes were the results of adjustments other sex therapists and I made to be more effective in treating sexual abuse survivors. To illustrate, I will show how sex therapists have challenged and changed six old tenets of traditional sex therapy through treating survivors.

In general, traditional sex therapy viewed all sexual dysfunctions as bad; the goal of treatment being to cure them right away. Techniques were directed toward this goal, and therapeutic success was determined by it. But the sexual dysfunctions of some survivors were, in fact, both functional and important. Their sexual problems helped them avoid feelings and memories associated with past sexual abuse.

When Donna entered therapy for difficulty achieving orgasm, she seemed most concerned with the effect her problem was having on her marriage. She had read many articles and a few books on how to increase orgasmic potential but had never followed through with any suggested exercises. For several months, I worked unsuccessfully with her, trying to help her stick with a sexual enrichment program.

Then we decided to shift the focus of her treatment. I asked Donna about her childhood. She reported some information that hinted at the possibility of childhood sexual abuse. Donna said that during her upbringing her father was an alcoholic whose personality changed when he was drunk. She disliked it whenever he touched her, she pleaded with her mom for a dead-bolt lock on her bedroom door when she was 11 years old, and she had few memories of her childhood in general.
After several sessions during which we discussed dynamics in her family of origin, Donna told me she had a very upsetting dream [that included a graphic description of sexual abuse by her father that the client felt was historically true].

No wonder Donna had been unable to climax. The physical experience of orgasm had been intimately associated with her past abuse. Her sexual dysfunction had been protecting her from the memory of her father's assault.

In numerous other cases, I encountered a similar process. Steve, a 25-year-old recovering alcoholic, had a chronic problem with premature ejaculation. As we explored his inner psychological experience in therapy, he was able to identify that when he allowed himself to delay ejaculation, he would start to feel an urge to rape his partner. Premature ejaculation was protecting him from this very upsetting feeling. It wasn't until he connected this urge to rape with his intense rage at his mother for sexually abusing him as a child that he was able to resolve the internal conflict and comfortably prolong gratification.

Impressing upon Donna or Steve the idea that their sexual dysfunctions were bad would have done them a disservice. Their dysfunctions were powerful coping techniques.
I also encountered another type of situation that challenged the old tenet that sexual dysfunctions are bad. For some survivors who had experienced little difficulty with sexual functioning, the onset of sexual dysfunction signaled a new level of recovery from sexual abuse.

Tony was a 35-year-old single man who had been in and out of abusive relationships for years. His partners were often sexually demanding and generally critical. Tony's father had raped him repeatedly when he was young, and his mother had molested him in his teens. As Tony resolved issues related to his past abuse, his choice of partners improved. One day he told me that he had been unable to function sexually with his new girlfriend. This was extremely unusual for him.

"She wanted to have sex, so she began to do oral sex on me," Tony explained. "I got an erection and then lost it and couldn't get it back." "Did you want to be having sex?" I asked him. "No, I really wasn't interested then," he replied. "So your body was saying no for you," I remarked. "Yeah, I guess so," he said somewhat proudly. "Wow, do you realize what's happening?" I declared, "You're becoming congruent! For all these years, your genitals have operated separately from how you really felt. Now your head, heart, and genitals are lining up congruently. Good for you!"

That day in therapy with Tony was a turning point for me as a sex therapist. l was amazed that I was actually congratulating him on his temporary sexual dysfunction. It felt appropriate. Instead of functioning, the goal of treatment shifted to self-awareness, self-care, trust, and intimacy-building. Insight and authenticity became more important than behavioral functioning.

While healthy sexual functioning is a desirable long-term goal, conveying the idea that all dysfunctions are bad and must be immediately cured is too simplistic. In working with survivors and others, sex therapists need to see sexual problems in context and we need to find out how people feel about a symptom before attempting to treat it. Therapists must respect dysfunctions, learn from them, work with them, and resist the urge to automatically try to change them.

In general, traditional sex therapy didn't make distinctions between different types of sex as long as sex was consensual and did not cause physical harm. That way of thinking does not hold up considering the sexual addictions and compulsions that are by products of sexual abuse. Little distinction was given to the type of sex that fostered addictive and compulsive behavior. The lack of distinction between the more specific nature of sexual interaction has left some people, including survivors, fearful of all sex. From working with survivors we have learned that sexual addictions and compulsions develop to a type of sex that incorporates or mimics the dynamics of sexual abuse.

On business trips Mark, a married man with two children, could not stop himself from cruising strange neighborhoods looking for pretty women whom he could watch from inside his car while masturbating. He knew all the video parlors in a four-state area and could not pass one without stopping to masturbate. He sought counseling because his wife had caught him in bed with his secretary. She threatened to leave him unless he got help.

When Mark entered therapy he described himself as being addicted to sex. I asked him to describe sex. He used terms like, "out-of-control, impulsive, exciting and degrading."

Mark's preoccupation and addiction was to a type of sex that was fueled by secrecy and shame. It was undertaken in a high state of dissociation; filled with anxiety; focused on stimulation and release; and lacking in true caring, emotional intimacy, and social responsibility. This type of sex was associated with power, control, dominance, humiliation, fear, and treating people as objects. It was the same type of sex that he was exposed to as a young man when his mother's best friend would pull down his pants, molest him, and laugh at him.

Helping Mark recover involved helping him make connections between what happened to him in the past and his present behavior. He needed to learn the difference between abusive and healthy sex. Sex, per se, was not the problem. It was the type of sex he had learned and developed arousal patterns to that had to change. Healthy sex, like healthy laughter, incorporates choice and self-respect. It is not addictive.

To help people overcome fears of sex, sex therapy involves teaching conditions for healthy sexuality. These include consent, equality, respect, safety, responsibility, emotional trust, and intimacy. While abstinence can be an important part of recovery from sexual addictions, it won't be enough unless new concepts and approaches to sex are also learned.