Then and Now: Sex Therapy
in my time
RSM Sexuality and Sexual Health
Sexual Pleasure
February 17th, 2012
Dr Michael Perring
Mikeperring@optimalhealth.org.uk
Definition of Sexual Health
Sexual health is the integration of
the somatic, emotional, mental and
social aspects of our sexual being,
with the intent to enrich and
enhance personal development,
communication and love.
modified from WHO
Sex in our Society
Sex in Western culture variously
describes adult recreation, a
reproductive act, a saleable
commodity, a set of techniques, or
the physical embodiment of
spiritual intimacy.
Sex Therapy in our Society
Sex therapy may be seen in
behavioural (eg Surveys, Masters
and Johnson), medical (eg Viagra)
and psychological (eg
psychosexual/psychodynamic)
terms.
It has been a task of my
generation of sex therapists to
integrate these perspectives.
Surveys on Sexual Attitudes
and Behaviour
Periodic Reviews: circa 1950,
1975 and 1994
The Kinsey
TheReport
Kinsey Report
Kinsey A, Pomeroy W, Martin C. Sexual Behaviour in the Human Male
ale. Saunders, 1948
Kinsey A, Pomeroy W, Martin C, Gebhard P. Sexual Behaviour in the Human Female,
Saunders, 1953
The Kinsey Report
Kinsey A, Pomeroy W, Martin C. Sexual Behaviour in the Human Male
ale. Saunders, 1948
Kinsey A, Pomeroy W, Martin C, Gebhard P. Sexual Behaviour in the Human Female,
Saunders, 1953
Pros:
Pro
s:reaking
Grou
n
d
b
Ground-breaking
Freshin
insig
hts hts
F
resh
sig
Showed variety of sexual behaviours
Showed v
ariety of sexual behaviours
variety
Cons:
Unrepresentative
Fewold, old people
Cons:
(Cochran et al, 1953)
Unrepresentative
Fewold, old people
(Cochran et al, 1953)
The US Consumer’s Report
Becker 1976

Surveyed population over age 50

Termed them ‘The Silent Generation’

Reported increasing range of sexuality with age

Poor correlation of satisfaction/dysfunction

Sexual activity declined with interest

Importance of intimacy despite absence of SI
Behavioural Therapy
Behavioural sex therapists
assumed sexual difficulties were a
conditioned (learned) anxiety
response for which extinction of
the (performance) anxiety could be
addressed by systematic
desensitisation.
Lazarus 1963
Behavioural Therapy
In the late 70’s behaviour therapy
still described techniques of
aversion therapy as treatment for
‘sexual deviance’. Eg apomorphine
for homosexuality.
Masters and Johnson
By means of physiological
observation they described 4
phases of arousal: excitement,
plateau, orgasm and resolution
(with analogous changes in men
and women)
Human Sexual Response 1966
Masters and Johnson
Their programme offered
behaviourally oriented, intense,
short-term therapy for specific
sexual symptoms; use of a cotherapist; ‘Sensate focus’ for
couples reduced ‘performance
anxiety’’.They described ‘stopstart’ and ‘squeeze’ techniques for
PE.
Human Sexual Inadequacy 1970
Masters and Johnson
Sexual dysfunction was measured
by the frequency of sexual activity
and adequacy of function; with a
focus on achieving penetration and
ejaculatory control and the goal of
intercourse and orgasm
Masters and Johnson
Surrogate Therapy
Surrogacy was considered
legitimate for single men as a
means to form their own
relationships and with supervision
of the surrogate distinguishing it
from prostitution.
Dr Helen Singer Kaplan
Used ‘sensate focus’ therapy with
short-term psychodynamic therapy
(for contemporary issues) plus
behavioural exercises and
masturbation.
The New Sex Therapy 1974
Her model of arousal introduced
the idea of desire as a required
precursor to excitement and
orgasm.
Disorders of Sexual Desire 1979
Medicalisation of Sex Therapy
Erectile Dysfunction (ED)
Pathogenesis:
Physical factors primary cause in 75% of cases.
(heart disease, hypertension, DM, and
medication)
Psychological factors predominate in 25% (anger,
depression and control issues)
A psychological reaction of anxiety and avoidant
behaviour is a common reaction to established
ED. Life-style factors (stress, cigarette smoking)
also correlate with ED.
Feldman 1994
A Study of Sexuality and Health
among Older adults in the US
Amongst the Sexually
Active
2007
Men
 ED occurred in 37%
Women
 Loss of desire 43%,
 Reduced vaginal lubrication 39%
 anorgasmia 34%
Medicalisation of Sex Therapy
Initially focused on male
dysfunction: ED was treated by
vacuum pumps, penile implants,
penile injections, intra-urethral
pellets and the PDE5 inhibitors
(Viagra, Levitra and ‘Cyalis); PE
treated with Paroxetine; Loss of
libido with testosterone.
Tiefer 1987, Sussman 1999
Medicalisation of Sex Therapy
Women were offered treatment for
vaginismus with dilators or
surgery; for loss of libido and
sexual aversion with testosterone.
Psychosexual Medicine
The Institute of Psychosexual Medicine
Originated in the UK in the late 60’s
from the work of Family Planning
Doctors treating sexual problems.
Under the tutelage of a psychoanalyst,
Dr Tom Main, the therapeutic potential
of links between a physical symptom
and the accompanying emotional state
was recognised.
Psychosexual Medicine
The British Institute of Psychosexual
Medicine initially explored the
emotional and psychological correlates
to vaginal examination.
The dynamics of Transference and
Counter transference, Projection and
Projective Identification between patient
and doctor/nurse continue as a basis
for understanding and resolving
problems.
Sexual and Relationship
Therapy
In the early 80’s the Association of
Sexual Therapists was formed from a
small group if practitioners of sex
therapy in the UK.
Comprised initially of marriage
guidance counsellors, psychologists
and psychiatrists members had an
eclectic approach to sex therapy
combining behavioural, medical and
psychodynamic traditions.
Sexual and Relationship
Therapy
Now well established and recently renamed The College of Sexual and
Relationship Therapists (COSRT), its
member’s background may be as
Systemic, Existential, Person-Centred,
Cognitive Behavioural, Humanistic or
Psychodynamic therapists.
The British Society for Sexual
Medicine
Founded in 1997 The British Society
for Sexual Medicine (BSSM) describes
as its remit ‘the basic science of sexual
function and dysfunction, and the
clinical aspects of diagnosis and
treatment of sexual problems in men
and women’.
Membership is for health professionals
and scientists working in the field of
human sexuality.
Observations
Sex therapy in the UK has
increasingly separated
psychological and medical
perspectives.
Sexual problems are increasingly
understood in physical terms
Practitioners in the field have
polarised as specialists in sexual
medicine or are trained as
psychosexual counsellors
Observations
Gender Clinics provide one
example where the complexity of
management has led to the
involvement of endocrinologists,
psychiatrists, psychotherapists
plus other health professionals,
with collective responsibility for
decision making.
Observations
Gender Clinics provide one
example where the complexity of
management has led to the
involvement of endocrinologists,
psychiatrists, psychotherapists
plus other health professionals,
with collective responsibility for
decision making