Stanley E. Althof1, 2 and Rachel Needle2, 3, 4
(1)
Case Western Reserve University School of Medicine, Cleveland, OH, USA
(2)
Center for Marital and Sexual Health of South Florida, West Palm Beach, FL, USA
(3)
Advanced Mental Health Training Institute, West Palm Beach, FL, USA
(4)
Nova Southeastern University, West Palm Beach, FL, USA
Stanley E. Althof
Email: Stanley.althof@case.edu
Keywords
Sexual dysfunctionInterpersonal difficultyConjoint psychotherapySex therapy
31.1 Introduction
Sexual dysfunctions do not occur in a vacuum; they impact the symptom bearer and his/her partner—sexually, emotionally, and interpersonally. This chapter will focus on the evaluation and treatment of sexual dysfunction(s) in the couple with an emphasis on the construct of the sexual equilibrium.
31.2 Sexual Equilibrium
The construct of couples having a sexual equilibrium is the foundation for understanding the impact that one partner’s sexual dysfunction has upon the other and the resistances that may be encountered in treating such couples. We have always thought of the sexual equilibrium akin to Newton’s second law of motion implying that any change in one partner will produce a change in the other [1]. It is not difficult to appreciate that a man’s erectile dysfunction (ED) could impact the female partner’s sexual arousal/interest/desire (FSAID) or that her genital pain disorder might affect the man’s ejaculatory function. Conversely, when treating couples, as one partner’s sexual dysfunction appears to be improving, it is always surprising when the other partner develops a new and seemingly unexplained sexual problem. The concept of sexual equilibrium needs to be broadened to include alterations in the interpersonal and emotional realms as well as the sexual. For instance, rather than developing a new and seemingly unexplained sexual problem, the partner may become depressed.
The construct of the sexual equilibrium needs to remain front and center when evaluating and treating couples for a sexual problem. The partner’s role as a precipitating or maintaining factor has often been overshadowed by focusing on the initial symptom bearer’s medical, psychological, or interpersonal issues. There is a dynamic and reciprocal relationship between each partner’s sexual function, sexual satisfaction, and physical and mental health [2, 3].
31.3 Vignette
The sexual life of a young professional couple that had been married for 1 year was marred by Joe’s psychogenic ED. His difficulties began shortly after they were married. His wife Laura felt entitled to a satisfying sexual life and was distressed by Joe’s lack of concern about his continued problem and avoidance of any form of sexual play. They had not touched one another for 6 months prior to their seeking consultation.
Both Joe and Laura had attended parochial schools; however, he was currently more invested in Catholicism than she. Prior to marriage, they had dated for 2 years and had engaged in premarital intercourse. While dating, Laura became pregnant and chose to terminate the pregnancy.
During the evaluation, Joe said, “It was like dragging her down the sewer. I forced her to have sex with me, and look what happened!” Laura responded that he didn’t force her, that she very much wanted to be sexual and had enjoyed it. She regretted the abortion but thought it was the right decision given the circumstances.
I (SA) suggested that treatment should focus on their premarital sexual life and resolving the feelings about the pregnancy termination. They agreed, and Joe’s potency returned the following week. Joe seemed pleased, but Laura had suddenly lost her sexual desire. As Joe was talking about “robbing Laura of her virginity,” she seemed increasingly uncomfortable. When I asked what was troubling her, she “confessed” that Joe had not been the first. We then shifted the focus as to why she had allowed Joe to believe she was a virgin. She explained that she felt very guilty about her past behavior and feared Joe would not love her if she told him about the others. Although Joe felt angry and betrayed by Laura’s “secret,” he also felt relieved that he was not the only one who had done something they both perceived as wrong sexually prior to their marriage. The couple began to appreciate their need for some sexual symptom to alleviate their collective guilt. Over the next two sessions, Laura’s desire returned and Joe’s potency remained intact. At a 2-month follow-up, the sexual gains were maintained.
31.4 Commentary
This vignette dramatically illustrates how sexual symptoms can impact the other partner (Laura’s disappointment with not having a satisfying sexual life) and that symptoms can shift between partners during treatment (Joe regaining his potency and Laura losing sexual interest). This was a resilient and loving couple who were able to integrate revelations about the other. They understood that their symptoms had meaning relating to their shared history, and they sought to forgive one another and move forward positively. While this case is atypical in terms of how quickly the symptoms shifted and resolved, it is offered to the reader to illustrate the importance of the sexual equilibrium construct.
31.5 The Biopsychosocial Model and Assessment
We strongly recommend that clinicians employ a biopsychosocial perspective when evaluating and treating couples who present with sexual dysfunction [4, 5]. The biopsychosocial model is an integrative and dynamic model that is always changing and helps to elucidate the multiple influences on the patient’s sexual dysfunction. It assesses the potential medical problems associated with the dysfunction—vascular, hormonal, neurologic, disease, and surgery related and potential problems with medication(s). It also takes into account lifestyle issues that may impact sexual function, such as obesity, smoking, drugs, alcohol, and exercise.
It is vital that the patient, partner, and clinician are mutually involved in the assessment process. Taking a collaborative approach, the clinician collects the sexual, medical, relational, contextual, and psychological information that he/she synthesizes into a cohesive treatment plan. When questions are asked in a logical and empathic manner, the patient and partner often gain a fresh perspective on the multiple issues related to his/her sexual problem. Not every partner will be present at the initial consultation; nonetheless, the partner should be invited to participate when able, as his/her perspective often proves helpful in understanding the context of the current situation (e.g., did he tell you he’s a drinker). The partner often has important insights regarding the relationship dynamics and is an important ally in the success of any treatment intervention [6].
The clinician should begin with a complete description of the presenting sexual problem, as well as other areas of sexual function, since there is often an overlap between dysfunctions. Other chapters in this volume will focus on the specifics of taking an individual’s sexual history; we are more focused on the partner and his/her response to the problem. If the partner is not present at the initial consultation, we suggest you begin by asking the patient if the partner knows that they have sought treatment. Ask whether the partner misses sexual intimacy and how he/she has responded to the sexual dysfunction. Is the partner angry, hurt, sad, or frustrated that the patient has delayed seeking treatment or pleased that because of the dysfunction sexual life is behind them? Is he/she likely to be a willing and supportive partner in the patient’s treatment or are there interpersonal obstacles that need to be overcome? Does he/she have any sexual problems and what have they done, if anything, to overcome their own difficulties?
Psychological factors are also assessed in the partner. Suggested questions include the following: Has the sexual dysfunction caused a loss of confidence? Has the patient or partner suffered from depression? Is the patient or partner now avoidant of sexual behavior or is there a relevant historical event that significantly influences the development and maintenance of the dysfunction? For instance, is there a history of sexual/physical/psychological abuse, an invasive traumatic surgery, or parental divorce or abandonment?
What is the quality of the interpersonal relationship? Is the couple’s attachment secure, anxious, or chaotic? What impact does the development of the dysfunction have on the partner? Does his/her response to the symptom bearer make matters better or worse? Also, how do previous relationship experiences such as abandonment, power and control struggles, infidelity, alcohol/drug abuse, etc. impact upon the present relationship?
Lastly, what are the cultural/social issues that are relevant to the dysfunction? How does the couple’s ethnic/religious background intersect with the couple’s sexual problems? Is there sufficient privacy? Do they work different shifts? Are there current economic or vocational concerns?
The answers to these questions help us to understand the forces that came together to give birth to and maintain a sexual symptom. Such a comprehensive biopsychosocial assessment allows for thoughtful stepwise treatment planning whether it is for individual, for couples, pharmacotherapy, or combined medical and psychological treatment.
31.6 Empirical Support for the Notion of the Sexual Equilibrium
In the late 1980s, the Case Western Reserve group began a research study of men who presented with erectile dysfunction and received either intracavernosal injection (ICI) or vacuum tumescence therapy (VTT). Those were the days that preceded the introduction of Viagra™, Cialis™, or Levitra™, and ICI and VTT were the most innovative treatments available at the time. All couples (except when medically contraindicated) were given the choice of which treatment they wished to receive. Couples were seen at baseline, 1 month after treatment was initiated, and then at 3, 6, and 12 months. At each visit, the men and women completed questionnaires that assessed sexual function, mental health (SCL-90R), relationship satisfaction (Dyadic Adjustment Scale), anxiety (Spielberger State-Trait Anxiety Inventory), self-esteem (personal evaluation questionnaire), and depression (Beck Depression Inventory).
After 12 months, men were injecting themselves 4.3 times per month with 83 % of the erections labeled as satisfactory, while the men in the vacuum group were using the device 3.5 times per month with 74 % of the erections labeled as satisfactory. Additionally, significant positive changes were observed in quality of the men’s erection, frequency of lovemaking (intercourse), sexual satisfaction, all 12 scales of the SCL-90R, Beck Depression Inventory, and Spielberger trait anxiety score [7, 8].
Women responded equally well to both interventions. In both the injection and vacuum groups, women demonstrated significant positive changes in sexual satisfaction, sexual arousal, frequency of lovemaking (intercourse), and frequency of coital orgasm. Women reported feeling more at ease in their relationships and attributed this to how the men felt about themselves. They emphasized how stressful intercourse had been before their partner initiated ED treatment—because the men fostered hurried and anxious attempts at lovemaking. Improving the men’s erectile difficulties led to measurable positive changes in the women and overall couple. The positive effects reported by the women seem to be the result of changes within the couple’s equilibrium. Any change in one partner produced a change in the other and in the dyadic system [9].
Fifteen years later, Fisher and colleagues published the results of their study entitled, “Sexual Experience of Female Partners of Men with Erectile Dysfunction : The Female Experience of Men’s Attitudes to Life Events and Sexuality (FEMALES) Study” [10]. They reported on the partners of 293 men with ED who received vardenafil (Levitra™) and responded to questionnaires assessing frequency of sexual activity, nature of their sexual experience, both before and after the development of their partner’s ED, and the nature of the partner’s sexual experience after her partner began using vardenafil.
ED had a significant negative effect on the female partners’ sexual experience. The women reported a reduced frequency of sexual activity after their partner developed ED and described declines in their sexual desire, arousal, orgasm, and satisfaction. Following the man’s treatment with vardenafil, the women’s desire, arousal, orgasm, and satisfaction almost returned to their pre-ED levels. The man’s use of vardenafil improved the woman’s sexual function.
There is also evidence of the negative impact of premature ejaculation (PE) on the female partner’s sexuality. This has been confirmed in several epidemiological studies where PE has been found to be correlated to overall female sexual dysfunction, sex not being pleasurable, and problems with desire, arousal and orgasmic problems, as well as low sexual satisfaction and sexual distress [11–14]. Graziottin described the impact of PE on female partners and the emotional process they experience [15]. Most women begin by not addressing the sexual problem for fear of hurting the man’s feelings and/or of increasing his feeling of inadequacy. They enter into a collusion of silence hoping that with time things will magically improve. When they don’t, she may raise the issue of her frustration with their sexual life but often the man is reluctant to discuss the problem. As the PE continues unabated, she becomes increasingly frustrated, angry, and contemptuous of the man’s problem. Finally, Hobbs describes the negative impact that PE has on the female partner’s sexual life [16]. Comparing the female partners of men with and without PE, Hobbs reported that the female partners of men with PE experienced half as much sexual desire, arousal, and orgasm.
Unfortunately, there is not a great deal of empirical research on the impact of female sexual dysfunction on male partners. Additionally, there has been very little research on the impact of male or female sexual dysfunction with men who have sex with men or with women who have sex with women.
Reporting on the male partners of women with vaginismus, Dogan and Dogan reported that 50 % of the partners of women with vaginismus had PE [17]. We believe that partners of women with female sexual interest/arousal disorder (FSIAD) are puzzled as to why the women have lost their desire or arousal. They may miss the intimacy, blame themselves for her dysfunction, and wonder if she is having an affair, or question whether she still loves him. Often times a vicious cycle develops where the male partner of a woman with low desire may become exasperated and demand lovemaking, causing her desire to diminish further—resulting in an increase in the man’s sexual demands.
31.7 Treatment Concerns
The first consideration, from the therapist’s perspective, is whether the presenting problem is best treated in an individual, conjoint, or a combined medical/psychological format. In the USA, there are currently no approved medications for female sexual dysfunction except for the treatment of dyspareunia. For men, there is an assortment of medical treatments for ED and testosterone therapy for hypogonadal men, but no approved treatment for premature ejaculation.
We generally see individuals with lifelong sexual problems in individual therapy because we consider such individuals as having failed to surmount some developmental hurdles that predated the relationship. We see acquired disorders more often in conjoint treatment with the exception of extremely chaotic relationships, or severe individual psychopathology, such as substance abuse, bipolar disorder, or profound character pathology. When there are no serious psychosocial obstacles and there is an approved medication available, we tend to favor a combination of medical and psychological treatment since it offers the best of both worlds.
Interventions that specifically address relationship issues are usually more successful than treatments focused only on the presenting sexual symptoms [18, 19]. Having a better pretreatment relationship has been associated with successful sex therapy treatment outcomes [20].
Much work still needs to be done in terms of empirically demonstrating the efficacy of individual and conjoint psychosocial interventions for sexual problems. Studies generally have small samples, consist of exclusively heterosexual couples, and have little to no follow-up.
31.8 Conclusion
The sexual equilibrium is a powerful construct when working with couples who present for treatment of a sexual dysfunction. Keeping this construct “front and center” allows the therapist to better understand and properly consider the partner’s responses to the sexual problem and help the couple to work through the sexual, psychological, and interpersonal issues related to the dysfunction.
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