Stephen B. Levine1, 2
(1)
Case Western Reserve University School of Medicine, Beachwood, OH, USA
(2)
Center for Marital and Sexual Health, Beachwood, OH, USA
Stephen B. Levine
Email: sbl2@case.edu
Keywords
SexImportanceSexual healthPsychological pathogenesis
2.1 Introduction
As the reader begins this book devoted to the modern treatment of sexual problems, it is useful to state the obvious. The primary purpose of clinical medicine is to assist patients with their limitations to physical and mental health. To this end, healthcare professionals are continuously educated about disorders and their therapies. Since 1970, this traditional focus on disease has been applied to sexual dysfunction, a term that artfully dodges the idea that many sexual problems are diseases. For several decades the scope of urology and gynecology has expanded to include sexual dysfunctions. A less than obvious benefit of the focus on diseases and their response to treatments is a clearer understanding of the processes that maintain health. For example, as clinical research recognized disease-inducing forms of immunological incompetence, the complex overlapping systems that preserve our health from pathogens were clarified. Similarly, as interventions for sexual dysfunction have evolved, knowledge has accumulated about sexual health. But sexual health, per se, is rarely the subject of sexual medicine articles. These articles assume sexual health equates with arousal or orgasmic functionality and suggest methods for restoring these capacities.
This chapter explores subtle, private aspects of sexual health. In doing so, it will define the lurking sources of disappointment that our patients are likely to feel when they request our assistance. In addition, the examination of sexual health and sexual distress will provide clinicians with some concepts concerning the psychological pathogenesis of many problems.
Sexual problems, theories of their cause, and treatment approaches date back to the earliest of medical writings [1]. Today, the sexual problems that attract clinical attention involve two broad categories: (1) sexual identity(transpositions of gender identity, variations in orientation, paraphilic patterns of arousal within and outside of a sexual addiction pattern) and (2) sexual dysfunction (symptoms include deficient sexual desire, incapacities in maintaining sexual arousal, anorgasmia, orgasm without pleasure, ejaculatory latency extremes, painful intercourse, and unwanted sexual arousal). Urologists, gynecologists, psychologists, psychiatrists, relationship therapists, sex therapists, and physical therapists each stake out their territories within this expanding array.
2.2 The First Principle of Clinical Sexuality
All sexual behavior—solitary or partnered, normal or dysfunctional, morally acceptable or socially disapproved of—is ultimately constructed from four general sources: biology, psychology, interpersonal relationships, and culture [2]. This principle is a humbling reminder not to oversimplify the determinants of sexual phenomena in our rush to find solutions to patients’ problems. Despite knowledge of this principle, all healthcare professionals are forced by their education, knowledge, and skill set to oversimplify this ordinary complexity in their everyday work. An elegant model that schematically illustrates the interaction of these four major determinants exists [3].
2.3 The Two Systems of Adult Nurturance in Sexual Relationships
Adult sexual relationships are well known to have the potential to stabilize and enrich individuals and make them happy with their interpersonal status. Psychological intimacy and partner sexual behaviorare the two behavioral systems that nurture adults. Partner sexual behavior can exist without psychological intimacy just as psychological intimacy can occur without partner sexual behavior. When they are successfully integrated, however, a positive feedback between them creates a greater degree of mutual nurturance and results in maximization of sexual functional capacities. Psychological intimacy motivates partner sexual behavior, and sexual behaviors create a new degree of psychological intimacy. In sexual health, the two systems function as one.
2.4 Three Paths to the Creation of Psychological Intimacy
2.4.1 Conversation
The usual way to attain psychological intimacy is through conversion [4]. One person speaks; the other person listens. In order to achieve a moment of psychological intimacy, the speaker has to meet three requirements. The speaker must talk about his or her inner subjective psychological self. The speaker must be able to trust in the safety of sharing this with the listener. The speaker must possess the language skills to express in words his or her thoughts, feelings, perceptions, and history. Psychological intimacy will not occur, however, unless the listener is able to evidence the following characteristics: The listener must provide undivided, uninterrupted attention to the speaker. The listener’s comments must be noncritical and reflect an accurate comprehension of what is being said and felt by the speaker. The listener needs to construe the opportunity to listen as a privilege to learn about the inner experiences of the speaker. Much conversation, even between established lovers, does not create psychological intimacy.
Psychological intimacy is a transformative moment of connection that occurs simultaneously in both the speaker and the listener. It is a bonding process that creates or reinforces the sense of belonging to one another. There are two basic forms of psychological intimacy. The first is the two-way psychological intimacy that ideally recurs in a couple’s life. Each member of the couple, of course, takes a turn being a speaker and a listener to potentially re-create moments of connection. In one-way psychological intimacy , however, a particular person is almost always the speaker and the other person is predominantly the listener. Physicians and mental health professionals create a one-way psychological intimacy with patients, as do parents with their young children. Psychological intimacies are part of the landscape of numerous kinds of relationships, ranging from friendship to sibling bonds to lawyer-client relationships. Unlike this wide array of psychological intimacies, psychological intimacy within a sexual relationship possesses a special power to repeatedly ease the way to sexual behavior.
These bonding moments of connection have profound consequences for the speaker. The moments strengthen the bond to the listener, causing pleasing thoughts such as “I am accepted.” “I feel more stable.” “I am happier.” “I feel healthier.” These moments erase loneliness, create optimism, and cause the speaker to look forward to the next opportunity for connection. After repeated moments of psychological intimacy , the speaker generates interest in sexual behavior with the listener. Psychological intimacy can be a powerful erotic stimulus. In certain contexts it is the most reliable and safest known aphrodisiac.
Moments of psychological intimacy have positive consequences for the listener as well. The listener gains a deeper understanding of the speaker and experiences pleasure in being of value to the speaker. The listener demonstrates an increased willingness to think about his or her own subjective self and comes to realize how important he or she is to the speaker. These subjective experiences reaffirm the bond to the speaker.
Psychological intimacy is not confined to the adult-adult relationship. Parents ideally maintain it with their children; friendships among any age group exist because of the individuals’ capacities to share aspects of themselves. The skill of psychotherapists is their ability to create and maintain psychological intimacy in order to promote psychological growth. Psychological intimacy creates a rarely discussed erotic stimulus in many relationships that are not intended to be sexual. As such, people have to carefully manage themselves so as not to complicate their lives.
2.4.2 Shared Intense Experiences
A second way of creating psychological intimacy, shared intense emotional experiences, does not require much conversation. An intense bond can readily be established or reestablished, for example, by enduring a frightening febrile illness in an infant, caring for a dying friend together, being together in combat, or being on an athletic team.
2.4.3 Sexual Behavior
The third way of attaining psychological intimacy is through sexual behaviors. It, too, is a largely nonverbal shared emotional experience. Many aspects of sex create private emotion. The sight of the partner’s naked body is a powerful experience of knowing the person, particularly early in the relationship. To this is added the perception of what the naked person feels about his or her naked body. One learns of the partner’s interest in and attitude toward specific sexual behaviors. Each person witnesses the other in arousal, a pleasurable knowledge that is augmented by facilitating, listening to, and watching the partner’s orgasm. These intensely private subjective experiences create the sense of knowing the partner in a way that others could not. This is a privilege. In these ways, sex creates a profound degree of connection.
The unmodified word “intimacy” is used to describe shared conversations about private experiences, nonverbal emotional experiences, and sexual pleasure. All avenues of attaining psychological intimacies promote the sense of loving and being loved.
2.5 What Is Learned Over Time Through Sex
Over time, individuals discover their partners’ range of sexual comfort . They witness the changing nature of this comfort. They come to discern their own and their partner’s variations in desire, arousal, and orgasm. They appreciate some of their partner’s motivations for sexual behaviors. Over months, years, or decades, sexual behavior may deepen the couple’s bond such that each has a rich, nuanced conviction of the sensual capacities of the other and how best to relate to them [5].
2.6 What Accounts for the Pleasures of Sex?
The pleasures of sex are physical and psychological. Sex can create novel delicious sensations and pleasant emotions before, during, and after orgasm. A person experiences the sense of power in giving the partner pleasure. The ability to give and to receive pleasure increases interest in the other, adds to the knowledge of the other, and creates the sense of being intertwined with the other. These are the means of creating a sense of oneness. The seamless interplay of physical and psychological pleasure during sex attenuates the sense of time as the individuals transport one another into the realm of sensation. The psychological pleasures of sex also involve personal meanings. These meanings, however, are often either closely held privacies from the partner or indescribable. “I feel it, but I can’t describe it. It just is!” “I love you!” is the occasional summary of this complexity.
2.7 Why Is Sex Important?
Sexual behavior stabilizes our sexual identity. Sex allows us to feel that we are confident as a man or woman. It helps us to clarify and stabilize our identity as a heterosexual, homosexual, or bisexual person. It clarifies the nature of our intentions as consisting of peaceable mutuality or varieties of sadomasochism or fetishism.
Sex is the vehicle for early romantic attachment at every stage in life—among the never attached, divorced, widowed, and those having affairs. It can facilitate the vital process of creating an entity from two individuals. Romance conveys the hidden quest for a safe, secure, comforting lasting unity. It is typically accompanied by an intense erotic desire for each other.
In established relationships, sexual behavior reinforces the sense that one is loved and capable of loving. It strengthens the sense of oneness enabling individuals to feel themselves to be an integral part of another. Sex has the capacities to erase the ordinary angers of everyday life, to elevate one’s mood, and to increase resiliency for tomorrow. It improves our capacity to withstand extra relationship temptation. And, of course, it is vital to our reproductive ambitions.
Sex remains a vehicle for self-discovery throughout life. It begins in adolescence when eroticism is dominated by fantasy, attraction, and masturbation and continues to reveal private aspects of the self during the many decades of regular or intermittent partner sexual behaviors and into the wistful final alone years.
2.8 The Second Principle of Clinical Sexuality
Sexual experience is a dynamic ever-evolving process. It changes in the short and in the long term in response to numerous biological, psychological, interpersonal, economic, and social factors. Individuals change psychologically, physically, and sexually over time as they mature, take on new responsibilities, and experience loss, personal dilemmas, and illness.
Changes in one person invariably impact on the partner. Therapeutic interventions can be immediately effective because of the responsiveness of the balance of the couple’s delicate interactions between sexual identity components and sexual function characteristics.
The second principle illustrates a limitation of medicine’s traditional reliance on designing interventions for individuals. For the treatment of coupled individuals, it is useful to expand this paradigm so that the clinician recognizes that forces emanating from the partner can render a therapy that has been scientifically demonstrated to be efficacious ineffective.
2.9 The Sexual Equilibrium
The second principle explains why the sexual fate of an individual entering into a monogamous relationship is not determined by his or her precommitment sexual capacities. Once that person enters into the new sexual equilibrium, what he or she experiences will heavily depend on the interplay between the person’s and the partner’s component characteristics (Table 2.1).
Table 2.1
The interaction of the sexual components in any sexual equilibrium
|
Partner A |
Partner B |
|
|
Gender identity |
↔ |
Gender identity |
|
Orientation |
↔ |
Orientation |
|
Intention |
↔ |
Intention |
|
Sexual desire |
↔ |
Sexual desire |
|
Ease of arousal |
↔ |
Ease of arousal |
|
Orgasmic pattern |
↔ |
Orgasmic pattern |
|
Pain-free penetration |
↔ |
Pain-free penetration |
The interaction of these components determines the frequency of sexual behavior, what sexual acts they share, how orgasm is attained, and their sexual psychological satisfaction. The sexual equilibrium of each couple has unique features. Some individuals come to know that different levels of satisfaction occur with different partners over their lifetimes. Clinicians have to be alert to the possibility that some patients who request interventions for improving sexual capacity are not planning to use them with the apparent partner. These men and women may have a more satisfying sexual equilibrium with someone who is unknown to the partner, whether or not they have sex with their mate.
2.10 What Is Sensuality?
Satisfying functional sex requires the abandonment of ordinary daily preoccupations and the substitution of a focus on bodily sensations. Sensuality is not how a person looks. It is what a person is capable of doing and feeling during sex. Sensuality has two faces. The readily appreciated face is the capacity to experience the preoccupying sensations of a kiss, lick, a touch, a breast or genital caress, and penetration. The more subtle face of sensuality is the person’s interest in transporting the partner to this realm where pleasure predominates.
2.11 An Ideal Life of Sexual Pleasure
High on the list of hoped for personal expectations from life is to have, at least for an extended period of time, a diet of emotionally satisfying sex [6]. It is as though individuals collectively know that sex can be wonderful and that it is a vehicle to feel and express love. In the last analysis, sex may be the easy way to access the much more difficult to describe subject of love [7]. Particularly in clinical medicine, where the topic of love is generally avoided, sex may be a surrogate topic for love.
A satisfying sexual life diminishes the sense that one has been cheated by life. Wonderful sex creates a comforting, stabilizing sense of happiness. People learn from it that in being a part of someone else, they not only do not lose their individuality by loving but their individuality is essential to their blissful sensual excursions. Satisfying sensual sex prevents envy of other people’s sexual experiences because people sense that “It could not get better than this.”
2.12 Sexual Health Is Only Potential
Recurrently satisfying sensuous interactions—sexual health—is a developmental achievement. It is not guaranteed for men or women by their biological normality, their sex-positive attitudes, or past history of sensuality. While physicians prefer to biologically intervene with sexual dysfunctions, to do so without paying attention to the psychological, interpersonal, and cultural contexts of a patient’s life will often disappoint the patient and the doctor. Comprehending the potentials of sex to enhance lives ironically helps clinicians to understand these three contexts.
Sex is important because it has the capacity:
1.
2.
3.
4.
5.
6.
7.
8.
Patients with sexual difficulties can be assumed to be currently lacking in the attainment of these potentials. Some have never, even briefly, attained them. Many have attained and lost them.
2.13 Sources of Distress
Modern criteria for sexual diagnoses require that the patient or the couple experience distress about their difficulty. While rating scales can be used to quantify distress [8] and are vital to clinical sexual research, numbers explain the intensity but not the sources of the distress. The right side of Table 2.2 clarifies the subjective contributions to the distress. These are obviously just the inverse of the positive potentials of sex. Understanding the reasons for the distress in these terms, whether or not they are explicitly stated, helps in the establishment of a trusting relationship with the patient.
Table 2.2
Positive and negative potential of sex
|
Positive potentials |
Negative potentials |
|
To please |
To displease |
|
To stabilize |
To destabilize |
|
To physically satisfy |
To physically frustrate |
|
To emotionally satisfy |
To emotionally frustrate |
|
To improve self-understanding |
To prevent self-understanding |
|
To improve understanding of the partner |
To obscure understanding of the partner |
|
To feel loved and loving |
To feel empty—unloved and uncaring |
|
To enhance life through reproduction and parenthood |
To prevent the pleasures of reproduction and parenthood |
2.14 Two Subtleties About the Sexual History
2.14.1 The Clinician’s Audition
Our contact with the patient begins with our taking a sexual history [9]. There have been many seminal writings published on this important topic since 1970 [10–12]. The clinician should realize, however, that the initial evaluation is a mutual process. The doctor is evaluating the sexual complaint by searching for the correct diagnosis and beginning to ascertain the pathogenesis and factors that may shape the approach to therapy. The individual patient, or the couple, all the while is assessing the clinician’s warmth, interest, understanding of their distress, and competence. Some initial evaluations are not followed by treatment. Some treatments are not continued for a reasonable duration. Doctors may be baffled when patients do not return or do not follow their recommendations. One of the possibilities that may be considered is that the clinicians may have flunked the patient’s evaluation of them. The goal of the sexual history taking from the patient’s perspective is the establishment of a hope-generating trusting alliance with the doctor. There will be no therapy, despite an accurate diagnosis and a state-of-the-art treatment plan, if the clinician fails the audition inconspicuously conducted by the patient.
2.14.2 There Is No Such Thing as a Complete Sexual History
The specifics of the sexual history vary, of course, with the presenting problem, the specialty of the clinician, the presumptions about the likely sources of the problem, and the patient’s capacity to talk about the matter. Despite the inherent pressure clinicians feel to gather a lot of information at the first encounter, there is no such thing as a complete sexual history. For example, a gynecologist and a psychologist may each be thorough in their assessments, but the details that will emerge will be quite different. The sexual history and the doctor’s ability to formulate the pathogenesis of the problem are evolving processes. This is more apparent among mental health professionals, but is nonetheless true as well among urologists, gynecologists, and pelvic floor specialists. As a general guideline to attaining a comprehensive sexual history, clinicians can recall the concept of the sexual equilibrium. Eventually, the history should reveal the individual’s sexual identity components and sexual functional capacities. It should clarify the partner’s capacities and how they interact. It is asking too much of any clinician to obtain a picture of all of this by the end of the first meeting.
Understanding the patient’s distress and disappointment with their sexual problem, although it takes only a brief moment or two, generates moments of empathy and one-sided psychological intimacy. This seems to be how many clinicians pass their audition with very high marks. With this achieved, the doctors can turn their attention to helping the patient to improve.
References
1.
Berry M. The history and evolution of sex therapy and its relationship to psychoanalysis. Int J Appl Psychoanal Stud. 2013;10(1):53–74.CrossRef
2.
Levine S. The first principle of clinical sexuality. J Sex Med. 2007;4:853–4.CrossRefPubMed
3.
Perelman M. The sexual tipping point: a mind/body model for sexual medicine. J Sex Med. 2009;6(3):629–32.CrossRefPubMed
4.
Levine S. Psychological intimacy: the pathway to love. In: Levine S, editor. Demystifying love: plain talk for the mental health professional. New York: Routledge; 2006.
5.
Kleinplatz P. Lessons from great lovers. In: Levine SR, Levine SR, editors. Handbook of clinical sexuality for mental health professionals. 2nd ed. New York: Routledge; 2010. p. 57–72.
6.
Byers E. Relationship satisfaction and sexual satisfaction: a longitudinal study of individuals in long‐term relationships. J Sex Res. 2005;42(2):113–18.CrossRefPubMed
7.
Levine S. Barriers to loving: a clinician’s perspective. New York: Routledge; 2013.
8.
Derogatis L, Clayton A, Lewis-D’Agostino D, Wunderlich G, Fu Y. Validation of the female sexual distress scale-revised for assessing distress in women with hypoactive sexual desire disorder. J Sex Med. 2008;5(2):357–64.CrossRefPubMed
9.
Althof S, Rosen R, Perelman M, Rubio Aurioles E. Standard operating procedures for taking a sexual history. J Sex Med. 2013;10(1):26–35.
10.
Masters W, Johnson V. Human sexual inadequacy. Boston: Little Brown; 1970.
11.
Maurice W. Sexual medicine in primary care. St. Louis, MO: Mosby; 1999.
12.
Althof S, Rosen R, Perelman M, Rubio Aurioles E. Standard operating procedure for taking a sexual history. Journal of Sexual Medicine. 2013, 10(1): 26–35.