Psychotherapy of sexual dysfunction.

There is a palpable tension in the sexological literature between an empirical/biological approach that focuses on the phenomenology of sexual behavior and a theoretical/psychological approach that explores the quality of the subjective experience of the sexual encounter of humans. Both paradigms have made valuable contributions, but any theorizing about human sexuality or description of psychotherapeutic treatments of sexual dysfunction has to take the societal developments of this past century into account. As Tiefer (1) says, "Sex is Not a Natural Act." Sexual habits and mores have been influenced by the Americanization of Freud, the Kinsey reports (2,3) and the emergence of pornographic media. Furthermore, the birth control pill, abortion and feminism shaped especially women's sexuality in a profound way. The Stone Wall Riot, Gay Liberation, and the Sexual Revolution of the 60s called longheld sexual beliefs into question. In the past two decades our sexual lives have been impacted upon by new technologies in reproduction, the AIDS epidemic, gender experimentation and transgenderism, the Internet and sex in cyberspace, and last, but not least, the remedicalization of sexuality via Viagra. Rather than of sexuality, we now speak of sexualities: anomie seems to be the condition of modern man/woman. Hence, we feel called upon to continuously reinvent ourselves: what (sexual) version of myself will I be today? Traditional sexual scripts (4) - the Who, Why, Where, What, When and With Whom of sexuality - have to be negotiated and renegotiated as individuals of divergent cultural and religious backgrounds encounter each other in the global marketplace of migrating populations. Radical conceptual changes in our notion of sexual problems and sex therapy have characterized the 20th century. Psychoanalysts, conditioned by theories of hysteria, tended to view sexual difficulties as indicative of repression and focused their efforts on the interpretation of intrapsychic conflict. With the publication of Masters and Johnson's Human Sexual Inadequacy (5), performance anxiety was postulated to be the basic ingredient to all sexual dysfunction. Therapeutic approaches utilized sensate focus and other directive techniques in order to promote an active relearning process. The initial optimism and enthusiasm of Masters and Johnson's pioneering work with quasi miraculous two week cures in St. Louis, however, gave way rather quickly to a sobering appreciation of the complexity of the sexual life of couples. Tiefer (1) challenged the scientific method of Masters and Johnson. She points out that these researchers do not refer to a human sexual response cycle (HSRC), but rather the HSRC, as if it were a natural constant. She questions the empirical validity of their research because the subjects were carefully selected volunteers with higher than average intelligence, more affluent socioeconomic backgrounds, and a greater level of sexual enthusiasm. They had to be able to experience orgasms with masturbation and coitus under laboratory conditions. (Not all of us would qualify! ) Given the selection bias, the findings could hardly be representative of ordinary men/women. Clearly, sexual response is not gender neutral. However, by establishing the semblance of gender equality, Masters and Johnson have, in fact, inadvertently contributed to a trivialization or denial of the social reality of women which is itself shaped by gender inequality. The focus on genital arousal and ability to achieve orgasm as the ultimate goal of a "functional" sexual encounter without consideration of the quality of the experience and the social context, in which the sexual encounter takes place, seems particularly unrepresentative of the emotional and sensual needs of women. In the long run, the idealized HSRC indeed became reified as a quasi "EKG" of sexuality. Even though common sense dictates that sexual response does not always follow a predictable pattern, couples define any deviation from the normative curve as "BAD SEX" and identify themselves as sexual failures. …