Figure 7-1.
Overlapping vicious circles in erectile dysfunction and consequences for the partnership.
Comparing sexual medicine with reproductive medicine, which equally deals with couples and sexuality, the differences in approach become evident: Even when the couple is invited for an assessment interview (to invite both partners is not imperative), the focus of reproductive medicine is placed on the child to be conceived and on the technological aspects necessary to achieve pregnancy rather than the relationship quality, effectiveness of parenting, motivation, and sexual functioning. In so doing, sexuality is reduced to only one dimension, the dimension of reproduction, which constitutes a too narrow focus on sexuality as a whole.
The Three Dimensions of Sexuality
From a holistic medicine perspective, a multifunctional understanding of sexuality is deployed, comprising three dimensions which interact with one another: the dimensions of desire, attachment, and reproduction.
The dimension of desire encompasses sexuality in all conceivable ways of experiencing and increasing desire by sexual stimulation. It provides sexuality with the unique sensual experience of sexual arousal and orgasm, which distinguishes it from other human experience. It establishes the motivational quality of sexuality and simultaneously provides the impulse and reward of sexual behavior. The dimension of desire can predominate in subjective experience in auto-eroticism and in experienced erotic interactions, passion, and ecstasy. It can be an isolated experience, without any connection to the reproductive dimension and the attachment dimension of sexuality. It is, however, difficult to view this dimension completely on its own, because it is so closely connected to the other dimensions and is obviously influenced by various factors outside and within the realm of sexuality.
The dimension of attachment emphasizes the importance of sexuality for the fulfillment of biopsychosocial fundamental needs for acceptance, closeness, warmth, and security by sexual communication in partnership [2, 3]. In the animal kingdom, sexuality has been attributed to social significance, to enhancing pair and group bonding in the sense of a change in meaning and function [4, 5]. In human beings—distinguishing themselves from their primate relatives mainly by the capability of speech and creating culture—the attachment dimension of sexuality specifically becomes one with a communication function: Attachment develops by communication, so communication and attachment are interchangeable terms. With reference to the fact that “you cannot not communicate” [6], “you cannot not interact” in relationships, and therefore, the function of social attachment in sexuality is an obligatory and lifelong relevant function. At the same time, this social function illustrates the specific human elements of sexuality.
The dimension of reproduction stands for the significance of sexuality in reproduction. Of the three dimensions, the reproductive dimension of sexuality is the phylogenetically oldest in higher animals. While at the stage of single-celled organisms multiplication is performed asexually, the more sophisticated multicellular organisms combined genetic recombination and multiplication to operate reproduction as we know it. Taking into account the gender difference, the significance of the dimension of reproduction varies, and is limited for women to the time span of reproductive capability extending from puberty to menopause. Furthermore, it is dependent on biographical decisions, making it optional. The availability of reliable contraceptive methods on the one hand, and the progress of reproductive medicine on the other, has made it possible to separate the dimension of reproduction from the other two dimensions of desire and attachment.
From a sexual medicine perspective, all three dimensions of sexuality contribute to sexual functions or dysfunctions. Furthermore, the biopsychosocial treatment of sexual disorders is not confined to the restoration of disturbed functions, but places, along with the couple itself, the quality of the relationship at the center of attention [7]. Since the human being is a relational being with a “social brain,” i.e., phylogenetically programmed to lead a life in pairs (Aristotle: syndyastikós), the relationship quality has a lifetime salutogenic and/or pathogenic importance, as has been revealed long ago by attachment research. The quality of relationship is even an indicator for the human’s morbidity and mortality risk, as can be seen in the extreme case of death from a “broken heart” (Tako-Tsubo cardiomyopathy).
When it comes to prevention and therapy, medicine—and not only sexual medicine—should attend more to the quality of essential relationships, especially love relationships. Therefore, when assessing sexual desire, arousal or orgasm dysfunctions, aspects of the sexual relationship need to be taken into account, as well [8]. This involves the question of whether or to which degree fundamental needs as, for example, the need to be accepted and respected the way one is have been frustrated or violated (see above).
However, on the part of the therapist or counselor it does not suffice to assess mere facts during anamnesis, but to understand their individual meaning for each person seeking help [9]. In spite of the universal validity of fundamental needs, their emotional significance, i.e., their subjectively felt meaning and urgency, can only be understood from personal history. The fulfillment or frustration of fundamental needs is achieved in everyday life through nonsexual couple interactions, but also—in a very intensive and intimate way—through the “language of sexuality ” [10]. Given the attachment dimension of sexuality, sexuality itself can become a means of communication expressing, for example, acceptance, belonging, openness, closeness, and warmth through body language in genital union. As such, it is not a symbolic, but rather physical and at the same time psychosocial, sensual reality.
The Communication Aspect
Taking into account the communication aspect of sexuality also contributes to a more complex understanding of sexual desire. The aspect of genital desire as being exclusively and one-dimensionally aimed at sexual arousal and orgasm is thereby complemented by the aspect of relationship reward , the stimulating joy of being chosen and accepted, of being released from loneliness into the new commonness of the couple-relationship. The more both genital desire and relationship reward are experienced consciously, the more they can reinforce each other. Although this perspective might appear unfamiliar to most couples and needs to be acquired first, it quickly leads to evidence-based experience: “Somehow this had always been inside of me, I have just never been consciously aware of it.”
What might at first appear to be a merely theoretical construct is put into effective clinical practice by Syndyastic Sexual Therapy (SST) . The SST is distinguished by a variety of features among other treatment methods of sexual disorders: First, while consequently assuming the treatment of the couple as a general rule, the SST does not focus on sexual dysfunctions or the intensification of genital desire in the first place, but on improving the relationship quality in general. It is concerned with the role of the couple-relationship as the condition of a primary or secondary deeper cause for dysfunctions. The fulfillment or frustration of the biopsychosocial fundamental needs serves as the crucial measurement criterion (syndyastic focus), because the degree of fulfillment of those needs forms the basis of relationship quality and couple (dis-)satisfaction. Hence, the SST combines the (re-)fulfillment of biopsychosocial needs and desires with the aspect of sexuality, or, more precisely, with sexuality as a way of communicating through body language. From kiss to coitus sexuality can be experienced as the embodiment of acceptance, belonging, openness, closeness, etc., being naked can signify a liberating, authentic revelation of oneself instead of mere exposure, and so forth.
Perceived in this way, the to date often isolated and orgasm-centered perspective on “sex” is changed to describe a means of communicating through body language vital desires and values central to—and often searched for in—(love) relationships. Table 7-1 demonstrates the difference between typical statements made by patients expressing an isolated view on sexuality compared to statements by patients after treatment. The aim of an integrated approach to sexuality is to overcome the pathogenic opposition between sex and love, so that a new meaning can be discovered to unfold its salutogenic potentials.
Table 7-1.
Patients’ quotations on isolated and integrated sexuality
Isolated sexuality (not perceived on a communicational level) | Integrated sexuality (consciously applied as a way of communication) |
I could do without sex without missing anything | On this level, sex is a way of reaching me |
Always the same procedure: direct foreplay . . . sleeping away afterwards | It’s deeper than just sex—not only him reducing his arousal. I respond differently to his ejaculation—it was something like pleasure |
Sex was physical sports—nothing more | Now it’s more like us sleeping together |
Sex does nothing for me. When sex begins, I retreat | For the first time my thoughts were involved—I didn’t think about anything else, that was liberating |
Sex was a one-way street to orgasm | You were different, you connected more to me |
I could live without sex, but not without love, tenderness and warmth | Romance is revived, it is like being married for not more than 6 months |
Sex drive—I don’t know what that is. I need you to be there, hugging me and caressing me, without it being there | Now, for the first time I have experienced sexual intercourse and cuddling not as two different things |
There are more important aspects to a partnership than sex | I have never looked at it that way—I was not aware of it, but it had been inside of me all the time |
Sex just belongs to a partnership | For us that is a completely revolutionary insight |
However, this should not result in a neglect of the dark sides of sexuality. Especially in light of the apparent predominance of compulsive sexual violence, abuse, exploitation, humiliation, or the global dispersion of commercialized, completely non-syndyastic pornographic sexuality (without any relationship aspect), the intent to emphasize, make aware of, and therapeutically utilize the joyful side of sexual communication might as well seem utopian, idealistic, or even cynical. What remains as a fact is that fundamental human needs are present in every individual seeking help, which—in case of prompt evidence-based experience and successful (re-)fulfillment of these needs—is likely to mobilize salutogenic energies to an unexpected extent. Therefore, SST , despite conceptually being a short-term therapy, can lead to long-lasting and sustainable results.
Meaning as a Salutogenic or Pathogenic Element
Because in sexual therapy , as in other fields, the decisive factor is the question of meaning, we will now expand on the already mentioned concept of Syndyastic Sexual Therapy in order to enable a more conscious access to the subjectively felt meaning of sexuality. This is necessary and helpful, given that the individual attribution of meaning can be an essential pathogenic element.
As already mentioned, sexuality is commonly perceived as a purely genital act, i.e., aimed at sexual arousal and orgasm. This genital sexuality is then again lived and experienced as isolated and separate from attachment and affection. However, a lack of subjectively felt meaning cannot be replaced by (arousal-increasing) “techniques”; on the contrary, those techniques themselves in fact presuppose meaning.
In a 2007 interview-study on “building blocks toward optimal sexuality” [11] among men and women involved in long-term partnerships, the interviewees did not refer to strong sexual desire, easy sexual arousability, optimal erectile or orgasmic functions, etc. as important elements of sexuality, but to focused attention for each other, authenticity, intense emotional connection, erotic intimacy, communication, and transcendence (understood as supra-individual experiences in the common sexual intimacy). Consequently, optimal sexual functions do not guarantee optimal sex, whereas optimal sexuality is possible even if function disorders exist, as long as the relationship as a whole conforms to the “building blocks” described above.
Principles of Biopsychosocial Assessment: As a Part of Treatment
In sexual medicine, diagnostics and therapy are interrelated more closely than in other medical fields: From the very beginning, we are dealing with a diagnostic-therapeutic process, because the diagnostic assessment is already indicative of the therapist’s perspective on sexuality and its disorders.
The Spectrum of Sexual Disorders
The suggested categories of the clinical classification systems ICD-10 [12] and DSM-5 [13] are purely descriptive concepts which fail to do justice to the complexity of human sexuality. Already by taking into account the sexologically required differentiation of the three dimensions of sexuality, the inadequacy of such categorization is unmasked. Thus, sexual disorders cannot only influence the dimension of desire, but very likely the dimension of attachment as well and hence not only the disturbed sexual function, but, moreover, the disturbance of partnership comfort turns out to be the actual reason for suffering.
According to present knowledge, chronic lack of feelings of security conveyed by body communication (frustration of psychosocial fundamental needs) increases the probability of developing psychological and physical disorders. Furthermore, it hinders overcoming prevailing illnesses [14]. The symptoms presented by patients seen in clinical practice are usually described as “psychosomatic disorders,” “depressive state of mood,” “anxiety and/or nervous restlessness,” i.e., “nervous anxiety, tension and restlessness” or, additionally, as “emotionally caused state of restlessness.” Therefore, it can be assumed that in many areas of medicine male and female patients with varying disorders or dysfunctions consult a practitioner because of a lack of availability of a functioning and therefore emotionally stabilizing intimate attachment. Also included are chronically ill or older persons suffering from psychosocial destabilization due to reduced opportunities for social contacts.
This explains why very different symptoms can dominate the clinical impression and, as a result, various medical disciplines may come into contact with the patients concerned: orthopedics for muscle tension; gynecology and urology for pelvic floor tensions, disturbances of micturition, etc.; general practice for symptoms of the autonomic nervous system; psychiatry for intrapsychic tension or states of depression; or andrology concerning involuntary childlessness. Also, sexual dysfunction may perhaps be only one of the many possible symptoms (apart from, of course, sexual disorders caused by illness, e.g., condition after paraplegia). The special quality of sexological therapy options (see section “Principles of Biopsychosocial Treatment of Sexual Disorders”) lies in the fact that it deals explicitly with the actual roots (the frustrated fundamental needs) of possible causes at a level not reached elsewhere, while it aims at restoring the feeling of complete attachment by physical acceptance through intimacy with the partner, which also has curative effects on symptoms and positive consequences in other areas of life (Figure 7-2).
Figure 7-2.
Connection between psychological fundamental needs and various symptoms.
Notwithstanding these limited and only partially useful systematic categorizations, clinically significant sexual disorders are compactly characterized as follows:
- 1.
Disorders of sexual function.
- 2.
Disorders of sexual development.
- (a)
Disorder of sexual maturity.
- (b)
Disorder of sexual orientation.
- (c)
Disorder of sexual identity.
- (d)
Disorder of sexual relationship.
- (a)
- 3.
Disorders of gender identity/gender dysphoria.
- 4.
Disorders of sexual preference/paraphilic disorders.
- 5.
Disorders of sexual behavior/dissexuality.
- 6.
Disorders of sexual reproduction.
Each sexual disorder is itself capable of causing other disorders which are encoded (e.g., chronic prostatitis, fluor genitalis, etc.), but they can also occur overlapping with one another: Disorders of sexual function are very often closely linked to disorders of sexual relationship. For those disorders of sexual preference which are not integrated into self-concept this is regularly the case (see section “Treatment of Sexual Preference Disorders”), often additionally involving disorders of sexual function (e.g., erectile disorder). This, again, underlines the serious impact of unfulfilled psychosocial fundamental needs, which play, in the end, a key role in all sexologically relevant disorders.
Assessment of the Sexual Disorder
In order to tackle the problem of a disturbed partnership and/or sexual life, it is essential to address the issue adequately and to explore sexual disorders, the level of syndyastic function (i.e., the extent of fulfillment of psychosocial fundamental needs for acceptance and appreciation within the relationship), as well as to evaluate physical findings and laboratory parameters in a qualified way.
At this point, the previous strict approach “first diagnosis, then therapy” should be changed into a dynamic, process orientated “diagnostic therapeutic circle” [15]: Every interview for assessment, empathically carried out, has a therapeutic effect in itself and every further therapeutic step produces new diagnostic material for the duration of the relationship between therapist and patient(s).
This calls for attentiveness on the part of the therapist on three information levels simultaneously: (1) on the level of given facts, (2) on the level of the significance these facts have for the patient(s), (3) on the level of partnership dynamics by observation of couple interaction. This demands complete awareness, never to be confused with not maintaining a professional distance to the involved couple.
At the same time the therapist offers a role model by speaking openly about sexuality as a basic element of human life. This is one of the most important foundations of sexological skills and definitely shows therapeutic effects. It has been long proven that patients actually wait for certain signals from the therapist concerning mentioning the issue of sexuality [16–19]. For instance, on prescribing a new medication, the therapist can provide a signal in terms of a question like: “Should the illness or its treatment lead to problems or changes in your sexual life, then we can talk about that and look for solutions.” It is essential, however, that the therapist should never retreat into the role of the “expert.” He/she will always be confronted by subjective interpretations—the patient’s as well as his/her own—making personal compassion inevitable.
Successfully carrying out treatment with decisiveness is based on extensive information on the specific sexual experience and behavior of a patient/couple. In the case of partnership involvement, the information has to provide the investigator with insight into the level of sexual functions and the sexual preference structure of both partners; otherwise therapeutic steps remain ineffective or can even cause harm (e.g., if a preference disorder remains undetected as a reason for a dysfunction). When couples are concerned, it must be decided whether the sexual assessment should be taken on with each partner alone or immediately with both partners together from the beginning.
Single anamnesis has the advantage that the partner may be more uninhibited and speak more openly than in the presence of the other, particularly on subjects like masturbation fantasies or topics like paraphilic inclinations and past relationships. The advantage of couple-interviews , on the other hand, is that all information issues are gathered together and processed from the beginning, which can demonstrate and increase the extent of openness and trust among the partners involved.
It is crucial to know which kind of disorder (e.g., direct or indirect disorder of sexual function; disorder of sexual partnership) is being dealt with and under which circumstances or conditions it arises (e.g., lifelong or acquired type; generalized or situational type). What is the partner’s opinion on this disorder? What attitude does each partner have toward sexuality, irrespective of the disorder in question? What kind of sex education are opinions based on? Does each partner know the opinions of the other and can they talk about them? Such generalized questions are imperative in order to put specific questions into the greater context of the partnership and to be able to judge their significance for each partner, e.g.: Who takes the initiative in sexual contact? Are there differences and where and how are they expressed? Which preferences or aversions are there and how are they dealt with?
This inevitably leads to the analysis of possibly existing peculiarities of the sexual preference structure, which should and can be systematically explored (see overview).
Overview Sexual Preference Structure: Exploration Tools
Three Axes
The human sexual preference structure is generally configured on three axes, i.e.,
Gender (of the desirable partner): the other or the same gender (or both);
Age (of the desirable partner): children, adolescents, adults, or the elderly; and
Way (of the desirable partner or object or of an interaction): type, object, mode, procedure, etc., all intermingling with one another and of which all (from non-conform to paraphilic) should be explored.
Three Levels
Sexual experience and behavior should be investigated into on three different levels, i.e.,
The sexual self-concept
The sexual fantasies; and
The concrete sexual behavior,
all intermingling with one another and of which all should be explored.
Three Forms
The concrete sexual behavior should again be explored within three forms:
Masturbation: self-stimulation and self-satisfaction;
Extragenital sexual interaction: e.g., stroking, cuddling, kissing; and
Genital stimulation: manual, oral, or other stimulation, e.g., petting incl. sexual intercourse, penis or penis surrogate penetrating vagina or anus, and these should also all be explored.
The extent of naturalness conveyed by the therapist during exploration has direct influence on the information flow. It obtains diagnostic-therapeutic relevance and underlines the necessity of acquiring a professional repertoire of knowledge and skills, which can be learned in the context of sexological advanced training (see section “The Dual Role of the Therapist as an Expert and an Attendant”).
Conducting partner interviews, which are an essential part of sexological practice, the following questions are of particular diagnostic interest: What is communication like within the partnership in general and in sexual matters in particular? Can personal feelings, needs and wishes be communicated and does this happen? Are boundaries respected? Are there self-strengthening mechanisms, “vicious circles” or self-fulfilling prophecies, and how do these affect partnership communication? Might problems result from misunderstandings due to misinterpretations of partner-behavior?
Exploration of the Three Dimensions of Sexuality
The assessment of the attribution of meaning regarding the three dimensions of sexuality (reproduction, desire, attachment) by each patient/couple is of essential—diagnostic and therapeutic—importance. Inquiring about the meaning of sexuality (“What does it mean for you to have sex?”), many patients/couples begin to realize that some things are not as obvious as previously assumed (“This is something I/we have not considered so far.”).
Dimension of attachment : Which needs or values are indispensable for a relationship? To what degree are those human fundamental needs realized within the couple relationship? How far is sexuality perceived as a form of communication through body language by which fundamental needs are communicated and simultaneously realized as “bodily expression and gestures” of the relationship? Is there an awareness of the communicative aspect of sexuality, is it lived implicitly, or does it lack any—“real-life” or mental—significance?
Dimension of reproduction : What role do the ability of reproduction and children play in the relationship? Is there a difference in attitude between the partners? Are there any problems affecting an unfulfilled desire to have children?
Dimension of desire : What is the importance attributed to genital desire within the three dimensions of sexuality? (How) did this change over the course of the relationship? Is there an awareness regarding the complexity of experiencing sexual desire?
Interaction of the three dimensions on the individual and relationship level: Are there any imbalances possibly related to the sexual disorder, e.g., potential discrepancies between fantasized and lived sexuality, a predominance of one dimension at the expense of the other two, or a strongly diverging distribution of the dimensions between both partners?
History of Diseases and Somatic Findings
All significant diseases treated medically at the present time or previously should be taken into account, but particularly those, which might be connected with the sexual disorder. This includes all urological, gynecological, or psychosomatic illnesses and surgery ; any medication and/or substance abuse or addiction; and/or information concerning pregnancies (abortions and miscarriages) and childbirth.
In addition, any therapy relevant to sexual disorders and previous psychotherapeutic treatment need to be looked into. Biopsychosocial anamnesis needs to include diagnostics for somatic findings . This concerns sexual functions as well as general physical functions. An overview of the necessary physical diagnostics concerning sexual dysfunctions in males is shown in Table 7-2 [20].
Table 7-2.
Organ diagnostics in sexual disorders in men
Physical diagnostics | Diagnostic method | For exclusion | Indication |
|---|---|---|---|
Clinical examination | Inspection, palpation, pulse, exercise tolerance test | Urogenital, neurological, and cardiovascular diseases | General examination in connection with risk factors (e.g., age, overweight) |
Laboratory | BS, lipids, testosterone, prolactin | Diabetes mellitus, dyslipidosis, hypogonadism, prolactinoma | General examination General examination If necessary in arousal disorder or erectile dysfunction (ED), depending on further hypogonadism symptoms |
Imaging | Duplex sonography with intracavernous pharmaco testing Neurophysiology (e.g., corpus-cavernosum-EMG) Penile angiography | Cavernous insufficiency Neurogenic deficit (e.g., following an accident) Pelvic vascular occlusion | if necessary in ED in the case of no response to oral medication and wish for SKAT If necessary in ED when expertise or scientific issues are concerned Only in planned revascularisation surgery |
Principles of Biopsychosocial Treatment of Sexual Disorders
Generally, similar to every medical branch, sexual medicine can be interpreted and practiced in two ways: focusing on disease or focusing on the patient. In sexual medicine, the ideal is: focusing on the couple and their partnership.
The first-mentioned approach deals primarily with “disorders” of sexual function, of gender identity, of sexual preferences and of sexual behavior. The pathogenesis is in the center of scientific interest. Anatomy, physiology, neuro-endocrinology, etc. are favored subjects. Diagnostics are made according to common classifications by assessment of facts, clinical examinations, laboratory results including hormone analysis and function tests, and are recorded in a “case history.” The therapy is aimed at fast and efficient elimination of the disorder, i.e., at the reestablishment of normal function. Until the end of the sessions with the therapist, pharmacological, surgical, and technical methods are available and most times applied to the one single person with such symptoms. Examples for this are, for instance concerning the most frequent indications, the disorders of sexual function, the reflex-like prescription of PDE5-inhibitors in erectile disorder without carrying out any differentiated assessment, not to speak of talks to the couple involved; or the treatment of vaginism with dilating measures, without ever having spoken to the male partner; or the administration of hormones, e.g., testosterones for hypoactive sexual desire disorder as first choice therapy, and so forth.
The Dual Role of the Therapist as an Expert and an Attendant
In contrast to a solely disease-centered approach, a biopsychosocial, couple- and relationship-centered sexual therapy focuses on the disease and the patient. This means a challenge concerning two emphases or roles of the physician/therapist: the medical (or psychotherapeutic) expert and the empathic assistant with their respective identity.
During standard undergraduate medical training a certain image of a physician may still be conveyed, which depicts him/her as a caring helper and healer but at the same time as a person thinking in terms of natural science, occasionally as a distanced expert-observer. He/she is the responsible problem-solver and solution-finder, the success of therapy depending on his/her skills and knowledge. He/she knows, what is best for his/her patients, clarifies, educates, teaches, gives authoritative orders and advice to be followed in trust by his/her patients.
The second—also aspired—image of the doctor aims at exactly that patient-focused conduct as an empathic companion, a good patient-listener who “reads between the lines,” who tries to assess the patient—in this case the couple—in their overall situation. To achieve this he/she applies his/her own reflected feelings, impressions, experiences at each ongoing doctor–patient relationship as a diagnostic instrument, as has been previously worked out, particularly by Balint [21, 22]. Within the “Balint groups,” named after him, these abilities can be learned and practiced [23], which is done more and more in regular medical training, while in psychology and psychotherapy it is general state of the art. Sexual medicine, however, is no “psycho subject” and sexual therapy is not a specialized form of psychotherapy, which is why specialists like urologists, andrologists, gynecologists, dermatologists, GPs and psychiatrists, who want to gain additional qualification in sexual medicine, definitely need to learn and train role security in this new identity as a companion, catalyst, mirror, midwife, and aide to problem-solving with the patient or the couple.
Beyond the necessity for every physician and therapist to develop his/her “second identity,” this comes especially true for the couple-centered approach in diagnosis and treatment in sexual medicine. In this—for many—unfamiliar or unsettling situation there is no means of reassurance according to customs and this may lead to wanting to return to the well-rehearsed role security of the expert and knowledgeable scientist. Fact is, however, that concerning the particular couple in question, one is actually the “not knowledgeable one,” having to rely on inquiries and observations, leaving the solving of the couple’s problems to the couple itself.
The couple heals itself, the therapist offers the necessary “sheltered workshop” and supplies the continuity of the process. He/she would be out of his/her depth with the role of the expert as far as the couple relationship goes.
Thus, it is crucial for him/her to be conscious of both his/her roles, the one of the expert and the one of the assistant, to have both roles available, feel comfortable in both, and to be able to apply any one of both wherever needed, particularly in a couple setting. This is a skill which needs to be taught and practiced. It represents an indispensable demand to every training program in sexual therapy.
Taking as an example the treatment of post-prostatectomy erectile disorder caused by prostatic cancer, a German study showed that in long-term exclusive use of medication or mechanical treatment options, the patients were clearly less satisfied than their treating urologists would have imagined (see [24]). Even concerning selection of therapy options the patients’ comments were clearly discrepant to the judgment of their treating physicians. Questions concerning the importance of partnership, of non-genital sexuality (the exchange of affectionate words and gestures) and genital sexuality (intercourse) put to prostate cancer patients and their partners before and after radical prostatectomy showed that only the importance of genital sexuality decreased and not the non-genital kind. Partnership in general and the meaning of physical attachment maintained an unchanged high value [25]. The high rating of satisfaction of psychosocial intimacy, closeness, and security in comparison to aiming at sexual erotic satisfaction has also been validated by other studies [26].
Sexological interventions, therefore, are imperatively based on consideration of biopsychosocial aspects of sexuality and on systematic involvement of partnership issues and communication (e.g., the couple is the patient). Such modifications of conventional patient concepts also lead to a different understanding of therapy.
The familiar concept of the “therapist–patient relationship” is extended—especially in the case of sexual disorders—to a new “therapist–couple relationship .” Advocacy for the patient turns into plural advocacy for the couple and their partnership, as long as this is the mandate given to the therapist. Furthermore, the dimension of attachment is taken into account beyond any function disorders and is considered as being an essential resource for sexual contentedness. In many cases, this turns out to be a helpful approach for the patients because an idea for behavioral change is given—within quite a short time (usually not more than two to three sessions) —and this is often enough to get things going. If this proves not to be sufficient, supportive sexual therapeutic interventions can be supplied systematically to achieve the aspired modification of attitude and behavior over a longer period of time.
Sexological Counseling
It is obvious that sexological counseling concerned with more than functional disorders is a very high-quality job, demanding not only vast knowledge, but also much empathic capability and self-restraint. Again and again it is a challenge, because it is about finding a new and individual path for each individual patient/couple. Here, again, it is true that diagnosis and therapy in sexological practice are knitted together creating a mutual and complementing whole: integral diagnostic assessment is already a part of therapy and each therapeutic step leads to further diagnostic insights. So it can be said that sexological counseling may have a “therapeutic” impact, if it were qualified, and on the other hand cause consequential damage, if not.
Here, too, the foremost principle is to make patients/couples aware of the attachment dimension of sexuality and to apply this therapeutic aspect (see section “The Dual Role of the Therapist as an Expert and an Attendant”). Many patients/couples do not realize that genital/coital sexuality is only one of many ways of satisfying wishes within a partnership concerning needs for authenticity, appreciation, satisfaction, closeness, security, etc. Accordingly, sexological counseling will be adapted to the specific needs of the patient/couple, in which the following priorities, alone or combined, may be of significance:
Passing on knowledge (where deficits are obvious) concerning anatomical, physiological or psychological processes of sexual reaction, and, if necessary, correcting false ideas in the sense of sexual myths (e.g., masturbation causes harm), which one or both of the partners may believe in. It would be quite appropriate to refer to the issue of “typical” gender differences in sexual/partnership feelings and behavior in males and females (i.e., in this particular partner, male or female), meaning to aim at understanding and realizing differences instead of finding fault in such differences.
Assessment of mutual hopes and expectations concerning sexuality and partnership.
Teaching communicative strategies, if general communication difficulties are a reason for the development or continuation of the disorder concerned.
When primary illnesses are involved, specific information must be obtained (1) about the length of elapsed time between surgery and resumption of sexual contact (usually after approx. 6 weeks); (2) about the use of lubrication gel, if, for instance, the vaginal epithelium is altered by radiological or chemotherapy or due to menopause; (3) in some cases concerning the use of auxiliaries (tools such as an erection ring, a vacuum pump, any oral or invasive medication options). However, the first step should be to deal with discrepancies in the relationship between the partners concerning the significance of the different dimensions of sexuality.
The Syndyastic Focus: A Case History on Partnership Counseling
The following is a case example of sexological counseling , starting out with two individual face-to-face sessions and a concluding couple session. The example demonstrates the importance, and at the same time great difficulty, to focus on the (re-)fulfillment of psychosocial fundamental needs (“syndyastic focus”) and to keep this perspective all the way through sexological counseling.
Case Report 1
First session with the husband
The 63-year-old man is a retired civil servant, married for 31 years, his wife is 4 years younger. He describes briefly, what leads him to the outpatient clinic: He is “impotent” and wants to know, whether, at his age, there is anything “to be done” here, considering that he has an enlarged prostate gland and has been taking “medication against high blood pressure” since his heart attack 6 years ago. Possibly it might all be connected with the medication? On the other hand, he feels it might just as well be caused by his high masturbation frequency, which—next to coital intimate contact—has been a fixed component of his sexuality throughout his whole marriage.
More detailed assessment revealed that the patient had been treated for 5 years with a beta receptor antagonist (propanolole) due to a moderate hypertonia. Exactly since 5 years he has been in early retirement and at about this time he first experienced erectile dysfunctions. These were not at all always prominent, particularly not during masturbation, which took place approx. Once a week, in former times 2 to 3 times a week. Since 2 years there had been no sexual contacts with his wife. It becomes obvious that the patient had withdrawn more and more, because he was sure that he was “a burden for his wife” alone for the existence of the erectile disorder. In fact, during intimate contact he would always be worried about the erection receding or he was dissatisfied, if it were “not sufficient.” He could hardly imagine his wife still being interested in him, however, both were suffering from this complete standstill of mutual sexuality. The assessment of this patient gave insight on many influencing factors, all with a tendency of unfavorably effecting sexual experience and behavior: firstly, the current condition following the heart attack with the consequence of early retirement and high blood pressure needing treatment including possible side-effects through medication; secondly, his personal image of “impotency,” for him already a fact, just because he was not in all circumstances—by own arousal or wishes from his partner—capable of an erection, even though principally sexual function was still given (such as during masturbation and morning erection); finally, the comprehensible psychological dimension of his conduct (anxious self-observation of his own sexual reaction; fear of failure toward his wife). Furthermore, there was a certain worry that he may have “used up” his sexual potency by masturbating too frequently in the past, claiming two to three times per week to be excessive, perhaps linked with feelings of guilt toward his wife.
This patient was suffering from a condition of frustrated needs for acceptance, closeness, etc. concerning the relationship to his wife and—most important!—during the initial interview this became quite obvious to himself. Because he loved his wife and wished for (re-)accomplishment of the syndyastic dimension of their sexuality, it seemed reasonable to him that this might be achieved by including the wife in the assessment and the counseling, particularly as there had never been any conversation between the couple on this subject.
First session with the wife
The wife is 59 years old and until 3 years ago had worked as a clerk in a housing management company. She is of slender stature, seems fragile and lowers her eyes during conversation. She very well knows that her husband is always worrying about his “erection problems,” it is depressing for her as well that there had been no intimate contact whatsoever now since 4 years (not 2 years, like the husband said). In other ways they were such a good match, had always gotten on well together and have mutually raised three fine children. Her own sexual experience is restricted to intimate contacts to her husband, she had always liked having sex. She is quite capable of orgasm and sometimes, perhaps once a month, she reaches climax by masturbation . All the more she regrets that some time ago her husband had withdrawn altogether following several coitus attempts which had failed due to his erectile disorder. She had accepted this and let him be, even though she herself would still have liked some sexual activity and actually does not really want to do without it altogether. After all, he had had a heart attack and suffers from high blood pressure, presumably his poor health has led to physical demands he could not cope with. Even so, their mutual sexuality was never really as pleasurable as she might have wished for—her husband had always had a very early orgasm, which he resented, too (this disorder of sexual function—a premature orgasm—was not mentioned by the husband). She, on the other hand, was still very appreciative for endearments and interested in an extended foreplay. She believes he is putting himself under extreme pressure, although she does not put pressure on him because she does not expect such performance. She would be very pleased about a revival of their sexual intimacy, even if this would not lead to intercourse. She loves her husband and would very much like to be intimately and physically close to him.Related posts:
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