Category: Men’s Health

The ultimate level in couple communication is sexual intercourse. When there is couple complaint of sexual dysfunction, the primary source of absolute communication is interfered with or even destroyed and most other sources or means of interpersonal communication rapidly tend to diminish in effectiveness.

Again, this loss of warmth and understanding is frequently due to fear and/or lack of comprehension on the part of either marital partner. The wife is afraid of embarrassing or angering her husband if she tries to discuss his sexually dysfunctional condition. The husband is concerned that his wife will dissolve in tears if he mentions her orgasmic inadequacy or asks for suggestions to improve his sexual approaches.

Usually the failure of communication in the bedroom extends rapidly to every other phase of the marriage. When there is no security or mutual representation in sexual exchange, there rarely is freedom of other forms of marital communication.

It should be made abundantly clear, in context, that Foundation philosophy does not reflect the concept that sexual functioning is the total of any marital relationship. It does contend, however, that very few marriages can exist as effective, complete, and ongoing entities without a comfortable component of sexual exchange. With detailed interchange of information, and with interpersonal rapport secured between marital partners, the dual-sex therapy team moves into direct treatment of the specific sexual inadequacy brought to its attention.

After roundtable discussion, the team anticipates that both partners in the distressed couple will have become reassured and relatively relaxed by the basic educational process and will have established a significant step toward effective communication. Treatment approaches to specific sexual dysfunctions will be discussed separately under appropriate headings in subsequent individual case.

Sexual Advice

From a professional point of view, formal training contributes little of positive value if a specific discipline is emphasized to a dominant degree in the treatment of sexual dysfunction. It is current foundation policy to pair representatives of the biological and behavioural disciplines into teams of cotherapists.

From a purely practical point of view, there is obvious advantage in having a qualified physician as a member of each team. This disciplinary inclusion avoids referring embarrassed or anxious couples to other sources for their vitally necessary physical examinations and laboratory (metabolic function) evaluations. The behavioural member provides invaluable clinical balance to each team with his or her particular contribution of psychosocial consciousness.

Many combinations of disciplines should and will be used experimentally as representative individuals are available, complying with the Foundation’s basic concept of a member of each sex on each team.

The Foundation is constantly looking for professionals with the individual ability necessary to work comfortably and effectively with people in the vulnerable area of sexual dysfunction. There must be an established research interest; this requirement is peculiar to the Foundation’s total research program but is unnecessary for purely clinical programs.

There also must be an expressed interest in and demonstrated ability to teach, for so much of the therapy is but a simple direct educational process. Not a negligible requirement is the willingness to make a commitment to a seven day week or its equivalent.

Most important, the individual must be able to work in continual cooperation with a member of the opposite sex in what might be termed a single standard professional environment. Team dominance by virtue of sex-linked or discipline-linked status by either cotherapist would tend to dilute their mutual effectiveness in this particular psychotherapeutic design.

Finally, individual members of any dual sex therapy team, if they are to concentrate professionally on the distress of the couples complaining of sexual inadequacy, must be fully cognizant and understanding of their own sexual responsivity and be able to place it in perspective. They must be secure in their knowledge of the nature of sexual functioning, in addition to being stable and confident in their own sexuality, so that they can in turn be objective and unprejudiced when dealing with the controversial subject of sex at the fragile level of its dysfunctional state.

Many men and women who are neither personally secure in nor confidently knowledgeable of sexual functioning attempt the authoritative role in counselling for sexual inadequacy. There is no place in professi6nal treatment of sexual dysfunction for the individual man or woman not culturally comfortable with the subject and personally confident and controlled in his or her own manner of sexual expression.

The possibility for disaster in a therapeutic program dealing with sexual dysfunction cannot be greater than when the therapist’s sexual prejudices or lack of competence and objectivity in dealing with the physiology and psychology of sexual functioning become apparent to the individuals or couples depending upon therapeutic support.

If the therapist is in any way uncomfortable with the expression of his or her own sexual role, this discomfort or lack of confidence inevitably is projected to the patient, and the possibility of effective reversal of the couple’s sexual dysfunction is markedly reduced or completely destroyed.

At onset of the program, couples were requested to devote three weeks of their time to the therapeutic program. This concept of time commitment was maintained for the first two years of this clinical research program.

Evaluation of sexual experience made clear that three weeks was simply too long for a couple’s comfortable commitment of time away from home and, from the stand point of therapy demand also was an unnecessarily extended period. Therefore, the outer limit of time demand became two weeks and has remained so for the last nine years.

An important clinical contribution to effective therapy in sexual dysfunction can be made by scheduling husband and wife partners on a continuum; all units in the acute phase of the treatment program are seen daily (seven days a week) during their two weeks in the foundation’s intensive educational program.

One of the therapeutic advantages inherent in the two-week phase of rapid education and/or symptom reversal is the isolation of the husband and wife partners from the demands of their everyday world.

Approximately 90 percent of all couples treated by the Foundation are referred from outside the St. Louis area. These people are regarded and treated as though they were guests. Every effort is made to insure their enjoyment of a “vacation” during time spent in the city.

Care is taken to familiarize them with the geographic area and supply up-to-date information regarding restaurants, areas of interest, amusement, educational potentials, etc.

Inevitably they rekindle, in part, their own communicative interests when there is no child crying, no secretary reminding of business commitments, or no relatives or friends inadvertently intruding. With this isolation from social demand, opportunity develops for closeness or a unity that almost always is missing between marital partners facing crises of sexual dysfunction.

This arbitrary social isolation certainly is an important factor supporting the effectiveness of the therapy program. Under these circumstances protected from outside pressures the marital partners frequently accept for the first time the Foundation’s basic premise that “there is no such thing as an uninvolved partner in any marriage distressed by a complaint of sexual inadequacy.”

Sexual Interest

Yet another advantage of the social-isolation factor is its effect upon the sexual interest of both marital partners. With the subject of sex exposed to daily consideration, sexual stimulation usually elevates rapidly and accrues to the total relationship. This specific psycho physiologieal support is indeed welcome to the cotherapists dealing with the blocking of sexual stimuli in individuals distressed by sexual inadequacy.

To help develop a level of sexual interest:
for the couple which is realistic to their life style, vacations from any form of specific sexual activity are declared for at least two 24-hour periods during the two weeks, in a system of timely checks and balances. However, daily consideration of sexual matters and social isolation continue to give maximum return to this facet of the psychotherapy.

It might be held as part of this therapeutic concept that patients must have the opportunity to make those mistakes which reveal factors contributing to their particular distress. This means of learning is particularly important in reversing sexual dysfunction. In this interest, the patients are told that the cotherapists are not interested in a report of perfect achievement when they are following directions in the privacy of their own bedroom. Article Sponsored Find something for everyone in our collection of colourful, bright and stylish socks. Buy individually or in bundles to add color to your drawer!

The cotherapists are interested in couple’s making their usual errors of reaction and interaction as they involve themselves in situations that provide opportunity for natural response to sexual stimuli. If the mistakes then are evaluated and explained in context, the educational process is infinitely less painful and more lasting. There are significant advantages in this technique.

When mistakes are made, they are examined impartially and explained objectively to the unit within 24 hours of their occurrence. Additionally, they are discussed within the context of the misunderstanding, misconceptions, or taboos that may have led to or influenced their occurrence initially.

There is yet another specific advantage in daily conferences. If the distressed unit waits a matter of days after mistakes are made before consulting authority, the fears engendered by their specific episode of inadequacy or mistake in performance increase daily in almost geometric progression. In such a situation, alienation between partners is a common occurrence. By the time the next opportunity for consultation arises, a great deal of the effectiveness of prior therapy may have been destroyed by the takeover of the fears.

Fears of performance do not wait a few days or a week until the next appointment; in the meantime, the couple, separately or together, must use their own methods of coping. Most often this will be withdrawal of sexual or total communication, which places them further away from altering the sexual distress than before therapy was initiated.

When patients do not make mistakes during their acute phase of treatment, the cotherapists arrange for them to do so. It is inevitably true that individuals learn more from their errors than from their ability to follow directions effectively on the first attempt.

If marital partners reverse their sexual dysfunction and fully understand, through comparison with episodes of failure, why and what made it possible for them to function effectively, the probability of reduplicating the success in the home environment is increased immeasurably.

As evidence of the advantage to the therapeutic program of the unit’s social isolation, those couples referred from the St. Louis area require three weeks to accomplish symptom reversal rather than the standard two weeks for those living outside the local area. It is difficult to isolate oneself from family demands and business concerns if treatment is being ear tied out in the environment in which the couple lives.

For this reason it has been found more effective to see patients referred from the St. Louis area on a daily basis for the first week, there after five times a week, and to assign a total of three weeks to accomplish reversal of symptomatology. Partners in sexually distressed marriages who cannot or do not isolate themselves from the social or professional concerns of the moment react more slowly, absorb less, and communicate at a much lower degree of efficiency than those advantaged by social retreat.

The Foundation’s request for two weeks’ withdrawal from daily demands, at first rather an overwhelming suggestion to most patients, pales into insignificance when compared to the isolation demands engendered by necessary hospitalization for acute surgical or medical problems. When the couple’s presenting complaint is one of sexual inadequacy, it should constantly be borne in mind that there is not only the equivalent of two distressed people but also an impaired marital relationship to be treated.

In therapeutic procedure involving the dual-sex teams, the control within the team rests primarily with the silent cotherapist during treatment sessions. The silent cotherapist is literally in charge of each therapeutic session. He or she, as the observer, is watching for and evaluating levels of patient receptivity to therapeutic concept and to the educative and directive material presented by the active cotherapist.

The silent cotherapist’s role is to define, if possible, degrees of understanding, acceptance, or rejection of material and to identify immediate areas of concern in either member of the dysfunctional couple.

The silent observer really acts as the coach of the team. As soon as it is apparent that there is need for a situational change of pace, that the individual subject under discussion can be presented in a different, possibly more acceptable or understandable manner, or that it requires further clarification, the roles reverse and the cotherapist functioning previously as the observer, fortified and advantaged with the salient features of patient reaction to the on going situation, becomes the active discussant.

The previous discussant then assumes the role of observer. And so roles change back and forth as indicated by patient responses or the immediate need for a particular sex-linked definition or explanation of material. Much of the patient’s reaction can be identified by the observer that cannot be immediately apparent to any individual therapist simultaneously attempting to direct therapy and to evaluate levels of patient receptivity.

In the finite cooperative interaction between mutually confident cotherapists in any dual-sex therapy team, the currently dominant partner influence at any particular time is not being exercised by the one that is talking, but by the one that is observing.

Inevitably any sexually dysfunctional couple has, as one of its fundamental handicaps, insecurity in any and all sexual matters.

How often have the sexual partners asked themselves if they are really “complete” as individuals?
Has their functional efficiency been diminished in stressful situations other than in bed?
How do their patterns of sexual response compare to those of their peers?
How can a particular sexual situation or any confrontation with material of sexual content be handled without awkwardness or embarrassment?

The cotherapists encounter a multiplicity of these problems to which they can respond by holding up a professional “mirror” and helping the marital partners understand what it reflects. With the non-judgemental mirror available, constructive criticism can be accepted in the same non-prejudiced, comfortable manner in which it must be presented.

With this educational technique of reflective teaching, the distressed couple can be encouraged to take that first step that ultimately presages success in therapy for sexual dysfunction. The step consists of putting sex back into its natural context.

Seemingly, many cultures and certainly many religions have risen and fallen on their interpretation or misinterpretation of one basic physiological fact. Sexual functioning is a natural physiological process, yet it has a unique facility that no other natural physiological process, such as respiratory, bladder, or bowel function, can imitate.

Sexual responsivity can be delayed indefinitely or functionally denied for a Iifetime. No other basic physiological process can claim such male ability of physical expression.

With the advantage of this unique characteristic, sexual functioning can be easily removed from its natural context as a basic physiological response. Everyone takes advantage of this characteristic every day as he rejects or defers untimely or inappropriate sexual stimuli in order to comply with the social requirements of the moment.

Religions have found dedicated support from those willing to sacrifice their functional physical expression of sexuality as a devotion to or an appeasement for their god or gods. If the natural physiological process of human sexual response did not encompass this completely unique adaptability, the sacrifice of denying one’s sexual functioning for a lifetime could never have been made.

But the individuals who involuntarily take sexual functioning further out of context than any other are those members of couples contending with inadequacy of sexual function. Through their fears of performance (the fear of failing sexually), their emotional and mental involvement in the sexual activity they share with their partner is essentially nonexistent.

The thought (an awareness of personally valued sexual stimuli) and the action are totally dissociated by reason of the individual’s involuntary assumption of a spectator’s role during active sexual participation.

It is the active responsibility of therapy team members to describe in detail the psychosocial background of performance fears and “spectator” roles. This explanation is best accomplished by the cotherapist of the same sex as that of the individual whose performance fears are to be discussed. Again, education is the basis for therapeutic success, and the dual-sex team can best present this information by following a sex-linked guideline.

Sexual Dysfunction Treatment

In any approach to a psycho-physiological process, treatment concepts vary measurably from school to school and, similarly, from individual therapist to individual therapist. The Reproductive Biology Research Foundation’s theoretical approaches to the treatment of men and women distressed by some form of sexual dysfunction have altered significantly and, hopefully, have matured measurably during the past 11 years. There are founded on a combination of 15 years of laboratory experimentation and 11 years of clinical trial and error.

Sexual Response

When the laboratory program for the investigation in human sexual functioning was designed in 1954, permission to constitute the program was granted upon a research premise which stated categorically that the greatest handicap to successful treatment of sexual inadequacy was a lack of reliable physiological information in the area of human sexual response.

It was presumed that definitive laboratory effort would develop material of clinical consequence. This material in turn could be used by professionals in the field to improve methodology of therapeutic approach to sexual inadequacy. On this premise, a clinic for the treatment of human sexual dysfunction was established at Washington University School of Medicine in 1959, approximately five years after the physiological investigation was begun. The clinical treatment program was transferred to the Reproductive Biology Research Foundation in 1964.

When any new area of clinical investigation is constituted, standards must be devised in the hope of establishing some means of control over clinical experimentation. And so it was with the new program designed to treat sexual dysfunction. Supported by almost five years of prior laboratory investigation, fundamental clinical principles were established at the onset of the therapeutic program. The original treatment concepts still exist, even more strongly constituted today. As expected, there were obvious theoretical misconceptions in some areas, so alterations in Foundation’s policy inevitably have developed with experience.

If there are to be dual-sex therapy teams, what roles do the individual cotherapists play? What guidelines do they follow? What therapeutic procedures ensue? What should be their qualifications as professionals in this sensitive, emotionally charged area? These are all pertinent questions, and, as would be expected, in some cases they are difficult to answer.

The major responsibility of each cotherapist assigned to a husband and wife problem is to evaluate in depth, translate for, and represent fairly the member of the distressed couple of the same sex. This concept should not be taken to suggest that verbal or directive interaction is limited to wife and female cotherapist or to husband and male cotherapist far from it. The interpreter role does not constitute the total contribution an individual cotherapist makes in accepting the major responsibility of sex-linked representation. The male cotherapist can provide much information pertaining to male-oriented sexual function for the wife of the distressed couple; and equally important, female-oriented material is best expressed by the female cotherapist for benefit of the husband.

Acute awareness of the two-to-one situation frequently develops when a sexually distressed couple sees a single counsellor for sexual dysfunction.

For example, if the therapist is male and there is criticism indicated for or direction to be given to the wife, the two-to-one opposition may become overpowering.

Who is to interpret for or explain to the wife matters of female sexual connotation? Where does she develop confidence in therapeutic material she cannot express her concepts adequately to the two males in the room?

Exactly the same problem occurs if the therapist is female and contending with a sexually dysfunctional couple. Who interprets for or to the husband?

Dual Sex Team

Avoids the potential therapeutic disadvantage of interpreting patient complaint on the basis of male or female bias. Experience has established a recognizable pattern in the various phases of response by a female patient to questioning by a male cotherapist.

As a rough rule of thumb, unless the distress is most intense, the wife can be expected to tell her male therapist first what she wants him to know; second, what she thinks he wants to know or can understand; and not until a third, ultimately persuasive attempt has been made can she consistently be relied upon to present material as it is or as it really appears to her. With the female cotherapist in the room, although the wife may be replying directly to interrogation of the male cotherapist.

During the first exposure to questioning she routinely is careful to present material as she sees it or as she believes it to be, for she knows she is being monitored by a member of her own sex. The inference, of course, is that “it takes one to know one.” The “presence” usually is quite sufficient to remove a major degree of persiflage from patient communication.

When the sexually dysfunctional male patient is interviewed by a female therapist, it is extremely difficult to elicit reliable material, for cultural influence inevitably will prevail. Many times the male tells it as he would like to believe it is, rather than as it is.

Sexual Dysfunction and Male Ego

His ego is indeed a fragile thing when viewed under the spotlight of untempered female interrogation. Not infrequently his performance fears, his anxieties, and his hostilities are magnified in the face of his concept of a prejudiced two-to-one relationship in therapy, when he presumes that his wife has the advantage of the therapist’s sexual identity.

The participation of both sexes contributes a “reality factor” to therapeutic procedure in yet another way. It lessens the need for enactment of social ritual designed to gain the attention of the opposite-sex therapist, an unnecessary diversion which often produces biased material in its effort to impress.

These hazards of interrogation and interpersonal misinterpretations can be bypassed through use of the dual-sex team. Certainly, during history-taking there is a session devoted to male cotherapist interrogation of the wife and female cotherapist interrogation of the husband, but in each instance within the method there is built-in protection to avoid the previously mentioned pitfalls.

First
The husband has had an extensive discussion with the male cotherapist the previous day (as has the wife with the female cotherapist); thus, the pattern for same-sex confrontation and information interchange has already been introduced, concomitantly establishing greater reliability of reporting.

Second
Both members of the sexually disturbed couple are aware that four persons are committed to a common therapeutic goal and that all parties will be brought together the next day for the roundtable discussion. Hence, any tendency of the patient to provide the cotherapist with inaccurate clinical material in the opposite-sex interrogative session usually is curbed in advance by the dual-sex team environment and the previously described progression of the treatment program.

Equal partner representation in a problem of sexual dysfunction is a particularly difficult concept to accept for those patients previously exposed to other forms of psychotherapy. When either partner has been accustomed to being the principal focus of therapy, he or she finds it strange indeed that neither partner holds this position. Rather it is their interpersonal relationship within the context of the marriage that is held in focus.

An additional fortunate therapeutic return from the presence of both sexes within the therapy team is in the area of clinical concern for transference. There always is transference from patient to therapist as a figure of authority. There is no desire to avoid this influence in the therapeutic program, but, beyond both patients’ and therapists’ need to establish the authority figure, every effort is made in the brief two-week acute phase of the therapy program to avoid development of a special affinity between either patient and either cotherapist .

Instead of generating emotional currents, especially those with sexual connotation, from one side of the desk to the other, the therapeutic team is intensely interested in stimulating the flow of emotional and sexual awareness between husband and wife and encourages this response at every opportunity.

For example, if the team were to observe the wife becoming intensely attentive to the male cotherapist, directing all questions to him, accepting or even prompting answers only from him, in short, replacing the husband with the cotherapist as the male figure of the moment. The team would take steps to counteract this distracting, potentially husband-alienating trend.

The male cotherapist would begin to direct questions only to the husband, and all material pertinent to the wife (even including basic information pertaining to male sexual response) would be presented by the female member of the team until it was obvious that the wife’s incipient tendency to establish special interpersonal communication with the male cotherapist had been counterbalanced by team intervention. Attempted recruitment of special rapport with the female cotherapist by the husband is handled in a similar manner.

To create further emotional trauma for either sexually insecure marital partner by encouraging or accepting such alignment, however deliberately or naively proffered, is not only professionally irresponsible, but also can be devastating to therapeutic results.

It cannot be emphasized too vigorously that the techniques of transference, so effective in attacking many of the major psychotherapeutic problems over the years, are not being criticized. The Foundation is entirely supportive of the proper usage of these techniques as effective therapeutic tools.

However, from the start of the clinical program, the Foundation has taken the specific position that the therapeutic techniques of transference have no place in the acute two-week attempt to reverse the symptoms of sexual dysfunction and establish, re-establish, or improve the channels of communication between husband and wife.

Anything that distracts from positive exchange between husband and wife during their time in therapy is the responsibility of the therapeutic team to identify and immediately nullify or negate.

Positive transference of sexual orientation can be and frequently is a severe deterrent to effective reconstitution of interpersonal communication for members of a couple, particularly when they are contending with a problem of sexual dysfunction.

Regardless of the particular form of sexual inadequacy with which both members of the couple are contending.

Fears of sexual performance are of major concern to both partners in the marital bed.

The impotent male’s fears of performance can be described in somewhat general terms. With each opportunity for sexual connection, the immediate and overpowering concern is whether or not he will be able to achieve an erection. Will he be capable of “performing” as a “normal” man? He is constantly concerned not only with achieving but also with maintaining an erection of quality sufficient for intromission

His fears of sexual performance are of such paramount import that in giving credence to or even directing overt attention to his fears, he is pulling sexual functioning completely out of context. Actually, the impotent man is gravely concerned about functional failure of a physical response which is not only naturally occurring, but in many phases involuntary in development.

To oversimplify, it is his concern which discourages the natural occurrence of erection. Attainment of an erection is something over which he has absolutely no voluntary control. No man can will, wish, or demand an erection, but he can relax and allow the sexual stimulation inherent in erotic involvement with his marital partner to activate his psycho-physiological responsivity. Many men contending with fears for sexual function have distorted this basic natural response pattern to such an extent that they literally break out in cold sweat as they approach sexual opportunity.

Impotence

Not only does the husband contend with fears of performance when impotence is the clinically presenting complaint, but the wife has her fears of performance as well. Her constant concern is that when her husband is given adequate opportunity for sexual expression, he will be unable to achieve and/or maintain an erection. She has grave fears for his ability to perform under the stress of the psychosocial pressure which both partners have unwittingly contrived to place upon this natural physical function.

Additionally, wives of impotent men are terrified that something they do will create anxiety, or embarrass, or anger their husbands. All of these crippling tensions in the marital relationship are gross evidence that two people are contending with sexual functioning unwittingly drawn completely out of context as a natural physical function by their fears of performance.

An exactly parallel situation can be a factor in female sexual inadequacy. Fifty years ago in this country the non orgasmic woman was led (or under the pressure of propriety, forced) to believe that sexual responsivity was not really her privilege. Sexual pleasure was considered an unnatural physical response pattern for women, and any admission of its occurrence was unseemly to say the least.

The popular magazines, with their constant consideration of the subject, have brought to the non orgasmic female a realization that in truth she is a naturally functional sexual entity.

Unfortunately they have also provided her with real fears of performance by depicting, often with questionable realism, the sexual goals of effectively responsive women.

Sexual Stimuli

Her frequently verbalized anxieties when she does not respond to the level of orgasm (at least a certain percentage of time) are: “What is wrong with me? Am I less than a woman? I certainly must be physically unappealing to my husband,” and so on. These grave self-doubts and usually groundless suspicions are translated into fears of performance.

It should be restated that fear of inadequacy is the greatest known deterrent to effective sexual functioning, simply because it so completely distracts’ the fearful individual from his or her natural responsivity by blocking reception of sexual stimuli either created by or reflected from the sexual partner.

Therapy concepts place major emphasis on the necessity for familiarizing the marital partner of a dysfunctional patient with details of the fear component. There must always be real awareness of the fears of performance by the marital partner attempting to support his or her mate in the distress of sexual inadequacy.

The husband of the non orgasmic woman may well have his own fears of performance. He worries about why he, as a sexually functional male, cannot give her the “gift” of response. Why is his wife non responsive to his sexual approaches? What really is wrong when he cannot satisfy her sexual needs?

The husband’s fear of performance when dealing with a non orgasmic wife reflects anxieties directed as much toward his own sexual prowess as to his wife’s inability to accomplish relief of sexual tensions. It is the influence of our culture, expressed in the demand that he “do something” in sexual performance, that gives the man responsibility for the woman’s sexual effectiveness as well as his own.

If his wife is non orgasmic, more times than not he worries about his inadequate performance rather than lending himself with personal pleasure to the mutual sexual involvement that would lead to release of his wife from her dysfunctional status. Together, these frightened people manage to take not only sexual functioning from its natural context, but also keep it in its unnaturally displaced state indefinitely.

One of the most effective ways to avoid emphasizing the patient’s fears of performance during any phase of the therapy program is to avoid all specific suggestion of goal oriented sexual performance to the couple.

Regardless of the length or the intensity of the psycho therapeutic procedures, at some point the therapist usually turns to his or her patient and suggests that the individual should be about ready for a successful attempt at sexual functioning, immediately the fears of performance flood the psyche of the individual placed so specifically on the spot to achieve success by this authoritative suggestion.

Rarely is this suggestion taken as an indication of potential readiness for sexual function, as intended, but usually is interpreted as a specific direction for sexual activity. If there is a professional suggestion that “tonight’s the night,” the individual feels that he has been told by constituted authority that he must go all the way from A to Z, from onset of sexual stimulation to successful completion.

In many instances, regardless of the duration or effectiveness of the psychotherapeutic program, the fears of performance created by this authoritative suggestion for end point achievement are of such magnitude that sensate input is blocked firmly, and there will be no effective sexual performance regardless of the degree of motivation.

Removal of such goal-oriented concept, in any form or application, is necessary to secure effective return of sexual function. This can be achieved by moving the interacting partners, not the dysfunctional individual, on a step-by-step basis to mutually desirable sexual involvement.

Sexual Discussion

Four way verbal exchange is maintained at an open, comfortable level during therapy. Communication is first developed across the desk between patients and cotherapists. Within a few days, verbal exchange is deliberately encouraged between patients.

The cotherapists are fully aware that their most important role in reversal of sexual dysfunction is that of catalyst to communication. Along with the opportunity to educate concomitantly exists the opportunity to encourage discussion between the marital partners wherein they can share and understand each other’s needs.

If the therapy team functions well, its catalytic role in marital communication, which initially is of utmost importance, becomes a factor of progressively decreasing importance over the two week period. If the catalytic role is well played, the marital partners will be communicating with increasing facility at termination of the acute phase of therapy; by then communication between the marital partners should be well established.

When considering intense pain elicited during coital functioning as opposed to vaginal aching or irritation, the therapist generally should look beyond the confines of the vaginal barrel for existent pathology involving the reproductive viscera.

Acute or chronic infections and endometriosis are pathological conditions involving the reproductive viscera; uterus, tubes, and ovaries that consistently may return a painful response as the female partner is sharing coital experience.

Although these two entities will be discussed separately, they do have in common similar physiological creation of painful response patterns during intercourse.

In both instances the response arises from peritoneal irritation resulting in local adhesions not only between folds of peritoneum but also involving tubes, ovaries, bowels, bladder, and omentum.

The combination of involuntary distention of the vaginal barrel created by female sex-tension increment and active male thrusting during coital connection places tension on relatively inelastic pelvic tissues stabilized by minor or even major degrees of fibrosis resulting from the infection or the endometriosis.

In short:
Any clinical condition that creates an untoward degree of rigidity of the soft tissues of the female pelvis, so that they do not move freely during sexual connection can return a painful response to the female partner involved.

Infections in the reproductive organs start with chronic involvement of the cervix (endocervicitis). By drainage through lymphatic channels, long-maintained endocervicitis can involve the basic supports of the uterus (Mackenrodt’s ligament) in a chronic inflammatory process. The resultant low-grade peritoneal irritation initiates painful stimuli when the cervix is moved in any direction, particularly by a thrusting penis.

The uterus itself can be involved with infection in the uterine cavity or endornetritis, or with a residual of infection throughout the muscular walls (myometritis) to such an extent that any pressure upon the organ is responded to with pain.

Retrograde involvement of the peritoneal covering of the uterus and its supports is quite sufficient to cause distress if the uterus is moved, either with involuntary elevation into the false pelvis with female sex-tension increment or during a male thrusting phase in coital connection.

Obviously there are many sources of infection of the oviducts (tubes). Any infections that originate in the cervix have opportunity to spread through the uterine cavity and into the tubal lumina.

The major infective agents are:
Gonococcus, streptococcus, staphylococcus, and coliform organisms. First infections in the tubal lumina frequently spill into the abdominal cavity, causing at least localized pelvic inflammation and at most generalized abdominal peritonitis.

Subsequently, as the acute stage of the infection subsides those areas involved in the infectious process remain open to the development of adhesions between loops of bowel, the omentum, and the pelvic viscera.

There even may be abscess formation involving the tubes and ovaries. In all these situations there is tension on and tightening of the peritoneum and rigid fixation of the pelvic soft-tissue structures to such an extent that vaginal distention and coital thrusting create a markedly painful response for the woman.

In no sense does this brief clinical description of pelvic inflammatory processes imply that whenever any woman acquires infection in the pelvic viscera she is committed thereafter to pain during coital connection.

With early and adequate medical care most pelvic infections do not create a residual of continuing pain with coital exposure. The degree of residual pelvic pain depends upon the severity of the occasional sequelae of the infectious process.

Where are the adhesions and how extensive are they? To what extent is natural expansion of the vaginal barrel restricted by filling of the cul-de-sac with an enlarged tube, by an ovary firmly adhered to the posterior wall of the broad ligament, or by a uterus held in severe third degree retroversion by adhesions? Any of these situations may create painful stimuli with penile thrusting.

There have been three cases referred as problems of dyspareunia in which individual women were involved in gang-rape experiences. In all three instances there were multiple coital connections, episodes of simultaneous rectal and vaginal mountings, and finally traumatic tearing of soft tissues of the pelvis associated with forceful introduction of foreign objects into the vagina.

Superficial and deep lacerations were sustained throughout the vaginal barrel and by other soft tissues of the pelvis. Included in the soft-tissue lacerations were those of the broad ligaments (in each case only one side was lacerated), but these lacerations were quite sufficient to produce severe symptoms of secondary dyspareunia.

For some years after the rape episodes each of the three women was presumed to be complaining of the subsequently acquired pain with intercourse as a residual of the psychological trauma associated with their raping.

The immediately necessary surgical repair to pelvic tissues had been conducted, but beyond the clinically obvious lacerations of vaginal barrel, bladder, and bowel, the remainder of the pelvic pathology understandably had not been described at the time of surgery.

Before gaining symptomatic relief by a second surgical procedure, these three women underwent a combined total of 21 years of markedly crippling dyspareunia, involving a total of five marriages.

The only way that broad-ligament lacerations can be handled effectively is by surgery. Operative findings are relatively constant: (1) The uterus usually is in third-degree retroversion and enlarged from chronic vasocongestion; (2) A significant amount of serous fluid (ranging from 20 to 60 ml in volume) arising from serous weeping developing in the broad-ligament tears is consistently found in the pelvis; (3) There may be unilateral or bilateral broad ligament and/or sacrouterine-ligament lacerations.

It is the inevitable increase in pelvic vasocongestion associated with sexual stimulation added to the already advanced state of chronic pelvic congestion in these traumatized women that can elicit a painful pelvic response.

Particularly does such a response arise when the chronically congested pelvic viscera are jostled by the vaginally encased thrusting penis.

It is not within the range of this textbook to describe the surgical procedures for repair of the traumatic tears of the uterine supports. The reader is referred to the bibliography for more definitive consideration. Subsequent to the definitive surgery, the symptoms of acquired dyspareunia, dysmenorrhea, and the sensations of extreme fatigue usually show marked improvement or may be completely alleviated.

These pelvic findings have been described in far more than usual detail for this type of text, primarily to alert examining physicians to the possibility of the broad-ligament laceration syndrome.

When these pelvic findings have been overlooked, the complaining woman frequently has been told by authority that the pain described with intercourse is due to her imagination. The intelligent woman bas grave difficulty accepting this suggestion. She knows unequivocally that coital activity particularly that of deep vaginal penetration is severely painful.

Actually, she finds that with vaginal acceptance of the full penile shaft, pain is almost inevitable.

Even if she has been orgasmic previously, it is rare that she accomplishes orgasmic release of her sexual tensions during intercourse after incurring broad-ligament lacerations, simply because she is always anxiously anticipating the onset of pain.

Any woman with acquired pelvic disability restraining her from the possibility of full sexual responsivity is frustrated. Without orgasmic release with coital connection there will be a marked residual of acute vasocongestion to provide further pelvic discomfort during a long, irritating resolution phase.

Probably the most frustrating factor of all is to have the acquired dyspareunia disbelieved by authority when the pain with penile thrusting is totally real to the woman involved. The vital question for the therapist to ask should be, “Did this pain with deep penile thrusting develop after a specific delivery?”

If the woman can identify a particular pregnancy subsequent to which the dyspareunia became a constant factor in her attempts at sexual expression, the concept of the broad-ligament-laceration syndrome should come to mind.

Many men complain:
Burning, itching, and irritation after coital connection with women contending with chronic or acute vaginal infections.

Not infrequently small blisters appear on the glans penis, particularly around the urethral outlet. If there are any abrasions on either the glans or shaft of the penis, secondary infection can occur in these local sites.

Irritative Penile Reaction

The same type of irritative penile reaction may develop from exposure to a non infectious vaginal environment as a response to the chemicals in contraceptive creams, jellies, foams, etc.

It may not be the female that responds in a sensitive manner to an intravaginal chemical contraceptive agent but rather her male partner. Sensitivity to intravaginal chemical contraceptives is seen quite frequently in the male and, if symptoms develop, contraceptive technique should be changed.

The same sort of irritative penile reaction can be elicited by a repetitive pattern of vaginal douching.

There are some douche preparations to which not the female but the male partner becomes sensitive.

Not infrequently, vesicles form on the glans penis. If these blisters rupture, the raw areas on the glans are quite painful, particularly during sexual connection.

Gonorrhea

In the actual process of ejaculation there are many situations that return painful stimuli to the involved male. If the individual has had gonorrhea there may be strictures (adhesions) throughout the length of the penile urethra, and attempts to urinate and/or to ejaculate may cause severe pain spreading throughout the penile urethra and radiating to the bladder and prostate.

Infection in the Bladder, Prostate, or the Seminal Vesicles

There may be the sensation of intense burning during and particularly in the first few minutes after ejaculation. Particularly if the offending agent has been the gonococcus, the pain with ejaculation sometimes is exquisite. Immediate medical attention should be given to any complaint of burning or itching during or immediately after the ejaculatory process.

Prostate and Ejaculation

There is a spastic reaction of the prostate gland seen in older men during the stage of ejaculatory inevitability. In this situation the prostate contracts spastically rather than in its regularly recurring contractile pattern, and the return can be one of very real pelvic pain and/or aching radiating to the inner aspects of the thighs or into the bladder and occasionally to the rectum.

This pathologic spastic contraction pattern can be treated effectively by providing a minimal amount of testosterone replacement therapy.

Care should be taken to evaluate the possibility of concurrent infection in the prostate. Occasionally, chronic prostatitis has caused significant degrees of pain during an ejaculatory process.

As a point in differential diagnosis, the painful response with prostatic infection is with the second, not the first, stage of the orgasmic experience, while that of prostatic spasm has just the reverse sequence. Careful questioning usually will establish specifically the timing in onset of the painful response and thus suggest a more definitive diagnosis.

Prostate

Benign hypertrophy of the prostate gland primarily and carcinoma of the prostate rarely may be responsible for onset of pain with the ejaculatory process. The pain is secondary (acquired) in character and radiates to bladder and rectum.

Usually confined to older age groups, onset of this type of dyspareunia should be investigated immediately by competent authority. This review of the major causes of dyspareunia has been primarily directed toward the female partner, for from her come by far the greater number of complaints of painful coital connection.

However, male dyspareunia no longer should be ignored by the medical and behavioral literature. The review of the etiology of male dyspareunia has not been exhaustive, nor is it within the province of this text to do so.

In concept, the entire chapter has been designed to suggest to cotherapists, faced daily with a myriad of problems focusing upon both male and female sexual dysfunction, that there are physiological as well as psychological causes for sexual inadequacy.

Combined pelvic and rectal examinations for the female and rectal examination for the male partner are a routine part of the total physical examination provided for both members of any marital unit referred to the Foundation for treatment of sexual dysfunction.

To attempt to define and to treat the basic elements of sexual dysfunction for either sex without including the opportunity for thorough physical examination and complete laboratory evaluations as an integral part of the patient’s diagnostic and therapeutic program is to do the individual and the marital unit a clinical disservice.

Painful Coition Is Not Limited to Women.

Many men are distracted from and even denied effective sexual functioning by painful stimuli occasioned during or after sexual functioning.

The symptoms will be described in relation to the anatomical site of pain, the external anatomy, such as the surface of the penis and the scrotal sac, or the internal anatomy, such as the penile urethra, the prostate, or the bladder.

No attempt will be made to provide definitive discussion for the varieties of male-oriented dyspareunia. Situations are mentioned only to emphasize their existence and to provide the therapist with an awareness of the fact that, in truth, there are badly mated men.

Penis Exterior Anatomy

Many men complain of severe sensitivity of the glans penis, not only to touch but to any form of containment, including intravaginal retention, immediately after ejaculation. This severity of glans pain recalls the intensely painful response that may be elicited from the clitoral glans when it is approached during forceful male manipulative attempts to incite sex-tension increment for his female partner.

Once a man is fully aware that immediately after his ejaculatory episode there may be exquisite tenderness of the glans, he realizes that he must immediately withdraw from intravaginal containment.

Generally there is marked variation in the severity of the individual response pattern. Men noting variation in the severity of glans pain have no pre-ejaculatory warning of the intensity of the particular response pattern, which may range from minor irritation with containment to crippling pain with the slightest touch.

The glans
Occasionally is irritated rather than protected, as might be presumed, by a retained foreskin. Two men have been referred to the Foundation complaining that relief from painful stimuli immediately after ejaculation can be obtained only by retracting the foreskin well back over the glans and in this fashion relieving the irritation of glans confinement.

Foreskin
There are occasional irritative responses created by the retained foreskin of uncircumcised men. In almost all instances these irritative responses have to do with lack of effective hygienic habits.

Primarily, smegma and, secondarily, various bacterial, trichomonal, or fungal infections sometimes collect beneath the foreskin. If the foreskin is not retracted regularly and the area washed with soap and water, chronic irritation can easily develop.

With chronic irritation or even frank infection present, there usually will be pain with coital thrusting or with any form of penile containment. In almost all instances the dyspareunia responds readily to adequate cleansing principles.

Phimosis

A tightness or constriction of the orifice of the prepuce, clinically is marked by a foreskin that cannot be retracted over the glans penis. With an excessively constrained foreskin, infection is almost always present to at least a minor degree, and penile irritation is a consistent factor for men so afflicted.

Adhesions frequently develop between the foreskin and the glans proper so that there is no freedom of movement between the two structures.

Engorgement of the penis with sex-tension increment may bring pressure to bear on the foreskin constraint of the glans. Without freedom of foreskin movement, this constriction frequently causes local pain with penile erective engorgement. When any male is diagnosed as having a degree of clinical phimosis sufficient for chronically recurrent infectious processes and/or pain or irritation with coital connection, circumcision certainly is in order.

There are also occasional men with a true hypersensitivity of the penile glans. These men are almost constantly irritated by underclothes or by body contact. They are continually aware of a multiplicity of irritants and are particularly susceptible to trauma to the glans.

One man referred for consideration found glans constraint in the vaginal environment intolerable. There was a constant blistering and peeling of the superficial tissues of the glans surface.

Despite a history of numerous changes in sexual partners, the postcoital results were identical. This individual simply could not tolerate the natural pH levels of the vagina. Since the reaction was confined to the glans area and never involved the penile shaft, there is room for presumption that if he had not been circumcised routinely, he might not have been so handicapped.

Protective coating of the glans area precoitally resolved his problem but was a nuisance factor for him and possibly for his sexual partners.

There are occasional instances of referred pain from the posterior urethra (usually occasioned by posterior urethritis) that produce pain in the glans penis. Very rarely, this type of glans pain is a factor in coition.

Among the most distressing of the many factors in dyspareunia are the complaints of burning, itching, or aching in the vagina during or after intercourse. The existence of chronic vaginal irritation frequently robs women of their full freedom of sexual expresssion, for they are well aware that any specific coital connection may be severely irritative rather than highly stimulative.

Presuming adequate production of vaginal lubrication, rarely, if ever, does a woman complain of burning, itching, or aching during coition or describe these symptoms immediately after or even in a delayed postcoital time sequence without concomitant evidence of established pathology in the vaginal barrel.

This form of dyspareunia registered as a complaint by the female partner should have an important connotation to the cotherapist. This specific response pattern is not described by women who are subjectively impelled to register an excuse to avoid impending or threatened coital connection.

When women use the complaint of pain to avoid or delay the necessity for submitting to psycho genically unappealing coital experience, their most frequent complaint is one of severe pain with penile thrusting, “a hurting” deep in the pelvis.

When considering the complaints of burning, itching, or aching in the vagina, initially clinical concern is focused on infectious vaginal invaders. The primary sources of vaginal infection are coition and rectal contamination; secondary sources are manual contact, clothing material, insertion of foreign material, and functional disuse.

Support of and control of the acidity of the vaginal environment is the fundamental means of protection against the bacterial pathogens that can create symptoms of burning, itching or aching. The vagina naturally maintains a strongly acid environment as a protective mechanism against all forms of infectious invasion.

With an experimentally controlled environment, vaginal acidity has been established as varying clinically from pH 3.5 to pH 4.0. Thus, there is a rather wide margin for error in vaginal protection against concurrent infectious agents, for acidity must be sufficiently neutralized to raise the pH level to five or above, before bacterial invaders can flourish freely in the vaginal environment.

The one time that natural vaginal protection against infection breaks down is during the period of established menstrual flow. For many women vaginal acidity consistently registers in the neighborhood of pH 5 or above during menstrual flow, particularly if vaginal tampons are employed.

The neutralizing effect of blood serum constrained to the vaginal tract by retentive tampons directs vaginal acidity into pH 5 levels routinely. It is not surprising, then, that most vaginal infections either have clinical onset or flourish during menstrual flow.

Bacteria

The infective organisms most constantly encountered in vaginal infections, yet trichomonal and fungal forms of infection are seen frequently enough to provide additional causes for clinical concern. Probably the most persistent vaginal-tract invader in any woman’s lifespan are the coliform organisms (Strepto coccus faecalis, Escherichia coli, and the type of Streptococcus viridans), which are the basic contaminants of bowel environment.

From the point of view of patterns of sexual functioning alone, a persistent vaginitis, from which pathogenic organisms repeatedly are cultured in the adult, sexually functioning woman, should always make the therapist question the possibility of occasions of rectal intercourse.

A popular technique employed during rectal intercourse includes the expected format of initial rectal penetration during the excitement phase and repetitive thrusting during the plateau phase of the male sexual response cycle.

Infected Penis

But many men withdraw from the rectum and plunge the bacterially contaminated penis into the vaginal barrel just before or during the stage of ejaculatory inevitability, terminating the orgasmic phase of their sexual cycle by ejaculating intravaginally. Recurrent coliform vaginal infections that are resistant to treatment may have origin in this coital technique.

When rectal intercourse is practiced, the ejaculatory episode should be confined to the lumen of the bowel. There should never be penetration of both rectal and vaginal orifices during any single coital episode, if the woman wishes protection against the probability of recurrent vaginal infections.

If coliform vaginitis persists despite both adequate treatment and patient denial of rectal intercourse, a direct rectal examination frequently will solve the therapist’s diagnostic dilemma. If a woman is experiencing rectal intercourse with some regularity, there may be a specific involuntary reaction of the sphincter to the rectal examination.

When the examining finger is inserted, the response of the rectal sphincter at first will be one of slight to moderate spasm, following the expected reactive pattern of most men or women undergoing routine rectal examinations. But if the examining finger is retained rectally for a few seconds, the sphincter may relax quite rapidly in a completely involuntary manner, as opposed to the routine response pattern of continuing in spastic contraction for the duration of the examination.

If involuntary sphincter relaxation develops, this response pattern, while certainly not reliably diagnostic, should make the cotherapist skeptical of the patient’s denial of rectal coital episodes.

The involuntary sphincter relaxation develops because the retained examining finger stimulates a pleasurable response for those women enjoying regularity of rectal coital exposure as opposed to those finding rectal examinations subjectively objectionable and objectively painful.

Clinical note:
The same type of involuntary sphincter relaxation may develop in male homosexuals whose preferred pattern of sexual expression includes interest in regularity of rectal penetration. Again, the involuntary sphincter response pattern has been used by the Foundation’s professional staff as a clinical diagnostic aid when dealing with homosexual male patients employing the rectum as the means of providing ejaculatory release for sexual partner or partners.

When the cotherapist can be reasonably certain by both history and examination of some regularity of rectal intercourse, techniques to avoid vaginal contamination with fecal material should be discussed at length with the women involved.

Although the basic premise of the clinical advice is to avoid recurrent episodes of coliform vaginitis if possible, there is an accrued secondary effect of reducing dyspareunia during occasions of intravaginal coitus.

Uncircumcised Penis

When trichomonal vaginitis is suggested by direct inspection of the vaginal barrel and confirmed by adequately stained vaginal smear or hanging-drop preparation of the vaginal discharge, which may be profuse and irritating.

The husband also should be suspected of harboring the trichomonads, possibly beneath the foreskin if he is uncircumcised, but more frequently in the prostate gland, the seminal vesicles, or the urinary bladder.

If both husband and wife are not treated simultaneously for this particular distress, the infection may become a source of chronic dyspareunia, as it may be exchanged frequently between marital partners during repeated opportunity at coital connection.

It does little good to treat the wife for trichomonal vaginitis and then have her reinfected by her husband. And it obviously does little good to treat the husband individually and have him reinfected by his wife. With chronic trichomonal vaginitis there may be recurrent bouts of dyspareunia, particularly with coital connection of any significant duration.

Fungal vaginitis is seen clinically more and more frequently. Incidence of this particular infectious entity used to be primarily confined to the late spring, summer, and early fall months, but now such pathogens as Monilia and Candida albicans are encountered regularly throughout the year.

Chronic fungal infection creates a debilitating situation for the recipient woman. Burning and itching is intense and swelling and weeping of soft tissues are frequent complications. Coital connection is virtually impossible due to the pain involved when a fungal infection dominates in the vaginal environment.

Infections with antibiotics frequently will protect women from the complications of fungal vaginitis.