HSX5555 - SECTION 5: FROM ASSESSMENT TO TREATMENT
Section 5: From Assessment to Treatment
Once all relevant assessment information has been gathered concerning the client’s sexual life and/or sexual concerns, you will need to make some difficult choices concerning whether this aspect of a client’s life is going to be addressed in treatment with you, or whether you will need to refer the client to a specialist with the expertise to address his/her sexual concerns.
In either event, it is important for you to know about what is involved in sex therapy. If you are going to make a referral to a specialist to address this aspect of the client’s life, you will need to have a certain measure of knowledge about sex therapy in order to prepare the client for the transition, answer any questions the client may have concerning what to expect, and/or help to motivate them to get the needed help for a concern that may be uncomfortable for the person to address.
Obviously, if your intention is to address their sexual concerns yourself, as a component of the overall clinical process with which you are engaged with the client, your level of knowledge must be greater and you must also possess a collection of skills sufficient to lead the client towards a healthier place.
You must also possess the humility, wisdom and self-awareness to know when you are not sufficiently prepared to try to work on sexual concerns, and be willing to allow a better prepared clinician to provide the needed help.
However, because people’s sexuality is almost inevitably intertwined with other aspects of their personality structure, in many cases sexual concerns can be symptoms or manifestations of underlying psychological problems in other parts of their psychological make-up. In many cases, a problem with sexuality is only one of many possible manifestations of deeper psychological problems, and the therapy will lead back to the psychological causes of the problems, rather than remaining focused on the symptomatic expression of those problems.
Likewise, sexuality can also be construed – in most cases – as an interactive event. Sex (apart from masturbation) is generally expected to occur within relationships. Should the relationship have underlying problems, symptoms can show up in the sexual side of the relationship. The sex therapy is actually more accurately viewed as relationship therapy, and skilled couples counselors are generally well prepared to engage in that kind of treatment.
In both such instances, the causes of sexual problems may be more in domains with which you are familiar and which you are prepared to address. With a good and thorough assessment, it should be possible to discern whether referral is needed or whether treatment can be successfully completed by you.
It is our hope that both of these purposes will be assisted by this course. As a starting point, it may be helpful to present some basic guiding principles for sex therapy. This is presented in an easy to print format on the next page.
BASIC PRINCIPLES OF SEX THERAPY
1. Mutual Responsibility
Both partners are responsible for creating or maintaining problems and for future change and solution of problems. Some clients resist this to protect self-image or maintain power and control. It is important to have a distinction between responsibility and blame. (See below for suggested ways to engage both partners)
2. Information and Education
Basic knowledge of anatomy and physiology and sexual techniques is very important. While information alone is not sufficient to cure, it is necessary for success, and the absence of information may be responsible for the low success rate of nondirective or dynamic treatment approaches.
3. Attitude Change
Part of the work of therapy involves changing of certain attitudes and beliefs about sex. Specific areas include: a) negative attitudes toward sex, b) sex therapy may threaten the male’s self image, c) decent women don’t enjoy sex, etc. Prescriptions incorporate reading, lectures, workshops, and the therapeutic relationship.
4. Eliminating Performance Anxiety
Clients are encouraged to focus on the process rather than the end. Intercourse may be prohibited, and the concept of non-goal-directed sex is encouraged (see the American Idea of Sex)
5. Increasing Communication and Effectiveness of Sexual Techniques
Clients are encouraged to read literature together, see explicit movies, and learn/practice communication techniques. They are encouraged not to use negatives such as ”That’s not right,” “That hurts,” etc. but instead to say, “I like it when” or “It feels better if,” etc.
6. Changing Destructive Lifestyles and Sex Roles
Many couples make sex the lowest priority and spend little time together. Rigid sex role separation can be a problem too—one version of this is today’s workaholic husband and the “desperate housewife.” Therapy is directive about this, and one of the therapeutic prescriptions is to plan dates, weekends, etc. together.
7. Prescribing Changes in Behavior
The hallmark of direct therapy for sexual dysfunction is prescription of a series of gradual steps of specific behaviors to be performed at home. Examples include Sensate Focus Techniques and the Stop-Start Technique. Step by step instructions are geared toward skills training, anxiety reduction, and elimination of performance demands.
When Masters and Johnson first developed sex therapy, a male-female co-therapy team made involvement of both partners easier, but expense often precludes this today. Interestingly, in terms of ensuring compliance, Masters and Johnson’s initial approach required that couples pay in advance for therapy and then their deposit was refunded if they complied with therapy. If they did not follow through, the deposit was forfeited to charity. How frequently this practice is utilized today is unknown. (LoPiccolo & LoPiccolo, 1978).
In the 1970s, there was a much more limited set of problems that sex therapy was designed to address. This is shown below, along with some information about the specific techniques that were incorporated into the treatment approach:
SEXUAL DYSFUNCTIONS INITIALLY ADDRESSED IN SEX THERAPY (Masters & Johnson, 1970):
1. Premature Ejaculation (PE)
Stop-Start Technique (a variation of the squeeze technique)
2. Male Orgasmic Disorder (Ejaculatory Incompetence, Inhibited or Retarded or Delayed)
3. Erectile Concerns
4. Orgasm Problems
5. Dyspareunia and Vaginismus
6. Sex in the Aging
Post-modern sex therapy moves past the traditional sexual performance concerns and deals with more complex and chronic sexual issues. Post-modern sex therapy also includes the integration of new medications, surgeries and/or equipment that had not been developed during the period of time in which Masters and Johnson were developing their sex therapy techniques.
Below you will see some information concerning some of the concerns that are being addressed in what is called post-modern sex therapy:
POSTMODERN SEX THERAPY (LoPiccolo & LoPiccolo, 1978):
1. Chronic Illness
2. Drug Effects
3. Sexual Desire Disorders
4. Unresolved relationship issues
5. Cultural Issues
6. Often used in conjunction with surgical, mechanical, or medical interventions
THE PLISSIT MODEL FOR COUNSELING
Another key foundation model for sex therapy is the PLISSIT Model, developed by Dr. Jack Annon (1975) to address patients’ sexual concerns. The basics of this model are presented here, and the model will be used in addressing the specific sexual concerns that follow. It will be presented in an easy to print format so that it can be retained by the trainee for later reference.
This technique can be used by clinicians who are not sex therapy specialists with a medium amount of study and preparation for use.
THE PLISSIT MODEL FOR COUNSELING
P = Permission—Bringing up the topic. This is the professional’s responsibility, and patients/clients may be too embarrassed to bring it up. When you as the professional bring it up, patients then know the topic is acceptable for conversation. They may initially deny any concerns in this area, but you have opened the door for dialogue, and they may come back to you at a future time to discuss concerns and ask questions.
LI = Limited Information - Giving facts and dispelling myths. Myths and misinformation about sexuality are widespread, even among educated people. Some examples are, “You can’t get pregnant the first time you have sex,” “Masturbation causes blindness or hair on the palms of the hands” (or a myriad of other maladies), “Older people don’t have sex.” One of the major downsides of myths is that people often live their lives based on these beliefs, and if the beliefs are not questioned, they are passed from generation to generation as truths. It’s akin to the story of the young girl who saw her mother cut off the ends of a ham before she put it in the oven. The little girl asked her mother, “Why do you cut off the ends of the ham?’ The mother replied, “Because my mother did it.” The young girl then went to the grandmother and asked her the same question, and the response was, “Because my mother did it.” Finally she went to the great grandmother with the question, “Why do you cut off the ends of the ham before you put it in the oven?” The great grandmother’s response was, “I don’t know why you do it, but I did it because it wouldn’t fit in my oven.” Mistaken beliefs about sexuality can get passed down in much the same way and can have a major impact on what we do and what we believe is acceptable or taboo. The Limited Information level offers an excellent opportunity to correct misinformation that can be having a major impact on an individual’s or a couple’s sexuality. It isn’t necessary to give detailed information at this point, although it can be helpful to offer patients an article reprint, a book/DVD list, or an Internet resource list for their later use.
SS = Specific Suggestions - Directed toward a particular concern. With this step, the therapist conducts a Sex Problem History interview to determine what is happening and then works with the client to set realistic goals. When the goals are set, the therapist, again working with the client, makes specific suggestions for accomplishing the goals.
IT = Intensive Therapy - This step is taken after the therapist has tried the first three steps and they are not working. Now you must decide if you want to keep working with the client, knowing that the problem may be more deep seated and difficult to resolve, or refer the client to a specialist in the particular area of concern. Suggestions for referral sources are given under Criteria for Counseling.
Note: 70% of sexual problems can be greatly alleviated by the first three steps. If you think of this in terms of numbers of clients you see, a large number can be effectively helped with permission, limited information, and specific suggestions (Annon, 1975).
Clinicians should be knowledgeable about sexual problems and solutions as originally envisioned by Masters and Johnson, as well as the principles of Postmodern Sex Therapy. The choice of which approach to apply to a client’s sexual concerns - or of which expert to refer a client to – will be based upon a close examination of the nature of the client’s concerns.
In order to be thorough, this course will first present information about traditional, medical approaches to sexual performance concerns. To provide the trainee with a fairly comprehensive grasp of what is currently being used, this will include some discussion of medications and mechanical approaches to sexual performance problems.
The post-modern approach to sexual performance concerns does not rule out the use of these kinds of treatments. However, it is more usual that post-modern sex therapy will also include psychobehavioral approaches and approaches that address the sexual concerns within the context of a relationship. The most well known approach to integrate these two areas is called Sensate Focus, and it will be presented later in this section.
Medical Options for Inhibited Female Orgasm
To date, there have been no medical interventions that can be considered the female equivalent of Viagra and other ED medications. This is not for a lack of effort on the part of drug companies, including experiments on the use of Viagra on women (unsuccessful), a testosterone patch (which the FDA refused to approve) and a medication called flibanserin, for which the FDA advisory panel voted 10-1 to declare as no better than a placebo.
While the industry still holds out hope for an experimental medication called bremalanotide, for now they must be content with just the $2 billion a year they reap from the male half of the population. In general, most sexual concerns in the female population must be addressed through psychobehavioral approaches. However, there is one approach that may have some applications for women experiencing problems with orgasmic potential and/or problems with arousal potential. Fortunately, this is something that is safe, readily available, and useful for other medical purposes: Kegel exercises.
I. Kegel Exercises
The Kegel exercises were originally developed by Arnold Kegel, M.D., to deal with the problem of urinary stress incontinence in his women patients. Quite unexpectedly he discovered that his orgasmic patients developed a greater capacity for experiencing orgasms, and his non-orgasmic patients began having orgasms. (Kegel, 1952).
The primary muscle involved is the pubococcygeal (PC) muscle which when exercised strengthens not only urinary sphincter control, but increases muscle tonus in the vagina, thus increasing ability to constrict the vagina voluntarily. Consequently female vaginal perception and response during penile-vaginal intercourse are increased. For women who desire to become more responsive to genital stimulation, the use and training of the PC and associated muscles is one of the most effective individual techniques in producing the desired therapeutic results.
Though prescribed in the past primarily for women, this exercise can also be used by men. Men who practice the Kegel exercises say they are more in control of their ejaculations and their ejaculations are more pleasurable. Knowing where the pelvic muscles are, becoming aware of how to use them, and keeping them toned—like any muscle--are important factors in the health and pleasure of both men and women.
To aid your client in identifying the PC muscle, instruct as follows: Sit on the toilet. Spread your legs as far apart as possible and start and stop the flow of urine. The PC muscle is the only one that can accomplish this while in this position.
The next page is designed to serve as a handout for your clients.
How to Master the Kegel Exercises
First, locate your PC muscle: Sit on the toilet. Spread your legs as far apart as possible and start and stop the flow of urine. The muscle you use to do this is the PC muscle. Then lie down and put your finger into the vaginal opening, and contract the muscle. See if you can feel the contraction around your finger.
Exercise I: Contract and release the PC muscle very rapidly three sessions a day. Start by doing 50 contractions during each session, and work up gradually to about 150 contractions per session. Because the PC muscle is a muscle like any other muscle, with too strenuous exercise it can become sore. If this happens, either stop doing the Kegels for one or two days until the temporary soreness disappears and then resume, or reduce the number done per day and gradually increase to the recommended number. Option: Exercise for 5 minutes.
Exercise II: Contract the PC muscle, hold for 8 seconds, relax, and repeat the process. Do this 3 times a day. Start by doing 20 contractions during each session, and work up gradually to about 50 during each of the 3 sessions. Option: Exercise for 5 minutes.
Exercise III: Pretend that there is a ping-pong ball or tampon sitting in front of your vagina. Tighten your vaginal muscles as though sucking the ball or tampon into the vagina until it hits the cervix. Insert a finger and feel the vagina drawing it in. Start by doing this 20 times during each of 3 sessions during the day, and work up gradually to 50 during each session. Option: Exercise for 5 minutes.
Exercise IV: This set of exercises involves bearing down as though trying to expel the "ping-pong ball" or a tampon from your vagina. For 4 seconds bear down....then relax and repeat. Do the same number as in Exercise III, or exercise for 5 minutes.
Note: Instead of dividing the series of exercises into 3 daily sessions, one may wish to do the same number of exercises divided into 4 or 5 sessions. All of the exercises can be continued indefinitely. Men have noted that when they practice these exercises, they are able to maintain their erections and delay ejaculation. Some men report that stopping thrusting and performing several voluntary contractions as they feel themselves getting closer to ejaculation enables them to last longer. Increased muscle tone results in greater sensation during intercourse for both partners.
Once one learns where this muscle is, the Kegel exercises can be done during daily activities which do not involve a great deal of moving around, e.g., driving an automobile, sitting, doing dishes, watching television, standing in lines, and many other places. (Barbach, 2000).
Guidelines, limitations, contraindications: This is a technique that a clinician can relatively easily learn in ways that allow for instruction to clients. If a clinician believes that a handout is a useful tool for clients, the handout provided above can serve as a starting point. The web site of the Mayo Clinic may also serve as a useful starting point for the client interested in this approach. The web site for this is located below.
This technique can be used by clinicians who are not sex therapy specialists with a small amount of study and preparation for use.
II. Self-stimulation Techniques
There are numerous reasons why a woman may have difficulties with inhibited or missing orgasmic potential. A thorough sexual assessment is critical to determining what cause or causes may be most important to understand in terms of formulating a treatment approach.
For women whose problems achieving orgasm are connected to complex feelings about their sexuality, it can sometimes be difficult, threatening, or even traumatic to first attempt to become orgasmic within the context of a sexual relationship with a partner. There are pressures and complications in this that may present too great a challenge. At times, it is helpful to have a client begin to build a more comfortable construct for being orgasmic through self-stimulation.
Moreover, as we noted earlier in this training, a great majority of women are simply not able to achieve an orgasm through intercourse alone, but rather require direct clitoral stimulation. When masturbating, a client can apply stimulation directly to the body areas that are maximally stimulating and enjoyable, while simultaneously establishing better conditions for avoiding the anxieties that accompany having another person observing and interacting with her.
The goal of self-stimulation is to unlock the client’s ability to reach an orgasm under conditions that may create greater safety and fewer anxieties so that a measure of self-confidence and a sense of mastery can be created about the capacity of the client to enjoy her sexuality. This can serve as a helpful intermediary step to being able to become orgasmic in the context of a sexual relationship with a partner.
As an additional benefit, it also allows the client an opportunity to explore what kinds of stimulation applied to which body areas create the most enjoyable sources of pleasure. In the context of a relationship with good communication, this can later allow the client to instruct her partner more effectively in terms of the best approaches to creating sexual pleasure.
For clients who hold particularly powerful inhibitions against exploring and experiencing their own sexual arousal and pleasure, it may be necessary to approach direct sexual stimulation in a gradual and controlled way – with a great deal of emotional support and encouragement. If, as Woody Allen notes, masturbation is just sex with somebody you love, it may be helpful to approach this kind of sexual experience with the same principles that might be applied to a couple working on gradually increasing their sensual experiments when utilizing Sensate Focus approaches.
For women who have never experienced an orgasm, a vibrator may provide the necessary stimulation for an orgasm to occur. A vibrator provides what is typically the most intense form of stimulation, and the time to reach orgasm may be decreased with vibrator use.
One of the downsides of vibrator use is that this may become the only way a woman is able to achieve an orgasm. If this is the case, a woman who wants to shift to other methods of stimulation may need to “wean” herself from the vibrator. This can be done by gradually decreasing the vibrator stimulation (e.g. by placing clothing or other item between the body and the vibrator) and bringing in other forms of stimulation (e.g. hand or partner hand) along with the vibrator and then shifting to the other form of stimulation. Another concern voiced by some therapists is that long term, frequent vibrator use may decrease the sensitivity of the clitoris.
Guidelines, limitations, contraindications: Self-stimulation techniques can be relatively easily learned by a clinician. Several excellent resources on orgasm are also available for women. One of the best is a book and videotape/DVD set called Becoming Orgasmic. The DVD depicts a young woman and her spouse going through a learning and unfolding process of the woman’s becoming orgasmic for the first time. One of the benefits of the DVD is that it takes the viewer inside the woman’s (in this case, the actress’s) head as you hear her reflecting on her thoughts and feelings—thoughts and feelings that are generally very similar to the ones clients are experiencing. The accompanying book, also entitled “Becoming Orgasmic,” allows the client to work through her own thoughts, feelings, and past experiences in order to understand the factors that are impacting her orgasmic response. In the DVD, the viewer sees the actress utilizing the book as a resource.
This technique can be used by clinicians who are not sex therapy specialists with a moderate amount of study and preparation for use.
David, C. Blank, J. Lin, H. & Bonillas, C. (1996). Characteristics of Vibrator Use Among Women, Journal of Sex Research 33(4), 313-320.
Semans, A. (2004). The Many Joys of Sex Toys: The Ultimate How-To Handbook for Couples and Singles. Broadway.
Book and Video:
Heiman, J., LoPiccolo, J., and Palladini, D. (1987). Becoming Orgasmic: A Sexual and Personal Growth Program for Women. Better Sex Video (the same name) produced by Mark Schoen (1993). Book and tape are available as a set from the Sinclair Institute (www.sinclairinstitute.com).
Medical Options for Male Erectile Dysfunction
For many years, erection problems were a topic rarely discussed in private, much less acknowledged in broad-based advertising. The word for erection problems was “impotence,” a word that was also used to describe individuals who were considered to be powerless and ineffective in any number of areas. The reaction toward someone described as impotent was compassion and even pity. Indeed, the term was considered so negative that many sex therapists avoided using the word with clients, but instead referred to a problem as “erectile difficulty.”
Then, in 1998 Viagra (sildenafil) came on the scene, and the subject was “out in the open,” usually in reference to someone else’s issue and not necessarily voiced with concern. Bob Dole, former U.S. Senator and presidential candidate, was a very visible advertising spokesperson for Viagra, and it quickly became the fastest selling drug of all time. Since that time, two other medications have come onto the market, Cialis (tadalafil) and Levitra (vardenafil).
All three drugs work by increasing blood flow to the penis, so that when a man is stimulated, he can get an erection. The drugs do not enhance libido, and users must be sexually excited to initiate the response. All three drugs take effect within 30 minutes -15 minutes for Cialis, although Cialis provides a longer period of erectile capability - up to 36 hours versus 4 for Viagra and 5 for Levitra. Because of its long-lasting effects, Cialis is referred to in France as “Le Weekender.”
The drugs have proven to be effective in 75-80% of men, although there is not yet enough data to make comparisons as to which drug is the best. Individual men say they have achieved a better response to one drug than another - the drug of choice varies from man to man. Side effects of all three include headaches, vision changes (seeing blue), bloodshot eyes, nasal congestion, upset stomach, and flushed cheeks.
They should never be used by men taking nitrates for heart conditions or in association with the use of nitrate street drugs such as “Poppers” - drugs sometimes taken to enhance sexual response. Concurrent use of erection drugs and nitrate drugs can lead to sudden death due to a rapid drop in blood pressure. Also, erection drugs should not be used by men taking alpha blockers for blood pressure or prostate problems, as this combination could also result in dangerously low blood pressure (Harvard Medical School Faculty, 2007).
As clinicians it is important to be aware that younger males, both heterosexual and homosexual, may be using erection drugs as psychological safety nets to eliminate concerns about performance or to see if they can fulfill a fantasy of being a “superman.” According to Pfizer, manufacturer of Viagra, about 10% of the 16 million prescriptions written between 1998 and 2003 were for men under the age of 39.
Some had realistic medical conditions such as diabetes that warranted use of Viagra, but many younger men wanted them for a variety of reasons unrelated to illness or disability. Reasons include today’s fast-paced, often chaotic dating climate with its attendant performance expectations and anxieties (St. John, 2003).
Since the drugs are considered relatively safe, many physicians are willing to write prescriptions for them, and they are also easily obtainable through the internet. Young men are also “engaging in their own clinical trials with little medical guidance, testing dosages and brands in the impotence-drug equivalent of the Pepsi Challenge” (St. John, 2003).
Although manufacturers deny that they are touting their products to younger men or for use as lifestyle enhancers rather than for serious medical conditions, advertisements for Viagra, Cialis and Levitra are now seen at events such as professional baseball games, NASCAR races, and National Football League games.
Interestingly in the 2005 football Superbowl, the drugs were heavily advertised, but these ads were not a part of the 2006 Superbowl advertising. In 2007, advertising during some NFL playoff games featured ads for condoms, a relatively rare occurrence on major television stations.
From a clinical perspective, there are complex choices about whether and when to recommend that a male client with sexual performance problems consider discussing the use of ED medications with a physician. Some sex therapists say the drugs can be valuable tools in helping young men overcome psychologically based erection problems. Studies show that the drugs are 80% successful in such cases.
Psychologically based erection problems can be caused by a wide variety of different factors, but one of the most usual components – either as a primary contributor or as a secondary contributor – is a phenomenon called spectatoring, i.e., remaining outside oneself as an observer and gauging one’s responses and performance.
Sexual responses, which are among the most primitive of reflexive responses in our repertory of behaviors, are designed to proceed forward relatively separate from our conscious decision making equipment. A sexual state of mind is a kind of flow state, where a person gets immersed in the experience, and thinking is de-emphasized. When the part of the brain that monitors behavior – our self-consciousness – gets too energetically activated during sex, it starts to interfere with that flow state, and with the smooth operation of our sexual responses.
When spectatoring begins to occur, it can set up a self-reinforcing feedback loop. As thinking increases, the sexual responsiveness that allows for an erection begins to be displaced by self-consciousness. This causes the erection to diminish, leading to increased worries about performance and increased spectatoring, leading to further decreases in the flow state and in the automatic functioning of the erectile equipment.
From a sex therapy perspective, the goal is to help a person return to the flow state that allows for easy sexual functioning. However, once spectatoring begins to occur, it can be difficult to turn off. This is why there may be legitimate reasons to consider the use of ED medications as an adjunctive treatment for this condition.
First, in combination with the chemical effects of the medications, there may be somewhat of a placebo effect that occurs, where men have an expectation that the medication will allow for a positive sexual experience. The increased flow of blood to the penis combined with this potential placebo effect may begin to establish a more positive feedback loop that precludes the emergence of spectatoring "It helps their confidence enough that they can relax," says Carolyn Hillman, a Manhattan sex therapist. (St. John, 2003)
With positive sexual experiences, the client may begin to internalize a sense of trust and confidence in his own responsiveness that allows the capacity to achieve a flow state to strengthen and consolidate. Working from a competence – and confidence – enhancing position, it may be that the use of these medications may help create the conditions similar to what occurs in Exposure Therapy or Systematic Desensitization, where an experiential sense of mastery is created and internalized through exposure to a challenge - where the challenge is undertaken under more favorable and supportive circumstances.
In such instances, there may come a time when the client can be weaned from the use of these medications and be able to trust his own capacity to enter a flow state and remain sexual without spectatoring. Obviously, there are counseling approaches that can help facilitate and complement this process of internalizing a model of success.
A husband age 62 and his 57 year-old wife came to a therapist complaining of the husband’s erection difficulty. The husband’s physician had found no definitive physical condition except for the normal changes of aging that could be interfering with his erections.
The wife, a therapist in training, thought that her frequent “nagging” of him had finally taken a toll that resulted in his resentment and subsequent problems with erections. While they were coming for therapy, the wife, who had never had an orgasm, said that she would also like to focus on becoming orgasmic. In the course of therapy, relationship issues were explored, and sexuality and communication homework exercises were prescribed.
A few weeks into therapy, the husband’s physician prescribed Viagra for him, and his previous erectile capability and functioning returned. In the next therapy session, the wife stated, “Now I know it wasn’t my nagging that was causing his erection problems. I’m feeling much better, and so is he. Also, I don’t really care if I ever have an orgasm—it feels like too much work, and it’s not that big a deal. So we’ve decided not to come back (to therapy).”
On the other side of the equation there are also situations in which spectatoring is not the most compelling cause of the sexual performance problems. In some cases, men may use the drugs to mask deeper psychological or relationship issues that might be better dealt with through psychotherapy. They may use the ED medications as a way to avoid feedback from psychological processes that are actually attempting to cue them into awareness of a problem that needs addressing.
In such instances, the therapeutic work will be much more complex and involved. It is for this reason that a comprehensive psychosocial assessment is recommended even when the presenting problem is defined by the client as “just a sexual issue.” Even the most thorough assessment of a client’s sexual concerns would not help the clinician to discriminate what therapeutic approaches would be needed with clients whose problems are deeper than just sexual performance.
Guidelines, limitations, contraindications: Mental health clinicians are not allowed to dispense medical advice to their clients concerning medication choices. Responsibility for a decision to take any medication must be shared between a client and his/her physician. The mental health clinician’s role in this decision is to help the client evaluate the circumstances related to the erectile problems, and help the client decide if it makes sense to raise the issue with his/her physician. A client’s primary care physician may elect to refer the client to a specialist to rule out the existence of a medical problem that may be contributing to the erectile problems. The clinician may elect to secure a release of information to exchange information with the client’s physician or the specialist.
Non-Surgical Treatment for Male Erectile Problems
In addition to the popular drugs now on the market (Viagra, Cialis, and Levitra), several reasonable nonsurgical treatment options exist and many authorities say almost any man who wants to have an erection can do so, regardless of the underlying cause of his problem. These options include external vacuum devices, hormonal therapy, penile injections, and intraurethral pellet therapy.
1. External vacuum devices
This is a device that consists of a plastic cylinder with tension rings of different sizes accompanied by a small pump designed to be used by hand. The cylinder is placed over the penis. The action of pumping air out of the cylinder causes a vacuum that draws blood into the penis creating an erection. The ring is then placed at the base of the penis to keep blood in the penis to maintain the erection (Harvard Medical School Faculty, 2007).
Guidelines, limitations, contraindications: There are potential risks for any medical device that interacts with a client’s penis. The decision to utilize a vacuum device must be made between the client and a doctor specializing in the use of this equipment. The clinician may elect to secure a release of information to exchange information with the client’s physician or the specialist.
2. Hormonal Treatment
If a man has low levels of testosterone, this may affect sex drive and erectile functioning. Testosterone can be administered by injection, patches, gels, or pills.
Guidelines, limitations, contraindications: There are potential risks for the use of powerful hormonal medications. The decision to utilize any such medications must be made between the client and a physician. The clinician may elect to secure a release of information to exchange information with the client’s physician or the specialist.
3. Penile Injection Therapy
An injectible vasodilating drug is injected directly into to shaft of the penis causing erection. Although a number of older drugs approved for other purposes have been used effectively for erectile dysfunction, the only one specifically approved for erectile dysfunction is alprostadil-Caverject, Edex (Harvard Medical School Faculty, 2007).
Guidelines, limitations, contraindications: There are potential risks for any medications that might be injected into a client’s penis. The decision to utilize this approach must be made between the client and a physician. The clinician may elect to secure a release of information to exchange information with the client’s physician or the specialist.
4. Intraurethral Pellet Therapy
The same drug used in penile injection therapy (alprostadil) is inserted into the urethra in the form of tiny pellets. This is known as MUSE therapy, i.e. Medicated Urethral System for Erection (Harvard Medical School Faculty, 2007).
Guidelines, limitations, contraindications: See above.
Surgical Treatment/Penile Implants
Penile implants come in two forms: silicone rods and inflatable cylinders. The devices have been effectively used in cases where erections were not possible due to radical surgeries, traumatic injuries, or long term medical conditions such as diabetes. The suggestion of a penile implant as a blanket treatment to correct all manner of erection problems should not be the first treatment considered.
In the 1970’s and 80s many penile implants were done to remedy all types of erectile dysfunction, and often the accompanying psychological/relational issues were not addressed. Even in cases where an implant is considered to be the optimal treatment option, the patient’s spouse or significant other should be included as much as possible in counseling about the procedure and its subsequent impact (Harvard Medical School Faculty, 2007).
As noted, many penile implants were done in the past, sometimes unnecessarily, and the ultimate value of these was later questioned. For some men, however, the ability to have erections is of paramount importance. For some men implants have been, “the best thing that ever happened to me” in spite of the radical nature of this surgery.
Guidelines, limitations, contraindications: Penile implants represent major surgery, with the potential for serious complications and surgical problems. The decision to utilize this approach must be made between the client and a physician. The clinician may elect to secure a release of information to exchange information with the client’s physician or the specialist.
A 72 year old client (with a long history of depression) and his 69 year old wife were referred to a sex therapist by a psychiatrist who had asked the man about his sexuality. The client was so pleased that someone still considered him sexual that he did perk up a bit just from being asked. During the interview with the sex therapist, the man said that he had had a penile implant 10 years before.
When asked about the reason for the implant, the client replied, “I really don’t know.” The therapist’s guess about this was that the man had begun to have some of the physiological changes of aging (erections less firm, taking longer, needing more direct physical stimulation, etc.), had become anxious and gone to a urologist, and been told that an implant would solve the problem.
Since that time, however, each time the man and his wife had tried to have intercourse, it seemed as though his penis was shorter and that it would “fall out.” He asked if it was possible that his penis was indeed shorter.
The therapist, not knowing the answer to this question, called a medical center that does a lot of penile implants to inquire. She was told that the older models of penile implants would make the penis get firmer but not longer and that indeed the client’s penis could be shorter than before, even by as much as two inches. The consultant also said that the newer implants were better and corrected the length problem.
In conducting the sex problem history with this couple, they revealed that because of the frustration associated with sexual contact, they had not attempted intercourse in a number of years. The therapist asked what types of touching they had been doing in lieu of intercourse. The couple looked at each other and then at the therapist and replied, “None.” They had stopped having any kind of physical contact.
This example highlights again that the American idea of sex is a goal-directed stair-step progression that ends in intercourse and the largely mythic and elusive multi-orgasmic simultaneous orgasm in intercourse for both partners. In the current couple this belief had led to an almost total lack of touching.
The therapist asked “Do you remember the kinds of touching you used to do when you first met, before you started having intercourse?” The couple again looked at each other and said, “Yes.” For the upcoming week, the therapist prescribed planned sessions of the couple’s touching one another like they had done in the past. They were also told to communicate verbally what they particularly liked and their responses to doing these touching exercises.
The next week the man walked into the therapist’s office with a smile on his face and said, “That was wonderful! Why did we ever quit?” His wife concurred. This illustrates the importance of health care providers’ recognizing and imparting to patients and clients the importance of non-goal-directed sex. It should also be noted that at the same time the man was acknowledging the value of the touching exercises, he was also saying he was eager to pursue the possibility of getting one of the newer types of penile implants.
Medical Options for Premature Ejaculation
Traditional methods of PE treatment are more likely to rely heavily on behavioral therapy and/or off-label use of older drugs that are approved for other conditions, all of which yield limited success. Current treatments options include self-help, psychobehavioral treatments, topical creams and local anesthetics, hormonal therapy, Viagra (sildenafil) or PD5 inhibitors, and the off-label use of the SSRIs. Development of other drug treatments is currently underway (Barada & McCullough, 2004).
Clients will often report self-help techniques they have developed to address PE (also called RE). In general these methods have not been particularly effective.
1. Use of multiple condoms to decrease sensitivity of the glans.
2. Desensitization ointments containing local anesthetic agents - these have been shown to increase the intravaginal ejaculatory latency time (IVELT or IELT), but they can also cause vaginal numbness in the partner and frequently are not satisfactory to either partner. (Latency is the time prior to ejaculation).
3. Masturbating prior to intercourse to try to lengthen the time before ejaculation, i.e. the latency period in intercourse. With increasing age, however, a second erection often becomes difficult to achieve.
4. Mental distraction, e.g. counting sheep or focusing on the football playoffs, so that he does not get “turned on” and ejaculate quickly. (Barada & McCullough, 2004).
Similar to what was described with erectile problems, the long-term goal of treatment for premature ejaculation is to create a positive feedback loop where an experiential sense of mastery is created and internalized through a history of successful sexual experiences. When a sense of trust and confidence in one’s own sexual capabilities is created, it reduces the anxiety that is typically the driving force for premature ejaculation.
If any of these self-help methods is successful in increasing a person’s confidence that a sexual experience will be more positive, it can become a self-fulfilling prophecy, supporting a sense of mastery that can then lead to further increases in confidence. Therefore, these approaches should not automatically be dismissed. The kind of placebo effect that may occur here has many applications in clinical work.
More likely though, any of these techniques would be used in combination with a variety of other techniques, such as Sensate Focus and other approaches to reduce performance anxiety within the context of a relationship.
Guidelines, limitations, contraindications: Self-help methods such as multiple condoms, desensitizing ointments, or masturbation prior to intercourse must be evaluated carefully to see whether they can be useful, temporary adjuncts to other therapeutic approaches that help create a sense of mastery and confidence. The use of thought redirection techniques (thinking about something else) to delay ejaculation may conflict with some of the goals of psychobehavioral techniques such as Sensate Focus, where the purpose is to teach the person to gain control through increased focus on the pleasurable sensations associated with intimate contact, but in the absence of performance anxiety.
II. Psychobehavioral Techniques
a. Squeeze Technique and Stop-Start Technique
The psychobehavioral technique known as the Squeeze Technique was developed by Masters and Johnson (1970). The goal of this technique and a similar technique known as the Stop-Start Technique is to teach the man to become aware of the sensations leading up to orgasm and then to begin to control and delay his orgasm.
Briefly described, the Squeeze Technique involves a man or his partner stimulating his penis while he pays attention to what is happening in his body. As he approaches the point of ejaculatory inevitability - the point beyond which ejaculation is definitely going to occur, the man or his partner will squeeze his penis until his erection subsides.
The Stop-Start Technique involves the same process except that at a point prior to ejaculatory inevitability, he stops the stimulation or tells his partner to stop (Belliveau & Richter, 1970).
Once again, the goal is to create an internalized sense of mastery for a sexual situation. Even though the ability to withhold an orgasm is, at first, only possible through the application of an external behavior, the client does begin to associate the sexual experience as occurring without inevitable premature ejaculation.
With repetition, this association begins to allow the client to have conscious decision making serve to determine the time of reaching orgasm, rather than anxiety driven unconscious processes. This insertion of conscious decision making diminishes anxiety, as well as other feelings that may contribute to the development of anxiety, such as shame, fear, and a self-conscious sense of being exposed.
One problem that has been noted in using these techniques is that if they are being practiced by a couple, a certain amount of choreography between the two is necessary. This can be difficult, and if it does not work, there can be some resentment issues that arise.
Also, some therapists believe that the techniques provide positive short-term benefits, but feel that over time the improvement tends to break down. Whether or not this is a result of a return to old familiar patterns of interaction and response is unclear. Other therapists question the view that the improvement breaks down over time.
It is reasonable to assume that resolution of this disagreement may lie in how successfully a sense of mastery and confidence can be consolidated and internalized for any specific client in question. The Squeeze Technique and the Stop-Start technique should be considered adjuncts to treatment, rather than the whole of treatment. They may be integrated into the larger picture of what is being attempted in the treatment of the client’s sexual concerns.
Guidelines, limitations, contraindications: The Squeeze and Stop-Start Techniques should be considered transitional approaches used to increase confidence and a sense of mastery over engaging in sexual activities.
The capacity to instruct clients in the use of this technique can be acquired by clinicians who are not sex therapy specialists with a small amount of study and preparation for use.
b. Changing Positions
For some couples, shifting intercourse positions to those that provide less intense stimulation to the man can be helpful in reducing the occurrence of PE.
Guidelines, limitations, contraindications: Changing positions should be considered only a transitional approach used to increase confidence and a sense of mastery over engaging in sexual activities.
c. Kegel Exercises
Interestingly, men who practice the Kegel Exercises say that they are more in control of their ejaculations and that their ejaculations are more pleasurable. Information on how to engage in Kegel exercises can be found in an earlier section.
Guidelines, limitations, contraindications: Kegel exercises, at the very least, serve as an easy and convenient way to keep strong the muscles that prevent urinary incontinence and perhaps improve the pleasure from ejaculation. As long as a clinician does not oversell the potential for Kegel exercises to offer a small measure of support for improving problems with premature ejaculation, there is very little risk in encouraging clients to add this to their treatment regimen.
This technique can be used by clinicians who are not sex therapy specialists with a small amount of study and preparation for use.
d. Sensate Focus Technique
As we will see when we examine this approach in more detail in a later section, sensate focus exercises are designed to lessen anxiety by promoting touching and stimulation without the pressure of intercourse and ejaculation. Sensate focus and the stop-start technique can be combined.
When intercourse is attempted, the couple can stop the thrusting/stimulation, allowing the man to settle down and ultimately, as a result of practicing and conditioning, to develop greater ejaculatory control. This technique is sometimes referred to as the quiet vagina. Guidelines, limitations, and contraindications will be addressed when we examine sensate focus in more detail.
III. Hormonal and Viagra (Sildenafil) Therapy
1. Testosterone replacement has not been shown to have an impact on either PE or erections (only on libido).
2. Viagra (sildenafil) has not been shown in studies to date to have a significant benefit in cases of PE (only on ED). It may improve the perception of control (Barada & McCullough, 2004).
Guidelines, limitations, contraindications: These approaches do not appear to have research support for their use and should probably not be encouraged as part of treatment.
IV. The SSRIs
At present there are no prescription medications approved by the FDA specifically for the management of PE. Prozac (fluoxetine), Zoloft (sertraline), and Paxil (paroxetine) at therapeutic doses have been proven to cause decreased libido, and some women will experience anorgasmia and men will be unable to have any ejaculation or orgasm, particularly if the dosage is high.
However, studies have shown that these drugs can improve intravaginal ejaculatory latency periods (IVELT) and thus have a positive impact on PE. (Riley & Segraves, 2006) Some authorities say these medications can be taken shortly before anticipated intercourse or they can be taken ongoing, depending on a variety of circumstances.
Others say the drugs have a delayed onset of action and a long half-life and are not suitable for on-demand usage. They require chronic dosing and the effect lasts only when the drug is in the body. Also, there are associated side effects, particularly with higher doses, that include dry mouth, nervousness, GI upset, headache, and drowsiness. Chronic dosing can lead to decreased libido and erectile dysfunction. (Riley & Segraves, 2006)
Guidelines, limitations, contraindications: These approaches appear to have some research support for some men, but the client should be encouraged to discuss with his physician the trade-off between the potential benefits and the potential side effects.
V. Drug Treatments under Development
In the wake of the success of the phosphodiesterase V (PD5) inhibitor drugs such as Viagra, Cialis, and Levitra, pharmaceutical companies are working diligently to develop medications for PE, expecting that men who suffer with PE will embrace a pharmacologic remedy.
At the present time researchers are working to custom design an SSRI that can be used on demand that will decrease the signal from the brain to the penis, be fast-acting, have a short half life—a pharmacokinetic profile similar to that of the PD5 inhibitors—and also be specific for the serotonin receptors that impact ejaculation.
Dapoxetine hydrochloride, a drug chemically similar to the SSRIs, is currently being tested, and it appears to be well tolerated and effective in improving PE (Waknine, 2004). If approved by the FDA, Dapoxetine hydrochloride would be the first prescription treatment designed specifically to treat PE. The drug has been approved in several European countries, but as of today (April 15, 2015) is still in phase III testing and awaiting final approval for use in the United States.
The move to treat premature or rapid ejaculation with drugs is sparking debate about whether drugs are always necessary, and some see it as just the latest step in the drug industry's growing push to target lifestyle issues. A number of past studies have shown that non-drug interventions, such as therapy and behavioral changes, can be successful, at least initially, in about two-thirds of cases, and these rates can often be sustained by follow-up psychotherapy sessions (Medscape Urology, 2004).
Like erection problems, however, premature ejaculation is recognized as a legitimate medical diagnosis and is listed in the official manual of mental disorders used by the psychiatric community. As with other conditions that were once thought to be purely psychological, such as depression, research increasingly suggests the condition has a biological basis.
Note: Frequent ejaculations lead to lower sperm counts. Sperm count falls about 29% with two ejaculations a week and falls 41% with three ejaculations.
VI. The Integrated Approach
An integrated approach to treating rapid ejaculation might well include the use of medications as an adjunct to sex therapy. The combination of medication and training has been noted by therapists to produce favorable results. Sex therapy would include attentional and attitudinal change and exercises the man can be taught to do either on his own or with a partner.
There are books, such as The Multi-orgasmic Man, by Chia and Abrams, that provide instructions for heightened attention to sensation, the achievement of conscious control of sensory enhancement, and an acute awareness of the breadth of options for pleasure available in the absence of ejaculation. It helps shift the paradigm from ejaculation to pleasurable sensation, which is really the key to prolongation. In line with Post-modern Sex Therapy, the idea is to change paradigms from performance driven ideas of sex to the concept of non-goal-directed sex. (Chia & Abrams (2002)
The ancient practice of tantra can open similar doors. Traditional sex therapy and Taoist/tantric practices are illustrative of Western and Eastern philosophies and traditions respectively and provide avenues for addressing sexual concerns in a variety of ways.