Psychotherapeutic Approaches to Sexual Problems An
Essential Guide for Mental Health Professionals
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Psychotherapeutic
Approaches to
Sexual Problems
An Essential Guide for
Mental Health Professionals
Stephen B. Levine, M.D.
Note: The author has worked to ensure that all information in this book is accurate at the time of
publication and consistent with general psychiatric and medical standards, and that information
concerning drug dosages, schedules, and routes of administration is accurate at the time of
publication and consistent with standards set by the U.S. Food and Drug Administration and the
general medical community. As medical research and practice continue to advance, however,
therapeutic standards may change. Moreover, specific situations may require a specific therapeutic
response not included in this book. For these reasons and because human and mechanical errors
sometimes occur, we recommend that readers follow the advice of physicians directly involved in
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Library of Congress Cataloging-in-Publication Data
Names: Levine, Stephen B., author. | American Psychiatric Association, issuing body
Title: Psychotherapeutic approaches to sexual problems : an essential guide for mental health
professionals / Stephen B. Levine.
Description: First edition. | Washington, D.C. : American Psychiatric Association Publishing, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019031916 (print) | ISBN 9781615372836 (paperback : alk. paper) | ISBN
9781615372850 (ebook)
Subjects: MESH: Sexual Dysfunctions, Psychological—therapy | Psychotherapy—methods | Mental
Health Services | Professional Practice
Classification: LCC RC557 (print) | LCC RC557 (ebook) | NLM WM 611 | DDC 616.85/830651—
dc23
LC record available at https://lccn.loc.gov/2019031916
LC ebook record available at https://lccn.loc.gov/2019031917
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
With love and gratitude to my admirable daughter-in-
law, Kathleen L. Levine, who is embarking on a career
as a mental health professional
Contents
Preface
1 A Professional View of Sexual Life
2 The Simple Male Dysfunction
3 The Developmental Female Dysfunction
4 Introduction to Erectile Dysfunctions
5 Women’s Sexual Desire: Life Cycle Perspective
6 Betrayals
7 The Gender Revolution
8 Another Barrier to Loving: Paraphilia
9 Sex Is a Psychosomatic Process: Mysteries
10 Your Professional Development
Appendix: Further Reading and Resources
Index
Preface
This book is primarily intended for new mental health professionals
during or shortly after their final training experiences. Its purpose is to
provide a sophisticated introduction to the sexual concerns of people who
seek mental health care. The book addresses young professional readers
from many backgrounds—psychiatry, psychology, social work, counseling,
marriage and family therapy, nursing, and the clergy. I hope to interest
readers from each of these groups to listen to their patients’, clients’, or
congregation members’ intimate relationship stories. While some patients
will occasionally directly ask for help with their sexual concerns, most will
first seek assistance with other problems. In doing so they often reveal
aspects of their sexual and relational lives and share their perceived
problems. Such revelations are often highly relevant to their presenting
difficulties and ideally should be of interest to the therapist.
At every age and stage of the life cycle, sexuality can be fraught with
concerns. There are times when a referral to a urologist, gynecologist, sex
therapist, or gender specialist is useful. Many patients assume, however,
that their mental health professional has an interest in, and knowledge
about, sexual life because they realize that their sexual life is so subjectively
psychological. They are dismayed when they are told such things as, “I
don’t specialize in sexual problems.” When the psychosocial contributions
to a problem are obvious to patients, they generally want to stay with their
therapist. Referral may be experienced as a rejection and as an indication
not to further discuss anything about their sexual lives with the therapist. In
writing this book, I intended to minimize the frequency of such dampening
responses. I thought I might best accomplish this goal by increasing my
readers’ comfort with the topic, stimulating their professional interest in this
subject, and demonstrating how frequently people are disappointed in this
aspect of their lives. An essential fund of knowledge is key in my
estimation. When we begin to attend to patients’ sexual disappointments
and concerns—a process that is rarely available in our culture—our
thoughtful interventions may prove to be of considerable help.
Sex is an important universal human functional activity for self-
discovery, bonding, pleasure, nurturance, and reproduction. It poses at least
three professional paradoxes. The first is that despite the fact that
sexuality’s importance to mental health has been recognized for over a
century, training in the preclinical and clinical years tends to gloss over the
topic. Trainees typically obtain few to no supervised experiences with
sexual problems and, despite their personal interest in sexual matters, often
steer clear of it in their clinical work. The second paradox is that sexual
experiences are well known to consist of a finite set of behaviors. This gives
the impression that it is a simple matter—that is, people have sexual
intercourse. The more one studies the topic, however, the more individual
the subjective and behavioral aspects are for each person and each couple.
People may have several definable ways of having sex, but many come to
not want to have any sexual activities or maintain highly restricted ones. In
this way, sexuality is as individual as is the human face. Sexuality is both
knowable at every stage of the life cycle and unique. The third paradox has
to do with the diversity of human sexual experience. There is a both a wide
range of behavioral and subjective expressions of sexual identity and a
broad range in sexual functional capacities. This range in expressions and
capacities is complicated further by the interaction of two people who may
be incompatible in some ways as they interact to produce their coupled
sexual lives. Despite this diversity of sexual lifestyles, interests, and
capacities, many health professionals are given to simplifying this
complexity so as to quickly treat problems. Erection problems: provide a
drug. Gender dysphoria: encourage transition. Vaginismus: recommend
dilators. Women’s anorgasmia: masturbate. Such clinical reflexes based on
the medicalization of sexuality do not reflect clinical sophistication.
Psychotherapeutic Approaches to Sexual Problems is intended to demystify
each of these paradoxes. I hope to provide readers with a conviction about
the individuality of a person’s sexual experience. In my view, this is vital to
successful clinical treatment, a process that begins with the correct
categorization of patients’ stories.
I do not intend this book to be difficult to read, dry, or academic. I am
content with not sharing all the known facts about a particular subject and
the basis for how they became facts. The book is far more a supervisory
guide to patients’ stories, one that provides a useful perspective on them. If
readers find this clinical introduction to be intellectually stimulating, there
are many additional resources to continue their learning process. These
include numerous textbooks, 86 specialty journals,1 databases such as
PubMed, and 31 national and international specialty organizations devoted
to these problems.2 The Internet provides easy access to many of these
resources. Some of these are listed in the appendix to this book.
Because one person wrote this book, its text reflects his values, biases,
limitations, strengths, clinical experiences, and understanding of the field.
There is no such thing as the final word or the best perspective on clinical
sexuality. All people possess this multidimensional complexity; there are
many lenses through which to view sexuality. Regardless of a person’s
gender identity, orientation, or sexual behavioral interest—that is, the
individual’s sexual identity—each person experiences an array of intensities
of sexual desire, arousal, and orgasm. Sexual function is far more
contextual and partner specific than is sexual identity. The study of sexual
function applies to all people regardless of how they identify. As
approximately 88% of the population labels themselves as heterosexual
with a conventional form of gender identity and sexual behavioral patterns,
much of this book addresses the problems they often encounter. But most of
the discussions about sexual dysfunction apply to all people regardless of
their sexual identities. As a significantly large minority of the population
has differing sexual identities, their unique struggles are discussed as well.
It is hoped that this book will prove to be a trustworthy beginning to a
lifelong educational process about individual sexualities. Perhaps one or
more readers may be inspired to spend their careers helping others to learn
about the ever-expanding topic of clinical sexuality.
Stephen B. Levine, M.D.
January 2019
References
1. Zucker KJ: Sex/gender/sexual science research 24/7. Arch Sex Behav 47(4):833–846, 2018
2. Wikipedia.org: List of sexology organizations. Available at:
https://en.wikipedia.org/wiki/List_of_sexology_organizations. Accessed December 24, 2018.
1 A Professional
View of Sexual
Life
As I welcome you to the fascinating but restricted realm of clinical
sexuality, I am aware that you are already knowledgeable about your own
sexuality. As you listen to the sexual problems of others, you will invariably
reflect on your own development and current sexual life. Please do not fear
this vital subjective process. A problem-free, concern-free, enjoyable sexual
life is not a requirement to help others. All of us who aspire to sexual
fulfillment are susceptible to disappointment. We face different challenges
as our youth imperceptibly passes through various stages to old age. Sexual
vulnerability always exists. As we allow ourselves to reflect on our own
life, we come to see that sexual pleasure is rife with nuance, curiosity,
possibility, and contradiction. I want to assure you that what you will be
hearing from your patients will prove to be a major source of your
expanding professional skills. Your patients will deepen your understanding
of life processes and of yourself.
Respect for Privacy
Despite the numerous sexual images in modern culture, public references to
sex and scandals, and commercial panaceas, the first important
characteristic of any individual’s sexuality is that it is private. Individuals
guard their sexual lives with several distinct protective layers. We do not
reveal everything to our partners. Partners keep their shared sexual
behaviors to themselves. Individuals may not clearly tell themselves of their
own desires. Children and adolescents keep their sexual thoughts and
behaviors from their parents. It is our professional privilege that patients are
willing to share aspects of their privacy so that we can help them. Session
by session they reveal what they consider to be relevant to their problem.
Privacy is so formidable a force, however, that it is not realistic for us to
expect that patients will ever reveal the entirety of their sexual lives to us.
We are always working with limited information. Please do not be insulted;
we aim for sufficient, not complete, knowledge.
Eroticism Versus Sexual Behaviors
An individual’s sexuality involves both eroticism—the subjective
experience of fantasy, desire, attraction, and preoccupation—and sexual
behaviors. Professionally, we distinguish between eroticism and solo and
partnered sexual behaviors, even though some of our colleagues and
patients use these words as synonyms. Privacy envelops patients’ eroticism
and the identity of some of their past and present partners, and what
behaviors they have engaged in. As a result of this natural guardedness, we
content ourselves with what has been revealed and do not push patients
beyond their comfort level. More details may or may not be forthcoming in
future sessions.
Certain professional characteristics make it easier for patients to reveal
their eroticism and sexual behaviors. Our interest, calm manner, knowledge
of the problem, clarifying questions, and nonjudgmental attitude increase
their confidence that it is safe to provide details to us. However, to the
extent that we demonstrate the opposite traits—apparent anxiety,
indifference, irrelevant questions, lack of information, and censoring
responses—our chances for therapeutic success diminish. These positive
professional characteristics are not different from the features required to
deal skillfully with other mental health challenges. They are just more
difficult to attain for young mental health professionals. There are several
important reasons for this.
All of us have socially learned that eroticism and sexual behavior are
matters so private that we should not ask such questions of a friend,
relative, or acquaintance. We learn to talk around the subject unless the
information is voluntarily shared. It is important to realize that our license
—our culturally prescribed role as a therapist—enables us to be curious
about this topic. Nonetheless, the layperson in a new professional role
naturally avoids the subject and, when first confronted with a patient’s
sexual concern, may experience unease. Without in-depth discussions in
seminars or in supervision, many young professionals will unfortunately
avoid directly discussing sexual matters for the rest of their professional
lives. They will use some justification, such as “Sexual problems are the
result of other issues that I do focus on.” The results are likely to be a
failure to get to the heart of the patient’s sexual experience and the
attainment of a glancing view of their patients’ sexuality. My colleagues and
I have benefited from uncomfortable therapists in our community who do
not feel equipped to respond to their patients’ sexual concerns. They refer
these patients to us. Sexual problems are too prevalent for this to be a good
idea. The purpose of this book is to prevent professional avoidance of
sexual concerns and to encourage therapists to try to personally be of
assistance.
The Natural Voyeuristic Response
There is another reason why sexual topics create so much clinical
discomfort. Each of us has a strong natural interest in the topic of sex, yet
professionals sidestep the subject. Why? One way to find the answer is to
consider the impact of movies on our subjective experiences. Scenes that
are romantic, that suggest the imminence of lovemaking, or that explicitly
display adults enjoying sex routinely sexually excite viewers. Our limbic
systems respond with arousal when imagining or watching others behave
sexually. This may occur even if we disapprove of what we are seeing. This
voyeuristic response extends to reading about sex and listening to accounts
of sexual behavior. Being slightly aroused, even transiently, in the context
of clinical activities seems dangerous to many. Some clinicians think it
forbidden. For instance, hearing about a patient’s pleasures in oral-genital
sex may immediately be arousing or take the professional to his or her own
experiences. This may create arousal, disgust, or envy. We are human. What
we listen to, we subjectively respond to. When we consider our private
response to be unprofessional, we will find a way to avoid repeating the
experience in the future.
What is forbidden, what is clearly unethical, are the behaviors that
constitute the slippery slope to violation—the flirtations, compliments, and
personal revelations. These behaviors typically precede sexual behavior
with the patient. Sex with a patient is defined as the use of the patient’s
body for the professional’s pleasure or the use of the patient’s mind for the
clinician’s arousal. Thus, sex can occur without intercourse and can include
sharing erotic fantasies about each other. We are not going to confuse such
professional sexual boundary violations, however, with our private transient
experiences of arousal and our private personal comparisons with what the
patients are reporting. Violation of the sanctity of the professional
relationship is light-years away from these ordinary momentary subjective
experiences when trying to improve a patient’s sexual life. The confusion of
these two phenomena creates the obstacle to future effective clinical work
with sexual problems.
Eroticism and the Limitation of Clinical Work
Much of conscious life about sexuality does not involve behavior. It
involves fleeting thoughts and brief waves of feeling. These subjective
erotic processes are far more common in adolescence and young adulthood
but are part of most people’s lives throughout the life cycle, particularly
when individuals are physically well and not overwhelmed by some
dilemma. When sharing eroticism, patients can only make general summary
statements about what is or what is not occurring in their minds about
themselves and others. The inherent limitations in the accuracy of patient
summaries of their erotic experiences derive from how difficult it is to be a
reliable narrator of this mental arena. Their need for privacy,
embarrassment, fear of your disapproval, and unexpected spontaneous
mental events contribute to this. We have discovered, for instance, that
many women who sought help for low or absent sexual desire had some
manifestations of sexual desire. It may have been that their summary was
correct about the paucity of their desire, or that desire reappeared during our
work together in research or in therapy, or that they understood desire to be
for their partner rather than for anyone in particular. We have also learned
that men may complain of erectile problems when, in fact, they have rapid
uncontrollable ejaculation, or complain that they have premature ejaculation
when, in fact, they have erectile dysfunction, or both. We need to accept
that patients tell us what they are able to share, and it is our responsibility to
clarify their complaint more accurately.
We Are Part of History
The work that we are undertaking to better understand how to assist patients
in this arena of life has its roots in the earliest of medical writings.1 In every
era, professional writings begin with classification, move on to theories of
causation, and end with therapeutic suggestions. These processes reflect
cultural understandings of illness in that period.2 In the last 60 years we
have witnessed a progression from a simple Freudian classification of
impotence and frigidity, to Masters and Johnson’s expanded list of three
sexual dysfunctions for each sex, to the further expanded nosology in DSM-
5, which will soon be challenged by the yet unfinished schema in ICD-11.
The sexuality patterns that we will be considering are those that are brought
to our clinical attention, only some of which can be found in a committee-
approved nosological schema.
The Natural Division
Health and disorder perspectives on the sexual universe naturally divide
into two broad dimensions: sexual identity and sexual function. Psychiatry,
psychology, and the numerous master’s degree–prepared fields of
psychotherapy usually begin the education of their students with the
designated problems in these two dimensions because those fields were
created to solve them. Wide variations in each of these major categories of
sexuality are more apparent now than ever before in history; diversity is
also seen in the behaviors that individuals engage in.3 In recent decades
mental health professionals are pathologizing less and understanding more.
This alone represents cultural progress.
Sexual identity has three components: gender identity, orientation, and
intention (see Chapter 7 for further discussion). Passionate politics surround
the variations in these components as different stakeholders defend or
condemn those with nonconforming gender identities, homosexual interests
and behaviors, and unconventional or paraphilic desires and behaviors. We
mental health professionals are not expected to be a part of those who
condemn because we are devoted to helping. In the past we have been
condemnatory, most vociferously, about homosexual lives.4 Groups of
people who in the past found themselves in classification systems of mental
disorders are today more neutrally referred to as sexual minority members
or their interests and desires are subsumed under the umbrella of sexual
diversity.
Sexual function has four components: desire, arousal, penetration, and
orgasm. Their problematic aspects are classified by genital anatomy. Male
DSM-5 diagnoses are male hypoactive sexual desire disorder, erectile
disorder, premature (early) ejaculation, and delayed ejaculation. Female
DSM-5 diagnoses are female sexual interest/arousal disorder, female
orgasmic disorder (anorgasmia), and genito-pelvic pain/penetration
disorder. Both men and women have substance/medication-induced
problems. DSM-5 creates other specified and unspecified categories for
other patterns. Do not be misled by the terms male and female in these
headings. Gender-nonconforming individuals may also qualify for these
DSM-5 sexual dysfunction diagnoses.
Where Do We Learn About the Sources of
Sexual Problems?
Movies, television, fiction, biography, newspapers, magazines, talks with
friends, watching dramas unfold in our family and the families of our
friends, and self-knowledge all contribute to what we know about the
causes of personal and interpersonal dilemmas that may limit sexual life.
Some of these are accurate illustrations of how people suffer, and even
though they may not deal with sexual identity and function directly, people
intuit how sexual life may be affected. We also learn about sexual life from
our knowledge of medicine, where sexually transmitted diseases, pregnancy
and its complications, gynecological and urological diseases, and organ
system failures interfere with self-concepts, pleasure, and sexual capacities.
And, depending on our knowledge of different cultures, we may realize
how the ideas unique to these cultures may facilitate or constrain sexual
development. All of us have ideas about what influences sexual life. One of
the things that limit our understanding of these influences is the enormous
variation in every aspect of sexuality.
The questions for professionals are 1) Do we know something that
observant laypersons do not know? 2) Do we have esoteric information or a
frame of understanding that is more or less unique to us? 3) To what extent
can clinical science help us? and 4) Is the knowledge generated by clinical
science useful to the process of helping? I will provide you with my
answers to these four closely related questions in Chapter 10.
How Individuals Become Patients
We live our lives. At times, our feelings and behaviors create situations that
we cannot master. This does not cause most people to seek assistance from
a mental health professional. At times, others tell individuals that they need
professional assistance. Even this does not necessarily result in their
seeking our assistance. At best about half of physician referrals to a mental
health professional are acted on and often not immediately. Numerous
studies have illustrated that most people with “mental disorders” do not
seek mental health care and that most people with sexual difficulties do not
directly ask for help.5 We assume that those who do arrive for care inform
us of the sexual vulnerabilities of the population who do not seek care. But
we can never be sure how great a public health problem our patients’
concerns represent. My synthesis is that my patients represent the very tip
of the iceberg of prevalence.
Happy, sexually well-adjusted, fulfilled people generally do not seek
our services. Most seek us out in crisis or after bearing the weight of a
