Harold I Lief, Richard C Friedman
Although psychologic treatment might be seen to include counseling and education as well as psychotherapy, for the purposes of the chapter on the history of psychologic treatments (see Chapter 1.1 of this book), we are restricting our overview to psychotherapy. The history of the typology of female sexual dysfunction is confusing, and the nosology remains unsettled and controversial (see Chapter 9.1). Before turning to the diagnostic labeling of female sexual dysfunctions and the psychotherapeutic methods and approaches that have evolved over the past century, we need to examine how society and the helping professions have perceived female sexuality.
Views of female sexuality
Throughout history, women have been viewed through male eyes. Men have defined the roles of women and, for the most part, have succeeded in characterizing female sexuality in terms of procreation and parenting.1 With few exceptions, usually those of queens, empresses, and concubines, women were socially and politically powerless. In what today would be called the Third World, they were savagely persecuted by men. For example, the practice of female circumcision, in which the clitoris and labia minora are excised and frequently much of the vagina is sutured closed, began before the birth of Christ in what are now Islamic countries and has continued to be practiced upon millions of women for hundreds of years since. This assault upon female sexuality is outlawed in many countries today but is widely practiced nonetheless. A common notion during various phases of Western European history was that women who were openly erotically expressive were instruments of the devil, whose purpose was to acquire power over the otherwise rational minds of men.
The minimizing of women’s sexual function persisted until the twentieth century, when the rise of feminism, in conjunction with a quasi-sexual revolution, made it appropriate for women to enjoy sex and to be assertive in seeking sexual gratification. However, conflicts between motherhood and occupational and sexual roles persist today, and are mirrored in societal confusion about what are appropriate roles for women.
Severe suppression of female sexuality continued into the nineteenth century, as women were moving from farms to factories during the Industrial Revolution and as class differences were accentuated. Women of the rising middle class, emulating upper-class society, became “ladies” for whom modesty was the most important virtue. Sexual desire, sexual drive, and female orgasm were taboo subjects for conversation as well as for study and research. As Bullough et al.1 put it, “The world came to be made up of good girls and bad girls. The bad girls represented sexuality, the good girls purity of mind and spirit, unclouded by the shadow of any gross or vulgar thought”.
Although there was a widespread trend toward this repressive view of female sexuality, there had been more enlightened views as well. For example, physicians of the seventeenth and eighteenth centuries equated female desire and receptivity with those of the male and made a sharp distinction between desire and coital response. Ellis stated that “all the old medical authors carefully distinguished between the heat of sexual desire and the actual presence of pleasure in coitus”.2 He regarded sexual impulse as a combination of interest (i.e., drive, desire) and responsivity (i.e., arousal, orgasm), and stated, in summary, “Such facts and considerations as these tend to show that the sexual impulse is by no means so weak in women as many would lead us to think”.
Around 1900, when Freud was developing his psychoanalytic theories, the professional view of female sexuality approximated the views of society, namely, that women’s sexual desire and responsivity were pale imitations of the more robust sexual drive in men. Modern clinicians sometimes forget that Freud’s famous phallocentrism and sexism placed him in the mainstream of nineteenth- and early twentieth-century European thought. When Freud began publishing his work, women throughout the then modern world still could not vote. In some countries, women could not inherit property. It was in this climate that Freud developed his ideas about human sexual development and functioning out of his self-analysis, carried out in 1897. Observations he made about himself were hypothesized to have universal validity. As numerous psychoanalytic critics have skeptically observed, the first psychoanalysis involved the male as a subject and an object, indicating that Freud’s ideas about the way a woman’s mind works were flawed. One such idea was that the clitoris was a tiny and inadequate penis. With this premise, Freud developed the vaginal transfer theory that clitoral responsivity has to be superseded in a mature woman by coital (i.e., vaginal) orgasm. The idea of “penis envy”, in which the inadequate female develops envy and possibly angry feelings toward the male, was another conclusion based on the false premise of clitoral insufficiency.
Freud believed that the young child’s reaction to the difference between male and female genitalia and her or his concerns about possible genital damage (e.g., castration anxiety) were of universal importance in sexual development. Vicissitudes in the way children respond to the genital difference were responsible for much sexual pathology. One of his more provocative observations about female psychosexuality was in a discussion of the anatomic differences between the sexes:
The feminist demand for equal rights for the sexes does not take us far, for the morphological distinction [e.g., in their genitalia] is bound to find expression in differences of psychical development. “Anatomy is destiny,” to vary a saying of Napoleon. The little girl’s clitoris behaves just like a penis to begin with; but when she makes a comparison with a playfellow of the other sex she perceives that she has “come off badly” and she feels this as a wrong done to her and as a ground for inferiority. The essential difference thus comes about that the girl accepts castration as an accomplished fact, whereas the boy fears the possibility of its occurrence.3
Freud suggested that women start life with a genital defect, awareness of which emerges by toddlerhood. The notion of universal penis envy in women was thought by Freud to be part of the biologic “bedrock”; an innate, inherent influence not only on sexual development, but also on the development of the total personality of all women. This idea is, of course, now discredited - as are many of Freud’s other ideas about sexual development. These include the theory that all little girls take their mothers as their first sexual/romantic love objects and that this fundamentally erotic relationship stimulates their (clitoral) masturbatory fantasies. As they grow older, however, “mature development” dictates that they relinquish this sexual fantasy tie in favor of an imagined coital relationship with their fathers. The wish to be sexually stimulated by mother is (hypothetically) replaced by the wish to have father’s baby. This latter wish is the “Oedipus complex” in girls - only to be repressed and replaced by a period of latency (e.g., latent quiescent sexual desire). Freud hypothesized that boys as well as girls experience Oedipal desires and castration fears and that this “complex”, normally repressed, can continue to exert pathologic effects throughout life if development is derailed. In fact, he attributed virtually all psychopathology to abnormal processing of Oedipal conflicts. For reasons that we cannot discuss here, Freud also thought that the complex sexual developmental pathway of girls is responsible for the fact that their conscience structure is not as fully developed as boys.4
Freud put forth his theories prior to the cascade of knowledge about child development that led to modern gender psychology. Virtually all of his speculations about female sexual development have been abandoned by modern clinicians. Freud was sufficiently grounded in reality and imaginative enough to recognize that new biologic findings might destroy his hypotheses. His bold prediction was, “On the other hand it should be made clear that the uncertainty of our speculation has been greatly increased by the necessity for borrowing from the science of biology. Biology is truly a land of unlimited possibilities. We may expect it to give us the most surprising information and we cannot guess what answers it will return in a few dozen years to the questions that we have put to it. They may be of a kind which will blow away the whole of our artificial structure of hypotheses.”5
Freud’s prediction came true. In 1953, the embryologist and endocrinologist Jost discovered that the “constitutional sex in mammalian fetal development is female” and that “a functioning ovary is not required for the female phenotype, whereas a testes is mandatory for male development”.6 Much research has demonstrated that the presence or absence of fetal testosterone organizes the fetal brain for later prototypically masculine or feminine behavior. Studies of females with congenital adrenal hyperplasia, of males with androgen insensitivity syndrome, and of patients with a variety of intersex disorders have been of particular value in this regard. Sex stereotypic behavior begins to be expressed during childhood well before puberty and at a time when no differences in sex steroid hormones are found between females and males.
In 1951, Ford and Beach7 expressed the view that the clitoris plays a primary role, if not the only role, in the female orgastic response, and Kinsey and his colleagues8 stated their belief that the vaginal orgasm is a biologic impossibility. In 1954, Judd Marmor9 criticized Freud’s theory of the nature of female orgasm, but it took the groundbreaking physiologic studies of Masters and Johnson in the early 1960s to produce more of the biologic facts that undermined the transfer theory. In 1961, Therese Benedek and Helene Deutsch attacked the transfer theory. For example, Benedek10 stated, “the expectation that clitoral sensation should be transferred to the vagina is inconsistent with the distribution of the sensory cells responsible for the perception of orgasm”; according to Benedek, Deutsch held that the clitoris is the primary sexual organ. Their ideas were simply not acceptable to the majority of psychoanalysts, who still believed the original Freudian theory.
The new findings did not penetrate the psychoanalytic community. For example, the vaginal transfer theory remained the hypothesis for psychoanalytic treatment of women for decades after the biologic facts began to emerge. Perhaps a historical vignette will illustrate the nature of this travesty. In 1947, the senior author was a student of A.A. Brill, one of the first American psychoanalysts and the translator of many of Freud’s early works. A small group of us assembled in Brill’s office one day to discuss a patient who had come to him with deep depression. She had been in treatment for this with another psychoanalyst. During the course of that analysis, the other analyst discovered that his patient could not have an orgasm with intercourse. It is uncertain how the analyst phrased it, but he made it clear to his patient that it was her immaturity that was keeping her from having a vaginal orgasm. She had had no trouble having an orgasm with clitoral stimulation, but had not been able to reach orgasm during coitus. The analyst’s words were such a blow to her self-esteem that her depression deepened. She had the good sense to leave this analyst and seek the help of Brill, who told her that the vaginal transfer theory was rubbish. At that point, no analyst had criticized the theory, at least in print, and it would be 6 or 7 years before a paper by Judd Marmor would be the initial critique. After the class was over, I lingered behind, thinking that Brill’s conclusions were so important that they should be in the literature, so I asked why he did not develop and write up his observations. Brill looked stunned and flushed, almost as if I had struck him across the face, and it became apparent to me that writing something in direct opposition to Freud, the “Master”, was unthinkable - this was 8 years after Freud had died. It was clear that the institution of psychoanalysis had the trappings of a church with doctrinal absolutism and demand for unquestioned fidelity to its belief system.
Psychoanalytic therapy based on psychoanalytic theory
For many years, psychoanalysts were less interested in the woman’s sexual function than in object choice (mainly sexual orientation) and personality development. Convinced of the universality of the libido theory and the Oedipus complex, analysts looked for their manifestations in every case. Case histories mainly concerned inappropriate partner choices, personality development, and masochistic relationships. In turn, the consequence of erotic feelings toward father substitutes was the guilty fear that ensued. Limited attention was paid to the inhibition of sexuality, usually played out against the theoretic superstructure described earlier. Some cases do make the psychoanalytic approach useful, however. A patient that the senior author saw at the Psychoanalytic Clinic of Columbia University is illustrative. A woman in her late twenties had married her lover, with whom she had had a very satisfactory sex life prior to marriage, including orgasm. On her wedding night, she found herself completely unresponsive. This lack of responsivity, of almost of any hint of arousal, continued for 10 months until she and her husband decided that there was no way that they could live together with this degree of sexual dissatisfaction. On the night that they separated, having had otherwise a satisfying relationship, they had sex and she was orgastic once again. As one might imagine, she had had a close, somewhat too dependent relationship with her father. (The dynamics in this case are much more common in men, creating what Freud termed the Madonna prostitute complex.) The guilty fear over her unconscious fixation on her father transferring to her husband by virtue of the symbolism of marriage is an example of unconscious mental processes, arguably the most important of Freud’s contributions.
In the treatment of sexual dysfunctions, the primary emphasis for many years was on the woman’s failure to have an orgasm during coitus. It was not until midcentury that doubts were expressed about the vaginal transfer theory. It takes a long time for criticisms to change belief systems. If only the analysts had been able to follow the dictum of Sandor Rado, who told his students, “Don’t marry a theory in a state that does not recognize divorce.”
The field of sex therapy was radically changed by the innovative research and clinical work of Masters and Johnson (see Chapters 17.2 and 17.3). Their ideas were presented in two books, Human Sexual Response (1966)11 and Human Sexual Inadequacy (1970).12 Until then, the only form of therapy was psychoanalytic or psychodynamic psychotherapy based on psychoanalytic theory and observations. With the results of Masters and Johnson’s treatment protocol, cognitive-behavioral therapy of sexual dysfunctions was widely accepted and practiced.
For the clinician, the most important findings of Masters and Johnson were as follows:
1. There is no separate vaginal orgasm; indeed, there is no such thing as a vaginal orgasm, although orgasm may occur during coitus.
2. The human female has the capacity to have intense and multiple orgasms without a refractory period. After males experience orgasm, there is a variable period of time when they are “refractory” to sexual stimulation and arousal. This is not true of females.
3. There are four stages of the human sexual response: excitement, plateau, orgasmic phase, and the resolution phase.
4. There is a need to treat the couple rather than an individual.
Masters and Johnson’s studies also indicated that there is great variability between women in their sexual response profiles, whereas men seem to follow a linear progression from excitement to plateau to orgasm, to resolution, to refractory period. Different women seem to follow different pathways. Responses may include a single orgasm, multiple orgasms, extreme sexual excitement/arousal without an apparent orgasm, or even orgasm without awareness of arousal, yet fall within a range experienced as being normal by a particular woman or couple. The four points described above became the bedrock of sexual therapy carried out by sexologists over the last quarter of a century. Later, the desire phase was added to the four phases described by Masters and Johnson, to make a five-phase approach.
Some early efforts at behavioral therapy preceded the work of Masters and Johnson. For example, in 1963, Arnold Lazarus13 treated “frigidity” with systematic desensitization. Early behavioral therapists proceeded on the assumption that behavioral changes would create changes in attitude. In order to avoid cognitive dissonance, it was assumed that the patient would change her attitudes so that they would be congruent with her changed behavior. This was just the opposite of the thinking of psychoanalysts, who had always assumed that it was necessary to change attitudes before there would be behavioral changes.
The principles of behavioral therapy as reported by Bancroft in 197714 still remain the key elements of this type of therapy. Those principles are (1) systematic desensitization, (2) shaping of fantasies, (3) operant methods, and (4) role rehearsal. There is an overlap between the operant methods of appraisal and systematic desensitization. In this approach, actual behaviors are described in detail in a hierarchal positioning from the least to the most troublesome. With systematic desensitization, these behaviors from the least to the most anxiety-provoking are faced in fantasy and then in reality. This includes homework assignments from session to session. In each session, the difficulties encountered in carrying out the assignments or the negative affects evoked are discussed. Rewarding positive reinforcers and eliminating negative ones are key concepts. As Bancroft states, “The patient is always given something to do between sessions, and not only does this represent behavioral progress during treatment, but it is a remarkably powerful method for revealing the underlying problems and the attitudes that block change”. He made this statement at a time before cognitive therapy had begun to dominate the thinking of therapists and before the integration of cognitive and behavioral therapy. It is therefore of interest to see the comment, “It is in the modification of such attitudes that the behavioral approach is less clearly defined and it is here that the main source of variance between therapists, and overlap with other psychotherapeutic approaches occurs”. The early behavioral therapists, while generally subscribing to the dictum that “behavioral changes precede attitudinal changes”, began to recognize that change would not take place simply by changing behavior; attitudes had to change as well. In some cases, attitudes were changed by behavioral changes, but in others they were not. Therefore, attention had to be paid directly to attitude change. In was in this setting that cognitive therapy arose. Attitudes could be changed by changes in cognitions or beliefs. Getting at thoughts, often preconscious, that triggered maladaptive behaviors was the key to cognitive therapy. It was in this way that behavioral therapy metamorphosed into cognitive-behavioral therapy.
It should be noted that the history of psychologic treatments is a history of steps in integrative psychotherapy. We have already seen one such step, namely, the integration of behavioral and cognitive therapies. Another step was the integration of individual and couple therapy. A third step was the integration of cognitive-behavioral therapy with psychodynamic or interpersonal therapies. At about the time (c.1970) that Masters and Johnson published their first report of their treatment methods, cognitive-behavioral therapy was just getting started, and psychologic therapy for women’s sexual dysfunction, psychoanalytic or briefer forms of psychodynamic psychotherapy, was still dominant.
In reviewing Masters and Johnson’s methods, it is clear that they used the principles of behavior therapy. Emphasizing sensual rather than erotic pleasure, and only gradually approaching vaginal penetration, is a form of systematic desensitization. Giving homework assignments between sessions, monitoring the couple’s responses, using positive reinforcers, and eliminating negative reinforcers is a form of operant conditioning. Role behavior, including role rehearsal, is an additional attribute of the method of Masters and Johnson. While exploration of fantasies does not seem to play an important role, Masters and Johnson’s methods certainly led to the unearthing of beliefs and attitudes, allowing the negative ones to be constantly challenged. Cognition was hardly neglected. A major emphasis was on effective communication. In this way it can be said that their methods were not behavioral alone; they were cognitive-behavioral therapy. Perhaps, in the long run, the major contribution of Masters and Johnson will turn out to be their insistence on couple therapy and their de-emphasis of therapy aimed at the individual.
Couple sex therapy
Couple sex therapy was given an enormous boost by the methods of Masters and Johnson. In the treatment of individual patients there had always been two key issues: (1) how nonsexual problems in a relationship affected the sexual function of the patient and (2) how changes in therapy would play out in the relationship. Masters and Johnson dealt with this head-on. They insisted on seeing only couples in a committed relationship and treating both at the same time. In at least half their cases, both partners had significant sexual problems and, even if that was not the case, relationship factors played an integral role in the development of symptoms of sexual dysfunction and in the process of therapy. By handing out homework assignments (as in behavioral therapy), they were able to elicit nonsexual problems, such as those dealing with power, intimacy, communication, respect, and role conflict, and discover the negative reinforcers used by the couple. By using systematic desensitization surrounding sen- sate focus, they enabled the couple to overcome negative affects, such as shame, anxiety, and anger. They also rewarded positive responses to increasing sensual and erotic pleasure through words of encouragement, thus changing the couple’s attitudes. The use of conjoint therapists reinforced the notion that sexual problems existed in the context of a relationship.
Despite the therapy research of Masters and Johnson demonstrating the effectiveness of couple therapy for sexual dysfunctions, couple therapy expanded slowly. Perhaps this was due to a need for a therapist to learn two methods of approach; relationship therapy as well as sex therapy. Most training programs emphasized only one approach or the other. McCarthy et al.,15 in a chapter on the integration of sex and couple therapy citing Basson, noted that sexual responsivity in women is usually limited to “an opportunity to be sexual, an awareness of the potential benefits to her and the relationship”. Facilitating that responsivity occurs when the woman learns to develop her “sexual voice” so that “she can request the type and sequence of touching and erotic scenarios that promote her sexual receptivity and responsivity.” They define the woman’s sexual voice as her sexual and erotic feelings and needs. Recognizing these, she can proceed at her own pace rather than be driven by the man’s erection and his needs. Another guiding principle is that a woman’s orgasm is much more varied than a man’s. There are a variety of normal sexual response patterns; certainly, the inability to have an orgasm during vaginal penetration is not a sexual dysfunction. Included in couple therapy is the enhancement of bridges to sexual desire, the essence of which is positive anticipation and the woman’s feeling that she deserves sexual pleasure.
The integration of cognitive- behavioral therapy and dynamic psychotherapy
We have discussed how behavior therapy became integrated with the field of cognitive psychology leading to cognitive- behavioral therapy. As Goldfried16 puts it, “Although desensitization was found to be very effective clinically, there were instances where one could readily observe that cognitively mediated anxiety undermined its effectiveness”. What drew psychodynamic therapists to cognitive-behavioral therapy was the recognition that the notion of “schema” could be a useful bridge between the two modalities. Cognitive-behavioral therapy was heavily reliant on the “here and now” appraisal of a patient’s problems, whereas psychodynamic therapies made extensive use of past experiences, including past relationships. Schema refers to a cognitive representation of one’s past experiences in situations or with people. It organizes one’s perceptions based on these past experiences and serves as a filter through which a person perceives current events in his or her life. It is selective in that it takes in those perceptions that fit the schema and excludes perceptions that do not seem to fit. In this way it is self-reinforcing. Briefly, it is the way we organize our perceptions based on past experience. It also serves to integrate perceptions and emotional reactions which tend to occur automatically in similar situations. In some ways this resembles Freud’s “repetition compulsion” and is manifest in transference phenomena. The analysis of schemas allows the therapist to understand the beliefs, attitudes, and accompanying emotions that may enhance, but too often undermine, sexual satisfaction.
The commonalities between cognitive-behavioral therapy and psychodynamic psychotherapy are far greater than the differences. The goal of reducing the anxiety that leads to the inhibition of pleasure-seeking behavior or of pleasure itself and the goal of reducing or eliminating maladaptive behaviors that decrease the chances of intimacy are the same for both modalities. Therapy techniques used to seek or reach these goals are also similar. These include increasing the woman’s capacity to identify her thoughts and feelings, her bodily sensations, and eventually her schemas and scripts. This helps the woman feel safe and secure in situations that provoke anxiety by providing her with corrective emotional experiences17 brought about by desensitization, role rehearsal, repetition of positive behaviors, recognition of positive responses in her partner, and changes in her own feelings and sensations. As a woman’s fearful expectations and negative responses are replaced by pleasurable anticipation, she begins to sense her own potential for growth and the new possibilities in her relationship with her partner.
The linkage between cognitive-behavioral therapy and psychodynamic psychotherapy is provided by the analysis of schemas and scripts. The perceptual mindsets and the consequent rules for sex-oriented behaviors become the centerpiece of therapy. If it tilts to the behavioral end of the spectrum, less attention is paid to schemas (they may never be identified to the patient), and attention is moved to the changed behaviors themselves. The more psychodynamic, the greater the attention to the less-than-conscious aspects of the schema.
The exploration of dreams and fantasies may be very helpful in uncovering psychic material that the patient may resist becoming conscious of. If dream metaphors are analyzed in terms of themes and are connected to the emotional events in the day or two preceding the dream, the underlying schema through which the patient views herself in the world may come into focus. The therapist must avoid using dreams as a way of uncovering childhood trauma. That path is treacherous, as “recovered memory” therapists have discovered. If sexual abuse in childhood has been corroborated, the connection between trauma, dreams, and fantasies may be useful.
Impetus to the integration of psychodynamic therapy with cognitive-behavioral therapy came from the clinical studies of Helen Kaplan. In The New Sex Therapy, published in 1974, Kaplan18 stated, “When sexual exercises are combined with psychotherapy conducted with skill and sensitivity, psychotherapy becomes immensely important, and in fact, is indispensable to the success of the new sex therapy” (p 221). Kaplan, probably projecting herself as the ideal therapist, set out requirements for sex therapy that few could claim. She said, “A sex therapist should have extensive knowledge of the theory and practice of psychoanalysis, marital therapy, and behavior therapy, and know how and when to apply these theoretic and therapeutic concepts to the couple’s specific sexual problems” (p 222).
Kaplan used her knowledge of psychoanalysis and psychotherapy and of sex therapy in a very specific and limited way. She suggested that dynamic therapy be used to overcome the blocks or impediments to more effective sexual function. In this way, she hoped to keep sex therapy a short-term therapy of a few weeks to a few months, and to avoid the lengthy treatment usually associated with psychoanalysis. It is not at all clear how many sex therapists have been able to carry out this type of integrative model of sex therapy. We suspect that it remains more of an ideal than a realized model.
In the 1970s, sexual desire was added to the four parts of the response cycle set forth by Masters and Johnson. Although Lief19 was the first clinician in the modern era to describe inhibited sexual desire as a serious clinical problem, Kaplan20 developed the concept in detail. This led to a change in the classification of women’s sexual dysfunction to include problems of desire along with problems of arousal and orgasm.
There used to be a single category for women’s sexual problems termed “frigidity”. The historical development of the classification of women’s sexual dysfunction can be traced in the successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) described elsewhere in this book. The sexual experiences of women are so much more varied than those of men that the classification of women’s sexual dysfunction has become a battleground for people of diverse and intense beliefs.21 The main objections to the current DSM (fourth edition; DSM-IV) classification are as follows:
1. The medical model of women’s sexual function is male- based and orgasm-centered.
2. The biopsychosocial model is discarded in favor of a biologic model.
3. The standard for sexual function in the female is based on the human sexual response cycle as defined by Masters and Johnson and modified by Kaplan. Selection bias is a problem in their research. In other words, the volunteer subjects in Masters and Johnson’s studies were nonrepresentative, as they were orgastic, came from a particular social class, and were enthusiasts about becoming good sexual “performers”. It is questionable whether the “cycle” discussed by Masters and Johnson should be considered a norm.
4. The DSM-IV classification is based on symptom description rather than etiology, and presumes that etiologies, including social, personal, relational, or medical ones, should be the basis of classification.
5. Satisfaction in sexual experiences may involve intimacy, comfort, safety, self-validation, power-sharing, or other experiences not entirely or even specifically erotic.
6. Sexual desire is multifaceted and therefore must always be viewed with a biopsychosocial perspective.
7. The desynchronization of psychologic sexual arousal and physiologic excitement (i.e., vasocongestion/lubrication) is so frequent that a “normal” sexual response is impossible to identify and label.
8. Sexual satisfaction is dependent on factors other than orgastic capacity, which may play no role or a limited role.
It is for all these reasons that female sexual response is so varied and so resistant to arbitrary classification.
If we compare 1900 with 2000, it is clear that enormous strides have been made in understanding woman’s sexual function and in the sophistication of psychologic methods of treatment of dysfunction. Sexual responses in females are much more varied than in males, and sexual dysfunctions are more difficult to diagnose. Treatment has to be based on a biopsychosocial perspective (see Chapter 17.6), has to be multifaceted, has to be oriented toward the woman’s relationships, and, wherever possible, has to involve the partner in couple therapy. Sexual problems provide an excellent opportunity for the integration of a number of therapeutic modalities, including cognitive- behavioral and psychodynamic, individual and couple, and biologic and psychologic.
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