It has been estimated that half of American marriages are flawed by some kind of sexual problem (Lehrman, 1970; Masters and Johnson, 1970). Sexual problems usually occur in the whole context of a relationship between two human beings. When sex goes badly, many other aspects of the relationship may go badly, and vice versa. Sex-often, but not always-mirrors the way two people feel about and act toward each other overall.
Sex therapists... often find that underneath the sexual problem are more basic problems of a relationship-love, tenderness, respect, honesty-and that when these are overcome, a fuller sexual relationship may follow.
In the last fifteen years, substantial progress has been made in treating those problems of arousal and orgasm which stem from psychological causes. Overall, only about 25 percent of individuals with these problems fail to improve with a brief course of therapy. Let's look closely at one case: When they came to therapy, Carol, age twenty-nine, and Ed, age thirty-eight, had been married for three-and-a-half years and had one child. When they were first married, Carol had achieved orgasm almost everytime they made love, but now orgasm was rare for her. She was feeling more and more reluctant to have inter course with Ed. Ed had a strong sex drive and wanted to have intercourse every day. But Carol had made rules about sex, stating what Ed could and could not do. As time went on, Carol found it more and more difficult to keep her part of the bargain.Carol's headaches, fatigue, and quarrels deterred Ed's effective initiation of lovemaking. When he did make love to her, Carol would complain about his love making technique. This effectively ended the encounter.
When they first sought out sexual therapy, they were having intercourse once every two weeks, but Carol was becoming progressively more reluctant and intercourse was becoming even more of a dreaded ordeal for her. (Adapted from Kaplan, 1974, case22.)
Masters and Johnson led us out of a period in which sexual dysfunction could not, by and large, be alleviated by therapy. Following their pioneering work on the anatomy and physiology of the human sexual response, they founded "direct sexual therapy" with sexually dysfunctional patients like Ed and Carol.
Direct sexual therapy differed in three important ways from previous sexual therapy. First, it defined the problem differently: sexual problems were not labeled as "neuroses" or "diseases" but rather as "limited dysfunctions." A woman like Carol was not labeled "hysterical," defending against deep intrapsychic conflicts by "freezing" her sexual response, as psychodynamic therapies claimed. Rather, she was said to suffer from "inhibition of arousal." Second, and most dramatic, through direct sexual therapy, the clients explicitly practiced sexual behavior with the systematic guidance of the therapists.
A couple like Carol and Ed would first receive education and instruction about their problem, then an authoritative prescription from Masters and Johnson about how to solve it, and most importantly, accompanying sexual practice sessions together. Their third major departure was that people were treated not as individual patients but as couples. In treating individuals, Masters and Johnson had often found that sexual problems do not reside in one individual but in the interaction of the couple. Carol's lack of interest in sex was not only her problem. Her husband's increasing demands, rage, and frustration contributed to her waning interest in sex. By treating the couple together, Ed and Carol's deteriorating sexual interaction could be reversed.
Sensate focus is the major strategy of direct sexual therapy for impaired excitement in females and erectile dysfunction in males. The basic premise of sensate focus is that anxiety occurring during intercourse blocks sexual excitement and pleasure. In the female, anxiety blocks the lubrication and swelling phase; in the male, it blocks erection. The overriding objectives of treatment are to reduce this anxiety and to restore confidence. The immediate goal is to bring about one successful experience with intercourse. This is accomplished, however, in a way in which the demands associated with arousal and orgasm are minimized. Sensate focus has three phases: "pleasuring," genital stimulation, and nondemand intercourse (Masters and Johnson, 1970; Kaplan, 1974). Let us look at the sensate focus treatment for Carol and Ed.
In the "pleasuring" phase, Carol and Ed were instructed not to have sexual intercourse and not to have orgasm during these exercises. Erotic activity was limited to gently touching and caressing each other's body. Carol was instructed to caress Ed first, and then the roles were to be reversed and Ed was to stroke Carol. This was done to permit Carol to concentrate on the sensations later evoked by Ed's caresses without being distracted by guilt over her own selfishness. It also allowed her to relax knowing that intercourse was not going to be demanded of her.
After three sessions of pleasuring, Carol's response was quite dramatic. She felt freed from pressure to have an orgasm and to serve her husband, and she experienced deeply erotic sensations for the first time in her life. Further, she felt that she had taken responsibility for her own pleasure, and she discovered that she was not rejected by her husband when she asserted herself. They then went on to phase two of sensate focus-"genital stimulation." In this phase, light and teasing genital play is added to pleasuring, but the husband is cautioned not to make orgasm-oriented caresses. Orgasm and intercourse are still forbidden. The woman sets the pace of the exercises and directs the husband both verbally and nonverbally, and then the roles are reversed.
The couple's response was also very positive here. Both felt deep pleasure and were aroused and eager to go on to the next step, "nondemand intercourse." In this final phase, after Carol had reached high arousal through pleasuring and genital stimulation, she was instructed to initiate intercourse. Ed and Carol were further instructed that there was to be no pressure for Carol to have an orgasm.
In spite of-or because of-the instruction, Carol had her first orgasm in months. At this point, Ed and Carol were able to work out a mutually arousing and satisfactory style of lovemaking, Carol and Ed's improvement was typical: only about 25 percent of patients fail to improve with sensate focus for female sexual unresponsiveness or for male erectile dysfunction (Masters and Johnson, 1970; Kaplan, 1974; and McCary, 1978). ~~~~~~ ~~~