The place and role of sex therapy in the age of pharmacotherapy

1. Sex Therapy
IN THE AGE OF PHARMACOTHERAPY

2. First things first
• Sex Therapy was the result of
Masters and Johnson’s seminal
work on ‘Human Sexual
Inadequacy’
• A multimodal therapeutic program
for mgmt of sexual dysfunctions.
• Individual, interpersonal, contextual
factors taken into consideration.

3. M & J Model
Primarily works with couples
▪ No such thing as uninvolved partner in a sexual dysfn.
in a committed relationship
▪ The partner may / not be the cause; but is affected
▪ Inputs by both partners prove more useful
▪ Opportunity to gain the coop. & understanding of both
partners in resolution

4. Cotherapy team
To build confidence & receive cooperation from both
To demonstrate effective communication skills
Integration of Physiologic & psychological data in assessment
& treatment
Rapid and intensive approach ( Daily for 2 weeks)
(Found to be effective compared to once/twice a week sessions)
M & J Model

5. Therapy is individualized
(to take into account, the values and objectives of the couple)
Other features
▪ Sex therapy does not "teach sexual response". It helps to
remove/overcome obstacles, so that natural responses flow.
▪ Fear of performance & spectatoring are considered central to SDs.
▪ Pressures to perform are removed by banning direct sexual contact
initially.
M & J Model

6. • Prescription of sensate focus home exercises
• Relabeling the expectations like "success" / "failure“
• Blame game discouraged.
Encouraged to assume responsibility for self.
A majority of time in the therapy sessions spent on
addressing negative sexual attitudes & non-sexual issues
Ex: Covert hostilities, anger, power struggle, self-esteem issues,
family disputes etc.
M & J Model

7. ▪ 1. Mutual Responsibility between the couple
▪ 2. Information, Education and Permission
▪ 3. Attitude Change
▪ 4. Anxiety Reduction
Anxiety reduction procedures: behavior therapy, breathing, relaxation, systematic
desensitization
▪ 5. Communication and feedback training
The Basic Elements of ST
– LoPiccolo

8. The Basic Elements of ST
– LoPiccolo
6. Intervention in destructive sex roles, life-styles, and
family interaction.
7. Prescribing changes in sexual behavior:
▪ Sexual performance anxiety & ED: Non-demand pleasuring
and sensate focus
▪ PE: Squeeze, start-stop
▪ Vaginismus: Digital dilatation

9. VARIANTS Followed soon thereafter
▪ Frequency -> Once a week
(Schiller, Wincze, Schmidt and Lucas)
▪ Single therapist approach:
(Kaplan, Annon, Ellis, Schiller, Lopiccolo)
▪ Group therapy or individual therapy
(Kaplan, Zilbergeld, Barbach)
▪ Hypnosis
(Alexander, Fuchs, Fabbri, and Brown & Schaves)

10. • Kaplan's New Sex Therapy:
▪ Integrates M & J model with psychoanalytic
principles.
▪ Standard sex therapy method suits problems
having roots in mild anxieties and conflicts
▪ Some sexual problems and esp. desire
problems are complex : deep-seated
psychol. difficulties
▪ Advocates Start-stop of Semans instead of
squeeze (M&J)
VARIANTS

11. • Behavior Therapy & Cognitive Restructuring:
Gagnon
Leiblum and Rosen
Barry McCarthy
Wincze and Carey
• Jack Annon's P LI SS IT model
Adjuvants

12. Additional Therapeutic models:
▪ Albert Ellis: Rational Emotive Therapy (RET)
▪ Lonnie Barbach's women's group therapy
(anorgasmia Tx.)
▪ Humanistic Sex Therapy
▪ Systemic sex therapy
▪ Existential sex therapy
▪ Somatic Experiential / Gestalt therapy

13. Medicalization of Sexual Problems- Identity Crisis for Sex
90:10  10:90
▪ Biomedical approaches to sexual problems
▪ Surgical therapy
▪ Penile implants
▪ vascular surgeries for venous leakage / arterial insufficiency
▪ Mechanical device
▪ Vacuum Erection Devices
▪ EROS-CTD
▪ Dildos

14. ▪ Pharmacological agents:
▪ Vasoactive agents like Papaverine, Phentolamine, PGE1 for
ED
▪ Alprostadil through MUSE (medicated Urethral System for
Erection)
▪ Testosterone & Bromocryptine therapy for HSDD
▪ SSRIs for PE

15. ▪ Finally … PDE5i’s (1998)
• Advent of Viagra
• change in entire landscape of ED treatment
• 90% of ED cases are treated with PDE5i’s
• SSRIs “stopped” the “stop-start” and “squeezed” the behaviour methods
out of PE mgmt.
• Other off-label medications for M & F sexual problems
• Pharmacotherapy takes front seat.

16. “Im”Patient Factors
• Lack of basic knowledge about sex, coupled with myths, misconceptions
• Unrealistic expectations - about sex, about therapeutic outcome
• Embarrassment and unwillingness to seek professional help - early.
• Preference to in absentia consultation (phone/online txt)
• Dependence on unreliable and fragmented information incl. from Dr. Google - the
all-in-all companion
• Self diagnosis
• Too impatient to get to the roots of the problem; Longing for effortless quick fix
solutions, especially drug-centric attitude (“prashad”)

17. New Therapeutic Technologies
▪ Platelet rich plasma infusion
▪ Genetic Engineering
▪ Stem Cell Therapy
▪ so on…

18. Where do you stand,
Sex Therapy?

19. “What surprised many, however, was the large
percentage of patients who discontinued
pharmacotherapy, a phenomenon not easily
explained by the robust efficacy and safety of
these interventions.” - Stanely Althof

21. Vigil blowers
• Several studies corroborated the deficits of pharmacotherapy-only approaches, and stressed the need to
incorporate modalities addressing other factors (psychological, sociocultural, relational, contextual)
• … return to some form of sex therapy!
• Melnik & Abdo (2005): psychotherapy+Sildenafil group achieved statistically significant improvement over
sildenafil-only group of patients.
• Phelps, Jain and Monga (2004) : Sildenafil + 1 session of psychoeducation group exhibited greater
treatment satisfaction over Sildenafil only group.
• Lottman et al. (1998) compared men receiving ICI plus 3 counselling sessions with ICI only group. At the
end of 6 months, 60% of the ICI Group discontinued the therapy while no one dropped out of the group
received counselling.
• Similar findings with vacuum erection therapy were reported by Wylie et al. (84% vs. 60% improvement)
• These studies suggest that combining sex therapy approaches to medical treatments improves sexual
dysfunction substantially.

22. Case example
A 54-year-old married man requested treatment of his ED. He suffers from Type II diabetes,
hypertension, and obesity and requires five medications for his medical problems. He reports poor
morning erections and weak erections with masturbation and foreplay. No Intercourse for the past 8
months. His sexual interest has decreased
In this case it is likely that the predisposing and precipitating factors for the erectile dysfunction are
entirely medical, namely, diabetes, hypertension, and possibly his medications
However, his mood, attitude, motivation to resume a sexual life, level of performance anxiety,
preoccupation with the symptom, expectations and fears of treatment, quality of his interpersonal
relationship, degree of his partner’s interest in resuming a sexual life, her health status, the couple’s
interval of abstinence, life stresses, and coping skills could all worsen the symptom and interfere with
responsiveness and continuation of treatment.
Simply giving a PDE5i without considering the impact and interaction of all the biopsychosocial issues
may be insufficient to overcome the amalgam of medical and psychosocial obstacles

23. Psychological & Relational responses
to psychotherapy
• Pharmacotherapy alters the sexual script (McCarthy) - patterns of love making disrupted. For ex.,
who initiates? What time?
• ‘Window of opportunity’ issues: shorter windows increase pressure to perform (ex: sildenafil vs.
Tadalafil), topical anesthetic creams in case of PE
• Partners and pts may be concerned about health hazards of medication and monitor his physical
reactions than focusing on their own sensations or pleasure
• Partners may resent men using medications. May complain of mechanical sexual activity devoid of
love and caring.
• Sometimes pharmacological agents may negatively alter the couple equilibrium ( ex: a pt on PDE5i
became sexually more demanding , to which wife objected, pt started insisting on wife taking
medication to match him)

24. To sum up
• Neither sex therapy nor pharmacotherapy can be undermined in their respective
roles.
• Sex therapy is crucial in even the 100% organic cases of sexual dysfunctions, as
there is a MIND behind every BODY.
• Sex therapy is still evolving, with more and more novel approaches - especially to
deal with psychosocial and relational elements are being developed
• The field requires solid evidence-based research supporting their efficacy.
• An integrated approach is order of the day.

25. • As the ancient Indian “surgeon” SUSRUTA put it:
• "Ekam saastram adheeyaano
• na vidyaat saastra nischayam
• Tasmaat bahusrutam saastro
vijaneeyaat chikitsakaha”
• one who depends on one science cannot make learned decisions, One has
to learn from many disciplines to be a (competent) physician”

26. Thank you!