Original Article
Sex Therapy:
Advances in Paradigms,
Nomenclature, and Treatment
Stanley Althof, Ph.D.
Objective: The author reviews the historical paradigms that
have influenced the treatment of sexual problems, changes in the
diagnostic nomenclature, and recent innovations in sex therapy.
Methods: The author reviews the literature and provides expert
opinion.
Results: The author gives a historical overview of how theoret-
ical models of understanding human sexuality have influenced
treatment, describes the changes in sexual dysfunction nomen-
clature, and focuses on the combined medical and psychological
treatment of sexual dysfunction.
Conclusion: Sex therapy continues to evolve with new para-
digms and definitions for understanding and diagnosing sexual
problems and innovative methods of treating sexual problems.
Academic Psychiatry 2010; 34:390 –396
Received October 12, 2009; revised January 1 and February 2, 2010;
accepted February 10, 2010. Dr. Althof is affiliated with the Department
of Psychiatry at the University of Miami Miller School of Medicine in
West Palm Beach, Florida. Address correspondence to Stanley Althof,
Ph.D., 1515 N. Flagler Dr., Suite 540, West Palm Beach, FL 33401;
Stanley.Althof@case.edu (e-mail).
Copyright © 2010 Academic Psychiatry
390 http://ap.psychiatryonline.org
C hanges in the field of sex therapy are occurring on
many levels, including theoretical paradigms, diagnos-
tic nomenclature, treatment interventions, research method-
ology, assessment measures, development of effective and
safe medications, and leadership. We have witnessed trans-
formations in the theoretical paradigms that shape how we
think about sexual problems from the classically psychoan-
alytic to more integrated medical and psychological models.
Similarly, treatment interventions have evolved from tradi-
tional, office-based, individual, group, or couples’ psycho-
therapy to combining medical and psychological treatments
in the office or providing treatment over the Internet.
In terms of leadership there has been a “changing of the
guard” from primarily mental health clinicians to primar-
ily urologists, gynecologists, and primary care specialists.
In the 1980s and 1990s, specialized sexuality training
centers and programs flourished within academic depart-
ments of psychiatry. Today, there are no centers located
within departments of psychiatry. This article will review
the historical paradigms that have influenced the treatment
of sexual problems, changes in the diagnostic nomencla-
ture, and recent innovations in sex therapy.
Depending on the definition of the sexual disorder, the
methodology utilized, and the geographic region, preva-
lence estimates for sexual problems vary widely. Taking
the most conservative estimates, 9% of women suffer from
hypoactive sexual desire disorder, 5.1% from female sex-
ual arousal disorder, and 4.6% from female orgasmic dis-
order (1). In men, prevalence of premature ejaculation is
approximately 22%, and the prevalence of hypoactive sex-
ual desire disorder is around 15% (2, 3). Erectile dysfunc-
tion is highly age dependent, with prevalence estimates of
less than 10% for men younger than age 40 and increasing
to more than 40% in men older than age 60 (3). These
statistics and the effect of sexual dysfunctions on an indi-
vidual’s and couple’s quality of life support the need for
Academic Psychiatry, 34:5, September-October 2010

psychiatry’s involvement in research, teaching, and clini-
cal care of individuals with sexual problems.
Sex Therapy
Sex therapy is a specialized form of psychotherapy that
draws on an array of technical interventions known to
effectively treat male and female sexual dysfunctions (4).
Treatment generally follows the principles of short-term
psychotherapy, with the therapist and patient(s) focusing
on specific issues in an individual, couples, or group for-
mat. While employing traditional psychotherapeutic tech-
niques such as support, interpretation, confrontation, cog-
nitive reframing, and homework, sex therapy also
incorporates technical interventions, such as sensate focus
to diminish performance anxiety, stop-start to help patients
with premature ejaculation, directed masturbation for
anorgasmia, and insertion of dilators paired with relax-
ation for sexual pain disorders.
Psychosexual evaluation goes beyond the conventional
mental status examination to examine the patient’s or cou-
ple’s sexual history, current sexual practices, relationship
quality and history, emotional health, and contextual fac-
tors influencing their lives (e.g., having young children,
chronic illness, financial concerns). Usually a thorough
psychosexual, developmental, and medical history is taken
to identify past or current experiences, illnesses, surgery,
and medication that may be contributing to the presenting
sexual or emotional problem (e.g., past sexual trauma, an
oversexualizing parent, diabetes, antidepressant medica-
tion). The evaluation seeks to identify all the predisposing,
precipitating, maintaining, and contextual factors in the
patient’s or couple’s life (5).
Historical Contexts and Evolving Paradigms
The first attempts to describe and classify sexual disor-
ders began with Richard von Krafft-Ebing and his Psy-
chopathia Sexualis (6), which influenced medical and le-
gal practice for more than 75 years. Observational studies
and data quantifying normal and abnormal sexual behav-
iors were cataloged and ultimately led to the seminal con-
tributions of Ellis (7) and Kinsey et al. (8, 9).
Historically, treatments of sexual dysfunctions have
been based on prevailing ideologies. Before 1950, psycho-
analytical concepts guided clinicians in their understand-
ing and treatment of sexual problems. Sexual symptom-
atology was linked to constellations of unresolved,
unconscious, conflict(s) (e.g., oedipal conflict, castration
anxiety, female immaturity, excessive narcissism, uncon-
Academic Psychiatry, 34:5, September-October 2010
ALTHOF
scious need to debase women) occurring during specific
developmental periods (10 –12).
In the late 1950s, the behavioral perspective gained
ascendancy. Interventions were modeled after classical
conditioning and assumed that the dysfunction was a
learned (conditioned) anxiety response. The guiding prin-
ciple of behavior therapy was to extinguish the anxiety or
performance demands that interfered with normal sexual
function (13, 14). For example, sensate focus, a series of
sensual touching exercises, gradually guides couples to
savor sexual touch while extinguishing performance anx-
iety. Other examples include the stop/start method to treat
premature ejaculation and using vaginal dilators and re-
laxation for vaginismus (15, 16).
In 1966, Masters and Johnson (17) reported the first
results of laboratory observations of male and female sex-
ual arousal and orgasm. Initially they described the phys-
iology of these phases of functioning (arousal, orgasm,
and resolution), and later they highlighted the deleterious
influence of performance anxiety (the fear of future sexual
failure on the basis of previous failures, which can con-
tribute to all sexual dysfunctions), the effect of relation-
ship factors, and the significance of biological factors on
the development of sexual dysfunctions (18). Their work
foreshadowed the later integration of medical and psycho-
logical interventions. Today we have placebo-controlled,
randomized studies that demonstrate the negative effect of
one partner’s sexual dysfunction on the other’s sexual
function and the positive effects of treating dysfunction in
both the patient and partner (19).
Masters and Johnson’s and Lief’s (20) four-step linear
model of sexual response was linear and sequential (Lief
added the desire component to the three-step model of
arousal, orgasm, and resolution). Alternatively, Basson
(21, 22) postulated an intimacy-based circular model of
sexual desire for women: women begin lovemaking from
a standpoint of sexual neutrality, arousal precedes desire,
and that the motivation for lovemaking is emotional inti-
macy as well as emotional and physical satisfaction. Two
studies (23, 24) have tested the validity of the Masters and
Johnson model versus the Basson model; it remains too
early to conclude which model should prevail.
The neo-Masters and Johnson era was heralded by the
publication of Helen Singer Kaplan’s book The New Sex
Therapy in 1974 (25). She integrated psychoanalytic the-
ory with Masters and Johnson’s cognitive behavior under-
standing of sexual dysfunction. Distinguishing between
recent and remote etiological causations, she recom-
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SEX THERAPY
mended behavioral approaches for the former and reserved
traditional psychodynamic methods for the latter.
Throughout this period, the etiology of sexual dysfunction
was conceptualized in binary terms—it was either psycho-
genic or organic. This binary model simplified treatment
planning, especially for men with erectile dysfunction. For
example, men diagnosed with psychogenic erectile dysfunc-
tion were referred for sex therapy, men deficient in testoster-
one received hormone replacement, and men with other or-
ganic conditions were referred for penile prosthesis. Over
time, a third category, mixed erectile disorder, evolved to
account for those patients with both psychological and or-
ganic factors. Yet “mixed” conveys a static rather than inter-
active and changeable concept. Disease conditions often
change, as do psychological issues.
These shortcomings led to the development of the bio-
psychosocial model, a dynamic and additive model that
captures the ever-changing influences of biology and psy-
chological life (26 –32). Regardless of the precipitating
causes, changes in biological and psychosocial domains
occur over time. This model encompasses both the psy-
chological life of the patient, the effect of the dysfunction
upon the partner and couple’s sexual life, and the fluctu-
ating influence on sexual function of life style, medication,
surgery, and disease. Additionally, the biopsychosocial
model enables stepwise treatment recommendations into
all three domains. By incorporating these issues into a
global assessment of sexual problems, one arrives at a
more accurate and comprehensive understanding of what
predisposes, precipitates, and maintains the dysfunction.
The late 1980s and 1990s ushered in the era of biolog-
ical discovery, identifying some of the biological under-
pinnings of sexual dysfunction and the negative effect of
life style, aging, disease, medication, and surgery. These
findings ultimately led to the introduction of phosphodi-
esterase type 5 inhibitor (PDE5i) drugs to treat erectile
dysfunction. These medications have dramatically altered
the treatment for erectile dysfunction. Physicians have a
simple, efficacious, and safe intervention that restores po-
tency in approximately 50 –70% of treated men (34, 35).
One might conclude that psychotherapy for erectile dys-
function is an obsolete and antiquated intervention, but
given the medication discontinuation rates hovering
around 60%, psychotherapy as an adjunct to pharmaco-
therapy is more relevant than ever. Psychosocial factors
may interfere with the use of efficacious treatments (36).
Another theoretical paradigm, the dual control model,
was set forth by Bancroft and Janssen (37), who believed
that simultaneous excitatory and inhibitory systems oper-
392 http://ap.psychiatryonline.org
ate in parallel and account for both sexual function and
dysfunction. They further divided inhibition into two in-
dependent dimensions: threat of performance failure and
threat of performance consequences.
Diagnostic Nomenclature
The first edition of the Diagnostic and Statistical Man-
ual of Mental Disorders (DSM-I) appeared in 1952 (38).
Although it included a section on sexual deviations, sexual
dysfunctions were absent. DSM-II was published in 1968
and strongly influenced by psychoanalytic notions (39). It
included two sexual diagnoses: impotence and dyspareu-
nia (painful intercourse).
Significant changes appeared in DSM-III, published in
1980 (40). Homosexuality was removed from the diagnos-
tic nomenclature and replaced by ego-dystonic homosex-
uality. Additionally, DSM-III included these sexual dys-
function diagnoses: inhibited sexual desire, inhibited
excitement (refers to male and female arousal disorder),
inhibited female orgasm, inhibited male orgasm, prema-
ture ejaculation, functional dyspareunia and functional
vaginismus. In 1987, DSM-III–R removed ego-dystonic
homosexuality and added sexual aversion (41). DSM-III-R
reflected the changing social, political, and scientific atti-
tudes and the influence of Masters and Johnson’s and
Lief’s four stage sexual response cycle.
DSM-IV and DSM-IV-TR changed the names of sev-
eral dysfunctions and redefined others (42, 43). The fol-
lowing sexual dysfunction diagnoses appear in DSM-IV-
TR: hypoactive sexual desire disorders for both men and
women, sexual aversion disorder, male erectile disorder,
female sexual arousal disorder, female orgasmic disorder
(redefined in terms of requiring adequate stimulation and
high arousal before making the diagnosis), premature ejac-
ulation, male orgasmic disorder (delayed ejaculation), dys-
pareunia, and vaginismus.
Perhaps the most significant change from DSM-III to
DSM-IV-TR was the inclusion of distress and interpersonal
difficulty as essential constructs in diagnosing sexual dys-
function.
DSM-IV-TR was criticized as being a heterosexist and
phallocentric model of sexual behavior. Intercourse was
considered the reference standard for many of the diag-
noses (44). In response, two consensus conferences com-
prising a multidisciplinary group of European and North
American experts in women’s sexuality were convened in
1998 and 2003 (45, 46) and offered several recommenda-
tions on definitions of female sexual dysfunctions.
The Consensus Conference recommended that hypoactive
Academic Psychiatry, 34:5, September-October 2010

sexual desire disorder be renamed women’s sexual interest/
desire disorder. It proposed including sexual receptivity into
the diagnosis of hypoactive sexual desire disorder and added
absent motivation for sexual behavior to the previous crite-
rion list, which included absent or diminished sexual interest
and absent sexual thoughts and fantasies.
Female sexual arousal disorder moved away from an
exclusive focus on genital arousal (lubrication) to also
consider the woman’s subjective experience of arousal and
was partitioned into three diagnostic entities: subjective
arousal disorder, genital sexual arousal disorder, and com-
bined genital and subjective arousal disorder.
Women’s orgasmic disorder was amended to incorpo-
rate the need for sufficient sexual stimulation where, de-
spite the report of high sexual arousal/excitement, there is
either lack of orgasm, markedly diminished intensity of
orgasmic sensations, or marked delay of orgasm from any
kind of stimulation. Regarding sexual pain disorders, the
committee suggested including noncoital sexual pain in
the dyspareunia definition.
Finally, the group recommended that persistent sexual
arousal disorder, defined as spontaneous, intrusive, and
unwanted genital arousal (e.g., tingling, throbbing, pulsat-
ing) in the absence of sexual interest and desire, be pro-
visionally included in the diagnostic nomenclature (44).
Binik et al. (47, 48) have cogently argued for the reclas-
sification of sexual pain disorders to genital pain disorders.
They contend that the pain is not sexual per se and should be
treated like other pain disorders. Although genital pain dis-
orders can interfere with sexual function, Binik et al. urge a
focus on the pain, not the function with which it interferes.
The definition for premature ejaculation has also under-
gone revision. The criterion set for premature ejaculation
promulgated in DSM-IV-TR is persistent or recurrent
ejaculation with minimal sexual stimulation before, on, or
shortly after penetration and before the person wishes it;
the disturbance causes marked distress or interpersonal
difficulty and is not due exclusively to the direct effects of
a substance. The DSM-IV-TR definition was criticized for
being authority based, excessively vague, and reliant on
the subjective interpretation of the clinician (49).
In 2008, the International Society for Sexual Medicine
convened an expert panel that redefined premature ejacu-
lation as
a male sexual dysfunction characterized by ejaculation which al-
ways or nearly always occurs prior to or within about 1 minute of
vaginal penetration, and the inability to delay ejaculation on all or
nearly all vaginal penetrations, and negative personal conse-
Academic Psychiatry, 34:5, September-October 2010
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quences, such as distress, bother, frustration and/or the avoidance of
sexual intimacy.
The panel concluded that insufficient published, objec-
tive data propose an evidence-based definition of acquired
premature ejaculation (49).
One final note on classification concerns comorbidity.
DSM-III and IV were heavily influenced by the concepts
of Masters and Johnson and Lief, who proposed the linear,
sequential, four-stage model of sexual response. Comorbid
sexual dysfunctions were generally not diagnosed in men
or women. However, population studies demonstrated that
it was not uncommon for women to complain of more than
one sexual dysfunction (50). Men, to a lesser degree, also
reported experiencing more than one dysfunction. Clini-
cians were urged to select one diagnosis as primary and
the others as secondary, and treatment interventions would
initially target the primary diagnosis.
Innovations in Sex Therapy
Examples of innovation in sex therapy include incorpo-
rating mindfulness techniques for women with complaints
of low sexual desire and arousal (51, 52), using the Inter-
net to provide psychological treatment (53, 54), and psy-
chological interventions for women with genital pain (55,
56). Although not treatment innovations per se, advance-
ments in developing validated patient report outcomes are
also worthy innovations. Many were initially underwritten
by the pharmaceutical industry to test the efficacy of spe-
cific interventions. However, some patient report out-
comes could just as easily assess the efficacy of psycho-
logical treatment interventions for sexual problems. To
assess the efficacy of erectile dysfunction interventions,
the International Index of Erectile Function is the gold
standard (57). The Index of Premature Ejaculation is also
an excellent measure that evaluates interventions (58). The
Female Sexual Function Index, in concert with the Female
Sexual Distress Scale—Revised measure, is helpful in di-
agnosing and measuring efficacy of interventions for fe-
male sexual dysfunction (59, 60).
I believe that combination medical and psychological ther-
apy ranks as the top innovation. Clearly this is not a new
innovation to psychiatry—for years it has been the standard
of care for depression and employed in treating childhood
anxiety, schizophrenia, and posttraumatic stress disorder (61,
62). However, combination therapy is relatively new to sex
therapy. It addresses the relevant biological, medical, and
psychosocial issues that predispose, precipitate, and maintain
sexual dysfunction and is the natural evolution for the bio-
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SEX THERAPY
psychosocial model. Combining medical and psychological
interventions harnesses the power of both treatments to en-
hance efficacy, increase treatment, and relational satisfaction,
and decrease patient discontinuation (63). Combination ther-
apy also provides patients with rapid symptom amelioration,
thereby “jump starting” the treatment process. Psychological
intervention alone may be time consuming and costly and fail
to yield rapid symptom amelioration. Conversely, medical
treatments for sexual dysfunction are narrowly or mechanis-
tically directed at sexual function and fail to address salient
psychosocial issues.
The majority of combination therapy studies have focused
on treating erectile dysfunction and combining sildenafil with
various psychoeducational interventions, such as a 90-minute
psychoeducational meeting, weekly group psychotherapy,
and infrequent individual counseling (64 – 69). Studies have
also combined intracavernosal injection or vacuum pump
therapy with psychological intervention (70 –72) with results
leading to improved efficacy of the medical intervention,
decreased discontinuation of treatment, and improved sexual
satisfaction over medical therapy alone.
Given the interrelated biological and psychological eti-
ologies of female sexual dysfunctions, it is likely that
combination medical and psychological therapy will ulti-
mately significantly benefit women. No female sexual dys-
function drug has been approved in the United States,
although Intrinsa (a testosterone patch) has been approved
in Europe for hypoactive sexual desire disorder. It would
be naive to expect a tablet, patch, or cream targeted at a
sexual symptom to rapidly reverse the dysthymia, anxiety,
and/or interpersonal problems that often accompany fe-
male sexual dysfunctions.
Similarly, although no medications are approved for
premature ejaculation in the United States, selective sero-
tonin reuptake inhibitors (SSRIs) have been effectively
used. Combining SSRIs and psychotherapy could offer
significant benefits (73). Teaching men, especially those
with acquired premature ejaculation, methods to monitor
their arousal and delay ejaculation may improve the effi-
cacy of the SSRI. Combination therapy for premature
ejaculation also targets interpersonal issues and the psy-
chosocial effect on the man and/or the partner.
Before uncritically accepting combination therapy,
more research is warranted. To be convincing, such stud-
ies should be controlled comparisons of a medical inter-
vention alone versus medical intervention plus some form
of psychotherapy. Validated patient report outcomes
should assess differences in efficacy, and data regarding
discontinuation should also be captured.
394 http://ap.psychiatryonline.org
Conclusion
Schover and Leiblum (74) wrote about the stagnation of
sex therapy in 1994 and criticized clinicians for failing to
develop innovative sex therapy techniques. Others believed
that with the introduction of the safe and effective PDE5i
drugs, sex therapy would wither away. On the contrary, sex
therapy seems very much alive and continuing to evolve, as
is evident in the development of new theoretical paradigms,
advances in the definitions of male and female sexual dys-
function, and the introduction of new treatment interventions
that require further assessment.
Psychiatry seems to have marginalized the treatment of
traditional sexual dysfunctions. For instance, psychiatrists
account for only 2% of all the PDE5i prescriptions written,
which led drug companies to strategically stop marketing
these agents to them. This is surprising given that many of
the medications psychiatrists routinely prescribe lead to
decreased sexual function.
There is a great deal that mental health clinicians can offer
individuals and couples with sexual dysfunction. Little expo-
sure to sex therapy during training sends a signal that sexual
life is not within the province of psychiatry. Residents and
other trainees require supervision to assist them in learning
treatment techniques for sexual dysfunction. It is genuinely
surprising that interns and residents tend to ignore/bypass the
sexual issues of patients they are treating for other disorders.
This lack of enthusiasm is also reflected in the paucity of
grand round presentations on sexuality in academic depart-
ments of psychiatry. We need to do more to interest our
colleagues and students to bring sexual therapy back into the
mainstream of psychiatry, perhaps by offering to present
mini-courses/seminars on sexuality topics as part the training
curriculum; presenting the results of our research to interested
colleagues; and developing interdisciplinary training experi-
ences for psychiatric residents.
Dr. Althof has provided full disclosure from several public and
private sources that are available upon request.
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