The Journal of Sex Research
ISSN: 0022-4499 (Print) 1559-8519 (Online) Journal homepage: http://www.tandfonline.com/loi/hjsr20
Sex therapy in Australia N. R. Rose To cite this article: N. R. Rose (1976) Sex therapy in Australia, The Journal of Sex Research, 12:4, 330-335, DOI: 10.1080/00224497609550951 To link to this article: http://dx.doi.org/10.1080/00224497609550951
Published online: 11 Jan 2010.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hjsr20 Download by: [Monash University Library]
Date: 14 November 2015, At: 16:15
The Journal of Sex Research Vol. 12, No. 4, pp. 330-335 November, 1976
Sex Therapy in Australia
Downloaded by [Monash University Library] at 16:15 14 November 2015
N. R. ROSE* A pilot study of forty consecutive couples referred to a private psychiatric practice for the diagnosis and management of sexual problems was conducted. The couples came from a socially diverse population and exhibited a wide range of sexual disorders. Diagnosis included general sexual inhibition, orgastic failure, vaginismus, impotence and premature ejaculation. Nine couples had severe interpersonal stress and of these, only one improved. Six out of thirteen couples where neurosis or psychosis was an important factor, improved. Of the eleven couples who were free of non-sexual problems, eight became symptom-free. A variety of treatment procedures including brief sex therapy were used. Assessment of the total clinical picture rather than diagnosis of the presenting sexual problem was used in determining treatment strategies.
In discussing the treatment of sexual disorders, one is hampered by the fact that there is no generally accepted theory of the causality of these sexual disorders. The aetiology of neurosis is equally controversial. All that can be universally agreed upon is the fact that in most cases, experiential rather than constitutional factors, are responsible for disordered sexual function. The sexual functioning of one partner inevitably influences that of the other. This is the prime reason why most sex therapists try to see both partners conjointly. Although psychoanalysis offers much in the understanding of individual psychic conflict, it is limited by its traditional exclusion of the partner and by the relative lack of emphasis on interpersonal factors. Learning theory, which finds its practical application in the form of behaviour therapy, is also of value. However, some of its most ardent proponents have accepted that the relationship between therapist and patient, something which is difficult to explain solely in terms of learning theory, is of crucial importance in theory. It is difficult to imagine dealing with interpersonal conflicts and crises by a rigid, exclusive adherence to this body of theory. Marital therapy which takes into account the development of pathological relationships and the nature of interpersonal behaviour in a dyadic * Dr. N. R. Rose is a psychiatrist in private practice specializing in the treatment of sexual disorders and in individual and group psychotherapy. He is a visiting psychiatrist and the Director of the Sexual Guidance Clinic at Prince Henry's Hospital, Melbourne, Australia. 330
SEX THERAPY IN AUSTRALIA
331
Downloaded by [Monash University Library] at 16:15 14 November 2015
system also has much to offer. I would therefore agree with Helen Kaplan that no single theory or technique is appropriate in managing all sexual problems and that one should be prepared to use a combination of methods determined by the specific needs of the people one is dealing with. Patients presenting sexual complaints often have deep, underlying interpersonal and intrapersonal difficulties. Sexual dysfunctioning in such cases often represents the tip of a psychopathological iceberg. An understaning of this is crucial in determining which patients or couples are likely to respond favourably to task-oriented therapy of specific sexual problems. I am not saying that the presence of severe neurotic stress or problems between partners necessarily means that sex therapy is inappropriate, but that should sex therapy proceed, these non-sexual factors should also be dealt with during sessions in the consulting room. My own survey of forty consecutive couples referred to me for assessment and treatmet of sexual problems, revealed that nine of these or 22.5% of the sample were experiencing marital conflict of such severity that either one or both partners seriously considered separation or that one or the other was able to sabotage therapy. A further five men or 12.5% were without a partner at the time of referral. This was due to estrangement either completely or sexually from erstwhile regular partners. Two patients or 5% reported that their partners were unwilling to co-operate in treatment although the partner's physical presence was not mandatory. In thirteen couples or 32.5% of the sample, one partner was suffering from severe neurosis or psychosis. Out of the forty referrals only eleven couples or 27.5% of the sample, presented with difficulties mainly attributable to specific gaps in sexual knowledge, awareness, openness and communication. The results of treatment support the hypothesis that a healthy relationship, or the potential for developing one, is crucial for the enhancement of sexual function. Among the nine couples with severe interpersonal stress, only one sexually dysfunctioning partner, a woman in a hostile marriage, managed to improve to any degree. She originally suffered from primary orgastic failure; but now, following treatment by means of sensate focus exercises, masturbation and exploration of the marital relationship, she can occasionally have an orgasm with the help of a vibrator. There are still formidable hostile components to her marriage. Of the thirteen couples where one partner was neurotic or psychotic,
Downloaded by [Monash University Library] at 16:15 14 November 2015
332
N. R. ROSE
six couples reported relief of sexual symptoms. Three of the neurotic partners were treated by insight psychotherapy in either a group or individual situation, and three couples were successfully helped by task-oriented sex therapy. The best results were seen in the eleven couples whose difficulties were mainly sexual and where interpersonal and intrapersonal stress were minimal. Eight of these couples obtained freedom from sexual symptoms, two left treatment after only several interviews and only one couple, with a wife who found any form of physical contact with her husband abhorent, failed to improve. Of the forty couples in this study, four were from Social Class I, five from Class II, sixteen from Class III, fourteen from Class IV and one from Class V. Thus the majority of couples came from social classes which only by virtue of adequate health insurance were able to enjoy the benefits of private treatment. I might add that in early 1975, when this study was being undertaken, 90% of the Australian population were covered by compulsory Government Health Insurance which continues fees regardless of the term of treatment. 100% of the population is now covered by compulsary Government Health Insurance which continues to pay patients 85% of a medical fee which is regarded as being reasonable by an independent tribunal. It was this very tribunal which two years ago, determined that there was merit in supporting prolonged consultations to a level of 85%. Prior to 1974, lengthy psychiatric consultations enjoyed a much lower insurance benefit. Of the eleven couples with exclusively sexual problems, seven were from Class IV, two from Class III and two from Class II. This group showed as favourable a response to treatment as reported by Masters and Johnson despite the difference in Social Class, the lack of co-therapists and the less intensive non-residential treatment programme. The patients seen in this study exhibited a wide range of sexual disorders. Seven women were suffering from general sexual inhibition, five from primary orgastic failure, nine from secondary orgastic failure and two from vaginismus. Five men had primary impotence, six had secondary impotence and eleven suffered from premature ejaculation. An interesting feature of this study was the high proportion of men with premature ejaculation associated with severe interpersonal stress. All of the five men with premature ejaculation in the interpersonal stress group, left therapy. They were unable to co-operate in penile squeeze exercises. A further three men with this condition had no available
Downloaded by [Monash University Library] at 16:15 14 November 2015
SEX THERAPY IN AUSTRALIA
333
partner due to a break of their marital relationship and one more had a partner who refused to attend with him or participate in any exercises. Thus a total of nine out of eleven men presenting with premature ejaculation could not be helped by sex therapy. . , ; . These results of a pilot study suggest that both care in the selection of couples for treatment and the use of a flexible broadly-based therapy model is essential in the management of sexual disorders. In both selection and treatment, the way each couple's functions must be seen at three levels: These levels are: (1) The individual's capacity to accept, experience and communicate sexuality. (2) The quality of the relationship. (3) Neurotic or psychotic problems in one or both partners. 1. Any person's capacity for sexual enjoyment is determined by the degree to which sexual function is free of guilt and performance anxiety. Early life experiences of touching and tenderness, of the lack of these, as well as the emotional environment of the family in which that person grows up, are crucial. Many families adopt a rigid implicit censorship on sexual matters, which not only deprives the children of adequate sexual information but also gives them the idea that sex is bad. Problems in being able to openly show feelings often lead to difficulties in experiencing and expressing sexual enjoyment. 2. The relationship. Here we must consider the history and the patterns of communication between the couples. Some couples actually destroy each other's sexuality by constant bickering and by undermining each other's self-esteem. Overpossessiveness or overprotection by one partner frequently results in chronic hostility. Nobody likes to be suffocated. In some cases, by the time couples decide for therapy, the future of the marriage is already regarded as being hopeless by one partner. The wife of an inadequate impotent husband absconded with her sexually more virile and adequate brother-in-law. What is necessary for successful sex therapy is a sense of commitment by each partner to the other's welfare. The patients in my sample displayed a variety of neurotic and psychotic disorders. Two wives were suffering from schizophrenia requiring hospitalization and drug treatment. There were several severe depressives and six patients with severe personality disorders. What was interesting in this group is that several patients with severe psychiatric problems responded very well to specific treatment of sexual problems.
Downloaded by [Monash University Library] at 16:15 14 November 2015
334
.•
N.R.ROSE
One patient with suicidal depression was in intense conflict about both adolescent sexual experiences and feelings of hostility towards rejecting parents. Following symptomatic treatment of her depression, sensate focus treatment was commenced, but this had to be abandoned when she consistently rejected being touched on her genitals. Her personality problems as well as her primary orgastic failure improved only after six months of group psychotherapy in which she was enabled to see that her neurotic clinging to feelings of guilt was destroying her chances of sexual happiness and fulfilment. Before ending a few comments about task-oriented sex therapy. Most of you will be familiar with the Masters and Johnson model. Mainly for economic reasons, I do not use a cotherapist. Much of what goes on in the consulting room is taken up with discussion of the allotted tasks. Therapy is directed towards symptomatic relief of specific sexual difficulties. When marital conflict or neurosis interferes with the proper carrying out of prescribed tasks, I initiate supportive psychotherapeutic manoeuvres designed to deal exclusively with current blocks to therapy. I like to emphasize sensuality and the need to dethrone intercourse and orgasm as indispensable goals, whilst at the same time giving permission to enjoy sexuality and their physical relationship. Sensate focus exercises, more often than not, provide intense and newly discovered intimacy which is not performance oriented. What is important is each person's capacity to experience and enjoy his or her own sexual and sensual feelings. It is necessary to be selfish in experiencing sexual pleasure. This selfishness in surrendering oneself to sexual feeling rather than being overconcerned about the partner's responses inevitably heightens sexual arousal in a receptive partner. I do not regard the sensate focus programmes as inflexible. I try to structure the tasks according to the needs and sexual value system of each couple. When I do challenge strongly held values such as the idea that masturbation is sinful, I try to be supportive. Often new ideas can be introduced gently by means of hypnosis. The couples that I see appear to be a different group both in social class and in severity of psychiatric distress to those reported in the American literature. The high proportion of psychiatrically disturbed patients in my sample is a consequence of my profession and my interest in general psychiatry. I see many patients from working class backgrounds, therefore I do not see a uniform group of patients from the professional
SEX THERAPY IN AUSTRALIA
335
and managerial classes with a low incidence of marital and psychological distress as reported by American workers. My approach to sexual distress like my approach to psychiatry, is both holistic and eclectic. My frame of reference emphasizes both interpersonal and intrapersonal factors as well as specific sexual difficulties. One must treat the whole person.
Downloaded by [Monash University Library] at 16:15 14 November 2015
References 1. KAPLAN H. S. The New Sex Therapy. New York: Brunner Mazel, 1974. 2. MASTERS W. H. AND JOHNSON V. E. Human Sexual Inadequacy. Boston. Little, Brown & Co., 1970.
ISSN: 0022-4499 (Print) 1559-8519 (Online) Journal homepage: http://www.tandfonline.com/loi/hjsr20
Sex therapy in Australia N. R. Rose To cite this article: N. R. Rose (1976) Sex therapy in Australia, The Journal of Sex Research, 12:4, 330-335, DOI: 10.1080/00224497609550951 To link to this article: http://dx.doi.org/10.1080/00224497609550951
Published online: 11 Jan 2010.
Submit your article to this journal
Article views: 10
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hjsr20 Download by: [Monash University Library]
Date: 14 November 2015, At: 16:15
The Journal of Sex Research Vol. 12, No. 4, pp. 330-335 November, 1976
Sex Therapy in Australia
Downloaded by [Monash University Library] at 16:15 14 November 2015
N. R. ROSE* A pilot study of forty consecutive couples referred to a private psychiatric practice for the diagnosis and management of sexual problems was conducted. The couples came from a socially diverse population and exhibited a wide range of sexual disorders. Diagnosis included general sexual inhibition, orgastic failure, vaginismus, impotence and premature ejaculation. Nine couples had severe interpersonal stress and of these, only one improved. Six out of thirteen couples where neurosis or psychosis was an important factor, improved. Of the eleven couples who were free of non-sexual problems, eight became symptom-free. A variety of treatment procedures including brief sex therapy were used. Assessment of the total clinical picture rather than diagnosis of the presenting sexual problem was used in determining treatment strategies.
In discussing the treatment of sexual disorders, one is hampered by the fact that there is no generally accepted theory of the causality of these sexual disorders. The aetiology of neurosis is equally controversial. All that can be universally agreed upon is the fact that in most cases, experiential rather than constitutional factors, are responsible for disordered sexual function. The sexual functioning of one partner inevitably influences that of the other. This is the prime reason why most sex therapists try to see both partners conjointly. Although psychoanalysis offers much in the understanding of individual psychic conflict, it is limited by its traditional exclusion of the partner and by the relative lack of emphasis on interpersonal factors. Learning theory, which finds its practical application in the form of behaviour therapy, is also of value. However, some of its most ardent proponents have accepted that the relationship between therapist and patient, something which is difficult to explain solely in terms of learning theory, is of crucial importance in theory. It is difficult to imagine dealing with interpersonal conflicts and crises by a rigid, exclusive adherence to this body of theory. Marital therapy which takes into account the development of pathological relationships and the nature of interpersonal behaviour in a dyadic * Dr. N. R. Rose is a psychiatrist in private practice specializing in the treatment of sexual disorders and in individual and group psychotherapy. He is a visiting psychiatrist and the Director of the Sexual Guidance Clinic at Prince Henry's Hospital, Melbourne, Australia. 330
SEX THERAPY IN AUSTRALIA
331
Downloaded by [Monash University Library] at 16:15 14 November 2015
system also has much to offer. I would therefore agree with Helen Kaplan that no single theory or technique is appropriate in managing all sexual problems and that one should be prepared to use a combination of methods determined by the specific needs of the people one is dealing with. Patients presenting sexual complaints often have deep, underlying interpersonal and intrapersonal difficulties. Sexual dysfunctioning in such cases often represents the tip of a psychopathological iceberg. An understaning of this is crucial in determining which patients or couples are likely to respond favourably to task-oriented therapy of specific sexual problems. I am not saying that the presence of severe neurotic stress or problems between partners necessarily means that sex therapy is inappropriate, but that should sex therapy proceed, these non-sexual factors should also be dealt with during sessions in the consulting room. My own survey of forty consecutive couples referred to me for assessment and treatmet of sexual problems, revealed that nine of these or 22.5% of the sample were experiencing marital conflict of such severity that either one or both partners seriously considered separation or that one or the other was able to sabotage therapy. A further five men or 12.5% were without a partner at the time of referral. This was due to estrangement either completely or sexually from erstwhile regular partners. Two patients or 5% reported that their partners were unwilling to co-operate in treatment although the partner's physical presence was not mandatory. In thirteen couples or 32.5% of the sample, one partner was suffering from severe neurosis or psychosis. Out of the forty referrals only eleven couples or 27.5% of the sample, presented with difficulties mainly attributable to specific gaps in sexual knowledge, awareness, openness and communication. The results of treatment support the hypothesis that a healthy relationship, or the potential for developing one, is crucial for the enhancement of sexual function. Among the nine couples with severe interpersonal stress, only one sexually dysfunctioning partner, a woman in a hostile marriage, managed to improve to any degree. She originally suffered from primary orgastic failure; but now, following treatment by means of sensate focus exercises, masturbation and exploration of the marital relationship, she can occasionally have an orgasm with the help of a vibrator. There are still formidable hostile components to her marriage. Of the thirteen couples where one partner was neurotic or psychotic,
Downloaded by [Monash University Library] at 16:15 14 November 2015
332
N. R. ROSE
six couples reported relief of sexual symptoms. Three of the neurotic partners were treated by insight psychotherapy in either a group or individual situation, and three couples were successfully helped by task-oriented sex therapy. The best results were seen in the eleven couples whose difficulties were mainly sexual and where interpersonal and intrapersonal stress were minimal. Eight of these couples obtained freedom from sexual symptoms, two left treatment after only several interviews and only one couple, with a wife who found any form of physical contact with her husband abhorent, failed to improve. Of the forty couples in this study, four were from Social Class I, five from Class II, sixteen from Class III, fourteen from Class IV and one from Class V. Thus the majority of couples came from social classes which only by virtue of adequate health insurance were able to enjoy the benefits of private treatment. I might add that in early 1975, when this study was being undertaken, 90% of the Australian population were covered by compulsory Government Health Insurance which continues fees regardless of the term of treatment. 100% of the population is now covered by compulsary Government Health Insurance which continues to pay patients 85% of a medical fee which is regarded as being reasonable by an independent tribunal. It was this very tribunal which two years ago, determined that there was merit in supporting prolonged consultations to a level of 85%. Prior to 1974, lengthy psychiatric consultations enjoyed a much lower insurance benefit. Of the eleven couples with exclusively sexual problems, seven were from Class IV, two from Class III and two from Class II. This group showed as favourable a response to treatment as reported by Masters and Johnson despite the difference in Social Class, the lack of co-therapists and the less intensive non-residential treatment programme. The patients seen in this study exhibited a wide range of sexual disorders. Seven women were suffering from general sexual inhibition, five from primary orgastic failure, nine from secondary orgastic failure and two from vaginismus. Five men had primary impotence, six had secondary impotence and eleven suffered from premature ejaculation. An interesting feature of this study was the high proportion of men with premature ejaculation associated with severe interpersonal stress. All of the five men with premature ejaculation in the interpersonal stress group, left therapy. They were unable to co-operate in penile squeeze exercises. A further three men with this condition had no available
Downloaded by [Monash University Library] at 16:15 14 November 2015
SEX THERAPY IN AUSTRALIA
333
partner due to a break of their marital relationship and one more had a partner who refused to attend with him or participate in any exercises. Thus a total of nine out of eleven men presenting with premature ejaculation could not be helped by sex therapy. . , ; . These results of a pilot study suggest that both care in the selection of couples for treatment and the use of a flexible broadly-based therapy model is essential in the management of sexual disorders. In both selection and treatment, the way each couple's functions must be seen at three levels: These levels are: (1) The individual's capacity to accept, experience and communicate sexuality. (2) The quality of the relationship. (3) Neurotic or psychotic problems in one or both partners. 1. Any person's capacity for sexual enjoyment is determined by the degree to which sexual function is free of guilt and performance anxiety. Early life experiences of touching and tenderness, of the lack of these, as well as the emotional environment of the family in which that person grows up, are crucial. Many families adopt a rigid implicit censorship on sexual matters, which not only deprives the children of adequate sexual information but also gives them the idea that sex is bad. Problems in being able to openly show feelings often lead to difficulties in experiencing and expressing sexual enjoyment. 2. The relationship. Here we must consider the history and the patterns of communication between the couples. Some couples actually destroy each other's sexuality by constant bickering and by undermining each other's self-esteem. Overpossessiveness or overprotection by one partner frequently results in chronic hostility. Nobody likes to be suffocated. In some cases, by the time couples decide for therapy, the future of the marriage is already regarded as being hopeless by one partner. The wife of an inadequate impotent husband absconded with her sexually more virile and adequate brother-in-law. What is necessary for successful sex therapy is a sense of commitment by each partner to the other's welfare. The patients in my sample displayed a variety of neurotic and psychotic disorders. Two wives were suffering from schizophrenia requiring hospitalization and drug treatment. There were several severe depressives and six patients with severe personality disorders. What was interesting in this group is that several patients with severe psychiatric problems responded very well to specific treatment of sexual problems.
Downloaded by [Monash University Library] at 16:15 14 November 2015
334
.•
N.R.ROSE
One patient with suicidal depression was in intense conflict about both adolescent sexual experiences and feelings of hostility towards rejecting parents. Following symptomatic treatment of her depression, sensate focus treatment was commenced, but this had to be abandoned when she consistently rejected being touched on her genitals. Her personality problems as well as her primary orgastic failure improved only after six months of group psychotherapy in which she was enabled to see that her neurotic clinging to feelings of guilt was destroying her chances of sexual happiness and fulfilment. Before ending a few comments about task-oriented sex therapy. Most of you will be familiar with the Masters and Johnson model. Mainly for economic reasons, I do not use a cotherapist. Much of what goes on in the consulting room is taken up with discussion of the allotted tasks. Therapy is directed towards symptomatic relief of specific sexual difficulties. When marital conflict or neurosis interferes with the proper carrying out of prescribed tasks, I initiate supportive psychotherapeutic manoeuvres designed to deal exclusively with current blocks to therapy. I like to emphasize sensuality and the need to dethrone intercourse and orgasm as indispensable goals, whilst at the same time giving permission to enjoy sexuality and their physical relationship. Sensate focus exercises, more often than not, provide intense and newly discovered intimacy which is not performance oriented. What is important is each person's capacity to experience and enjoy his or her own sexual and sensual feelings. It is necessary to be selfish in experiencing sexual pleasure. This selfishness in surrendering oneself to sexual feeling rather than being overconcerned about the partner's responses inevitably heightens sexual arousal in a receptive partner. I do not regard the sensate focus programmes as inflexible. I try to structure the tasks according to the needs and sexual value system of each couple. When I do challenge strongly held values such as the idea that masturbation is sinful, I try to be supportive. Often new ideas can be introduced gently by means of hypnosis. The couples that I see appear to be a different group both in social class and in severity of psychiatric distress to those reported in the American literature. The high proportion of psychiatrically disturbed patients in my sample is a consequence of my profession and my interest in general psychiatry. I see many patients from working class backgrounds, therefore I do not see a uniform group of patients from the professional
SEX THERAPY IN AUSTRALIA
335
and managerial classes with a low incidence of marital and psychological distress as reported by American workers. My approach to sexual distress like my approach to psychiatry, is both holistic and eclectic. My frame of reference emphasizes both interpersonal and intrapersonal factors as well as specific sexual difficulties. One must treat the whole person.
Downloaded by [Monash University Library] at 16:15 14 November 2015
References 1. KAPLAN H. S. The New Sex Therapy. New York: Brunner Mazel, 1974. 2. MASTERS W. H. AND JOHNSON V. E. Human Sexual Inadequacy. Boston. Little, Brown & Co., 1970.
