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Treatment of sexual dysfunction

Article in Journal of Consulting and Clinical Psychology · April 1986

DOI: 10.1037/0022-006X.54.2.158

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Journal of Consulting and Qinical Psychology Copyright 1986 by the American Psychological Association, Inc.
1986, Vol. 54, No. 2, 158-167 0022-006X/86/S00.75

Treatment of Sexual Dysfunction

Joseph LoPiccolo and Wendy E. Stock
Texas A&M University

The current state of our knowledge of treatment of sexual dysfunction is reviewed, focusing on es-
tablished techniques, recent developments, and methodological limitations in recent literature. Primary
orgasmic dysfunction in women responds well to directed masturbation training programs. Lack of
coital orgasm, which is not clearly a true dysfunction in that it involves value judgments about
"normality," is more resistent to change. More complex issues of habit formation, male partner
performance, and marital satisfaction seem to be related to this lower treatment effectiveness. Male
premature ejaculation is easily treated, although little is known about the causes of premature ejaculation
or the mechanisms that account for treatment effectiveness. There has been much recent work on
differential diagnosis of physical and psychological causes of erectile failure, but relatively little new
offered beyond the standard Masters and Johnson treatment techniques. Much of the clinical literature
on treatment of sexual dysfunction is difficult to interpret because of recurring problems in methodology,
including small sample sizes, confounded treatments, and lack of objective outcome measures.

This article is not intended to be an exhaustive review of the J. LoPiccolo and Lobitz (1972). Masturbation has been shown
literature on treatment of sexual dysfunction. Several such in- to be the most probable method of producing an orgasm, as well
tegrative literature reviews on treatment outcome have appeared as producing the most intense orgasm (Masters & Johnson, 1966).
recently (Andersen, 1983; Dow, 1981; Kilmann & Auerbach, In addition to providing accurate proprioceptive feedback to the
1979; Mills & Kilmann, 1982; Reynolds, 1977; Schull & Spren- woman, enabling identification of sexually arousing stimulation
kle, 1980). Rather, this article will summarize our knowledge techniques, it has also been suggested that intense orgasm leads
concerning sexual dysfunction. We will focus on current con- to increased vascularity in the vagina, labia, and clitoris (Bard-
troversies, recurring methodological problems, and major gaps wick, 1971). Not only does an increased number of orgasms lead
in our knowledge. to psychological anticipation of pleasure in sex (Bardwick, 1971)
but the findings of Kegel (1952) also support the notion that
Female Dysfunction increased vascularity increases orgasmic potential. Kegel found
Organic Dysfunctions that patients who strengthened the pubococcygeus muscle
through systematic exercise experienced an increase in their fre-
Primary orgasmic dysfunction. Arousal and orgasm problems quency of orgasm. As exercising a muscle leads to increased
in women are the most common presenting sexual complaints. vascularity, it is quite possible that the increased vascularity in
Low sexual desire in women is usually secondary to lack of the pubococcygeus could cause an increase in orgasmic fre-
arousal and orgasm. Orgasmic dysfunctions in women have tra- quency. Thus, on both physiological and psychological grounds,
ditionally been divided into two major categories: Primary or- masturbation is a logical treatment for inorgasmia in women.
gasmic dysfunction applies to women who have never experi- The masturbation program developed by J. LoPiccolo and Lobitz
enced orgasm through any means. Secondary inorgasmia refers (1972) is based on a sexual skills learning model and is an adjunct
to women who are not orgasmic during sexual intercourse, but to a behavioral, time-limited treatment program involving both
in the more recent clinical literature, also describes women who the male and the female partners. The basic components of the
only have orgasm in masturbation, and not through any type of treatment program for lack of orgasm include education, self-
partner stimulation, or who define their limited repertoire of exploration and body awareness, and directed masturbation. As
stimulation techniques leading to orgasm as problematic. The some women and their male partners are woefully lacking in
adoption of a fine-grained descriptive system of sexual function- knowledge about the anatomy and physiology of the female sexual
ing (Schover, Friedman, Weiler, Heiman, & LoPiccolo, 1982) response cycle, a number of self-help books are often used as
has avoided the judgmental and perjorative labeling of women treatment adjuncts (Barbach, 1975; Heiman, LoPiccolo, &
who have normal variations in orgasmic response as frigid or LoPiccolo, 1976). The directed masturbation component of
inadequate. treatment includes self-exploration, body awareness, effective self-
The most effective treatment to date for lifelong lack of orgasm stimulation training, and the use of "orgasm triggers" (Heiman
in women is a program of directed masturbation developed by et al., 1976; J. LoPiccolo & Lobitz, 1972). The use of directed
masturbation has been questioned by some and is not a com-
ponent of all treatment for primary inorgasmia. Masters and
Preparation of this article was supported in part by a research grant
from the National Institute of Health, U.S. Public Health Service. Johnson (1970), for example, stressed performing couple-focused
Correspondence concerning this article should be addressed to Joseph sensate exercises and addressing historical issues that result in a
LoPiccolo, Department of Psychology, Texas A&M University, College sex-negative orientation. However, a number of studies (e.g.,
Station, Texas 77843-4235. Kohlenberg, 1974; Riley & Riley, 1978) have shown that a pro-
158
 SPECIAL SERIES: SEXUAL DYSFUNCTION 159

gram of directed masturbation training is a more effective method stimulation if she has only experienced orgasm through mastur-
for the woman who has never had an orgasm to achieve her first bation is perhaps a more realistic goal to adopt.
orgasm. The program developed by LoPiccolo (J. LoPiccolo, Kilmann (1978) and Andersen (1983) reviewed a number of
1977; J. LoPiccolo & Lobitz, 1972), which forms the basis of studies on the treatment of primary and secondary orgasmic
the Becoming Orgasmic self-help book (Heiman et al., 1976), dysfunction. In addition to directed masturbation for treatment
involves nine steps, progressing from education on basic sexual of primary orgasmic dysfunction, other treatment programs
physiology and anatomy, visual and tactile self-exploration, di- consist of a combination of sexual technique training, systematic
rected masturbation, development of sexual fantasy and imagery, desensitization, communication technique training, and reedu-
sensate focus individually and with a partner, and eventually cation procedures. Various studies have involved different treat-
sharing effective techniques of masturbation with the partner. ment formats, including individual, couple, and group therapy.
Stimulation is encouraged to facilitate orgasm during intercourse. The existing studies may be criticized for incorporating a number
Although female orgasm during intercourse should not be of interventions that are never systematically evaluated, for ex-
stressed as a goal for all couples, as this is not always a realistic ample, inclusion of the partner in treatment, directed homework
expectation, concurrent clitoral stimulation may maximize this assignments, and efficacy of different assignments. No studies
occurrence, if so desired by a couple in treatment. have systematically examined whether continued intercourse
Results based on approximately ISO women treated in our during treatment or abstinence has differential effects on treat-
clinic with this program show about 95% success in terms of the ment outcome nor have studies attempted to identify character-
woman being able to reach orgasm in her own masturbation. istics of women who would benefit from this procedure. Although
Around 85% of these women are also able to have orgasm during some (e.g., Madsen & Ullmann, 1967) have suggested that per-
direct genital stimulation by the male partner. Around 40% of mitting sexual activity during the course of treatment provides
our women patients have been able to obtain orgasm during a direct means for couples to assess progress in their sexual func-
penile-vaginal intercourse following this program. Riley and Ri- tioning and thus may serve as a source of reinforcement, others
ley (1978) compared a program of directed masturbation against have contended that repeated sexual intercourse without orgasm
a combined sensate focus and supportive therapeutic approach or perhaps without arousal for the woman is anxiety producing
in the treatment of female primary orgasmic dysfunction and and exposes the woman to repeated failure experiences, coun-
also found directed masturbation to be a superior and highly teracting treatment gains in other areas (e.g., Masters & Johnson,
effective treatment method. In a recently completed study (Mo- 1970).
rokoff & LoPiccolo, in press), the effectiveness of the self-treat- The most common outcome criterion for treatment success
ment book and film, Becoming Orgasmic (Heiman et al., 1976), has generally been each woman's self-report of orgasm respon-
when used in a limited therapist contact self-help program, was sivity (Kilmann, 1978; Andersen, 1983). However, different cri-
found to be equally effective to a full program of therapist-ad- teria for treatment success have been used across studies. Some
ministered sex therapy. This study suggests that for clients who authors do not mention criteria or use more than one criterion
have no other major clinical presenting complaints, an approach for successful treatment. Treatment goals vary regarding coital
that relies on education, information, and systematically pro- orgasm and/or orgasm through self- or partner masturbation. In
gressing through the program of directed masturbation will be addition, partner variability in sexual functioning introduces an
an effective approach with respect to treatment of inorgasmia. unavoidable confound in the evaluation of the impact of treat-
Secondary orgasmic dysfunction. A second type of orgasmic ment on orgasm through partner stimulation or through coitus,
dysfunction, which perhaps includes an even larger group of although this confound is not present in the attainment of orgasm
women than those who have never experienced an orgasm, are through masturbation.
women experiencing situational or secondary orgasmic dysfunc- Only a few researchers have reported whether the women at-
tion. Masters and Johnson (1970) use the term secondary or- tained greater satisfaction in their sexual functioning, regardless
gasmic dysfunction to include (a) any woman who was previously of changes in orgasmic responsivity. The issue of whether or-
able to achieve orgasm from some means of stimulation but who gasmic response translates to sexual satisfaction in women has
is currently rarely orgasmic and also to describe (b) any woman been raised by Jayne (1981), who found that more women en-
who is currently able to attain orgasm only in response to re- gaged in and preferred intercourse to masturbation because in-
stricted types of stimulation. The label of secondary inorgasmia tercourse was associated with a greater feeling of intimacy and
has thus been applied to women with a wide range of sexual closeness with their partners, although masturbation was a much
functioning, including those women who attain orgasm only with more reliable means of achieving orgasm. Thus, it would be
strong interfemoral pressure, or while lying face-down in bed; mistaken to equate only frequency, of orgasm with sexual satis-
women who are orgasmic only with vibrator stimulation; or faction in women without considering other variables, including,
women who are multiply orgasmic through partner stimulation, affective responses. As most previous research efforts have focused
but not with sexual intercourse. Conceptually, then, secondary on orgasm as the criterion of interest, future research directed
inorgasmia is a nonspecific term that has been used perjoratively at affective measures would allow us to more fully address the
as a diagnosis for women who may be functioning in a completely entire concept of sexual satisfaction.
adequate and normal manner. It is quite difficult to avoid making One factor that appears to determine treatment success is
value judgments in the treatment of such cases, as patients may marital happiness prior to therapy. McGovem, Stewart, and
define unrealistic goals (i.e., orgasm during intercourse without LoPiccolo (1975) treated six cases each of primary and secondary
clitoral stimulation) for therapeutic intervention. Enabling a orgasmic dysfunction. Although the primary inorgasmic cases
woman to experience orgasm through some means of partner improved dramatically, the secondary inorgasmic women gen-
160 JOSEPH LOPICCOLO AND WENDY E. STOCK

erally did not report increased frequency of orgasm with genital mined by the ability of the woman to achieve an orgasm and
caress by partner or during intercourse. It was proposed that attitude change measures. Seventy percent of the women in the
secondary inorgasmic women may respond better when tradi- under-35 group reported that they were orgasmic with vibrator
tional marital therapy is combined with sex treatment, whereas stimulation, masturbation, or partner stimulation by the end of
primary inorgasmic women may respond best to therapy that is the 10-week program. None were orgasmic with intercourse. In
focused specifically on sexual matters. Snyder, LoPiccolo, and the group of women over age 35, only 40% were orgasmic in any
LoPiccolo (1975) also found a combination treatment approach way at the termination of therapy. None were orgasmic with
to be successful in cases where marital problems contribute to intercourse. During the treatment program, some of the women
secondary orgasmic dysfunction. Another possible explanation from both groups reported that this therapy appeared to be a
for differences in treatment outcome is that among many sec- potential threat to their partners, in that as they became more
ondary inorgasmic women, a long history of exclusive reliance assertive sexually, the men became increasingly anxious in re-
on one particular and narrow technique of self-stimulation tends sponse to their partner's new behaviors. Before therapy, the men
to bring orgasm under very narrow stimulus control. In this sense, in these relationships generally had been the sole initiators of
the primary inorgasmic client can simply be taught a new and the coital experience, and the women had usually been passive
adaptive response pattern, whereas the secondary inorgasmic recipients who felt obligated to participate. Once the women
client must first unlearn maladaptive habits. were instructed to initiate sexual activity as homework exercises,
Another treatment approach that is often incorporated into male partners reacted either by being very supportive of their
behavioral short-term treatment of orgasmic dysfunction is sys- mate's activities or, in four couples, by becoming increasingly
tematic desensitization, especially when the dysfunction is as- resistant and refusing to cooperate fully with the exercises.
sociated with high levels of sexual anxiety (Husted, 1975; Jones Schneidman and McGuire noted that it was necessary to call a
& Park, 1972; Obler, 1973). Results reported include anxiety meeting of all male partners in the group of women under age
reduction, increased frequency of orgasm coitally and extraco- 35 between the fifth and sixth sessions to discuss their anxieties
itally, and increased sexual communication. and treatment goals. Most couples found that the sexual rela-
Munjack et al. (1976) examined the effects of a multiple-tech- tionship continued to improve after therapy, consistent with Bar-
nique behavioral therapy program on 12 primary and 10 sec- bach's (1974, 1975) findings in her preorgasmic women's groups
ondary inorgasmic women. Components of the treatment pack- that the transfer of orgasmic capacity to partner-related activities
age included systematic desensitization, assertion training, mod- usually occurred within 8 months of termination.
eling, behavioral rehearsal, and education. Results offer support The issue of inclusion of male partners in group therapy for
for a behavioral treatment package, although the contributions women with orgasmic dysfunction was subsequently addressed
of each component cannot be evaluated. by Ersner-Hershfield and Kopel (1979), who evaluated the effects
Another format that has shown demonstrated effectiveness in of partner participation on treatment. Two treatment groups in-
the treatment of primary and secondary orgasmic dysfunction cluded mixed sexual dysfunctions and primary orgasmic dys-
in women is group treatment. Group treatment has varied on a function and did not involve partner participation. A third group
number of dimensions in the treatment literature, such as the (with mixed sexual dysfunctions) included partners on two oc-
inclusion of male partners, number of treatment sessions, the casions. Results for all groups were similar: Of the 16 women
inclusion of primary versus secondary inorgasmic women, and involved, 14 became reliably orgasmic through self-stimulation.
which treatment techniques are presented in each group. In gen- However, generalization to orgasm through partner stimulation
eral, the literature indicates that group treatment can provide a or coitus was infrequent, whether partners were involved with
cost-effective and supportive type of intervention that seems most treatment or not. Although partner presence did not seem to
effective for clients without severe psychopathology, relationship enhance behavioral outcome measures, highly significant findings
distress, or other major psychological problems. Wallace and were achieved in terms of enhanced marital and sexual satisfac-
Barbach (1974) were the first to popularize group treatment for tion, with better results in the group that included partners.
primary inorgasmia, introducing the term preorgasmic to de- Leiblum and Ersner-Hershfield (1977) raised the question of
scribe women who have never previously experienced an orgasm. whether orgasm during intercourse for all women is a necessary,
Seventeen women participating in their treatment program or even reasonable, goal. Kaplan (1974) has suggested that given
demonstrated 100% success in attainment of orgasm through the variations in such factors as genital anatomy, type of stim-
masturbation within a 5-week treatment program. Within 8 ulation provided, and length of stimulation prior to ejaculation,
months posttreatment, over 87% of the women were capable of coital orgasm is highly unreliable. Other research with women's
orgasm in partner-related activities. In addition, Barbach (1974) therapy groups has supported the finding that transfer of orgasm
reported that women showed increased enjoyment of coitus and to coitus is low, regardless of treatment format (Heinrich, 1976;
sexual satisfaction, increased sexual communication with their Kuriansky & Sharpe, 1976; Schneidman & McGuire, 1976).
partner, and improved overall level of happiness and relaxation. Leiblum and Ersner-Hershfield (1977) also emphasized that the
In order to determine the appropriateness of sex therapy for extent to which the male partner is himself dysfunctional, either
younger and older women, Schneidman and McGuire (1976) in terms of negative sexual attitudes or performance inadequacy,
used group therapy for the treatment of primary inorgasmic dys- must be considered in evaluation of treatment outcome. To sum-
function, comparing treatment effects for 10 women below age marize the effects in the treatment literature on orgasmic dys-
35 and 10 women above age 35. Treatment combined a Masters function, it would seem that a careful assessment for each in-
and Johnson-styled behavioral therapy and a program of directed dividual is needed to identify those elements that would comprise
masturbation. Success of the therapeutic program was deter- the most effective intervention. The research evidence is un-
 SPECIAL SERIES: SEXUAL DYSFUNCTION 161

equivocal that a program of directed masturbation is an effective comfort will only make the vaginismus worse, as it confirms her
treatment for primary inorgasmia. Other elements of treatment fear that penetration is traumatic. In treating many women with
may be used in conjunction with directed masturbation, including the progressive dilation program, it is clear that the program is
systematic desensitization, education and information, body im- extremely effective if the couple can be convinced to follow it,
age work, sexual technique training, and couples communication without rushing progress to larger dilators, finger insertion, and
training. Intercourse should be restricted during early stages of entry of the penis. Other factors, including rape, incest, or other
treatment if it generates anxiety or perpetuates a goal orientation. sexual trauma, may require further therapeutic attention ad-
When a male partner is available, incorporating him into treat- dressed to issues raised by these events. In addition, a thorough
ment is indicated (a) to treat him if he suffers from a sexual assessment may uncover couple systems issues to be addressed
dysfunction himself, (b) to work on couple's communication or before effective intervention can be undertaken for the initial
relationship problems, (c) to avoid feelings of threat or being left presenting complaint of vaginismus. Failure to consider such
out on the part of the male partner, and (d) to perhaps neutralize factors typically results in the client being unwilling to undertake
potential resistance. Finally, although orgasm achieved during a program of dilation.
intercourse may be an unrealistic goal of treatment, there is no
reason to expect that achieving orgasm with a partner through
some form of genital stimulation will not occur for most women
Male Sexual Dysfunctions
in relationships with cooperative partners. Future research di-
Low Sexual Desire
rected at nongenitally focused criteria for sexual satisfaction is
needed. Low sexual desire in men is an especially interesting dysfunc-
Vaginismus. The term vaginismus refers to spastic contrac- tion, in that it involves a man behaving in a manner that is
tion of the circumvaginal musculature, such that the penis, or inconsistent with our cultural sexual script for men (J. LoPiccolo
any other object, cannot be admitted to the vagina without great & Heiman, 1977). Current literature contains little empirical
difficulty and great pain. Vaginismus is distinguished from dys- research on the syndrome of low sexual desire in men and consists
pareunia, which refers to pain during coitus from any source primarily of case studies and theorizing (L. LoPiccolo, 1980;
other than vaginismus. Vaginismus is often a situation-specific Zilbergeld & Ellison, 1980). In current literature, the three major
disorder. For example, it may be possible to complete a pelvic etiological factors for male low sexual desire that have been pro-
exam, but when intercourse is attempted, the woman experiences posed are hormonal problems, family of origin theories, and
great pain, and penetration is not possible. In other cases, the relationship dynamic theories.
reverse has been observed in women who are able to engage in Low levels of testosterone, high levels of estrogen, excess pro-
sexual activity involving introduction of a finger or penis into lactin, and insufficient luteinizing hormone releasing factor have
the vagina, but who cannot tolerate a pelvic exam. J. LoPiccolo been proposed as causes of low desire. Certain antihypertensive
and Stock (in press) note that women who have a history of agents and many psychotropic drugs have also been found to
incestuous molestation in childhood or adolescence are especially depress sexual drive levels (Bancroft, 1984a, 1984b; J. LoPiccolo,
likely to present with vaginismus as part of their sexual dys- 1983). Although the hormonal and drug effect literature include
function. Often, these women present with an aversion to sex, only a small number of double-blind placebo control studies,
an inability to become aroused, inability to have orgasm, and these studies indicate that the correlation between hormone levels
also have vaginismus. Many such cases are also unconsummated and sexual interest is a weak one. Some recent studies (e.g., Ban-
marriages. croft, 1984a) have demonstrated that for men who are low in
In vaginismus, by definition, there is no actual physical lesion testosterone, administration of testosterone will usually increase
causing pain. The problem is a psychosomatic contraction of interest in sex. However, most men with low sexual drive have
the vaginal musculature caused by fear of penetration. Pain re- normal testosterone levels, and a small percentage of men who
sults from attempts to force the penis into the vagina, but there have been castrated continue to show high levels of sexual interest
is no organic basis for the pain. It is not infrequent that a diagnosis and activity (Bancroft, 1984a;Schiavi& White, 1976). Similarly,
of vaginismus is mistakenly made when dyspareunia, which in- high levels of prolactin, caused by prolactin-secreting pituitary
volves a physical lesion as the source of the pain, is in fact the tumors, or high levels of estrogen secondary to alcoholic liver
correct diagnosis (Abarbanel, 1978; Bancroft, 1983; P. Sarrel, dysfunction may suppress sex drive in men, but these are rare
1977). disorders (Pogach & Vaitukaitis, 1983). Hormone levels and
If a careful history and pelvic exam has substantiated the di- medication side effects account for only a small percentage of
agnosis of vaginismic response to sexual activity, as opposed to male low drive cases.
dyspareunia, the case may appropriately be treated using sex Family of origin theories of low sexual drive have been based
therapy techniques. The effective treatment element in resolution primarily on case studies, without empirical validation (Kaplan,
of vaginismus is a combination of relaxation training and pro- 1979; L. LoPiccolo, 1980; Zilbergeld & Ellison, 1980). This lit-
gressive dilation of the vagina (Fuchs et al., 1978; J. LoPiccolo, erature stresses factors such as an incestuously eroticized rela-
1984; L. Sarrel & Sarrel, 1979). tionship with the parent of the opposite sex, exposure to a dis-
Research in this area does not indicate differential effectiveness tressed relationship between the parents, failure to introject the
of dilation performed by the gynecologist or by the client herself sex role of the same-sex parent, and a host of similar mechanisms.
at home. The important element is that the dilation be under Relationship dynamic explanations for low drive in men have
the woman's control. The gynecologist, woman, or her partner tended to focus on the functional value of low drive (Friedman,
forcing a dilator into her vagina and causing her pain and dis- 1983; Hogan & Friedman, in press; J. LoPiccolo & Friedman,
162 JOSEPH LoPICCOLO AND WENDY E. STOCK

in press). This clinical literature stresses the adaptive value of In attempting to differentiate physiologic and psychologic
low desire as a way of maintaining relationship equilibrium. For causes of erectile failure, a number of diagnostic strategies have
example, low drive is cited as being a passive-aggressive way for been proposed. One class of such efforts has been the use of
a man to deal with an overt power imbalance in the marriage or paper-and-pencil questionnaires. A number of such inventories
as a way of maintaining emotional distance. have been proposed (e.g., Beutler et ah, 1975; Derogatis, Meyer,
There is little published outcome research on the treatment & Dupkin, 1976; El-Senousi, 1964). However, it has been typically
of low sexual desire. Two recent studies (Friedman, 1983; Schover the case that other investigators using different samples of patients
& LoPiccolo, 1982), using a complex, cognitive-behavioral have not been able to replicate these discriminative results (Mar-
treatment program, found generally good treatment results. shall & Delver, 1980; Melman & Redfield, 1981; Segraves,
These studies indicate a need for a treatment focused specifically Schoenberg, Zarins, Knopf, & Camic, 1981; Staples, Ficher,
on low desire, as standard sex therapy often fails to raise sexual Shapiro, Martin, & Goncik, 1980).
desire (Kaplan, 1979). With the failure of psychological assessment, there has recently
There are major methodological problems apparent in the developed a great interest in noninvasive and cost-effective phys-
available literature on diagnosis and treatment of low sexual de- iologic evaluation procedures for evaluating erectile functioning
sire. In much of the current literature, clinician's subjective (Krane, Siroky, & Goldstein, 1983; Melman & Leiter, 1982).
judgment, rather than an objective measure, is used to establish Current procedures include evaluation of penile blood flow (Jev-
the diagnosis of low sexual desire. Other studies have used an tich, 1983) and evaluation of pelvic reflexes and sensory thresh-
arbitrary behavioral index, such as frequency of intercourse. olds (Goldstein, 1983). Although such procedures have been
However, such a simple frequency count ignores socioeconomic shown to successfully differentiate organic from psychogenic er-
influences on coital frequency; the issues of masturbation or ex- ectile failure in various small sample studies, there is a common
tramarital sex; and misdiagnosed cases in which high frequency result of failure to replicate in studies by other investigators (Say-
occurs because of coercion, but in which actual desire is absent. pol, Peterson, Howards, & Yazel, 1983; Zorgniotti, 1984). Cur-
A more complex operational definition of low desire would in- rently, there is no clear consensus as to which measures of vas-
clude frequency of occurrence of sexual wishes, fantasies and cular or neurologic function are best discriminators of organfc
images, masturbation, noncoital sexual activity, coitus with the erectile failure.
partner, and any non-partner-related sexual activity. Proceptivity, Another well-established approach to differential diagnosis is
indicating spontaneous interest, must be distinguished from pos- recording of nocturnal penile tumescence (NPT; Wasserman,
sibly coerced receptivity to partner's initiation. A further dis- Pollak, Spielman, & Weitzman, 1980). However, several recent
tinction is needed between men with only a passive low interest investigations have raised some questions concerning the reli-
in sex and those whose low interest reflects an active aversion to ability and validity of NPT. That is, the NPT researchers tend
sexual contact. Because low desire can develop in response to a to state that if a man is organically intact, he will always show
sexual dysfunction, cases of "pure" low desire should be distin- normal NPT, and the lack of normal NPT occurs only in or-
guished from cases with a coexisting problem in sexual function. ganically impaired men (Karacan, 1970). In contrast to earlier
Greater diagnostic objectivity and specificity will facilitate our optimistic reports, more recent data (e.g., Schiavi & Fisher, 1982;
understanding of this disorder. Wasserman et al., 1980) seem to indicate somewhat lower validity
At the current state of our knowledge, we clearly need de- of NPT. Although mean values for number of episodes and total
scriptive studies of men with low drive who are matched on age, time of NPT do differ in, for example, groups of diabetic men
years married, and socioeconomic status with a control group with erectile failure and normal functional controls, there is con-
of normal, or even high drive, nonpatients. Because a number siderable overlap in the distribution of scores, making diagnosis
of sex therapy outcome studies have demonstrated that the fre- on the basis of NPT scores prone to a certain rate of false positives
quency of sex declines on 1-year follow-ups, we need more studies and false negatives. For example, in our own laboratory, we have
with long-term follow-up for cases of low sexual desire (Heiman seen highly abnormal NPT records from normal, fully sexually
& LoPiccolo, 1983; LoPiccolo, Heiman, Hogan, & Roberts, functional control subjects. Some such normal subjects have
1985). shown only one erection, lasting 15 min, in a total of 3 nights
of normal sleep. Similarly, a number of investigators have re-
Erectile Dysfunctions ported that the reliability of NPT is not as high as previously
thought, as a patient's NPT scores may vary markedly from night
The major focus of recent work on erectile failure has been to night (Procci, Moss, Boyd, & Barren, 1983; Schiavi & Fisher,
on differential diagnosis. In 1970, Masters and Johnson stated 1982).
that 95% of all erectile failure cases were psychogenic in origin Because full NPT recording in a laboratory is expensive, several
and did not involve any physiological pathology. More recent inexpensive devices for evaluation of nocturnal erection have
studies have indicated that neurologic, vascular, and hormonal been developed. These devices consist of a ring of perforated
abnormalities are involved in a considerable percentage of cases gummed stamps or a plastic snap gauge that is fastened around
of erectile failure (Krauss, 1983). Although some studies (e.g., the penis. Breakage of the gauge or ring is postulated to indicate
Spark, White, & Connolly, 1980) have reported very high rates normal NPT and thus psychogenic erectile failure. However,
of physiologic pathology in cases of erectile failure, it seems to available data indicate that results with these devices do not cor-
be the case that selective referral accounts for such extremely relate well with continuous recordings of NPT (Barry, Blank, &
high rates (Bancroft, 1984a; Segraves, Schoenberg, & Ivanoff, Boileau, 1980; Ek, Bradley, & Krane, 1983). If the patient has
1983). only one brief erection (an abnormal NPT pattern), the torn
 SPECIAL SERIES: SEXUAL DYSFUNCTION 163

snap gauge or stamp ring observed the next morning will lead high risk or low risk for organic impairment. For example, a
to a misdiagnosis. Furthermore, in the absence of recording of patient who reports a total lack of erection in any circumstance
rapid eye movement (REM) sleep, during which NPT occurs, and who also has one of the chronic diseases that are known to
failure to break the ring is not interpretable. cause physiologic damage to the erection system will be classified
In regard to this issue of differential diagnosis, there are serious as high risk. Similarly, a patient who has intermittent erectile
conceptual and methodological flaws evident in virtually all of failure and is in good general health is considered to be at low
the currently published research. Conceptually, most of the re- risk for organic impairment. Applying discriminate function
search suffers from the flaw of categorizing the patients into cat- analysis allows us to search for physiologic and psychologic mea-
egories of organic or psychogenic erectile failure. Many cases, sures that differentiate the high-risk from the low-risk group.
however, involve both organic and psychogenic factors. Some These measures must then be cross-validated on two new samples
researchers do categorize patients on a bipolar scale, from pri- to avoid capitalizing on chance differences between the original
marily organic to primarily psychogenic, in an attempt to avoid groups.
this simple two-part typology. However, as Bern (1974) has Although the diagnosis of erectile failure has advanced greatly
pointed out on the issue of masculinity and femininity, the di- in the recent past, little in the way of new treatment techniques
mensions of organic and psychogenic logically are not the op- has appeared in the recent sex therapy literature.
posite ends of a bipolar, unidimensional scale, but rather represent In terms of outcome, the initially optimistic reversal rates for
two orthogonal dimensions. That is, a man may be high in both erectile failure reported by Masters and Johnson and others do
organic and psychogenic causation of erectile failure, low in both not seem to be typical of more objective empirical research (J.
factors, or any combination of high on one factor and low on LoPiccolo et al., 1985; Reynolds, 1977). However, as the ability
the other. Although this may seem obvious, one frequently sees to identify organic impairment of the erectile system is a very
statements that if one finds a clear psychological cause of the recent development, low success rates may reflect inclusion of
erection problem, one need not conduct any organic evaluation. patients with occult physiological problems.
Similarly, presence of an organic abnormality is often taken to A trend to physical treatment of erectile failure is evident in
mean that sex therapy is doomed to failure. However, there are recent literature. There has been a surge of interest in prosthetic
many cases in which a man has a mild organic impairment, implants, hormonal treatment, and vascular surgery. Although
which then makes his erection more vulnerable to being disrupted hormonal treatment is indicated for men with endogenous de-
by psychological, behavioral, and sexual technique factors. If ficiencies, if a man is hormonally within the normal range, ad-
these psychological and behavioral difficulties are eliminated by ministration of exogenous hormones has no effect beyond a pla-
sex therapy, the patient's mildly impaired physiologic capacity cebo effect (Bancroft, 1984b; Krane et al., 1983). Unfortunately,
may now be sufficient for full erection. The alternative in such it is common medical practice to administer testosterone to nor-
cases of mixed organic and psychogenic etiology is a penile pros- mal men. The risks of liver damage, activating an occult prostatic
thesis (Sotile, 1979). Although patients are typically eager to have tumor, and other negative side effects of testosterone raise ques-
a prosthesis implanted, long-term follow-up indicates poor sexual tions about this procedure.
adjustment in many such cases. If a man has a number of psy- After an initial flurry of highly positive reports (Metz & Ma-
chological, marital, or sexual technique problems that lead him thiesen, 1979; Michal, Kramar, Pospichal, & Hejhal, 1977), vas-
to have erectile failure, the implantation of the prosthetic device cular surgery, as a means of correcting insufficient penile blood
may only result in his having these same difficulties, but with an flow, currently seems less promising. Vascular surgery is quite
artificially rigid penis. One would not expect the frequency or effective in the rare cases of blockage of a specific, large artery
quality of sexual activity to be high in such cases. or a penile structural defect. Unfortunately, diffuse, small-vessel
Methodologically, attempts to validate procedures for estab- atherosclerotic disease is much more common, and vascular sur-
lishing the relative contribution of organic and psychogenic fac- gery is ineffective in these cases (Melman & Leiter, 1982).
tors in erectile failure have been flawed by a number of recurring The major research question concerning erectile functioning
errors. In the medical literature, small samples are the norm, as is the issue of valid, reliable, and cost-effective differential di-
is lack of a control group. Cross-validations on additional samples agnosis of organic and psychogenic factors. Conceptual and
are rare. Often, "normal" and "abnormal" values for a test are methodological problems plague the medical literature, and re-
reported, with no statistical basis given for these scores. Fre- search on psychological diagnosis has commonly failed to cross-
quently, only t tests of differences in group mean scores are re- replicate. An overreliance on the penile prosthesis as a panacea
ported. A significant / value can occur despite a considerable is evident in much of the literature.
overlap in distributions, leading to high rates of false positive
and false negative classification when using a score that merely Premature Ejaculation
significantly differs between patient and control groups.
Another methodological problem in much of the literature on The treatment of premature ejaculation, using the pause and
differential diagnosis concerns circularity in the reasoning of the squeeze procedures developed by Semans (1956) and by Masters
investigation. A study on a penile blood flow index, for example, and Johnson (1970), has been found to be highly effective. Re-
will use NPT as the validating criterion. Another study will in- search has demonstrated that such procedures work well in group
vestigate an NPT index and will use penile blood flow as the as well as in individual treatment, in self-help programs, and
validating criterion. The most successful attempts to date to deal can be done in individual masturbation with relatively good gen-
with this circular reasoning problem have used a group mem- eralization to sex with a partner. Success rates of 90% to 98%
bership strategy. In our own research, we categorize patients as "cure" are reported (Kilmann & Auerbach, 1979).
164 JOSEPH LoPICCOLO AND WENDY E. STOCK

We do not have any definitive data on the causes of premature an ejaculation and thus may make the pause and squeeze pro-
ejaculation. Recently, sociobiologists have theorized that pre- cedure ineffectual. Empirical data on the effectiveness of this
mature ejaculation offers an evolutionary advantage and thus is technique are lacking.
built into the human organism (Hong, 1984). Such theorizing Another procedure that has been proposed is to have the pa-
does not effectively deal with the extremely large variability in tient perform a Valsalva maneuver while pausing or squeezing
duration of intercourse observed across free-living mammalian (J. LoPiccolo, 1977). The Valsalva maneuver involves forced ex-
species. halation with the airways closed and is purported to reduce sym-
Kaplan (1974) theorized that men with premature ejaculation pathetic nervous system anxiety. Because ejaculation is posited
are unable to accurately perceive their own level of sexual arousal to be sympathetically mediated, the Valsalva should delay ejac-
and thus do not engage in self-control to avoid rapid ejaculation. ulation. However, more recent neurologic evidence indicates that
One recent laboratory analogue study found that premature there are also major parasympathetic elements in ejaculation
ejaculation patients, compared with controls, had better aware- (Kedia, 1983). Furthermore, performing a Valsalva may simply
ness of their physiologic arousal level (Spiess, Geer, & O'Dono- lower arousal by distracting the patient. Again, empirical research
hue, 1984). Premature ejaculation patients, because of their con- is lacking in clinical reports on the procedure.
cern about rapid ejaculation, may constantly self-observe their
arousal and thus may have more training and experience in self- Inhibited Ejaculation
observation than do controls.
Kinsey, Pomeroy, and Martin (1948) proposed that premature Inhibited ejaculation has received very little attention in the
ejaculation was primarily related to a low frequency of sexual therapeutic literature. As initially reported by Masters and John-
activity. Some research has indicated that sensory thresholds in son, this remains a relatively rare dysfunction, and etiology re-
the penis are lowered by infrequent sexual activity (Kedia, 1983) mains unclear. Clinical case studies suggest a variety of psycho-
and that premature ejaculation patients have a low rate of sexual logical factors, but there is virtually no supporting empirical
activity (Spiess et al., 1984). However, it may well be that pre- research (Dow, 1981; Schull & Sprenkle, 1980).
mature ejaculation causes low rates of sex, because premature Inhibited ejaculation can result from a number of physiologic
ejaculation makes sex an unpleasant failure experience, rather conditions, such as multiple sclerosis (Kedia, 1983). Similarly,
than that low frequency of sexual activity causes premature ejac- several medications, including antihypertensives, sedatives, anti-
ulation. anxiety, and anti-psychotic agents, may have the side effect of
We also have no real understanding of why the pause and preventing ejaculation (Ban & Freyhan, 1980). One aspect of
squeeze procedures described by Semans (1956) and Masters the "postconcussion syndrome" may be inability to ejaculate,
and Johnson (1970) work. The usual procedure involves stim- apparently caused by damage to the hypothalamus, which reg-
ulation of the penis until high arousal, but not threshold for ulates production of pituitary gonadotrophins (Kosteljanetz et
ejaculation, is reached. Following a pause for arousal to subside, al., 1981).
stimulation is repeated until high arousal is again reached. This Reduction of performance anxiety and increasing physical
procedure fits the paradigm for Guthrie's (1952) counter-con- stimulation remain the major treatment elements for inhibited
ditioning extinction procedure of crowding the threshold. Al- ejaculation. Additionally, elements from the treatment program
ternatively, the stimulate and pause procedure may train a man for inorgasmic women, including the use of electric vibrators,
in more accurately monitoring his arousal level. The stimulation behavioral orgasm triggers, and role play of exaggerated orgasm,
and pause procedure involves the man repeating the procedure are often used (J. LoPiccolo, 1977).
several times per week, thus raising the frequency of sex and
raising the sensory threshold of the penis. Any or all of these General Methodologic Problems
mechanisms may underlie the effectiveness of treatment. The
meaning of the 98% cure often cited is unclear. Although a num- A number of methodologic problems have been alluded to
ber of studies have demonstrated that latency to ejaculation in previously in this article. However, a few general points may be
both foreplay and intercourse is markedly increased by therapy, made at this juncture. There is far too little empirical research
the small amount of available long-term follow-up data does not with rigorous methodology done on treatment of sexual dys-
necessarily indicate such good results (Kilmann & Auerbach, functions. Much of the clinical literature consists of uncontrolled
1979). Much of the current literature does not specify whether case studies. Many articles published as experimental reports
the patient must continue to use a pause or squeeze procedure are, in reality, demonstration projects that do not involve random
posttreatment or whether the patient is instead able to engage assignment to experimental conditions; manipulation of inde-
in normal, uninterrupted sexual activity following treatment. pendent variables; and assessment with objective, quantified de-
Some variations on the pause and squeeze procedure have pendent variables (J. LoPiccolo, 1980).
been reported, typically as clinical case reports. One variation In many studies, patients are identified only as having sexual
involves reversing one of the physiologic changes that occur dur- dysfunction, or orgasm problems. In such studies, differences
ing high arousal (J. LoPiccolo, 1977). At this time, the scrotum between heterogeneous patients probably have much greater im-
contracts and elevates the testes close to the body. As well as pact on treatment outcome than do any difference in treatment.
having the patient cease stimulation and/or squeeze on the penis, Much more fine-grained multiaxial diagnosis, as proposed by
the patient is also instructed to stretch out the scrotum and reverse Schover et al. (1982), is necessary before one can expect variations
this testicular elevation. However, during high arousal, any ad- in treatment to show differential outcomes.
ditional stimulation of the scrotum and perineum may trigger Relatively little attention has been paid to therapist variables
 SPECIAL SERIES: SEXUAL DYSFUNCTION 165

that affect sex therapy outcome. However, two recent studies have Bern, S. L. (1974). The measurement of psychological androgyny. Journal
shown equal effectiveness for single therapist treatment compared of Consulting and Clinical Psychology, 42, 155-162.
to dual-sex cotherapy teams, thus questioning the standard sex Bergin, A. E., & Lambert, M. J. (1978). The evaluation of therapeutic
therapy dictum that a dual-sex cotherapy team is needed (Ar- outcomes. In S. Garfield & A. E. Bergin (Eds.), Handbook of psycho-
therapy and behavior change (2nd ed., pp. 139-190). New York: Wiley.
entewicz & Schmidt, 1983; J. LoPiccolo et al., 1985).
Beutler, L., Karacan, I., Anch, H. M., Sails, P., Scott, F. B., & Williams,
Sex therapy treatment interventions consist of broad spectrum,
R. (1975). MMPI and MIT discriminators of biogenic and psychogenic
multifaceted combinations of a variety of procedures (J. Lo- impotence. Journal of Consulting and Clinical Psychology, 43, 899-
Piccolo, 1980). Although a good deal of current research has 903.
focused on the effects of variations in treatment format (one vs. Derogatis, L. R., Meyer, J. K., & Dupkin, C. N. (1976). Discrimination
two therapists, daily vs. weekly treatment, and group vs. indi- of organic vs. psychogenic impotence with DSFI. Journal of Sex and
vidual therapy), there have been very few studies attempting to Marital Therapy, 2, 229-237.
identify which components of the total sex therapy package are Dow, S. (1981). Retarded ejaculation. Journal of Sex and Marital Therapy,
active ingredients and which are inert fillers. 7, 49-53.
Failure to clearly specify the criterion for therapeutic change Ek, A., Bradley, W., & Krane, R. J. (1983). Nocturnal penile rigidity
is a recurring problem. A clinical global judgment of outcome measured by the snap gauge band. Journal of Urology, 129, 964-966.
is often all that is reported, especially in the medical and psy- El-Senousi, A. (1964). The male impotence test. Los Angeles: Western
Psychological Services.
chiatric journals. Recently, this issue has surfaced in a popular
Ersner-Hershfield, R., & Kopel, S. (1979). Group treatment of preorgasmic
press publication (Zilbergeld & Evans, 1980) in regard to the
women: Evaluation of partner involvement and spacing of sessions.
outcome results reported by Masters and Johnson. At the present Journal of Consulting and Clinical Psychology, 47, 750-759.
time, the sex therapy field needs studies in the model proposed Friedman, J. (1983). Treatment program for low sexual desire. Unpub-
by Bergin and Lambert (1978), in which therapist characteristics, lished doctoral dissertation, State University of New York at Stony
client characteristics, treatment format, and treatment content Brook.
are systematically varied in multivariate designs with objective Fuchs, K., Hoch, Z., Paldi, E., Abramovici, H., Brandes, J., Timor-Tritsch,
pre- and posttreatment assessments. Nonspecific and placebo I., & Kleinhaus, M. (1978). Hypnodesensitization therapy of vaginis-
effects in sex therapy need to be further elucidated, although mus: In vitro and invivo methods. In J. LoPiccolo & L. LoPiccolo
studies of psychotherapy placebo effects present difficult practical (Eds.), Handbook of sex therapy (pp. 261-270). New York: Plenum
Press.
and ethical problems (J. LoPiccolo, 1980; O'Leary & Borkovec,
Goldstein, I. (1983). Neurologic impotence. In R. J. Krane, M. B. Siroky,
1978). Further studies of the role of biological and physiological
& I. Goldstein (Eds.), Male sexual dysfunction (pp. 193-202). Boston:
factors in sexual problems are badly needed, as are more long- Little, Brown.
term studies of the lasting effects of sex therapy. It is unfortunately Guthrie, E. R. (1952). The psychology of learning. New York: Harper.
the case that a great deal of work in the area of treatment of Heiman, J. R., & LoPiccolo, J. (1983). Clinical outcome of sex therapy:
sexual dysfunction is at a clinical level. It is hoped that this dis- Effectiveness of daily vs. weekly treatment. Archives of General Psy-
cussion will stimulate others to engage in more empirical re- chiatry, 40, 443^*49.
search. Heiman, J., LoPiccolo, L., & LoPiccolo, J. (1976). Becoming orgasmic:
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