12. Sexual Dysfunctions, Counseling, and Therapies

A. Brief History of American Sexual Therapy

The scientific study of sexual dysfunctions and the development of therapeutic modalities in the United States started with Robert Latou Dickinson (1861-1950). Born and educated in Germany and Switzerland, he earned his medical degree in New York and began collecting sex histories from his patients in 1890. In the course of his practice, he gathered 5,200 case histories of female patients, married and single, lesbian and heterosexual, and published extensively on sexual problems of women (Brecher 1979; Dickinson and Beam 1931, 1934; Dickinson and Person 1925).

The turn-of-the-century popularity of Sigmund Freud's psychoanalysis strongly influenced early American sexual therapy. Although its popularity has faded significantly, the psychoanalytic model is still practiced or integrated with other modalities by some therapists working with sexual problems. The 1948 and 1953 Alfred Kinsey studies brought an increased awareness of human sexuality as a subject of scientific investigation that could include the treatment of sexual disorders as part of psychiatry and medicine. The pioneering work of Joseph Wolpe and Arnold Lazarus (1966) in adapting behavioral therapy, shifted sexual therapy away from the analytical and medical model, as therapists began to view dysfunctional sexual behavior as the result of learned responses that can be modified.

William Masters and Virginia Johnson began their epoch-making study of the anatomy and physiology of human sexual response in 1964. Their initial research with 312 males and 382 females, published as Human Sexual Response (1966), remains the keystone of modern sex therapy, not just in the United States, but anywhere sex therapy is studied or practiced. Human Sexual Inadequacy followed in 1970. Masters and Johnson used a male-female dual-therapy team, and a brief, intensive, reeducation process that involved behavior-oriented exercises like sensate focus. It appeared to be highly successful because they worked with a select population of healthy people in basically solid relationships. After their success with relatively simple cases, they and other therapists began to encounter more difficult cases, which could not be solved with the original behavioral approach.

In the early 1970s, Joseph LoPiccolo advocated the use of additional approaches designed to reduce anxiety within the behavioral therapy model suggested by Masters and Johnson (LoPiccolo and LoPiccolo 1978; LoPiccolo and Lobitz 1973; Lobitz and LoPiccolo 1972). LoPiccolo's (1978) analysis of the theoretical basis for sexual therapy identified seven major underlying elements in every sex therapy model: (1) mutual responsibility, (2) information, education, and permission giving, (3) attitude change, (4) anxiety reduction, (5) communication and feedback, (6) intervention in destructive sex roles, lifestyles, and family interaction, and (7) prescribing changes in sex therapy.

John Gagnon and William Simon (1973) stressed the importance of addressing social scripting in sex therapy. Harold Lief, a physician and family therapist, pointed out the importance of nonsexual interpersonal issues and communications problems as factors in sexual difficulties. Lief (1963, 1965) also advocated incorporating the principles of marital therapy into sex therapy. As therapists began to integrate other modes of psychotherapy, such as cognitive, gestalt, and imagery therapies, it soon became apparent that there was no single “official” form of sex therapy. In addition, some sex therapists became sensitive to the impact and influence of ethnic values on some sexual problems (McGoldrick et al. 1982).

Helen Singer Kaplan, a psychiatrist at Cornell University College of Medicine, made an important and profound contribution to sex therapy when she blended traditional concepts from psychotherapy and psycho-analysis with cognitive psychology and behavioral therapy. Kaplan's New Sex Therapy (1974) explored the role of such important therapeutic issues as resistance, repression, and unconscious motivations in sex therapy. This new approach focused not only on altering behavior with techniques like the sensate-focus exercises, but also with exploring and modifying covert or unconscious thought patterns and motivations that may underlie a sexual difficulty (Kaplan 1974, 1979, 1983).

Specific areas of sexual therapy have been developed, including Lonnie Barbach's (1980) and Betty Dodson's (1987) independent work with non-orgasmic women, Bernard Apfelbaum and Dean Dauw's use of surrogates in their work with single persons, William Hartman and Marilyn Fithian's (1972) integration of films, body imagery, and body work with dysfunctional couples, and Bernie Zilbergeld's (1978, 1992) focus on male sexual health and problems.

There have been no major innovative treatments developed in sex therapy programs in recent years, although new refinements continue to occur. Some would comment that one does not have to reinvent the wheel when the results are good, but the early success rates have declined as the presenting problems have become more complicated and difficult to treat. Nevertheless, self-reported success rates from reputable sex therapy clinics run between 80 percent and 92 percent. However, critical reviews of sex therapy treatment models emphasize the paucity of scientific data in determining the effectiveness of such programs.

Today, few professionals who counsel clients with sexual difficulties see themselves as pure sex therapists. More and more, the term “sex therapy” refers to a focus of intervention, rather than to a distinctive and exclusive technique. Individual psychologists, psychotherapists, marriage counselors, and family therapists may be more or less skilled in providing counseling and applying therapeutic modalities appropriate to specific sexual problems, but each tends to apply those interventions and techniques with which they are more comfortable.

Informal support groups also provide opportunities for dealing with sexual problems and difficulties. Many hospitals and service organizations provide workshops and support groups for patients recovering from heart attacks, for persons with diabetes, emphysema, multiple sclerosis, cystic fibrosis, arthritis, and other chronic diseases. These support groups usually include both patients and their partners.

B. Current Status

Recently, American sex therapy has incorporated important advances in medicine and pharmacology. More-precise knowledge and techniques now allow a therapist to develop a hormone profile for a patient, monitor nocturnal penile tumescence, and check penile and vaginal blood flow. With patients now reporting the negative side effects of medications on their sexual responses, doctors have developed strategies for altering the course of medication. New surgical methods improve penile blood supply. Moreover, prosthetics and other aids, like injections and electrical devises to stimulate erection, have been developed.

Breakthroughs are also occurring in female sex research with direct implications for sex therapy. Examples include the efforts of sex-affirming women to redefine sexual satisfaction in women's terms and expand our appreciation of the spectrum of erotic/sexual responses beyond the phallic/coital (Ogden 1995), Joanne Loulan's (1984) exploration of lesbian sexual archetypes, sexual responses of women with a spinal cord injury, the effects on women's libido of homeopathics to increase the bioavailability of testosterone, and work combining testosterone with estrogen replacement to increase both sexual desire and pleasure in perimenopausal women.

One sidelight in this exciting female sex research is that the old methods of sensate focus and pleasuring exercises are still working successfully. For example, the self-help materials are still very useful in working with preorgasmic women. The traditional sensate-focus exercises are still effective in working with desire issues, painful intercourse, and vaginal spasms.

More good news are the trends in treating male sexual dysfunction today. For the motivated and cooperative male, there is treatment for virtually every dysfunction. In addition to the ever-helpful sensate-focus exercises, we have medications for increasing desire and arousal, such as yohimbe, a bark extract of the African tree yohimbe, and a combination of green oat and palmetto-grass extract. These are available through a physician's prescription, at health food stores, or through mail-order catalogs. As of mid-1995, there is enthusiastic anecdotal feedback from individual therapists who are using yohimbe and oat extract with their clients, but what is anxiously awaited - and needed - in this area are the results of controlled clinical studies to document the actual therapeutic effects, if any.

The vacuum pump for erections has been much improved with automatic monitoring of blood flow. With some clients, penile injections produce remarkable results. Monoxydyl and nitroglycerin are being used as topical preparations, as are prostaglandin El suppositories inserted into the urethral meatus. Taken alone, these medications are not effective. Without therapy, the person will often stop using the medication or method. However, when sex therapy is added, the success rate increases dramatically, because both the relationship and the dysfunction are being treated.


Several problems currently impede the delivery of sex therapy to clients. Primary among these is the state of flux in the insurance industry (third-party payers) with the shift toward managed care, health maintenance organizations, and provider networks. The availability of third-party payment makes it much more feasible for patients to avail themselves of sex therapy. The insurance industry has changed the entire health-care-provider field by creating the impression that therapists, like others in the medical field, are not to be trusted to know how long therapy should last, or what methods should be used to treat psychodynamic problems. This has created the image that all psychological problems can be treated by brief therapy within a predetermined number of sessions. The insurance industry has also made confidentiality problematic, because clients must sign away the right to confidentiality in order to receive mental-health coverage. Increasingly, insurance plans refuse to pay for sex therapy. This has prompted many therapists to give a diagnosis that is acceptable to the plan, and then include sex therapy as an Axis II diagnosis.

Secondly, the rise of the religious right appears to have had a negative impact on sex therapy in America. Although there has been no general decline in premarital sex in America, the “abstinence only until marriage” ethic can be a considerable barrier to normal adolescent sexual rehearsal explorations for some people, and may well result in trauma and dysfunction when newlywed couples confront their sexuality and sexual functioning on the wedding night. Thirty years ago, Masters and Johnson found that religious orthodoxy was a primary cause of sexual dysfunction. Two responses are likely, the individuals and/or couple may become so stressed that it is difficult for them to function naturally within the permitted circumstances, or they may rebel even before marriage and get involved in promiscuous and/or risky practices.

A third concern is a growing challenge as to whether sex therapy is even a separate discipline. There are those who believe that sex therapy needs to be subsumed under psychology, marriage and family therapy, social work, or psychiatry. The fact is that few of these disciplines have educational or training programs that teach about the healthy aspects of sex and sexuality or the creative treatment of sexual problems.

Finally, the amount of money and effort given to research on female sexuality significantly lags behind research on male sexuality (di Mauro 1995).

Because humans are born sexual but not lovers, sex therapy is increasingly seen as including good sex education, good medicine, and good psychotherapy/counseling. In the last ten years, sex therapy has added important concerns related to gender-identity dysphoria, sexual (gender) orientations, and lifestyle issues.

C. Recent Developments

Psychotropic Drugs

Antidepressants, antianxiety, and antipanic medications are being used with psychotherapy in treating desire-phase problems and in treating paraphilic compulsive-obsessive behaviors (Coleman 1991). Recent anecdotal reports and some early controlled studies are finding a category of antidepressant medications useful in treating sexual disorders. SSRIs, such as Zoleft, Paxix, and Prozac, are useful in increasing the latency time for ejaculation, and thus are helping some men who present with problems of ejaculatory control (early ejaculation). Another medication, Anafranil, and antidepressants used in treating obsessive-compulsive disorders, have been demonstrated in at least one study to help in the treatment of premature ejaculation. Of course, these results occur when therapy is provided, for if medication is discontinued, there can be a resumption of symptoms. That suggests the presence of untreated anxiety, relationship problems, or a constitutional tendency towards difficulty with ejaculation control.

An unfortunate side effect of SSRIs is the frequent complaint by patients of some loss of sexual desire. This has been reported by patients on these medications for depression. In some patients, however, the lifting of their depression symptoms alone is enough to increase their libido, despite the use of medication. Wellbrutrin, a relatively recent antidepressant, is claimed to have few negative effects on sexual desire. A newly marketed antidepressant, Serzone, is also being hailed for having no negative effects on libido.

Vulvodynia, a Newly Identified Syndrome

One of the new challenges facing American sex therapists and gynecologists today is the occurrence in many women of a painful burning sensation in the vulvar and vaginal area. This condition, recently named vulvodynia, or burning vulva syndrome, is a form of vestibulitis that can have a number of causes, from microorganisms that cause dermatosis to inflammation of the vestibular glands. The presenting complaint of these women is burning and painful intercourse. Some women develop secondary vaginismus. Discomfort varies from constant pain to localized spots highly sensitive to touch. In many cases, the psychological and relationship consequences are grave. Many women become depressed as a result and frustrated by attempts at treatment.

Current treatment includes topical preparations, laser surgery to ablate affected areas, dietary restrictions, and referral to a physical therapist to realign pelvic structure and reduce pressure on the spinal nerves serving the genital area. Some affected women have sought relief with acupuncture. Therapy may be enhanced by focusing on the effects of the condition on the sexual functioning of the patient, her relationship with her partner, and self-image. Pain-reduction techniques, including self-hypnosis, have proven valuable in some cases. Low doses of an antidepressant, including some SSRIs, may reduce the pain.

There is much work to be done in the treatment of vulvodynia, including making the public aware of this condition and educating physicians in the role that sex therapists can play in supporting these women and their partners.

The Medicalization of Sex Therapy

There is an increasing medicalization in sex therapy today. Although this may at first seem to benefit many patients - and it does - there is a concern among sex therapists that many conditions will be summarily treated through medications by primary physicians, with a corresponding failure to address the dynamic and interpersonal aspects of the patient. In short, there is a danger of incomplete evaluation of the patient's status if only the medical aspects are considered and the therapist is left out of the process. In the ideal situation, the sex therapist and physician would collaborate on the treatment plan, using medication as indicated.

D. Education and Certification of Sex Therapists

Since American sex educators, counselors, and therapists are not licensed by any government agency, reputable professionals in the field operate under one of several traditional professional licenses, as part of their practice as a physician, psychologist, psychoanalyst, social worker, marriage and family counselor, or pastoral counselor.

The American Association of Sex Educators, Counselors, and Therapists (AASECT) does offer its own certification for sex educators, counselors, and therapists following successful completion of specified training programs that include supervised practice. Continuing education credits are required for renewal of this certification.

E. Sex Surrogates: The Continuing Controversy

Three decades after Masters and Johnson pioneered modern sex therapy, the use of sexual partner surrogates continues despite a long history of controversy, largely because it has been found by some professionals to be an effective therapeutic modality in certain circumstances for persons without partners and for specially challenged persons with physical limitations. Still, as Dauw (1988) has noted, little in-depth research has been conducted about surrogates, their effectiveness, or their appropriateness in working with specific sexual dysfunctions. Misconceptions about surrogates are widespread (Apfelbaum 1984), in part, because of a common confusion between the roles of sex surrogates and prostitutes, based on the potential for intimate sexual interaction and the surrogate being paid for her or his work. Roberts (1981) has suggested that “the most common misconception” is of the surrogate as “an elitist type of prostitute.” In addition, some authors have commented on the effects of media accounts of sex surrogates, which have tended to focus on the bizarre, the sensational, and even the untrue (Braun 1975; Lily 1977).

The distinction commonly noted between surrogates and prostitutes usually relies on the intent of the sexual interaction: the prostitute's intent being immediate gratification localized on genital pleasure, whereas the surrogate's intent is long-term therapeutic reeducation and reorientation of inadequate capabilities of functioning or relating sexually (Brown 1981; Jacobs et al., 1975; Roberts 1981). In 1970, Masters and Johnson noted that “... so much more is needed and demanded from a substitute partner than effectiveness of purely physical sexual performance that to use prostitutes would have been at best clinically unsuccessful and at worst psychologically disastrous.”

IPSA, the International Professional Surrogates Association (n.d.), wrote,

A surrogate partner is a member of a three-way therapeutic team consisting of therapist, client and surrogate partner. The surrogate participates, as a partner to the client, in experiential exercises designed to build the client's skills in the areas of physical and emotional intimacy. This partner work includes exercises in communication, relaxation, sensual and sexual touching and social skills training.
Others, including Allen (1978), Apfelbaum (1977, 1984), Brown (1981), Dauw (1988), Masters and Johnson (1970), Roberts (1981), Symonds (1973), Williams (1978), and Wolfe (1978) have described, either briefly or in part, typical surrogate sessions or alternative models. According to Jacobs, et al. (1975): “The usual therapeutic approach is slow and thorough. Exercises are graduated and concentrate on body awareness, relaxation and sensual/sexual experiences that are primarily non-genital.” Where appropriate, the surrogate also teaches “vital social skills and traditional courtship patterns which finally include sexual interaction.” However, none of these writers gave a perspective of the relative amount of time or importance that each aspect of the surrogate therapy session or program places on the entire process. Such a perspective would give a clearer understanding of the true functions of a sex surrogate that would allow the integration of the use of surrogate therapy into a useful theoretical perspective relative to clinical sexology, as well as to normative sexual functioning.

The use of sex surrogates was introduced by Masters and Johnson (1970) as a way to treat single men who did not have partners available to participate in their couple-oriented sex-therapy program. As the practice evolved, surrogates sometimes specialized in working with specific populations, such as single heterosexual or homosexual men, with couples as a coach, or with people with physical disabilities.

Today, the use of surrogates remains controversial with complex legal, moral, ethical, professional, and clinical implications. Although Masters and Johnson abandoned the practice (Redlich, 1977), the use of professional sex surrogates has been ethically permissible as part of the sex therapist's armamentarium, according to the American Association of Sex Educators, Counselors, and Therapists (AASECT 1978, 1987). Still, the most recent version of AASECT's (1993) Code of Ethics has ceased to mention the use of surrogates explicitly. Instead, the 1993 code merely states that a member of AASECT should not make a “referral to an unqualified or incompetent person” (p. 14), which would presumably refer to surrogates, among others.

In their 1987 Code of Ethics, however, and in at least one earlier version, AASECT addressed the issue of surrogates directly, and promulgated the parameters for their ethical use, including the understanding that the surrogate is not a sex therapist or psychotherapist, and that the therapist must protect the dignity and welfare of both the client and the surrogate. In addition, it outlined how issues of confidentiality and consent should be addressed. In many ways, this document is similar in putting the client's welfare first to the Code of Ethics espoused by the International Professional Surrogates Association (IPSA, 1989). Among IPSA's strict requirements for members are the necessity that surrogates practice only within the context of the therapeutic triangle consisting of the client, surrogate, and supervising therapist, that the relationship with the client always be within the context of the therapy, that the surrogate recognize and act in accordance with the boundaries and limitations of her competence, and that the surrogate be responsible for all precautions against pregnancy and disease. Confidentiality and continuing-education requirements are also among the seventeen items listed in the code, although the surrogate's primary role as a co-therapist or substitute partner in any given therapeutic situation is left open to agreement between the therapist and surrogate.

In 1997, there are estimated to be fewer than 200 surrogates worldwide, according to Vena Blanchard, president of IPSA (personal communication, March 15, 1997), with maybe 100 practicing in the U.S.A. This number is down by about two thirds from the 300 estimated to be practicing in the U.S.A. in 1983-1984 (Noonan 1995/1984), a time when the number of surrogates peaked. However, the downward trend of the subsequent decade, caused primarily by fears surrounding AIDS, has been showing signs of reversing since the mid-1990s, according to Blanchard, who pointed to the number of new surrogates being trained and requesting training by IPSA. Still, according to Blanchard, only a few urban areas, primarily on the two coasts, have surrogates working, with most of the country not being served.

Noonan (1995/1984) surveyed fifty-four sex surrogates who were part of a surrogates' networking mailing list representing about 65 to 70 percent of all known legitimate trained surrogates in 1983-1984. The fifty-four surrogate respondents represented about 36 percent of the 150 estimated known surrogates, who were estimated to be approximately one half of all surrogates practicing in the U.S. at the time. In addition to demographic data, the instrument asked respondents to estimate the percentage of time they spent in each of seven activities with clients. The data gathered seemed to support strongly the hypothesis that sex surrogates provide more than sexual service for their clients, spending about 87 percent of their professional time doing non-sexual activities. In addition to functioning as a sexual intimate, Noonan found that the surrogate functions as educator, counselor, and co-therapist, providing sex education, sex counseling, social-skills education, coping-skills counseling, emotional support, sensuality and relaxation education and coaching, and self-awareness education. The results indicated that a majority of time is spent outside of the sexual realm, suggesting further that surrogate therapy employs a more holistic methodological approach than previous writings, both professional and lay, would seem to indicate. Clearly, the sex surrogate functions far beyond the realm of the prostitute.

Specifically, Noonan's (1995/1984) results showed that the surrogate spends much of her or his time talking with the client, with approximately 34 percent of the time spent giving sexual information, as well as reassurance and support. Almost one half of the surrogate's time (48.5 percent) is spent in experiential exercises involving the body non-sexually, with the majority of that time devoted to teaching the client basically how to feel - how to be aware of what is coming in through the senses. Combining the two averages, we find that the surrogate typically spends 82.5 percent of the therapeutic time enhancing the cognitive, emotional, and sensual worlds of the client. Only after this foundation is developed does the surrogate spend almost 13 percent of the time focusing on erotic activities, including sexual intercourse, cunnilingus, and fellatio, and teaching sexual techniques. The remaining 4.5 percent focuses on social skills in public settings, clearly the least important aspect of what the surrogate deals with.

Finally, a profile emerged of the “average” sex surrogate in 1983-1984: she is a white female, in her late 30s/early 40s, and not very religious. She is one way or another single with 1.4 children, college-educated, lives in California, has been practicing as a surrogate for four years three months, and sees twenty-seven clients per year. Finally, she is a heterosexual who does not need to concern herself or her partner with chemical or mechanical methods of contraception, because she has been sterilized (Noonan 1995/1984). It is interesting to note that among the fifty-four respondents, six of the surrogates had earned doctorates, with the average being a bachelor's degree plus some advanced study, indicating the atypically high level of educational achievement in this group.

Present and Future Issues

Surrogate therapy has no doubt changed somewhat over the past decade and a half for various reasons. These changes need to be elucidated, documented, and incorporated into our collective knowledge about normative sexuality and how to address the various problems we have created or maintained around its expression.

Since 1983, the impact of AIDS has become a deep concern of both surrogates and therapists. Exactly how it has affected the work of surrogates remains to be studied. Certainly in the years immediately following Noonan's (1995/1984) study of the functions of sex surrogates, many surrogates, who in retrospect were not particularly at risk for HIV infection, stopped practicing or modified their practice as surrogates out of fear. Many therapists also stopped referring clients to surrogates out of fear of legal liability. As the reality of HIV infection has become better known, surrogates, who are mostly female working with heterosexual males, are continuing to help clients function better sexually while promoting responsible sexual behavior at all levels. Little or no research exists that has investigated how gay male surrogates, who worked mostly with gay male clients in the 1980s, have changed their practice.

Since the 1980s, women have become more aware of how surrogates might help them effectively deal with various sexual dysfunctions. Some female clients will ask their therapists, or seek out therapists who are open to the possibility, to find a male surrogate with whom they might work. Largely because of the sexual double standard that continues to operate in many, if not most, therapists, however, most clients of surrogates continue to be male. The degree to which women have begun to work with surrogates to solve their sexual problems, or who consider it a viable option, are questions that require additional research. In addition, the differences that may exist in the design of the therapy program itself and how a female client might work with a surrogate, as compared to how males work with surrogates, is also a topic open to research. It appears that heterosexual male surrogates remain today the rarest of sex surrogates, as in the early 1980s.

Despite these research needs, the population of surrogates is likely to remain resistant to study, both because of the legal ambiguities often involved with their practice and the fact that the use of surrogates retains a relatively high visibility in public consciousness, although surrogates themselves are usually quite invisible. Because they are a small group, they will be difficult to study with any reasonable assurances of confidentiality.

The most troubling aspect of research on sex surrogates may be the indication, yet to be verified by any research, that there are probably many more surrogates working with clients and therapists in the United States, who are independently trained by varying standards by the therapists with whom they may be working, and who are both isolated from other surrogates and from researchers. This leaves them unaware of the most recent knowledge and advances in the field, because rarely are therapists trained in working with surrogates. It also deprives us of the knowledge gained from experience that these “hidden” surrogates may have learned.