Journal of Sex & Marital Therapy
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
A sexual enhancement program for elderly couples Kay F. Rowland PhD & Stephen N. Haynes PhD To cite this article: Kay F. Rowland PhD & Stephen N. Haynes PhD (1978) A sexual enhancement program for elderly couples, Journal of Sex & Marital Therapy, 4:2, 91-113, DOI: 10.1080/00926237808403010 To link to this article: http://dx.doi.org/10.1080/00926237808403010
Published online: 14 Jan 2008.
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Date: 24 October 2015, At: 23:18
Journal of Sex 8c Marital Therapy Vol. 4, No. 2, Summer 1978
A Sexual Enhancement Program for Elderly Couples
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Kay F. Rowland, PhD and Stephen N . Haynes, PhD
ABSTRACT: This study was designed to examine the effects of a group sexual enhancement program for elderly couples. Ten marital couples whose ages ranged from 5 1 to 7 1 were placed in one of three sexual enhancement groups based on their scheduling preferences. All groups followed the same format, but each was conducted by a different pair of group leaders. The sexual enhancement program was divided into three 2-week phases: (1) a pretreatment period in which there was no contact with the therapists, (2) an education phase in which subjects were provided with information on human sexual functioning in aging people in particular, and (3) a communication exercises-sexual techniques phase in which subjects were instructed on methods to improve communication and increase enjoyment of sexual contact. Following an initial interview in which the purpose of the study was explained, subjects were administered a questionnaire assessing satisfaction and frequency of sexual activities and perception of partner's sexual satisfaction. The questionnaire was readministered after the pretreatment phase, after the education phase, and 4 weeks following the end of the program. I n general, significant increases in sexual satisfaction, frequency of certain sexual activities, and positive attitudes about marital and life satisfaction were found to occur over the course of the sexual enhancement program. These significant increases occurred either during the pretreatment period or during some combination of phases.
In the past 30 years there has been a growing interest in human sexual behavior and attitudes as a topic for scientific investigation (e.g., Kaplan,' Kinsey, Pomeroy, & mar ti^^,^.^ Masters & Johnson4s5).However, little of this attention has been d.irected to the sexual functioning and satisfaction of individuals past middle age, or the elderly as they are sometimes called. As Berezin6 points out, for example, although the two Kinsey Dr. Rowland is director of the Psychosocial Clinic for People Over 65 at the Neuropsychiatric Institute of the University of California at Los Angeles. Dr. Haynes is a member of the Departent of Psychology, Southern Illinois University, Carbondale, Illinois 62901. This study was submitted in partial fulfillment of the requirements for a Ph.D. degree at the University of South Carolina. Requests for reprints may be addressed to Kay F. Rowland, Neuropsychiatric Institute, UCLA, 760 Westwood Boulevard, Los Angeles, California 90024. The authors would like to express their appreciation to Johanna Mayer, Thatcher Beaty, and Wayne Sotile for serving as group leaders and to Ernest Furchtgott, Murray Vincent, Peter Kilmann, and Will Drennen for their helpful comments on the manuscript. @ 1978 Human Sciences Press 0092-623X/78/ 1400-009 1$00.95
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report^^.^ are prodigious, out of 1,700 pages only three are devoted to this age group. Similarly, in the pioneering work of Masters and J o h n ~ o n 694 , ~ subjects were studied, but only 73 were over 50 years of age and of those only 21 were above age 60. There does seem to be a widespread belief that old age is a sexless era, or if it is not, it should be. Berezin6 in reviewing the literature on sex and old age found that many of the articles were introduced by defensive and apologetic statements. Similarly, Puner' observed that the current large number of jokes about sexual inability or disinterest of elderly people reflects the pervasive myth that sexual enjoyment is limited to the early years of life. It does seem evident from the literature that there is a decline in sexual activity and interest with old age, although patterns of stable as well as of increasing activity also o c c ~ r r .Declines ~'~ in sexuality were also apparent in a study by Cameron'O in which young, middle-aged, and old adults were compared on their responses to a questionnaire. T h e old judged themselves as being the least sexually knowledgeable, desirous, and skillful, besides possessing the least ability to perform sexually, making the fewest sexual attempts, and having the least access to sexual partners. A number of physical, social and psychological factors have been suggested as possible causes for the decline in sexual activity and interest in old age. Masters and Johnson4 found that the postmenopausal woman develops a thinning of the vaginal walls and a reduction in speed and degree of lubrication. T h e aging woman although still capable of having as many orgasms, often reports that they are usually shorter in duration and experienced as less intense. According to Masters and Johnson, the older man is slower to erect and ejaculate and the resolution phase refractory period also lengthens. Masters and Johnson caution that, while physical changes may affect sexual behavior and response, many other factors play a part in determining the sex drive and activity of aging men and women. Among these other factors is the psychological reaction of aging males to changes in their sexual f ~ n c t i o n i n g . ~ *Masters " and Johnson4 suggest that the aging male may withdraw from coital activity rather than risk repeated episodes of sexual inadequacy. Societal attitudes may also affect the frequency of sexual behavior and attitudes of the elderly. For example, the Christian teaching that sexual activity should be reserved only for the purpose of procreation and the romantic concept identifying sexual attractiveness with youth and beauty have been cited as beliefs in this society which link youth with sexual activity."-14 As many clinicians have noted, these teachings may discourage individuals from acknowledging their sexual desires and pursuing sexual activities in later year^.^*'^*'^-'^ Sexual activity in the elderly may also be limited because of the unavailability of a partner4J5 or by boredom with the partner who is available.4*'3Researchers have suggested, too, that previous sexual habits (i.e.,
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past enjoyment, interest, and frequency of sexual activities) of a couple may determine their sexual activity in old age.2*3*4 Physical health may also be a factor limiting the frequency and types of sexual behavior. Newman and N i c h o l ~ ,for ' ~ example, found that among their 250 subjects 60 to 93 years of age cessation of sexual activity was usually attributed to poor health, either of themselves or of their spouses. These authors caution, along with others (e.g., Cole,'* Scheingold 8c Wagnerlg),that the degree of limitation placed on an individual depends not only on his physical disability but also on his attitude toward it. Unfortunately, although all these factors-fears related to impotence, societal attitudes, lack of an available partner, boredom with partner, previous sexual habits, and physical disabilities-have all been cited as possible causes for declining sexual activity, there has been only one systematic investigation of the determinants of sexual behavior in elderly people. I n this study Pfeiffer and Davisz0administered a questionnaire to 502 persons between the ages of 45 and 69. They found that many diverse factors influence the level of sexual interest, frequency of sexual relations, and enjoyment derived from sexual relations. For men, greater enjoyment of past sexual experiences, more interest and frequency of sexual behaviors in the past, lower age, higher social class, and better subjective and objective health ratings were among the factors significantly positively correlated with interest, enjoyment and frequency of current sexual activity. Among women, relatively fewer variables seemed to determine the extent of sexual interest and activity. Marital status, lower age, and greater perceived enjoyment derived from sexual experience in younger years were significantly related to greater interest, enjoyment, and frequency of sexual behaviors for females. This study suggests, then, that there are many variables contributing to declining sexual activity in later years-age being only one of these. Although a decline in reported sexual activity and interest does seem to occur with old age, there have been several surveys of older people which have indicated that sexual ability and interest does continue for some into later years (DeNicola & Peruzza,zl Kinsey et al,2*3Masters & J o h n ~ o n , ~ ~ example, Newman & Nichols,15 PfeiffeP). Newman and N i c h o l ~ , 'for assessed the attitudes and activities of 250 volunteers who ranged in age from 60 to 93 years of age. Their interviews revealed that 54% of those who were married indicated that they still regularly engaged in sexual intercourse (frequency in this group ranged from three times weekly to once every other month). Still others have found that 7 out of every 10 healthy married couples over 60 years were still engaging in sexual intercourse, some into their late 80szZand that by age 75, 50% of married .~~ and Peruzza males were continuing to engage in i n t e r ~ o u r s eDeNicola have reported similar findings with Italian populations.21 Despite the high rate of sexual concerns and sometimes decreasing sexual activity of this age group, they have received little attention in the
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Journal of Sex & Marital Therapy
burgeoning field of sex therapy. A number of medical and mental health professionals have recognized the need for the extension of sex therapy to older people ( B u r n ~ i d eChartham,25 ,~~ Comfort,26Kaplan,' L e ~ i t o n , ~ ~ ,~ but there have only been two reports of Masters & J o h n ~ o n Sviland", successful treatments of elderly couples with sexual problems (Masters & J ~ h n s o n Sviland17). ,~ Evidence has been presented to support the effectiveness of group sexual treatment and enhancement for younger ~ o ~ p l e s .These ~ ~ , ~ ~ * ~ ~ programs have been designed in some cases for groups of dissatisfied couples who find their sexual lives unrewarding despite the absence of any specific sexual d y s f ~ n c t i o nand ~ ~ in others, for groups of couples who have different types of sexual dysfunction^.^^.^^ They have emphasized increasing knowledge of human sexual functioning, improving communication between partners, and training in specific sexual techniques.
PURPOSE OF STUDY T h e purpose of the present study was to examine the effects of a group sexual enhancement program for elderly couples. Because previous sexual therapy programs for elderly couples have not systematically measured improvement, this investigation was designed to assess changes in sexual satisfaction and frequency of sexual behaviors of couples participating in a three-phase sexual enhancement program. As in the sexual treatment used with groups of younger couples, the sexual enhancement program in this study emphasized increasing knowledge of human sexual functioning, improving communication between partners, and training in specific sexual techniques. However, unlike other studies of group treatment, the present investigation was designed to evaluate the effects of three components of a treatment program (pretreatment, education, and communication exercises-sexual techniques training). This study also attempted to control for therapist effects by utilizing three therapist teams. A final purpose was to allow for prediction of treatment effectiveness. Because sexual enhancement for couples past middle age represents a virtually unexplored area, the present investigation attempted to identify variables associated with response to such an intervention.
METHOD Subjects Ten marital couples whose ages ranged from 51 to 71 (average age = 59.8), recruited from the city of Columbia, South Carolina, and nearby areas, served as subjects in this
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study. Length of marriage for these couples ranged from 3 to 45 years, with a mean duration of 30.3 years.
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Recruitment. Several methods of soliciting subjects were used. The first author participated in television and radio interviews concerning the planned sexual enhancement groups and articles describing the sexual enhancement program also appeared in area newspapers. In addition, announcements of the program were placed on the bulletin boards of several high-rise apartment buildings for the elderly and in a monthly newsletter sent out by the South Carolina Council on Aging. Selection. In order to be accepted as subjects in the study, volunteers were required to have a regular sexual partner who would also agree to attend group meetings and at least one member of the couple had to be over 55 years old. Approximately 20 individuals or couples responded to the initial recruitment procedures. Of these, 13 couples met criteria for participation, but 3 couples decided not to participate. Initial Program Organization Assignment to groups. Couples were allowed to specify which group they would like to attend, choosing from three available nights. They were then placed in one of three sexual enhancement groups on the basis of their scheduling preferences with an attempt to make the groups as equal in size as possible. All three groups followed the same format, but each was conducted by a different pair of leaders. Medical consultation. A physician specializing in internal medicine consulted with the program. Although not present at any group meetings, he was available to the group leaders to answer their questions about the effects of physical problems on sexual behavior, and subjects were informed that any concerns about the effects of physical ailments on sexual activities would be referred to him. Subjects were also asked the names of their personal physicians and letters were sent notifying the physician of their participation in the group. Group leaders. T o control for therapist effects, a different male and female team conducted each of the three sexual enhancement groups, although one female was a leader for two groups. Four of the coleaders were advanced doctoral candidates in psychology and one was a clinical psychologist. Leaders received training, through seminars and readings, on sexual functioning of the elderly and on the format of the group meetings. As part of their training, each leader read the sections entitled “Geriatric Sexual Response” in Masters and Johnson’s Human Sexual Response4 and
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Journal of Sex G? Marital Therapy
“Sexual Inadequacy in the Aging Male and Female” in Human Sexual Inadequacy5. An outline of topics and/or exercises to be covered in each group meeting was also distributed and discussed with the group leaders. I n order to insure that each group followed the same format and received the same material, group leaders observed other teams through a one-way mirror at random group meetings and provided feedback to each other after the meeting.
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Program Sequence Each couple participating in the program went through the same procedure: an initial interview with the firs: author followed by the program itself, which was divided into three 2-week phases (a pretreatment phase, an education phase, and a communication exercises sexual techniques phase). The program was divided into three phases so that the independent effects of these traditional components of sexual enhancement programs could be assessed.
Initial interview. Each of the 13 volunteer couples was asked to come for an initial interview in order to learn more about the program. During this introductory meeting couples were given an explanation about the organization of the sexual enhancement program and requirements of participation. During the initial interview couples were told that the program would be free of charge as long as participation in the program was completed. T h e couples were informed that the program would be most beneficial if they attended all group meetings; in order to encourage them to complete the program, they were asked to make an initial deposit of $20. They were told that their checks would be returned uncashed after they completed the program. Of those attending, 10 couples decided to participate in the study. Pretreatment phase. Following the initial interview and testing, each couple went through a pretreatment period of 2 weeks in which there was no contact with the group leaders. Reactivity to assessment has been frequently discussed (cf., Lana,35 T h a r p & W e t ~ e l ~As ~ ) .these investigators have noted, the process of discussing, observing, or recording one’s behavior is sometimes associated with behavior change. Inclusion of this phase allowed for the assessment of changes in the subjects’ satisfaction and frequency of sexual activity in response to the initial interview, testing procedures, and anticipation of treatment. Education phase. Immediately following the pretreatment phase, subjects began a 2-week education phase in which they attended 1% hour group meetings twice a week. T h e overall goal of this portion of the program was to provide couples with information on human sexual function, in general and on sexual functioning in aging people in particular.
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Meeting 1: Attitudes about sexual interest and activity in old people were discussed. Group leaders introduced topics such as societal taboos against sexual activity among the elderly, changes in body image among the elderly, female menopause and the possibility of a male menopause, and attitudes in other countries toward sexuality in the elderly. At this meeting, couples were given a copy of an article by Dean entitled “Geriatric Sexuality: Normal, Needed, and Neglected”13 to read at home. Meeting 2: General information on sexual functioning was presented, including the anatomy and physiology of the male and female sex organs, the four stages of sexual response, and various erogenous zones. Meeting 3: This meeting focused on physical changes with aging and their effects on sexual responsiveness. For males, the longer and more intense stimulation required for erection and ejaculation, longer refractory period between erections, and less forceful ejaculate were noted. Changes cited for females included the slower occurrence of vaginal lubrication, smaller amount of lubrication, and decreased intensity of orgasms. Meeting 4:T h e topic was physical illnesses, operations, and drugs and their effect on sexual function. Conditions such as heart disease, sexsteriod starvation, prostate trouble, fatigue, hysterectomy, excessive intake of food or alcohol, and diabetes were discussed in terms of their effect on sexual interest and activity. Following the fourth and final meeting of the education phase, there was a 1-week period of no meetings. This period between phases was included to allow time for changes in behavior resulting from the education phase to occur before beginning the third phase.
Communication exercises-sexual technique phase. After a 1-week period of no group meetings at the end of the education phase, subjects began the communication exercises-sexual techniques phase. During this phase, which provided exercises designed to improve communication and training in sexual techniques, subjects again attended 1% hour group meetings twice a week for weeks. Meeting 5: This meeting began with the verbal disinhibition exercise used by LoPiccolo and Miller.32 In this exercise, the leaders supply the participants with a verbal list of common sexual terms (such as “penis,” “vagina,” and “intercourse”)and the participants respond to each term by saying common synonyms. Finally, techniques used in foreplay such as kissing, caressing, breast manipulation, oral and manual manipulation of the genitals were presented, based on a chapter entitled “Techniques in ’ a home exercise, Sexual Arousal” in Human Sexuality by M ~ C a r y . ~As couples were urged to engage in two petting sessions before the next meeting, with each partner initiating a session. They were instructed to begin by caressing and kissing each other while fully clothed and to continue this activity until both felt comfortable and free of anxiety.
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Journal of Sex L9 Marital Therapy
Meeting 6: Following a procedure described by Sviland,I7couples were encouraged to increase physical attractiveness and relearn flirtation techniques. Subjects were encouraged to define explicit attire and mannerisms for themselves which would increase erotic attraction. It was explained that sexual fantasies could also be used to increase interest in sexual interactions. T h e therapists read aloud to the group sexual fantasies from Friday's My Secret Garden3s and Forbidden Flowers39 as examples. As a home exercise, subjects were told to write, in detail, their ideal sexual or romantic fantasy, then to spend 30 minutes discussing their fantasies with each other. Meeting 7 : Leaders discussed how to increase pleasuring and sensitivity by sensate ~ O C U S In . ~ addition to providing specific instructions on how to proceed with the exercises, group leaders also focused on how to give effective feedback during sexual activity. Couples were asked to spend 30 minutes a day before the next meeting engaging in sensate focus without genital touching. Meeting 8: Reactions to sensate focus were elicited in this session. Also, Xeroxed diagrams of positions for genital caressing and positions for sexual intercourse were presented, with the advantages for each position being noted. A t this time couples were encouraged to continue practicing sensate focus including genital touch. Measures Questionnaires were administered at the initial interview, at the beginning of the education phase, at the beginning of the communication exercises-sexual techniques phase, and 4 weeks following the termination of the program. T h e Sexual Interaction Inventory (SII)4"was administered on all four occasions, a preliminary questionnaire was added at the initial interview, and at the final testing a follow-up questionnaire and a personal evaluation of treatment form were also given. At each testing couples were instructed to fill out the questionnaires independent of their partner so that their individual perceptions could be determined. After the final testing each couple was informally interviewed to determine their subjective reactions to the program (e.g., which part of the program had been perceived as most and least helpful, most and least enjoyable, etc.). T h e preliminary questionnaire administered to each subject at the end of the initial interview asked for information about marital history, present sexual functioning, current physical illnesses, and sexual attitudes. Th e Sexual Interaction Inventory was administered to each subject at the end of the initial interview, at the beginning of the first meeting in each phase of the program (Meetings 1 and 5 ) and 4 weeks after the program ended, before a follow-up interview. T h e SII is a self-report inventory for assessing the sexual adjustment and sexual satisfaction of heterosexual couples.40 I t consists of a list of 17 heterosexual behaviors, ranging from seeing the partner nude to sexual intercourse with both partners having orgasms. For each behavior the male and female separately answer six questions on a 6-point rating scale with verbal labels. Responses from each member of a couple are summed across all 17 behaviors, and these totals are used to derive an 1I-scale profile. T h e I 1 scales obtained from the SII are as follows: male frequency dissatisfaction, male self-acceptance (the differences between the male's current rating of pleasure obtained from each of the 17 behaviors and his rating of how pleasurable he would like the activity to be), male
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pleasure mean (a global measure of how much pleasure the male is obtaining from sexual activity), male perceptual accuracy of female (how accurately the male knows which particular sexual activities are pleasurable for the female), male acceptance of female (how much the male sees the female as responsive o r deriving pleasure from sexual activity), total disagreement (a summary score, indicating the total disharmony and dissatisfaction in the sexual relationship), female frequency dissatisfaction, female self-acceptance, female pleasure mean, female perceptual accuracy of male, and female acceptance of male. T h e SII scales have been shown to be generally internally consistent, reliable on retest, able to discriminate clients from nonclients, and correlated with self-report of sexual ad ju ~tme n t.~Research " has also demonstrated that the SII is reactive to treatment.32*40 O n the bottom of the SII couples were asked to indicate the frequency with which they had engaged in the 17 sexual behaviors in the past week. Thus, weekly rates of sexual activities were obtained at each of the four testings. Finally, a questionnaire containing the same attitudinal items as the preliminary questionnaire and a personal evaluation of treatment form in which subjects were asked to rate the degree to which factors such as interest shown by the group leaders, homework assignments, or learning new facts contributed to any perceived improvement were administered at the time of the follow-up interview.
RESULTS Differences Between Groups in Response to Program As mentioned earlier, couples were assigned to one of three sexual enhancement groups based on their scheduling preferences. A11 three followed the same format but each was conducted by a different pair of group leaders. A repeated measures analysis of variance examining group X time interactions yielded only t w o significant interactions out of a possible 28. Of the 11 Sexual Interaction Inventory (SII) scores and the 17 sexual behavior frequency scores, only 1 SII score, female selfacceptance-F(6, 21) = 2.64,p < .05-and 1 behavior frequency, female body massage-F(6, 21) = 3.33, p < .05--were found to have significant group X time interactions. Because of a failure to find a consistent pattern of differential leader effects and because such a small number of significant group X time interactions occurred, the three groups were combined for all other statistical analyses.
Changes in Sexual Satisfaction, Attitudes, and Behavior Over Time To assess the contribution of program components, sexual satisfaction (as reflected in the SII) and frequency of sexual behaviors were measured four times over the course of the research program: (1) after the initial interview and before the pretreatment phase, (2) after the pretreatment phase and before the education phase, (3) after the education phase and before the communication exercises sexual techniques phase, and (4) after the communication exercises sexual techniques phase.
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Marital Therapy
Changes in sexual satisfaction. Examination of Table 1 reveals that for each of the SII scores, means across subjects changed in the expected direction. ‘To evaluate changes in sexual satisfaction over time, a one-way repeated measures analysis of variance of the SII variables over the four measurement times was conducted. On the main SII variable, total disagreement, designed to reflect the total amount of dissatisfaction expressed by husband and wife regarding sex, significant changes in the expected direction were found, F(3, 21) = 7.903, p < .01. In addition, significant changes in the expected direction were found for three other variables: male’s frequency dissatisfaction,F(3,21) = 6.28,p < -01:male’s perceptual accuracy of the female, F(3, 21) = 7.98, p < .01; and male’s acceptance of the female, F(3, 21) = 4.06, p < .05. Post hoc analyses of variables demonstrating significant change, by means of Duncan’s New Multiple Range Test, showed that total disagreement decreased significantly over the pretreatment period. Total
Table 1 Hean
SII Scores Acroas Treatment Pharem
Measurement t h e S I I Variable
Before Pretreatment
After Pretreatment
After Education
Exercisca-Sexual techniques
Gmmuni$!%
F-Value
Frequency dtssarisfaction,
21.3
15.6
12.4
11.9
Self acceptance, male
7.9
6.9
7. I
1.2
.2lb
Pleasure mean. male
4.56
4.52
4.5s
1.67
.83?
male
6.279**
Perceptual accuracy. male of female
22.9
20.5
18.0
16.0
7.976”
H a t e acceptance, male of
female Total dlsagreemnt
17.9
13.1
12.6
13.1
4.059.
135.8
114.8
104.9
97.6
7.903**
Frequency d i s s a t i s f a c t i o n .
female S e l f acceptance. female Pleasure mean. female
16.5
13.1
10.5
8.7
13.6
15.5
11.1
12.4
4.32
4.11
6.15
6.38
1.970 .802
1.574
Perceptual accuracy. female of male
18.8
19.0
11.7
14.9
1.633
16.9
10.9
13.5
13.4
2.09
Mate acceptance. female o f male
Note.
A
decrease i n acores represents
pleasure mean, female.
.. ‘E
< .05.
E < .Ol.
improvement on a l l v a r i a b l e s , except pleasure mean. male and
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disagreement continued to decrease over both of the other periods, with the scores at the end of the education phase and at the end of the communication exercises-sexual techniques phase also significantly lower than at the beginning of pretreatment. Similar patterns were noted for the other variables. Male’s frequency dissatisfaction was significantly lower after the education phase and after the communication exercisessexual techniques phase as compared with before the pretreatment phase. Male’s perceptual accuracy of the female was significantly changed in the expected direction after the education phase and after the communication exercises-sexual techniques phase as compared with before the pretreatment phase; significant changes in this variable also occurred between the end of pretreatment and the end of the communication exercises-sexual techniques phases. Finally, when compared with its level at the beginning of the pretreatment phase, the male’s acceptance of the female was significantly changed in the expected direction after pretreatment, after the education phase, and after the communication exercises-sexual techniques phase. Changes in frequency of sexual behaviors. Across the four measurement periods, 60% of the couples increased the total number of sexual behaviors engaged in; 40% did not change (Table 2). A one-way repeated measures analysis of variance of the behavioral frequencies showed that only one, oral-genital stimulation of the female, changed significantly: F(3, 21) = 3.71, p < .05 (Table 2). A post hoc analysis of the mean frequencies of this behavior, with Duncan’s New Multiple Range Test, indicated that female oral-genital stimulation increased significantly after the communication exercises-sexual techniques phase, as compared with its frequency both before pretreatment and after pretreatment. Changes in agreement of self-report. The accuracy of self-reported frequency of sexual behaviors was computed by a percent agreement method. That is, an agreement estimate was calculated by dividing the number of times the husband and wife agreed exactly on the frequency of each of the 17 behaviors assessed at each of the four measurement times by the total possible agreement. Agreement varied widely from couple to couple (44% to 97%), with a mean percent agreement of 73% for all couples. Mean agreement for all couples remained fairly consistent across the four measurement times, changing from 72% to 78% to 7 1% to 69%. When couples did not agree on the frequency of a behavior, the average of their reported estimates was used as the frequency for statistical analyses. Changes in attitude. Before beginning the sexual enhancement program and again 1 month after finishing, husbands and wives were asked a series of questions about their attitudes toward their own sexuality, marriage, and life. Their pre- and postprogram mean responses are shown in Table 3. Inspection of this table shows that after participation in
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Journal of Sex L3 Marital Therapy
Table 2 Wean Weekly Rates
of Sexual Behaviors
During Treatment Phases
k a s u r e m t time &crud
behavior
lerore
After
Pretreatment
Pretrertmt
After Education
After Cmunication-Exerciser-Sexual Techniques
?-Value
1.7
1.1
2.1
1.95
1.812
1.8
1.85
2.1
2.1
.916
1.4
1.2
1.75
1.5
.345
.8
.9
1.35
1.2
1.216
.6
.6
1.5
.9
1.071
2.45
2.2
2.2
2.95
.65
1.15
1.55
2.089
.I
1.45
1.8
2.88
.65
I .05
1.414
1.)
1.65
I . 365
b l e seeing the f c u l e
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Dude ?emale seeing the male nude SlS~l"9. for on.? rn1nute CODt
I nunlr-il y
Wale g l v l n p the female
body rna$=na~,p Penale g l v l n ~ , t h o n a l e a
body r n , % s a e
H a l e c.lre??ln;:
fen.al?
bren.;ts v l t h hand?
,614
Wale cares7lng f e m a l e
breasts v l t h tr,ngire
.8
Male careqfiln% female
genltal4 w l t h hands
Wale carc9sl"E
1.15
femnle
g e n l t a l q u l t h hands
orgasm
.7
.45
1.0
.8
t o orgasm
0.0
1.0
2.0
3.0
1.623
Ul""l1 1ngus
0.0
.05
.1
.L
3.709'
Cunnilingus to orgasm
0.0
.05
.I
.I5
.05
.I
.2
to
Female r a r e q . i l n g m a l e
geenltals v l t h hands Female caresslng male I l e n l t a l s ulth hands
?cll.tio
Icll.tio
.05 t o orgasm
Intcrcourae
0.0
1.25
0.0
.933
1.723
0.0
0.0
.95
1.2
1.55
1.196
.35
.5
.I5
1.662
lntercourae ulth both partners having
orgasm
.4s
Total frequency of d l s e w n 1 behaviors
14.15
12.0
18.4s
20.0
1.912
Kay F . Rowland and Stephen N . Haynes
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Tbbls 3
Prs- LO Pomt-trsatmnt Change in A t r i t ~ d e m
Pre-treatActituds
Post-treatment mean
Direction of change
1.2s
1.05
increase
1.95
2.05
increase'"
0.6
0.L
increase
female-I
female-1
ment mean
9 s s l i n f p of bcrr.ctivenesb to t h b oppomir. sex I s s l i n g s of msxubl expere m p a r a d ro othera
isnc.
of mbm
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8.li.f
bg.
and sex
in rh. i n p o r t a c e
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*** E
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
A sexual enhancement program for elderly couples Kay F. Rowland PhD & Stephen N. Haynes PhD To cite this article: Kay F. Rowland PhD & Stephen N. Haynes PhD (1978) A sexual enhancement program for elderly couples, Journal of Sex & Marital Therapy, 4:2, 91-113, DOI: 10.1080/00926237808403010 To link to this article: http://dx.doi.org/10.1080/00926237808403010
Published online: 14 Jan 2008.
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Date: 24 October 2015, At: 23:18
Journal of Sex 8c Marital Therapy Vol. 4, No. 2, Summer 1978
A Sexual Enhancement Program for Elderly Couples
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Kay F. Rowland, PhD and Stephen N . Haynes, PhD
ABSTRACT: This study was designed to examine the effects of a group sexual enhancement program for elderly couples. Ten marital couples whose ages ranged from 5 1 to 7 1 were placed in one of three sexual enhancement groups based on their scheduling preferences. All groups followed the same format, but each was conducted by a different pair of group leaders. The sexual enhancement program was divided into three 2-week phases: (1) a pretreatment period in which there was no contact with the therapists, (2) an education phase in which subjects were provided with information on human sexual functioning in aging people in particular, and (3) a communication exercises-sexual techniques phase in which subjects were instructed on methods to improve communication and increase enjoyment of sexual contact. Following an initial interview in which the purpose of the study was explained, subjects were administered a questionnaire assessing satisfaction and frequency of sexual activities and perception of partner's sexual satisfaction. The questionnaire was readministered after the pretreatment phase, after the education phase, and 4 weeks following the end of the program. I n general, significant increases in sexual satisfaction, frequency of certain sexual activities, and positive attitudes about marital and life satisfaction were found to occur over the course of the sexual enhancement program. These significant increases occurred either during the pretreatment period or during some combination of phases.
In the past 30 years there has been a growing interest in human sexual behavior and attitudes as a topic for scientific investigation (e.g., Kaplan,' Kinsey, Pomeroy, & mar ti^^,^.^ Masters & Johnson4s5).However, little of this attention has been d.irected to the sexual functioning and satisfaction of individuals past middle age, or the elderly as they are sometimes called. As Berezin6 points out, for example, although the two Kinsey Dr. Rowland is director of the Psychosocial Clinic for People Over 65 at the Neuropsychiatric Institute of the University of California at Los Angeles. Dr. Haynes is a member of the Departent of Psychology, Southern Illinois University, Carbondale, Illinois 62901. This study was submitted in partial fulfillment of the requirements for a Ph.D. degree at the University of South Carolina. Requests for reprints may be addressed to Kay F. Rowland, Neuropsychiatric Institute, UCLA, 760 Westwood Boulevard, Los Angeles, California 90024. The authors would like to express their appreciation to Johanna Mayer, Thatcher Beaty, and Wayne Sotile for serving as group leaders and to Ernest Furchtgott, Murray Vincent, Peter Kilmann, and Will Drennen for their helpful comments on the manuscript. @ 1978 Human Sciences Press 0092-623X/78/ 1400-009 1$00.95
91
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JOUTTKZ~of
Sex & Marital Therapy
report^^.^ are prodigious, out of 1,700 pages only three are devoted to this age group. Similarly, in the pioneering work of Masters and J o h n ~ o n 694 , ~ subjects were studied, but only 73 were over 50 years of age and of those only 21 were above age 60. There does seem to be a widespread belief that old age is a sexless era, or if it is not, it should be. Berezin6 in reviewing the literature on sex and old age found that many of the articles were introduced by defensive and apologetic statements. Similarly, Puner' observed that the current large number of jokes about sexual inability or disinterest of elderly people reflects the pervasive myth that sexual enjoyment is limited to the early years of life. It does seem evident from the literature that there is a decline in sexual activity and interest with old age, although patterns of stable as well as of increasing activity also o c c ~ r r .Declines ~'~ in sexuality were also apparent in a study by Cameron'O in which young, middle-aged, and old adults were compared on their responses to a questionnaire. T h e old judged themselves as being the least sexually knowledgeable, desirous, and skillful, besides possessing the least ability to perform sexually, making the fewest sexual attempts, and having the least access to sexual partners. A number of physical, social and psychological factors have been suggested as possible causes for the decline in sexual activity and interest in old age. Masters and Johnson4 found that the postmenopausal woman develops a thinning of the vaginal walls and a reduction in speed and degree of lubrication. T h e aging woman although still capable of having as many orgasms, often reports that they are usually shorter in duration and experienced as less intense. According to Masters and Johnson, the older man is slower to erect and ejaculate and the resolution phase refractory period also lengthens. Masters and Johnson caution that, while physical changes may affect sexual behavior and response, many other factors play a part in determining the sex drive and activity of aging men and women. Among these other factors is the psychological reaction of aging males to changes in their sexual f ~ n c t i o n i n g . ~ *Masters " and Johnson4 suggest that the aging male may withdraw from coital activity rather than risk repeated episodes of sexual inadequacy. Societal attitudes may also affect the frequency of sexual behavior and attitudes of the elderly. For example, the Christian teaching that sexual activity should be reserved only for the purpose of procreation and the romantic concept identifying sexual attractiveness with youth and beauty have been cited as beliefs in this society which link youth with sexual activity."-14 As many clinicians have noted, these teachings may discourage individuals from acknowledging their sexual desires and pursuing sexual activities in later year^.^*'^*'^-'^ Sexual activity in the elderly may also be limited because of the unavailability of a partner4J5 or by boredom with the partner who is available.4*'3Researchers have suggested, too, that previous sexual habits (i.e.,
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past enjoyment, interest, and frequency of sexual activities) of a couple may determine their sexual activity in old age.2*3*4 Physical health may also be a factor limiting the frequency and types of sexual behavior. Newman and N i c h o l ~ ,for ' ~ example, found that among their 250 subjects 60 to 93 years of age cessation of sexual activity was usually attributed to poor health, either of themselves or of their spouses. These authors caution, along with others (e.g., Cole,'* Scheingold 8c Wagnerlg),that the degree of limitation placed on an individual depends not only on his physical disability but also on his attitude toward it. Unfortunately, although all these factors-fears related to impotence, societal attitudes, lack of an available partner, boredom with partner, previous sexual habits, and physical disabilities-have all been cited as possible causes for declining sexual activity, there has been only one systematic investigation of the determinants of sexual behavior in elderly people. I n this study Pfeiffer and Davisz0administered a questionnaire to 502 persons between the ages of 45 and 69. They found that many diverse factors influence the level of sexual interest, frequency of sexual relations, and enjoyment derived from sexual relations. For men, greater enjoyment of past sexual experiences, more interest and frequency of sexual behaviors in the past, lower age, higher social class, and better subjective and objective health ratings were among the factors significantly positively correlated with interest, enjoyment and frequency of current sexual activity. Among women, relatively fewer variables seemed to determine the extent of sexual interest and activity. Marital status, lower age, and greater perceived enjoyment derived from sexual experience in younger years were significantly related to greater interest, enjoyment, and frequency of sexual behaviors for females. This study suggests, then, that there are many variables contributing to declining sexual activity in later years-age being only one of these. Although a decline in reported sexual activity and interest does seem to occur with old age, there have been several surveys of older people which have indicated that sexual ability and interest does continue for some into later years (DeNicola & Peruzza,zl Kinsey et al,2*3Masters & J o h n ~ o n , ~ ~ example, Newman & Nichols,15 PfeiffeP). Newman and N i c h o l ~ , 'for assessed the attitudes and activities of 250 volunteers who ranged in age from 60 to 93 years of age. Their interviews revealed that 54% of those who were married indicated that they still regularly engaged in sexual intercourse (frequency in this group ranged from three times weekly to once every other month). Still others have found that 7 out of every 10 healthy married couples over 60 years were still engaging in sexual intercourse, some into their late 80szZand that by age 75, 50% of married .~~ and Peruzza males were continuing to engage in i n t e r ~ o u r s eDeNicola have reported similar findings with Italian populations.21 Despite the high rate of sexual concerns and sometimes decreasing sexual activity of this age group, they have received little attention in the
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Journal of Sex & Marital Therapy
burgeoning field of sex therapy. A number of medical and mental health professionals have recognized the need for the extension of sex therapy to older people ( B u r n ~ i d eChartham,25 ,~~ Comfort,26Kaplan,' L e ~ i t o n , ~ ~ ,~ but there have only been two reports of Masters & J o h n ~ o n Sviland", successful treatments of elderly couples with sexual problems (Masters & J ~ h n s o n Sviland17). ,~ Evidence has been presented to support the effectiveness of group sexual treatment and enhancement for younger ~ o ~ p l e s .These ~ ~ , ~ ~ * ~ ~ programs have been designed in some cases for groups of dissatisfied couples who find their sexual lives unrewarding despite the absence of any specific sexual d y s f ~ n c t i o nand ~ ~ in others, for groups of couples who have different types of sexual dysfunction^.^^.^^ They have emphasized increasing knowledge of human sexual functioning, improving communication between partners, and training in specific sexual techniques.
PURPOSE OF STUDY T h e purpose of the present study was to examine the effects of a group sexual enhancement program for elderly couples. Because previous sexual therapy programs for elderly couples have not systematically measured improvement, this investigation was designed to assess changes in sexual satisfaction and frequency of sexual behaviors of couples participating in a three-phase sexual enhancement program. As in the sexual treatment used with groups of younger couples, the sexual enhancement program in this study emphasized increasing knowledge of human sexual functioning, improving communication between partners, and training in specific sexual techniques. However, unlike other studies of group treatment, the present investigation was designed to evaluate the effects of three components of a treatment program (pretreatment, education, and communication exercises-sexual techniques training). This study also attempted to control for therapist effects by utilizing three therapist teams. A final purpose was to allow for prediction of treatment effectiveness. Because sexual enhancement for couples past middle age represents a virtually unexplored area, the present investigation attempted to identify variables associated with response to such an intervention.
METHOD Subjects Ten marital couples whose ages ranged from 51 to 71 (average age = 59.8), recruited from the city of Columbia, South Carolina, and nearby areas, served as subjects in this
Kay F . Rowland and Stephen N . Haynes
95
study. Length of marriage for these couples ranged from 3 to 45 years, with a mean duration of 30.3 years.
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Recruitment. Several methods of soliciting subjects were used. The first author participated in television and radio interviews concerning the planned sexual enhancement groups and articles describing the sexual enhancement program also appeared in area newspapers. In addition, announcements of the program were placed on the bulletin boards of several high-rise apartment buildings for the elderly and in a monthly newsletter sent out by the South Carolina Council on Aging. Selection. In order to be accepted as subjects in the study, volunteers were required to have a regular sexual partner who would also agree to attend group meetings and at least one member of the couple had to be over 55 years old. Approximately 20 individuals or couples responded to the initial recruitment procedures. Of these, 13 couples met criteria for participation, but 3 couples decided not to participate. Initial Program Organization Assignment to groups. Couples were allowed to specify which group they would like to attend, choosing from three available nights. They were then placed in one of three sexual enhancement groups on the basis of their scheduling preferences with an attempt to make the groups as equal in size as possible. All three groups followed the same format, but each was conducted by a different pair of leaders. Medical consultation. A physician specializing in internal medicine consulted with the program. Although not present at any group meetings, he was available to the group leaders to answer their questions about the effects of physical problems on sexual behavior, and subjects were informed that any concerns about the effects of physical ailments on sexual activities would be referred to him. Subjects were also asked the names of their personal physicians and letters were sent notifying the physician of their participation in the group. Group leaders. T o control for therapist effects, a different male and female team conducted each of the three sexual enhancement groups, although one female was a leader for two groups. Four of the coleaders were advanced doctoral candidates in psychology and one was a clinical psychologist. Leaders received training, through seminars and readings, on sexual functioning of the elderly and on the format of the group meetings. As part of their training, each leader read the sections entitled “Geriatric Sexual Response” in Masters and Johnson’s Human Sexual Response4 and
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Journal of Sex G? Marital Therapy
“Sexual Inadequacy in the Aging Male and Female” in Human Sexual Inadequacy5. An outline of topics and/or exercises to be covered in each group meeting was also distributed and discussed with the group leaders. I n order to insure that each group followed the same format and received the same material, group leaders observed other teams through a one-way mirror at random group meetings and provided feedback to each other after the meeting.
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Program Sequence Each couple participating in the program went through the same procedure: an initial interview with the firs: author followed by the program itself, which was divided into three 2-week phases (a pretreatment phase, an education phase, and a communication exercises sexual techniques phase). The program was divided into three phases so that the independent effects of these traditional components of sexual enhancement programs could be assessed.
Initial interview. Each of the 13 volunteer couples was asked to come for an initial interview in order to learn more about the program. During this introductory meeting couples were given an explanation about the organization of the sexual enhancement program and requirements of participation. During the initial interview couples were told that the program would be free of charge as long as participation in the program was completed. T h e couples were informed that the program would be most beneficial if they attended all group meetings; in order to encourage them to complete the program, they were asked to make an initial deposit of $20. They were told that their checks would be returned uncashed after they completed the program. Of those attending, 10 couples decided to participate in the study. Pretreatment phase. Following the initial interview and testing, each couple went through a pretreatment period of 2 weeks in which there was no contact with the group leaders. Reactivity to assessment has been frequently discussed (cf., Lana,35 T h a r p & W e t ~ e l ~As ~ ) .these investigators have noted, the process of discussing, observing, or recording one’s behavior is sometimes associated with behavior change. Inclusion of this phase allowed for the assessment of changes in the subjects’ satisfaction and frequency of sexual activity in response to the initial interview, testing procedures, and anticipation of treatment. Education phase. Immediately following the pretreatment phase, subjects began a 2-week education phase in which they attended 1% hour group meetings twice a week. T h e overall goal of this portion of the program was to provide couples with information on human sexual function, in general and on sexual functioning in aging people in particular.
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Meeting 1: Attitudes about sexual interest and activity in old people were discussed. Group leaders introduced topics such as societal taboos against sexual activity among the elderly, changes in body image among the elderly, female menopause and the possibility of a male menopause, and attitudes in other countries toward sexuality in the elderly. At this meeting, couples were given a copy of an article by Dean entitled “Geriatric Sexuality: Normal, Needed, and Neglected”13 to read at home. Meeting 2: General information on sexual functioning was presented, including the anatomy and physiology of the male and female sex organs, the four stages of sexual response, and various erogenous zones. Meeting 3: This meeting focused on physical changes with aging and their effects on sexual responsiveness. For males, the longer and more intense stimulation required for erection and ejaculation, longer refractory period between erections, and less forceful ejaculate were noted. Changes cited for females included the slower occurrence of vaginal lubrication, smaller amount of lubrication, and decreased intensity of orgasms. Meeting 4:T h e topic was physical illnesses, operations, and drugs and their effect on sexual function. Conditions such as heart disease, sexsteriod starvation, prostate trouble, fatigue, hysterectomy, excessive intake of food or alcohol, and diabetes were discussed in terms of their effect on sexual interest and activity. Following the fourth and final meeting of the education phase, there was a 1-week period of no meetings. This period between phases was included to allow time for changes in behavior resulting from the education phase to occur before beginning the third phase.
Communication exercises-sexual technique phase. After a 1-week period of no group meetings at the end of the education phase, subjects began the communication exercises-sexual techniques phase. During this phase, which provided exercises designed to improve communication and training in sexual techniques, subjects again attended 1% hour group meetings twice a week for weeks. Meeting 5: This meeting began with the verbal disinhibition exercise used by LoPiccolo and Miller.32 In this exercise, the leaders supply the participants with a verbal list of common sexual terms (such as “penis,” “vagina,” and “intercourse”)and the participants respond to each term by saying common synonyms. Finally, techniques used in foreplay such as kissing, caressing, breast manipulation, oral and manual manipulation of the genitals were presented, based on a chapter entitled “Techniques in ’ a home exercise, Sexual Arousal” in Human Sexuality by M ~ C a r y . ~As couples were urged to engage in two petting sessions before the next meeting, with each partner initiating a session. They were instructed to begin by caressing and kissing each other while fully clothed and to continue this activity until both felt comfortable and free of anxiety.
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Journal of Sex L9 Marital Therapy
Meeting 6: Following a procedure described by Sviland,I7couples were encouraged to increase physical attractiveness and relearn flirtation techniques. Subjects were encouraged to define explicit attire and mannerisms for themselves which would increase erotic attraction. It was explained that sexual fantasies could also be used to increase interest in sexual interactions. T h e therapists read aloud to the group sexual fantasies from Friday's My Secret Garden3s and Forbidden Flowers39 as examples. As a home exercise, subjects were told to write, in detail, their ideal sexual or romantic fantasy, then to spend 30 minutes discussing their fantasies with each other. Meeting 7 : Leaders discussed how to increase pleasuring and sensitivity by sensate ~ O C U S In . ~ addition to providing specific instructions on how to proceed with the exercises, group leaders also focused on how to give effective feedback during sexual activity. Couples were asked to spend 30 minutes a day before the next meeting engaging in sensate focus without genital touching. Meeting 8: Reactions to sensate focus were elicited in this session. Also, Xeroxed diagrams of positions for genital caressing and positions for sexual intercourse were presented, with the advantages for each position being noted. A t this time couples were encouraged to continue practicing sensate focus including genital touch. Measures Questionnaires were administered at the initial interview, at the beginning of the education phase, at the beginning of the communication exercises-sexual techniques phase, and 4 weeks following the termination of the program. T h e Sexual Interaction Inventory (SII)4"was administered on all four occasions, a preliminary questionnaire was added at the initial interview, and at the final testing a follow-up questionnaire and a personal evaluation of treatment form were also given. At each testing couples were instructed to fill out the questionnaires independent of their partner so that their individual perceptions could be determined. After the final testing each couple was informally interviewed to determine their subjective reactions to the program (e.g., which part of the program had been perceived as most and least helpful, most and least enjoyable, etc.). T h e preliminary questionnaire administered to each subject at the end of the initial interview asked for information about marital history, present sexual functioning, current physical illnesses, and sexual attitudes. Th e Sexual Interaction Inventory was administered to each subject at the end of the initial interview, at the beginning of the first meeting in each phase of the program (Meetings 1 and 5 ) and 4 weeks after the program ended, before a follow-up interview. T h e SII is a self-report inventory for assessing the sexual adjustment and sexual satisfaction of heterosexual couples.40 I t consists of a list of 17 heterosexual behaviors, ranging from seeing the partner nude to sexual intercourse with both partners having orgasms. For each behavior the male and female separately answer six questions on a 6-point rating scale with verbal labels. Responses from each member of a couple are summed across all 17 behaviors, and these totals are used to derive an 1I-scale profile. T h e I 1 scales obtained from the SII are as follows: male frequency dissatisfaction, male self-acceptance (the differences between the male's current rating of pleasure obtained from each of the 17 behaviors and his rating of how pleasurable he would like the activity to be), male
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pleasure mean (a global measure of how much pleasure the male is obtaining from sexual activity), male perceptual accuracy of female (how accurately the male knows which particular sexual activities are pleasurable for the female), male acceptance of female (how much the male sees the female as responsive o r deriving pleasure from sexual activity), total disagreement (a summary score, indicating the total disharmony and dissatisfaction in the sexual relationship), female frequency dissatisfaction, female self-acceptance, female pleasure mean, female perceptual accuracy of male, and female acceptance of male. T h e SII scales have been shown to be generally internally consistent, reliable on retest, able to discriminate clients from nonclients, and correlated with self-report of sexual ad ju ~tme n t.~Research " has also demonstrated that the SII is reactive to treatment.32*40 O n the bottom of the SII couples were asked to indicate the frequency with which they had engaged in the 17 sexual behaviors in the past week. Thus, weekly rates of sexual activities were obtained at each of the four testings. Finally, a questionnaire containing the same attitudinal items as the preliminary questionnaire and a personal evaluation of treatment form in which subjects were asked to rate the degree to which factors such as interest shown by the group leaders, homework assignments, or learning new facts contributed to any perceived improvement were administered at the time of the follow-up interview.
RESULTS Differences Between Groups in Response to Program As mentioned earlier, couples were assigned to one of three sexual enhancement groups based on their scheduling preferences. A11 three followed the same format but each was conducted by a different pair of group leaders. A repeated measures analysis of variance examining group X time interactions yielded only t w o significant interactions out of a possible 28. Of the 11 Sexual Interaction Inventory (SII) scores and the 17 sexual behavior frequency scores, only 1 SII score, female selfacceptance-F(6, 21) = 2.64,p < .05-and 1 behavior frequency, female body massage-F(6, 21) = 3.33, p < .05--were found to have significant group X time interactions. Because of a failure to find a consistent pattern of differential leader effects and because such a small number of significant group X time interactions occurred, the three groups were combined for all other statistical analyses.
Changes in Sexual Satisfaction, Attitudes, and Behavior Over Time To assess the contribution of program components, sexual satisfaction (as reflected in the SII) and frequency of sexual behaviors were measured four times over the course of the research program: (1) after the initial interview and before the pretreatment phase, (2) after the pretreatment phase and before the education phase, (3) after the education phase and before the communication exercises sexual techniques phase, and (4) after the communication exercises sexual techniques phase.
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Journal
of Sex ti?
Marital Therapy
Changes in sexual satisfaction. Examination of Table 1 reveals that for each of the SII scores, means across subjects changed in the expected direction. ‘To evaluate changes in sexual satisfaction over time, a one-way repeated measures analysis of variance of the SII variables over the four measurement times was conducted. On the main SII variable, total disagreement, designed to reflect the total amount of dissatisfaction expressed by husband and wife regarding sex, significant changes in the expected direction were found, F(3, 21) = 7.903, p < .01. In addition, significant changes in the expected direction were found for three other variables: male’s frequency dissatisfaction,F(3,21) = 6.28,p < -01:male’s perceptual accuracy of the female, F(3, 21) = 7.98, p < .01; and male’s acceptance of the female, F(3, 21) = 4.06, p < .05. Post hoc analyses of variables demonstrating significant change, by means of Duncan’s New Multiple Range Test, showed that total disagreement decreased significantly over the pretreatment period. Total
Table 1 Hean
SII Scores Acroas Treatment Pharem
Measurement t h e S I I Variable
Before Pretreatment
After Pretreatment
After Education
Exercisca-Sexual techniques
Gmmuni$!%
F-Value
Frequency dtssarisfaction,
21.3
15.6
12.4
11.9
Self acceptance, male
7.9
6.9
7. I
1.2
.2lb
Pleasure mean. male
4.56
4.52
4.5s
1.67
.83?
male
6.279**
Perceptual accuracy. male of female
22.9
20.5
18.0
16.0
7.976”
H a t e acceptance, male of
female Total dlsagreemnt
17.9
13.1
12.6
13.1
4.059.
135.8
114.8
104.9
97.6
7.903**
Frequency d i s s a t i s f a c t i o n .
female S e l f acceptance. female Pleasure mean. female
16.5
13.1
10.5
8.7
13.6
15.5
11.1
12.4
4.32
4.11
6.15
6.38
1.970 .802
1.574
Perceptual accuracy. female of male
18.8
19.0
11.7
14.9
1.633
16.9
10.9
13.5
13.4
2.09
Mate acceptance. female o f male
Note.
A
decrease i n acores represents
pleasure mean, female.
.. ‘E
< .05.
E < .Ol.
improvement on a l l v a r i a b l e s , except pleasure mean. male and
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disagreement continued to decrease over both of the other periods, with the scores at the end of the education phase and at the end of the communication exercises-sexual techniques phase also significantly lower than at the beginning of pretreatment. Similar patterns were noted for the other variables. Male’s frequency dissatisfaction was significantly lower after the education phase and after the communication exercisessexual techniques phase as compared with before the pretreatment phase. Male’s perceptual accuracy of the female was significantly changed in the expected direction after the education phase and after the communication exercises-sexual techniques phase as compared with before the pretreatment phase; significant changes in this variable also occurred between the end of pretreatment and the end of the communication exercises-sexual techniques phases. Finally, when compared with its level at the beginning of the pretreatment phase, the male’s acceptance of the female was significantly changed in the expected direction after pretreatment, after the education phase, and after the communication exercises-sexual techniques phase. Changes in frequency of sexual behaviors. Across the four measurement periods, 60% of the couples increased the total number of sexual behaviors engaged in; 40% did not change (Table 2). A one-way repeated measures analysis of variance of the behavioral frequencies showed that only one, oral-genital stimulation of the female, changed significantly: F(3, 21) = 3.71, p < .05 (Table 2). A post hoc analysis of the mean frequencies of this behavior, with Duncan’s New Multiple Range Test, indicated that female oral-genital stimulation increased significantly after the communication exercises-sexual techniques phase, as compared with its frequency both before pretreatment and after pretreatment. Changes in agreement of self-report. The accuracy of self-reported frequency of sexual behaviors was computed by a percent agreement method. That is, an agreement estimate was calculated by dividing the number of times the husband and wife agreed exactly on the frequency of each of the 17 behaviors assessed at each of the four measurement times by the total possible agreement. Agreement varied widely from couple to couple (44% to 97%), with a mean percent agreement of 73% for all couples. Mean agreement for all couples remained fairly consistent across the four measurement times, changing from 72% to 78% to 7 1% to 69%. When couples did not agree on the frequency of a behavior, the average of their reported estimates was used as the frequency for statistical analyses. Changes in attitude. Before beginning the sexual enhancement program and again 1 month after finishing, husbands and wives were asked a series of questions about their attitudes toward their own sexuality, marriage, and life. Their pre- and postprogram mean responses are shown in Table 3. Inspection of this table shows that after participation in
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Journal of Sex L3 Marital Therapy
Table 2 Wean Weekly Rates
of Sexual Behaviors
During Treatment Phases
k a s u r e m t time &crud
behavior
lerore
After
Pretreatment
Pretrertmt
After Education
After Cmunication-Exerciser-Sexual Techniques
?-Value
1.7
1.1
2.1
1.95
1.812
1.8
1.85
2.1
2.1
.916
1.4
1.2
1.75
1.5
.345
.8
.9
1.35
1.2
1.216
.6
.6
1.5
.9
1.071
2.45
2.2
2.2
2.95
.65
1.15
1.55
2.089
.I
1.45
1.8
2.88
.65
I .05
1.414
1.)
1.65
I . 365
b l e seeing the f c u l e
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Dude ?emale seeing the male nude SlS~l"9. for on.? rn1nute CODt
I nunlr-il y
Wale g l v l n p the female
body rna$=na~,p Penale g l v l n ~ , t h o n a l e a
body r n , % s a e
H a l e c.lre??ln;:
fen.al?
bren.;ts v l t h hand?
,614
Wale cares7lng f e m a l e
breasts v l t h tr,ngire
.8
Male careqfiln% female
genltal4 w l t h hands
Wale carc9sl"E
1.15
femnle
g e n l t a l q u l t h hands
orgasm
.7
.45
1.0
.8
t o orgasm
0.0
1.0
2.0
3.0
1.623
Ul""l1 1ngus
0.0
.05
.1
.L
3.709'
Cunnilingus to orgasm
0.0
.05
.I
.I5
.05
.I
.2
to
Female r a r e q . i l n g m a l e
geenltals v l t h hands Female caresslng male I l e n l t a l s ulth hands
?cll.tio
Icll.tio
.05 t o orgasm
Intcrcourae
0.0
1.25
0.0
.933
1.723
0.0
0.0
.95
1.2
1.55
1.196
.35
.5
.I5
1.662
lntercourae ulth both partners having
orgasm
.4s
Total frequency of d l s e w n 1 behaviors
14.15
12.0
18.4s
20.0
1.912
Kay F . Rowland and Stephen N . Haynes
103
Tbbls 3
Prs- LO Pomt-trsatmnt Change in A t r i t ~ d e m
Pre-treatActituds
Post-treatment mean
Direction of change
1.2s
1.05
increase
1.95
2.05
increase'"
0.6
0.L
increase
female-I
female-1
ment mean
9 s s l i n f p of bcrr.ctivenesb to t h b oppomir. sex I s s l i n g s of msxubl expere m p a r a d ro othera
isnc.
of mbm
Downloaded by [Universite Laval] at 23:18 24 October 2015
8.li.f
bg.
and sex
in rh. i n p o r t a c e
of eex ro mnrriaga Opinion on vho should be t h b mbxual
aggreemor
male-8
male-2
either-11
either-1 7
..*
Earimatb of a r r m g c h of female aexu.1
desire 2.15
1.9
stronger
i n t a r e m t mhould end
5.7
5.7
no change
Sbcimfbcrion w i t h life
3.9s
2.8
increase*
2.1
2.6
increase**
as compared t o male
Opinion on vhen maxual
S.Liafe.ction
-
with marriage
A c t i t u d e a war'.
Note.
mraaursd b e f o r e the pre-rreatmcnc
pha?le (pre-
rrsaLm.mt
man) and f o u r vecks f a l l o w i n g t h e end of t h e communication
exsrcimbs
- ..ma1
techoiques phaae (post-crencmanr mean).
*** E
