The scientific study of sexual dysfunctions and the development of therapeutic modalities in the United States started with Robert Latou Dickinson (1861-1950). Born and educated in Germany and Switzerland, he earned his medical degree in New York and began collecting sex histories from his patients in 1890. In the course of his practice, he gathered 5,200 case histories of female patients, married and single, lesbian and heterosexual, and published extensively on sexual problems of women (Brecher 1979; Dickinson and Beam 1931, 1934; Dickinson and Person 1925). The turn-of-the-century popularity of Sigmund Freud’s psychoanalysis strongly influenced early American sexual therapy. Although its popularity has faded significantly, the psychoanalytic model is still practiced or integrated with other modalities by some therapists working with sexual problems. The 1948 and 1953 Alfred Kinsey studies brought an increased awareness of human sexuality as a subject of scientific investigation that could include the treatment of sexual disorders as part of psychiatry and medicine. The pioneering work of Joseph Wolpe and Arnold Lazarus (1966) in adapting behavioral therapy, shifted sexual therapy away from the analytical and medical model, as therapists began to view dysfunctional sexual behavior as the result of learned responses that can be modified. William Masters and Virginia Johnson began their epoch-making study of the anatomy and physiology of human sexual response in 1964. Their initial research with 312 males and 382 females, published as Human Sexual Response (1966), remains the keystone of modern sex therapy, not just in the United States, but anywhere sex therapy is studied or practiced. Human Sexual Inadequacy followed in 1970. Masters and Johnson used a male-female dual-therapy team, and a brief, intensive, reeducation process that involved behavior-oriented exercises like sensate focus. It appeared to be highly successful because they worked with a select population of healthy people in basically solid relationships. After their success with relatively simple cases, they and other therapists began to encounter more difficult cases, which could not be solved with the original behavioral approach. In the early 1970s, Joseph LoPiccolo advocated the use of additional approaches designed to reduce anxiety within the behavioral therapy model suggested by Masters and Johnson (LoPiccolo and LoPiccolo 1978; LoPiccolo and Lobitz 1973; Lobitz and LoPiccolo 1972). LoPiccolo’s (1978) analysis of the theoretical basis for sexual therapy identified seven major underlying elements in every sex therapy model: (1) mutual responsibility, (2) information, education, and permission giving, (3) attitude change, (4) anxiety reduction, (5) communication and feedback, (6) intervention in destructive sex roles, lifestyles, and family interaction, and (7) prescribing changes in sex therapy. John Gagnon and William Simon (1973) stressed the importance of addressing social scripting in sex therapy. Harold Lief, a physician and family therapist, pointed out the importance of nonsexual interpersonal issues and communications problems as factors in sexual difficulties. Lief (1963, 1965) also advocated incorporating the principles of marital therapy into sex therapy. As therapists began to integrate other modes of psychotherapy, such as cognitive, gestalt, and imagery therapies, it soon became apparent that there was no single “official” form of sex therapy. In addition, some sex therapists became sensitive to the impact and influence of ethnic values on some sexual problems (McGoldrick et al. 1982). Helen Singer Kaplan, a psychiatrist at Cornell University College of Medicine, made an important and profound contribution to sex therapy when she blended traditional concepts from psychotherapy and psycho-analysis with cognitive psychology and behavioral therapy. Kaplan’s New Sex Therapy (1974) explored the role of such important therapeutic issues as resistance, repression, and unconscious motivations in sex therapy. This new approach focused not only on altering behavior with techniques like the sensate-focus exercises, but also with exploring and modifying covert or unconscious thought patterns and motivations that may underlie a sexual difficulty (Kaplan 1974, 1979, 1983). Specific areas of sexual therapy have been developed, including Lonnie Barbach’s (1980) and Betty Dodson’s (1987) independent work with non-orgasmic women, Bernard Apfelbaum and Dean Dauw’s use of surrogates in their work with single persons, William Hartman and Marilyn Fithian’s (1972) integration of films, body imagery, and body work with dysfunctional couples, and Bernie Zilbergeld’s (1978, 1992) focus on male sexual health and problems. There have been no major innovative treatments developed in sex therapy programs in recent years, although new refinements continue to occur. Some would comment that one does not have to reinvent the wheel when the results are good, but the early success rates have declined as the presenting problems have become more complicated and difficult to treat. Nevertheless, self-reported success rates from reputable sex therapy clinics run between 80 percent and 92 percent. However, critical reviews of sex therapy treatment models emphasize the paucity of scientific data in determining the effectiveness of such programs. Today, few professionals who counsel clients with sexual difficulties see themselves as pure sex therapists. More and more, the term “sex therapy” refers to a focus of intervention, rather than to a distinctive and exclusive technique. Individual psychologists, psychotherapists, marriage counselors, and family therapists may be more or less skilled in providing counseling and applying therapeutic modalities appropriate to specific sexual problems, but each tends to apply those interventions and techniques with which they are more comfortable. Informal support groups also provide opportunities for dealing with sexual problems and difficulties. Many hospitals and service organizations provide workshops and support groups for patients recovering from heart attacks, for persons with diabetes, emphysema, multiple sclerosis, cystic fibrosis, arthritis, and other chronic diseases. These support groups usually include both patients and their partners. Sexual Dysfunctions, Counseling, and Therapies Brief History of American Sexual Therapy WILLIAM HARTMAN AND MARILYN FITHIAN


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