Dr Michael Perring traces the evolution of sex therapy over the decades and celebrates a new interdisciplinarity in the field. This article was first published in the June 2015 edition of ‘The Psychotherapist’.
In the 1970s I remember uncertainty about how we, as sex therapists, should identify ourselves and the clinics we ran. The label over my clinic door said ‘Sexual Dysfunction Clinic’ and only much later ‘Psychosexual Counselling’. As service providers, the staff might be, by training, a psychologist, psychiatrist, urologist, gynaecologist, marriage guidance counsellor or even a sexologist.
I have selected three sex surveys, not entirely at random, done approximately 25 years apart, which show the attitudes and context in which sex therapy has evolved. The Kinsey Reports (1948, 1953) came out in the late 1940s and 50s. Controversially, they asserted that sexuality is diverse and prone to change over time. In place of the three categories of homosexual, heterosexual and bisexual, Kinsey developed the seven-point Kinsey Scale, also called the Heterosexual–Homosexual Rating Scale, using a scale from 0, meaning exclusively heterosexual, to 6, meaning exclusively homosexual, with an additional grade, ‘X’, which meant ‘no socio-sexual contacts or reactions’, currently referred to as asexuality.
Kinsey’s findings were controversial and they have been criticised as unscientific. For example, he used data that were not randomised and he included an insufficient number of older people in the survey to enable statistical conclusions to be made.
Freedom and experimentation
For the second survey I recall Professor Brecker (1984) on the staff at the Institute for the Advanced Study of Human Sexuality – no modesty in that title – in San Francisco, where I was an extramural student. In the late 70s, he surveyed the marital relations of older couples in the permissive period following the arrival of the contraceptive pill and before anxiety about HIV led to caution in sexual exploration. In the gap between the two, there was a sense of freedom in sexuality and pleasure in its experimentation. Becker showed that continuance of sexual activity into later life was a matter of choice and the level of activity for couples related less to age than to the duration of the relationship.
The books still on my shelf show the enthusiasms of the time: sexual variance, conducting multiple relationships and, of course, Alex Comfort's (1972) book with line drawings of possible positions for sex. What more can I write about the enthusiasm of the people I met during those times? I remember the founder of the Institute, the Reverend Ted McIlvenna, charismatic and constantly challenging the social norms of sexual behaviour.
Benefiting from field experience
My summer in San Francisco in the late 70s was informative and eye opening: the spectacle of the Gay Parade, conversations with members of the transgendered community, immersion in 'desensitisation' to erotic videos, a video presentation on the 'G' spot, sadomasochistic practices by someone who brought their whips and handcuffs. I remember having to take my clothes off and talk about my body for five minutes while being watched by 100 people. Afterwards, in other people's descriptions of themselves, I realised the extent that feelings distort the reality of appearance. It was one experience in an immersive fortnight leading me to the conclusion that sex therapy in theory benefits from field experience.
The third survey is the 1994 NatSal Survey of UK Sexual Attitudes and Behaviour (Johnson et al, 1994) by an academic team funded owing to concern about HIV. One conclusion of the survey, I recall, was that the most common reason for sexual activity to end in a heterosexual relationship is the death of a partner, obvious but important when women live longer than men and accounting for the preponderance of women looking for a partner in later life.
Important things have not changed
Let me say this about the surveys: if you take each of them, about a generation apart, you might rightly think that much has changed about attitudes to sexual behaviour. But equally, some important things have not changed: companionship in a couple's relationship has continued to be rated more highly than the level of sexual activity in it, and the security and trust a relationship offers are highly rated in all three surveys. Perhaps unsurprisingly, in general, sexual activity is rated more highly by men than women.
Returning to the mid 70s, I was working in a psychiatric unit at Knowle Hospital between Portsmouth and Southampton. The hospital was run as a community, with extensive grounds, a hospital football team and an occupational health department offering work in the kitchen garden and the craft skills of basket-making and painting. In the long-stay wards, some inmates had not left the hospital for decades and were institutionalised – there was little clarity among any of us why they were there. New medications for psychosis, including long-acting phenothiazines, led to patients’ easier management and fitted the prevailing economic policy to discharge patients from long-stay wards into the community. In the psychology department, the influence of Skinner's behaviourism was still evident. In that setting, the use of aversion therapy for dystonic homosexuality was practised using erotic images and apomorphine, while bilateral ECT was regularly given for depression.
Masters and Johnson and co-therapy
As for sex therapy, Masters and Johnson (1970), and their model of co-therapy for couples, was published in the States and I, with a multidisciplinary team of volunteers, started a ‘sexual dysfunction’ clinic. Working in a Southampton family planning clinic, the team consisted of a marriage guidance counsellor, a health visitor, a social worker and my co-worker Dr Margaret White, a psychologist. Within two years, the clinic had a long waiting list of referrals from GPs responding to the highly publicised new therapy. Recognition of sexual medicine as a specialty at this time led to my appointment by Professor John Dennis as a Lecturer in Sexual Medicine in the Department of Human Reproduction at the University of Southampton. I remained in post there for six busy years.
In the sexual dysfunction clinic, we worked in co-therapy with two therapists and the dyadic couple along lines described by Masters and Johnson. Our training was a shoestring operation, which grew from the work, co-therapist support and weekly lunch break discussions. Typically we saw a couple every two weeks for between three to six months. We followed the M&J description of 'sensate focus' therapy and used their model of homework assignments. We had the enthusiasm of novices, engaged with our couples, and enjoyed what we were doing. With hindsight, the relational style of therapy we adopted and the genuineness of our concern for clients may well have accounted for our 'substantial improvement' rating of 75 per cent reported by the evaluating psychologist, Dr John Sketchley. We celebrated our success in the new Journal of Sexual Medicine edited by Dr Alan Riley who was later to become the Professor of Sexual Medicine at York. In parallel to our clinic, Dr Liz Stanley was appointed to a post in Sexual Medicine at St George's Hospital and started the first of a dozen training programmes in psychosexual counselling available in the UK by the 1990s.
Both Liz Stanley and I had exposure at Ted McIlvenna's Institute in San Francisco to the videotaped erotic material used there by trainees to 'desensitise' them to explicit sexual behaviour. The tapes were made by the Institute's students and portrayed explicitly their sexual preferences. Liz, after delays at UK customs, succeeded in importing some of the material for educational purposes in the newly established psychosexual training programmes. I used them with medical students to explore with them their feelings and attitudes to the different sexual lifestyles they would encounter in medical practice. For three or four years, these videos were a focus of discussion on subjects such as 'what language is appropriate when talking about sex?' and 'how to remain impartial to sexual preferences which are different from our own'. Of course, the erotic content of the tapes was not without its effect and a straw poll of participating medical students showed an increase in sexual activity over the weekends the programme was run. But over time the novelty of the tapes wore off and, in truth, I think those of us who had worked with them 'immersively' became thoroughly sick of their repeated use. I have not heard these novel erotic desensitisation tapes discussed for the past 20 years.
A briefer approach to sex therapy at this time, advocated by the psychologist Dr Jack Anonn (1974), was succinctly described as the PLISSIT model. The letters stood for permission, limited information, specific suggestions, and intensive therapy, and the model provided a good novitiate's guide to the territory!
Diverging options for managing problems
In the UK in the 1980s the different traditions of medicine and psychotherapy became evident in the diverging options for managing sexual problems. Health workers and doctors in particular had permission to touch and physically examine their patients. For me, as a part-time GP, physical examination was accepted as normal practice and, in a tradition that was ritualised and structured, it assisted as a proper means to establish a diagnosis. I was also aware of the importance it had in creating trust in the relationship between patient and doctor. By contrast, in the 'talking' therapies, physical contact with patients was taboo. Psychotherapists by tradition listened and promoted catharsis and 'insight' as the basis for change, while for an analyst working with transference the intimacy of physical contact was seen as a boundary violation that would be counter-therapeutic to the process of therapy.
Bridging the divide between these two traditions were family planning doctors who routinely examined patients when advising on contraception. The intimacy of examination was leading women to talk more easily about their sexual difficulties. Discussion in training seminars led to the formation of the Institute of Psychosexual Medicine and the psychiatrist, Dr Tom Main, became its founding president. I attended a seminar Tom Main held at the Brompton Hospital in 1987. He was a charismatic figure and a pioneer in an organisation mostly composed of women. A key understanding of the help offered was the recognition that vaginal examination was a moment when truth might be spoken. A study of the treatment of vaginismus with an attentive ear to what it represented for the patient while the examination was being made could be constructively interpreted. As I saw it, here was further evidence of the importance of touch to the patient–doctor relationship.
Better means of investigation
Meanwhile, amongst those of us working in several sexual dysfunction clinics around the UK there was a need to share our understanding of the work we were doing. It led to the formation of the Association of Sexual and Relationship Therapists. The majority of our members were either doctors or counsellors and Dr Elizabeth Stanley became our first president. Over the next decade, medicalisation of treatment led to the separate formation of the British Institute of Sexual Medicine, which could accommodate those members who preferred the primacy of diagnostic formulation and prescription. A medical approach was boosted by the discovery of a group of drugs of which the best known was Viagra. The striking benefits it provided to male function and to male confidence led GPs, whom patients often first approached, to prescribe for erectile dysfunction (ED). A generation before it was thought that about three-quarters of ED had a psychological basis. With better means of investigation available, the presence of physical – and for the most part vascular – factors were recognised as underlying the problem in three-quarters of the cases seen. It also highlighted the fact that not all men benefited from a 'one size' solution and that psychological factors, including relationship dynamics, required consideration alongside exploration of physical disease.
A further point about the medicalisation of sexual problems has been the tendency to add to the diagnostic categories of sexual dysfunction. Historically, I recall that, before the 1950s, female anorgasmia was not described as a problem and until the 1980s the American DSM classification of disease did not distinguish dystonic homosexuality. In the late 70s Dr Helen Kaplan (1979) drew attention to complex factors in the disorders of sexual desire and from early this century a distinction has increasingly been made between disorders of female arousal.
A seminal book
Published in 1983, John Bancroft's Problems of Human Sexuality provided a seminal book for those of us working in the sexual dysfunction field. He brought together, as a scientist and a practitioner, the provable with the practical, the scientifically valid with what could be understood and justified pragmatically as treatment.
Over two decades there has been maturation of the organisations providing services for sexual dysfunction and the sexual minorities. There is a UK College of Sexual and Relationship Therapists, the British Association of Sexual Medicine and The UK Institute of Psychosexual Medicine. There is also a psychosexual service provided by Relate and services offered by other voluntary bodies for the sexual minorities and LGBT community. Pressure for regulation of psychosexual counselling has come from the United Kingdom Standing Conference for Psychotherapy and for doctors from the General Medical Council. These in turn have responded to expectations in the wider community for improved access to healthcare and less autocracy in its delivery. The outcome has been regulation from without and self-governance from within the healthcare field. Alongside this, there have been stringent economic considerations affecting the provision of services in the NHS. Inevitably, services are more structured, and more attention is being paid to training practitioners and the qualifications and standards of their practice. The demands of regulation on our time are the new norm for doctors and psychotherapists alike.
A buzz of excitement
Finally, on a more upbeat note, I think the enthusiasm that led to my entering the field of sex therapy is still evident in the work of my colleagues. There is a new recognition of plasticity in the brain and possibilities for change in our behaviour. New investigative techniques may show that neural networks, once established, are resistant to change, but we have a capacity to overlay their patterns with the sprouting of new connections and behaviours. The theories on which psychotherapy has been predicated are compatible with neurobiology. It is possible to integrate models and there is a buzz and excitement in the fields of attachment, psychoanalytic and relational theory as, together with our understanding of neurobiology, we find new ways of thinking about and working with our clients. As for myself, I am validated in a way of being with my patients, which encourages empathy, realness and constructive enactment between us. It is an approach that should continue to encourage all of us in our enquiries into sex, relationships and life itself.
Annon JS (1974). The behavioral treatment of sexual problems. Honolulu: Kapiolani Health Services.
Bancroft J (1983). Human sexuality and its problems. USA: Longman Group Limited.
Brecker E (1984). Love, sex and aging. Consumer’s Union.
Comfort A (1972). The joy of sex. A gourmet guide to lovemaking. UK: Mitchell Beasley.
Johnson AM, Wadsworth J, Wellings K and Field J (1994). Sexual attitudes & lifestyles. Oxford: Blackwell Scientific Publications.
Kaplan HS (1979). Disorders of sexual desire. New York: Brunner/Mazel.
Kinsey A, Pomeroy WB and Martin CE (1948). Sexual behavior in the human male. Philadelphia: Saunders.
Kinsey A, Pomeroy WB, Martin CE and Gebhard P (1953). Sexual behavior in the human female. Philadelphia: Saunders.
Masters WH and Johnson VE (1970). Human sexual inadequacy. Toronto; New York: Bantam Books.
ｷ The books still on my shelf show the enthusiasms of the time
ｷ Companionship has continued to be rated more highly than the level of sexual activity
ｷ The more involved and interested in a subject one has been, the more it remains etched on the wall of Plato's cave, and one's perception of life
ｷ The importance of touch to the patient–doctor relationship
ｷ Psychological factors, including relationship dynamics, require consideration alongside exploration of physical disease
ｷ The theories on which psychotherapy has been predicated are compatible with neurobiology
ｷ Empathy, realness and constructive enactment
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