The STP in application

1. INVITED COMMENTARY
Why the Sexual Tipping Point®
Model?
Michael A. Perelman1
Published online: 29 February 2016
# Springer Science+Business Media, LLC 2016
Abstract The editorial thread of Current Sexual Health
Reports aspires to cultivate a biopsychosocial-behavioral and
cultural perspective for the reader that also results in more
healthcare professionals embracing the importance of a trans-
disciplinary approach that integrates counseling with current
and emerging medical/surgical techniques for the treatment of
male and female sexual disorders (Perelman in Curr Sex
Health Rep, 7(1):1–2, 2015). Supporting a related goal in
2011, the author founded the MAP Education & Research
Fund, a 501(c)(3) public charity dedicated to educating
healthcare providers that sexual health is more than just biol-
ogy. The Fund’s website, mapedfund.org, was just launched in
order to offer the resources of its Sexual Tipping Point (STP)
model for free! It remains critical to advance a model that
would help students, professionals, and the public alike un-
derstand that sex is always both “Mental And Physical.” All
the biopsychosocial-behavioral and cultural models of sexual
dysfunction provide a compelling argument for sexual medi-
cine treatments that integrate sex counseling and medical and/
or surgical treatments. Given the choice of so many different
biopsychosocial-cultural models, why embrace the Sexual
Tipping Point model? Perhaps, the greatest advantage of the
STP model is the ease with which it provides clinicians as well
as their patients (and their partners) with a common sense
explanation of sexual problems and potential solutions. At
Weill Cornell Medicine, when contemplating the clinical need
for understanding etiology, diagnosis, and treatment, we find
the Sexual Tipping Point both helpful and convenient.
Keywords Sexual tipping point model . Sexual dysfunction .
Dual control models . Transdisciplinary approach . Integrated
treatment approach
The editorial thread of Current Sexual Health Reports aspires
to cultivate a biopsychosocial-behavioral and cultural per-
spective for the reader that also results in more healthcare
professionals embracing the importance of a transdisciplinary
approach that integrates counseling with current and emerging
medical/surgical techniques for the treatment of male and fe-
male sexual disorders [1]. Supporting a related goal in 2011,
the author founded The MAP Education & Research Fund,1
a
501(c)(3) public charity dedicated to educating healthcare pro-
viders that sexual health is more than just biology. It was
particularly timely to respond affirmatively to the Publishing
Editor’s invitation to write this commentary as The Fund’s
website, mapedfund.org, was just launched in order to offer
the resources of its Sexual Tipping Point Model®2
to profes-
sionals and the public alike for free!
Many sex therapists and sexual medicine specialists are
hyperaware of the difficulty patients face in achieving the
sexual satisfaction they deserve. The problem is multilayered
and systemic, but such failure often hinges on limited and
sometimes inaccurate communication between patient and
physician. This is not an indictment of most physicians, who
regrettably receive little (sometimes no) medical school edu-
cation in human sexual function and dysfunction [2]. Of
course, it is not just physicians who require postgraduate ed-
ucation regarding human sexuality. Too many mental health
practitioners lack the necessary knowledge and tools to be
able to adequately assist their patients who suffer with sexual
1
Also known as The MAP Educational Fund
2
Trademark registration owned and maintained by the MAP Educational
Fund
* Michael A. Perelman
michael@mapedfund.org
1
Weill Cornell Medicine | NewYork-Presbyterian, New York, NY,
USA
Curr Sex Health Rep (2016) 8:39–46
DOI 10.1007/s11930-016-0066-1

2. concerns and disorders [2]. However, the media especially
exacerbate the physician’s dilemma, as a deluge of pharma-
ceutical advertisements repeatedly tells patients to Bspeak to
you doctor about your sexual concerns.^
Unfortunately, too many physicians are poorly equipped to
understand and treat sexual problems (beyond prescribing the
most current medications), and some are uncomfortable even
discussing sexual matters with their patients [3]. Still others
are disinclined to treat what they misconstrue as Bmere life-
style problems,^ despite the overwhelming evidence of the
pejorative impact of such disorders on their patients [4–10].
It does not help that our media continuously present a sexually
over-saturated society, promoting unrealistic expectations and
misinformation that result in more unnecessary suffering.
Regrettably and more rapidly than any sex therapist could
imagine, the exaggerated mid-century notion that psycholog-
ical problems caused most sexual dysfunctions was replaced
by a media fueled equally fallacious argument that sexual
problems were almost exclusively the result of organic causes
[11••]. Dismissed from the public discourse and all but forgot-
ten was the truism that every sexual disorder, regardless of the
severity of its organic etiology, also has a psychosocial com-
ponent—if not causative, then certainly consequential [12].
The etiology of ED had not changed (it has always been men-
tal and physical), but the medical profession and the lay pub-
lic’s outlook would shift dramatically by the new millennium
[11••]. It was in that environment that the STP model was
unveiled at the end of the twentieth century.
The Fund’s trademarked Sexual Tipping Point (STP) dual-
control bio-psychosocial model provides clinicians with a
simple way to conceptualize and explain to their patient (and
his/her partner) the overwhelming number of interrelated or-
ganic and psychosocial factors that predispose, cause, main-
tain, and exacerbate sexual disorders in a way that minimizes
blame and hurt feelings. It simultaneously provides hope with
the offer and explanation of an integrated treatment approach.
This author believes that widespread adoption of the STP
model by sexual health practitioners would help demystify
the delicate system of balances that determines sexual satis-
faction, leading to a better patient outcomes.
The History of the Sexual Tipping Point Model3
The Sexual Tipping Point model had actually evolved over the
last 40 years, beginning with 2 decades of collaboration with
Helen S. Kaplan at NY Weill Cornell Medicine’s Human
Sexuality Program, which she founded at the Payne Whitney
Clinic of the New York Hospital. Her first book, The New Sex
Therapy [13], described that program’s outpatient treatment
approach, which modified [14] 2-week pioneering residential
program [15]. As Kaplan’s book became the standard text for
most students and medical institutions around the world, it had
an impact on where and how people were treated for sexual
problems both nationally and internationally. Kaplan brought
the principles of multi-determinism and multilevel causality to
sex therapy [16•]. Kaplan practiced a therapeutic eclecticism
that anticipated current sexual medicine approaches that
combine/integrate appropriate selection of medical and surgi-
cal treatments with sex counseling, described by Althof,
Leiblum, McCarthy, Perelman, Rosen, Segraves, and Wylie,
among others, by the turn of the twenty-first century [17, 18•,
19–24, 25•, 26–29].
In Kaplan’s final book, published in 1995, she described a
“psychosomatic” dual-control model of sexual motivation
emphasizing “inhibition/excitation” processes. Kaplan’s con-
cept was derivative of the work of Kupferman [30] wrote, “All
examples of physiological motivational control seem to in-
volve dual effects—inhibitory and excitatory—which func-
tion together to adjust the system” (p. 751). In response to that
insight, Kaplan wrote, “Control of sexual motivation is no
exception and also operates on such a “dual steering” princi-
ple… Once again, we can learn from the similarities between
eating and sex” ([31], p. 17).
Kaplan’s description and illustration of the dual control
elements underlying human sexual motivation and sexual de-
sire dysregulation anticipated the work of Bancroft and his
Kinsey Institute colleagues, including Graham, Heiman,
Janssen, Sanders, and others. They later provided continuing
erudite articulation of dual-control theory, research, and relat-
ed psychometrics becoming the best known of these various
models [32–34, 35••, 36•, 37]. Kaplan also foreshadowed the
work of Pfaus [38••] concepts of satiation of appetite being
related to satiation of sexual desire as a theoretical mechanism
to explain hypoactive sexual desire disorder.
An artist by training, in that book [31], Kaplan had
sketched a cartoon (see Fig. 1) that foreshadowed the current
digital graphics developed for use in the STP model, all of
which can be found on the mapedfund.org website.
Kaplan dedicated that final book to her 2-decade collabora-
tion with her colleagues at Cornell. In 1995, appointed as the
next Co-Director of that program, this author found inspiration
from Kaplan’s sketch to refine his own mind/body ideas into
the Sexual Tipping Point model. The model’s graphics would
provide a visual heuristic for Cornell clinicians that would de-
pict the intra and inter-individual variability of all sexual func-
tion and dysfunction. The Sexual Tipping Point is the charac-
teristic threshold for an expression of a given sexual response.
The Sexual Tipping Point name derived from a concept that
was “in the air” at the end of the twentieth century. In fact, with
the publication of his book in 2000, journalist Malcolm
Gladwell made the concept iconic [39]. While Gladwell wrote
and lectured about social epidemics and other macro forces,
3
Some of this information was originally posted online at mapedfund.org
and is used with permission.
40 Curr Sex Health Rep (2016) 8:39–46

3. such as viral marketing, the STP was focused on individual
uniqueness and the continuous variability of both interpersonal
and intrapersonal factors from a biopsychosocial–cultural per-
spective. Its initial application was for sex therapy; later, it
expanded to incorporate all aspects of sexual medicine. To
document and distinguish the differences between Gladwell’s
exceedingly well-known views and the Sexual Tipping Point
concepts, a trademark registration was sought and awarded by
the US Patent and Trademark Office in 2005 [40••].
The Sexual Tipping Point model easily illuminates the
mind–body concept that mental factors can Bturn you on^ as
well as Bturn you off^; the same is true of the physical factors.
Therefore, an individual’s Sexual Tipping Point represents the
cumulative impact of the interaction of a constitutionally
established capacity to express a sexual response elicited by
different types of stimulation as dynamically impacted by var-
ious psychosocial-behavioral and cultural factors. An individ-
ual’s threshold will vary somewhat from one sexual experi-
ence to another based on the proportional effect of all the
different factors that determine their tipping point at a partic-
ular moment in time, with one factor or another dominating
while others recede in importance. It illustrates both intra and
inter-individual variability that characterizes sexual response
and its disorders for both men and women [40••].
Besides illustrating all etiological permutations, including
normal sexual balance, the Sexual Tipping Point concept is
particularly useful for modeling treatment and can easily be
used to explain risks and benefits for patients with sexual
disorders. The STP model can be used to teach patients where
different treatment targets should be focused, depending on
diagnosis of their etiological determinants [41]. Typically
expressed erroneous binary beliefs can be politely disabused
and the patient can be reassured that BNo, it is not all in your
head,^ nor Ball a physical problem.^ Reciprocally, their part-
ner can be assured it is Bnot all their fault^! Teaching the STP
model to the patient and partner can reduce patient and partner
despair and anger, while providing hope through a simple
explanation of how the problem’s causes can be diagnosed,
parsed, and Bfixed^ [42•]. In fact, the Sexual Tipping Point
also allows for modeling of a variety of future treatments,
including medical or surgical interventions not yet discovered
or proven, such as novel pharmacotherapy, genetic engineer-
ing or nanotechnology [43•]. The reader is referred to the
mapedfund.org website resources that explain the STP con-
cepts in much greater detail.
Some ideas embedded within the STP were first incorpo-
rated into the author’s presentations on BSex Coaching for
Physicians^ and were also referred to as part of the author’s
1998 Journal of Sex & Marital Therapy commentary on the
BCornell Model.^ The author first introduced the BSexual
Tipping Point^ term to the professional public in a lecture
called BThe Role of Sex Therapy, an Overview,^ delivered
at a CME sexual medicine update course called BSexual
Dysfunction 2001^ at Columbia University’s College of
Physicians and Surgeons’ Department of Urology. That was
also the first time that BFemale Sexual Dysfunction^ was
discussed in that forum, and the STP model was used to illus-
trate how all the mental and physical factors both implicit and
explicit in male sexual dysfunction were also true for disorders
and common concerns of women. While obvious to some at
Fig. 1 Kaplan’s illustration of the
psychosomatic dual-control
model of sexual motivation.
Adapted with permission from
Kaplan HS, The Sexual Desire
Disorders. Dysfunctional
Regulation of Sexual Motivation.
Brunner-Routledge (Taylor and
Frances, London, 1995: p. 15
[Fig. 2])
Curr Sex Health Rep (2016) 8:39–46 41

4. the time and to all in retrospect, the profound success of the
1998 launch of sildenafil by Pfizer had overwhelmingly tilted
urologists’ attention at the millennium to focus on male disor-
ders with little recognition of the problems and concerns of
women.
A number of ensuing presentations and publications de-
scribed how the STP model could be applied across the full
spectrum of specific sexual concerns and disorders. That work
led to a presentation at the combined 2008 American
Urological Association & Society for Basic Urologic
Research summer institute devoted to young investigators in-
terested in the field of sexual medicine. The proceedings of
that conference were published in the 2009 Journal of Sexual
Medicine, which included the manuscript BThe sexual tipping
point: a mind/body model for sexual medicine,^ thus greatly
expanding awareness of the model.
The graphic representation of the STP has evolved rapidly
over the past 20 years. Early images of the STP through 2009
were generated from Microsoft Office graphics and, their res-
olution was modest as reflected in illustrations from 2006 (See
Fig. 2).
Today’s more sophisticated and nuanced figures feature
tactile Bbuilding blocks^ that can be used to assemble unique
representations of any given individual’s STP at a particular
moment in time. A key to the STP images is provided in
Fig. 3, although a fully narrated video description may be
found on mapedfund.org, as well as on YouTube and Vimeo
channels.
In 2012, the first retrospective of the various STP images
used over the previous decade was presented to the 15th World
Meeting of The International Society For Sexual Medicine
(ISSM).4
In 2013, the STP trademark registration was assigned
to the MAP Education & Research Fund, Inc. so that the Fund
could distribute STP resources worldwide for free.
The Importance of Integrated Treatment
Regardless of which healthcare professional the patient con-
sults first, they are entitled to receive optimized care. For many
patients, neither sex therapy alone nor medical/surgical inter-
ventions alone are sufficient to facilitate lasting improvement
and satisfaction for a patient or partner with sexual dysfunc-
tion. For those patients who have sexual dysfunction based on
deep-seated psychosocial and emotional issues, a simple
single-agent pharmacologic therapeutic will not be sufficient.
Furthermore, a patient who has physical issues related to age,
illness, and so forth is extremely unlikely to be fully restored
(versus helped to adapt) by sex counseling exclusively.
The degree of advancement in our neurobiological, molec-
ular and genetic understanding of the mechanisms of sexual
function and dysfunction at both the central and peripheral
levels is extraordinary. There is no indication that this pace will
slow down and fortunately there is every indication that the rate
at which we are accumulating such knowledge is accelerating.
Basic and early-stage clinical research using new investigative
techniques such as molecular imaging, genetic analyses (in-
cluding sophisticated techniques like whole-genome sequenc-
ing), neuroimaging with PET and fMRI studies, and better-
quality plethysmography and thermography will deepen our
understanding of the biological underpinnings of sexual func-
tion and dysfunction. Precision medicine and nanotechnology
represent exciting trends and are some of the most interesting
applied scientific developments of the day [43•, 44•].
Of course, most mental health practitioners are neither capa-
ble of nor licensed to provide the medical care to the full extent
needed by a patient with a significant organic determinant caus-
ing and/or maintaining their sexual disorder. Mental health
4
A poster that supplemented that ISSM presentation can be downloaded
free at: Sexual Balance: The Universal Versatility of the Sexual Tipping
Point Model.
Fig. 2 Illustrations of the Sexual Tipping Point model in 2006
42 Curr Sex Health Rep (2016) 8:39–46

5. practitioners who wish to maintain their expertise in the treat-
ment of sexual disorders must familiarize themselves with the
most recent knowledge of medical and surgical advances in
treatment. That is required to be able to adequately consult with
physician colleagues who refer to them, and also essential to
have maximum competency in recognizing when to refer their
own patients for adjunctive consultation.
Despite the above guidance, we must all be mindful of the
risk of medicalization and pharmaceuticalization that some
continuously warn about [45, 46]. The influx of new biolog-
ical discovery does risk returning us to the unnecessary binary
thinking that characterized the late twentieth century where
many health professionals advocated an outdated, dichoto-
mous, simplistic, and etiological model of organic versus psy-
chological. We must avoid falling back into the continuation
of a centuries-old debate pitting reductionism again holism.
What is the alternative to a back-to-the-future rush to overly
reductionist thinking and an unnecessary binary view of the
mental and physical? The solution is an integrated treatment,
where the psychological balance to the medical equation is
equally important. Medical care would then become opti-
mized and more sophisticated, while mental health practi-
tioners can more often than not be part of the solution and
not merely relegated to helping patients (and partners) nobly
Badjust^ to the problem [43•, 44•].
The bottom line is the notion that there is a single pathoge-
netic pathway to a sexual disorder is highly implausible. A
Bdisease model^ focus and overemphasis on evidence-based
treatment does not adequately prepare healthcare profes-
sionals to understand and treat individuals suffering from sex-
ual problems. Yet, an overemphasis on psychological etiology
and treatment of sexual disorders is not the answer either.
Clarity of understanding requires that clinician and researcher
alike maintain a biopsychosocial-behavioral and cultural view
of sexual response and dysfunction. Besides the obvious com-
mon sense appeal of such models, there is an ever-expanding
body of empirically based quantitative and qualitative evi-
dence supporting a multidimensional conceptualization, espe-
cially in the areas of treatment optimization, treatment adher-
ence, and continuation of recommended therapies [1, 11••,
16•, 42•, 43•, 44•, 47, 48, 49•, 50, 51••, 52, 53••, 54–57,
58•, 59, 60•, 61].
Conclusion
It remains critical to advance a model that would help stu-
dents, professionals and the public alike understand that sex
is always both BMental And Physical.^ Greater success will
be found within such integrated thinking. All the
Two pans hold 2 inter-related weights which contain all known
and unknown Mental & Physical factors regulating sexual response.
Each circle represents
a factor which is
HOT or NOT.
Sex Positive (+)
or Sex Negative (-)
Or currently unknown?
Hot
Neutral
Not
Sexual response “at rest” usually balances within a normal range.The STP varies
within and between sexual experiences depicting intra & inter-individual variability.
The Sexual Tipping Point® model depicts the continuously dynamic and variable
nature of an individual’s sexual response on a distribution curve.
Understanding Sexual Balance: A Key To The Sexual Tipping Point Model
ON
HOT
OFF
NOT
M P PM
(+)Micro/macro Factors:
Psychological,Behavioral
Sociocultural,Interpersonal
Biological
(-)Micro/macro Factors:
Psychological,Behavioral
Sociocultural,Interpersonal
Biological
All factors that impact sexual response are found
within these Mental And Physical weights although
their relative iinfluence varies between individuals.
®
SEXUAL
BALANC
E
SCALE
SEXUAL
BALANC
E
SCALE
SEXUAL
BALANC
E
SCALE
SEXUAL
BALANC
E
SCALE
Fig. 3 A key to the images in the current Sexual Tipping Point model
Curr Sex Health Rep (2016) 8:39–46 43

6. biopsychosocial-behavioral and cultural models of sexual
dysfunction provide a compelling argument for sexual medi-
cine treatments that integrate sex counseling and medical and/
or surgical treatments [16•]. Given the choice of so many
different biopsychosocial-cultural models, why embrace the
Sexual Tipping Point Model? Perhaps the greatest advantage
of the STP model is its simplicity and the ease with which it
provides clinicians as well as their patients (and their partners)
with a common sense explanation of sexual problems and
potential solutions. At Weill Cornell Medicine, when contem-
plating the clinical need for understanding etiology, diagnosis
and treatment, we find the Sexual Tipping Point (STP) dual-
control model particularly helpful and easy to use.
Sometimes we can even surpass alleviation of our patient’s
sexual symptoms, and when possible improve their overall
intimate relational lives. Restoration of lasting and satisfying
sexual function requires a multifactorial understanding of all
of the forces that created the problem, whether a solo clinician
or multidisciplinary team approach is applied. The healthcare
professional that can accomplish a patient-centered, holistic
view of healing within the context of an integrated treatment
will offer the most optimized approach and the most elegant
solution [44•]. Copies of a Sexual Tipping Point Model ex-
planatory video and related animations, publications, and pre-
sentations are all available free from mapedfund.org.
Acknowledgments The author wishes to thank Barry McCarthy
PhD, Alexander Pastuszak MD, PhD, and R. Taylor Segraves MD,
PhD, for their helpful suggestions and comments on earlier drafts of
this commentary.
Compliance with Ethical Standards
Conflict of Interest Michael A. Perelman is the Founder of the MAP
Educational Fund.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by the
author.
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Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
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