Theoretically, a psychotherapist can start out in any single area of application and expand in any direction. In practice, it is unusual at this time for a person to begin his or her career as a sex therapist and proceed to individual/dyadic/ family therapy; the reverse is much more likely. It is crucial that such a person, no matter what his or her background may be, undertake training at a recognized sex therapy institute.

Sex therapy is simultaneously a theory, a body of behavioral techniques, and an encounter with patients. The theory is easy to grasp. The exercises and their applications are not difficult to learn. The encounter with patients can be devastating unless adequate preparation has been made.

The reason for this is in the difference between sex on a symbolic level in the mind, and sex in the body as organs with sensations. Most psychotherapists of all persuasions have had some sort of training therapy or analysis in which their own sexual history, fears, and fantasies were considered in terms of ideas, symbols, and emotions. Issues of Oedipal conflicts, homosexual impulses, fetishes, fixations, orality, anality – all have been explored. On the ideational and emotional level, most qualified psychotherapists can function very well. This training also is very useful in working with the resistances to sex therapy.

But none of it has the slightest use in, for example, telling a woman how to masturbate her husband being treated for premature ejaculation. One does not speak of impulses, drives, desires; one speaks of organs and parts of organs in the patients’ own language, which may range from the formal to the obscene. And one describes, in great detail, exactly what the patient and the partner are to do with those organs. For the inexperienced therapist, this kind of confrontation may be virtually impossible.

A psychiatric resident was undergoing sex therapy training in a sex therapy clinic. His first actual session as a trainee dealt with an anorgasmic woman. In the course of the session, the woman was helped to overcome her inhibitions against pleasuring herself, and was given detailed instructions on how to stimulate her genitalia, in brief, how to masturbate. Later, in going over the session, the trainee remarked that he was fine up until the point at which the step-by-step physiological instructions began, but from then -on he couldn’t remember a thing!

Another psychiatric resident, after a few sessions of sex therapy training, left the program with the comment that it had been the most valuable training he had ever had, but that he knew now that he could never be a sex therapist.

The exposure to sex therapy training on the organ/sensation level reawakens many of the anxieties associated with sex that were thought to have been resolved or understood but have not been eliminated completely. The typical reaction of the inexperienced sex therapist is to deny (as in the example given) or to avoid. Beginning trainees typically are eager to treat intrapsychic or interpersonal difficulties (which may be very minor), even when these are not resistances to the sex therapy and should be bypassed, postponing their confrontation with the physicality of sex for as long as possible. Working through the trainee’s anxieties takes varying amounts of time, but the individual, dyadic, or family therapist who wishes competence in sex therapy should allow for a training period of approximately two years.

Sex is one of the dominant factors in the functioning of whole people with, presumably, greater awareness of the barriers to experiencing one’s wholeness. Like everyone else, therapists are not immune to problems in the sexual sphere; like everyone else, their individual and interpersonal lives benefit greatly when sexual difficulties are alleviated. So does their impact as therapists. For the patient, holistic therapy is most effective when it is performed by therapists secure and enthusiastic in their own holistic functioning.

*263/187/5*

But in their extrasexual functioning elderly couples exhibit all the variations in type, intimacy, and style as do younger couples. Once age-related changes are recognized, sex therapy for the elderly is the same as sex therapy for the younger, with perhaps a stronger attitude on the part of the therapist that “forbidden” normal practices are in fact not merely permissible but even desirable.

The elderly are popularly supposed to be resistant to change, but I have not encountered this phenomenon in my own practice. I have concluded that this resistance of the elderly is not so much inherent as evoked. It is a reaction to two complementary sets of changes experienced by the elderly: those they perceive in their own physical functioning and those they perceive in the way they are treated by others.

The perception of internal change, especially the perception of weakening powers, can provoke anxiety. However, this anxiety can be managed satisfactorily by most of the elderly when they understand that weakening powers do not mean reduced gratification. But when this anxiety is coupled with the attitude of most other people that the elderly person is less competent and less useful than other people are, the elderly feel diminished indeed. This external attitude is harder to fight against because it seems to be confirmed by their own aging bodies. Undermined by the loss of their sense of themselves as accomplished, whole people, they regain a sense of mastery by assuming a rigid posture, by insisting on no-change. When the elderly then are directed to change, this insistence can be defended successfully and a sense of strength is gained.

But only let the therapist encourage the elderly with the same attitude of optimism with which he or she encounters younger patients, and the results are striking. When the external world confirms not the diminution but the sustenance of the elderly, the elderly most often will respond with a mental and emotional (and often physical) vigor that can serve as a lesson to the younger.

*262/187/5*

Sometimes one has an affair in order to obtain the sexual (and other) satisfactions missing in the marriage, but often the purpose is to retaliate for the injuries, real or imagined, or to alert the partner that the marriage has reached the breaking point.

In two ways, the extramarital affair can at least temporarily assist the marriage. When it is done in order to obtain otherwise unavailable gratification, it can help that partner to be more generally content and better able to tolerate the other stresses in the family. Clearly, when the unfaithful partner deliberately allows the other to learn of the affair (one man phoned his lover from his home, knowing that his wife usually listened to his conversations on an extension phone), it is a signal that the relationship has become too dysfunctional to be tolerated, and a stimulus for change. Often it is the last stimulus for change before a permanent separation.

Although the early problems of the dysfunctional, experienced married couple may not have been sexual in nature, sooner or later (usually sooner) they reach the sexual sphere. A sexual dysfunction appears or becomes aggravated, or the sex life of the couple begins to suffer in one way or another. From that point on, as with the young married dyad, the experienced married couple usually identifies the sexual problem as the core problem. Although in an etiological sense this may not be true, the therapist may take advantage of this belief by starting sex therapy as early as possible (if hostility between the couple has not progressed too far). With the experienced married couples, the most dramatic extrasexual effects of sex therapy are encountered. Like most couples, they have begun their relationship by being in love and over a period of time have seen all or most of their positive feelings for each other change to or become over-laden with tension, hostility, distrust, resentment, and defensiveness, until they seem to themselves to be trapped in a situation at once intolerable and unchangeable. As sex therapy proceeds and as the initial and intermediate results bring both partners not only new sexual satisfaction but also new ways of relating, the incrustation of negative feelings and habits begins to drop off, and the couple experiences again the initial feelings of love, trust, and excitement. Whether or not other problems remain, and usually they do, this recaptured early ardor is almost always enough to propel them through those problems with eagerness and hope.

Of all the types of dyads or couples who come into sex therapy, the quickest and smoothest progress is often made by the experienced unmarried dyad or newly remarried. Usually but not always, these two people have been married before, care about each other, and are committed to a long-term relationship, usually remarriage. Resolved not to repeat the mistakes of the past, they also have learned how to help their partner avoid falling into old, painful patterns.

One middle-aged couple had just been married to each other, the second marriage for both. The presenting symptom was secondary impotence in the man. During their courtship he occasionally had experienced secondary impotence, but after their marriage it seemed to have become permanent. The man suggested to the woman that she see other men for sexual satisfaction, a clear regression to an earlier mode of coping with anxiety. The woman flatly refused and insisted that they go into sex therapy together. Within four sessions, with the wife’s full cooperation every step of the way, the secondary impotence was cleared up.

Although the rapidity of this cure was unusual, the general outlines of the case are not. The experienced unmarried couple, or the experienced newly married, are very promising candidates for sex therapy.

*261/187/5*

When sex therapy begins, both partners tend to be equally enthusiastic. As the therapy proceeds and as the results become apparent, covert sabotaging often begins on the part of the non-dysfunctional partner.

A couple in their late twenties, married for two years, had not consummated their marriage. The husband would become flaccid upon attempting entrance to the vagina and had never been able to penetrate. After the first six months, he was even unable to obtain the firm erections he had had up until the attempted entrance.

In the first phase of therapy, with intercourse prohibited, the husband was able to sustain long, firm erections. When intercourse was permitted, at the couple’s discretion, the couple reported a very strange phenomenon. Even though the wife (not a virgin) was well lubricated, even using the least-threatening (for the male) female superior position, and even with good erections, the husband had not been able to penetrate.

Questioning revealed that the wife was actually dodging the husband’s penis; by her movements she was preventing him from entering the vagina. Further discussion helped the wife realize that she was fearful that once her husband became fully potent and functional, he would be unfaithful and then desert her.

This session was enough to dissolve the unconscious sabotaging problem, and four more sessions concluded the sex therapy. Therapy for other problems, however, continued.

As noted earlier, sabotaging usually results from low self-esteem, although more complicated intrapsychic factors may be present. Ironically, as mentioned earlier, it is rare for the cured partner to leave the other partner, either formally or by seeking extramarital sex, or for example, by the newly orgastic woman turning into a nymphomaniac. In almost every case the whole relationship is bolstered by improved sexual functioning; the typical reaction of both partners is to wish that they had had sex therapy when the problem first arose.

It probably has been noted that I did not define “young” in young dyads. The reason is that there is no real line of demarcation between the young and what I have called the experienced. But it is reasonable, I believe, to consider as young those who are in their twenties, who have been married (or have had a strong commitment) to each other for up to five years, and who do not have children past the age of two. When children come, the couple’s perception of itself alters radically, but it takes some time for the transformation to be complete. When the baby first is born, the couple remains a young couple with a baby; only after about two or three years does the couple consider themselves a family. At that point they are or may be an experienced couple.

How the experienced married dyad views themselves as individuals and as a couple is reflected in their approach to therapy. Most often, when problems, including sexual problems, arise, the couple’s initial visit will be to a marital or family therapist. Even if the patients believe explicitly or tacitly that the sexual difficulty is and has been at the root of their global problem, they still will tend to start out with marital or family therapy.

By the time they do seek therapy, the global problem usually has become severe. Problems neglected before the children came have grown worse. The children, even those without problems, have added new stresses to the relationship, and those with problems have exacerbated the tension and hostility.

*260/187/5*

Sometimes the blood-flow problem can be corrected by replacing the narrow artery with a new, artificial one; sometimes the solution is to insert a tiny, deflated surgical balloon into the partially blocked artery and inflate the balloon to dilate the artery. Both types of surgery offer a real chance of restoring potency.

Another option for men whose potency problems can be blamed on malfunctioning arteries is to bring in a new blood supply to the penis. There are two basic ways to do this.

One method involves taking an artery, usually from the abdominal wall, and rerouting it so it carries blood into the penis. One end of the artery stays in the normal position, while the other is cut and swung around so it supplies the penis. The operation qualifies as major surgery and takes several hours.

The other option is to remove a well-functioning vein from the leg and hook it into an artery which normally supplies the leg. The vein then actually carries some of the blood meant for the leg into the penis. It’s a type of bypass operation, and the replaced vein actually functions as an artery.

*169\184\8*

When you first have a shot, your erection should be gone before you go home. If the erection isn’t gone within four hours, or sometimes sooner, the doctor should remove the blood without delay.

Although these shots represent a real breakthrough in diagnosing impotence, they are not without risk. Clearly, patients who have such injections require expert supervision and care by physicians (usually urologists) who are able to handle the possible complications. Be sure you understand the procedure thoroughly before you agree to it.

Some experts think that the penile shots will become a commonly used diagnostic tool, and some researchers even believe the technique may eventually replace the NPT test in many cases.

*129\184\8*

When I saw him five months later, his condition had greatly improved, but now he had a new complaint: periodic episodes of ED. Since he had responded so well to Lasix and had incorporated lifestyle changes into his daily routine, I decided to try lowering his dosage. The intention, of course, was to maintain his improved circulation as well as combat his ED. First, he tried taking the medicine every other day instead of daily. The result was a return of the edema and sporadic ED. The next step was to reintroduce the daily dose, but at lower levels. This time, the edema was reduced and the ED was eliminated.

Lowering the Dosage and Adding Another Drug

Bill was taking 100 mg of Hygroton, a diuretic used to lower his hypertension. Although the medicine worked, the forty-six-year-old soon developed erection problems. To counteract his ED, I chose to lower the dosage to 25 mg, although I knew that this alone would not be enough to control his blood pressure. So, I also prescribed a small dose °f Hytrin, a vasodilator. The combination of the two controlled the hypertension and got rid of his ED.

*101\183\8*

Nature has done a fairly good job of protecting the testicles despite their somewhat vulnerable location. Simply getting bumped or bruised in the groin will not usually cause any permanent damage to these sexually vital organs—although it can be excruciatingly painful. But severe injury to the testicles, which results in significant swelling, bleeding and bruising, can permanently damage these organs and impair their ability to manufacture testosterone. Luckily, nature has given men some protection by providing testicles in pairs; if just one testicle is injured, the other will almost always produce enough testosterone to keep the body running properly. For potency to be affected, both testicles must be impaired.

Testosterone: Pills or Shots?

Your doctor can prescribe testosterone in pill form, or give you injections. Because the pills aren’t absorbed efficiently in the body, and may cause liver damage, we favor taking any needed testosterone by shot. The slight inconvenience of the needle seems outweighed by the increased effectiveness and safety of the drug. (Usually, the shots must be given about every three weeks.)

Nerve Diseases

Any disease or injury that damages the nervous system can cause erection problems. Multiple sclerosis, spinal cord injuries and other back problems, epilepsy, stroke and Parkinson’s disease are among the most common causes of nervous system-linked potency problems, a few of which are discussed below.

*72\184\8*

An erection is not something a man consciously decides to do, like flexing his biceps, kicking a ball or raising his arm. Instead, erection is a complicated physical and emotional response. The stage is best set with a willing (hopefully, enthusiastic) partner, a comfortable setting free from distractions and enough time not to feel pressured. Assuming all systems are go—that he has no medical problems that affect his ability to get or maintain an erection, isn’t too tired, depressed or distracted and is sufficiently aroused—the man will probably find himself with an erection. But because erection is such a complex, delicate process, there are many things that can prevent it from happening. Some are within a man’s control.

One key to sexual success is to know how to avoid sabotaging yourself so you don’t unknowingly create situations that make having and maintaining potency difficult, or downright impossible.

*37\184\8*

If the man picks up his partner, the greatest amount of exertion is the initial lift. Once he has achieved this, the standing position is not particularly demanding because the weight is evenly distributed between the two partners. From here, making love can continue while standing up, walking or even dancing.

1 To facilitate insertion, the woman should lift one leg, turn it sideways so that her partner can introduce his penis, and then use both legs for support. The vagina then clasps the penis firmly; she can use her pelvis to make strong sexual movements.

2 Once the man is inside, he can lift his partner by placing his hands under her thighs while she firmly clasps her hands behind his neck and holds on to it. She should then cross her legs behind his back and press her thighs around his hips.

3 If both partners are agile, insertion can be achieved after the woman has been raised off the ground. Now t man can move his partner and forth with his hands and alter tempo and motion.

She can entwine herself around his body, gripping with her arms and thighs to distribute some o her weight. Her muscle tension can heighten sexual excitement for both of them

With his legs bent he can freely thrust into his partner

Man

The main benefit of standing positions is the novelty factor, since a degree of agility and strength is required, but they are ideal when the man wishes to dispense with preliminaries. More vigorous thrusting can be achieved if the woman is pressed against a wall or door for extra support.

Woman

Standing positions are useful when the time and place for sex is limited, and when she wants to add some variety to her sex life. She can produce a very powerful stimulation on her vaginal lips and-clitoris if she leans forward a little and bends her knees while her feet are on the floor.

*121\79\2*