DIAGNOSIS AND TREATMENT
Marital Sexual Dysfunction: Introductory Concepts STEPHEN B. LEVINE, M.D., Cleveland, Ohio
The concepts presented in this overview of marital sexual dysfunction are derived from increasing clinical experience with couples who seek help for their sexual problems. These couples, in marked contrast to couples with good sexual functioning, usually report a steady state of emotional dissatisfaction and minimal physical pleasure from sex. The affectual and behavioral consequences of persistent dysfunction are reviewed. Sexual therapy is discussed in terms of its two elements, sensate focus and psychotherapy. The various tasks which the sexual therapist may have to accomplish with individual couples are described. Consideration is given to the specific hypotheses usually offered as explanation for sexual dysfunction—i.e., organic factors, varying degrees of relationship failure, poor communication, sexual ignorance, performance anxiety, and intrapsychic residua of past experience. A protocol for the screening physician to use in the formulation of a reasonable clinical plan for dysfunctional couples is included.
delay ejaculation, and inability to achieve orgasm. Female sexual dysfunctions include the inability to become sexually aroused, inability to become aroused to the point of orgasm, and inability to tolerate vaginal penetration. While these dysfunctions are variously labeled by different authors, they are commonly accepted as "the" sexual dysfunctions. The sexual dysfunctions, while very important, do not encompass the entire spectrum of marital sexual problems. Complaints about sexual life encountered clinically range beyond well-defined dysfunctions to include little or no desire for sex, little or no emotional pleasure from sex, an unexplained reluctance to initiate or participate in sex, and dissatisfaction with a major dimension of the partner's personality. Many of these problems seem to exist in the face of intact physiologic functioning. Some Basic Characteristics of Good Sexual Functioning
* It is quite impossible through references alone to convey the enormous influence of Masters and Johnson's contributions. Besides providing physiologic data and showing the treatability of sexual problems, they have put forth a number of concepts that have clinical usefulness and heuristic value (1, 2 ) .
Both men and women have the neurophysiologic capacity to pass through the excitement, plateau, orgasm, and resolution phases of sexual arousal (2) in a smooth, wellintegrated fashion. These physiologic events have psychologic prerequisites that are central to the understanding of marital sexual functioning. These prerequisites help to explain the universal fluctuation in quality of sexual experience. They delineate what does not happen in dysfunctional relations. They describe what therapy is aiming to help couples create in their sexual lives. The following characteristics of good sexual functioning are helpful, though incompletef. Both partners are willing to make love. Each is able to relax. Nonsexual concerns disappear from awareness. A special alteration of consciousness supervenes marked by exclusive attention to one's own and one's partner's pleasurable sensations. The concern for the partner's sensations inconspicuously results in the formation of a feedback system whereby clues from skin, breathing, posture, and utterances are used somewhat automatically to direct what happens next. The pleasure and excitement of each partner is infectious and augments the pleasure and excitement of the other. The rights of each partner to give and receive sexual pleasure, if not equal, are fully acceptable to both. Sex is completed with a high degree of personal pleasure and also with the sense of having shared a meaningful experience.
• From the Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio.
t This list is derived from clinical experience with recovering dysfunctional couples.
to sexual problems has changed considerably in the last decade*. The number of private and academic institutions and individual practitioners providing treatment for sexual problems has visibly multiplied. The traditional view that sexual problems are the legitimate and sole domain of psychiatry has changed. Other medical and nonmedical disciplines now actively participate in treatment programs. A new vocabulary for sexual problems has emerged (1). The basic term "dysfunction," only recently introduced, is already in widespread usage. The notion of an impairment of specific aspects of sexual physiology has made it unacceptable for physicians to classify all problems of function as impotence or frigidity. The delineation of specific dysfunctions has increased the possibility that separate pathogeneses will be elucidated and highly specific treatment methods can be devised. Male sexual dysfunctions include the inability to obtain an erection, inability to maintain an erection, inability to THE CLINICAL APPROACH
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When these basic ingredients are combined, the sexual experience tends to be described in superlative terms. But when achievement of one of these psychologic states is impeded, that is, when one person is not willing or cannot relax, cannot free the mind from a concern, cannot drift into the state of intense concentration on sensation, cannot perceive or give signals, or is incapable of being infected with excitement, the sexual experience invariably suffers. This does not mean that the experience is without pleasure, however. Even without these ingredients, the intense pleasure of orgasm can reliably occur. The sexual life of every couple fluctuates in the degree to which these characteristics combine. Couples come to expect that variation in pleasure is a basic characteristic of sexual life and intuitively appreciate the fact that sexual functioning is a dynamic equilibrium affected by forces from many directions. If sex is not always superlative, it sometimes is. If sex is occasionally pleasureless, it is not that way for long. The variation in the degree of physical pleasure and emotional satisfaction of couples without dysfunction contrasts to the steady state of minimal pleasure and dissatisfaction that couples seeking help for sexual problems describe. Characteristics of Dysfunctional Couples
It is very difficult for dysfunctional couples to emotionally share a sexual experience. One partner is inhibited from developing the necessary relaxed abandonment to sensation by a mental preoccupation. This preoccupation often involves some aspect of sexual physiology (erection, ejaculation, orgasm). When the partner senses the lack of excitement and involvement in pleasure produced by this preoccupation, he or she, in turn, withdraws. Sex then is reduced to a mechanical behavior devoid of emotion, which is its very essence. One person's sexual problems Invariably have profound effects on the partner. These effects are the basis for the generalization that there is no such thing as an uninvolved sexual partner (1). Certain characteristics recur often enough in help-seeking couples to provide a predictable composite of the concomitants of the dysfunctional person. 1. Avoidance of sexual behavior. Periodic hugs, caresses, kisses, and intercourse decrease in frequency. 2. Avoidance of discussing sex. The pain associated with the deterioration of sexual life is frequently dealt with by diminishing communication. This area of silence makes it harder to talk about anything. 3. Spectatoring. When sexual behavior does occur, both partners are preoccupied with how things are going. They are mentally watching the proceedings. 4. Anger. The nondysfunctional partner becomes seriously disappointed and eventually angry. At first, individuals may deny the disappointment: "Oh it really doesn't matter! I don't mind." Fault-finding may occur but often is displaced outside the bedroom by substantial issues such as child rearing and income, or by trivia. If disappointment and anger over sexual deprivation are not recognized and shared, these pent-up feelings may erupt periodically to produce ugly destructive accusations: "You frigid . . . !" "You impotent.. . !"
5. Worries of the nondysfunctional partner. The partner feels that he or she is not really loved and feels responsible for having caused the problem through personal inadequacy. 6. Decreased self-esteem of the dysfunctional partner. The individual feels incomplete as a man or woman. Shame over the dysfunction delays help-seeking, which contributes to the hopelessness and to the sense of being trapped by the problem. 7. Thoughts, fantasies, and dreams of partner substitution in both partners. Those persons who cannot accept the wish fulfilling nature of these mental activities bear an additional burden of guilt and anxiety. The hypothesis, "Maybe I wouldn't have it with somebody else," invariably occurs to the dysfunctional person. When the hypothesis is acted on, guilt over infidelity and the need for deceit further compromise the couple's capacity for spontaneous, honest communication. 8. Masturbation. The continuation of, return to, or beginning of masturbation is usually a well-kept secret and can be a source of considerable self-degradation and anger at the partner. Considering the emotionless quality of dysfunctional sex and the forces its persistence sets in motion, one can appreciate the fact that sexual dysfunction may become a burden of unhappiness, emotional isolation, and relationship failure. Yet these factors, however important, are only the end results; they do not explain the pathogenesis of sexual dysfunction. The Nature of Sexual Therapy
There are two basic elements to sexual therapy: sensate focus and "psychotherapy" (3). Sensate focus is an elegantly simple method based on the principle that sex is the totality of a couple's physical sharing, rather than just intercourse (1). The therapist(s) briefly directs the couple's sexual behavior, usually beginning by instructing them to touch and kiss each other everywhere except the breasts and genitals. This first instruction, by freeing the couple from performance worries, encourages relaxation and the drift into sensation awareness. It provides the opportunity to explore and talk about giving and receiving pleasure. The ideal end result is sexual excitement. When mastery of these tasks is achieved, the breasts and genitals are added to the areas of pleasuring. Major emphasis continues on learning about and providing for partner desires and on giving and receiving pleasure, rather than on performance. Breast and genital pleasuring usually generates a high degree of arousal; orgasm may follow through extravaginal means. The third major instruction, after good sexual functioning in noncoital modes is achieved, is to include intercourse. When sensate focus progresses smoothly, the results are hard for everyone—patients, therapist, and professional peers—to believe. A couple with a long history of dysfunction may, in the course of a few days or weeks, find sexual experience to be an easy, richly pleasurable recreation. The dysfunctional physiology is reversed. The couple grows together, having shared a very intimate process of learning about one another. Levina • Marital Sexual Dysfunction
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This ideal state, often present early in sensate focus, frequently does not last. The progress of sensate focus is blocked by other feeling states. Attention to these affects, and not the method of sensate focus itself, comprises the psychotherapy component of sex therapy ( 3 ) . Good sexual functioning cannot be achieved if the intensity, source, and meaning of these feelings are not appreciated. The presence of interfering feelings or attitudes is signaled by the couple's inability to carry out the sensate focus instructions or become emotionally involved in the sexual behavior. The major challenge for the sex therapist is essentially a psychotherapeutic one: working with persons to overcome their resistance to emotional participation in the tasks of sensate focus. The sources of resistance vary from person to person and are not always completely definable. They do, however, frequently derive from couples' nonsexual relationships, their sense of gender-appropriate sexual behavior, and their individual capacities to tolerate emotional and physical intimacy. The resistances encountered during sex therapy generate some of the current causal hypotheses explaining dysfunctions. Pathogenesis of Sexual Dysfunction
Emotional or behavioral problems are rarely attributable to a single cause. The notion of multiple determinants for any behavioral state is a basic principle of mental life ( 4 ) . A dominant cause may be defined for practical purposes. However, both normal and abnormal behavior result from a complex interaction of biology, maturation, conceptual learning, interpersonal relationships, and culture. Sex therapy emphasizes symptom reversal rather than a thorough elucidation of the causes of dysfunction. Causal factors are appreciated only insofar as they are immediately apparent from the initial history and physical examination, uncovered during therapy, or deduced by the therapist. Improved sexual functioning does not necessarily mean the causes of the problem have been determined and eradicated. The current apparent causes of a dysfunction may not be the reasons for its original appearance. Notions of causality should be regarded as hypotheses, especially since they are rarely subjected to subsequent scientific study. Current understanding of the causes of sexual dysfunction is a collage of hypotheses derived from differing schools of psychologic thought ( 3 ) . The following factors seem to be causally related to most of the dysfunctions encountered in sex therapy. They are not mutually exclusive; rather, they often blend into and complement each other in a mixture of precipitating events, current factors, and remote influences. ORGANIC FACTORS
There is much to be discovered about the organic substrate of sexual behavior. The understanding of the human endocrinology and neurophysiology of sex is in its most rudimentary phase (5). It would be clinically useful to be able to assess accurately the biological component of sexual interest. Currently, this assessment can only be derived from the individual's lifelong history of sexual expression. It is assumed that there is a considerable amount 450
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of individual variance in the constitutional aspects of sexual interest. Kinsey's (6, 7) data on the total number of orgasmic outlets from all sources over a period of time support this assumption. Such data do not, however, separate biological from environmental determinants. It would also be useful to understand specifically how aging affects sexual capacity. A sizeable minority of healthy couples in their seventies continue to enjoy an active sexual life ( 8 ) . There is also evidence that the responses of the genitals to sexual stimulation change with age ( 2 ) . But there would be great clinical usefulness in being able to discriminate between subtle endocrinic, neurologic, circulatory, and psychologic factors. Certain disease processes, specific lesions, and pharmacologic agents can profoundly affect sexual functioning. The effects of other organic factors are less clear. The mechanism of interference with sexual functioning varies from local tissue damage, peripheral or central nervous system effects, and systemic effects on energy and libido, to psychologic damage. Organic factors must be carefully sought out and scrutinized. Underestimation of their effects can lead to economically and psychologically expensive prolongation of dysfunction; overestimation may lead to premature cessation of sexual functioning. RELATIONSHIP DETERIORATION
Obvious Relationship Problems: Dysfunctional couples whose relationships are characterized by unreliability, dishonesty, and hatred are not often accepted for sex therapy. The causes of their dysfunction are assumed to be a direct product of the alienation or estrangement that has occurred in nonsexual areas. Although the alienation may have originally occurred in part because of a sexual dysfunction, severe estrangement, regardless of cause, is not treatable by sex therapy ( 3 ) . Subtle Relationship Problems: When partner alienation, that is, rejection of one spouse by the other, is perceived by neither the couple nor the clinician, its existence is soon made clear by a persistent resistance to therapy. A stable period of good sexual functioning followed by dysfunction is a clue to the presence of relationship deterioration. For most of these couples, the quality of sexual life is an accurate barometer of their nonsexual relationship. They do not need sensate focus as much as an opportunity to understand the significance of their loss of sexual responsiveness. Dissatisfaction with Specific Character Traits: Dysfunctional couples whose commitment to each other has not deteriorated often articulate complaints about nonsexual aspects of each other's personality or past behavior. Some examples include the following: "He always criticizes me," "She's too selfish," "He's insensitive," "She never understands," "He's too passive," "She's too pushy," "He avoids being close to me," "She always has to win," and so forth. These complaints are usually accurate descriptions of the partner's character traits that interfere with the couple's relationship. They are a source of disappointment, anger, and frustration to the complainer and often to the partner as well. They are not insurmountable obstacles to progress in therapy, but they do limit the emotional satisfaction
from participation. The therapist, in dealing with these couples, is occupied with recognizing these character traits, acknowledging the feelings and events that they have been responsible for, and exploring their sources and the possibilities for modifying the behavior. These activities seem to be a necessary condition for returning to focus on the sexual dysfunction. POOR COMMUNICATION AND IGNORANCE
There are couples who are troubled with dysfunction despite being generally satisfied with their nonsexual relationship. Although their problem has always been a part of their relationship, they continue to emotionally value one another. These problems often seem to be associated with a remarkable inability to talk about sex, a limited knowledge of sex, and very restrictive standards of how sexual life should be conducted (1, 3). Poor Communication: It is inherently difficult to talk about sex*. There is, in addition, a significant cultural taboo against too direct communication about the subject. If a couple has a serious problem communicating in nonsexual areas, their sexual communications are apt to be worse. Effective communication about sex requires that both partners be able to transmit and receive information about their needs and desires. Transmission depends on the capacity to recognize a need or desire, as well as the freedom and ability to communicate it. Receiving requires an awareness of the mode of transmission (often not direct statements) and a willingness to receive and to respond. Thus, a sexual communications system can be ineffective in many different ways for many different reasons. Poor communication, although a highly relevant concept in sex therapy, is a rather nonspecific causal factor that can result from a diverse group of interpersonal/intrapsychic states. Fear of emotional and physical abandonment, struggle for dominance and power, anger, low selfesteem, inability to accept one's sexuality, guilt over pleasure, fear of intimacy, generalized inarticulateness, and constricted views on how one ought to behave sexually within a marriage are only some examples. Whatever the particular cause, the therapist usually places considerable stress on improving communications. Talking together, sharing previously taboo subjects, and discovering something unknown about the spouse's feelings and preferences provide a great deal of subjective relief and hopefulness for a dysfunctional couple. Sexual Ignorance: It is hard to know precisely what to make of ignorance as a cause of dysfunction. Ignorance certainly does limit people's sexual lives, but the overriding question remains: what factors have managed to keep the couple so unknowledgeable? Dysfunctional couples are apt to be ignorant about a number of things. Lack of knowledge regarding basic details of female external genital structure is encountered in both men and women. Couples do not know each other's preference for stimulation, and what behaviors their partners would like to engage in and the places and ways they like to be touched remain mysteries. Couples do not * This phenomenon is repeatedly observed in the practice of psychiatry.
appreciate the nonvisible physiologic concomitants of sexual arousal. They do not know about their own sexual potentials in foreplay, genital play, and intercourse. These informational deficiencies are, in part, a result of a cultural lack of opportunities to learn about sexual matters. Subcultures vary considerably in their tolerance for transmission of sexual knowledge to the young. The first opportunities to learn occur in the immediate family, but later they are derived from progressively wider segments of society. A child acquires different behavioral expectations for boys and girls, which culminate in the sexual double standard. The child learns where, when, and in how much detail sexual information may be transmitted and is exposed to stereotypic idealizations of how to be sexual. There is another dimension to the explication of sexual ignorance. Some sexual ignorance is the result of an earlier need not to know. At any given time, the impact of sexual knowledge may be more than the child is equipped to handle ("My parents don't do that!"). Exposure to sexual knowledge without maturational readiness may produce confusion, anxiety, and a subsequent unwillingness to learn more. It is an oversimplification to view sexual ignorance solely as a reflection of parental failure to honestly discuss sexual matters at adolescence. The highly idiosyncratic reaction of the child must be considered. Constricted Sexual Standards: How adults acquire their sexual standards is by no means understood. The way the family handles inquiries about the anatomic differences between the sexes, the origin of babies, and relationships between the sexes has much to do with both the family's and the child's capacities to later deal with more complex issues like pubertal changes, masturbation, petting, birth control, and sexual behavior in marriage. This "sexual value system" (1), as it has recently been labeled, contains general expectations for how both genders ought to behave sexually—that is, notions about sexual normality and standards for one's personal sexual behavior. In couples whose constricted sexual value systems seem etiologically related to their dysfunction, the therapist imparts factual information, encourages an honest exchange of preferences for modes of stimulation, suggests new behavioral possibilities, and helps to establish nonstereotypic, age-appropriate expectations. INTRAPSYCHIC FACTORS
Performance Anxiety: After the recognition of a dysfunction, every couple becomes preoccupied with the question of its recurrence. The mental accompaniment of sexual behavior becomes, "When is (erection, ejaculation, penetration, excitement, orgasm) going to happen?" This concern with performance is always a problem. Occasionally it reaches the immense proportions of a marked anxiety attack, accompanied by sweating, palpitations, tachycardia, hyperventilation, nausea, fatigue, and light-headedness (9). The methods for allaying performance anxiety include authoritative advice to relax, reassurance, placebo, hypnosis, and sensate focus. These are sometimes so effective that the cause of the dysfunction seems to have been the performance concern itself. Levine • Marital Sexual Dysfunction
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Sexual failures due to anger, alcohol, fatigue, miscellaneous worries, and transient depression may occasionally trigger lasting performance concerns. But therapeutic methods do not often dramatically and completely eradicate anxiety about sexual performance. Most persons cannot be advised, reassured, tricked, suggested, or behaviorally shaped completely out of their anxieties. Moreover, careful history of the dysfunctional person's earlier sexual experiences often reveals considerable anxiety or behavioral restriction. Performance anxiety, in these cases, is the culmination of these long-standing sexual anxieties, plus the addition of more recent concerns induced by the recognition of the dysfunction. The therapist's attention is drawn to the remote sources of anxiety only because the person cannot relax enough to become aroused, even when faced with a warm, nondemanding relationship. There are many potential intrapsychic sources of anxiety in sexual situations and a number of ways to conceptualize them. Irrational Ideas: Powerful irrational ideas may continually generate anxiety in sexual situations (10). These ideas are considered causes since realizing their existence, understanding their implications, and expressing their attached feelings may lead to a dramatic improvement in sexual functioning. Several recurrent themes are involved: conscience—Sex is wrong, evil, dirty; I will be punished; loss of control—I will be swept away to a terrible but unknown fate; I will get sick or die; My very being will be engulfed; aggression—I will injure myself or injure my partner; inadequacy—My true self will be discovered; I an not a real man or a real woman; I am nothing without a penis; I am unlovable; I will be abandoned; I cannot assert myself; secret revelation—My hidden wishes and fantasies will become clear to me; My sordid past (for example, childhood experience, masturbation, promiscuity, homosexuality) will be discovered. These powerful, persistent, and sometimes unconscious ideas may exist with a lesser emotional impact in nondysfunctional persons. In fact, some of these fears are temporarily present during the usual course of child development. Conflicts: The intrapsychic causes of dysfunction are usually conceptualized in terms of conflict. The conscience can produce various inhibitions when self-expectations are offended by a person's sexual behavior or choice in partners (11, 12). A related but more subtle and baffling series of unconscious conflicts underlie some dysfunctions (13, 14). They are usually referred to as Oedipal conflicts because, when examined in intensive psychotherapies, earlier appropriate son-mother or daughter-father attachments are seen to have been inappropriately transferred into the marital relationship. Conflicts over agressive impulses that arise in sexual situations are also described (15). Before the advent of sexual therapy, most dysfunctions were attributed by dynamic psychiatry to Oedipal conflicts. Certainly Oedipal conflicts live on with great intensity in some persons and are the basis for their irrational fears and sexual inhibitions. But now a large body of clinical experience challenges the hypothesis that sexual problems are invariably Oedipal in origin (1,3). 452
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Developmental Influences: A more speculative way to conceptualize the intrapsychic causes of sexual anxieties is to search for those factors that account for the persistence of irrational ideas, motivate poor judgment about sexual behavior and partner choice, prevent the resolution of Oedipal conflicts, or leave the person with aggressive conflicts. These factors may not be sexual at all. They may ultimately depend on the adequacy of the child's negotiation of the psychosocial developmental stages. The identified causes in this conceptual framework derive from psychiatric common sense and may, therefore, be suspect. Impressions come from psychoanalytic work with both adults and children. A few of the many possible causes for sexual anxiety in this framework are premature separations, excessive intimacy, parental rejection, sexual trauma, and misrepresentations of reality—supported by ignorance or religious orthodoxy. Character: A more diffuse conception of the intrapsychic causes of dysfunction is the view that sexual function and dysfunction are expressions of character. Sexual life is seen as a product of past conflicts, adaptations, and capacities. Causes are discussed in terms of capacity to form relationships, maturational accomplishments, self-esteem, character style, tolerance for pleasure, energy level, and current psychologic issues facing the individual. Sexual life is viewed simply as a potential reflection of the entirety of the inner person (16). Its force of argument derives from the interrelatedness of all psychologic dimensions; it is limited, however, by its lack of specificity. These four conceptions overlap considerably. The previously discussed causal hypotheses merge with each other and with the intrapsychic causes. None of these ideas even begins to deal with the wider social forces (17-20), such as social class, subculture, and historical and economic influences, that shape sexual functioning in general. Those persons searching for a simple or rigorous explanation for sexual dysfunctions are bound to be frustrated by the complex, highly speculative nature of the subject. A Suggested Clinical Protocol for Any Sexual Dysfunction
Most physicians, especially those providing primary care, are at least occasionally consulted about a sexual dysfunction (21). A number of tasks should be accomplished in an adequate initial evaluation (not necessarily one visit) of a marital sexual problem. Such tasks differ from the usual clinical approach to symptoms only in that the physician must be comfortable thinking about, hearing about, and discussing sexual matters (22). Initial evaluation should include the following. 1. Clarification of the problem—the current specific impairment of sexual physiology and its duration should be defined. Any antecedent dysfunction should also be identified. 2. Organic influences—a search should be made for any organic factors that may be contributing to the current physiologic impairment. 3. Estimation of the strength of sexual desire—an evaluation of the current level of sexual desire is a quick way to place the dysfunction in the context of the patient's
life as a whole. Depression, expressed through a severely reduced sexual desire, is the clinician's primary differential diagnostic concern. Sexual dysfunction is but one of many ways that depressions may present. Other causes of a severely reduced or absent sexual desire include physical illness, drug effect, life crisis, extreme sexual inhibition, relationship failure, and adaptation to partner unavailability. 4. Sexual preferences—the conscious sexual preferences of the patient should be defined—that is, heterosexual, homosexual, bisexual. In addition, an inquiry should be made as to whether the spouse is the object of the patient's sexual interest. 5. Assessment of the spouse's sexual functioning— knowledge of the spouse's capacity to experience arousal and orgasm is essential to appreciate the patient's situation. 6. Characterization of the quality of the relationship— the patient should be asked to describe the marriage and his or her private plans for it. 7. Patient's view of the cause of the problem—although patients may be wholly inaccurate on this account, their opinions, directly or indirectly, lead the search for a causal factor. Careful attention to the patient's view helps to establish physician-patient rapport. 8. Formulation of a clinical plan—the patient's request for consultation implies the wish for the physician to suggest a plan. Possible plans include doing nothing further at this time, further evaluation (including the spouse), dealing with only the organic factors, personally dealing with the problem in a larger sense, informing the patient of the referral sources available, and making a specific referral. It is vitally important that the referring physician be acquainted, personally or through reputation, with the local resources for dealing with sexual problems. Skepticism about the professional background, personal integrity, and psychotherapeutic skills of sex therapists is justifiable considering the newness of the field and its potentials for patient exploitation. Referrals need not be restricted to sex therapists. Psychodynamic psychiatry has considerable experience in dealing with sex problems. ACKNOWLEDGMENTS: The author thanks Mrs. Barbara Juknialis of the Department of Community Health and David Agle, M.D., of the Department of Psychiatry for their editorial assistance. Grant support: by a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey. The opinions, conclusions, and proposals in this paper are those of the author and do not necessarily represent the views of the Robert Wood Johnson Foundation, in
whose program Dr. Levine is a Clinical Scholar specializing in sexual problems. Received 12 September 1975; revision accepted 17 November 1975. • Requests for reprints should be addressed to Stephen B. Levine, M.D., 2040 Abington Rd., Cleveland, OH 44106. References 1. MASTERS WH, JOHNSON VE: Human Sexual Inadequacy. Boston, Little, Brown and Company, 1970 2. MASTERS WH, JOHNSON VE: Human Sexual Response. Boston, Little, Brown and Company, 1966 3. KAPLAN HS: The New Sex Therapy. New York, Brunner/Mazel Publishers, 1974 4. BRENNER C: An Elementary Textbook of Psychoanalysis. New York, International Universities Press, Inc., 1955 5. RUBENSTEIN EA, GREEN R: Sex research: future directions (editorial). Arch Sexual Behav 4:481-482, 1975 6. KINSEY AC: Sexual Behavior in the Human Male. Philadelphia, W. B. Saunders Company, 1948, pp. 193-217 7. KINSEY AC: Sexual Behavior in the Human Female. Philadelphia, W. B. Saunders Company, 1953, pp. 510-564 8. PFEIFFER E: Sexual behavior in old age, in Behavior and Adaptation in Late Life, edited by BUSSE E, PFEIFFER E. Boston, Little, Brown and Company, 1969 9. COOPER AJ: Clinical and therapeutic studies in premature ejaculation. Compr Psychiatry 10:285-295, 1969 10. BIEBER I: The psychoanalytic treatment of sexual disorders. J Sex Marital Ther 1:5-15, 1974 11. STEKEL W: Impotence in the Male, vol. 2. New York, Liveright Publishing Corporation, 1927 12. STEKEL W: Frigidity in Woman, vol. 1. New York, Liveright Publishing Corporation, 1926 13. FREUD S: Psychology of love, I, in The Complete Psychological Works of Sigmund Freud, edited by STRACHEY J. London, The Hogarth Press, 1957, pp. 165-175 14. FREUD S: Psychology of love, II, in The Complete Psychological Works of Sigmund Freud, edited by STRACHEY J. London, The Hogarth Press, 1957, pp. 179-190 15. FENICHEL O: Psychoanalytic Theory of Neurosis. New York, W W Norton and Company, 1945 16. SHAINESS N : Sexual problems of women. J Sex Marital Ther 1:110-123, 1974 17. REISS IL: Heterosexual relationships of patients: premarital, marital and extramarital, in Human Sexuality: A Health Practitioner's Text, edited by GREEN R. Baltimore, The Williams and Wilkins Company, 1975, pp. 37-52 18. BELL RR: Female sexual satisfaction as related to levels of education, in Sexual Behavior—Current Issues, edited by GROSS L. New York, John Wiley and Sons, Inc., 1974, pp. 3-15 19. STAPLES R: The sexuality of black women, in Sexual Behavior— Current Issues, edited by GROSS L. New York, John Wiley and Sons, Inc., 1974, pp. 23-43 20. RAINWATER L: Some aspects of lower class sexual behavior. Med Aspects Hum Sexuality 2:15-25, 1968 21. BURNAP DW, GOLDEN JS: Sexual problems in medical practice. J Med Educ 42:673-680, 1967 22. Assessment of Sexual Function. A Guide to Interviewing. Vol. VIII. Report no. 88, Group for Advancement of Psychiatry (GAP Report), Appendix A. New York, Group for the Advancement of Psychiatry, 1973
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Marital Sexual Dysfunction: Introductory Concepts STEPHEN B. LEVINE, M.D., Cleveland, Ohio
The concepts presented in this overview of marital sexual dysfunction are derived from increasing clinical experience with couples who seek help for their sexual problems. These couples, in marked contrast to couples with good sexual functioning, usually report a steady state of emotional dissatisfaction and minimal physical pleasure from sex. The affectual and behavioral consequences of persistent dysfunction are reviewed. Sexual therapy is discussed in terms of its two elements, sensate focus and psychotherapy. The various tasks which the sexual therapist may have to accomplish with individual couples are described. Consideration is given to the specific hypotheses usually offered as explanation for sexual dysfunction—i.e., organic factors, varying degrees of relationship failure, poor communication, sexual ignorance, performance anxiety, and intrapsychic residua of past experience. A protocol for the screening physician to use in the formulation of a reasonable clinical plan for dysfunctional couples is included.
delay ejaculation, and inability to achieve orgasm. Female sexual dysfunctions include the inability to become sexually aroused, inability to become aroused to the point of orgasm, and inability to tolerate vaginal penetration. While these dysfunctions are variously labeled by different authors, they are commonly accepted as "the" sexual dysfunctions. The sexual dysfunctions, while very important, do not encompass the entire spectrum of marital sexual problems. Complaints about sexual life encountered clinically range beyond well-defined dysfunctions to include little or no desire for sex, little or no emotional pleasure from sex, an unexplained reluctance to initiate or participate in sex, and dissatisfaction with a major dimension of the partner's personality. Many of these problems seem to exist in the face of intact physiologic functioning. Some Basic Characteristics of Good Sexual Functioning
* It is quite impossible through references alone to convey the enormous influence of Masters and Johnson's contributions. Besides providing physiologic data and showing the treatability of sexual problems, they have put forth a number of concepts that have clinical usefulness and heuristic value (1, 2 ) .
Both men and women have the neurophysiologic capacity to pass through the excitement, plateau, orgasm, and resolution phases of sexual arousal (2) in a smooth, wellintegrated fashion. These physiologic events have psychologic prerequisites that are central to the understanding of marital sexual functioning. These prerequisites help to explain the universal fluctuation in quality of sexual experience. They delineate what does not happen in dysfunctional relations. They describe what therapy is aiming to help couples create in their sexual lives. The following characteristics of good sexual functioning are helpful, though incompletef. Both partners are willing to make love. Each is able to relax. Nonsexual concerns disappear from awareness. A special alteration of consciousness supervenes marked by exclusive attention to one's own and one's partner's pleasurable sensations. The concern for the partner's sensations inconspicuously results in the formation of a feedback system whereby clues from skin, breathing, posture, and utterances are used somewhat automatically to direct what happens next. The pleasure and excitement of each partner is infectious and augments the pleasure and excitement of the other. The rights of each partner to give and receive sexual pleasure, if not equal, are fully acceptable to both. Sex is completed with a high degree of personal pleasure and also with the sense of having shared a meaningful experience.
• From the Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio.
t This list is derived from clinical experience with recovering dysfunctional couples.
to sexual problems has changed considerably in the last decade*. The number of private and academic institutions and individual practitioners providing treatment for sexual problems has visibly multiplied. The traditional view that sexual problems are the legitimate and sole domain of psychiatry has changed. Other medical and nonmedical disciplines now actively participate in treatment programs. A new vocabulary for sexual problems has emerged (1). The basic term "dysfunction," only recently introduced, is already in widespread usage. The notion of an impairment of specific aspects of sexual physiology has made it unacceptable for physicians to classify all problems of function as impotence or frigidity. The delineation of specific dysfunctions has increased the possibility that separate pathogeneses will be elucidated and highly specific treatment methods can be devised. Male sexual dysfunctions include the inability to obtain an erection, inability to maintain an erection, inability to THE CLINICAL APPROACH
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When these basic ingredients are combined, the sexual experience tends to be described in superlative terms. But when achievement of one of these psychologic states is impeded, that is, when one person is not willing or cannot relax, cannot free the mind from a concern, cannot drift into the state of intense concentration on sensation, cannot perceive or give signals, or is incapable of being infected with excitement, the sexual experience invariably suffers. This does not mean that the experience is without pleasure, however. Even without these ingredients, the intense pleasure of orgasm can reliably occur. The sexual life of every couple fluctuates in the degree to which these characteristics combine. Couples come to expect that variation in pleasure is a basic characteristic of sexual life and intuitively appreciate the fact that sexual functioning is a dynamic equilibrium affected by forces from many directions. If sex is not always superlative, it sometimes is. If sex is occasionally pleasureless, it is not that way for long. The variation in the degree of physical pleasure and emotional satisfaction of couples without dysfunction contrasts to the steady state of minimal pleasure and dissatisfaction that couples seeking help for sexual problems describe. Characteristics of Dysfunctional Couples
It is very difficult for dysfunctional couples to emotionally share a sexual experience. One partner is inhibited from developing the necessary relaxed abandonment to sensation by a mental preoccupation. This preoccupation often involves some aspect of sexual physiology (erection, ejaculation, orgasm). When the partner senses the lack of excitement and involvement in pleasure produced by this preoccupation, he or she, in turn, withdraws. Sex then is reduced to a mechanical behavior devoid of emotion, which is its very essence. One person's sexual problems Invariably have profound effects on the partner. These effects are the basis for the generalization that there is no such thing as an uninvolved sexual partner (1). Certain characteristics recur often enough in help-seeking couples to provide a predictable composite of the concomitants of the dysfunctional person. 1. Avoidance of sexual behavior. Periodic hugs, caresses, kisses, and intercourse decrease in frequency. 2. Avoidance of discussing sex. The pain associated with the deterioration of sexual life is frequently dealt with by diminishing communication. This area of silence makes it harder to talk about anything. 3. Spectatoring. When sexual behavior does occur, both partners are preoccupied with how things are going. They are mentally watching the proceedings. 4. Anger. The nondysfunctional partner becomes seriously disappointed and eventually angry. At first, individuals may deny the disappointment: "Oh it really doesn't matter! I don't mind." Fault-finding may occur but often is displaced outside the bedroom by substantial issues such as child rearing and income, or by trivia. If disappointment and anger over sexual deprivation are not recognized and shared, these pent-up feelings may erupt periodically to produce ugly destructive accusations: "You frigid . . . !" "You impotent.. . !"
5. Worries of the nondysfunctional partner. The partner feels that he or she is not really loved and feels responsible for having caused the problem through personal inadequacy. 6. Decreased self-esteem of the dysfunctional partner. The individual feels incomplete as a man or woman. Shame over the dysfunction delays help-seeking, which contributes to the hopelessness and to the sense of being trapped by the problem. 7. Thoughts, fantasies, and dreams of partner substitution in both partners. Those persons who cannot accept the wish fulfilling nature of these mental activities bear an additional burden of guilt and anxiety. The hypothesis, "Maybe I wouldn't have it with somebody else," invariably occurs to the dysfunctional person. When the hypothesis is acted on, guilt over infidelity and the need for deceit further compromise the couple's capacity for spontaneous, honest communication. 8. Masturbation. The continuation of, return to, or beginning of masturbation is usually a well-kept secret and can be a source of considerable self-degradation and anger at the partner. Considering the emotionless quality of dysfunctional sex and the forces its persistence sets in motion, one can appreciate the fact that sexual dysfunction may become a burden of unhappiness, emotional isolation, and relationship failure. Yet these factors, however important, are only the end results; they do not explain the pathogenesis of sexual dysfunction. The Nature of Sexual Therapy
There are two basic elements to sexual therapy: sensate focus and "psychotherapy" (3). Sensate focus is an elegantly simple method based on the principle that sex is the totality of a couple's physical sharing, rather than just intercourse (1). The therapist(s) briefly directs the couple's sexual behavior, usually beginning by instructing them to touch and kiss each other everywhere except the breasts and genitals. This first instruction, by freeing the couple from performance worries, encourages relaxation and the drift into sensation awareness. It provides the opportunity to explore and talk about giving and receiving pleasure. The ideal end result is sexual excitement. When mastery of these tasks is achieved, the breasts and genitals are added to the areas of pleasuring. Major emphasis continues on learning about and providing for partner desires and on giving and receiving pleasure, rather than on performance. Breast and genital pleasuring usually generates a high degree of arousal; orgasm may follow through extravaginal means. The third major instruction, after good sexual functioning in noncoital modes is achieved, is to include intercourse. When sensate focus progresses smoothly, the results are hard for everyone—patients, therapist, and professional peers—to believe. A couple with a long history of dysfunction may, in the course of a few days or weeks, find sexual experience to be an easy, richly pleasurable recreation. The dysfunctional physiology is reversed. The couple grows together, having shared a very intimate process of learning about one another. Levina • Marital Sexual Dysfunction
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This ideal state, often present early in sensate focus, frequently does not last. The progress of sensate focus is blocked by other feeling states. Attention to these affects, and not the method of sensate focus itself, comprises the psychotherapy component of sex therapy ( 3 ) . Good sexual functioning cannot be achieved if the intensity, source, and meaning of these feelings are not appreciated. The presence of interfering feelings or attitudes is signaled by the couple's inability to carry out the sensate focus instructions or become emotionally involved in the sexual behavior. The major challenge for the sex therapist is essentially a psychotherapeutic one: working with persons to overcome their resistance to emotional participation in the tasks of sensate focus. The sources of resistance vary from person to person and are not always completely definable. They do, however, frequently derive from couples' nonsexual relationships, their sense of gender-appropriate sexual behavior, and their individual capacities to tolerate emotional and physical intimacy. The resistances encountered during sex therapy generate some of the current causal hypotheses explaining dysfunctions. Pathogenesis of Sexual Dysfunction
Emotional or behavioral problems are rarely attributable to a single cause. The notion of multiple determinants for any behavioral state is a basic principle of mental life ( 4 ) . A dominant cause may be defined for practical purposes. However, both normal and abnormal behavior result from a complex interaction of biology, maturation, conceptual learning, interpersonal relationships, and culture. Sex therapy emphasizes symptom reversal rather than a thorough elucidation of the causes of dysfunction. Causal factors are appreciated only insofar as they are immediately apparent from the initial history and physical examination, uncovered during therapy, or deduced by the therapist. Improved sexual functioning does not necessarily mean the causes of the problem have been determined and eradicated. The current apparent causes of a dysfunction may not be the reasons for its original appearance. Notions of causality should be regarded as hypotheses, especially since they are rarely subjected to subsequent scientific study. Current understanding of the causes of sexual dysfunction is a collage of hypotheses derived from differing schools of psychologic thought ( 3 ) . The following factors seem to be causally related to most of the dysfunctions encountered in sex therapy. They are not mutually exclusive; rather, they often blend into and complement each other in a mixture of precipitating events, current factors, and remote influences. ORGANIC FACTORS
There is much to be discovered about the organic substrate of sexual behavior. The understanding of the human endocrinology and neurophysiology of sex is in its most rudimentary phase (5). It would be clinically useful to be able to assess accurately the biological component of sexual interest. Currently, this assessment can only be derived from the individual's lifelong history of sexual expression. It is assumed that there is a considerable amount 450
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of individual variance in the constitutional aspects of sexual interest. Kinsey's (6, 7) data on the total number of orgasmic outlets from all sources over a period of time support this assumption. Such data do not, however, separate biological from environmental determinants. It would also be useful to understand specifically how aging affects sexual capacity. A sizeable minority of healthy couples in their seventies continue to enjoy an active sexual life ( 8 ) . There is also evidence that the responses of the genitals to sexual stimulation change with age ( 2 ) . But there would be great clinical usefulness in being able to discriminate between subtle endocrinic, neurologic, circulatory, and psychologic factors. Certain disease processes, specific lesions, and pharmacologic agents can profoundly affect sexual functioning. The effects of other organic factors are less clear. The mechanism of interference with sexual functioning varies from local tissue damage, peripheral or central nervous system effects, and systemic effects on energy and libido, to psychologic damage. Organic factors must be carefully sought out and scrutinized. Underestimation of their effects can lead to economically and psychologically expensive prolongation of dysfunction; overestimation may lead to premature cessation of sexual functioning. RELATIONSHIP DETERIORATION
Obvious Relationship Problems: Dysfunctional couples whose relationships are characterized by unreliability, dishonesty, and hatred are not often accepted for sex therapy. The causes of their dysfunction are assumed to be a direct product of the alienation or estrangement that has occurred in nonsexual areas. Although the alienation may have originally occurred in part because of a sexual dysfunction, severe estrangement, regardless of cause, is not treatable by sex therapy ( 3 ) . Subtle Relationship Problems: When partner alienation, that is, rejection of one spouse by the other, is perceived by neither the couple nor the clinician, its existence is soon made clear by a persistent resistance to therapy. A stable period of good sexual functioning followed by dysfunction is a clue to the presence of relationship deterioration. For most of these couples, the quality of sexual life is an accurate barometer of their nonsexual relationship. They do not need sensate focus as much as an opportunity to understand the significance of their loss of sexual responsiveness. Dissatisfaction with Specific Character Traits: Dysfunctional couples whose commitment to each other has not deteriorated often articulate complaints about nonsexual aspects of each other's personality or past behavior. Some examples include the following: "He always criticizes me," "She's too selfish," "He's insensitive," "She never understands," "He's too passive," "She's too pushy," "He avoids being close to me," "She always has to win," and so forth. These complaints are usually accurate descriptions of the partner's character traits that interfere with the couple's relationship. They are a source of disappointment, anger, and frustration to the complainer and often to the partner as well. They are not insurmountable obstacles to progress in therapy, but they do limit the emotional satisfaction
from participation. The therapist, in dealing with these couples, is occupied with recognizing these character traits, acknowledging the feelings and events that they have been responsible for, and exploring their sources and the possibilities for modifying the behavior. These activities seem to be a necessary condition for returning to focus on the sexual dysfunction. POOR COMMUNICATION AND IGNORANCE
There are couples who are troubled with dysfunction despite being generally satisfied with their nonsexual relationship. Although their problem has always been a part of their relationship, they continue to emotionally value one another. These problems often seem to be associated with a remarkable inability to talk about sex, a limited knowledge of sex, and very restrictive standards of how sexual life should be conducted (1, 3). Poor Communication: It is inherently difficult to talk about sex*. There is, in addition, a significant cultural taboo against too direct communication about the subject. If a couple has a serious problem communicating in nonsexual areas, their sexual communications are apt to be worse. Effective communication about sex requires that both partners be able to transmit and receive information about their needs and desires. Transmission depends on the capacity to recognize a need or desire, as well as the freedom and ability to communicate it. Receiving requires an awareness of the mode of transmission (often not direct statements) and a willingness to receive and to respond. Thus, a sexual communications system can be ineffective in many different ways for many different reasons. Poor communication, although a highly relevant concept in sex therapy, is a rather nonspecific causal factor that can result from a diverse group of interpersonal/intrapsychic states. Fear of emotional and physical abandonment, struggle for dominance and power, anger, low selfesteem, inability to accept one's sexuality, guilt over pleasure, fear of intimacy, generalized inarticulateness, and constricted views on how one ought to behave sexually within a marriage are only some examples. Whatever the particular cause, the therapist usually places considerable stress on improving communications. Talking together, sharing previously taboo subjects, and discovering something unknown about the spouse's feelings and preferences provide a great deal of subjective relief and hopefulness for a dysfunctional couple. Sexual Ignorance: It is hard to know precisely what to make of ignorance as a cause of dysfunction. Ignorance certainly does limit people's sexual lives, but the overriding question remains: what factors have managed to keep the couple so unknowledgeable? Dysfunctional couples are apt to be ignorant about a number of things. Lack of knowledge regarding basic details of female external genital structure is encountered in both men and women. Couples do not know each other's preference for stimulation, and what behaviors their partners would like to engage in and the places and ways they like to be touched remain mysteries. Couples do not * This phenomenon is repeatedly observed in the practice of psychiatry.
appreciate the nonvisible physiologic concomitants of sexual arousal. They do not know about their own sexual potentials in foreplay, genital play, and intercourse. These informational deficiencies are, in part, a result of a cultural lack of opportunities to learn about sexual matters. Subcultures vary considerably in their tolerance for transmission of sexual knowledge to the young. The first opportunities to learn occur in the immediate family, but later they are derived from progressively wider segments of society. A child acquires different behavioral expectations for boys and girls, which culminate in the sexual double standard. The child learns where, when, and in how much detail sexual information may be transmitted and is exposed to stereotypic idealizations of how to be sexual. There is another dimension to the explication of sexual ignorance. Some sexual ignorance is the result of an earlier need not to know. At any given time, the impact of sexual knowledge may be more than the child is equipped to handle ("My parents don't do that!"). Exposure to sexual knowledge without maturational readiness may produce confusion, anxiety, and a subsequent unwillingness to learn more. It is an oversimplification to view sexual ignorance solely as a reflection of parental failure to honestly discuss sexual matters at adolescence. The highly idiosyncratic reaction of the child must be considered. Constricted Sexual Standards: How adults acquire their sexual standards is by no means understood. The way the family handles inquiries about the anatomic differences between the sexes, the origin of babies, and relationships between the sexes has much to do with both the family's and the child's capacities to later deal with more complex issues like pubertal changes, masturbation, petting, birth control, and sexual behavior in marriage. This "sexual value system" (1), as it has recently been labeled, contains general expectations for how both genders ought to behave sexually—that is, notions about sexual normality and standards for one's personal sexual behavior. In couples whose constricted sexual value systems seem etiologically related to their dysfunction, the therapist imparts factual information, encourages an honest exchange of preferences for modes of stimulation, suggests new behavioral possibilities, and helps to establish nonstereotypic, age-appropriate expectations. INTRAPSYCHIC FACTORS
Performance Anxiety: After the recognition of a dysfunction, every couple becomes preoccupied with the question of its recurrence. The mental accompaniment of sexual behavior becomes, "When is (erection, ejaculation, penetration, excitement, orgasm) going to happen?" This concern with performance is always a problem. Occasionally it reaches the immense proportions of a marked anxiety attack, accompanied by sweating, palpitations, tachycardia, hyperventilation, nausea, fatigue, and light-headedness (9). The methods for allaying performance anxiety include authoritative advice to relax, reassurance, placebo, hypnosis, and sensate focus. These are sometimes so effective that the cause of the dysfunction seems to have been the performance concern itself. Levine • Marital Sexual Dysfunction
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Sexual failures due to anger, alcohol, fatigue, miscellaneous worries, and transient depression may occasionally trigger lasting performance concerns. But therapeutic methods do not often dramatically and completely eradicate anxiety about sexual performance. Most persons cannot be advised, reassured, tricked, suggested, or behaviorally shaped completely out of their anxieties. Moreover, careful history of the dysfunctional person's earlier sexual experiences often reveals considerable anxiety or behavioral restriction. Performance anxiety, in these cases, is the culmination of these long-standing sexual anxieties, plus the addition of more recent concerns induced by the recognition of the dysfunction. The therapist's attention is drawn to the remote sources of anxiety only because the person cannot relax enough to become aroused, even when faced with a warm, nondemanding relationship. There are many potential intrapsychic sources of anxiety in sexual situations and a number of ways to conceptualize them. Irrational Ideas: Powerful irrational ideas may continually generate anxiety in sexual situations (10). These ideas are considered causes since realizing their existence, understanding their implications, and expressing their attached feelings may lead to a dramatic improvement in sexual functioning. Several recurrent themes are involved: conscience—Sex is wrong, evil, dirty; I will be punished; loss of control—I will be swept away to a terrible but unknown fate; I will get sick or die; My very being will be engulfed; aggression—I will injure myself or injure my partner; inadequacy—My true self will be discovered; I an not a real man or a real woman; I am nothing without a penis; I am unlovable; I will be abandoned; I cannot assert myself; secret revelation—My hidden wishes and fantasies will become clear to me; My sordid past (for example, childhood experience, masturbation, promiscuity, homosexuality) will be discovered. These powerful, persistent, and sometimes unconscious ideas may exist with a lesser emotional impact in nondysfunctional persons. In fact, some of these fears are temporarily present during the usual course of child development. Conflicts: The intrapsychic causes of dysfunction are usually conceptualized in terms of conflict. The conscience can produce various inhibitions when self-expectations are offended by a person's sexual behavior or choice in partners (11, 12). A related but more subtle and baffling series of unconscious conflicts underlie some dysfunctions (13, 14). They are usually referred to as Oedipal conflicts because, when examined in intensive psychotherapies, earlier appropriate son-mother or daughter-father attachments are seen to have been inappropriately transferred into the marital relationship. Conflicts over agressive impulses that arise in sexual situations are also described (15). Before the advent of sexual therapy, most dysfunctions were attributed by dynamic psychiatry to Oedipal conflicts. Certainly Oedipal conflicts live on with great intensity in some persons and are the basis for their irrational fears and sexual inhibitions. But now a large body of clinical experience challenges the hypothesis that sexual problems are invariably Oedipal in origin (1,3). 452
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Developmental Influences: A more speculative way to conceptualize the intrapsychic causes of sexual anxieties is to search for those factors that account for the persistence of irrational ideas, motivate poor judgment about sexual behavior and partner choice, prevent the resolution of Oedipal conflicts, or leave the person with aggressive conflicts. These factors may not be sexual at all. They may ultimately depend on the adequacy of the child's negotiation of the psychosocial developmental stages. The identified causes in this conceptual framework derive from psychiatric common sense and may, therefore, be suspect. Impressions come from psychoanalytic work with both adults and children. A few of the many possible causes for sexual anxiety in this framework are premature separations, excessive intimacy, parental rejection, sexual trauma, and misrepresentations of reality—supported by ignorance or religious orthodoxy. Character: A more diffuse conception of the intrapsychic causes of dysfunction is the view that sexual function and dysfunction are expressions of character. Sexual life is seen as a product of past conflicts, adaptations, and capacities. Causes are discussed in terms of capacity to form relationships, maturational accomplishments, self-esteem, character style, tolerance for pleasure, energy level, and current psychologic issues facing the individual. Sexual life is viewed simply as a potential reflection of the entirety of the inner person (16). Its force of argument derives from the interrelatedness of all psychologic dimensions; it is limited, however, by its lack of specificity. These four conceptions overlap considerably. The previously discussed causal hypotheses merge with each other and with the intrapsychic causes. None of these ideas even begins to deal with the wider social forces (17-20), such as social class, subculture, and historical and economic influences, that shape sexual functioning in general. Those persons searching for a simple or rigorous explanation for sexual dysfunctions are bound to be frustrated by the complex, highly speculative nature of the subject. A Suggested Clinical Protocol for Any Sexual Dysfunction
Most physicians, especially those providing primary care, are at least occasionally consulted about a sexual dysfunction (21). A number of tasks should be accomplished in an adequate initial evaluation (not necessarily one visit) of a marital sexual problem. Such tasks differ from the usual clinical approach to symptoms only in that the physician must be comfortable thinking about, hearing about, and discussing sexual matters (22). Initial evaluation should include the following. 1. Clarification of the problem—the current specific impairment of sexual physiology and its duration should be defined. Any antecedent dysfunction should also be identified. 2. Organic influences—a search should be made for any organic factors that may be contributing to the current physiologic impairment. 3. Estimation of the strength of sexual desire—an evaluation of the current level of sexual desire is a quick way to place the dysfunction in the context of the patient's
life as a whole. Depression, expressed through a severely reduced sexual desire, is the clinician's primary differential diagnostic concern. Sexual dysfunction is but one of many ways that depressions may present. Other causes of a severely reduced or absent sexual desire include physical illness, drug effect, life crisis, extreme sexual inhibition, relationship failure, and adaptation to partner unavailability. 4. Sexual preferences—the conscious sexual preferences of the patient should be defined—that is, heterosexual, homosexual, bisexual. In addition, an inquiry should be made as to whether the spouse is the object of the patient's sexual interest. 5. Assessment of the spouse's sexual functioning— knowledge of the spouse's capacity to experience arousal and orgasm is essential to appreciate the patient's situation. 6. Characterization of the quality of the relationship— the patient should be asked to describe the marriage and his or her private plans for it. 7. Patient's view of the cause of the problem—although patients may be wholly inaccurate on this account, their opinions, directly or indirectly, lead the search for a causal factor. Careful attention to the patient's view helps to establish physician-patient rapport. 8. Formulation of a clinical plan—the patient's request for consultation implies the wish for the physician to suggest a plan. Possible plans include doing nothing further at this time, further evaluation (including the spouse), dealing with only the organic factors, personally dealing with the problem in a larger sense, informing the patient of the referral sources available, and making a specific referral. It is vitally important that the referring physician be acquainted, personally or through reputation, with the local resources for dealing with sexual problems. Skepticism about the professional background, personal integrity, and psychotherapeutic skills of sex therapists is justifiable considering the newness of the field and its potentials for patient exploitation. Referrals need not be restricted to sex therapists. Psychodynamic psychiatry has considerable experience in dealing with sex problems. ACKNOWLEDGMENTS: The author thanks Mrs. Barbara Juknialis of the Department of Community Health and David Agle, M.D., of the Department of Psychiatry for their editorial assistance. Grant support: by a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey. The opinions, conclusions, and proposals in this paper are those of the author and do not necessarily represent the views of the Robert Wood Johnson Foundation, in
whose program Dr. Levine is a Clinical Scholar specializing in sexual problems. Received 12 September 1975; revision accepted 17 November 1975. • Requests for reprints should be addressed to Stephen B. Levine, M.D., 2040 Abington Rd., Cleveland, OH 44106. References 1. MASTERS WH, JOHNSON VE: Human Sexual Inadequacy. Boston, Little, Brown and Company, 1970 2. MASTERS WH, JOHNSON VE: Human Sexual Response. Boston, Little, Brown and Company, 1966 3. KAPLAN HS: The New Sex Therapy. New York, Brunner/Mazel Publishers, 1974 4. BRENNER C: An Elementary Textbook of Psychoanalysis. New York, International Universities Press, Inc., 1955 5. RUBENSTEIN EA, GREEN R: Sex research: future directions (editorial). Arch Sexual Behav 4:481-482, 1975 6. KINSEY AC: Sexual Behavior in the Human Male. Philadelphia, W. B. Saunders Company, 1948, pp. 193-217 7. KINSEY AC: Sexual Behavior in the Human Female. Philadelphia, W. B. Saunders Company, 1953, pp. 510-564 8. PFEIFFER E: Sexual behavior in old age, in Behavior and Adaptation in Late Life, edited by BUSSE E, PFEIFFER E. Boston, Little, Brown and Company, 1969 9. COOPER AJ: Clinical and therapeutic studies in premature ejaculation. Compr Psychiatry 10:285-295, 1969 10. BIEBER I: The psychoanalytic treatment of sexual disorders. J Sex Marital Ther 1:5-15, 1974 11. STEKEL W: Impotence in the Male, vol. 2. New York, Liveright Publishing Corporation, 1927 12. STEKEL W: Frigidity in Woman, vol. 1. New York, Liveright Publishing Corporation, 1926 13. FREUD S: Psychology of love, I, in The Complete Psychological Works of Sigmund Freud, edited by STRACHEY J. London, The Hogarth Press, 1957, pp. 165-175 14. FREUD S: Psychology of love, II, in The Complete Psychological Works of Sigmund Freud, edited by STRACHEY J. London, The Hogarth Press, 1957, pp. 179-190 15. FENICHEL O: Psychoanalytic Theory of Neurosis. New York, W W Norton and Company, 1945 16. SHAINESS N : Sexual problems of women. J Sex Marital Ther 1:110-123, 1974 17. REISS IL: Heterosexual relationships of patients: premarital, marital and extramarital, in Human Sexuality: A Health Practitioner's Text, edited by GREEN R. Baltimore, The Williams and Wilkins Company, 1975, pp. 37-52 18. BELL RR: Female sexual satisfaction as related to levels of education, in Sexual Behavior—Current Issues, edited by GROSS L. New York, John Wiley and Sons, Inc., 1974, pp. 3-15 19. STAPLES R: The sexuality of black women, in Sexual Behavior— Current Issues, edited by GROSS L. New York, John Wiley and Sons, Inc., 1974, pp. 23-43 20. RAINWATER L: Some aspects of lower class sexual behavior. Med Aspects Hum Sexuality 2:15-25, 1968 21. BURNAP DW, GOLDEN JS: Sexual problems in medical practice. J Med Educ 42:673-680, 1967 22. Assessment of Sexual Function. A Guide to Interviewing. Vol. VIII. Report no. 88, Group for Advancement of Psychiatry (GAP Report), Appendix A. New York, Group for the Advancement of Psychiatry, 1973
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