TREATMENT OF SEXUAL DYSFUNCTION

Hartman, William E. and Fithian, Marilyn A. Treatment of Sexual Dysfunction: A Bio-Psycho-Social Approach. New York: Jason Aronson. 1974.  pp 268.

This book provides detailed information on Hartman and Fithian’s clinical sex therapy program that was based on the 2-week intensive programs of Masters and Johnson, and involved a total research and therapy population of 1,167 people over seven years. It outlines the daily schedule and the 34-step treatment procedure, includes illustrations and graphs, offers the forms used in treatment in the appendix, and includes a lengthy annotated bibliography.  Each chapter goes into detail about the various elements of the program. The book’s intent was to disseminate the latest information and techniques in sex therapy.

In chapter one, the authors discuss their approach to sex therapy.  It is action oriented, reflecting the active nature of sex itself, and the program was designed with the intent of making couples more intimately aware of each other’s bodies and feelings. The authors discuss the importance of working together as a “co-ed” team—the dual-sex team approach—that enables them to comprehend and work with a wider scope of socio-economic, cultural, religious, and educational points of view. This approach also multiplies their observations, and enables them to handle any sexual offers or indication of sexual interest with greater scrutiny, also making touch between therapist and client more safe and comfortable.

In chapter two, the authors discuss the psychological testing that takes place on day one of the program, and includes examples of the personality and temperament testing. The first test administered is the Minnesota Multiphasic Personality Inventory (M.M.P.I.), which is comprised of 550 true or false statements.  It measures psychological depression as expressed by anger, resentment, quiet resignation, or attempted suicide, gives the therapists objective data about the emotional state and psychological characteristics of clients, and supplements their clinical evaluation.

The second test given is the Taylor-Johnson Temperament Analysis (T-JTA.) It’s designed for diagnostic, counseling and research purposes. It measures nine distinct personality traits and their opposites that may significantly influence personal, social, and marital adjustment. It is noted that the most common traits found in sexually “dysfunctional” couples are “quiet, inhibited, and indifferent,” and that the most effective method for altering traits is action-oriented therapy.

The third test is the “Draw a Person” test, combined with the Luscher color test, in which each client chooses from 25 colors, one color to draw a nude view of self, and one color for a nude view of one’s partner. They are told to choose a color that best suits the personality of the person, and talk about why they chose that color. It is noted that the feet and face are the most significant areas and that no feet drawn is symbolic of an unstable foundation, and no face drawn is symbolic of no feeling or identity. It is also noted that the size of the drawing is revealing and symbolic of how big or small one feels.

In chapter three, the authors discuss the sex history, also administered on day one. This is considered to be one of the most significant diagnostic and therapeutic aspects of the program. It gives clients a chance to talk about their sexual behavior and their feelings about their sexual behavior, which many have never before had the opportunity to do. It helps them become freer in their sexual thinking and attitudes and opens communication about sex between partners. A lot of learning and most of the individual counseling takes place during the sex history. There is often much reassurance that one’s behavior is similar to the majority of Americans, as well as discussion of any emotional problems for the client concerning any of the material.

The questions asked are included in the chapter and combine items from Kinsey’s and Masters and Johnson’s sex histories, as well as the authors’ own items. They are asked in an assumptive manner, forcing denial or involvement in areas. They start with emotionless material first, before going into emotion-laden material and then back to more neutral material, allowing clients to get comfortable with the process, before offering more sensitive information. The major categories are: 1. Identification and Background;  2. Sex Education;  3. Masturbation, Fantasy, and Dreams;  4. Contraception;  5. Heterosexuality;  6. Homosexuality;  7. Group Sex Activities;  8. Erotic Responses;  9. Spouses History;  10. Presenting Problems;  11. Expectations;  and 12. Summarize Client’s History. The questions are asked by the opposite sex therapist, and the whole sex history usually takes from 2-3 hours. The histories are audio taped and transcribed, becoming part of the case history that may be referred to by the therapists as needed.

It is noted that the therapists must be comfortable with all sexual material and treat it objectively, without any value judgment. Therapists should always try to alleviate guilt about behaviors or fantasies whenever possible, and mention the normalcy of masturbation, and always work within the sexual value system of the clients. The sex history allows the therapist to get a complete picture of the clients, including information about previous sexual involvements and functioning, as well as possible patterns of sexual dysfunction. There is a 15-30 minute follow-up on day two after which the same sex therapist then discusses the history and its most significant points in a one-hour review.

In chapter four, the physical exam, which takes place on day three, is discussed. Each client completes a two-page checklist prior to the exam, and then a half hour is spent going over the information that is related to sexual functioning, including any possible use of medication or drugs. A medical doctor administers the physical in the presence of the therapists, who transcribe the doctor’s verbal statements during the exam. The purpose of the physical is to rule out any possible physical dysfunction before proceeding with therapy. With the woman, the doctor checks specifically for clitoral adhesions, which are often a factor for the pre-orgasmic female, and also measures the vaginal muscles in an un-stimulated state with a perineometer. The man’s exam focuses on his penis, testicles and prostate.

The round table discussion follows the physical exam, still on day three. The couple is first given the opportunity to indicate their desire to continue or to withdraw from the program. It is important that the couple be motivated in order to ensure success in sex therapy. Next, the therapists briefly review the results of the psychological tests to ascertain whether the clients will benefit in continuing with the program.

In chapter five, the sexological exam, which takes place on day four, is discussed. The clients first fill out a one-page questionnaire, independently. It asks about the number of people they’ve had intercourse with, their preferred coital positions, most satisfying positions, most often used positions, their last intercourse, their orgasmic response, and how long the male can go in intercourse. The sexological exam checks for sexual response, and often reveals information about the client’s sexual response that contradicts what they reported in their sex history.
The female sexological exam is first and a form is filled out to record the date collected during exam. The breasts and nipples are stimulated and checked for engorgement or erection. Also, any referred feeling or response in the yoni upon stimulation of the breasts is noted. The clitoris is checked and if smegma is present, the therapists explain the importance of washing the genitalia with mild soap and water. Next, the woman’s vaginal sensitivity is evaluated, and the therapists look for any scarring, fibrosity, pain, or separation of the muscle in the wall of the vagina. The therapist team alternates stimulating the vaginal area while the client focuses on what they are doing. They are determining whether there is any sensation or awareness in the vagina and encouraging her to enjoy the pleasurable sensations. If a sex flush develops, they give the female client a mirror so that she can see it.
Next, a series of vaginal exercises are taught to the woman, with the examining finger of the therapist in the yoni, in order to ensure they are being done correctly. It is noted that approximately one in ten women they see are not able to move the pubococcygeus muscle at all. Dr. Kegel’s film “Pathologic Physiology of the Pubococcygeus Muscle in Women” is discussed, as well as his contribution of locating the centers of sensory perception at the “4:00 and 8:00” positions in the yoni. These positions are specifically checked for sensitivity. The husband participates by inserting his finger in her yoni and moving it around to different positions to determine if his penis would feel good there.
The four PC exercises given are: 1. Hold the PC muscle for 3 seconds and then relax it—25-50 times/day; 2. Flick the PC muscle rapidly—25-50 times/day; 3. Take a deep breathe while pulling the PC muscle up and tightening it and then relaxing the whole pelvic region and then exhale—10 times/day; and 4. Bear down as if to expel something from yoni, and then pull the PC back up and tighten it. The importance of these exercises is emphasized due to their ability to increase the pleasure and satisfaction of the woman herself and her partner as well. Finally, the perineometer is used to measure vasocongestion once again, this time in a stimulated state. This provides her with feedback of the effectiveness of such exercises.

The male sexological exam is less complex. It includes checking the penis to ensure that the foreskin is loose and movable. The man is asked about any possible bleeding or discomfort during intercourse or breaking out of the skin of the penis. The woman participates by visually and manually examining the penis and the testicles, taking note of sensitive areas. She is then taught the squeeze technique. The therapists note whether or not the woman is reluctant to touch her spouse’s genitals, as some have never done so and are indeed very uncomfortable about it and need help learning.

In chapter six, the body imagery work, also done on day four, is discussed. This work was evolved from a combination of nudist research, where it was discovered that people’s more basic feelings about themselves tend to surface when they are naked in front of others, and the presumably Freudian concept that all the images one has of oneself come from one’s basic biological image. It is intended to help people realistically upgrade their own self-perception, thereby enabling them to relate deeply to another.

The body imagery work takes from 1 1/2 to 2 hours and is done individually. The first portion takes place with the client in front of a three-way mirror. The client is asked to start by placing both hands on the top of their head and work down to the bottom of their feet, while on a tactile and emotional level share how they feel about and perceive all parts of their body, addressing the positive and the negative. It is noted that clients will often exclude or overlook parts that they have negative feelings about, and it is the therapist’s job to direct them back to these areas. At the end of this exercise, the mirrors are closed around the client and they are asked how they feel about the person “in there” with them, whether or not they would like to spend more time with that person, and then, while looking full-length into the mirror, asked to give themselves a rating on a scale of 0 to 100.

The second portion of the body imagery work is done with the client’s eyes closed, while exploring the inside of their body in fantasy, guided by the therapists. They “travel” to such places as the seat of their emotions, sexuality, and intelligence, and inform the therapists what they see and feel in these “places.” A huge part of the chapter is devoted to a sample body imagery session of a male. This is a word-for-word transcription that goes into complete detail of the work.

The final portion of the body imagery work involves sensitivity exercises. The couple is first asked to stand in front of the mirror and show the therapists how they physically touch and relate to one another, and then how each of them likes to be kissed and held. Finally, they are given some hand exercises that reveal a lot to the therapists about how the couple relates, how they express any negative or positive emotion they have for each other. They are asked to touch each other’s hands as if it is the last time they will be touching them. And then they are asked to imagine they are touching these hands they never thought they would touch again, after a long period of time. These exercises often bring up a good deal of warmth between couples, despite years of bickering, hostility, and power struggles.

In chapter seven, the caress exercises are discussed. These are done in the therapists’ office initially in order to observe the degree of warmth and feeling or hostility and rejection. The therapists involve themselves by asking feedback questions of the receiver: what they are experiencing, whether or not they like it, if they would like it lighter, heavier, faster, or slower, etc. The therapists also use this time to give permission to the couple to experiment by making quiet suggestions, as they caress. The clients are also asked to refrain from coitus the first week of the program and the caress exercises in conjunction with a non-coital framework are intended to establish a good emotional climate, so that the relationship can have a solid foundation of warmth, love, and affection on which to build the sexual relationship.

The foot caress is done first, on day five, and involves bathing the feet in warm soapy water before moving onto caressing the foot with baby oil. The therapists watch to see how quickly the giver’s hands move during this exercise, as they perceive a correlation between the premature ejaculator and the fast foot caress. Later on that same day, the couple revisits and watches a video of a research couple doing the foot caress that they just did, and the face and body caress they have yet to do. After this, the couple switches previous giver and receiver, and they do the face caress, using face cream. About half way through the face caress, the receiver puts their hands over the giver’s hands and shows how they would like to be touched. This principle is then carried over to all other exercises, with the intent of encouraging this kind of non-verbal communication between partners.

The body caress, done on day six, is also discussed in chapter seven. The clients are provided with warm lotion and asked to stay in the present moment, and in touch with their feelings as they give and receive. After the back is caressed, the giver “spoons” the receiver from behind and matches their breathing for two to three minutes before asking them to roll over so that the front of their body can be caressed. This breathing together is first presented to them on videotape, and is intended to help the couple pay attention to the each other’s responses.

The sexual caress, also demonstrated on videotape, is added to the body caress. It includes caressing the back of neck and hairline, the spine three inches up from the coccyx, and the inside of the thighs with the thighs spread while lying on both the back and then the stomach. For the woman, the male partner will also use his finger to massage the inside of the yoni, and for the man, the female partner will massage him from penis to collarbone using only her breasts. It is recommended that the body caress always precede the sexual caress. After this is completed, all caressing exercises take place in the privacy of the client’s motel room.

In chapter eight, the homework assignments, which begin on day four and are done in the couple’s motel room, are discussed. The first of these is to wash and comb or brush each other’s hair. Next, they are asked to take a shower or bath together and wash each other all over, in preparation for the caress exercises. And they are asked to suggest activities to each other that they would both enjoy, with the intent of getting them in touch with their own creative ability to enhance pleasure in their relationship. Also, once they have completed the caress exercises in the office, they are given a case with a variety of lotions and oils, as well as a tub for the footbath, to continue caressing on their own.

Also, the couple learns some non-demand techniques on videotape and practices these in their motel room as part of their homework. These techniques are to be done with the emphasis on pleasure, not arousal. There should be no demand for sexual response or performance. They are to practice the squeeze technique, regardless of whether or not there is a premature ejaculation problem. They practice a couple of female pleasuring techniques. They are assigned the “quiet vagina,” in which the couple lies for 20 to 30 minutes, with the penis inside the vagina without movement, other than that needed to maintain the erection. And finally, the couple’s last assignment is one on spontaneity. They are asked to develop some technique unique to them that they both enjoy and find pleasurable, and either report it or show it to the therapists at the center.

In chapter nine, the use of audio-visual aids in the program, is discussed. These include the caress video and the non-demand video, and two 8 mm films of coital positions. Also included in the program is an audiotape of a woman describing how she became orgasmic and how she taught other women to function well sexually, of which the entire transcript is offered in this chapter. 

In chapter ten, the videotapes of sexual intercourse used in the program, are discussed. The couples see a minimum of three videotapes of sexual functioning.  These tapes include the “Fun Tape,” the “Romantic Tape,” and the “Effective Sexual Functioning” tape. The authors go into depth about the “Effective Sexual Functioning” tape that is followed in the training by a discussion. It emphasizes fifteen main points: preliminaries, emoting, accentuating the positive, maximizing female turn-on, oral stimulation, sex flush, ease of penetration, use of hands, building body tension for orgasmic response, female legs together to counteract tenting of the vagina, variations of coital positions and thrusting, change in breathing, ejaculation/orgasm, and afterglow.

In chapter eleven, miscellaneous treatment techniques used in the program are discussed. Hypnosis is recommended for couples or individuals who are still having difficulty relaxing and enjoying a sexual encounter after the first week of the program. About half of all couples in treatment end up experiencing hypnosis in order to bring about such changes as longer lasting erections, permission to experience orgasm, and more arousal, lubrication, and feeling. Two techniques briefly discussed that are sometimes beneficial in treating impotence are: 1) Insert a flaccid penis into the vagina, allowing some movement to take place until an erection occurs; and 2) Rhythmically squeeze the flaccid penis with a hand until an erection occurs. Several examples of daily verbal interaction between therapists and clients are offered in this chapter as well.

Finally, the goodbye session is talked about, during which the therapists address how the clients will integrate what they have learned in the program into their life back home. A follow-up telephone date is set so that the therapists can see how the couple is doing. The couple is instructed to call immediately if any sexual difficulties arise and they will have the opportunity to go back and do some more therapy if needed. It is noted that if a problem is not resolved in the initial two weeks of the program, it is unlikely that it will be resolved at a later date by follow-up with the therapists.

In the final chapter, “Where Do We Go From Here,” the authors discuss the group workshops they developed, that were essentially a mini-version of the two-week intensive. These lasted from one to six days and were comprised of seven to ten couples. They eliminated the psychological tests, physical exams, and sex history altogether, did a modified version of the body image and sexological exams, and presented videos as time permitted. It is noted that these groups worked best for couples more recently married and that working in groups had the added benefit of contagion—couples would be positively influenced by others in the group, particularly in slowing down and taking more time in caress exercises. Also briefly discussed in chapter twelve are the dual-sex therapy team training program that began in 1972 and the clinical program devoted to lab research on more effective methods of treating sexual dysfunction.

This book belongs to a category of books written for clinicians or professionals who work with people, particularly couples, on their sexual concerns or issues. Other books in this category are Masters and Johnson’s “Human Sexual Inadequacy” and Helen Singer Kaplan’s “The New Sex Therapy.” All of these books are geared toward the treatment of sexual “dysfunctions,” each addressing concerns about lack of desire, lack of orgasm and painful sex in women and premature or retarded ejaculation and erectile difficulty in men. The techniques offered are virtually all the same, as well. This book, along with Kaplan’s “The New Sex Therapy,” both of which came out in 1974, were inspired by Masters and Johnson’s “Human Sexual Inadequacy,” written just four years earlier. Both books borrowed extensively from the clinical work of Masters and Johnson.

“Treatment of Sexual Dysfunction,” does, however, vary quite a bit from both “Human Sexual Inadequacy” and “The New Sex Therapy.” Its focus is on the actual treatment program and the exercises, and it does not go into the same amount of detail of any given “dysfunction” that the other two books do. It assumes the reader already knows about the various “dysfunctions” and sticks to the program. The authors also seem less concerned with focusing on a diagnosis, and more concerned with treating the couple in a more holistic fashion, that could also be considered preventative. This leads to another underlying assumption that many of the exercises offered will be effective in treating the gamut of sexual issues that plague people, simply by getting people more in touch with their bodies and feelings and each other’s feelings. I certainly agree with this line of thinking. It seems to me a much more compassionate, and in the end, effective way of working with people to help bring about positive changes in their sexual functioning, attitudes, and behaviors.

The authors strongly state their bias of working as dual-sex teams, as did Masters and Johnson, believing that working thus gives them a greater capacity for understanding the variety of backgrounds their clients come from, as well as a safer and more comfortable climate overall.  Another unspoken, but obvious bias of the authors is to strictly work with heterosexual couples. Perhaps no gay couples were seeking this kind of therapy—the gay rights movement was just getting underway itself—but there is no reason why a gay couple couldn’t benefit from this treatment as well. Another bias is to work within the clients value system. If clients believe it is not okay to masturbate, that is okay…they can function fine sexually without that—this is the assumption. They do not see it as their job to challenge the values of their clients.

Another unspoken, and perhaps less obvious, bias I noticed was a focus on female arousal. Both the physical exam and the sexological exam focus a great deal more on the woman, and there is little mention of male issues. PC exercises are given to women only and little time is spent in the male sexological exam finding out what strokes or what kind of pressure might feel best to him. They suggest that some women may have never really even looked at their spouse’s erect penis much and may be very uncomfortable just looking, let alone stroking—perhaps this has something to do with the lack of attention given to the male in the sexological. Maybe digitally stimulating the woman in a clinical environment was more easily justified because of the need for more sensitive and conscious exploration of what might lead to pleasure for her. And also perhaps an engorged and lubricated vulva is somehow less “sexual” than a flow blown erection, and perhaps less “intimidating” to the clinicians.

The fact that this book was written when it was, during a time of sexual revolution, gives it a special place in the field of sexology. The work of Hartman and Fithian grew organically out of an age ripe for this kind of exploration. While it is exciting to learn about the beginnings of clinical sex therapy, I am aware that we live in a different climate now and have my doubts that this kind of therapy would be received well today—particularly the sexological exams—although I would like to be proven wrong about this. Are there currently therapists in practice who work in this way with couples? I know this kind of work is done in workshops, but the focus is on pleasure, not treatment, and there are no therapists, only workshop facilitators, who do not themselves participate in a hands-on manner with workshop participants. Boundary issues and ethics concerns have most therapists and educators in this field reluctant to be touching their clients at all, let alone touching their genitals. Another way in which this book shows its age is in its lack of discussion of condom use, STD’s, or AIDS. These topics are very much a part of sex education these days.

The authors most certainly fulfilled their own goals in disseminating the information about their treatment program and the latest techniques for sexual problems. The book is for the most part well-written, certainly easy to read and understand. The last two chapters seemed a little disjointed, as though literally a few odds and ends just got thrown together and titles made in a feeble attempt to define the contents of the chapters. I like that the book was divided into chapters focusing on the different procedures in treatment, and not on the variety of “dysfunctions,” as both Masters and Johnson’s and Kaplan’s books did.

Indeed, the field of sex therapy has evolved into something very different than that of Hartman and Fithian’s 1970’s era. Today, there seems to be a greater focus over all on educating and healing, and less on treating. We now have sexual “concerns, issues, or wounding,” not “dysfunctions.” We no longer pathologize, at least those of us who are “in the know.” The authors of this book, to their credit, did seem to steer us in that direction by their lack of emphasis on the “dysfunction” itself, clearly a separation from Masters and Johnson’s work. Hartman and Fithian’s action-oriented approach to sex therapy was certainly a remarkable contribution to the field—what we would call today “proactive,” in its effort to remain focused on the solution, not the problem.