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Principles and Practice of Sex TherapyReview - Principles and Practice of Sex Therapy
Fourth Edition
by Sandra R. Leiblum (Editor)
Guilford, 2006
Review by Sandra Levy Ceren, Ph.D.
Apr 29th 2008 (Volume 12, Issue 18)

Twenty three prestigious authors, academicians and clinicians have contributed to the fourth edition of this large comprehensive body of work.  A multitude of challenging sexual complaints are fully described and attention given to the most current, integrated, evidence-based, clinically sophisticated methods.

After thoroughly digesting the information provided in this work, the reader should gain a higher level of competence in the field of sex therapy.  A word of caution: there remains much speculation about the etiology and best treatment for many sexual maladies and the need for more definitive research is clearly acknowledged.

Female sexual problems are given much needed attention.  Lack of sexual desire is the most frequent sexual complaint reported by 35% of women as cited in the book.  This figure appears to be somewhat lower than observed in clinical practice.  It is unclear whether it represents 35% of all women, or 35% of women reporting a sexual problem.

In order to benefit these women, the author stresses the importance of understanding their mental health, self-esteem, body image, energy level, sexual history, general health, and emotional feelings about a partner.

For women, sexual arousal is often dependent upon emotion.  Thus women experiencing low arousal may be in relationships in which they do not feel they are valued.  It is understood that women’s arousal level is far more sensitive to emotional factors than that of most men.  While this is not news, it reiterates the necessity of understanding the full picture of every patient.   Physical factors and mood disorders significantly diminish desire as well as reduced hormone production.  It is interesting to learn that vaginal lubrication can occur without sexual arousal.  This is determined by a test in which a tampon is inserted into the vagina to measure the lubrication in the absence of the perception of sexual arousal. For non-responsive women, it may be beneficial to learn if she can be aroused by fantasy.

While men may choose to take Viagra, the author does not advise the use of androgens for women as there is no long term safety data currently available.

While the chief sexual complaint of women is a lack of desire and arousal there are other disorders women present such as PGAD--persistent genital arousal disorder—an unusual, perplexing, distressing condition only recently recognized, therefore no research is cited.  Women may hesitate to report this condition to their doctors out of shame and humiliation.  In an effort to bring awareness of the problem, it has been described in magazine articles, on TV and on the Internet and more women are revealing their secret.  The condition appears unrelated to age and is experienced as unsolicited genital arousal that persists for hours our days in the absence of sexual desire or stimulation.  It may lead to self or partner induced or spontaneous multiple orgasm that brings only temporary relief.  The feelings persist without the provocation of sexual thoughts or fantasy and are distressing to the patient desperate for relief.  The author, Sandra Leiblum and editor of the book was the first to label the disorder.  She advises against the use of interventions without a clear rationale and follow up and suggests an interdisciplinary treatment approach, but does not provide specific suggestions.  

Leiblum states that while PGAD may resemble hyper-sexuality or sexual compulsivity the disorders are different.  In hyper-sexuality or sexual compulsivity, frequent intense sexual thoughts or fantasies and urges lead to masturbation or other sexual behavior and may be associated with side effect of drugs for psychiatric or neurological conditions wheras in PGAD, unremitting feelings persist in the absence of sexual thoughts, fantasies, or external stimulation. 

PGAD is similar to vulvodynia and both are medical conditions.  Little is known about the etiology of either condition and there is no definite efficacious therapy.  Dietary changes, topical anesthetizing agents, SSRI or dopaminergic medication are sometimes prescribed.  While a few women may profit from these substances, no reliable results have been indicated for all women.  We know that Serotonin influences sexual response, but it is unclear whether it inhibits or excites, thus further study is needed.

Priapism in men is a similar condition discussed, but without evidence to support the hypotheses that sufferers from these conditions may have high-flow arterial or stuttering priaspism.

Interesting case studies illustrate conditions, possible etiologies and treatment options.  Although some of the options may not benefit all patients, they should be considered as they may benefit others.  Making an accurate assessment and the best treatment plan is the hardest part of the work since a complex mix of factors must be considered. 

The most interesting and enlightening sections of the book are the case presentations.  They offer the reader a greater understanding and appreciation of the need for assessment tools based on research, and provides a good rationale with illustrations of multi-faceted sex therapy.  

It is rare to find an easy case, but a simple one was discussed.  A man consulted the doctor for help in prolonging his ejaculation in order to satisfy his girlfriend.  She had told him his lasting a mere twenty minutes was too short.  She had led him to believe incorrectly that he had a problem.  In discussion with the doctor, he was relieved to learn that the average man lasted 5-10 minutes and that the girlfriend had blamed him for her own sexual dysfunction.

Premature ejaculation or rapid ejaculation is said to affect one in three men, but this number may be an inaccurate assessment since some men will not seek treatment either because they aren’t distressed by it, or they are too ashamed to seek a consultation.  In past years PE was attributed to a psychological cause. A few prominent psychoanalysts declared themselves experts at curing it, but the current view considers a physiological basis.  Again, a thorough study of each patient is recommended.  It is believed that performance anxiety may not cause the initial episode but may contribute to maintaining the problem.

Orgasmic disorders were first studied in a laboratory setting by Masters and Johnson. They documented that the whole body was involved in the process.  However, current controversy exists as to which parts of the body are specifically involved.  It is now believed that neuroanatomic, physiological, psychological, socio-cultural and interactional factors may interfere with a woman’s orgasm.

Among the treatment approaches suggested are psychoanalytic, cognitive-behavior, system theory and drug therapy.  The latter is not recommended for the reasons mentioned earlier in this review.  While the authors have learned much from Masters and Johnson, they do not follow the protocol, but have developed their own based on contemporary findings.

Contrary to what most sex therapists believe, sexual pain, (dyspareunia and vaginismus) are not regarded as sexual problems by the authors of the chapter on this subject.  The authors consider the complaints as secondary to the anticipated experience of pain.  The reader may dispute this fine nuance, but the authors make a good case for this belief.  They prefer a multidisciplinary assessment and treatment to deal with the complex interaction between physical and psychosocial factors.

The chapter following the preceding one is devoted to physical therapy for these conditions.  Such therapy includes educational information, vaginal dilators, and actual exercises to strengthen pelvic muscle, relaxation and other modalities to decrease pain and improve tissue mobility.  Success has been reported in decreasing penetration pain and improving sexual functioning.

Sexual desire disorders in men include hypoactive sexual desire disorder (HSDD) and sexual aversion disorder (SAD) Etiological factors are broken down into three sub-categories.  Consideration is given to the possible influence of the Madonna/Prostitute Syndrome, intimacy, and relationship discord. major depression, concurrent sexual dysfunction, psychosocial issues, hormones and age related hypo-gonadal syndrome.  Sexual desire disorders in men cover the spectrum of psychological, psychosocial, biological factors.  These disorders are not considered to be a disease and may have many different roots.

Treatment of rapid ejaculation, delayed ejaculation, erectile dysfunction, sexuality and illness, sexual dysfunction and childhood sex abuse, therapy with sexual minorities, sexuality and culture, paraphilia related disorders, gender dysphoria and transgender experiences, and the new sexual pharmacology complete this much needed contemporary comprehensive volume.


© 2008 Sandra Levy Ceren


Sandra Levy Ceren, Ph.D., Clinical Psychologist, Diplomate, Marital and Sex Therapy, American Board of Family Psychology, Fellow, Academy of Family Psychology



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