SEXUALITY AND SEX THERAPY
by Edward A. Dreyfus, Ph.D.

Despite the fact that we live in the post-Victorian, post-human potential movement, post-free love movement, we are still uncomfortable with our own sexuality. One would think that with all of the talk about sex, all of the books written about sex, and all of the movies depicting sexuality, we would finally have reached a point in our evolution where we would be as comfortable talking about and experimenting with sex as we are talking about food, sharing sexual information as readily as we share recipes. But this is not the case.

We are uncomfortable talking to our friends about sex; we are uncomfortable asking for help with our sexuality, and we certainly would not take lessons in how to increase our enjoyment of sex. We will take cooking classes to learn how to prepare a gourmet meal. We will take dancing lessons to better be able to trip the lights fantastic. We will take golf lessons, tennis lessons, and any number of other lessons to increase our expertise and enhance our abilities. However, when it comes to sex we assume that we should be able to function optimally without help. Furthermore, if we should want to increase our sexual pleasure or should we feel uncomfortable with some aspect of our sexual life, we feel embarrassed in seeking counsel.

Generally we carry the belief that we should know everything there is to know about sex as if sexual behavior was encoded in our DNA. Most of us carry attitudes about sexuality that we learned when we were adolescents. We seldom take the time to update that information and so as adults we operate on the basis of adolescent notions of sexuality. Ignorance is one of most effective deterrents to effective sexual functioning.

Human Sexuality

There are no rules for the human sexual response. We can respond to the same sex or the opposite sex. We can have a sexual response when we are alone or with someone. We respond to living beings and inanimate objects. Human sexuality includes all of the senses - smell, touch, sound, sight, and taste. Sexuality involves imagination, fantasy, and imagery.

Boys tend to learn about their sexuality through locker room talk, erotic magazines and movies, and trial and error. Girls gain their sexual knowledge through conversations with other girls and women, love stories and movies, and experience. For men the sexual act is a combination of pleasure, sexual release, and power. For women, sexuality is intimacy, affection, and pleasure. Just think about the terms men and women use when referring to sex. Male terms tend to be aggressive, even hostile, while female terms are gentle, loving, and even spiritual. Women make love, men get laid.

These attitudes and values affect the manner in which the genders approach sexuality and, in large measure, contributes to their appreciation of the sex act. Furthermore, these values affect how men and women perceive themselves and how they view each other. Generally, men establish their identity through performance. From childhood through adulthood, they measure themselves by such things as how far they can spit, how fast they can run, how far they can throw a football, grade point average, penis size, salary size, staying power in bed, and the number of women they can “conquer.” One way or another, performance matters. Women measure themselves by how attractive they are to men, the power held by the men that are attracted to them, and by how they are treated by these men. If men treat them kindly then they are good, if men treat them poorly they perceive themselves as bad.

Men and women bring these attitudes into the bed room, playing out their roles as performer and seductress. During love making, the male is concerned with whether he will perform well enough or whether he will fail. Rather than focusing on his loved one, he is concerned whether she will be pleased with his performance. She, on the other hand, is concerned with whether he will think she is attractive enough. Is her buttocks too big or are her breasts are too small?

The Dance of Sex

Love making is similar to ballroom dancing. Each person may or may not be a good dancer. One person may be a great dancer and the other may not be terrific. However, it is how they dance together that matters. Some people can dance well alone, but not with a partner. To be beautiful and satisfying, ballroom dancing demands cooperation, communication, and consideration. One partner must not go on his or her own without communicating to the partner; and the partners must cooperate. No couple expects to dance well together, no matter how well either one may dance alone, without practicing together. It does not matter how easy it might be to dance with other partners, one’s current partner is the one that matters if you wish to become a good ballroom dance team.

All of this is true for love making as well. Yet we often believe that good love making should “come naturally,” without education. We covet beliefs that somehow people should know how to make love together and should not have to talk about it or practice with the intent of improving our style so that it is mutually satisfying. Clearly, if your dance partner continuously stepped on your toes and was unwilling to discuss the matter, it would not take long before you either stop dancing or find a different partner. Yet the majority of couples do not communicate about their love making and are not open to exploring their sexuality with one another. Even the most experienced lovers often practice poor love making strategies. People, especially men, become defensive when their partner wants to discuss their sex life as if they were about to be criticized.

Communication between dance partners and lovers is essential for having a satisfying experience. The partners must frequently communicate verbally and nonverbally with one another in order to learn to anticipate each others moves. With sufficient practice, the dance of love seems effortless. Lovemaking should be fun, playful, affectionate, intimate, and fulfilling. When something goes awry, either because of faulty communication, inappropriate attitudes, or antiquated beliefs, a sexual dysfunction may emerge.

Causes of Sexual Dysfunction

Most sexual dysfunction occurs because of faulty beliefs and attitudes about sexuality, poor habits, ignorance, and early experiences. There are some sexual dysfunctions that are precipitated by physiological, biological, or chemical factors. However, all physiological dysfunctions have a psychological component. When men are unable to obtain or maintain an erection, whether from physiological or psychological causes, they feel inferior, less manly. When a woman is unable to reach orgasm she feels less feminine. Therefore, in all cases of sexual dysfunction it is necessary to attend to the psychological aspects of the difficulty and what it means to the individual.

Physiological factors. Some of the more common nonpsychological precipitants of sexual dysfunction include hormonal imbalance, medications, neurological impairment, physiological disorders, and even vitamin deficiency. Certain illnesses and medications can have side effects that affect sexual functioning including impotence and increased or decreased libido.

Many people prefer to think of only a medical approach to sexual dysfunction since it is more acceptable to one’s self image to believe that there is an organic basis for the dysfunction. Even in those instances when there is a recognizable medical condition affecting sexual functioning, the psychological component cannot be overlooked. We all have varying psychological reactions to physical illness or impairment. This psychological reaction can exacerbate the physical problem. This is especially true for infertility problems. Most people who have difficulty conceiving a child choose to investigate the medical aspects to the exclusion of the psychological aspects. Yet we all know of many cases where a couple after years of frequenting the fertility clinics to no avail, finally decide to adopt a child only to conceive a few months afterward. Clearly this would suggest that psychological factors were at play.

Psychological factors. Most sexual dysfunctions have a psychosocial etiology. Dr. Helen Singer Kaplan states, “In a general sense we see the immediate causes of the sexual dysfunctions as arising from an antierotic environment created by the couple which is destructive to the sexuality of one or both. An ambiance of openness and trust allows the partners to abandon themselves fully to the erotic experience.” She lists four specific sources of anxiety and defenses against full sexual enjoyment: 1) Avoidance of or failure to engage in sexual behavior which is exciting and stimulating to both partners. 2) Fear of failure, exacerbated by pressure to perform, and overconcern about pleasing one’s partner rooted in fears of rejection. 3) A tendency to erect defenses against erotic pleasure. 4) Failure to communicate openly and without guilt and defensiveness about feelings, wishes and responses.

Common Sexual Dysfunctions

The following are the most common forms of sexual dysfunction. They are all treatable with a high probability of success.

Male Dysfunctions

Inhibited Sexual Desire: Inhibited sexual desire or response refers to the lack of desire for erotic sexual contact. In almost all cases when there is a lack of sexual desire the underlying causes are psychological in nature. Avoidance of sexual contact because of fears of rejection, failure, criticism, feelings of embarrassment or awkwardness, body image concerns, performance anxiety, anger towards a partner or women in general, lack of attraction towards a partner, all play a part in reducing or eliminating the sexual response. Most men are too uncomfortable to talk to their partner or anyone else about these issues preferring to simply avoid sex or attribute their lack of sexual appetite to stress, worries, etc. Some of these men have a very active fantasy life and prefer the solitude of masturbation to the intimacy of sexual relations.

Premature Ejaculation: Premature ejaculation is the most common dysfunction and it is the easiest to treat. Masters and Johnson define premature ejaculation as the inability to delay ejaculation long enough for the woman to orgasm fifty percent of the time. (If the woman is not able to have an orgasm for reasons other than the rapid ejaculation of her partner, this definition does not apply.) Other therapists define premature ejaculation as the inability to delay ejaculation for thirty seconds to a minute after the penis enters the vagina.

For the most part, premature ejaculation occurs as a function of a learned response. Early sexual experiences were hurried in nature. Even masturbatory activity had to be hurried for fear of being caught. From youth onward men have trained themselves to be more concerned with the end result and their own pleasure rather than with the sexual process and their partner. The object of sex for most of these men, was and often continues to be, ejaculating as quickly as possible. This rapid ejaculating pattern can easily become a way of life after even only a few episodes. It then begins to create a pattern of anxiety in the male each time he engages in coitus thus increasing the probability of it occurring. Fearful of displeasing their partner and feeling inadequate as a function of it, men would rather avoid sex rather than experience the humiliation and discomfort.

Retarded Ejaculation or Ejaculatory Incompetence: Ejaculatory incompetence is the opposite of premature ejaculation and refers to the inability to ejaculate inside the vagina. Men with this difficulty may be able to maintain an erection for 30 minutes to an hour, but because of psychological concerns about ejaculating inside a woman, are not able to achieve orgasm. One of the reasons this dysfunction goes undetected is because the male’s partner is satisfied and indeed often is able to achieve several orgasms. Most of these men can readily achieve orgasm through masturbation or in some cases through felatio. Many factors contribute to this condition, some of which are religious restrictions, fear of impregnating, and lack of physical interest or active dislike for the female partner. In addition such psychological factors as ambivalence toward one’s partner, suppressed anger, fear of abandonment, or obsessional preoccupation also play a significant role in developing retarded ejaculation.

Erectile Dysfunction: Primary & Secondary Impotence Primary impotence refers to a man who has never been able to maintain an erection for purposes of intercourse either with a female or a male, vaginally or rectally. In secondary impotence a man cannot maintain or perhaps even get an erection, but has succeeded at having either vaginal or rectal intercourse at least one time in his life. The occasional failure to get an erection is not to be confused with secondary impotence. Familial, societal, and intrapsychic factors contribute to primary impotence. Some of the more common influences are (1) performance anxiety, (2) a seductive relationship with a mother, (3) religious beliefs in sex as a sin, (4) traumatic initial failure, (5) anger toward women, and (6) fear of impregnating a woman.

Female Dysfunctions

General Dysfunction. These dysfunctions, according to Kaplan, “are characterized by an inhibition in the general arousal aspect of the sexual response. On a psychological level there is a lack of erotic feelings” manifested by lack of lubrication, her vagina does not expand, and “there is no formation of an orgasmic platform. She may also be inorgasmic. In other words, these women manifest a universal sexual inhibition which varies in intensity.”

Orgastic Dysfunction: The most common sexual complaint of women involves the specific inhibition of orgasm. Orgastic dysfunction refers solely to the impairment of the orgastic component of the female sexual response and not arousal in general. Nonorgastic women can become sexually aroused and in fact enjoy most other aspects of sexual arousal. Inhibition and guilt about masturbation, discomfort with one’s body, and difficulty giving up control, contribute to orgastic dysfunction. With a combination of education and practice most women can be taught to achieve orgasm.

Vaginismus: This relatively rare sexual disorder is characterized by a conditioned spasm of the vaginal entrance. The vagina involuntarily closes down tight whenever entry is attempted, precluding sexual intercourse. Otherwise, vaginismic women are often sexually responsive and orgastic with clitoral stimulation. Similar attitudes to those found in impotent males are often found in these women. Religious taboos, physical assault, repressed or controlled anger, and a history of painful intercourse all contribute to this dysfunction.

Sexual Anesthesia: Some women complain that they have no feelings on sexual stimulation, although they can enjoy the closeness and comfort of physical contact. Clitoral stimulation does not evoke erotic feelings though they do feel a sensation of being touched. Dr. Kaplan believes that sexual anesthesia is not a true sexual dysfunction, but rather represents a neurotic disturbance and should be treated through psychotherapy rather than sex therapy.

As with sexual dysfunctions in men, the female dysfunctions also have to be understood from a social, familial and psychological perspective. Attitudes, values, childhood experiences, adult trauma, all contribute to the sexual response in women. The attitudes and values of her partners as well as their sexual technique play a major role in the sexual response as well. An inept or mysogynistic lover can significantly affect the female response. Since a woman often does not want to “damage the male ego,” she will try to accommodate her responsiveness to him often sacrificing her satisfaction in the process. She then builds up a secondary inhibition to sexual arousal in order to avoid the frustration accompanying an unsatisfying sexual experience. This inhibition or accommodation then becomes a habituated conditioned response.

Sex And Aging

There is no reason for elderly persons to discontinue sexual activity merely because of the aging process. Human beings can enjoy an active sexual life well on into their 80s or beyond. Many senior citizens hold onto invalid beliefs about their sexuality believing that sex should be reduced or eliminated during the latter years of one’s life. Enjoyment of sexual relations is largely a function of the breadth of activities in ones repertoire and the degree to which one is open to learn and explore. Again we can use our dancing analogy. It is true that as we age we may no longer be able to jitterbug or engage in a fast mambo. However, we can develop a beautiful waltz and fox trot. New forms of sexual activity can be added to the sexual experience. One of the problems faced by many elderly folks is that they believe in the adage that you “can’t teach an old dog new tricks.” Nothing could be further from the truth. There are many things that we can no longer do or do as well or in the same way as we could when we were younger. However, we are perfectly capable of discovering alternative ways of performing certain activities. Necessity gives us the opportunity to discover new approaches to old activities.

As we age we can become better lovers, depending on our attitude. Being a good lover does not mean doing sexual acrobatics or being able to orgasm a half dozen times. Being a good lover means that we are sensitive to our partner’s needs; we are responsive to their wants. Being a good lover means that we communicate and listen with an open heart and mind. It is unfortunate that we don’t learn these things when we are young. As we age we are “forced” to have to learn how to be good lovers because we cannot get by with the same old performance orientation. Aging gives us the opportunity to explore alternative lovemaking styles and techniques that we may have avoided when we were younger.

Sex Therapy

Sex therapy provides information and counseling on all aspects of human sexuality, including enhancing sexual pleasure, improving sexual technique, and learning about contraception and venereal diseases. Sex therapy is used in the treatment of all of the dysfunctions discussed earlier. In many cases treatment is relatively short, requiring specific techniques, homework, and practice. In some cases, the underlying issues are more complicated requiring an exploration into historical and psychological factors, both conscious and unconscious, that are contributing to the dysfunction. However, there is a very high probability of success even in those cases if people are motivated, cooperative, and willing to learn. Unfortunately, most people would rather live with a sexual dysfunction and a less than satisfying sexual life than seek help. The embarrassment they feel in discussing their sex life with a professional is too great. And there are others who have adjusted to their sex life and despite the fact that their spouse might be unhappy they refuse to seek help. When these people hear that their spouse is unhappy about their sex life they experience it as a criticism, become defensive, and often become either hurt or angry, rather than open themselves up to exploration with a sex therapist.

Stress often produces temporary sexual dysfunction which can become permanent. Unfortunately, people often consider sexuality such a private matter that they are reluctant to discuss it with others. Even those who have had sexual difficulties as a consequence of disease or surgery, have difficulty seeking sex therapy to facilitate adjustment to the dysfunction. Many men prefer to needlessly avoid sex altogether rather than seek professional help. Their pride gets in the way of sexual satisfaction.

One of the most significant contributing factors in sexual dysfunction is your attitude toward the dysfunction. If you view it as a diminishing your self worth and reflecting negatively on your overall value as a human being, sex therapy will take a little longer since we first have to overcome these initial feelings. Another contributing factor is your motivation and that of your spouse or partner. Your partner’s cooperation, participation, and support can accelerate the process and in many cases is essential for effective treatment. Remember, when one member of the dance team is impaired, the team is impaired. Sex therapy, like sex itself, is a cooperative venture.

For forty years Dr. Dreyfus has been practicing as a clinical psychologist and life coach in Santa Monica, California where he specializes in individual psychotherapy, relationship counseling, and sex therapy. He has recently published two books, Someone Right for You: 21st Century Strategies for Finding Your Special Someone and Keeping Your Sanity (In an Insane World). For further information or consultation regarding psychological issues, or life coaching, email Dr. Dreyfus.

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