More than half a century has passed since famed sex researchers William Masters, MD, and Virginia Johnson began their pioneering research on sexuality and sexual dysfunction. That work laid the foundation for modern sex therapy, and some of the techniques they described in the 1960s are still being used today, says Jennifer Vencill, PhD, a licensed psychologist and certified sex therapist at the Mayo Clinic in Rochester, Minnesota. “They were the foremost people in their field for a reason,” she says.
Yet times have changed since those days when miniskirts could scandalize and television couples slept in separate beds. Building on the tools described by Masters and Johnson, a new generation of researchers has identified novel ways to view sexuality and innovative ways to treat sexual problems, including issues with arousal, desire, pain and inability to orgasm.
Even in 2019, such topics can make people blush. Yet psychologists owe it to their patients to update their understanding of sex therapy, experts say. “Sexuality is part of general mental health, and I think all psychologists have a responsibility to know a bit about human sexuality,” says clinical psychologist Zoë Peterson, PhD, an associate research scientist at the Kinsey Institute, associate professor of counseling and educational psychology at Indiana University and editor of the 2017 “Wiley Handbook of Sex Therapy.” “While it’s useful to have a sex therapy specialization, all psychologists should be able to provide their clients some guidance about human sexuality.”
Whether sex therapy is a cornerstone of your practice or something you address only briefly, here are five developments to watch.
1: Mindfulness-based interventions
Sex therapists use a variety of approaches to treat sexual dysfunction. In addition to the techniques outlined by Masters and Johnson, tools such as cognitive-behavioral therapy (CBT), emotion-based therapy and couples communication techniques have been the treatment mainstays for sexual problems. Now, mindfulness-based sex therapy is increasingly recognized as an effective intervention, many sex therapists say. Mindfulness-based therapies are exciting because they are both effective and broadly applicable to many types of sexual problems, Peterson says. “Mindfulness is being applied fairly widely for arousal and desire problems, pain during penetration, lack of orgasm and sexual problems following medical conditions.”
Clinical psychologist Lori Brotto, PhD, Canada Research Chair in Women’s Sexual Health and director of the University of British Columbia Sexual Health Laboratory, pioneered the use of mindfulness for sexual dysfunction. She first encountered mindfulness during her psychology residency and postdoctoral training in 2002 and 2003, while working with people with parasuicidal behaviors (in which people engage in self-harm activities that are not likely to be fatal—what some people call “cry for help” gestures). The patients were receiving dialectical behavior therapy, which emphasizes mindfulness meditation as a way to address emotion dysregulation. At the same time, she was studying sexual difficulties among women who had survived gynecologic cancer. It struck her that the two groups shared similarities: a lack of sense of self and feeling disconnected from their bodies. If mindfulness could help those with suicidal thoughts, Brotto wondered, might it also help cancer survivors feel connected and present during sexual encounters?
The intervention Brotto developed involves eight weekly sessions delivered in a group format. The treatment is similar to mindfulness-based cognitive therapy, Brotto says, but tailored for a sexual context. Patients learn how to tune in to erotic sensations, for instance, and how to integrate the techniques into sexual encounters back in the bedroom.
In a series of controlled trials over the years, she and her colleagues have demonstrated the effectiveness of mindfulness-based sex therapy, not only among gynecologic cancer survivors but also for people with other sexual disorders. Recently, for instance, they tested the intervention in a small pilot study of women with low sexual desire and arousal—the most common sexual complaint in women, and one with few treatment options. Participants reported significant improvements in sexual desire, sexual function and sex-related distress after the treatment (The Journal of Sex Research , Vol. 54, No. 7, 2017).
Mindfulness-based sex therapy is now used around the world, and several other research groups are testing it in various populations. A meta-analysis by Kyle Stephenson, PhD, found evidence that mindfulness-based therapy was effective for treating female sexual dysfunction ( The Journal of Sex Research , Vol. 54, No. 7, 2017). Brotto and colleagues have also begun applying mindfulness to men’s sexual disorders, finding in a feasibility pilot study that the approach has promise for treating men with situational erectile dysfunction ( The Journal of Sexual Medicine , Vol. 15, No. 10, 2018). She’s now studying the intervention in men with premature ejaculation, as well as in prostate cancer survivors.
“Adapting mindfulness to sexual problems has really been helpful for both men and women,” says Stanley Althof, PhD, professor emeritus at Case Western Reserve University in Cleveland and executive director of the Center for Marital and Sexual Health of South Florida. “It’s been one of the most significant changes in the field.”
2: Psychotherapy interventions over medications
Viagra, the first FDA-approved oral treatment for erectile dysfunction, hit the market in 1998. Two decades later, there’s still a big emphasis on pharmacological treatments for sexual problems, notes Cynthia Graham, PhD, a professor of sexual and reproductive health at the University of Southampton in England and editor of The Journal of Sex Research. Drug companies have introduced multiple Viagra competitors for men, and in 2015, the FDA approved the drug Addyi (flibanserin) to treat low sexual desire in premenopausal women.
Meanwhile, however, psychologists are demonstrating that more focus should be put on psychological interventions, which have proven to be effective.
In a consensus statement from the 2015 International Consultation on Sexual Medicine, Marita McCabe, PhD, and colleagues concluded that psychosocial factors are clear risk factors for sexual dysfunction, and both women and men with the condition should be offered psychosocial evaluation in addition to medical evaluation and treatment, when appropriate ( The Journal of Sexual Medicine , Vol. 13, No. 2, 2016).
Even when a man’s sexual dysfunction can be treated with medications like Viagra, he can experience psychological consequences that also need to be addressed. “A man with a sexual problem is likely to have issues of self-esteem, lack of confidence and perhaps avoiding intimacy,” says David Rowland, PhD, a professor of psychology at Valparaiso University in Indiana and past editor-in-chief of the Annual Review of Sex Research. “Most sex therapy in men is directed toward the fallout that occurs because of a sexual problem.”
In men, sexual desire is strongly influenced by testosterone, Rowland notes. But in women, sexual dysfunction is often more complex. “Sexual desire in women is more likely driven by a desire for intimacy, feeling close and valued,” he says. “It’s a common saying—though not entirely accurate—that men just need a place to have sex and women need a reason.” That may help explain why sales of flibanserin have been disappointing—and why, Rowland says, psychosocial interventions such as CBT and mindfulness-based sex therapy usually remain the best choice for women.
Of course, both men and women with sexual dysfunction should rule out biological causes, Althof says. But pharmaceuticals alone won’t cure most sexual disorders. “We must take the psychology, the culture and the relationship into account,” he says.
3: Expanding inclusivity
Historically, sex therapy has been rooted in a traditional view: cisgender, heterosexual encounters between a man and a woman. Even within that already narrow definition, sex therapy has mostly been available to white, middle- and upper-middle-class married couples. Increasingly, though, researchers who study sexuality and sex therapy are taking a broader perspective.
“There’s been a trend toward expanding inclusivity,” Vencill says, to include the full span of human sexuality and gender identity, including transgender and gender nonbinary people, those in same-sex relationships and people in nonmonogamous relationships.
Vencill’s work focuses on adapting sex therapy tools to be more relevant to transgender and gender-diverse clients. For example, she says, using the Masters and Johnson sex therapy technique of “sensate focus,” couples take turns touching one another as they learn how to better tune in to physical sensations in the body. But the traditional sensate focus script is very heterosexual and describes gendered anatomy. “That script might not apply to people who are gender diverse or nonbinary,” she says. “It’s important not to assume that someone has a penis or clitoris or, even if they do, that they describe their bodies in this manner,” she adds. A more inclusive script would talk about clients’ bodies using words they themselves would use.
There’s also growing awareness that sexual- and gender-minority people who experience sexual dysfunction may have complicating factors that need to be addressed in treatment. “In many cases, sexual- and gender-minority patients experience a lot of the same problems that any majority group would experience in terms of sexual functioning. But they are often dealing with an added layer of discrimination and marginalization,” Peterson says.
Portrayals of transgender bodies are often presented in demeaning or hypersexualized ways in popular culture, which can contribute to negative feelings that transgender people have about their own bodies and sexuality. “In that case, treatment might involve CBT interventions to address sexual functioning, but it might also involve challenging and countering negative messages that the individual has internalized as a result of lifelong exposure to transphobia,” Peterson says.
While diversity and inclusivity in sex research are gaining momentum, there’s been little yet in the way of published evidence about how best to treat these populations, Peterson and Vencill say. But they predict that this will be an important area for future research. “What do we do to make our existing sex therapy techniques relevant for people who are not part of a heterosexual, cisgender couple?” Vencill asks. “We have to make sure the techniques we use are applicable and generalizable.”
4: The couple’s perspective
It’s hardly a new discovery that it takes two to tango, but most studies have focused on sexual problems at the individual level—especially research on interventions for those problems. Increasingly, researchers are looking more closely at the role of partners. “Sexual dysfunction is often seen as an individual problem, when of course it’s so often a couple’s issue,” says Graham.
When one partner has sexual dysfunction, it can make sex more stressful and less pleasurable for his or her partner. “No wonder that would impact sexual desire,” Vencill says. In a review of the literature for the 2015 International Consultation on Sexual Medicine, Brotto and colleagues found studies consistently demonstrating that dysfunction in one partner often contributes to problems in sexual satisfaction as well as sexual functioning for the other partner ( The Journal of Sexual Medicine , Vol. 13, No. 4, 2016).
Now, more researchers are beginning to look at both individual and relational data in studies of sexual dysfunction, Vencill says. For instance, among heterosexual women who experience pain during intercourse, sympathetic partners might be inclined to stop a sexual encounter that becomes painful. Yet research by Natalie Rosen, PhD, and colleagues shows that women with these sympathetic or “solicitous” partners have greater pain intensity and poorer sexual satisfaction compared with women with partners who encourage them to adapt and find ways to create sexual intimacy without engaging in the activity that is painful ( The Journal of Sexual Medicine , Vol. 9, No. 9, 2012).
Such findings are starting to inform the way sex therapists treat patients and their partners, Vencill says. “Moving forward, more research on the role of partners in sexual functioning and satisfaction is really critical.”
5: Changing attitudes toward sex
In some ways, sex is less taboo than it was when Masters and Johnson began their research. “There’s a much greater openness” in younger generations to talk about sex and sexuality, Rowland says. “The conversations are very different today than they were 20 or even 10 years ago.”
Nonetheless, sex is still a topic that makes people uneasy. “Culturally, we have a lot of anxiety around sex,” Vencill says.
In the United States (and many other cultures), sex often involves mixed messages. “You can joke about sex, but you’re not supposed to talk about how it’s really going—especially if you’re having problems,” Peterson says. “On the other hand, there are all these messages suggesting we should be having these amazing sex lives. We’re inundated in the popular culture with these very narrow messages about what ‘good sex’ is, and those messages can create a lot of stress.”
At the same time, many people still balk at the idea of seeking help for their sexual problems. That’s one reason that sex therapists are optimistic about the development of telepsychology and web-based interventions. McCabe and Catherine Connaughton, PhD, at Australian Catholic University, described internet-based approaches to sex therapy in a chapter in the 2017 “Wiley Handbook of Sex Therapy.” They concluded that more research is needed, though early studies have shown cybertherapy to be effective for treating a variety of sexual problems in men and women.
Digital interventions can build a bridge to people who have reservations talking about sex in person. “There are a lot of people out there with sexual problems who would never feel comfortable sitting face-to-face and talking about their sexuality or their sexual problems,” Peterson says.
Looking ahead
There’s another trend that sex therapists would like to see: Many say they wish more psychologists would take a greater professional interest in sex and sexuality.
“So many aspiring psychologists and graduate students I talk to think that sexual health is in the domain of medicine,” Brotto says. “But the bulk of treatment for sexual dysfunction is psychological, and psychologists have a huge role to play in assessing, treating and managing these problems.”
While most psychologists’ training gives them a strong foundation for treating sexual difficulties, sex-specific training is valuable, especially as it helps psychologists confront their own beliefs, biases and discomfort around sex. “We live in a very sexualized culture, but many of us haven’t been taught to have healthy conversations around sexuality or are even taught much about our bodies in a scientifically accurate way,” Vencill says. “Where the extra training comes into play is around sexual knowledge, values and attitudes.”
For those interested in learning more, the American Association for Sexuality Educators, Counselors and Therapists offers continuing education and certification for sex counselors, therapists and educators. The Society for Sex Therapy and Research also offers resources for professionals, including psychologists, with clinical or research interests in human sexual concerns.
Researchers, too, can find much to explore in the fields of sexual functioning and sexuality, Althof adds. “There’s sexual dysfunction, gender issues, the effect of illness and aging on sexuality,” he says. “There’s often a reluctance to embrace this very important piece of people’s lives. But it’s a vital field with so many things happening.”
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