The Health Blog

In restoring “good sex” to a person or dyad, three aspects of sex therapy are noteworthy. One is the area of treatment: sexual functioning. Another is the treatment process, the way in which the therapy is practiced. The third is the nature of psychotherapy itself, the way in which it works, the goals it attempts to achieve.

To begin with sexual functioning, it may simply be stated that one’s sexual self-concept is almost always basic to one’s entire ego-concept, and the sexual relationship within the dyad is almost always crucial to the overall dyadic relationship. This is true even of dyads with good relationships in spite of bad sex; when they come into sex therapy, and their sex life improves, the rest of the relationship typically blossoms and intensifies in ways previously unimaginable to them. For most people and certainly for most dyads, satisfactory sex is the nucleus of the successful, intimate, holistic relationship.

It is the goal of sex therapy to help the couple achieve satisfactory sex, and this makes the definition of “satisfactory sex” critical. To a great extent, the therapist’s view of what makes sex satisfactory will determine his or her attitude toward the patient.

It is worth summarizing here the definition of satisfactory sex given by or implicit in Masters and Johnson and in Kaplan (with which the writer agrees). Sex consists not only of desire, excitement, and good performance in intercourse—erection of the penis, engorgement of the vagina, penetration, and orgasm for both partners—but also of the mutual “pleasuring” of the partners, and may include all, none, or some of the “performance” factors. In giving and receiving pleasure, the goal, sex, spreads physiologically away from the primary sex organs to encompass the entire body, and psychologically away from the sensations connected with those organs and nothing else, to the sensations and emotions connected with the entire pleasuring experience. In brief, sex as pleasuring involves more of the total being of the participants than does sex as performance, and sex therapy addressed to pleasuring will address a larger portion of the patient’s personality. Further, as the dyad learns to accept pleasuring as a goal, they learn to exchange, for at least a portion of their sexual experiences, the strong sensory excitement of intercourse for the perhaps lower sensory excitement but stronger emotional responses of mutual pleasure-giving. In pleasuring, then, the emotional aspects of the dyadic sexual relationship assume greater importance.

It is these relational (as well as intrapsychic) aspects that are addressed by the sex therapist. Kaplan makes explicit the need for the modern, effective sex therapist to depart from performance therapy as necessary to help the dyad achieve the better relationship from which better sex can grow, and deliberately to incorporate non-behavioral, nonsexual modalities in the treatment approach.

Thus, when sex therapy is successful, two results are obtained. First, good functioning has been restored to a central part of the human personality. Second, some of the broader intrapsychic and interpersonal aspects of the relationship have been treated, the aspects touched by the “ripples” of the therapy.

But these do not wholly account for the ripple effects nor their power—in a sense, the effects are not really ripples but upheavals, major shifts in personality structure. No claim is made that successful sex therapy and the resultant good sexual functioning are the be-all and end-all of psychotherapeutic treatment. Like every other significant, therapy-induced change, the results of sex therapy need time and work to become fully integrated into the functioning of the individual and the dyad. As with other therapeutic results, successful sex therapy often leaves much work still to be done on other dysfunctional aspects of the self. Still, sex therapy is a powerful instrument for psychological change and to account for its power, consideration of the general nature or goals of therapy is necessary.

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It seems more than likely, as we have come to realize in so many areas of development of psychoanalytic understanding, that we will be less likely to abandon earlier understandings and more apt to realize their complexity and the limitation of their application. As far as I can tell now, analytic thinking is moving toward a more complex appreciation of the factors in the oedipal involvements, both from our increasing depth and sophistication in understanding preoedipal factors, and from post-oedipal influences. The latter would include a variety of learning, educative, social, and cultural dimensions which were only rudimentarily understood in Freud’s time and which currently contribute much more significantly to our understanding of the functioning of human beings and their complex interrelationships. Undoubtedly, this dimension of the overall problem will continually yield more knowledge and insights.

Obviously, the psychoanalytic perspective cannot remain isolated from these evolving contexts of understanding, nor is there any need for it to do so. Rather, analysts remain sensitively attuned to the clinical evidences brought to the analytic couch by their patients in the contemporary setting. Thus, the analytic understanding of the processes by which sexual identity, both male and female, are established, consolidated, and reinforced, are continually being revised and expanded. Nonetheless, it is unlikely that the classic concepts, let us say of penis envy or castration anxiety, will be eradicated from this evolving perspective. It seems much more likely that their interplay with other complex factors and their position in the consolidation of healthy personality organization and functioning, in contrast to the more pathological manifestations in various levels and ranges of psychopathology, will be more clearly discriminated and differentiated. At this point in our clinical experience, the classic paradigms certainly cannot be unequivocally applied without carefully considering the patients’ individual variance and modifying circumstances.

Undoubtedly, in Freud’s thinking, the Oedipus complex served as a central organizing point for his views about personality development and for the organization of various forms of pathology. He saw the Oedipus complex as the nucleus of the development of the neuroses and other forms of symptom formation. In addition, the admixture of libidinal fixations, object attachments, and identifications with which the child emerges from the oedipal situation are important to the development of character and personality. The crucial introjections, for example, accompanying the resolution of oedipal fixations provide the nucleus of the emerging psychic substructure serving as the core of the organization of the superego. The resolution of oedipal conflicts at the close of the phallic period is the basis for the development of powerful internal resources to regulate drive impulses and their channeling in constructive directions. The superego is one such internal source of regulation based on identifications with the parental figures, but it is also accompanied by complex internal acquisitions which contribute to the organization and critical internal integration of the child’s emerging personality.

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Despite the legal communities’ lack of interest in the behavioral and social correlates of exposure to erotica, scientists have spent considerable time and effort looking for empirically valid connections between these variables.

One of the first approaches to studying the effects of erotica was simply to ask people what they thought the effects were on themselves and others. Athanasiou, Shaver, and Tavris reported on a sample of 20,000 Psychology Today readers who indicated rather high levels of exposure. It is generally accepted that four out of five Americans between puberty and senility have been exposed one or more times to explicit sexual materials (Abelson and others, in COP).

It is interesting to note that the majority of Americans, when surveyed, accepts the display of erotica to adults who choose to see it. Most people report that their own response to erotica has been neutral or mildly positive and quite transient. There is much ignorance because (1) each person seems to feel that he or she is more tolerant than the average and (2) that although he or she himself or herself is not troubled by erotica, there are some undefinable “others” who would be (Abelson and others, COP; Abelson and Wilson).

The large sample (2,486 adults) survey data of the Abelson and others study have been reanalyzed (Merritt, Gerstl, and LoSciuto) to clarify those characteristics of the subgroups who felt erotica was beneficial versus those who felt it was not. The most striking finding was an age gradient. This age gradient persisted despite controls for gender, education, and levels of exposure. As might be expected, the authors found that “younger age groups tended to attribute solely desirable and/or neutral effects to erotica. . . . those who believed that pornography has largely or solely undesirable effects on its consumers were the oldest”. It is not at all clear whether these age-related changes in attitude are developmental or generational. Because the major technological changes in our society have affected sexual behavior (e.g., birth control and abortion techniques), it does not seem unreasonable to postulate generational differences as a major factor in the observed age gradient.

Other variables which often have been found to correlate with judgment of erotica and the effects of exposure to it are authoritarianism, religious preference, and church attendance.

Zurcher and others studied two towns in which antipornography “crusades” had been mounted. They found that the “conporns” tended to be individuals who were satisfied with what they perceived to be the social status quo, rather authoritarian, dogmatic, intolerant of others’ political views, with traditional and restrictive views on sexual matters. They also favored censorship to service and protect those views. Conporns associated the use of pornography with sexual deviance, crime, violence, drugs, family disruption, organized crime (87%) and/or a communist conspiracy (61%). Proporns by contrast tended to be far less disturbed by the topic and tended to oppose censorship.

Kirkpatrick is less kind than Zurcher in describing antipornography crusades. Writing in the Psychoanalytic Review he states:

“Antipornography crusading is a result of repressed sexuality and resultant moral indignation among the petty [sic] bourgeois. . . . We feel that sexual repression is the most fundamental category and that it in turn leads to repression in general and to the motivation for social movements which oppose pornography, and the ideologies of moral indignation which accompany these forms of social control”. Kenyon in a brief but entertaining and thought-provoking review of censorship up to 1974 notes:

One underlying fear is that the advocacy of too much sexual license will lead to the decline of family life, thus undermining the whole fabric of society, with resultant anarchy. Frequently quoted in this context is the decline and fall of the Roman Empire. However, if Gibbon’s famous account is to be believed, a powerful influence in bringing this about was the disastrous effect of the introduction of Christianity, with its misogyny and unhealthy preoccupation with sexual intercourse, chastity, mortification and flagellation.

One’s response to erotica and the labeling of erotic material as obscene is a complex and interactive process. Colson has shown that when subjects with low tolerance of erotica were given false Galvanic Skin Response feedback suggesting they were sexually aroused by the presentation of pedophilic material, they labeled the material unfavorably and called it obscene. It would seem that an operational, if totally idiosyncratic, definition of obscenity for an individual would be sexual arousal in response to material one is not supposed to like.

Byrne and others have proposed that an individual’s response to erotic material (that response being the final outcome of long-term socialization, experience, value judgments, and the like) is attributed to the object itself.

Thus, an erotic depiction is not just pleasing or displeasing to oneself, the depiction itself is good or bad. Next there is an attempt to justify such judgments and to vindicate them by attributing a general benefit or harm to the object. . . . What begins as a personal affective response can end as an elaborate belief system … it is not surprising that research data which are relevant to such systems tend to be accepted or rejected not on their own merits but on the basis of the justification or vindication which they provide.

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The amount and quality of sex education for children varies widely from society to society. At one extreme we find Dahomean girls who, under the supervision of instructresses, learn the “language of love” or “adultery,” and later, the eleven positions of sexual intercourse (Herskovits). The Irish girls of Inis Beag, who are unprepared for and traumatized by their first menstrual period, occupy a place near the opposite extreme (Messenger).

Programs of formal or informal instruction are one measure of children’s and adolescents’ sexual knowledge. They also indicate the didactic and emotional relationship between generations and the relationship adults have to their own sexuality. Reports such as Schapera’s for the Kgatla that “from an early age children are familiar with the nature of copulation” suggest that these adults have a relaxed and direct relationship to their own sexuality. Wagley saw Tapirape boys and girls imitating or “playing” at copulation in full view of adults who made no move to stop the children or reprimand them.

Trukese men’s transition from adolescence to a fully adult male marital role is eased by legitimate sexual outlets (Goodenough). A man can sleep with his wife’s sister or his brother’s wife. Goodenough implies that men later in life are in fact faithful, but he does not demonstrate this. On the contrary, Goodenough found Trukese men’s interests in sex “surprisingly like those of American adolescents, or of men working in lumber camps, or in the Army, or in other places where women are relatively unavailable . . . Indeed, what might be called adolescent behavior in this respect lasts in the case of men into the late twenties and early thirties” Goodenough comes close to suggesting that Trukese men do not achieve a mature sexuality until relatively late in life, a suggestion that many other ethnographers might have wanted to make about other peoples but do not.

What is it that children, adolescents, and even adults are learning? Although explicit sexual “technique” is taught in some societies, everywhere people learn about relations, definitions, and contexts. Although Dahomean girls learn sexual technique, apparently in much detail, the girls of Inis Beag, caught by the surprise of their first menstruation, learn of the inherent weakness and imperfection of their own bodies. Adults could hardly provide a better lesson for these girls through formal instruction.

Mead has addressed the “educational” dimension of sexual knowledge in Samoa. She laments that Samoan boys and girls do not interact with each other sufficiently “to give boys or girls the real appreciation of personality in members of the opposite sex”. Mead recognizes that the Samoans’ emphasis on sexual technique is advanced at the expense of a regard for relationships. For Samoans, “sex is an end in itself, rather than a means, something which is valued in itself, and deprecated inasmuch as it tends to bind one individual to another”. Samoans do not reserve sexuality for important relationships that produce sexual satisfaction. Perhaps it is correct to say that Samoans reserve sexuality for important occasions, rather than for important relationships and that Samoans do not tend to value or especially appreciate relationships that produce sexual satisfaction. Apparently Samoans enjoy sex, but not the relationships in which sexuality is experienced, a finding which troubles Mead.

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Changing patterns of activity in old age were examined (Verwoerdt). The results again supported the activity differences between males and females. Age-related, intraindividual differences as well as age differences per se were examined by analyzing data from the same group of 154 subjects at two points in time. Patterns of activity were assessed by categorizing differences in self-reported activity from Study I to Study II and looking at the proportions of each age and sex falling into these categories.

Four behavioral activity patterns were classified in the following ways: continual absence of activity in both Study I and II was designated as A(bsent); continually sustained activity (equally active in Study I and II) was denoted by C(ontinued); those less active in Study II than in Study I were labeled as D(eclining), and those more active in Study II than in Study I as R(ising).

The most typical pattern for the sixty-nine females was A (74%), and the most common pattern for the eighty-five males in the study was D (31%). For males, pattern A was reported by 27% and pattern Ñ by 22%. Ñ and D each were reported by 10% of the female sample. Rising activity (R) was relatively infrequent in the female sample (6%) but was much more common for males (20%). These findings from the total sample suggest that the changes in sexual activity patterns had already occurred for females but were in the process of changing for males.

When patterns by age were examined cross-sectionally, the largest increases in proportions of activity pattern A came between the early (sixty to sixty-five) and the late sixties (sixty-six to seventy-one), 6% and 30%, respectively and the early to mid-seventies (seventy-two to seventy-seven) and the late seventies (seventy-eight and older), 29% and 50%, respectively. For females, the percentage increases in pattern A were fairly constant from the sixties through the late seventies. The percentage of sample classified as A were 50% at ages sixty to sixty-five, 77% from ages sixty-six to seventy-one, 90% at ages seventy-two to seventy-seven, and a full 100% at ages seventy-eight and above.

When patterns by age at the time of Study II were examined, the largest increases in pattern A occurred in the sixties and seventies. The percentage of the total sample reporting pattern A at ages sixty to sixty-five was 6% compared with 30% of those ages sixty-five to seventy-one. During the early and mid-seventies, 29% reported this pattern with a 50% incidence in the late seventies (seventy-eight and older). For women, the largest proportion increase was in the early sixties (50%); this figure grew to 90% in the early and mid-seventies and went up to 100% at age seventy-eight. Only one-half of the male sample at age seventy-eight and older reported continually absent activity.

From the age changes in pattern A for females, it is obvious that some other patterns decrease with the increasing age of the sample. The most marked shift in declining activity (D) occurred between the early (18%) and late (4%) sixties. Ten percent of the women in their early seventies (and no women past age seventy-eight) reported D. For males, the percentage of sample classified as D was roughly the same (between 28 to 30%) at all age levels.

The proportion of the total sample who exhibited Rising activity showed the largest drop between the early (33%) and late (15%) sixties. In fact, at age seventy-eight, 20% of the males actually reported JR.

The number of females of all ages showing Ê was low (6%). The proportions remained constant in the sixties (14%) and dropped to 0% from age seventy-two up.

In Verwoerdt’s sample, 13% of the males and 57% of the females were unmarried. In the total sample, almost three times as many unmarried (46%) as married men (16%) reported pattern

R. Unmarried women (92%) showed a much higher incidence of A than did married women (50%).

These data on activity patterns again support the finding that women are less active than men.

In the sample which included younger individuals (ages forty-five to sixty-nine), Pfeiffer (1972) examined subjects’ assessments of changes in their own sexual-activity levels. At the time of interview, 50% of the men and 42% of the women under fifty said they did not notice any decline in their sexual activity relative to their “younger years.” The largest drop in proportion of respondents unaware of change was between the late forties and early fifties. Only 29% of the men and 22% of the women said that they detected no decline. By the late sixties, only 4% of the women and 12% of the men reported no awareness of change.

Almost three times as many women (40%) as men (14%) had stopped having sexual relations at the time of the interview. When asked when sexual relations had stopped, answers ranged from within the past year (2%) to twenty years ago (2%). Sixty-four percent of the women reported having stopped more than five years ago. Reasons for termination were given by almost all respondents. Women overwhelmingly blamed someone other than themselves (80%), usually their husbands, and men often blamed themselves (71%). Forty percent of the men compared with 4% of the women said that they themselves were unable to perform sexually. For females, “death of spouse” was the most frequently cited reason for a change in sexual activity (36%). When death as a cause was eliminated, reasons most frequently cited were illness of spouse (20%) and spouse’s inability to perform sexually (18%). Loss of interest by spouse was reported by 9% of males and 4% of females, but loss interest by self occurred with a frequency of 14% for males and 4% for females.

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Sometimes medical problems determine the type of implant you should have. A man in poor health, for example, isn’t a good candidate for a general anesthetic, and for that reason his physician may quite rightly refuse to put in an inflatable prosthesis. A man with extensive scarring in his penis may not be able to have an inflatable implant because the prosthesis can’t expand properly if the corpora cavernosa are severely scarred. Jonathan, for example, a 47-year-old government official, has systemic lupus, a disease which, among other things, injures the small blood vessels. His illness was a major factor in his potency problem, because the effects of the disease made it impossible for blood to get into his penis in sufficient quantities to produce an erection.

Jonathan’s physician recommended a semirigid implant, and as it turned out, that was the only option for him. “They thought it would be a 45- to 90-minute operation. It was a 3-hour operation. Both urologists on the case said they had never seen a case of scarring like mine,” Jonathan reports. In fact, Jonathan’s scarring was so extensive that the surgeons were forced to use a slightly smaller sized prosthesis, because there wasn’t more room in the penis.

Some men with nerve injuries suffer from partial numbness in their penises. A man with this condition is more prone to the problem of the traveling semirigid implant, because he can hurt his penis without realizing it. So, for him, an inflatable implant, which puts less pressure on the penis when if s not erect, may be preferable.

Doctors, like patients, have their own preferences. What’s important is that you understand your doctor’s recommendations and the reasons for them. Some doctors put in only one type of prosthesis; some have a particular manufacturer they prefer.

If you’re confused or unsure about your options, be sure you get all the information you need. And consider getting a second opinion. You and your lover are the people who are going to live with your implant—not your physician. Your happiness and peace of mind is most important.

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Insurance coverage for impotence varies widely. Some plans pay for only physically caused potency problems, while other policies are more liberal. Some insurers pay for only certain types of implants. And some plans require specific documentation, such as test results, to show that the problem is indeed physically caused,

You should check your policy to see if sexual dysfunction is included. Even if it isn’t, you may be able to obtain coverage if your problem is due to a medical condition which is itself covered. Then get prior approval for payment. Ask your doctor to write the insurance provider and give them the specific facts of your case. One insurance expert recommends that the physician attach a medical journal article discussing the particular condition you have and the treatment proposed. And it doesn’t hurt for the physician to note that a speedy reply is necessary, since treatment has been scheduled by a certain date.

If you’re having implant surgery, the manufacturer of the prosthesis may be able to help with insurance problems. Your doctor will know how to contact the company.

If, after all this, the coverage is denied, appeal the decision. Be sure the medical director or another high-ranking executive reviews your case. And if the denial remains firm, you may want to consider complaining to your state insurance commissioner’s office.

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Self-help is sometimes the best way to solve a potency problem, because when it works, self-help can save time, anxiety, and money and give you a real understanding of your body. The key to making self-help work is informed analysis. You’ve got to know what you are doing. You’ve got to take a good hard look at your habits, stresses and feelings and then decide just how they might affect your potency.

The best time to try self-help is at the beginning of your problem, before your potency difficulties have had a chance to become part of the pattern of your life. You’ll also be in better shape emotionally to help yourself—and your lover—than you would be after months or years of frustration and disappointment.

We think it’s extremely important that you decide up front how much time you will spend on self-help before turning to professional help. We recommend that you try self-help for no more than 12 weeks after the erection problem starts—after that, you should see a specialist. Since it can take that much time to get an appointment with some experts, you may want to schedule a visit and then use the waiting time productively on self-help.

So that you won’t jump blindly into a self-help program that might do more harm than good, we’ve designed a safe, effective plan for you. Here’s what you should do.

(A note of caution before we begin describing the program. Sometimes a self-help program is not the proper first step. If your erection problem has persisted more than 12 weeks, you should see your physician first, to make sure impotence is not your body’s way of signaling an illness. And of course, if you have any symptoms other than the erection problem, you should see your physician without delay.)

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Testicles that don’t work properly can ruin a man’s ability to get or maintain an erection, because the testicles produce testosterone, the male hormone vital to erection and sexual desire.

Men commonly develop testicular problems after the testicles have functioned normally for many years. Many things can hamper the testicles’ ability to do their hormone-producing job: infections (such as mumps), chemotherapy, radiation treatments and prolonged alcoholism.

Occasionally, a man’s testicles never function properly. If the testicles don’t get in gear in time for puberty, a boy may never mature into a man. He will grow into normal size but he won’t develop the large muscles, body hair, beard and enlargement of the penis typically found in adult males. But if the boy who suffers from such damage or defects is treated with testosterone, he will develop normally.

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It’s important that testosterone not be seen as a miracle substance or a cure-all. Increasing testosterone so that it’s above the normal level doesn’t turn a man into a sexual super-stud. In fact, too much testosterone can actually throw a monkey wrench into a man’s sexual functioning, and possibly cause other health problems. A man with normal testosterone levels can find himself in a no-win situation if he takes the hormone.

A case in point is Jerry, a college athlete who took testosterone for more than a year to help build up his muscles. Jerry’s body responded to the extra (unneeded) amounts of the hormone by shutting down his own testicles’ production of testosterone. Unfortunately, when Jerry stopped taking the shots, his body didn’t get the message. Several months after he stopped the injections, Jerry’s system was still out of whack. His pituitary gland was taking a very long time to send messages to his testicles to start producing testosterone again. After six months, Jerry’s sexual desire began gradually returning, and his testosterone level started its slow climb back to normal. Jerry was lucky; he gambled with his health and his sexuality, but he recovered. Not surprisingly, he vowed never to take the hormone again.

Unfortunately, particularly in the case of older men, some physicians still prescribe testosterone to patients with erection problems without first doing tests to see if the hormone is abnormally low. We believe this is a real disservice to the men who do have adequate testosterone levels because their problem remains undiagnosed and untreated. Morever, their testicles may stop producing testosterone and take time to revert to normal after the shots have stopped.

Two other male hormones also influence potency. Luteinizing hormone (LH) is made by the pituitary gland in the brain; it stimulates the testicles to produce testosterone. Low levels of LH caused by pituitary disease can lead to low testosterone and potency problems. The other hormone, prolactin, is also made by the pituitary gland. Very high levels of prolactin, sometimes caused by tumors in the pituitary gland, can block the effectiveness of testosterone in the body and decrease sexual desire. Simple blood tests can measure the levels of these hormones in the body.

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