The State of Theory in Sex Therapy

Article excerpt

Studies conducted in the U.S. indicate that a substantial proportion of the adult population experiences some sort of sexual dysfunction (Laumann, Gagnon, Michael, & Michaels, 1994; Rosen, Taylor, Leiblum, & Bachman, 1993; Spector & Carey, 1990). Although many individuals do not seek professional intervention for their sexual difficulties, a great number of people do. Despite criticism from some professionals regarding its legitimacy (e.g., Szasz, 1980, 1983), a specific field, commonly referred to as sex therapy, has evolved to address sexual difficulties presented by clients.

In the past 25 years, numerous articles and books have been published on the practice of sex therapy. Indeed, periodicals such as the Journal of Sex and Marital Therapy have been established explicitly as vehicles for the publication of empirical and theoretical articles in this field. At this point, it is legitimate to reflect on the history of sex therapy. Specifically, what is the current state of theory underlying the clinical enterprise of sex therapy? Attempting to answer this question is the primary focus in the current article.

In attempting to elucidate the current state of theory in sex therapy, I first provide a brief overview of the history of contemporary sex therapy. Subsequently, I discuss some basic assumptions underlying various sex therapy approaches. In other words, the emphasis in the current article is on the implicit and explicit assumptions underlying sex therapy with regard to a few primary dimensions. For example, what assumptions do different sex-therapy approaches entail with regard to etiological factors? What is seen as the appropriate unit of treatment (individual versus couple)? Last, what is the nature of the prescribed therapeutic intervention within each theoretic approach?

As will become apparent, underlying assumptions in these three domains are related yet help define each particular sex-therapy approach. In the current article, the term sex therapy is defined broadly and refers to any systematic attempt by a health professional to alleviate sexual dysfunction or difficulties experienced by a specified client. Also, the references cited in the current article are not meant to be exhaustive, but rather representative, of the reports and treatises published thus far.

Historical Overview

The history of sex therapy as a discipline is relatively brief (Leiblum & Rosen, 1989). From the start of the twentieth century until the late 1960s, sexual dysfunction was typically treated within a psychoanalytic framework (Rosen & Weinstein, 1988), as were most psychological problems (Comer, 1995). From such a psychoanalytic perspective, psychological and sexual problems were viewed as originating from unresolved conflicts dating back to childhood, particularly conflicts over problematic attachments and tension in relation to one's parents (Patterson & Watkins, 1996). Sexual problems were seen as symptoms of greater "core" psychopathology (Rosen & Weinstein, 1988). As such, treatment consisted of long-term, individual psychotherapy to unmask the underlying (and often unconscious) intrapsychic conflicts that manifested themselves as disruption of "healthy" or "mature" sexual functioning. In contrast to this dominant perspective, a few clinicians (e.g., Lazarus, 1971; Obler, 1973; Wolpe, 1958) explicitly applied behavioral principles in the treatment of sexual dysfunction, but such approaches were not the norm prior to the 1970s.

Sex therapy as it is known today was essentially founded by Masters and Johnson (1970), whose published report on a "new" therapeutic approach to sexual problems revolutionized what health professionals saw as the appropriate treatment for such difficulties. In contrast to psychoanalytic approaches, the "new" sex therapy was relatively brief, problem focused, directive, and behavioral with regard to technique. Rather than intrapsychic factors, Masters and Johnson (1970) emphasized social and cognitive causes of sexual dysfunction; ultimately, the large majority of sexual difficulties were seen as arising from a sexually restrictive or religiously orthodox upbringing. …