Attitude change during behavioural treatment of sexual inadequacy

Two Adaptable, Valid, and Reliable Data-Collection Measures

Finding an appropriate, statistically sound means of collecting data is an important step in developing research. Researchers in counseling psychology have recently been criticized for studies unrelated to actual practice. Goal attainment scaling and the semantic differential are presented as two flexible, reliable, and valid data-collection methodologies useful for practitioners. Procedural instructions and examples for constructing each instrument are provided. A short history of the two instruments is presented, along with a discussion of the specific type of research most appropriate for each methodology.

Treatment of sexual dysfunctions by sex therapy and other approaches

BACKGROUND

The treatment of sexual dysfunctions underwent a great change when sex therapy was developed more than 25 years ago. Since then the treatment programme has been modified in various ways, the response to treatment evaluated and other treatment approaches introduced.

METHOD

A review of the literature concerning the application and outcome of sex therapy and other treatments for sexual dysfunction was conducted.

RESULTS

The format of effective conjoint sex therapy is now fairly clear and there is good understanding of the sexual dysfunctions that respond best to this treatment and the couples most likely to benefit. Less is known about the effects of treatment of individuals without partners, bibliotherapy and combining sex therapy with marital therapy and with physical methods of treatment.

CONCLUSIONS

Sex therapy is now a well-established form of treatment. It should be more widely available for patients seen in psychiatry departments.

Couples referred to a sexual dysfunction clinic. Psychological and physical morbidity

Two hundred couples referred to a sexual problems clinic were assessed in a standardised way for their suitability for sex therapy. The assessment focused on the nature of the sexual dysfunction, motivation for treatment, marital and relationship problems, psychiatric status, and physical problems. Approximately one-third of the couples were found to have significant marital and relationship problems, and more than 30% were suffering from psychiatric disorders, although these were usually of mild to moderate intensity. A third of males and 18% of females were suffering from physical disorders likely to contribute to the sexual dysfunction. Patients who were offered sex therapy and who completed their course of treatment were more likely to show high levels of motivation and an absence of physical disorders, marital relationship problems and psychiatric disorder. There should be careful assessment of couples suffering from sexual dysfunction before specific treatment is offered.

Sex therapy outcome research: a reappraisal of methodology. 1. A treatment study of male sexual dysfunction

In the first section a controlled treatment study of male sexual dysfunction is described. 'Unlucky' randomization of subjects yielded treatment groups which differed with respect to variables of possible prognostic significance. Hence the results are largely uninterpretable. In the second section the predominantly negative or inconsistent findings in sex therapy outcome research are reviewed and methodological problems, such as those described in the first part, are considered as possible reasons for these negative findings. The interrelationships are explored between small treatment groups, prognostic variability, bias, power, and small expected treatment effects. A strategy for future research is proposed, with particular emphasis on the recognition and use of relevant prognostic indices.

Factors related to successful outcome in the treatment of sexually unresponsive women

Couples in whom the main complaint was of a lack of female sexual response were treated using a practical counselling approach. A number of pre-treatment measures were studied to determine which factors were predictive of treatment outcome. While age and chronicity were not predictive, the quality of the general relationship and measures of sexual attitude did give useful indications of likely outcome.

Sexual responsiveness in diabetic women

Sexual responsiveness in 82 Type 1 (insulin-dependent) diabetic women was compared with that of 47 normal control subjects, using an interview method for rating various aspects of sexual response, and attitude questionnaires. The diabetic women were questioned about symptoms of autonomic neuropathy, and cardiovascular autonomic nerve function tests were performed. There were differences between the two groups in the reports of vaginal lubrication, but in most other respects the groups were similar. The diabetic women were not less orgasmic, and reported significantly fewer unpleasant feelings during sexual intercourse. They saw themselves and their husbands as less 'potent' than did the normal subjects. The possible enhancing effect of diabetes on the marriage of some diabetic women possibly counteracted the relatively mild physiological deficits involved. There was very little difference in sexual response between women with and without symptomatic autonomic neuropathy.

Psychological and hormonal factors in the treatment of female sexual dysfunction

Forty-eight couples with a presenting problem of female sexual unresponsiveness were treated in a controlled study using a balanced factorial design. The factors varied in this design were medication (testosterone or placebo), treatment frequency (weekly or monthly sessions), and the number of therapists involved (one female or a male/female pair). All counselling was adapted from that described by Masters & Johnson (1970) and Heiman et al. (1976). Results were assessed before and after a 3-month treatment period, and again 6 months later. Contrary to expectations from earlier work, there was no benefit attributable to testosterone or to the use of two therapists; self-ratings favoured weekly sessions with one therapist. It was concluded that testosterone (at least in the dosage used) is unlikely to have a useful place in the treatment of sexually unresponsive women, but that weekly counselling sessions with a single therapist is a reasonably effective and economic form of sex therapy. Findings from this research suggest the need for a clearer understanding of aetiological and treatment mechanisms.

Progress in the treatment of female sexual dysfunction

Over a decade of research since the publication of Human Sexual Inadequacy by Masters and Johnson has confirmed the effectiveness of psychological treatment for sexual problems, but has not advanced our understanding of aetiology very much. It is generally assumed that anxiety blocks normal function in sexual disorders such as impotence or frigidity, although hormonal changes have also been suggested. Evidence for either proposition is lacking. Our own attempts to understand mechanisms have included the use of a dismantling strategy to investigate the effective components of psychological treatment, and latterly the role of exogenous androgens. In our first study, brief treatment modelled on that of Masters and Johnson proved superior to another version of graded practice in sexual contact which lacked the counselling component. Similarly, the fuller version had more effect than did imaginal desensitization, suggesting that sexual dysfunctions cannot be treated like phobic anxiety. A second study focused on women complaining of little sexual interest or enjoyment. The use of a minor tranquillizer was compared with that of androgen (testoral) in the hope that different treatments would be shown to be best for different types of disorder. Unexpectedly, the androgen proved best overall while another variable, monthly vs weekly sessions, did not produce any differences in effect. In the most recent study, a further 48 women were given androgens or placebo, and were seen weekly or monthly for four months by either one or two therapists. There were few significant differences, the most consistent being greater subjective improvement by the women being seen at weekly intervals. The failure to find a positive hormone effect in comparison with placebo raises the possibility that the anxiolytic used earlier may have been counter-productive. If so, it seems unlikely that either excessive anxiety or simple androgen deficiency is an adequate aetiological explanation for female sexual dysfunction.

Symposium on sexual dysfunction. The behavioural treatment of sexual dysfunction

The past 12 years have witnessed the establishment of behavioural methods of treating sexual problems based on the principles developed by Masters and Johnson (1970). Such methods, with some modifications, have proved to be well suited to the needs of our health service (Bancroft, 1975). It is an expedient time to take stock with regard to the current situation in this field, particularly the extent to which treatment facilities are meeting patients' needs, the type of methods being used, and how successful they are. In view of the rapid developments that have occurred in sex therapy it is also appropriate to consider what are now the oustanding clinical and research needs in this area.

Androgen replacement with oral testosterone undecanoate in hypogonadal men: a double blind controlled study

The effects of androgen withdrawal and replacement were investigated in six hypergonadotrophic and six hypogonadotrophic men with hypogonadism. A double blind cross-over design was used comparing testosterone undecanoate (T.U., Organon International), 160 mg daily by mouth, with placebo. There was a significant effect of T.U. on all measures of sexual interest and behaviour. Sexual interest increased within the first week of T.U. administration, ejaculation usually returning within the second week. Behavioural responses were similar in the hyper- and hypogonadotrophic groups. The rise in plasma testosterone during T.U. administration was modest, not reaching the normal range in several cases. 5 alpha dihydrotestosterone rose more substantially. There was a significant fall in sex hormone binding globulin, a rise in oestradiol and no significant change in gonadotrophin concentrations during T.U. administration.

Changes in personality scores among couples subsequent to sex therapy

Changes in personality scores and self-perception of 92 couples through sex therapy are reported. The sample included 52 couples with female symptoms (orgasmic dysfunction and vaginismus) and 40 couples with male symptoms (erectile dysfunction and premature ejaculation), who all completed therapy. One-year follow-up showed significant changes indicating a general increase of emotional stability and a reduction of neurotic tendencies in both partners.

Androgens and sexual behaviour in women using oral contraceptives

Twenty women using oral contraceptives and complaining of impaired sexual function were compared with twenty women without sexual problems, matched for age and oral contraceptive. Whilst the sexual behaviour differed in the two groups, the plasma testosterone, androstenedione, oestradiol and SHBG concentrations were very similar. The total androgen levels were low in both groups. Plasma testosterone and oestradiol concentrations were correlated with measures of sexual interest in the no-problem group, but not in the problem group. Administration of exogenous androstenedione to women in the problem group, using a double blind cross-over comparison with a placebo, failed to improve their sexual function except in one case. The majority of women showed a rise in androgen and oestradiol between day 24 of one pill cycle and day 4 of the next. The possible behavioural indications of this pattern are discussed.

Combination of hormonal and psychological treatment for female sexual unresponsiveness: a comparative study

Thirty-two couples with the presenting problem of female sexual unresponsiveness were treated in a controlled study using a balanced factorial design. Treatment involved a combination of drug therapy and counselling. Half the subjects received testosterone and half diazepam, half received weekly and half monthly counselling. They were assessed before treatment, at the end of treatment and at six months follow-up. Those receiving testosterone did significantly better on a number of behavioural and attitudinal measures than the diazepam group. There were no notable differences in outcome between the two counselling regimes. There were no undesirable side-effects with the testosterone. Further work is needed to establish the indications for testosterone therapy for unresponsive women.

Androgens and human sexual behaviour

Androgens are generally believed to be necessary for normal sexual responsiveness in the human male and female. The evidence for this is limited and sometimes conflicting. This paper considers evidence from experiments in which exogenous androgens are given to people with impaired sexual response. Results from a study in which testosterone was given to unresponsive women are reported, together with the preliminary results of giving androstenedione to sexually unresponsive women taking oral contraceptives and giving testosterone undecanoate to hypogonadal males. In the first study, when testosterone was combined with counselling, significant effects were produced by the addition of testosterone. In the androstenedione study, where no counselling was given, beneficial effects of the androgen have been unusual. Examples of the evaluation of androgen replacement in hypogonodal males are also presented. Finally, some methodological problems of evaluating the effects of exogenous hormone in human sexual behaviour are briefly discussed.