The Evolution of Modern Sex Therapyby Katy Butler
Twenty years after the sexual revolution, in the most sexually explicit culture in the world, a surprisingly large number of people continue to have difficulties with the sexual basics. The Social Organization of Sexuality, a statistically balanced 1994 survey of the sexual habits of 3,432 Americans, found that 24 percent of the women questioned had been unable to have an orgasm for at least several months of the previous year. Another 18.8 percent of the women (24 percent of those over 55) reported trouble lubricating; 14 percent had had physical pain during intercourse; and 11 percent were anxious about their sexual performance. Equally high proportions of men reported interlocking difficulties: 28 percent said they climaxed too quickly, 17 percent had performance anxiety and 10.4 percent (20 percent of those over 50) said they'd had trouble maintaining an erection.
Before the 1950s, people with these sorts of problems were given pejorative labels like "impotent" and "frigid." Psychoanalytic therapy had little to offer them beyond symbolic explorations of their upbringings and "Oedipal" conflicts. Things got slightly better in the 1950s, when Joseph Wolpe and other behaviorists taught people to reduce their fear by breathing deeply and relaxing while imagining sexual situations that had made them tense. This was of some help, but things only really changed in the 1970s, after gynecologist William Masters and his research associate Virginia Johnson began studying the physiology of human sexual response in the laboratory.
Modern sex therapy--a repertoire of precise physical techniques that teach the body new responses and habits, lower anxiety and increase focus on the here-and-now--builds on Masters and Johnson's work. Therapy consists mainly of counseling and "homework" in which new experiences are tried and new skills practiced. If clients are too tense or reluctant to try something new, systems approaches, couples therapy, drugs and psychodynamic therapy may be tried as well.
Modern sex therapy often begins with instruction in "sensate focus." The pressure to have an orgasm, keep a firm erection or prolong intercourse is taken away. Instead, individuals or partners are told to set aside time to caress themselves or each other in a relaxed environment, without trying to achieve any sexual goal. Once anxiety is lowered, sex therapy often proceeds successfully, especially in treating the following common problems:
Vaginismus. Vaginismus is the spastic tightening of the vaginal muscles and can make intercourse impossibly painful. It can be so severe that not even a Q-tip can be inserted in the vagina, and some women with vaginismus have never, or rarely, completed sexual intercourse in the course of years of marriage. Often the result of physically painful experiences like childbirth, painful intercourse, rape or molestation, it is a learned fear response. Therapy involves teaching the woman to relax and breathe while gently inserting the first of a graduated series of lubricated rods, starting with one as small as is necessary for comfort. In ensuing weeks, the woman uses incrementally thicker rods and then inserts her partner's finger and finally his penis into her vagina. Nothing is forced, and insertion is always under the control of the woman.
Premature ejaculation in men. Treatment involves lowering anxiety and teaching the man to become aware of his arousal during lovemaking, until he recognizes the sensations that precede his "point of no return." Then he practices what sex therapist Barbara Keesling, author of Sexual Healing, calls "peaking"--pausing before the point of no return and relaxing, breathing and stopping movement until his arousal subsides. After a few minutes' rest, the man returns to movement, stimulation and arousal. The "peak and pause" routine is repeated five or six times per homework session. The exercise can be done by a man masturbating alone, while his partner is giving him oral sex or during intercourse. Men can squeeze their pubococcygeal or PC muscles during the pause to dampen arousal, or the man's partner can squeeze on the coronal ridge just below the head of the penis.
Erectile difficulties in men. A common problem among older men, erectile failure is often caused by an interaction of physical and psychological factors. Smoking, diabetes, blood pressure drugs, alcoholism, neurological injury and normal aging can all worsen erectile problems. Treatment has been revolutionized since the introduction of Viagra, which not only helps men with primarily physical problems, but can also jump-start those suffering primarily from anxiety.
Men who awaken with erections or have them while masturbating can probably blame anxiety if they have trouble during intercourse: muscular tightness and breath-holding can send blood out of the penis, causing it to wilt. Sex therapy requires slowly disarming anxiety and performance pressure, and learning to enjoy sex with and without an erection. Therapy often begins with declaring intercourse off-limits and encouraging the couple to enjoy each other orally and manually, without demanding that the penis perform.
In the next "stop-start" phase, the man's partner stimulates him to the point of erection, stops until his penis becomes totally soft and then stimulates him again, repeating the process up to three times if the erection returns. Other exercises include "stuffing," which allows the man to become familiar with the sensation of being in the vagina without having to perform sexually. The female partner gently folds his flaccid penis into her vagina, using her fingers as a splint while lying in a scissors position, at right angles to the man, with one of his thighs between her legs. The couple then lies together for 15 to 30 minutes without moving. In subsequent sessions, as anxiety lessens, the man practices moving slowly while breathing evenly and staying relaxed.
Orgasmic difficulties in women. Therapy with "pre-orgasmic" women was pioneered by psychologists Lonnie Barbach of San Francisco, author of For Yourself: The Fulfillment of Female Sexuality, and Joseph LoPiccolo, a coauthor, with Julia Heiman, of Becoming Orgasmic. It has extraordinarily high success rates with women once written off as frigid. In group and individual programs lasting 6 to 10 weeks, women are given basic information about female sexual response and are encouraged to spend one hour a day on self-pleasure "homework," familiarizing themselves with their own anatomies and sexual responses, examining their vulvas with a mirror and speculum, massaging themselves, perhaps reading Nancy Friday's collections of sexual fantasies and masturbating. Most of the women soon learn to give themselves orgasms, and then gradually transfer their new skills to lovemaking. First they masturbate to orgasm in front of their partners, then learn to come while touching themselves during intercourse, and then teach their partners to pleasure them to orgasm using their fingers or penis.
Most women successfully transfer their new responsiveness to partnered sex. The exceptions tend to be women who have learned to reach orgasm by squeezing their thighs tightly together--a position that makes it virtually impossible for them to have an orgasm with a penis inside them. In LoPiccolo's clinic at the University of Missouri in Columbia, such women relearn a more fluid orgasmic response by deconstructing their masturbation rituals step-by-step and gradually learning to have orgasms without clenching their thighs. They may begin by simply uncrossing their ankles while masturbating and then slowly change their patterns until they can have orgasms with their legs apart.
If a woman can reach orgasm with digital stimulation from her partner, LoPiccolo considers that therapeutic goals have been met. Women respond orgasmically to a wide variety of stimuli--some to dreams and fantasies; others to the rubbing of an earlobe or breast; others to digital caressing of the clitoris or G-spot; and still others to intercourse. All are considered normal human variations. At an American Association of Marriage and Family Therapy conference last year, LoPiccolo said that when couples come to him saying they'd like the woman to have an orgasm during intercourse, he doesn't consider this a therapy goal so much as a growth goal, like learning to dance. "If you want to learn the tango," he said by way of analogy, "You get tango lessons, not therapy."
Tantra at Home
Modern Tantric techniques to improve anyone's sex life:Heighten Awareness of All the Senses William Masters and Virginia Johnson introduced to the West a technique called "sensate focus," in which the receiving partner focused on his or her own sensations while being slowly and nonsexually caressed.
Tantric versions are more playful and aesthetic: Tantric teacher Margo Anand of Mill Valley, California, for instance, recommends that the receiving partner sit blindfolded on the bed, while the nurturing partner wafts a variety of smells, such as peppermint, licorice, gardenia, or even Chanel No. 5, under his nose. Next he is treated to sounds--bells, gongs, even crackling paper. Then he is fed distinctive-tasting foods--almonds, grapes dipped in liqueur, whipped cream, fruit or bittersweet chocolate. Finally, the nurturing partner strokes the receiving partner's body with pleasant textures--silk scarves, fur mittens or feathers. The ritual closes gently and formally. "With utmost gentleness, as if you had never touched him before, let your hand rest on his heart," writes Anand. "Allow your hands to radiate warmth, tenderness, and love."
Create Intimacy Through Gentle Contact: Modern Tantrism focuses strongly on the subtle physical harmony between partners. In Tantra: the Art of Conscious Loving, yoga teachers Charles and Caroline Muir of the Source School of Tantra in Maui, Hawaii, recommend spoon meditation:
Lovers lie together spoon-fashion on their left sides and gently synchronize their breathing. The outer person, the nurturer, rests his right hand on the heart of his partner. Placing his left hand on her forehead, he visualizes sending love and energy from his heart down his arm and into her heart on his out-breath. On the in-breath, he draws energy back from her forehead and into his body in an endless circle.
The Muirs also recommend that partners do yogic breathing in unison: inhaling, holding the breath for a few seconds, exhaling and holding the breath out for a few more seconds. While breathing out, one partner visualizes accepting energy while the other visualizes projecting it. Couples can also inhale and exhale in counterpoint, visualizing "shooting out" energy on the out-breath through heart, head or groin and receiving it on the in-breath.
Focus on Connection Rather Than Orgasm: Much of conventional sex therapy has focused on orgasm. Many previously unsatisfied women were liberated in the process, but it also turned intercourse into a big project, made orgasm the be-all and end-all of being together sexually, and defined any other sexual interaction as "the failure to achieve orgasm." Tantrism extols the joys of brief sexual connections without orgasm. In The Tao of Sexology, for example, Taoist teacher Stephen Chang recommends that couples practice the "Morning and Evening Prayer" for at least 2 to 10 minutes, twice a day. Every morning and evening, partners are to lie together in the missionary position, lips touching, with arms and legs wrapped around each others' bodies and the man inside the woman. The couple breathes together in a peaceful, relaxed state, with the man moving only enough to maintain his erection. "The couple enjoys and shares the feelings derived from such closeness or stillness for as long as they desire," writes Chang, who notes that orgasm sometimes follows without any movement. "Man and woman melt together, laying aside their egos to exchange energies to heal each other."
Enhance Sexual Pleasure: Ancient and modern Tantric and Taoist sex manuals are full of sophisticated physical techniques designed to enhance the pleasure of both partners, stimulate orgasm in the woman and delay orgasm in the man. Chang, for example, recommends a Taoist practice called "Sets of Nine." The man slowly penetrates the first inch or so of his lover's vagina with the head of his penis only. He repeats this shallow stroke slowly nine times, followed by one slow stroke deep into the vagina. The next "set" consists of eight shallow strokes and two deep strokes, followed by seven shallow strokes and three deep strokes and so on until a final set of one shallow stroke and nine deep strokes. The "sets" help men prolong intercourse by balancing intense and less intense forms of stimulation and arouse women by stimulating the G-spot and numerous nerve endings in the neck of the vagina.
Separate Orgasm From Ejaculation: In its most signal departure from Western sex therapy, modern and ancient Tantrism recommend that men, especially older men, frequently enjoy what it calls a "valley orgasm"--orgasm without ejaculation. Chang recommends that as the man senses himself approaching the "point of no return," both partners stop all movement while the man clenches his pubococcygeal or PC muscle (the urination-stopping muscle known to many women from the Kegel exercises they were taught to strengthen uterine and bladder muscles after giving birth). The man also slows and deepens his breathing, looks into his partner's eyes, connects with her heart and channels energy upward from his groin toward his heart and the crown of the head. Orgasm without ejaculation often follows. Ejaculation can also be reserved, without stopping the experience of orgasm, by pressing on what Chang calls "The Million Dollar Point," in a small hollow between anus and scrotum.
Honor Sex, But Keep It in Perspective: "When sex is good," Charles Muir said at a recent workshop, "It's 10 percent of the relationship. When it's bad, it's 90 percent."
Networker associate editor Katy Butler, a former reporter for The San Francisco Chronicle, has contributed to The Los Angeles Times, The New Yorker, The New York Times Book Review and The Washington Post. For more information on Charles Muir, write to P.O. Box 69, Paia, HI 96779. Correspondence to Katy Butler may be sent to the Networker .