This article was downloaded by: [McMaster University] On: 14 February 2015, At: 10:28 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
A sexual-enhancement workshop: Beyond group systematic desensitization for women's sexual anxiety a
b
Wayne M. Sotile PhD , Peter Kilmann PhD & Diane R. Follingstad PhD
b
a
Department of Medical Social Science and Marital Health , Bowman Gray School of Medicine , Winston-Salem, North Carolina b
Department of Clinical Psychology , University of South Carolina , Columbia, South Carolina Published online: 14 Jan 2008.
To cite this article: Wayne M. Sotile PhD , Peter Kilmann PhD & Diane R. Follingstad PhD (1977) A sexual-enhancement workshop: Beyond group systematic desensitization for women's sexual anxiety, Journal of Sex & Marital Therapy, 3:4, 249-255, DOI: 10.1080/00926237708402992 To link to this article: http://dx.doi.org/10.1080/00926237708402992
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 3, No. 4, Winter 1977
A Sexual-Enhancement Workshop: Beyond Group Systematic Desensitization for Women’s Sexual Anxiety
Downloaded by [McMaster University] at 10:28 14 February 2015
Wayne M . Sotile, PhD, Peter Kilmann, PhD, and Diane R . Follingstad, PhD
ABSTRACT: This study investigated whether six women who previously had received 15 sessions of group systematic desensitization (SD) for their sexual anxiety would report additional treatment gains from participation in a sexual-enhancement workshop with their partners. After group SD six couples participated in six, I I12 hour weekly group sessions. T h e women reported a significant increase in marital adjustment and a significant decrease in sexual anxiety. A significant decrease was found in the women’s sexual nonresponsiveness as perceived by their partners. Future studies should ( 1) contrast the effects of group SD with women alone versus couple group treatment, (2) determine which treatment components are most influential for defined subject types, and (3) obtain data on men’s sexual functioning.
I n recent years a number of procedures have been developed for the treatment of primary and secondary nonorgasmic I n general, these procedures have had positive effects. However, as noted by Sotile and Kilmann6 in their comprehensive review, research efforts need to determine whether different treatments build upon one another for additional treatment gains. Sotile and Kilmann’ investigated the impact of group systematic desensitization (SD) on varied aspects of sexual functioning in 8 primary and 14 secondary nonorgasmic women. T h e 22 subjects received 15 sessions of group SD using four common hierarchies of sexual scenes. Significant positive treatment effects were found on measures of general and specific sexual adjustment and in extracoital orgasmic frequency. Treatment also enhanced sexual communication among subjects and their partners, increased the females’ acceptance of their mates as being Dr. Sotile is affiliated with the Department of Medical Social Science and Marital Health, the Bowman Gray School of Medicine, Winston-Salem, North Carolina. Drs. Kilmann and Follingstad are affiliated with the Department of Clinical Psychology, University of South Carolina, Columbia, South Carolina. Reprint queries should be directed to Dr. Wayne M. Sotile. Bowman Gray School of Medicine, Department of Medical Social Science and Marital Health, Winston-Salem, North Carolina 27103.
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satisfactory sexual partners, and increased the females’ self-acceptance as sexual beings. All but one of the treatment effects (degree of pleasure experienced during extracoital stimulation) were maintained at the 6week follow-up. The present study investigated whether six of the women in the Sotile and Kilmann’ study would report additional treatment gains from participation in a sexual-enhancement workshop with their partners.
Downloaded by [McMaster University] at 10:28 14 February 2015
METHOD Subjects In order to be included in the initial investigation,’ all subjects were required to meet all of the following criteria: (1) each subject had to exhibit either primary or secondary orgasmic dysfunction as defined by Masters and J ~ h n s o n ;(2) ~ each subject had to be currently involved in an intimate sexual relationship with a male partner who had no difficulties with premature ejaculation (as defined by Masters and J o h n ~ o n )or~ with either obtaining or maintaining an erection during sexual relations; (3) each subject had to have a sex partner who was willing to participate in the treatment program by responding to measures of sexual and marital adjustment; (4) all subjects had to show specific sexual anxiety as measured by an experimenter-devised scale; and (5) each subject had to have an anatomically normal pelvic structure as determined by a recent medical examination. T h e subjects were obtained from advertisements and referrals from the University of South Carolina and the Columbia, South Carolina area. A more elaborate description of the 22 subjects who completed the experiment and the treatment procedure can be found in Sotile and Kilmann.’ After the completion of the 6-week follow-up of the group SD procedure, the subjects were asked if they wished to participate in a 6-week sexual-enhancement workshop with their husbands present. All 22 subjects expressed an interest. However, due to conflicting husband-wife schedules, as well as a lack of interest by some partners, only seven couples were able to meet the designated schedule. One couple dropped out of the group after the third session with no explanation. Thus, there were six couples who completed t h e experiment. It should be noted that prior to group SD, four of the women were classified as primary nonorgasmic while two of the women were classified as secondary nonorgasmic. After group SD three of the women classified as primary nonorgasmic remained nonorgasmic, either from intercourse or extracoital stimulation; the other primary nonorgasmic woman reported one orgasm through extracoital stimulation midway through group SD; thus, she lost her “primary status.” One of the two secondary nonorgasmic women reported a monthly percentage of extracoital stimulation resulting in orgasm of 90- 100% throughout the group SD procedure; thus, she was considered orgasmic according to Masters and Johnsons’ definition.‘ T he other secondary nonorgasmic woman reported a monthly percentage of extracoital stimulation resulting in orgasm of 10% throughout group SD; thus, she was still classified as secondary nonorgasmic. All of the subjects were Caucasian. Five of the couples were married, with the average length of marriage being 6.7 years (range = .3 to 17 years). T h e sixth couple had been living together for 2.5 years. T h e mean age of the women was 29 years (range, 19 to 42 years). T h e mean educational level was 15.8 years (range 12 to 18 years). T he mean number of children was 1.
Treatment Th e workshop was conducted by a cotherapy team of a female who held a PhD in clinical psychology and a male doctoral student in clinical psychology. Both leaders had consider-
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251
able experience in conducting groups. Neither therapist had conducted a sexualenhancement workshop prior to the experiment, although both had considerable experience in treating couples with marital and sexual difficulties. T h e overall treatment format was highly structured and was derived from a variety of treatment appro ache^.*^^^^^**^ T h e first session began with a general orientation. T he couples were told that the purpose of the program was to promote sexual communication. I t was emphasized that the focus of the workshop would be on the couple as a unit, n o t individuals. The therapists emphasized that each couple must take responsibility for improvement in their sexual functioning and that each couple should identify factors in their sexual relationship that they would like to change. Group discussion dealt with couples' apprehensions, hesitations, and goals for their participation. T h e therapists lectured on male and female sexual response cycles. T he various causes and types of sexual dysfunction were outlined according to various sources.2p6T he couples were instructed to refrain from sexual intercourse until the fourth week of treatment. They were given a sensate-focus homework a~ s i gnm ent . ~ T h e second session began with the therapists getting feedback from the couples regarding the sensate-focus homework exercise. Couples were asked how it felt to give and demand pleasure with no pressure to engage in coitus. Because both members of each couple were feeling that they had disappointed their partner, the therapists then discussed with the group typical male and female reactions when one partner is perceived as sexually dysfunctional. Further information was given in that the therapists stressed the necessity of clitoral stimulation for orgasmic response. Personal reactions from the group were obtained regarding the possibility that manual or oral clitoral stimulation may always be required for female orgasm and that coital orgasm may not occur. As a homework assignment, the couples were given a handout that included exploring body imagery and a continuation of the sensate-focus exercises begun the previous week. In the third session group discussion topics included the couples' reactions to treatment thus far and the role of sexual fantasies in sexual functioning. T h e steplike nature of sexual arousal was emphasized, and the couples were told not to become upset if they experienced a temporary cessation in mounting arousals. T h e therapists oriented the women toward masturbation retraining.'O T h e therapists revealed aspects of their own ersonal sexual responsiveness as an attempt to establish masturbation as normal. For Romework assignment masturbation retraininglo and reading and utilizing fantasy materials" w e r e recommended for all females. T h e therapists allowed the couples to employ manual and/or oral stimulation in order to reach orgasm if desired. Each couple was seen for 5 to 15 minutes at the end of the group in order to discuss specific goals and to make specific suggestions for each couple's sexual relationship. T h e fourth session began with a group discussion about the couples' reactions to treatment at this point and a discussion about any problems encountered thus far. Five of the six couples either reported that they experienced some discouragement or that they had not completed their homework assignment. This revelation led to a discussion of possible resistances to treatment and possible fears of changing sexual behaviors. T h e therapists then discussed Kegel's works on the pubococcygeus muscle. T he women were instructed to exercise their pubococcygeus muscle three times per day, 15 contractions each time. T h e therapists encouraged all group members to develop their own sexual fantasies and to focus on them when experiencing problems in becoming sexually aroused. T h e therapists discussed the natural tendency to have a variety of sexual fantasies that might include persons other than partners. In a 5 to 15-minute session held with each couple separately unique concerns were dealt with by specific sexual-enhancement exercises. In the fifth session group discussion focused on resistances to change and the effects of sexual fantasies on performance. T h e therapist stressed the importance of giving partners verbal feedback during the sexual interaction. Further steps of masturbation retraining were outlined. Individual sessions with each couple again were held with goals established for couples for the next week. The homework assignment for all couples consisted of each member physically and verbally role playing orgasm, at first alone and then in front of their partner to desensitize them to the emotional response that they anticipated would occur at the time of an orgasm. T h e women were instructed to continue pubococcygeus muscle exercises.
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In the sixth and final session the therapists led a general discussion of the concepts outlined in the program. A review of each couple's progress was conducted. The therapists emphasized the notion of couple responsibility and underscored the positive gains that they felt that the couples had made. The therapists urged the couples to continue to enrich their sexual relationships and to implement the new learnings in the months that followed. Each couple was given a sheet summarizing the important points covered in the workshop and instructions that could be utilized as they progressed.
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Procedure The six couples were told that the sexual-enhancement workshop would be free of charge. It was emphasized that treatment would be maximally effective only if all sessions were attended. It was stressed that no treatment session should be missed except in the case of a valid emergency. Couples also were told that they were receiving free treatment in return for their cooperation in an ongoing research project that required that they fill out questionnaires after treatment and at a 6-week follow-up. The following measures were administered to all subjects and their partners before and after the workshop and at a 6-week follow-up: the Sexual Interaction Inventory, the Marital Adjustment Scale, and the Sexual Behavior and Attitudes Questionnaire.
Measures Used Sexual znteractzon inventory (SZZ). The SII was designed by LoPiccolo and StegerI2 to provide both a diagnostic device and an outrome measure for therapists treating heterosexual couples with sexual dysfunctions. LoPiccolo and Steger demonstrated that the SII had acceptable levels of internal consistency and test-retest reliability. They also reported data suggesting that the SII discriminates between sexually dysfunction clients and a sexually satisfied control group and that the SII is reactive to treatment effects. The SII format consists of a list of 17 typical heterosexual behaviors. For each behavior both couple members separately answer 6 questions using a 6-point rating scale. Responses for each partner are summed across all 17 behaviors, and are combined into 1 1 scales. '~ a brief test Locke- Wallace marital adjustment scale. Locke and W a l l a ~ e devised of marital adjustment by isolating the most significant items of lengthy marital adjustment
inventories published prior to 1959. Using a sample representing 236 marriages, they demonstrated that their instrument differentiated between well-adjusted and maladjusted marriages. The test consists of 15 items that are independently answered by each 'partner, thus providing separate estimates of each partner's assessment of marital adjustment.
Sexual anxiety scale. Sotile14developed the Sexual Anxiety Scale as a measure of specific sexual anxiety. The scale consists of 39 items that ask the respondent to rate, on a 7-point scale, the degree of anxiety experienced during the following forms of sexual activity: (1) thoughts of sexual activity; (2) casual sexual contacts; (3) seductive behavior, male to female; (4) precoital sexual activity, male to fcmale; ( 5 ) precoital sexual activity, female to male; (6) coital activity; (7) experiencing arousal; (8 )various sexual activities; (9) sexual communication; and (10) anxiety from retarded orgasm. This scale was used as an aid to construct anxiety hierarchies during treatment and as an outcome measure. For the latter purpose the subjects' responses to the 39 items were added to derive a total score for the statistical analyses. Sexual behavior and attitudes questionnaire. SotileIs devised the Sexual Behavior and Attitude Questionnaire in order to gain specific behavioral information on
Wuyynr M Sotile, Petrr Kilniam arid Dzanr R. Follzngslad
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each subject's sexual functioning. The instrument consists of 14 questions concerning the frequency and degree of pleasure derived from various sexual acts, the frequency of and the types of Stimulation leading to orgasm, and the degree of anxiety experienced while thinking of and while engaging in sexual relations.
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RESULTS AND DISCUSSION The means and standard deviations for the six women on the dependent variables by testing periods (pretest, posttest, follow-up) are presented in Table 1. For each variable t tests were conducted on the mean difference scores between the pretest and posttest and between the pretest and the follow-up. Between the pretest and posttest a significant increase ( p < .05) was found on the Marital Adjustment Test (see Table 1). Although the pretest/follow-up difference was not significant, the follow-up score Table 1 Means and Standard Deviations of Female Subjects by Testing Periods
Time Periods Posttest
Pretest (N=6)
Follow-up (N=6)
"=6)
Dependent Variables
SD
M
M
Marital Adjustment Test
M
SD
~
~~
SD
~
~~
15.2
111.3
11.5
16.8
6.9
15.0
7.7
2.7
1.6
3.2
3.5
0.2
5.6
0.3
5.7
0.2
13.2
3.1
9.5
3.4
12.8
5.7
16.2
11.4
12.2
5.9
12.3
8.4
89.3
15.3
89.3
22.6
94.3
22.9
20.5
5.5
21.2
5.0
24.0
5.8
9.5
6.0
8.0
3.9
9.3
5.5
5.0
0.7
5.3
0.4
5.2
0.5
11.5
8.3
9.0
7.3
9.0
4.4
10.0
8.9
10.0
5.2
8.7
4.7
22.3
117.3
22.2
5.5
1.8
2.4
5.6
105.8
Sexual Interaction Inventory: Freqvency dissatisfaction Self-acceptance Pleasure Mean
-
-
-
Male
Male
Male
Perceptoal accuracy
-
Male
of Female Mate acceptance - Male
of Female Total Disagreement Frequency disatisfaction
-
Female Self-acceptance
-
Female
Pleasure mean - Female Perceptual accuracy
-
Female
of Male Mate acceptance - Female of Male Sexual Anxiety Scale
607.5 457.2 ~
262.7 209.7
340.2 317.0
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Journal of Sex and Marital Therapy
remained higher than the pretest. On the Sexual Interaction Inventory a significant decrease was found between the pretest and posttest on the male’s acceptance of the female ( p < .05), which was maintained at the follow-up ( p < .05). This finding represents a decrease in the women’s sexual nonresponsiveness as perceived by their partners. T h e women’s scores on the other 10 scales of the Sexual Interaction Inventory did not fluctuate significantly over the three testing periods. Thus, the workshop was not more powerful than group SD with women alone on these 10 scales. T h e Sexual Anxiety Scale scores showed a significant decrease between the pretest and posttest ( p < .05) and between the pretest and follow-up periods ( p < .05). Thus, the workshop facilitated an even greater reduction in reported sexual anxiety than group SD. Regarding orgasmic responsivity, three of the women maintained their primary nonorgasmic status regarding extracoital stimulation and intercourse over both group SD and the couples group. One woman who had been categorized as primary nonorgasmic before group SD but reported one orgasm through extracoital stimulation midway through group SD reported one orgasm through extracoital stimulation at the follow-up of the workshop. Another woman initially categorized as secondary nonorgasmic reported being able to experience orgasm from extracoital stimulation 90% to 100% of her attempts throughout both treatments. T h e other secondary nonorgasmic woman reported a 10% monthly percentage of extracoital stimulation resulting in orgasm during group SD, which increased to 100% at the posttest and follow-up of the workshop. Thus, although the workshop had positive effects on women’s self-reports of their marital and sexual interaction, the workshop was not successful in facilitating orgasm for all women. It should be noted that the workshop consisted of a combination of specific procedures (e.g., masturbation retraining, fantasy exercises) presented to the couples in individual sessions and/or in the group setting. Future investigators should explore the comparative impact of these procedures. As recommended by Sotile, Kilmann, and Scovern,16 women with orgasmic difficulties should be identified on historical-etiological factors and on descriptive data regarding their current sexual functioning with their current partners. This specificity in reporting subject variables should result in the eventual determination of the treatment procedures that are most helpful for a defined subject type. Using larger samples, future researchers should randomly assign women to treatment with and without their partners. I n this manner the necessity of having partners in treatment can be explored. Future studies also should obtain data on men’s sexual functioning by obtaining women’s ratings of their partners. Long-term follow-ups are needed to determine if treatment gains are maintained over time.
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REFERENCES
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1. Jones W, Jr, Park P: Treatment of single partner sexual dysfunction by systematic desensitiza-
tion. Obstet Gynecol39:411-417, 1972. 2. Kaplan H: The New Sex Therapy. N e w York, BrunnerlMazel, 1974. 3. Lobitz W, LoPiccolo J: New methods in the behavioral treatment of sexual dysfunction. Behav Ther Exp Psychiatry 3265-271,1972. 4. Masters W, Johnson V: Haman Sexual Inadequacy. Boston, Little, Brown, 1970. 5. McCovern KB, Stewart RC, LoPiccolo J: Secondary orgasmic dysfunction I. Analysis and strategies for treatment. Arch Sex Behav 4265-275,1975. 6. Sotile WM, Kilmann, PR: Treatments of psychogenic female sexual dysfunctions. Psychof Bull, 84(4):619-633, 1977. 7. Sotile WM, Kilmann PR: T h e effects of group systematic desensitization on primary and secondary orgasmic dysfunctions. Arch Sex Behav in press. 8. Kegel A: Sexual functions of the puboccoccygeus muscle. Ubskt Gynecol60:521,1952. 9. Keller DE:Applied Sex Therapy. Tappan, N Y , Center for Sex Education Incorporated, 1970. 10. LoPiccolo J, Lobitz W: T h e role of masturbation in the treatment of orgasmic dysfunction. Arch Sex Behav 2:163-17 1, 1972. 11. Hartman W, Fithian M: Treatment of Sexual Dysfunction: A Biqpsychosocial Approach. Long Beach, Calif, Center for Marital and Sexual Studies, 1972. 12. LoPiccolo J, Steger JC: T h e Sexual Interaction Inventory: A new instrument for assessment of sexual dysfunction. Arch Sex Behav 3:585-595,1974. 13. Lockc HJ, Wallace KM: Short marital and prediction tests: Their reliability and validity. Marr Fam Living 21 251-255,1959. 14. Sotile WM: Sexual anxiety scale. Unpublished manuscript, University of South Carolina, 1976. 15. Sotile WM: Sexual behavior and attitudes questionnaire. Unpublished manuscript, University of South Carolina, 1976. 16. Sotile WM, Kilmann PR, Scovern AW: Definitions and classifications of psychogenic female sexual dysfunctions. Sex Educ Thm 2:163-171,1977.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
A sexual-enhancement workshop: Beyond group systematic desensitization for women's sexual anxiety a
b
Wayne M. Sotile PhD , Peter Kilmann PhD & Diane R. Follingstad PhD
b
a
Department of Medical Social Science and Marital Health , Bowman Gray School of Medicine , Winston-Salem, North Carolina b
Department of Clinical Psychology , University of South Carolina , Columbia, South Carolina Published online: 14 Jan 2008.
To cite this article: Wayne M. Sotile PhD , Peter Kilmann PhD & Diane R. Follingstad PhD (1977) A sexual-enhancement workshop: Beyond group systematic desensitization for women's sexual anxiety, Journal of Sex & Marital Therapy, 3:4, 249-255, DOI: 10.1080/00926237708402992 To link to this article: http://dx.doi.org/10.1080/00926237708402992
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 3, No. 4, Winter 1977
A Sexual-Enhancement Workshop: Beyond Group Systematic Desensitization for Women’s Sexual Anxiety
Downloaded by [McMaster University] at 10:28 14 February 2015
Wayne M . Sotile, PhD, Peter Kilmann, PhD, and Diane R . Follingstad, PhD
ABSTRACT: This study investigated whether six women who previously had received 15 sessions of group systematic desensitization (SD) for their sexual anxiety would report additional treatment gains from participation in a sexual-enhancement workshop with their partners. After group SD six couples participated in six, I I12 hour weekly group sessions. T h e women reported a significant increase in marital adjustment and a significant decrease in sexual anxiety. A significant decrease was found in the women’s sexual nonresponsiveness as perceived by their partners. Future studies should ( 1) contrast the effects of group SD with women alone versus couple group treatment, (2) determine which treatment components are most influential for defined subject types, and (3) obtain data on men’s sexual functioning.
I n recent years a number of procedures have been developed for the treatment of primary and secondary nonorgasmic I n general, these procedures have had positive effects. However, as noted by Sotile and Kilmann6 in their comprehensive review, research efforts need to determine whether different treatments build upon one another for additional treatment gains. Sotile and Kilmann’ investigated the impact of group systematic desensitization (SD) on varied aspects of sexual functioning in 8 primary and 14 secondary nonorgasmic women. T h e 22 subjects received 15 sessions of group SD using four common hierarchies of sexual scenes. Significant positive treatment effects were found on measures of general and specific sexual adjustment and in extracoital orgasmic frequency. Treatment also enhanced sexual communication among subjects and their partners, increased the females’ acceptance of their mates as being Dr. Sotile is affiliated with the Department of Medical Social Science and Marital Health, the Bowman Gray School of Medicine, Winston-Salem, North Carolina. Drs. Kilmann and Follingstad are affiliated with the Department of Clinical Psychology, University of South Carolina, Columbia, South Carolina. Reprint queries should be directed to Dr. Wayne M. Sotile. Bowman Gray School of Medicine, Department of Medical Social Science and Marital Health, Winston-Salem, North Carolina 27103.
24Y
250
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4 Sex and Marital
Therapy
satisfactory sexual partners, and increased the females’ self-acceptance as sexual beings. All but one of the treatment effects (degree of pleasure experienced during extracoital stimulation) were maintained at the 6week follow-up. The present study investigated whether six of the women in the Sotile and Kilmann’ study would report additional treatment gains from participation in a sexual-enhancement workshop with their partners.
Downloaded by [McMaster University] at 10:28 14 February 2015
METHOD Subjects In order to be included in the initial investigation,’ all subjects were required to meet all of the following criteria: (1) each subject had to exhibit either primary or secondary orgasmic dysfunction as defined by Masters and J ~ h n s o n ;(2) ~ each subject had to be currently involved in an intimate sexual relationship with a male partner who had no difficulties with premature ejaculation (as defined by Masters and J o h n ~ o n )or~ with either obtaining or maintaining an erection during sexual relations; (3) each subject had to have a sex partner who was willing to participate in the treatment program by responding to measures of sexual and marital adjustment; (4) all subjects had to show specific sexual anxiety as measured by an experimenter-devised scale; and (5) each subject had to have an anatomically normal pelvic structure as determined by a recent medical examination. T h e subjects were obtained from advertisements and referrals from the University of South Carolina and the Columbia, South Carolina area. A more elaborate description of the 22 subjects who completed the experiment and the treatment procedure can be found in Sotile and Kilmann.’ After the completion of the 6-week follow-up of the group SD procedure, the subjects were asked if they wished to participate in a 6-week sexual-enhancement workshop with their husbands present. All 22 subjects expressed an interest. However, due to conflicting husband-wife schedules, as well as a lack of interest by some partners, only seven couples were able to meet the designated schedule. One couple dropped out of the group after the third session with no explanation. Thus, there were six couples who completed t h e experiment. It should be noted that prior to group SD, four of the women were classified as primary nonorgasmic while two of the women were classified as secondary nonorgasmic. After group SD three of the women classified as primary nonorgasmic remained nonorgasmic, either from intercourse or extracoital stimulation; the other primary nonorgasmic woman reported one orgasm through extracoital stimulation midway through group SD; thus, she lost her “primary status.” One of the two secondary nonorgasmic women reported a monthly percentage of extracoital stimulation resulting in orgasm of 90- 100% throughout the group SD procedure; thus, she was considered orgasmic according to Masters and Johnsons’ definition.‘ T he other secondary nonorgasmic woman reported a monthly percentage of extracoital stimulation resulting in orgasm of 10% throughout group SD; thus, she was still classified as secondary nonorgasmic. All of the subjects were Caucasian. Five of the couples were married, with the average length of marriage being 6.7 years (range = .3 to 17 years). T h e sixth couple had been living together for 2.5 years. T h e mean age of the women was 29 years (range, 19 to 42 years). T h e mean educational level was 15.8 years (range 12 to 18 years). T he mean number of children was 1.
Treatment Th e workshop was conducted by a cotherapy team of a female who held a PhD in clinical psychology and a male doctoral student in clinical psychology. Both leaders had consider-
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able experience in conducting groups. Neither therapist had conducted a sexualenhancement workshop prior to the experiment, although both had considerable experience in treating couples with marital and sexual difficulties. T h e overall treatment format was highly structured and was derived from a variety of treatment appro ache^.*^^^^^**^ T h e first session began with a general orientation. T he couples were told that the purpose of the program was to promote sexual communication. I t was emphasized that the focus of the workshop would be on the couple as a unit, n o t individuals. The therapists emphasized that each couple must take responsibility for improvement in their sexual functioning and that each couple should identify factors in their sexual relationship that they would like to change. Group discussion dealt with couples' apprehensions, hesitations, and goals for their participation. T h e therapists lectured on male and female sexual response cycles. T he various causes and types of sexual dysfunction were outlined according to various sources.2p6T he couples were instructed to refrain from sexual intercourse until the fourth week of treatment. They were given a sensate-focus homework a~ s i gnm ent . ~ T h e second session began with the therapists getting feedback from the couples regarding the sensate-focus homework exercise. Couples were asked how it felt to give and demand pleasure with no pressure to engage in coitus. Because both members of each couple were feeling that they had disappointed their partner, the therapists then discussed with the group typical male and female reactions when one partner is perceived as sexually dysfunctional. Further information was given in that the therapists stressed the necessity of clitoral stimulation for orgasmic response. Personal reactions from the group were obtained regarding the possibility that manual or oral clitoral stimulation may always be required for female orgasm and that coital orgasm may not occur. As a homework assignment, the couples were given a handout that included exploring body imagery and a continuation of the sensate-focus exercises begun the previous week. In the third session group discussion topics included the couples' reactions to treatment thus far and the role of sexual fantasies in sexual functioning. T h e steplike nature of sexual arousal was emphasized, and the couples were told not to become upset if they experienced a temporary cessation in mounting arousals. T h e therapists oriented the women toward masturbation retraining.'O T h e therapists revealed aspects of their own ersonal sexual responsiveness as an attempt to establish masturbation as normal. For Romework assignment masturbation retraininglo and reading and utilizing fantasy materials" w e r e recommended for all females. T h e therapists allowed the couples to employ manual and/or oral stimulation in order to reach orgasm if desired. Each couple was seen for 5 to 15 minutes at the end of the group in order to discuss specific goals and to make specific suggestions for each couple's sexual relationship. T h e fourth session began with a group discussion about the couples' reactions to treatment at this point and a discussion about any problems encountered thus far. Five of the six couples either reported that they experienced some discouragement or that they had not completed their homework assignment. This revelation led to a discussion of possible resistances to treatment and possible fears of changing sexual behaviors. T h e therapists then discussed Kegel's works on the pubococcygeus muscle. T he women were instructed to exercise their pubococcygeus muscle three times per day, 15 contractions each time. T h e therapists encouraged all group members to develop their own sexual fantasies and to focus on them when experiencing problems in becoming sexually aroused. T h e therapists discussed the natural tendency to have a variety of sexual fantasies that might include persons other than partners. In a 5 to 15-minute session held with each couple separately unique concerns were dealt with by specific sexual-enhancement exercises. In the fifth session group discussion focused on resistances to change and the effects of sexual fantasies on performance. T h e therapist stressed the importance of giving partners verbal feedback during the sexual interaction. Further steps of masturbation retraining were outlined. Individual sessions with each couple again were held with goals established for couples for the next week. The homework assignment for all couples consisted of each member physically and verbally role playing orgasm, at first alone and then in front of their partner to desensitize them to the emotional response that they anticipated would occur at the time of an orgasm. T h e women were instructed to continue pubococcygeus muscle exercises.
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Journal (fSPXand Morital Therapy
In the sixth and final session the therapists led a general discussion of the concepts outlined in the program. A review of each couple's progress was conducted. The therapists emphasized the notion of couple responsibility and underscored the positive gains that they felt that the couples had made. The therapists urged the couples to continue to enrich their sexual relationships and to implement the new learnings in the months that followed. Each couple was given a sheet summarizing the important points covered in the workshop and instructions that could be utilized as they progressed.
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Procedure The six couples were told that the sexual-enhancement workshop would be free of charge. It was emphasized that treatment would be maximally effective only if all sessions were attended. It was stressed that no treatment session should be missed except in the case of a valid emergency. Couples also were told that they were receiving free treatment in return for their cooperation in an ongoing research project that required that they fill out questionnaires after treatment and at a 6-week follow-up. The following measures were administered to all subjects and their partners before and after the workshop and at a 6-week follow-up: the Sexual Interaction Inventory, the Marital Adjustment Scale, and the Sexual Behavior and Attitudes Questionnaire.
Measures Used Sexual znteractzon inventory (SZZ). The SII was designed by LoPiccolo and StegerI2 to provide both a diagnostic device and an outrome measure for therapists treating heterosexual couples with sexual dysfunctions. LoPiccolo and Steger demonstrated that the SII had acceptable levels of internal consistency and test-retest reliability. They also reported data suggesting that the SII discriminates between sexually dysfunction clients and a sexually satisfied control group and that the SII is reactive to treatment effects. The SII format consists of a list of 17 typical heterosexual behaviors. For each behavior both couple members separately answer 6 questions using a 6-point rating scale. Responses for each partner are summed across all 17 behaviors, and are combined into 1 1 scales. '~ a brief test Locke- Wallace marital adjustment scale. Locke and W a l l a ~ e devised of marital adjustment by isolating the most significant items of lengthy marital adjustment
inventories published prior to 1959. Using a sample representing 236 marriages, they demonstrated that their instrument differentiated between well-adjusted and maladjusted marriages. The test consists of 15 items that are independently answered by each 'partner, thus providing separate estimates of each partner's assessment of marital adjustment.
Sexual anxiety scale. Sotile14developed the Sexual Anxiety Scale as a measure of specific sexual anxiety. The scale consists of 39 items that ask the respondent to rate, on a 7-point scale, the degree of anxiety experienced during the following forms of sexual activity: (1) thoughts of sexual activity; (2) casual sexual contacts; (3) seductive behavior, male to female; (4) precoital sexual activity, male to fcmale; ( 5 ) precoital sexual activity, female to male; (6) coital activity; (7) experiencing arousal; (8 )various sexual activities; (9) sexual communication; and (10) anxiety from retarded orgasm. This scale was used as an aid to construct anxiety hierarchies during treatment and as an outcome measure. For the latter purpose the subjects' responses to the 39 items were added to derive a total score for the statistical analyses. Sexual behavior and attitudes questionnaire. SotileIs devised the Sexual Behavior and Attitude Questionnaire in order to gain specific behavioral information on
Wuyynr M Sotile, Petrr Kilniam arid Dzanr R. Follzngslad
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each subject's sexual functioning. The instrument consists of 14 questions concerning the frequency and degree of pleasure derived from various sexual acts, the frequency of and the types of Stimulation leading to orgasm, and the degree of anxiety experienced while thinking of and while engaging in sexual relations.
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RESULTS AND DISCUSSION The means and standard deviations for the six women on the dependent variables by testing periods (pretest, posttest, follow-up) are presented in Table 1. For each variable t tests were conducted on the mean difference scores between the pretest and posttest and between the pretest and the follow-up. Between the pretest and posttest a significant increase ( p < .05) was found on the Marital Adjustment Test (see Table 1). Although the pretest/follow-up difference was not significant, the follow-up score Table 1 Means and Standard Deviations of Female Subjects by Testing Periods
Time Periods Posttest
Pretest (N=6)
Follow-up (N=6)
"=6)
Dependent Variables
SD
M
M
Marital Adjustment Test
M
SD
~
~~
SD
~
~~
15.2
111.3
11.5
16.8
6.9
15.0
7.7
2.7
1.6
3.2
3.5
0.2
5.6
0.3
5.7
0.2
13.2
3.1
9.5
3.4
12.8
5.7
16.2
11.4
12.2
5.9
12.3
8.4
89.3
15.3
89.3
22.6
94.3
22.9
20.5
5.5
21.2
5.0
24.0
5.8
9.5
6.0
8.0
3.9
9.3
5.5
5.0
0.7
5.3
0.4
5.2
0.5
11.5
8.3
9.0
7.3
9.0
4.4
10.0
8.9
10.0
5.2
8.7
4.7
22.3
117.3
22.2
5.5
1.8
2.4
5.6
105.8
Sexual Interaction Inventory: Freqvency dissatisfaction Self-acceptance Pleasure Mean
-
-
-
Male
Male
Male
Perceptoal accuracy
-
Male
of Female Mate acceptance - Male
of Female Total Disagreement Frequency disatisfaction
-
Female Self-acceptance
-
Female
Pleasure mean - Female Perceptual accuracy
-
Female
of Male Mate acceptance - Female of Male Sexual Anxiety Scale
607.5 457.2 ~
262.7 209.7
340.2 317.0
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Journal of Sex and Marital Therapy
remained higher than the pretest. On the Sexual Interaction Inventory a significant decrease was found between the pretest and posttest on the male’s acceptance of the female ( p < .05), which was maintained at the follow-up ( p < .05). This finding represents a decrease in the women’s sexual nonresponsiveness as perceived by their partners. T h e women’s scores on the other 10 scales of the Sexual Interaction Inventory did not fluctuate significantly over the three testing periods. Thus, the workshop was not more powerful than group SD with women alone on these 10 scales. T h e Sexual Anxiety Scale scores showed a significant decrease between the pretest and posttest ( p < .05) and between the pretest and follow-up periods ( p < .05). Thus, the workshop facilitated an even greater reduction in reported sexual anxiety than group SD. Regarding orgasmic responsivity, three of the women maintained their primary nonorgasmic status regarding extracoital stimulation and intercourse over both group SD and the couples group. One woman who had been categorized as primary nonorgasmic before group SD but reported one orgasm through extracoital stimulation midway through group SD reported one orgasm through extracoital stimulation at the follow-up of the workshop. Another woman initially categorized as secondary nonorgasmic reported being able to experience orgasm from extracoital stimulation 90% to 100% of her attempts throughout both treatments. T h e other secondary nonorgasmic woman reported a 10% monthly percentage of extracoital stimulation resulting in orgasm during group SD, which increased to 100% at the posttest and follow-up of the workshop. Thus, although the workshop had positive effects on women’s self-reports of their marital and sexual interaction, the workshop was not successful in facilitating orgasm for all women. It should be noted that the workshop consisted of a combination of specific procedures (e.g., masturbation retraining, fantasy exercises) presented to the couples in individual sessions and/or in the group setting. Future investigators should explore the comparative impact of these procedures. As recommended by Sotile, Kilmann, and Scovern,16 women with orgasmic difficulties should be identified on historical-etiological factors and on descriptive data regarding their current sexual functioning with their current partners. This specificity in reporting subject variables should result in the eventual determination of the treatment procedures that are most helpful for a defined subject type. Using larger samples, future researchers should randomly assign women to treatment with and without their partners. I n this manner the necessity of having partners in treatment can be explored. Future studies also should obtain data on men’s sexual functioning by obtaining women’s ratings of their partners. Long-term follow-ups are needed to determine if treatment gains are maintained over time.
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REFERENCES
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1. Jones W, Jr, Park P: Treatment of single partner sexual dysfunction by systematic desensitiza-
tion. Obstet Gynecol39:411-417, 1972. 2. Kaplan H: The New Sex Therapy. N e w York, BrunnerlMazel, 1974. 3. Lobitz W, LoPiccolo J: New methods in the behavioral treatment of sexual dysfunction. Behav Ther Exp Psychiatry 3265-271,1972. 4. Masters W, Johnson V: Haman Sexual Inadequacy. Boston, Little, Brown, 1970. 5. McCovern KB, Stewart RC, LoPiccolo J: Secondary orgasmic dysfunction I. Analysis and strategies for treatment. Arch Sex Behav 4265-275,1975. 6. Sotile WM, Kilmann, PR: Treatments of psychogenic female sexual dysfunctions. Psychof Bull, 84(4):619-633, 1977. 7. Sotile WM, Kilmann PR: T h e effects of group systematic desensitization on primary and secondary orgasmic dysfunctions. Arch Sex Behav in press. 8. Kegel A: Sexual functions of the puboccoccygeus muscle. Ubskt Gynecol60:521,1952. 9. Keller DE:Applied Sex Therapy. Tappan, N Y , Center for Sex Education Incorporated, 1970. 10. LoPiccolo J, Lobitz W: T h e role of masturbation in the treatment of orgasmic dysfunction. Arch Sex Behav 2:163-17 1, 1972. 11. Hartman W, Fithian M: Treatment of Sexual Dysfunction: A Biqpsychosocial Approach. Long Beach, Calif, Center for Marital and Sexual Studies, 1972. 12. LoPiccolo J, Steger JC: T h e Sexual Interaction Inventory: A new instrument for assessment of sexual dysfunction. Arch Sex Behav 3:585-595,1974. 13. Lockc HJ, Wallace KM: Short marital and prediction tests: Their reliability and validity. Marr Fam Living 21 251-255,1959. 14. Sotile WM: Sexual anxiety scale. Unpublished manuscript, University of South Carolina, 1976. 15. Sotile WM: Sexual behavior and attitudes questionnaire. Unpublished manuscript, University of South Carolina, 1976. 16. Sotile WM, Kilmann PR, Scovern AW: Definitions and classifications of psychogenic female sexual dysfunctions. Sex Educ Thm 2:163-171,1977.
