Sex Therapy: A Cognitive Behavioural Approach
Prepared By: Fr. Immanuel, M.Phill Clinical Psychologist, Thiruvanathapuram
- Definition of Sexual Dysfunctions
- Classification of Sexual Dysfunctions
- Historical Overview
- Approaches Used in Sex Therapy
- Treatment sexual dysfunctions based on behavioral and cognitive approach
- Co-therapy and Conjoint Therapy
- Research Outcomes: problems and issues
Two events in the late 1950s marked the beginning of a new, direct approach to the treatment of sexual dysfunctions. The first event was the publication of an article by Semans (1956) describing a simple technique for treating premature ejaculation. The second event was the publication of Wolpe’s Psychotherapy by Reciprocal Inhibition (1958), which described the application of conditioning procedures to the treatment of various sexual dysfunctions. These techniques did not receive widespread attention until 1970, when Masters and Johnson’s Human Sexual Inadequacy expanded these direct approaches into a comprehensive therapy program for sexual dysfunctions. Since then numerous articles have been published on sex therapy, sex therapy clinics have sprung up and many additional techniques have been added to the repertoires of clinicians who treat sexual dysfunctions (Hogan, 1978).
Sexual dysfunctions are cognitive, affective, and/or behavioral problems that prevent an individual or couple from engaging in and/or enjoying satisfactory intercourse and orgasm (Hogan, 1978). Thus sexual dysfunctions are distinguished from sexual variations, in which the individual may successfully engage in intercourse in an unconventional way or with an unconventional object choice (Kaplan, 1974b).Masters and Johnson (1966), divided the common pattern of sexual response cycle in both sexes into four specific phases such as a) Excitement phase, b) Plateau phase, c) Orgasm phase and Resolution phase. Based on these divisions sexual dysfunctions are also seen as disturbances in one or more of the sexual response cycle's phases, or pain associated with arousal or intercourse.
Hogan (1978) classified sexual dysfunctions in to male and female dysfunctions. Male sexual dysfunctions can be subdivided into erectile failure, retarded ejaculation, premature ejaculation, and dyspareunia. The term impotence has been used in the past to refer to the first three categories. However, the importance of distinguishing among these three disorders is emphasized both by Kaplan (1974b) and by Masters and Johnson (1970), since the three differ both physiologically and in their response to treatment.
Erectile failure (EF) refers to the inability of the male to achieve or maintain an erection to such an extent that he is unable to engage in satisfactory intercourse.
Retarded ejaculation (RE), also termed "ejaculatory incompetence" (Masters and Johnson, 1970) and "ejaculative impotence" (Cooper, 1968a), is a disorder in which the male suffers from delayed intravaginal ejaculation or the inability to ejaculate intravaginally.
Premature ejaculation (PE) is topographically the opposite of RE: The patient suffering from PE ejaculates prior to or soon after inserting his penis into his partner's vagina. There are no objective criteria for what constitutes premature ejaculation. However, data do indicate that increasing ejaculatory latency beyond seven minutes is not strongly associated with increased incidence of coital orgasm for women, and that the median duration of intercourse for men is somewhere between four and seven minutes (Gebhard, 1966). Thus, one might suggest that a latency to ejaculation of less than four minutes may be a tentative indicator for treatment. Such a definition must be tempered by several other factors: How much manual and oral foreplay stimulation of his genitals can the male tolerate without ejaculation; whether the male is unrestrained in intercourse or can only delay ejaculation by slowing thrusting, thinking unpleasant, antierotic thoughts, biting his tongue, or wearing a condom; frequency of intercourse; age of the patient; and use of alcohol, drugs, and even topical anesthetic creams to dull sexual responsivity and delay ejaculation. It is therefore easier to describe what not premature ejaculation is: both husband and wife agree that the quality of their sexual encounters is not influenced by efforts to delay ejaculation (LoPicolo, 1978).
The final male dysfunction is dyspareunia, or painful intercourse. ,This disorder is usually caused by organic factors (Masters and Johnson, 1970).
Female sexual dysfunctions have been divided into five categories: general sexual dysfunction, primary and secondary orgasmic dysfunction, dyspareunia, and vaginismus. General sexual dysfunction consists of the inhibition of the vasocongestive/ arousal stage of the sexual response, so that vaginal lubrication and swelling develop minimally or not at all. General sexual dysfunction is experienced subjectively by the female as a lack of erotic feelings. This dysfunction was first recognized as a discrete disorder in 1974 by Kaplan (1974a,), and most investigators have not yet adopted the term. Patients presenting with this disorder are classified by other researchers as either inorgasmic or "frigid”.
Orgasmic dysfunction consists of the inhibition of the orgasm phase of the female sexual response. It is subdivided into primary orgasmic dysfunction, which exists when the patient has never experienced an orgasm in any way, and secondary orgasmic dysfunction, a disorder in which the client has had an orgasm at least once through some form of sexual stimulation but currently experiences coital orgasms rarely or not at all.
The term frigidity is often used in the literature on sexual dysfunctions as a catchall category for orgasmic dysfunction and general sexual dysfunction. The term has little utility, since it does not even inform one as to which of the two components of the sexual response has been inhibited, let alone finer details (e.g., whether the problem is primary or secondary).
Dyspareunia (painful intercourse) in the female can range from postcoital vaginal irritation to severe pain during penile thrusting. It is far more common in the female than in the male (Masters and Johnson, 1970), and female dyspareunia is more likely to involve psychological factors than is male dyspareunia.
Vaginismus, the final female dysfunction to be discussed, is a condition in which the vaginal introitus closes tightly when intercourse is attempted, thus preventing penetration. It is caused by an involuntary spastic contraction of the sphincter vaginae and the levator ani, the muscles surrounding the vagina.
ICD-10 classifies sexual dysfunctions, not caused by organic disorder or disease under ten headings. These are lack or loss of sexual desire, sexual aversion and lack of sexual enjoyment, failure of genital response, orgasmic dysfunction, premature ejaculation, nonorganic vaginismus, nonorganic dysparenunia, excessive sexual drive, other sexual dysfunction, not caused by organic disorder or disease, and unspecified sexual dysfunction, not caused by organic disorder or disease.
The history of sex therapy as a discipline is relatively brief (Leiblum & Rosen, 1989). From the start of the twentieth century until the late 1960s, sexual dysfunction was typically treated within a psychoanalytic framework (Rosen & Weinstein, 1988), as were most psychological problems (Comer, 1995). As such, treatment consisted of long-term, individual psychotherapy to unmask the underlying (and often unconscious) intrapsychic conflicts that manifested themselves as disruption of "healthy" or "mature" sexual functioning. In contrast to this dominant perspective, a few clinicians (e.g., Lazarus, 1971; Obler, 1973; Wolpe, 1958) explicitly applied behavioral principles in the treatment of sexual dysfunction, but such approaches were not the norm prior to the 1970s.
Sex therapy as it is known today was essentially founded by Masters and Johnson (1970), whose published report on a "new" therapeutic approach to sexual problems revolutionized what health professionals saw as the appropriate treatment for such difficulties. In contrast to psychoanalytic approaches, the "new" sex therapy was relatively brief, problem focused, directive, and behavioral with regard to technique. Rather than intrapsychic factors, Masters and Johnson (1970) emphasized social and cognitive causes of sexual dysfunction; ultimately, the large majority of sexual difficulties were seen as arising from a sexually restrictive or religiously orthodox upbringing. On the heels of Masters and Johnson, Helen Kaplan (1974, 1979) introduced and elaborated her version of the "new" sex therapy. Potentially viewed as an integration of, or bridge between, the traditional psychoanalytic and more contemporary behavioral approaches, hers included an initial emphasis on immediate symptoms. If the direct approach to symptom treatment worked, the case was closed. If, however, the "new" behavioral techniques met with resistance, the therapist relied on psychodynamic theory, or consideration of "deeper" issues, to understand the possible intrapsychic and interpersonal roles the sexual dysfunction might be serving.
The new sex therapy, as elaborated by Masters and Johnson (1970), included short-term but intensive work with the couple (conjoint therapy). Detailed information about relevant human anatomy (structure) and physiology (functioning) was provided, as was more general counseling as needed. The therapists conducted their work as a male-female pair of cotherapists; hence, traditional sex therapy involved four individuals (the cotherapists and the client couple). Additionally, the intervention consisted of direct behavioral exercises, including prescription of nondemand pleasuring, or "sensate focus," wherein the objective was to (re)experience sexual pleasure in the absence of anxiety from perceptions of performance demand or excessive self-monitoring of sexual performance ("spectatoring").
Over the past decade or so, the types of cases commonly seen in sex-therapy clinics have changed dramatically from the earliest days of contemporary sex therapy (Leiblum & Rosen, 1995; Rosen & Leiblum, 1995). As the proportion of clients who simply needed education and direction dwindled, the proportion of clients with more pervasive and chronic sexual problems increased. Accordingly, instances of erectile failure (Rosen & Leiblum, 1992), low sexual desire (Beck, 1995; Kaplan, 1979; Leiblum & Rosen, 1988), and compulsive sexual behavior (Coleman, 1991; Goodman, 1993) have become an increasing part of sex therapists' caseloads (Schover & Leiblum, 1994). These problems present a greater challenge to clinicians and hence do not evidence the high rates of improvement found among the earlier reports on the success of sex therapy (Kilmann, Boland, Norton, Davidson, & Caid, 1986; Rosen & Leiblum, 1995). Currently, sex therapists appear to employ a broad range of treatment modalities, including bibliotherapy and group therapy (Hawton, 1992; Shah, 1996). At the same time, sex therapists have witnessed a marked "medicalization" of treatment for many sexual problems (Schover & Leiblum, 1994; Tiefer, 1994).
Causes of sexual dysfunctions
Hogan (1978) summarizes the causes of sexual dysfunctions as psychological, physical, interpersonal and socio-cultural.
Psychological causes can include:
stress or anxiety from work or family responsibilities
concern about sexual performance
conflicts in the relationship with your partner
unresolved sexual orientation issues
previous traumatic sexual or physical experience
body image and self-esteem problems
Physical causes can include:
pelvic injury or trauma
medication side effects
hormonal changes, -related to pregnancy and menopause
alcohol or drug abuse
Interpersonal relationship causes may include:
partner performance and technique
lack of a partner
relationship quality and conflict
lack of privacy
Socio-cultural influence causes may include:
conflict with religious, personal, or family values
Masters and Johnson’s Approach
Treatment begins with assessment procedures, including a physical examination and interviews with therapists who took medical and personal histories. On the third day, the therapists met with the couple to discuss their assessment of the nature, extent, and origin of the sexual problem to recommend treatment procedures and to answer any questions (Wiederman, 1998).
Assists the partners in achieving their sexual goals in as short a time as possible. Sessions are usually held once or twice a week while the partners continue to live at home.(Wiederman, 1998).
The PLISSIT Model Approach (Annon,1976)
The model provides for four levels of approach, and each letter or pair of letters designates a suggested method for handling presenting sexual concerns. The four levels are: Permission-Limited Information-Specific Suggestions-Intensive Therapy.
The First Level of Treatment: Permission
Sometimes, all that people want to know is that they are normal, that they are okay, that they are not "perverted," "deviated," or "abnormal," and that there is nothing wrong with them. Mostly, they would like to find this out from someone with a professional background or from someone who is in a position of authority to know. If permission giving is not sufficient to resolve the client's concern, then therapist can combine their permission giving with the second level of treatment.
The Second Level of Treatment: Limited Information
In contrast to permission giving, which is basically telling the client that it is all right to continue doing what he or she has been doing, limited information is seen as providing the client with specific factual information directly relevant to his or her particular sexual concern. For example, providing specific information for a young man concerned that his penis may be somewhat smaller than average may be all that is necessary to resolve his concern (e.g., the foreshortening effect of viewing his own penis, that there is no correlation between flaccid and erect penis size, that the average length of the vagina is usually three to four inches, that there are very few nerve endings inside the vagina, etc. Providing limited information is also an excellent method of dispelling sexual myths, whether they are specific ones such as those pertaining to genital size, or more general ones such as that, on the average, men and women differ markedly in their capacity to want and to enjoy sexual relations and in their fundamental capacity for responsiveness to sexual stimulation, or that men are more quickly aroused than women, etc. If giving limited information is not sufficient to resolve the client's sexual concern then the therapist may proceed to the third level of treatment.
The Third Level of Treatment: Specific Suggestions.
What the clinician needs is a sexual problem history. This is not to be confused with a sexual history. If clinicians begin to take a sexual history, then they are heading into intensive therapy, not brief therapy. It is an assumption of the model proposed here that a comprehensive sexual history is not relevant or necessary at this level. The application of the specific suggestion approach may resolve a number of problems that filtered through the first two levels of treatment; but, needless to say, it is not expected that it will successfully deal with all such problems. If the third level of approach is not helpful to the client, then a complete sexual history may be a necessary step for intensive therapy.
The Fourth Level of Treatment: Intensive Therapy
Intensive therapy in the model proposed here does not mean an extended standardized program of treatment. In the P-LI-SS-IT model, intensive therapy is seen as highly individualized treatment that is necessary because standardized treatment was not successful in helping the client to reach his or her goals. Many learning-oriented therapists have decried the restrictive use of one or two standardized procedures and have advocated a broad-spectrum approach to therapy.
The Cognitive Therapy Approach
Method based on exploring more positive ways of viewing sex and sexuality to eliminate negative thoughts and attitudes about sex that interfere with sexual interest, pleasure, and performance (LoPicolo & LoPicolo,1978)
Cognitive Behavior Therapy Approach
Because positive sexual fantasies are associated with positive affect, general physiological arousal, and sexual arousal, cognitive behavior therapists encourage their use by asking the patient to deliberately identify arousing sexual fantasies (LoPicolo & LoPicolo,1978).
Basic Principles of Direct Treatment of Sexual Dysfunction (LoPicolo, 1978)
It must be stressed that all sexual dysfunctions are shared disorders; that is, the husband of an inorgasmic woman is partially responsible for creating or maintaining her dysfunction, and he is also a patient in need of help. Regardless of the cause of the dysfunction, both partners are responsible for future change and the solution of their problems.
Information and Education
Most patients suffering from sexual dysfunction are woefully ignorant of both basic biology and effective sexual techniques. Sometimes this ignorance can directly lead to the development of anxiety, which in turn produces sexual dysfunction. For example, a recent patient dated the onset of her aversion to sex as beginning when she first noted that her clitoris “disappeared” during manipulation. She interpreted this normal retraction of the clitoral shaft during the plateau phase of arousal (Masters and Johnson, 1966) as a pathological sign that she was not becoming aroused. This anxiety led to a complete loss of her arousal and enjoyment of sexuality. Similarly, many cases of vaginismus seem to begin as a result of the husband's forceful attempts to accomplish intromission in spite of his uncertainty about the exact location of the vagina.
Negative societal and parental attitudes toward sexual expression, past traumatic experiences, and the current acute distress combine to make the dysfunctional patients approach each sexual encounter with anxiety or, in extreme cases, with revulsion and disgust.
Eliminating Performance Anxiety
In the culture of the 1970s, with its heavy emphasis on youth, beauty, and sexual attractiveness, demands for sexual competence and expertise seem to be assuming a larger role in the development of sexual dysfunction. Accordingly, for therapy to succeed, the dysfunctional patients must be freed from anxiety about their sexual performance. Patients, regardless of presenting complaint, are told to stop “keeping score,” to stop being so goal-centered on erection, orgasm, or ejaculation, and instead to focus on enjoying the process rather than trying for a particular end result.
Increasing Communication and Effectiveness of Sexual Technique
Dysfunctional couples tend to be unable to clearly communicate their sexual likes and dislikes to each other, due to inhibitions about discussing sex openly, excessive sensitivity to what is perceived as hostile criticism by the spouse, inhibitions about trying new sexual techniques, and the incorrect assumption that a person's sexual responsiveness is unchanging, i.e., that an activity that is pleasurable on one occasion will always be pleasurable. Accordingly, direct therapy encourages sexual experimentation and open, effective communication about technique and response. Procedures that are used include having the patient couple share their sexual fantasies with each other, read explicit erotic literature, and see explicit sexual movies that model new techniques, and training the couple to communicate during their sexual interaction.
Changing Destructive Life-Styles and Sex Roles
Direct therapy for sexual dysfunction often involves the therapist's stepping outside the usual therapeutic posture of responding to the patient, and instead taking an active, directive, and initiating role with the patient in regard to general life-style and sex-role issues. For example, many dysfunctional patients make sex the lowest priority item in their life. Sex occurs only when all career, housework, child-rearing, home management, friendship, and family responsibilities have been met. This usually ensures that sex occurs infrequently, hurriedly, late at night, and when both partners are physically and mentally fatigued. In such a case, patients may be instructed to make "dates" with each other for relaxing days or evenings (Annon, 1974).
Prescribing Changes in Behavior
If there is any one procedure that is the hallmark of direct treatment of sexual dysfunction, it is the prescription by the therapist of a series of gradual steps of specific sexual behaviors to be performed by the patients in their own home. These behaviors are often described as “sensate focus” or “pleasuring” exercises. Typically, intercourse and, indeed, breast and genital touching are initially prohibited, and the patients only examine, discuss, and sensually massage each other's bodies. Forbidding more intense sexual expression allows the patients to enjoy kissing, hugging, body massage, and other sensual pleasures without the disruption that would occur if the patient anticipated these activities would be followed by intercourse or other sexual behaviors that have not been pleasurable in the past. The couple's sexual relationship is then rebuilt in a graduated series of successive approximations to full sexual intercourse. At each step, anxiety reduction, skill training, elimination of performance demands, and the other components described above are used to keep the couple's interactions pleasurable and therapeutic experiences.
The Correction of Misconceptions
Direct advice, guidance, information, reassurance, or instruction may suffice to overcome the milder, simpler, and more transient cases of impotence and frigidity. The correction of faulty attitudes and irrational beliefs is often an essential forerunner to specific techniques of lovemaking. One should endeavor to impart nonmoralistic insights into all matters pertaining to sex. It is often helpful to prescribe nontechnical but authoritative literature (Lazarus, 1978).
Graded Sexual Assignments
Wolpe (1958) evolved a simple but effective procedure for promoting sexual adequacy and responsiveness in those cases where anxiety partially inhibits sexual performance. A cooperative sexual partner is indispensable to the successes of the technique. The patient is instructed not to make any sexual responses that engender feelings of tension or anxiety but to proceed only to the point where pleasurable reactions predominate. The partner is informed that she must never press him to go beyond this point, and that she must be prepared for several amorous and intimate encounters that will not culminate in coitus. The theory is that by maintaining sexual arousal in the ascendant over anxiety, the latter will decrease from one amorous session to the next. Thus, positive sexual feelings and responses will be facilitated and will, in turn, further inhibit residual anxieties. In this manner, conditioned inhibition of anxiety is presumed to increase until the anxiety reactions are completely eliminated.
The role of Desensitization Procedures in Overcoming Frigidity
Treatment of chronic frigidity by systematic desensitization was first reported Lazarus (1963). Desensitization has also been successfully applied to groups of impotent men and frigid women (Lazarus, 1969). The preferred size of desensitization groups is between four and eight members. The sessions are conducted at the pace of the slowest (most anxious) individual. If one group member obviously delays the progress of the other patients, he is given a few individual sessions to expedite matters. The typical hierarchy applied to the frigid women consisted of the following progression: embracing, kissing, being fondled, mild petting, undressing, foreplay in the nude, awareness of husband's erection, moving into position for insertion, intromission, changing positions during coitus.
In the treatment of vaginismus (as well as in those cases suffering from generalized fears of penetration), desensitization, first in imagination, followed at home by gradual dilation of the vaginal orifice, has proved highly successful. The patient, under conditions of deep relaxation, is asked to imagine her inserting a graded series of objects into the vagina. When she is no longer anxious about the imagined situation, she is asked to use real objects. One might commence with the tip of a cotton bud, or the tip of the patient's little finger, followed by the gradual insertion of two or more fingers, internal sanitary pads, various lubricated cylinders, and eventually by the gradual introduction of the penis, culminating with vigorous coital movement. Masters and Johnson (1970) consider it necessary for husband and wife to cooperate in all phases of dilatation therapy.
Assertive Training for Impotent Men
Many impotent men appear to have servile attitudes toward women and respond to them with undue deference and humility. Their sexual passivity and timidity are often part of a generally nonassertive outlook, and their attendant inhibitions are usually not limited to their sex life. These men feel threatened when required to assume dominance in a male-female relationship. Therapy is aimed at augmenting a wide range of expressive impulses, so that formerly inhibited sexual inclinations may find overt expression. This is achieved first by explaining to the patient how ineffectual forms of behavior produce many negative emotional repercussions. The unattractive and exceedingly distasteful features of obsequious behavior are also emphasized. The patient is then told how to apply principles of assertiveness to various interpersonal situations. For instance, he is requested to "express his true feelings; stand up for his rights," and to keep detailed notes of all his significant attempts (whether successful or unsuccessful) at assertive behavior. His feelings and responses are then fully discussed with the therapist, who endeavors to shape the patient's behavior by means of positive reinforcement and constructive criticism (Lazarus, 1978).
Aversion- Relief Therapy in the Treatment of a Sexually Unresponsive Woman
Here patient is given aversive stimuli such as electric shock. When the electrical impulses became intolerable, she was required to turn her attention toward several photographs of nude men on the desk in front of her. Upon looking at the pictures, the shock is immediately terminated (producing definite signs of relief). She receives intermittent shocks when averting her gaze from the pictures . A slightly modified method can be at a later stage. The therapist says, "Shock!" and administered a very strong burst of electricity to the patient's palm if she did not proceed to look at the pictures within eight seconds. She is told that she could avoid the shock by looking at the pictures in good time. (Lazarus, 1978).
The Treatment of Premature Ejaculation
Premature ejaculation is sometimes a symptom of anxiety. The amelioration of anxiety by such techniques as relaxation, desensitization, and assertive training has therefore proved helpful in certain instances. In general, however, it should be noted that psychotherapeutic efforts have not proved especially effective in altering the premature response pattern. Nevertheless, some essentially simple tricks may occasionally meet with gratifying success. For instance, some individuals have managed to delay orgasm and ejaculation merely by dwelling on nonerotic thoughts and images while engaged in sexual intercourse. Others have found it more effective to indulge in self-inflicted pain during coitus (e.g., pinching one's leg, biting one's tongue). Masters and Johnson (1970), however, are not in favor of distraction techniques. The use of depressant drugs (e.g., alcohol or barbiturates) may also impede premature ejaculation in some individuals. The reduction of tactile stimulation (e.g., by wearing one or more condoms, or by applying anesthetic ointments to the glans penis) is also often recommended. All of the foregoing procedures are of limited value (Lazarus, 1978).
Two very effective techniques for the treatment of premature ejaculation are the pause (Semans, 1956) and the squeeze (Masters and Johnson, 1970) procedures. The pause technique consists of the female stimulating the male manually until he feels the physical sensations immediately preceding orgasm. At this point, the wife stops stimulating him until the sensations subside, then begins stimulating the penis again, and stops just before ejaculation. As this procedure is repeated, the male begins to develop ejaculatory control. The next step consists of repeating the procedure with the penis lubricated, so that the intravaginal environment is more closely approximated.
Masters and Johnson (1970) have developed a modification of this procedure in which the wife manually stimulates the penis until it becomes erect. She then squeezes the penis at the coronal ridge for three to four seconds, which causes the man to lose the urge to ejaculate and to lose 10-30% of his erection. The wife waits fifteen to thirty seconds, then repeats the procedure. After practicing for a few days, the couple repeats the procedure with intravaginal containment of the penis, but no thrusting, to produce stimulation. The next steps are intravaginal containment with slow movement, and than fast movement, using the squeeze as before.
Masters and Johnson (1970) write: "Definitive laboratory experience supports the concept that a more successful clinical approach to the problems of sexual dysfunction can be made by the dual-sex teams of therapists than by an individual male or female therapist. Certainly, controlled laboratory experimentation in human physiology has supported unequivocally the initial investigative premise that no man will ever fully understand a woman's sexual function or dysfunction. . . . The exact converse applies to any woman."
Conjoint Therapy: Another Masters and Johnson (1970) dictum is that the relationship, rather than either of the partners, is the patient. Because of this, they treat couples and not individual patients. Kaplan (1974b) and LoPiccolo (1975) echo this view. LoPiccolo (1975) emphasizes to the husband and wife that they are both responsible for future change, and Kaplan (1974b) believes that conjoint therapy is more effective than individual therapy because the shared sexual experiences are the crucial factor in therapy.
More than a decade after Masters and Johnson (1970), LoPiccolo (1983) noted that sound empirical evidence about the relative efficacy of sex therapy compared to other types of interventions was lacking. What is conspicuously missing from the sex-therapy literature are large, well-done studies involving adequate comparisons among specified treatment and control groups (Rosen & Leiblum, 1995; Schover & Leiblum, 1994).
In general, conducting outcome research in psychotherapy is a daunting enterprise (Bergin & Garfield, 17994), and conducting outcome research in sex therapy may be even more difficult, given the variety of physical and psychological etiological factors that may be relevant to a group of individuals, all of whom evidence the same manifest sexual dysfunction. This issue may partially explain the apparent decrease in outcome studies in sex therapy (see Schover & Leiblum, 1994, for discussion of other factors). As the clinical presentation of sexual difficulties has become more complex, the idea of applying the same therapeutic approach to all cases may seem increasingly absurd (LoPiccolo, 1992, 1994; Rosen & Leiblum, 1995). Still, in an era of increasingly complex clinical presentations, it is even more important to determine empirically the active ingredients in sex therapy, especially as matched with particular types of clients, dysfunctions, and etiological factors. In other words, we are lacking the necessary data to answer the question, "What type of sex-therapy approaches, with what type of sexual problems, what type of clients, and what type of sex therapist is most likely to result in a positive outcome?" (McCarthy, 1995).
In a broad sense, the future of sex therapy is dependent on the future of sexual science. Advances in theory and research on the components of, and factors related to, human sexual experience allow for further growth regarding interventions to alleviate sexual dysfunction. However, it is also incumbent on those who actually perform sex therapy to elaborate their theoretical assumptions and test the relative efficacy of their interventions through empirical study. The current nature of the complex cases with which the sex therapist is faced makes such research both more difficult and more needed than was true two decades ago (Wiederman, 1998).
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