NEW DIRECTIONS IN SEX THERAPY
by BRIAN  HICKMAN Phd MAPS
Psychologist and Sex Therapist
Founding president of the Australian Society for Sex Educators, Researchers and Therapists (ASSERT)(Vic)

Yet another sexual revolution is upon us. This time it is the sexual pharmaceutical revolution. Pills, patches, pellets, injections, suppositories, creams and even nasal sprays are being developed for all aspects of male and female sexual behaviour.
However this revolution didn’t start with Viagra as popularly thought but with a more important discovery. The discovery of the nitric oxide pathway.
This is a fundamental biological mechanism where cells communicate, surprisingly, by releasing, a gas, nitric oxide and received the Nobel Prize in 1998. The nitric oxide pathway regulates brain function, blood flow, and can be used to treat cancer, shock and lung disease. Sexually, the nitric oxide pathway is the major link between our brains and our genitals as it increases blood flow and consequently arousal and orgasm. While Viagra was accidentally discovered a few years earlier it works on the same pathway and now we knew how and why it worked
The irony is that Alfred Nobel made his money from nitroglycerin and set up the Nobel prize for scientific research. While ill with chest pain his doctor suggested he eat nitroglycerin as it was well known to help by increasing blood flow to the heart. Alfred refused, but could see the irony, - it has taken 100 years to understand how the nitric oxide produced by a nitrate (nitroglycerin) would have facilitated a natural process and helped him.

Several other factors have occurred to add to the revolution. Firstly the DSMIV definition of sexual dysfunction have been overhauled so that interpersonal difficulty is replaced with personal distress. Hence a couple where the male complains of her low desire and it causes relationship problems would still have the female classified as the one with the disorder. Now it is the women's distress that is important. A more comprehensive definition, developed by feminists, includes social, political and psychological factors and provides a more complete picture.
Secondly, the definitions of sexual disorders have been standardised worldwide to assist research, diagnosis. The two principle classifications being the international index of erectile dysfunction and the four female sexual arousal disorder dysfunctions Berman and Berman (2001). Thirdly, the publicity and profits of Viagra have increased the public awareness of drug solutions and the demand for medical solutions to sexual problems. The enormous popularity and profit of Viagra, (the most prescribed drug ever and currently prescribed every 4 seconds) has prompted many drug companies to research and develop new sex enhancing products. I have found over 30 hormonal, chemical, and neurotransmitter drugs and 20 complementary medicine products in development. The medical products are likely to be released in Australia from 2003 and many of the complementary products are available now.
Finally, a  study by Laumann  et al in 1999 using a representative sample of Americans attracted a lot of publicity when they reported the prevalence of sexual dysfunction at 43% for women and 33% for men. These figures will increase with the ageing populations of the Western world.

PSYCHOLOGISTS and VIAGRA
 The sex area since Viagra will never be the same again and there are a number of important implications for those promoting the talking cure.
Understandably a lot of controversy and criticism surrounded Viagra, much of it from therapists (myself included). Therapists outlined problems such as men with Viagra erections demanding sex from their unwilling wives, the futility of using medical solutions to psychological or relationship problems -  “the quick fix”, as well as the commercialisation of sex and the unpalatable dependency on a tablet for the rest of ones life.
Often these criticisms were seen as psychologists being resistant to medical solutions and as being threatened and greedy for “protecting their turf”. Medico’s are seen as the handmaidens of drug companies forging results for profit. If you have read the literature of psychogenic and organic etiology of sexual problems I suggest you use a rule of thumb that I use even today. That is, in the first paragraph their will be a comment on what causes sexual problems psychic or organic factors. The results can be reliably predicted by looking at the bottom of that page to see whether the researcher is a psychologist or a medico. Every psychologist knows that the majority of sexual problems are psychological and every medico knows that the majority are organic. Both pay lip service to the other and rarely, if ever, investigate both. I have only been able to find one paper that adequately investigated both factors (it incidently put the split as 70% psychic 20% organic and 10% both) and it concentrated on one sexual problem, erectile dysfunction and had a restricted age range. It may surprise but in my experience one of the most important factors in sexual dysfunction is age. Young women and older men have the most problems and for both it is matters of the heart. For the women its love and for the men its blood flow. My point is clear – Viagra has swung the pendulum back to organic factors and solutions that therapists need to acknowledge, understand and use.

Now with all of these scientific, pharmacological discoveries a therapist would think that the pendulum has swung against psychology and there is little room for our input. However this is untrue as Viagra and most of the new products is that they mimic the natural sexual response of which the brain is the most important factor.  So Viagra needs sexual desire to work properly and this is where counsellors can help.

There are two other points that I wish to make to counsellors. One is that the greatly feared relationship dynamic homoeostasis of Viagra would cause couples untold misery and they would be running to our doors for therapy. In fact they run back to the pharmacist for more Viagra because women want their man happy and they know how depressed he gets because he cant get it up anymore. It is the women who initiate seeking help fro the men, and are receptive to the solution and this is backed up by research.
The other point is the lure of the quick fix the majic cure. In therapy, we encounter this all of the time in many guises and who would blame clients when working through or experiencing “bad feelings” is painful and scarey. That causes me to admire my clients for their courage. But these are the clients who actually get to my office and we know that only 10% seek help for sexual problems and one in four of those referred actually do so and even more drop out no matter how talented and insightful we are. So for most people the choice is do therapy which is nebulous and confusing, hard confronting fears, may not work, is expensive, may have to involve a resistant partner, or the alternative buy a tablet. Which would you choose? Most people have tried medical solutions before they get to my office.
The point is that human nature is such that the quick fix will be attempted first. Our opportunity and responsibility is to be knowledgeable about the new discoveries, educate the public and other professionals and support their use in combination with psychological interventions. Otherwise we are viewed as greedy, protecting our own turf, offering vague warm touchy feely ie useless suggestions and even incorrect generalizations.
Finally, Gerald Brock found in his study of erectile dysfunction. "A significant number of men also reported an increase in return of spontaneous erections
Related to this is the “pill in the pocket” syndrome. Most men who take Viagra do so reluctantly as they fear becoming addicted or dislike the idea of becoming dependent on a pill for the rest of their lives. Those reluctantly using Viagra become less depressed, less anxious, get the necessary physical exercise of their genitals and increase their confidence. I don’t know of any research on this but my clinical observation says that a large group ( the placebo effect would be 30% minimum) keep Viagra in their pocket just in case and only ever need to use it a few times. This is a technique I use to shift relationship power struggles and assist very anxious men.
Obviously, my assertions and therapeutic experience are based on the little research available (which will increase and be another consequence of  Viagra)

What is really happening out there?
 Of course the picture is incomplete but I will try and present an overview for the therapist that is useful and applies to the majority of the population , not the clinical samples we are so used to and biased by.
 
With a sexual dysfunction rate in America of 43% of women and 33% of men what does it actually mean. Laumann (1999) observed that sexual dysfunctions were largerly uninvestigated and represented a significant public health concern. In particular, females experienced a strong association between sexual dysfunction and well being. Sexual dysfunction is important as the co-morbidity is high with 64% of American men with hypertension, 27% with depression and 18% with diabetes have erectile dysfunction (Padma-Nathan 2001). The interaction of factors is important clinically as the inability to obtain vaginal penetration is an early sign of prostrate disease, cardiovascular problems or brain tumour. Of those with ED over 50% are depressed (Padma-Nathan 2001).

So is sex important or are we just creating a problem? The answer is that sex is very important. Sex is still important to72% of men at 66 years of age (Padma-Nathan 2001). 75% of participants in the sexual intelligence (sexIQ) survey reported that sex more than moderately important to them but less than 25% claimed to have a satisfying sex life.
Research , in fact reveals that the majority of couples are not satisfied with their sex life . Seven years into marriage, three-quarters of couples say they are dissatisfied with their sex lives and might consider straying. (Boteach 2000)
 
Why have sex?
  Because its good for you physically, emotionally, spiritually and there is scientific proof. Having sex twice a week is the equivalent cardio vascular exercise of jogging 60 kilometres per year. Sex increases testosterone levels which makes us stronger and more confident. It also reduces prostrate problems, lowers stress and heart problems. For women sex increases testosterone levels, protecting the heart and lungs  and keeping vaginal tissues supple, reducing irregular periods and decreasing the pain and stress of PMS. Sex is also good for your mental health with a clear link between satisfaction with sex life and psychological tests (Conrad and Milburn 2000).

Even though people may want a good sex life – what do they actually do about getting it. Not much! After work, stress, and being tired 30% of people don’t have the energy to think about improving their sex life. This is very likely to be a combination of the hectic lives many  people lead and making excuses, of course.

The most frightening statistic for therapists  is that in 1998 some 50% of Americans said that “a good sex life is something you cant work at – it either happens or it doesn’t” (p51 Conrad and Milburn 2001). Partners seldom discuss their sexual desires According to one survey, only 41 percent of women said they have discussed their sex life with their partners or told them what turns them on.(Boteach 2000). The majority of couples are not satisfied with their sex life Seven years into marriage, three-quarters of couples say they are dissatisfied with their sex lives and might consider straying. Partners seldom discuss their sexual desires. According to one survey, only 41 percent of women said they have discussed their sex life with their partners or told them what turns them on. So buying a sex product or video, for example has been scientifically proven to improve a couples sex life.

Sexual Dysfunction in the United States
The myth perpetuated in popular media that everyone is having great sex is false according to a recent study reported in the Journal of the American Medical Association. Researchers from the University of Chicago asked nearly 3,000 men and women across the United States whether, in the past year, if they had gone through several months in which they had problems with sex. Between 22 and 28 percent of women in different age categories said they're unable to achieve orgasm during sex. Thirty-two percent of women 18 to 30 years old said they lacked interest in sex . The percentage of men who have trouble maintaining or achieving an erection was 7 percent among those age 18 to 20, and 18 percent of those aged 50 to 59.The percentage of women who have trouble becoming aroused was 18 to 19 percent among women age 18 to 39, compared with 21 percent of women in their 40s and 27 percent of women in their 50s.

So who has sexual problems?
As sexual dysfunction for women decreases with age and increases with age for men the major groups needing help are men over 60 years chiefly for erection problems and young women with desire, arousal and pain problems. So if you see those older men running off with cute young women you can console yourself as you now know that the are probably having the worst sex!!
It is the women who actually initiate 90% of male clinic visits as they can see how 50% of men with erection problems are depressed. 50% of the women whose partners have a sexual dysfunction also have one and 66% of that group have more than one sexual dysfunction. (Chen et al 2001) and they also miss the intimacy as men, after a few failures, avoid sex altogether. Gp’s  ( psychologists as well I would predict) are twice as likely to not ask sexual history questions of women (21%) as men (43%)  or of older patients – who are the very groups at most risk (Brock 2001).

Prevalence of Sexual Problems
 While data on the prevalance of sexual problems has been notoriously difficult to ascertain with different definitions, clinical samples, lack of controls etc  Spector and Carey (1990) and Simons and Carey (2001) found similar results (except for premature ejacualtion) ten years later have reviewed studies and presented the following.

Laumann (1999) designed a national probability that is 97% representative of the American population and found overall the total prevalence of sexual dysfunction was higher for women than men (43% v 31%).

This study provides a context for risk factors and is clinically useful. In terms of overall health men have an increased risk of all sexual dysfunctions if they are unhealthy whereas the only effect for women is urinary tract infections. Social status is also effected with men who have a drop in income also have an dropping off of erections. Having more liberal attitudes only causes problems for men who have 3 times more premature ejaculation. A strong difference between men and women continues.
Women who have little interest in sex do so because they have arousal and desire problems –men don’t. That is, if a man isn’t having sex regularly its probably due to lack of opportunity whereas for women its due to a problem. For young men premature ejaculation is 90% on a Friday night and 50% on the next night – this is the biological build up of sexual tension and anxiety.
The effects of sexual assault were profound and long term for both males and females. For males erection, ejaculation and desire problems are at least doubled and for women assault mostly affects sexual arousal. The effects for women on their quality of life are great with significantly more unhappiness, lower physical and emotional wellbeing.

Conclusion
The place for both organic and psychological solutions to sexual problems are upon us and it is the responsibility of the professionals involved to become informed of all the issues and treatments available. We are truly on the dawn of a new era in helping people enhance their sex lives and happiness.

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