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This is a chapter excerpt from Guilford Publications. Sexual Dysfunction, Second Edition: A Guide for Assessment and Treatment, John P. Wincze and Michael P. Carey, Copyright 2001 1
Overview of This Book
Interest in sexual behavior increased dramatically in the last two decades.
During the 1980s (and continuing to the present), the emergence of HIV andAIDS raised awareness of the health implications of sexual behavior. Duringthe 1990s, there have been highly visible developments in the pharmacologi-cal treatment of sexual problems, most notably, the development and market-ing of Viagra (sildenafil citrate) for the treatment of erectile dysfunction.
Private and publicly supported research promises more pharmacological treat-ments of sexual problems in the decade to come.
With the launching of Viagra and subsequent worldwide attention, ques- tions were raised about the need for psychological treatments. Doubts aboutthe role of mental health professionals in treating sex dysfunction have beenshort-lived. Although Viagra alone as treatment has been sufficient for somemen suffering from erectile dysfunction, for many others this has not been thecase. Viagra has not cured marital and relationship problems, has not cor-rected myths and misunderstandings (nor has it provided accurate educationalmaterial), has not overridden negative sexual messages and sexual trauma, andhas not taught sexual skills (nor how best to create sexual feelings and a con-ducive sexual environment). No pharmacological agent will substitute forthese basic and essential ingredients of enjoyable and fulfilling sexual experi-ences.
Viagra has had the most impact on primary care physicians, who are the largest prescribers of this medication. Unfortunately, primary care physiciansdo not typically have the time or skills to screen sexual problems adequatelyand often prescribe Viagra when nonmedical factors may be contributingheavily to the problem. Viagra “failures” are most likely a result of insufficient Overview of This Book
psychosocial screening and a purely biomedical approach to a complex, bio-psychosocial experience.
A decided benefit of the Viagra craze is that it has legitimized help seek- ing for sexual problems. With the frequent commercial appearances of formerU.S. senator and presidential hopeful Bob Dole (extolling the benefits ofViagra for treating erectile dysfunction), the American public has been given avery powerful message that sexual problems are commonplace and treatable,and there is no need for shame.
Sex is important to people. This is more evident today than at any other time in our history. Our goals in writing this book are (1) to provide a state-of-the-science overview of the most common sexual dysfunctions, and (2) topresent an introductory guide to the assessment and treatment of these prob-lems.
This book is intended for health care professionals at various levels of ex- pertise and for both medical and nonmedical disciplines. Accomplished sextherapists may wish to compare their own approaches with ours and may findsome interesting ideas described herein. This book is also intended for healthcare professionals currently in training (e.g., graduate students, medical in-terns, and residents), or currently practicing but who have little (or no) previ-ous training in the assessment and treatment of sexual dysfunctions. Finally,this book is also intended for practicing physicians (e.g., internists, familypractitioners, urologists, and gynecologists) who treat patients’ sexual dys-function complaints and who wish to learn more about the psychological as-pects of sexual dysfunction. This book is not intended to replace other types offormal training and should be used in conjunction with supervision from anexperienced sex therapist.
We begin in this chapter with an overview of our current understanding of sexual function and dysfunction, and describe our general approach to themanagement of sexual difficulties. The remainder of the book is divided intotwo parts and incorporates the most up-to-date clinical and research informa-tion available. In Part I (Chapters 2–5), we provide a more detailed discussionof each of the main classes of sexual dysfunction. We focus on definitions anddescriptions, prevalence, and etiology. In Part II (Chapters 6–10), we describeour approach to assessing and treating these problems, present seven detailedcase histories, and provide information about how you can obtain furthertraining and even establish a practice in sex therapy.
Definitions of Sexual Function and Dysfunction
We are educators, clinicians, and researchers. In the context of our teachingand supervision, we often wrestle with the constructs of “normality and abnor- Overview of This Book
mality,” “health and pathology,” and “function and dysfunction.” We arethankful that our students and supervisees continually challenge our defini-tions and help us to remain open-minded and responsive to new information.
This is particularly important in a socially sensitive and value-laden field suchas human sexuality—a field where popular beliefs about function and dys-function seem to be quite labile. To illustrate this point, we can use two exam-ples: thinking about masturbation and sexual desire.
In previous times, masturbation received widespread condemnation. For example, in the 18th century, numerous treatises were written describing thephysical and mental consequences of masturbation (see Caird & Wincze,1977; Gagnon, 1977). It was during this time that a particularly well-knownSwiss physician, Tissot (1766), published a volume titled Onania, or a Trea-tise upon the Disorders Produced by Masturbation. Among the many physicaland mental disorders purportedly caused by masturbation were failing eye-sight, consumption, gonorrhea, hemorrhoids, digestive disorders, melancholy,catalepsy, imbecility, loss of sensation, lethargy, pervasive weakness of thenervous system, impotence, and insanity! Eventually, because of the scientificwork of Kinsey and others, more enlightened views about masturbationemerged. Today, in stark contrast, masturbation is prescribed as therapy (e.g.,see LoPiccolo & Lobitz, 1972; Zilbergeld, 1999). In fact, it turns out that di-rected masturbation (see Chapter 7) is a particularly effective treatment forlifelong female orgasmic disorder (see Heiman & LoPiccolo, 1988). (As anaside, we are reminded of the exchange between the Countess and Boris inWoody Allen’s movie Love and Death. Countess: “You are a wonderful lover.”Boris: “I practice a lot when I am alone.”) Before we rest on our accomplishments, however, we should note that we are not entirely free of 18th-century thinking. It was just a few years ago thatSurgeon General Jocelyn Elders was forced to resign her post for suggestingthat masturbation might be an acceptable substitute for high-risk sexualbehavior! Yes, change has occurred, but there is still room for improvement.
Related beliefs about sexual appetite, desire, and behavior have also changed. Beginning with the writing of the Christian theologian Paul, sexualabstinence and chastity were seen as virtuous. Indeed, those interested in max-imizing their spiritual development were required to take vows of celibacy andchastity (Cole, 1956). In the first half of the 20th century, however, scientistsbegan to question whether sexual abstinence was contrary to human beings’basic biological nature (e.g., Parshley, 1933) and potentially harmful. Today,the absence of sexual desire is seen as a clinical disorder that warrants properdiagnosis and treatment. Who knows what the next decade will bring? We hope that these two examples (from many that we might have selected) serve to illustrate our point: Definitions of sexual function and dys-function are inevitably influenced by current social mores, values, and knowl-edge. In the past 10 years, we have noticed an increase in sexual dysfunctionresearch studies from different cultures. Whenever possible, we have incorpo- Overview of This Book
rated cross-cultural comparisons. As these and other influences change, so toowill our definitions of sexual function and dysfunction. Mindful of this caveat,then, we are poised to discuss current clinical definitions.
Current approaches to define sexual function and dysfunction have been influ-enced by recent biomedical research and clinical practice. Current thinkingsuggests that human sexual functioning, for most people on most occasions,proceeds sequentially. This axiom, accepted by most sexologists (i.e., expertsin human sexuality), has its formal beginning with Havelock Ellis (1906), whopostulated that sexual functioning has two stages: tumescence (i.e., theengorgement of genitals with blood, resulting in erection in males and vaginallubrication in females) and detumescence (i.e., the outflow of blood from thegenitals following orgasm). Ever since, scientist–practitioners have attemptedto delineate more precisely the basic biological sequencing of sexual function.
William Masters and Virginia Johnson, household names to most Ameri- cans, contributed immensely to our understanding of sexual functioning.
During the 1950s and 1960s, they conducted a very extensive (and equallycontroversial) series of scientific observations of sexual activity with humanvolunteers. In their 1966 book Human Sexual Response, based upon thousandsof hours of careful laboratory research, Masters and Johnson suggested thatphysiological responding in healthy, well-functioning adults proceeds throughfour stages: (1) excitement, (2) plateau, (3) orgasm, and (4) resolution. Theydocumented the genital and extragenital physiological changes that typicallyoccur during each of these phases. The model they provided was instructiveand elegant.
Yet something was missing. That something was most apparent to those practitioners working with not-so-well-functioning individuals and couples(e.g., Kaplan, 1979; Lief, 1977). Some of these sexually troubled personscomplained of an inability to become amorous, a lack of interest in sex, oreven an aversion to sexual activity. In the decade following the publication ofHuman Sexual Response, it became increasingly clear that there was a “stage”preliminary to the excitement phase identified and described by Masters andJohnson. This preliminary stage, subsequently labeled sexual “desire,” in-volved a person’s cognitive and affective readiness for, and interest in, sexualactivity. Without sexual desire, physiological and subjective arousal, and sub-sequent orgasm were much less likely to occur.
Subsequent theoretical writing and empirical research have served as the basis for our current understanding of sexual function and dysfunction. Mostsexologists agree that healthy sexual functioning comprises three primarystages: desire, arousal, and orgasm. (Each of these terms is defined and dis-cussed further in the coming chapters.) Sexual dysfunction, then, consists of Overview of This Book
an impairment or disturbance in one of these stages. Although this stagemodel is somewhat arbitrary in that it identifies discrete stages in what maywell be a continuous process, we believe that it provides a useful heuristicfrom which to conceptualize and discuss sexual health. Not surprisingly, thismodel is compatible with current diagnostic schemes.
Recognizing Sexual Dysfunctions:
The Challenge of Diagnosis
Although several diagnostic approaches have been proposed to classify thesexual dysfunctions (e.g., Schover, Friedman, Weiler, Heiman, & LoPiccolo,1982), the diagnostic scheme that has been most widely adopted for sexualdysfunctions is that contained in the Diagnostic and Statistical Manual ofMental Disorders (hereafter abbreviated as DSM; American Psychiatric Asso-ciation, 1994). This series of manuals was developed to aid mental health careprofessionals in the diagnosis and treatment of the so-called “mental disor-ders.” (The first edition of DSM appeared in 1952, and new editions appearedin 1968 and 1980; the third edition was revised in 1987. The fourth edition ofDSM was published in 1994 and its text revision—DSM-IV-TR—in 2000.)Although the manual was not developed for sex therapists, it contains diag-nostic categories and criteria for the most commonly seen sexual difficulties.
There are nine major diagnostic categories for sexual dysfunction in DSM-IV-TR. These diagnostic categories, depicted in Table 1.1, include thefollowing: hypoactive sexual desire disorder, sexual aversion disorder, female TABLE 1.1. Categories of Sexual Dysfunction among Men and Women
Overview of This Book
sexual arousal disorder, male erectile disorder, female orgasmic disorder, maleorgasmic disorder, premature ejaculation, dyspareunia, and vaginismus.
(These terms, and their diagnostic criteria, are described in detail in Chapters2–5.) All nine of the dysfunctions identified in DSM-IV-TR should be furtherconceptualized along two dimensions. First, they may be characterized as“lifelong” (also known as “primary”) or “acquired” (also known as “second-ary”). Second, a dysfunction may be “generalized” (i.e., occurring across allsexual situations and partners) or “situational” (i.e., limited to certain situa-tions and partners). These distinctions are believed to be important with re-spect to both etiology and treatment.
DSM-IV-TR represented an improvement over previous editions of DSM but is still far from perfect. The primary limitations within sexual dysfunctiondiagnosis is the inherent subjectivity of criteria in most categories. Terms suchas “minimal sexual stimulation” or “normal sexual excitement” leave much toclinical judgment.
Despite limitations, DSM-IV-TR classifications continue to be used in professional journal articles, by most health professionals (from whom refer-rals may originate), and by insurance companies (for third-party reimburse-ment). It should be noted, however, that most insurance companies still do notreimburse for treatment of sexual dysfunction. Often, a diagnosis of anxietydisorder or depression is justifiable. Familiarity with DSM-IV-TR categoriesand criteria is essential.
Sexual Deviations, Dysfunctions, and Dissatisfaction The DSM diagnostic scheme includes the sexual deviations (i.e., paraphilias),as well as sexual dysfunctions. Paraphilias are disorders in which an individ-ual experiences recurrent and intense sexual urges and fantasies involving ei-ther (1) nonhuman objects (i.e., a fetish), (2) suffering or humiliation of one-self or one’s partner (i.e., sadomasochism), or (3) nonconsenting partners(e.g., pedophilia, exhibitionism, frotteurism). Assessment and treatment of theparaphilias are not covered in this book. (Interested readers are referred toKafka, 2000; Laws, 1989; Laws & O’Donohue, 1997; Wincze, 2000.) However, knowledge of the assessment and treatment of the paraphilias or atypical sexual behavior (that does not meet the criteria for paraphilia) isimportant for assessment and treatment of sexual dysfunction. Unusual typesof sexual preferences or stimulation are at times at the root of sexual dysfunc-tion in both men and women. Incorporating or controlling the atypical sexualbehavior of one partner within a couple’s sexual practices may be an impor-tant component of the treatment of sexual dysfunction. Therapists treatingsexual dysfunction problems can best serve their patients by being knowledge-able of and comfortable with “atypical” sexual behaviors.
In addition to being willing to explore, understand, and accept a person’s unusual sexual practices and preferences, the therapist dealing with sexual Overview of This Book
dysfunction problems must also understand and accept that not everyone isconcerned or distressed by their sexual dysfunction. Indeed, DSM-IV-TR in-cludes the criteria of distress and/or interpersonal difficulty for each sexualdysfunction description (i.e., “The disturbance causes marked distress or in-terpersonal difficulty”).
Thus, a person may be “dysfunctional” but not necessarily dissatisfied. In a landmark study published in the New England Journal of Medicine, Frank,Anderson, and Rubenstein (1978) investigated 100 happily married Americancouples. These researchers attempted to determine the frequency of sexualdysfunctions experienced and the relationship of these problems to sexual sat-isfaction. Although over 80% of the couples reported that their marital andsexual relations were happy and satisfying, 40% of the men reported erectileand ejaculatory dysfunction, and 63% of the women reported arousal or orgas-mic dysfunction! Even more surprising was the finding that the number ofdysfunctions was not strongly associated with overall sexual satisfaction.
These findings have been corroborated in a similar study conducted byNettelbladt and Uddenberg (1979) in Europe. These authors reported that sex-ual dysfunction was not significantly related to sexual satisfaction in theirsample of 58 married Swedish men.
These empirical findings remind us that sexual health involves more than just intact physiology and typical “functioning” (i.e., progression through de-sire, arousal, and orgasm phases). In our culture, and in many others as well,sexual health is enhanced to the extent that it occurs in a rich interpersonalcontext that involves respect and trust, open lines of communication, and mu-tual commitment to all aspects of the relationship. (This is not to say that otherapproaches to sexual behavior are wrong, but rather to describe the conditionsunder which sexual satisfaction is maximized.) Sexual health is most likely tooccur in individuals who are psychologically as well as neurologically,hormonally, and vascularly intact. Because existing diagnostic schemas,which focus exclusively on sexual “functioning,” cannot encompass the rich-ness of sexual health, such schemas (and diagnoses in general) have been criti-cized (e.g., Schover et al., 1982; Szasz, 1980; Wincze, 1982). This limitationnotwithstanding, most scientist–practitioners find the DSM classificationschema useful for communicating among themselves, for presenting informa-tion about subclasses of problems, and for treatment planning. Indeed, the ex-istence of the diagnostic system allows researchers to conduct epidemiologi-cal studies in order to determine the frequency with which disorders occur.
Prevalence of the Sexual Dysfunctions
With the recent explosion of interest in sexual dysfunction due to pharmaco-logical treatments, there is every reason to believe that sexual dysfunctions areprevalent psychological disorders in the general population. Simons and Overview of This Book
Carey (2001) point out that although sexual disorders tend not to be includedin large-scale epidemiological studies, there have been 52 empirical studiessince 1990 that provide data on sexual dysfunctions. Comparing various prev-alence rates across studies can be misleading, however, because studies differin research methodology, definition of sexual disorders, and the sample understudy (e.g., a sample drawn from a diabetes clinic cannot be compared to onedrawn at random from a community). Nonetheless, we now have some confi-dence in the prevalence range for most sexual dysfunctions within the generalpopulation. Community samples indicate a current prevalence ranging up to3% for male orgasmic disorder, 5% for erectile disorder, 3% for malehypoactive sexual desire disorder, 10% for female orgasmic disorder and 5%for premature ejaculation (Simons & Carey, 2001). These prevalence data areconsistent with anecdotal evidence from practicing social workers, psycholo-gists, psychiatrists, and primary care nurses and physicians whose patientscomplain frequently about sexual dysfunction problems.
Etiology of the Sexual Dysfunctions
To treat sexual dysfunction or dissatisfaction effectively, it is helpful (butprobably not necessary) to understand how that dysfunction or dissatisfactiondeveloped. Unfortunately, our understanding of the cause(s) of the sexualdysfunctions remains incomplete. Moreover, much of our understandingcomes from clinical observation rather than well-controlled research. As in thestudy of disease and psychopathology, this is not unusual; however, wedo need to be mindful of the methodological limitations of such quasi-experimental research, cautious about our judgments, and continually open tonew clinical and research data.
With these caveats in mind, we are nonetheless confident about the fol- lowing general statements regarding the etiology of the sexual dysfunctions: 1. In most cases, sexual difficulties are multiply determined; that is, there is usually not just a single cause for a problem; rather, one can expect tofind an array of factors that contribute to the development of a sexual diffi-culty. Appreciation of this principle can help to explain why treatments needto be customized to the individual, as well as why treatments need to be em-pirically eclectic, multimodal (Lazarus, 1988), or broad-spectrum (LoPiccolo& Friedman, 1988) rather than dogmatically designed and narrowly focused.
2. Within such a multicausal context, causes can be organized for com- munication purposes into three temporal categories (Hawton, 1985). First,“predisposing” factors are those prior life experiences (e.g., childhood sex-ual trauma) and inherited characteristics (e.g., diabetes) that make a personvulnerable to certain types of dysfunction. These predisposing factors serve Overview of This Book
as diatheses that place an individual at risk; predisposing factors may benecessary, but they are rarely sufficient to produce a dysfunction. Second,“precipitating” (or triggering) factors (e.g., stress associated with job diffi-culties) are those life events and experiences associated with the initial onsetof a symptom or dysfunction. A precipitating factor serves as the proverbial“straw that broke the camel’s back.” Third, “maintaining” factors (e.g., lackof privacy) are those ongoing life circumstances or physical conditions thathelp to explain why a dysfunction persists.
3. Causes can also be classified, again for heuristic purposes, into three human systems or frames of reference. First, causes may be inherently bio-logical or medical. Thus, for example, the presence of penile microangio-pathy (i.e., small-vessel disease) in a middle-aged male diabetic can causeerectile difficulties. Similarly, the hormonal changes that can accompanymenopause in women can produce vaginal dryness and dyspareunia. Sec-ond, causes can be psychological in nature. Gross disturbances in realitytesting (e.g., paranoid delusions), major depression, and serious anxiety dis-orders have all been implicated in the pathogenesis of sexual dysfunction.
Less obvious psychological contributions to dysfunction include negativebody image and fear of negative evaluation or rejection. Finally, causes canarise from a person’s social context. At the dyadic level, factors such aspoor communication and relationship inequalities can foster sexual dysfunc-tion. Larger sociocultural influences, such as sex-role or religious proscrip-tions, may also have an impact upon sexual functioning.
In summary, we propose that the etiology of most sexual dysfunctions will be multiply determined, involving the transaction of biological, psycho-logical, and social factors over a period of time. Thus, a major challenge for usas sex therapists is to recognize these multiple sources of influence, and to ap-preciate that sexual dysfunction represents but one manifestation of a complexprocess. As our knowledge of etiology increases, it is likely that we will alsodevelop more reliable and valid assessments, as well as more efficacious treat-ments.
Assessment and Treatment
After introducing the dysfunctions in Part I of this book, we devote Part II tothe assessment and treatment of sexual dysfunction and dissatisfaction. Thismaterial commences in Chapter 6. Before then, however, we wish to makeclear the beliefs that influence our approach to assessment and treatment.
First, we are strong advocates of the biopsychosocial approach to health care, which has received increased attention in the training of many healthcare professionals (see Engel, 1977). This model has important implications Overview of This Book
for both assessment and treatment that will become manifest throughout this book. Clearly, this model requires continuing efforts to stay abreast of developments—not only in one’s own discipline but also in related disciplines.
Second, we are equally committed to the scientist–practitioner model of health care training and delivery. This model, espoused by the American Psy- chological Association as its primary training approach, has been much mis- understood, misapplied, and subsequently criticized. However, as we under- stand it, this model requires practicing clinicians (1) to stay abreast of recent scientific developments and, more importantly, (2) to adopt an empirical ap- proach to their work. We discuss each of these “requirements” in turn.
It is important to stay current and remain informed of recent advances, controversies, and other developments in our field. Certainly, the arrival of ef- fective pharmacological treatments for some sexual dysfunction problems is a prime example of this. All clinicians working with male erectile dysfunction must now be informed of the advantages and limitations of Viagra.
The recommendation that one adopt a scientific approach to one’s work requires careful, ongoing assessment and critical self-evaluation (see Barlow, Hayes, & Nelson, 1984; Carey, Flasher, Maisto, & Turkat, 1984). We believe that a scientific approach is especially necessary in a controversial and under- studied area such as human sexuality, because there is an increased probability of conjecture and subjective (or even distorted) information. Thus, the scientist–practitioner approach, which sensitizes one to the need to be critical of current “knowledge,” is especially valuable in a field that is susceptible to Third, we believe that a wide variety of sexual practices and orientations have been prematurely labeled as psychopathological, deviant, or abnormal.
Therefore, with some obvious exceptions (e.g., coercive sexual practices witha nonconsenting partner), we try not to make value judgments regarding the“rightness” or “wrongness” of practices that are not universally approved inour culture (e.g., gay and bisexual practices). Instead, we call for continued re-search and study of these practices to increase our understanding of the rich-ness and diversity of human sexual expression.
We have attempted to prepare a book that is equally applicable to male and female, as well as to gay and straight, concerns. At points where our cov-erage seems biased or one-sided, please understand that this was not our inten-tion; such instances may reflect the state of current knowledge or our inabilityto express ourselves as well as we would have liked.
Finally, we would like to encourage all professionals to adhere closely to the ethical principles of their disciplines. Because our own professional train-ing is in psychology, we follow the guidelines proffered by the American Psy-chological Association. Further information is available from the Casebook on Ethical Principles of Psychologists (American Psychological Association, 1987), or from the state licensing boards of the various professions.
Copyright 2001 The Guilford Press. All rights reserved under International Copyright Convention. No part of this text may be reproduced, transmitted, downloaded, or stored in or introduced into any information storage or retrieval system, in any form or by any means, whether elknown or hereinafter invented, without the

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