This article was downloaded by: [Monash University Library] On: 07 January 2015, At: 18:44 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Group treatment of sexual dysfunction in men without partners Bernie Zilbergeld Ph.D.
a
a
Male Sexuality Program, Sex Counseling Unit , University of California School of Medicine , 624 Parnassus Avenue, San Francisco, California, 94143 Published online: 14 Jan 2008.
To cite this article: Bernie Zilbergeld Ph.D. (1975) Group treatment of sexual dysfunction in men without partners, Journal of Sex & Marital Therapy, 1:3, 204-214, DOI: 10.1080/00926237508405290 To link to this article: http://dx.doi.org/10.1080/00926237508405290
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 1, No. 3, Spring 1975
Group Treatment of Sexual Dysfunction in Men Without Partners
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Bernie Zilbergeld, Ph.D.
ABSTRACT: This paper describes various group techniques used to treat sexually dysfunctional men who have no regular sex partners or whose partners are unwilling or unable t o come for treatment. The relative effectiveness of two male co-leaders versus a male and female combination is also discussed. Preliminary results show that the program has been successful in achieving the goals of most of the members. Many of the men also reported favorable changes in nonsexual areas. Group treatment, therefore, does seem promising as a viable, relatively inexpensive, and efficient method of dealing with the sexual problems of men without available partners.
The “New Sex Therapy” has been applied primarily to couples. Clients are typically seen in treatment with their partners, and many clinics refuse t o treat individuals who have no partners or partners who are unable or unwilling to come for therapy.’ In the last few years, it has been increasingly recognized that sexually dysfunctional men and women without partners constitute a very large and neglected population and, further, that it is futile to tell such people not to come back for treatment until ufter they have found a partner. We have found that they simply will not attempt to form relationships until they have learned some new ways of relating to their sexuality and problems. Two main approaches have been used in treating singles: therapy with a surrogate partner for men, and sex therapy groups for women. Although there is some evidence suggesting that surrogate treatment is an effective approach for the sexual problems of partnerless men,2 it is subject to a number of limitations. It is usually very expensive relative to other forms of treatment, and is unavailable in most parts of the country. Also, some men have ethical or other objections to this type of therapy. It is therefore clear that surrogate therapy cannot meet the needs of many of the men without partners who want sex therapy.
Dr. Zilbergeld is head of the Male Sexuality Program, Sex Counseling Unit, University of California School of Medicine, 624 Parnassus Avenue, San Francisco, California 94 143.
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To meet the need for an effective and relatively inexpensive treatment modality for men without available partners, the Sex Advisory and Counseling Unit, University of California School of Medicine, San Francisco, has been conducting a pilot study of group treatment for the last year. This work was prompted in large part by the successful application of group treatment t o preorgasmic women at our Unit.3 This paper is a report of our first four groups: their nature, format, and composition; the results obtained; some of the most promising techniques used; and some of the tentative conclusions we have formulated in the process of running the groups.
PROCEDURE Four groups have been completed, and two new ones have been started. We have complete data-including a ‘%-monthfollow-up interview-only for the first group. However, the leaders have had various types of informal contact with many of the men in the other groups, and information obtained this way has been included in this report. All of the completed groups contained six or seven members and two leaders, one of whom was the author. In one group, the co-leader was female. In the other three, both co-leaders were male; in two of these, a woman sex therapist attended for 2 or 3 sessiens. The groups met for 12 2-hour sessions, usually 1 session per week, but toward the end of each group, sessions were spaced 2 or 3 weeks apart. Before the group started, prospective members were seen for a I-hour interview by one of the leaders to screen out those for whom a group might not be appropriate or who might be disruptive in a group. Only a few individuals were screened out for these reasons, but some did elect a different form of treatment (e.g., individual behavior therapy, surrogate therapy) and a few decided against any treatment. Although we refer to the men in these groups as single, or men without partners, it is important to note that there are at least three distinguishable categories of clients in our groups. One category consisted of men who, because of their sexual problem, usually avoided any but the most necessary social contacts. Several men, for example, had hardly talked t o women at all for periods ranging from 6 months to 4 years. Others in this category had dated sporadically but beat a hasty retreat into isolation when they felt sex was becoming a possibility. A second group consisted of men who were dating, and some were having sex with one or more of their companions but, because of the newness or instability of their relationships, were not willing to ask their partners to come for therapy with them. The last, and smallest, group of “single” men were not single at all. They were in relationships of 8 months’ to 18 years’ duration, but the partner was unwilling to come for couple counseling. With regard to presenting complaints, the first three groups included both premature ejaculation and erectile problems (we have not yet dealt with retarded ejaculation in a group). The fourth group and the two new ones are homogeneous with regard to problem. The basic format of the groups is similar to that of the behavior therapy groups described by Lazaruf and Fensterheim.’ Most of the communications in the group are between group members and one or both of the leaders, and most of each session is spent discussing the progress or lack of it in the homework assignments given at the last meeting, and exploring ways of dealing with the problems that arose in the course of doing the homework. As in other types of sex therapy, the practice of homework is crucial. Group and individual assignments are given. A t the first one or two sessions of a group, the same assignments are made for everyone. As the group progresses, assignments are tailored to meet the situations and needs of the various members. Toward the end of a group, members are asked to create some of their own assignments, subject to the approval of the leaders.
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GOALS We attempt to achieve two goals in the groups: first, t o correct the specific dysfunctions of the members, for example, t o help the premature ejaculator exercise more voluntary control over his ejaculatory process; and second, to assist the clients in developing the understanding and skills necessary to cope satisfactorily with a wide variety of sexual situations. Since the men are either in unstable relationships or none at all, they must look forward to new partners and new situations. Simply t o help them function better with their current partner, assuming they have one, would not be sufficient. One way in which group treatment surpasses individual treatment for partnerless men is that the group consists of people with different experiences and current situations, who provide an opportunity for vicarious learning. Thus Joe, whose only sexual experiences were those in which he took the initiative and had most of the control, learns something about a different type of sexual situation from listening to Sam, whose experiences included many in which his partners took the initiative. As the leaders work with Sam, Joe can learn new ways of relating t o this situation. If role playing is used, Joe may have a chance t o play either Sam’s partner or Sam himself. In these ways, Joe, perhaps without even being aware of any relationship between Sam’s experiences and his own, vicariously broadens his own experience and prepares himself for situations he has never before encountered.
RESULTS What follows is based on the group leaders’ evaluation of self-reports in the last group sessions, and formal and informal self-reports made at varying times after the termination of treatment. Almost all of the clients benefited. Approximately two-thirds felt they had completely achieved their goals by the end of therapy. These gains were maintained or extended as time went on. Most of the remaining one-third were qualified successes by their last group session; that is, they had acquired some degree of ejaculatory control or were getting erections in appropriate situations most or some of the time, but they wanted to extend their gains and feel more confident. For all those in this category for whom we have follow-up information, continued progress did occur. This phenomenon of consolidation and extension of progress after therapy termination is also reported by Barbach’ for women’s sex therapy groups. We are uncertain about the evaluations for a few men. Two, for example, were in long-standing relationships that were in trouble and had no sex with their partners during treatment. They completed their groups, concentrating on masturbation exercises. They both believe that when their relationships
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improve and they resume sex with their partners, they will be able to apply what they learned in the groups. We have no way of knowing whether this is wishful thinking or a real possibility. Those men who have had sex with new partners during or after treatment report that they are able to deal adequately with these new situations. Problems do, of course, arise, but group members discover that they have acquired the ability t o take the problems in stride and deal with them in ways that feel good to them, and usually t o their partners as well. Almost all the clients indicate positive change in nonsexual areas: more openness, greater ability to get what they want, feeling better about themselves, and, in general, feeling more in control of their lives. These changes parallel those reported for women’s sex therapy group^.^
MAJOR TECHNIQUES We have experimented with a wide variety of techniques and methods. Some of the most promising are described in the sections that follow.
Masturbation Masturbation exercises are relied on very heavily in our group program. Since the men usually do not have steady partners or will go through periods when they have no partner at all, masturbation is a way t o give themselves sexual satisfaction and to develop the skills they will need in a partner situation. With the premature ejaculator, masturbation is used to teach the client to focus on his penile sensations and to stop stimulation before the point of ejaculatory inevitability. We do not use Masters and Johnson’s’ squeeze technique; Semans’6 stop-start method is preferred since it is easier to teach and use and also because a man with a new partner finds it easier t o tell the partner to stop when stimulation is too intense than t o teach her the squeeze. The first step in our procedure is to masturbate, focusing all one’s attention on penile sensations. When ejaculatory inevitability is approached, stimulation is stopped. As the urge t o ejaculate subsides, stimulation is resumed. When the man can masturbate for 15 minutes-including stopswithout ejaculating, and feels confident that he is sufficiently in touch with his sexual response cycle to sustain high levels of excitement without having to ejaculate, he moves on to the next step of masturbating using lotion or oil. If the man has a partner when this step is mastered, they proceed to the next step, partner stimulation with dry hand. For those without partners, we introduce the use of fantasy. One method is to have them fantasize doing the remaining steps (partner stimulation, vaginal containment, etc.) with a partner. Throughout, they are to stop before ejaculatory inevitability. Another
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technique involves masturbating to a fantasy of a complete sexual experience, from the first kiss to whatever the last step would be for that particular person. After this, a type of flooding fantasy is employed, where masturbation is accompanied by images of anxiety-laden situations (for premature ejaculators usually the moment of insertion or the feeling accompanying ejaculating prematurely constitutes a peak anxiety point). For men with erectile problems, we use other types of masturbation exercises. One of the simplest is having the client stop at some point during self-stimulation and lose his erection; he then resumes stimulation and, in most cases, regains his erection. This experience, if repeated often enough, serves t o teach the man that a lost erection need not be catastrophic and that, with proper stimulation, it can usually be regained. As with the premature ejaculator, the impotent man is taught t o focus on the sensations in his penis while masturbating. This exercise is designed t o divert attention away from obsessive concerns about his erection or lack of it. He is told repeatedly that it is of little concern whether or not he gets an erection, the only important point being his ability to be aware of whatever sensations occur in his penis. We have found that it is much easier to teach this type of focusing with masturbation than during sex with a partner. After he has learned to focus well while masturbating, he can transfer this skill t o a partner situation. If focusing on sensation is not successful, we use focusing on arousing fantasies while masturbating. After a man is confident of his ability to get and maintain an erection in the preceding exercises, we have him draw up and fantasize during masturbation a hierarchy of sexual situations that elicit anxiety in him, starting with the least anxiety provoking. We follow the standard desensitization procedure except for pairing the images with home sessions of masturbation. At the first sign of anxiety, the client stops masturbating and focuses on a relaxing image. The process continues until he is able to masturbate without any anxiety while visualizing the images highest on the hierhchy. Thus, sexual arousal is paired with images of situations that formerly inhibited sexual response in the natural environment. These exercises appear to be highly effective in helping the men t o “develop friendly relations with their penises” (a goal they are unable to accomplish at the beginning of treatment) and to progress on their own toward solving their problems. Contrary t o some reports in the literature,? we have found that a man who has successfully gone through these exercises has gone a long way toward resolving the sexual problems he faces in a partner situation.
Self-Disclosure Many dysfunctional men we have seen try to solve their problem by hiding its existence and their anxiety about it from their partners. Usually this
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“solution” serves only t o increase the pressure and the fear that the partner will discover the secret, and, therefore, it plays a large part in maintaining the problem. It is not easy for most men t o disclose their fears and failings, particularly in an area as senstivie as sex, t o partners whom they don’t know well. Yet, since we have found that hiding one’s concerns and feelings only increases the fear and the pressure t o perform well, we suggest the tactical utility of sharing feelings with partners. We do not preach openness as a moral issue, nor do we push a “total openness” approach. Rather, we suggest that one way of taking pressure off of oneself is by being open with a partner, to whatever extent one is comfortable. Sharing their sexual problems and tensions with fellow group members is a new experience for most of the clients, and usually their first chance t o test for themselves the possible benefits of sharing feelings. Self-disclosure is reinforced by the leaders, who provide a model by talking about their own feelings in the group, and about sexual problems they have had. Role playing is used extensively t o give practice in talking to another about these issues; a female co-leader is invaluable in this exercise. There is no doubt that most of the men became much more open as a result of the groups, not only with group members and sex partners but also with others, such as friends and business associates. They all agree that life is a bit better for them since they have been able to share some of their previously hidden feelings with others.
Assertive Training While much has been written about the need for helping women stand up for themselves and get what is rightfully theirs, little has been said about the need for assertive training for men. Of the men we see, most simply cannot follow their own inclinations in a sexual situation. They are so focused on pleasing their partners and being “real men” that they often have difficulty discriminating between behaviors that match their needs and compliance with demands that do not. Thus, we find men making love when they don’t want to, when they are too tense or uncomfortable t o respond fully (“She expected it, so what could I do?”), in ways they don’t like, and sometimes even with partners they find unattractive. We teach the men that they too have sexual prerogatives: the right to refuse a sexual advance (a right many men have never felt entitled to); the right t o get the type of stimulation or activity they want; the right to decide when and how they want t o respond in a sexual situation. To teach the men t o be able to handle a wide variety of situations in an assertive way, we begin by having the members pair up t o do a basic exercise. In the session they are required to react to 15 t o 20 situations that men typically have trouble with (e.g., “being asked to make love by a date whom
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you like but whom you don’t feel ready to have sex with”; “being stimulated in a way that is uncomfortable or displeasing”; “asking t o stop in the middle of love play or intercourse”). By doing this exercise, each man learns to pinpoint areas in which he has trouble in getting what he wants. The discoveries facilitate discussion of each man’s expectations of himself, how realistic and appropriate these expectations are, and his fears of being assertive. Assertiveness homework is assigned at every group meeting, and extensive role playing is done during the sessions, usually in relation to specific problem situations encountered by the clients in the course of doing this homework. The principles and techniques are similar to those described by Lazarus’ and Aiberti and Emmons.’ The results are striking: Almost all the men reported that they became more assertive in both sexual and nonsexual areas.
R elaxa t io n Training We have done modified versions of formal relaxation training in some of the groups, using a wide variety of methods to help the client become more aware of his tensions and to facilitate more relaxation and comfort. Since we believe that the tension produced by anxiety is antithetical to a satisfying sexual experience, we establish a blanket rule for all sexual situations, including masturbation: When you feel anxious, stop the sexual activity and do something that will allow you to get more comfortable. Among the alternatives presented for personal experimentation are: visualizing a relaxing scene; discussing feelings with the partner; doing some deep breathing; muscle relaxation, facilitated by instructional cassettes for home practice; and switching to a less anxiety-provoking type of stimulation or activity, with resumption of sexual stimulation when anxiety subsides. Debunking Male Sexual Mythology Rigid ideas learned in early life about what one must do to be a “real man” solidify into male myths. Some of the more common ones include: a man is obligated to have sex if there is a willing partner available; being strong or manly excludes the expression of feelings and fears; intercourse is the only natural or normal way to have sex, everything else being merely a prelude to this ultimate act; there can be no sex without an erection; there is something wrong with a man’s attractiveness or virility if his partner does not have coital orgasms. Trying to live up t o these myths is a major factor in producing and maintaining sexual problems, and adherence to them is a formidable obstacle to a successful resolution of existing problems. Our aim is to create questions and doubts about the utility and necessity of holding these myths, and then to present alternative ways of thinking about maleness and sexuality. A simple way of opening up this area is to
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have the group list all the things that a real man has to accomplish in a sexual situation. The absurdity of the mythology readily becomes obvious. This exercise is followed by discussions of male and female anatomy and physiology, sexual norms, and the leaders’ own experiences, the aim of which is to help members to realize that their expectations are far too high (and they always are), and that trying to live up to them is maintaining their difficulties. The debunking of male mythology continues throughout the group. As they are ready, members are urged to experiment outside the group with behavior that matches what they want to do and to comply with their partner’s requests only when they want to. The reinforcements that maintain and solidify the process begun in the group come from positive feedback from partners and new feelings about oneself. The following statement, presented in a group session, is typical: It was our second date, and I automatically started thinking about fucking her. I feel that if I don’t make at least some moves pretty soon, she’ll think I’m queer or don’t like her. But when we started making out, two things happened. I realized I wasn’t all that turned on to her, and I remembered what you [the leaders] said about not having to prove anything, that I was OK just doing whatever I wanted. So I just gave her a backrub and she gave me one, and then I went home. I felt really good about myself. I had done exactly what I wanted and it felt fine. I didn’t care if she thought I was queer. She didn’t. She said she had a good time, and I think she was being honest. I don’t know if I’ll see her again since I’m not so attracted to her as I thought at first. But I’m going to remember this. I can do what I want and not break my ass trying to live up to some standard I got from Playboy.
TENTATIVE CONCL USZONS In the course of listening and relistening to the tapes of the group sessions, talking to current and ex-group members, and discussing the procedures among the group leaders, we have reached certain tentative conclusions about what is important in doing men’s sex therapy groups. In some cases, old opinions were confinned, but other old ideas were replaced by new understandings. Of course, at this point all of our opinions are based on clinical observations of a small number of groups and must therefore be regarded as tentative. But until we have data derived from controlled experimental studies, the following observations may serve as guidelines for those starting or planning men’s groups.
The Partner Issue We were surprised by the finding that men who are in long-standing relationships and whose partners will not come for treatment are the most resistant to change. Usually, when assigninents involving the partner are given to such men, the work is either not done or is undermined in some way. We now
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believe that in these cases the sexual problem is closely tied to broader relationship problems, and therefore the couple have difficulty working productively on sex until some of the other problems are dealt with. In any case, a disproportionate amount of group time was spent on these cases, and it has been very difficult to work on ingrained relationship problems in a group with the partner absent. We have not found a good way to deal with men in this situation. We would prefer to put them in couples’ groups, such as the one reported by Kaplan, Kohl, Pomeroy, Offit, and Hogan, but this cannot be done when the partner refuses treatment. So far, with one exception, men with uncooperative partners have stayed for the duration of their group, concentrating on exercises not involving their partners. We do not know as yet how their work in the group will affect them if and when they resume sexual relations with their partners.
Number of Sessions Necessary We now believe that the desired results can be achieved in fewer than 12 sessions, but we do not know exactly how many are required. While it is doubtful that a group of men without steady partners could achieve the dramatic 4-session cures reported by Kaplan et al.’ in a couples’ group, we think that perhaps 8 or 10 sessions might be sufficient. Narrow versus Broad Focus Upon listening for a second time to the tape recordings of the earlier groups, we realized that our focus was extremely broad: We were doing as much teaching of elementary social skills (how t o meet women, how to state one’s needs) as we were sex therapy. While some of this basic work is necessary in a group of partnerless men-some of whom have been socially isolated for months or years-we now believe that we did too much of it and that many of these skills are best learned in a different setting. (To meet the need for dealing with these issues, the Sex Counseling Unit now offers social enhancement groups, which bring together men and women who want to practice and gain confidence in the use of rudimentary social skills.) We also progressed very slowly in the homework, going through many body image and sensate focus exercises before getting t o the masturbation assignments. We now think that such extensive preliminaries are unnecessary. We believe that revising the procedures, as outlined above, would produce equivalent results in fewer sessions.
Heterogeneous versus Homogeneous Groups We have completed three mixed groups (i.e., primary complaints of impotence and premature ejaculation in the same group) and one group composed
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only of men complaining of premature ejaculation. On the basis of this small sample, we believe that homogeneous composition is preferable, since it appears that treatment proceeds at a faster pace when group members share the same problem. Because of this belief, our new groups are homogeneous with regard to major problems. Mixed groups are not necessarily undesirable, but they do appear to require a bit more time to achieve the same results.
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Importance of a Female Co-leader While a female co-leader is not essential for the group’s progress, group members, without exception, have agreed that the presence of a female co-leader-either on a continuous basis or as a guest for a few sessions-is highly desirable. Talking to the female co-leader provides many members with their first experience of sharing their sexual and other feelings with a woman. Many have reported that this experience helped them t o share feelings and talk about sex with the actual partners. The men have also appreciated and benefited from hearing the female therapist talk about her own sexual experiences and feelings. Many have said that they had never before heard a woman’s point of view about sex in a way they could understand and believe. As a result, they began to question some of their rigid ideas about sex. For example, one man who complained of premature ejaculation, who was able to last well over half an hour with the stop-start masturbation exercise, refused t o believe that it would be acceptable to ask a partner to stop stimulation. He was firmly convinced that women wanted a continual buildup of excitement from the first kiss to orgasm and that they would not tolerate stops or “breaks.” I was unable to make a dent in his conviction, but when a female co-leader joined the group for a few sessions he asked her how she would feel if, in the midst of intercourse, her partner said he wanted t o stop for a minute. She replied that it would be fine with her and, moreover, that most of her sexual experiences included many breaks and stops. A long conversation followed, in which he asked many questions and she talked about her own feelings and experiences, and he slowly started to question his assumptions about what women wanted. This conversation broke the ice for him. A few weeks later, he was able t o have satisfying intercourse, stopping a few times when excitement was too intense. Of course, other men might achieve the same results by hearing the male leaders talk about their experiences or by role playing female partners, but much more time would be required.
The Importance of the Group For men without partners group therapy offers several advantages over individual treatment. We have already commented on the opportunities a
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group provides for vicarious learning, a very important consideration for this population. There are also other benefits of a group. Peer understanding and support, found in many therapy groups, are operative here, too. Many ex-group members have commented on the importance t o them of hearing other normal-looking and normal-sounding men describe problems similar to their own. Strong group support and encouragement have been available for all its members, and at times one member has been able to offer comfort or useful advice to another. Another important aspect of the group is the impetus supplied when one member resolves his problem. Although there are some feelings of envy, the main result is that others now believe more firmly that change is possible, and they return to working on their own problems with renewed vigor.
REFERENCES 1. Kaplan HS: The New Sex Thempy. New York, Brunner/Mazel, 1974. 2. Masters WH,Johnson VE: Human Sexual Inadequacy. Boston; Little, Bmwn, 1970. 3. Barbach LG: Group treatment of preorgasmic women. J Sex Marit Ther 1 : 139-145, 1974. 4. Lazarus AA: Behavior therapy in groups. In GM Cazda (Ed), Basic Approaches to Group Psychothempy and Group Counseling. Springfield, 111; Charles C Thomas, 1968. 5. Fensterheim H: Behavior Therapy: Assertive training in groups. In CJ Sager & HS Kaplan (Eds), Progress in Group and Family Therapy. New York; Brunner/Mazel, 1972. 6. Semans J: Premature ejaculation: A new approach. Southern Med J 49:353-358, 1956. 7. Lazarus AA: Behavior Thempy and Beyond New York;McCraw-Hill, 1971. 8. Alberti RE,Emmons ML: YourPerfect Right. San Luis Obispo, Calif, Impact, 1974.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Group treatment of sexual dysfunction in men without partners Bernie Zilbergeld Ph.D.
a
a
Male Sexuality Program, Sex Counseling Unit , University of California School of Medicine , 624 Parnassus Avenue, San Francisco, California, 94143 Published online: 14 Jan 2008.
To cite this article: Bernie Zilbergeld Ph.D. (1975) Group treatment of sexual dysfunction in men without partners, Journal of Sex & Marital Therapy, 1:3, 204-214, DOI: 10.1080/00926237508405290 To link to this article: http://dx.doi.org/10.1080/00926237508405290
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 1, No. 3, Spring 1975
Group Treatment of Sexual Dysfunction in Men Without Partners
Downloaded by [Monash University Library] at 18:44 07 January 2015
Bernie Zilbergeld, Ph.D.
ABSTRACT: This paper describes various group techniques used to treat sexually dysfunctional men who have no regular sex partners or whose partners are unwilling or unable t o come for treatment. The relative effectiveness of two male co-leaders versus a male and female combination is also discussed. Preliminary results show that the program has been successful in achieving the goals of most of the members. Many of the men also reported favorable changes in nonsexual areas. Group treatment, therefore, does seem promising as a viable, relatively inexpensive, and efficient method of dealing with the sexual problems of men without available partners.
The “New Sex Therapy” has been applied primarily to couples. Clients are typically seen in treatment with their partners, and many clinics refuse t o treat individuals who have no partners or partners who are unable or unwilling to come for therapy.’ In the last few years, it has been increasingly recognized that sexually dysfunctional men and women without partners constitute a very large and neglected population and, further, that it is futile to tell such people not to come back for treatment until ufter they have found a partner. We have found that they simply will not attempt to form relationships until they have learned some new ways of relating to their sexuality and problems. Two main approaches have been used in treating singles: therapy with a surrogate partner for men, and sex therapy groups for women. Although there is some evidence suggesting that surrogate treatment is an effective approach for the sexual problems of partnerless men,2 it is subject to a number of limitations. It is usually very expensive relative to other forms of treatment, and is unavailable in most parts of the country. Also, some men have ethical or other objections to this type of therapy. It is therefore clear that surrogate therapy cannot meet the needs of many of the men without partners who want sex therapy.
Dr. Zilbergeld is head of the Male Sexuality Program, Sex Counseling Unit, University of California School of Medicine, 624 Parnassus Avenue, San Francisco, California 94 143.
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To meet the need for an effective and relatively inexpensive treatment modality for men without available partners, the Sex Advisory and Counseling Unit, University of California School of Medicine, San Francisco, has been conducting a pilot study of group treatment for the last year. This work was prompted in large part by the successful application of group treatment t o preorgasmic women at our Unit.3 This paper is a report of our first four groups: their nature, format, and composition; the results obtained; some of the most promising techniques used; and some of the tentative conclusions we have formulated in the process of running the groups.
PROCEDURE Four groups have been completed, and two new ones have been started. We have complete data-including a ‘%-monthfollow-up interview-only for the first group. However, the leaders have had various types of informal contact with many of the men in the other groups, and information obtained this way has been included in this report. All of the completed groups contained six or seven members and two leaders, one of whom was the author. In one group, the co-leader was female. In the other three, both co-leaders were male; in two of these, a woman sex therapist attended for 2 or 3 sessiens. The groups met for 12 2-hour sessions, usually 1 session per week, but toward the end of each group, sessions were spaced 2 or 3 weeks apart. Before the group started, prospective members were seen for a I-hour interview by one of the leaders to screen out those for whom a group might not be appropriate or who might be disruptive in a group. Only a few individuals were screened out for these reasons, but some did elect a different form of treatment (e.g., individual behavior therapy, surrogate therapy) and a few decided against any treatment. Although we refer to the men in these groups as single, or men without partners, it is important to note that there are at least three distinguishable categories of clients in our groups. One category consisted of men who, because of their sexual problem, usually avoided any but the most necessary social contacts. Several men, for example, had hardly talked t o women at all for periods ranging from 6 months to 4 years. Others in this category had dated sporadically but beat a hasty retreat into isolation when they felt sex was becoming a possibility. A second group consisted of men who were dating, and some were having sex with one or more of their companions but, because of the newness or instability of their relationships, were not willing to ask their partners to come for therapy with them. The last, and smallest, group of “single” men were not single at all. They were in relationships of 8 months’ to 18 years’ duration, but the partner was unwilling to come for couple counseling. With regard to presenting complaints, the first three groups included both premature ejaculation and erectile problems (we have not yet dealt with retarded ejaculation in a group). The fourth group and the two new ones are homogeneous with regard to problem. The basic format of the groups is similar to that of the behavior therapy groups described by Lazaruf and Fensterheim.’ Most of the communications in the group are between group members and one or both of the leaders, and most of each session is spent discussing the progress or lack of it in the homework assignments given at the last meeting, and exploring ways of dealing with the problems that arose in the course of doing the homework. As in other types of sex therapy, the practice of homework is crucial. Group and individual assignments are given. A t the first one or two sessions of a group, the same assignments are made for everyone. As the group progresses, assignments are tailored to meet the situations and needs of the various members. Toward the end of a group, members are asked to create some of their own assignments, subject to the approval of the leaders.
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GOALS We attempt to achieve two goals in the groups: first, t o correct the specific dysfunctions of the members, for example, t o help the premature ejaculator exercise more voluntary control over his ejaculatory process; and second, to assist the clients in developing the understanding and skills necessary to cope satisfactorily with a wide variety of sexual situations. Since the men are either in unstable relationships or none at all, they must look forward to new partners and new situations. Simply t o help them function better with their current partner, assuming they have one, would not be sufficient. One way in which group treatment surpasses individual treatment for partnerless men is that the group consists of people with different experiences and current situations, who provide an opportunity for vicarious learning. Thus Joe, whose only sexual experiences were those in which he took the initiative and had most of the control, learns something about a different type of sexual situation from listening to Sam, whose experiences included many in which his partners took the initiative. As the leaders work with Sam, Joe can learn new ways of relating t o this situation. If role playing is used, Joe may have a chance t o play either Sam’s partner or Sam himself. In these ways, Joe, perhaps without even being aware of any relationship between Sam’s experiences and his own, vicariously broadens his own experience and prepares himself for situations he has never before encountered.
RESULTS What follows is based on the group leaders’ evaluation of self-reports in the last group sessions, and formal and informal self-reports made at varying times after the termination of treatment. Almost all of the clients benefited. Approximately two-thirds felt they had completely achieved their goals by the end of therapy. These gains were maintained or extended as time went on. Most of the remaining one-third were qualified successes by their last group session; that is, they had acquired some degree of ejaculatory control or were getting erections in appropriate situations most or some of the time, but they wanted to extend their gains and feel more confident. For all those in this category for whom we have follow-up information, continued progress did occur. This phenomenon of consolidation and extension of progress after therapy termination is also reported by Barbach’ for women’s sex therapy groups. We are uncertain about the evaluations for a few men. Two, for example, were in long-standing relationships that were in trouble and had no sex with their partners during treatment. They completed their groups, concentrating on masturbation exercises. They both believe that when their relationships
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improve and they resume sex with their partners, they will be able to apply what they learned in the groups. We have no way of knowing whether this is wishful thinking or a real possibility. Those men who have had sex with new partners during or after treatment report that they are able to deal adequately with these new situations. Problems do, of course, arise, but group members discover that they have acquired the ability t o take the problems in stride and deal with them in ways that feel good to them, and usually t o their partners as well. Almost all the clients indicate positive change in nonsexual areas: more openness, greater ability to get what they want, feeling better about themselves, and, in general, feeling more in control of their lives. These changes parallel those reported for women’s sex therapy group^.^
MAJOR TECHNIQUES We have experimented with a wide variety of techniques and methods. Some of the most promising are described in the sections that follow.
Masturbation Masturbation exercises are relied on very heavily in our group program. Since the men usually do not have steady partners or will go through periods when they have no partner at all, masturbation is a way t o give themselves sexual satisfaction and to develop the skills they will need in a partner situation. With the premature ejaculator, masturbation is used to teach the client to focus on his penile sensations and to stop stimulation before the point of ejaculatory inevitability. We do not use Masters and Johnson’s’ squeeze technique; Semans’6 stop-start method is preferred since it is easier to teach and use and also because a man with a new partner finds it easier t o tell the partner to stop when stimulation is too intense than t o teach her the squeeze. The first step in our procedure is to masturbate, focusing all one’s attention on penile sensations. When ejaculatory inevitability is approached, stimulation is stopped. As the urge t o ejaculate subsides, stimulation is resumed. When the man can masturbate for 15 minutes-including stopswithout ejaculating, and feels confident that he is sufficiently in touch with his sexual response cycle to sustain high levels of excitement without having to ejaculate, he moves on to the next step of masturbating using lotion or oil. If the man has a partner when this step is mastered, they proceed to the next step, partner stimulation with dry hand. For those without partners, we introduce the use of fantasy. One method is to have them fantasize doing the remaining steps (partner stimulation, vaginal containment, etc.) with a partner. Throughout, they are to stop before ejaculatory inevitability. Another
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technique involves masturbating to a fantasy of a complete sexual experience, from the first kiss to whatever the last step would be for that particular person. After this, a type of flooding fantasy is employed, where masturbation is accompanied by images of anxiety-laden situations (for premature ejaculators usually the moment of insertion or the feeling accompanying ejaculating prematurely constitutes a peak anxiety point). For men with erectile problems, we use other types of masturbation exercises. One of the simplest is having the client stop at some point during self-stimulation and lose his erection; he then resumes stimulation and, in most cases, regains his erection. This experience, if repeated often enough, serves t o teach the man that a lost erection need not be catastrophic and that, with proper stimulation, it can usually be regained. As with the premature ejaculator, the impotent man is taught t o focus on the sensations in his penis while masturbating. This exercise is designed t o divert attention away from obsessive concerns about his erection or lack of it. He is told repeatedly that it is of little concern whether or not he gets an erection, the only important point being his ability to be aware of whatever sensations occur in his penis. We have found that it is much easier to teach this type of focusing with masturbation than during sex with a partner. After he has learned to focus well while masturbating, he can transfer this skill t o a partner situation. If focusing on sensation is not successful, we use focusing on arousing fantasies while masturbating. After a man is confident of his ability to get and maintain an erection in the preceding exercises, we have him draw up and fantasize during masturbation a hierarchy of sexual situations that elicit anxiety in him, starting with the least anxiety provoking. We follow the standard desensitization procedure except for pairing the images with home sessions of masturbation. At the first sign of anxiety, the client stops masturbating and focuses on a relaxing image. The process continues until he is able to masturbate without any anxiety while visualizing the images highest on the hierhchy. Thus, sexual arousal is paired with images of situations that formerly inhibited sexual response in the natural environment. These exercises appear to be highly effective in helping the men t o “develop friendly relations with their penises” (a goal they are unable to accomplish at the beginning of treatment) and to progress on their own toward solving their problems. Contrary t o some reports in the literature,? we have found that a man who has successfully gone through these exercises has gone a long way toward resolving the sexual problems he faces in a partner situation.
Self-Disclosure Many dysfunctional men we have seen try to solve their problem by hiding its existence and their anxiety about it from their partners. Usually this
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“solution” serves only t o increase the pressure and the fear that the partner will discover the secret, and, therefore, it plays a large part in maintaining the problem. It is not easy for most men t o disclose their fears and failings, particularly in an area as senstivie as sex, t o partners whom they don’t know well. Yet, since we have found that hiding one’s concerns and feelings only increases the fear and the pressure t o perform well, we suggest the tactical utility of sharing feelings with partners. We do not preach openness as a moral issue, nor do we push a “total openness” approach. Rather, we suggest that one way of taking pressure off of oneself is by being open with a partner, to whatever extent one is comfortable. Sharing their sexual problems and tensions with fellow group members is a new experience for most of the clients, and usually their first chance t o test for themselves the possible benefits of sharing feelings. Self-disclosure is reinforced by the leaders, who provide a model by talking about their own feelings in the group, and about sexual problems they have had. Role playing is used extensively t o give practice in talking to another about these issues; a female co-leader is invaluable in this exercise. There is no doubt that most of the men became much more open as a result of the groups, not only with group members and sex partners but also with others, such as friends and business associates. They all agree that life is a bit better for them since they have been able to share some of their previously hidden feelings with others.
Assertive Training While much has been written about the need for helping women stand up for themselves and get what is rightfully theirs, little has been said about the need for assertive training for men. Of the men we see, most simply cannot follow their own inclinations in a sexual situation. They are so focused on pleasing their partners and being “real men” that they often have difficulty discriminating between behaviors that match their needs and compliance with demands that do not. Thus, we find men making love when they don’t want to, when they are too tense or uncomfortable t o respond fully (“She expected it, so what could I do?”), in ways they don’t like, and sometimes even with partners they find unattractive. We teach the men that they too have sexual prerogatives: the right to refuse a sexual advance (a right many men have never felt entitled to); the right t o get the type of stimulation or activity they want; the right to decide when and how they want t o respond in a sexual situation. To teach the men t o be able to handle a wide variety of situations in an assertive way, we begin by having the members pair up t o do a basic exercise. In the session they are required to react to 15 t o 20 situations that men typically have trouble with (e.g., “being asked to make love by a date whom
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you like but whom you don’t feel ready to have sex with”; “being stimulated in a way that is uncomfortable or displeasing”; “asking t o stop in the middle of love play or intercourse”). By doing this exercise, each man learns to pinpoint areas in which he has trouble in getting what he wants. The discoveries facilitate discussion of each man’s expectations of himself, how realistic and appropriate these expectations are, and his fears of being assertive. Assertiveness homework is assigned at every group meeting, and extensive role playing is done during the sessions, usually in relation to specific problem situations encountered by the clients in the course of doing this homework. The principles and techniques are similar to those described by Lazarus’ and Aiberti and Emmons.’ The results are striking: Almost all the men reported that they became more assertive in both sexual and nonsexual areas.
R elaxa t io n Training We have done modified versions of formal relaxation training in some of the groups, using a wide variety of methods to help the client become more aware of his tensions and to facilitate more relaxation and comfort. Since we believe that the tension produced by anxiety is antithetical to a satisfying sexual experience, we establish a blanket rule for all sexual situations, including masturbation: When you feel anxious, stop the sexual activity and do something that will allow you to get more comfortable. Among the alternatives presented for personal experimentation are: visualizing a relaxing scene; discussing feelings with the partner; doing some deep breathing; muscle relaxation, facilitated by instructional cassettes for home practice; and switching to a less anxiety-provoking type of stimulation or activity, with resumption of sexual stimulation when anxiety subsides. Debunking Male Sexual Mythology Rigid ideas learned in early life about what one must do to be a “real man” solidify into male myths. Some of the more common ones include: a man is obligated to have sex if there is a willing partner available; being strong or manly excludes the expression of feelings and fears; intercourse is the only natural or normal way to have sex, everything else being merely a prelude to this ultimate act; there can be no sex without an erection; there is something wrong with a man’s attractiveness or virility if his partner does not have coital orgasms. Trying to live up t o these myths is a major factor in producing and maintaining sexual problems, and adherence to them is a formidable obstacle to a successful resolution of existing problems. Our aim is to create questions and doubts about the utility and necessity of holding these myths, and then to present alternative ways of thinking about maleness and sexuality. A simple way of opening up this area is to
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have the group list all the things that a real man has to accomplish in a sexual situation. The absurdity of the mythology readily becomes obvious. This exercise is followed by discussions of male and female anatomy and physiology, sexual norms, and the leaders’ own experiences, the aim of which is to help members to realize that their expectations are far too high (and they always are), and that trying to live up to them is maintaining their difficulties. The debunking of male mythology continues throughout the group. As they are ready, members are urged to experiment outside the group with behavior that matches what they want to do and to comply with their partner’s requests only when they want to. The reinforcements that maintain and solidify the process begun in the group come from positive feedback from partners and new feelings about oneself. The following statement, presented in a group session, is typical: It was our second date, and I automatically started thinking about fucking her. I feel that if I don’t make at least some moves pretty soon, she’ll think I’m queer or don’t like her. But when we started making out, two things happened. I realized I wasn’t all that turned on to her, and I remembered what you [the leaders] said about not having to prove anything, that I was OK just doing whatever I wanted. So I just gave her a backrub and she gave me one, and then I went home. I felt really good about myself. I had done exactly what I wanted and it felt fine. I didn’t care if she thought I was queer. She didn’t. She said she had a good time, and I think she was being honest. I don’t know if I’ll see her again since I’m not so attracted to her as I thought at first. But I’m going to remember this. I can do what I want and not break my ass trying to live up to some standard I got from Playboy.
TENTATIVE CONCL USZONS In the course of listening and relistening to the tapes of the group sessions, talking to current and ex-group members, and discussing the procedures among the group leaders, we have reached certain tentative conclusions about what is important in doing men’s sex therapy groups. In some cases, old opinions were confinned, but other old ideas were replaced by new understandings. Of course, at this point all of our opinions are based on clinical observations of a small number of groups and must therefore be regarded as tentative. But until we have data derived from controlled experimental studies, the following observations may serve as guidelines for those starting or planning men’s groups.
The Partner Issue We were surprised by the finding that men who are in long-standing relationships and whose partners will not come for treatment are the most resistant to change. Usually, when assigninents involving the partner are given to such men, the work is either not done or is undermined in some way. We now
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believe that in these cases the sexual problem is closely tied to broader relationship problems, and therefore the couple have difficulty working productively on sex until some of the other problems are dealt with. In any case, a disproportionate amount of group time was spent on these cases, and it has been very difficult to work on ingrained relationship problems in a group with the partner absent. We have not found a good way to deal with men in this situation. We would prefer to put them in couples’ groups, such as the one reported by Kaplan, Kohl, Pomeroy, Offit, and Hogan, but this cannot be done when the partner refuses treatment. So far, with one exception, men with uncooperative partners have stayed for the duration of their group, concentrating on exercises not involving their partners. We do not know as yet how their work in the group will affect them if and when they resume sexual relations with their partners.
Number of Sessions Necessary We now believe that the desired results can be achieved in fewer than 12 sessions, but we do not know exactly how many are required. While it is doubtful that a group of men without steady partners could achieve the dramatic 4-session cures reported by Kaplan et al.’ in a couples’ group, we think that perhaps 8 or 10 sessions might be sufficient. Narrow versus Broad Focus Upon listening for a second time to the tape recordings of the earlier groups, we realized that our focus was extremely broad: We were doing as much teaching of elementary social skills (how t o meet women, how to state one’s needs) as we were sex therapy. While some of this basic work is necessary in a group of partnerless men-some of whom have been socially isolated for months or years-we now believe that we did too much of it and that many of these skills are best learned in a different setting. (To meet the need for dealing with these issues, the Sex Counseling Unit now offers social enhancement groups, which bring together men and women who want to practice and gain confidence in the use of rudimentary social skills.) We also progressed very slowly in the homework, going through many body image and sensate focus exercises before getting t o the masturbation assignments. We now think that such extensive preliminaries are unnecessary. We believe that revising the procedures, as outlined above, would produce equivalent results in fewer sessions.
Heterogeneous versus Homogeneous Groups We have completed three mixed groups (i.e., primary complaints of impotence and premature ejaculation in the same group) and one group composed
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only of men complaining of premature ejaculation. On the basis of this small sample, we believe that homogeneous composition is preferable, since it appears that treatment proceeds at a faster pace when group members share the same problem. Because of this belief, our new groups are homogeneous with regard to major problems. Mixed groups are not necessarily undesirable, but they do appear to require a bit more time to achieve the same results.
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Importance of a Female Co-leader While a female co-leader is not essential for the group’s progress, group members, without exception, have agreed that the presence of a female co-leader-either on a continuous basis or as a guest for a few sessions-is highly desirable. Talking to the female co-leader provides many members with their first experience of sharing their sexual and other feelings with a woman. Many have reported that this experience helped them t o share feelings and talk about sex with the actual partners. The men have also appreciated and benefited from hearing the female therapist talk about her own sexual experiences and feelings. Many have said that they had never before heard a woman’s point of view about sex in a way they could understand and believe. As a result, they began to question some of their rigid ideas about sex. For example, one man who complained of premature ejaculation, who was able to last well over half an hour with the stop-start masturbation exercise, refused t o believe that it would be acceptable to ask a partner to stop stimulation. He was firmly convinced that women wanted a continual buildup of excitement from the first kiss to orgasm and that they would not tolerate stops or “breaks.” I was unable to make a dent in his conviction, but when a female co-leader joined the group for a few sessions he asked her how she would feel if, in the midst of intercourse, her partner said he wanted t o stop for a minute. She replied that it would be fine with her and, moreover, that most of her sexual experiences included many breaks and stops. A long conversation followed, in which he asked many questions and she talked about her own feelings and experiences, and he slowly started to question his assumptions about what women wanted. This conversation broke the ice for him. A few weeks later, he was able t o have satisfying intercourse, stopping a few times when excitement was too intense. Of course, other men might achieve the same results by hearing the male leaders talk about their experiences or by role playing female partners, but much more time would be required.
The Importance of the Group For men without partners group therapy offers several advantages over individual treatment. We have already commented on the opportunities a
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group provides for vicarious learning, a very important consideration for this population. There are also other benefits of a group. Peer understanding and support, found in many therapy groups, are operative here, too. Many ex-group members have commented on the importance t o them of hearing other normal-looking and normal-sounding men describe problems similar to their own. Strong group support and encouragement have been available for all its members, and at times one member has been able to offer comfort or useful advice to another. Another important aspect of the group is the impetus supplied when one member resolves his problem. Although there are some feelings of envy, the main result is that others now believe more firmly that change is possible, and they return to working on their own problems with renewed vigor.
REFERENCES 1. Kaplan HS: The New Sex Thempy. New York, Brunner/Mazel, 1974. 2. Masters WH,Johnson VE: Human Sexual Inadequacy. Boston; Little, Bmwn, 1970. 3. Barbach LG: Group treatment of preorgasmic women. J Sex Marit Ther 1 : 139-145, 1974. 4. Lazarus AA: Behavior therapy in groups. In GM Cazda (Ed), Basic Approaches to Group Psychothempy and Group Counseling. Springfield, 111; Charles C Thomas, 1968. 5. Fensterheim H: Behavior Therapy: Assertive training in groups. In CJ Sager & HS Kaplan (Eds), Progress in Group and Family Therapy. New York; Brunner/Mazel, 1972. 6. Semans J: Premature ejaculation: A new approach. Southern Med J 49:353-358, 1956. 7. Lazarus AA: Behavior Thempy and Beyond New York;McCraw-Hill, 1971. 8. Alberti RE,Emmons ML: YourPerfect Right. San Luis Obispo, Calif, Impact, 1974.
