Before Masters and Johnson came on the scene in the late 1950s, any sexual problem was thought to be the result of a deep-seated neurosis that needed to be unearthed. It is now recognized that an understanding of physiology and couples dynamics-along with a practical approach-are required interventions, said Harvard's Derek Polonsky, M.D.
The psychiatry instructor and lecturer has specialized in couples therapy and sexuality since the turbulent 1970s, when Beth Israel Hospital was a "hotbed of individually oriented psychoanalytic psychotherapy," he recalled. "That's how I got to see couples early on. After a while, they began to bring up issues of sexuality, which I must admit was a shock to me [at the time].
"The field of sexuality over the last 25 years has grown enormously to encompass a full range of disciplines: on the one hand, mental health professionals and on the other, gynecologists, urologists, internists and the lay profession," said Polonsky, author of Talking About Sex (American Psychiatric Press, 1994).
He advises that before beginning couples sex treatment, therapists need to assess three factors. First, do either of the patients have medical conditions that play a role in the problem, such as arteriosclerosis, diabetes, thyroid problems, depression, alcoholism and the side effects from medications? Drugs used for high blood pressure are notorious for dampening sex drive, as are antidepressants, particularly selective serotonin reuptake inhibitors. Despite claims by pharmaceutical companies that only a minority of people experience significant sexual side effects from antidepressants, independent studies report high percentages of subjects who experience effects upon libido, arousal, ability to get or maintain an erection or capacity to have an orgasm.
Second, assess the intrapsychic components-such as issues of self-esteem, intimacy, assertion and conflict around competence or aggression-that each individual brings to a sexual situation. Third, because sexuality often is the stage upon which relationship issues get played out, assess what interpersonal components (the marital couple dynamic, the power play, what gets reenacted from the family of origin) are involved.
"Fifty percent of people deal just fine with the kinds of challenges involved in separating from families of origin, mastering the tasks of forming a close relationship with somebody outside the family and integrating that with sexual feelings in the context of the close relationship," said Polonsky. "But that leaves another 50% of the population who struggle with these [issues]."
Polonsky's treatment approach integrates couples therapy with sex therapy and is analogous to what a coach does. In other words, he identifies the strengths people bring to the relationship, figures out which activities need help and develops drills to help people with those areas.
During the initial meeting with a couple, he inquires about the nature of their sexual difficulty, a history of it over time and the evolution of their relationship. Next, he schedules individual meetings to learn about each person's family of origin "because that supplies the template for behavior and expectations that often get transposed into the marriage." At this time he also gets a more detailed sexual history. Then he brings the pair back and shares his ideas of what he thinks is going on.
He gives the couple an assignment, structuring what they do and reducing their sexual activities to the lowest common denominator by shifting the focus from performance to pleasure and playfulness. The following week's discussion centers around what happened.
Polonsky creates a safe climate for talking about issues of sexuality, providing a model for talking about sex, and using humor and a comfortable vocabulary to diminish anxiety. He educates his patients by providing information about physiology, myths and patterns of behavior.
"Couples therapy differs from traditional psychotherapy in that the therapist is more active," he said. "In addition, the transference occurs between the two partners rather than between patient and therapist."
Taking the Sexual History
While on the surface it would appear that as a culture we are more comfortable talking about sexuality, that is deceptive, Polonsky said. "We only have to look back at 1994 when Jocelyn Elders, the Surgeon General, was fired for daring to talk about masturbation, to realize that we still have a long way to go."
Learning to take the sexual history is hard for new therapists because they've had no models for being open and explicit. Most medical schools and training programs have either dropped the programs they had or ignore sexuality altogether.
"When I first started taking histories from my patients, I would choke on some of the words," he said. "At times I would be so hypertechnical using the anatomical jargon that I would be greeted by vacant stares from my patients. They didn't have a clue what I was talking about.
"There also was a cross-generational awkwardness. Many of my patients seemed to be in my parents' age group. To ask them about the details of their sexual relationship just seemed to be crossing a boundary...Now that I'm a parent of an adolescent kid, I'm aware of how parents are similarly uncomfortable about their children's sexuality."
There is no "right" way of getting the history, Polonsky said. Therapists have to experiment until they find a model that is down-to-earth and comfortable for them and their patients. Couples will follow along, in terms of tone and terminology.
He begins with the general ("Tell me about your relationship. Are you satisfied? Would you want anything to be different?") and works toward the specific. He asks couples about patterns of initiation, whether they enjoy fantasies, what kind of experimentation they're comfortable with, whether they read erotic material or watch pornographic movies, whether they are comfortable experimenting with sexual toys. He asks about their communication with each other: Do they talk about their likes and dislikes? Are they comfortable asking for things? Is there reciprocity?
Sometimes you have to be "stupid in listening," he said, and inquire about the fine points rather than make assumptions. Does "losing an erection," for example, refer to an erectile difficulty caused by anxiety? Or does someone really mean premature ejaculation?
These details about the sexual interaction give the therapist a portrait of the couple's relationship. "I don't believe one can do sex therapy in a vacuum," he said. "One has to recognize that [there are] two people involved in this interaction, each with their own histories and backgrounds."
Contrary to finding this intense questioning intrusive-a worry of new therapists-most people are relieved to bring the problem into the open. "Often when a couple has a sexual problem," he said, "they've tried initially to deal with it, failed, and then they enter into a conspiracy of silence where there's a tacit agreement that they're not going to discuss these issues more directly." People go for years, even decades, suffering under an enormous burden of shame, blame and inadequacy. "They're convinced that they are the only ones to flunk Sexuality 101. Just talking with a therapist and being reassured that they are not alone goes far to diminish anxiety," Polonsky added.