Introduction
One of the most dynamic areas of growth and development in the mental health profession is the field of human sexuality. In less than one-quarter of a century, there have been major advancements in the treatment of sexual dysfunctions (Zilbergeld and Kilmann, 1984). Sexual dysfunctions cover a wide variety of sexual problems. I have chosen to focus my study on male impotence.
I have chosen the specific area of premature ejaculation because 1) it is a prevalent problem, 2) it can have tremendous impact on both parties in a relationship, and can create serious problems with a male/female partnership, and 3) it presents a perfect opportunity to show the balance among theory, practice, and self-awareness. A female therapist working with a male client must have sensitivity and self-awareness to deal with this problem. I must be conscious that some clients may find it difficult to broach this subject with me, while other clients will experience a natural transference that must be kept strictly within the bounds of proper therapy. For my own part, I will discuss the impact of societal programming I find in myself while dealing with this subject, and the blocks and discomfort I feel about sexuality in general.
I intend to discuss the different causes and treatments from the wide range of mental health viewpoints and will illustrate the development of my clinical self-awareness using excerpts of case histories that will demonstrate this growth in theories, practical, and critical assimilation.
Definition
Premature ejaculation has been with us a long, long time. The ancient Hindus (Herman, 1969) and the Greeks (Ehrentheil, 1974) both discuss premature ejaculation in their writings. Lawrence K. Hong (1984) traces it back to protohominids whose likelihood of survival may have been increased by rapid ejaculation, and further states that it is considered dysfunctional today due to the lag between biological and social evolution.
In spite of its long history, the definition of premature ejaculation varies according to the definer. At one end of the spectrum, Thomas Szasz (1980) claims that premature ejaculation is not a disease, but a disorder of the self. Most others agree that a man who ejaculates immediately upon penetration suffers from premature ejaculation, although the definition becomes murkier thereafter. Some have put a time limit on it or require a certain number of strokes (Kaplan, 1974), while others require the partner’s satisfaction a certain percentage of the time (Masters and Johnson, 1980). To me, these seem to be quantitative attempts to measure a quintessentially non-quantitative experience.
Bernie Zilbergeld (1978) defines premature ejaculation in terms of control:
A man with good control is one who usually can decide approximately when he will ejaculate.
DSM III (1980) takes a similar tack in its diagnostic criteria:
Ejaculation occurs before the individual wishes it because of recurrent and persistent absence of reasonable voluntary control of ejaculation and orgasm during sexual activity. The judgment of ’reasonable control’ is made by the clinician’s taking into account factors that affect the duration of the excitement phase, such as age, the novelty of the sexual partner, and the frequency and duration of coitus.
Dr. Szasz notwithstanding, for the purposes of this paper I will assume that premature ejaculation both exists and is a sexual dysfunction, as does the mainstream of modern psychotherapy. Furthermore, it is my opinion that a client who has this problem even some of the time would feel a sense of inadequacy. And even if he is not diagnosed as clinically dysfunctional, the major issue is not the diagnosis but the client’s perception of the problem. Viewing it this way, I see the need for creative, multi-dimensional treatment approaches to this disorder.
Etiology
Premature ejaculation usually is cited as the most common male sexual dysfunction (Wiesmeier and Forsythe, 1982; Nettelbladt and Uddenberg, 1979) and has no specific psychopathology (Williams, 1984). It is found in all socio-economic groups, in both loving and unloving relationships.
Physical Factors
Premature ejaculation is untypical of other forms of male impotence: It is highly unlikely that a physical factor is involved with premature ejaculation, especially if the man has never had any ejaculatory control in the past. However, if the client has had good ejaculatory control and then loses it, a thorough urinary and neurological examination may be indicated. Although rare, there could be a local disease of the posterior urethra (Kaplan, 1974). Other possible physical factors include sexual abstinence (Spiess et al, 1984) asthma (Plattner and Brinkley, 1982), myocardial infarctions (Mehta and Krop, 1979) the effects of drugs (Mintz et al, 1974; Story, 1974), etc.
Psychological Factors
Each of the therapeutic disciplines finds different psychological factors involved in premature ejaculation.
Behaviorism
Masters and Johnson emphasize the role of learned response in premature ejaculation. A lot of men, especially in older generations, had their first sexual encounters with prostitutes who wanted them to climax as soon as possible. In present times initiation often takes place in the back seat of a car where fear of discovery leads to fast sexual encounters. Heavy petting, hurried masturbation in the bathroom, and the withdrawal technique all contribute to premature ejaculatory patterning.
Psychoanalysis
Freudians see premature ejaculation as a manifestation of a man’s deep unconscious conflict regarding women. Kaplan reduces the exceedingly complex Freudian point of view to three main steps. First is the male’s basic ambivalence towards women. Second, his emotional immaturity prevents him from overcoming this ambivalence. Third, his unconscious feelings give rise to premature ejaculation, which is his way of striking back at the woman while at the same time avoiding resolution of the original conflict (Kaplan, 1974).
Dr. Wardell Pomeroy advances the approach that anxiety is the cause of premature ejaculation. The anxiety may be related to fear of pleasure, success, or performance, but when he reaches a high level of excitement, the anxiety triggers an involuntary orgasm (Pomeroy, 1974).
Transactional Analysis/Systems Theory
Theorists in this camp find interpersonal difficulties responsible for the man’s prematurity, as would be the case if the male was getting secondary gains from his impotence. For example, in the case where a husband loses his ejaculatory control when his wife initiates intercourse, this might be seen as the husband’s unconscious tactic in the couple’s power struggle (Salzman, 1974). Sager (1974) suggests that a man doesn’t want to delay his ejaculation and views a woman’s desire for this as an attempt to dominate him. He rebels against the controlling “mother” by ejaculating rapidly. A vengeful attack on the female’s self-esteem might use manifest itself as premature ejaculation (Roth, 1978). Even hypochondria can express itself in premature ejaculation.
Herb Goldberg (1980) puts forth the belief that so long as a man has premature ejaculation only sometimes and only with some partners, he is not truly dysfunctional. The trouble with this standard, of course, is that not all men have a multitude of partners at a variety of times.
“Common Sense” Theory
The “common sense” theory as depicted by Kaplan (1974) maintains that some men are excessively sensitive to erotic stimulation. If these men can reduce stimulation or raise their threshold of stimulation, their sexual performance will improve. Cold showers, local anesthetics, self-inflicted pain, drugs, and mental redirection all have been used at one time or another, although the end result is frustration because performance is gained at the expense of enjoying the experience.
“Lack of Sensory Perception” Theory
Kaplan (1974) has another explanation for regularly occurring premature ejaculation (as opposed to a temporary reflection of feeling state). She infers that because some highly effective physical therapies require the dysfunctional man to focus on his sensations, he must not be doing so initially. To quote Kaplan:
… premature ejaculators do not clearly perceive the sensations premonitory to orgasm, which, in turn, deprives them of the regulatory power of the higher nervous influences. As a result, reflex discharge, i.e., ejaculation, occurs automatically when the physiological threshold of excitation is reached. Therefore, treatment based on this concept is analogous to the `biofeedback’ techniques which bring automated functions under voluntary control. It may be speculated that the hypothesized perceptual deficiency results from conflict and anxiety surrounding sexuality and the consequent inhibition of such perceptions. I have hypothesized that the premature ejaculator attempts to deal with the anxiety engendered by sexuality by erecting defenses against the perception of the intense erotic sensations that precede orgasm.
Thus, learning ejaculatory control is comparable to a child learning urinary control. In order for a child to control his urinary function, he must perceive those sensations that indicate a full bladder. Until then, he will continue to wet his pants.
Treatment
The treatment of premature ejaculation, despite the proliferation of theories as to its cause, is quite straightforward and successful in a high percentage of the cases when behavioral techniques are used (Masters and Johnson, 1970). The catch is that the underlying cause may still exist after premature ejaculation has been cured (Kinder and Blakeney, 1977).
Goldberg (1980) sees a danger in using behavior modification techniques indiscriminately because it would enable a man “to disown the immediate statement made by his body.” He sees such attempts as:
A reflection on how depersonalized and how compulsively performance oriented the traditional man has been that he has always expected himself to be potent and a good performer, regardless of how he felt toward the woman he was with.
Kaplan concurs. In commenting on the practice of curing sexual dysfunctions in seven or fewer therapeutic sessions, she points out that the rapid treatment of sexual problems fosters experiences of previously avoided discomfort, which is used in therapy to reveal the roots of the problem. It is not unusual for sexual symptoms to serve as defenses for the male. Occasionally, the sexual symptom is a major and irreplaceable defense against the emergence of highly pathological and intolerable material (Kaplan and Kohl, 1972).
Treatment of premature ejaculation, therefore, must be two-fold. First, the client’s psychological problems must be addressed. Second, the therapist must have techniques for curing premature ejaculation. The psychological aspects of treatment will be covered later in the case study. For now, I will examine the therapeutic techniques.
Masters and Johnson (1980) divide human sexual response into four stages: excitement, plateau, orgasm, and resolution. A man who ejaculates prematurely must learn to prolong that plateau stage without reaching “ejaculatory inevitability;” the point of no return. There are a number of methods for helping the client prolong the plateau stage.
Sensate Focus
A couple is asked to massage and fondle each other with the purpose of giving and receiving pleasure. Neither partner is to approach the other’s genital areas, nor should the woman’s breasts be approached. The idea is to place awareness on pleasurable, sensuous feelings without the pressure of the goal orientation of orgasm, the seeking of personal reassurance, the feeling of being compelled to “return the favor,” etc. (Masters and Johnson, 1970). This helps keep the male’s attention focused on the here-and-now.
Masturbation
Bernie Zilbergeld (1978) strongly urges his clients to use masturbation as a means of practicing control. His clinical experience reveals that at first, it is easier for a man to learn how to focus his attention on his erotic sensations when he alone sets the pace for stimulation. As a man learns the fundamentals of control, he can transfer the skill to situations with his lover.
Stop-Start Technique
Once the couple is ready to begin genital stimulation they can use the stop-start technique developed by urologist James H. Semans. In this procedure, the woman manually or orally stimulates her partner’s erect penis, while the man focuses his attention on his erotic sensations. When the man feels that he’s close to ejaculating, stimulation is stopped until the sensation subsides, at which time the stimulation resumes. The woman leads the man through increasing levels of stimulation until he feels he is ready for intercourse. The purpose of the exercise is for the man to get comfortable with his erotic sensations, which have previously been repressed or denied.
Squeeze Technique
Masters and Johnson utilize a similar technique. However, instead of having the couple just stop when the man feels the sensations preceding ejaculation, the woman squeezes his penis, which makes him lose his urge to ejaculate. The specifics of the squeeze technique are as follows (Masters and Johnson, 1980):
The female partner’s thumb is placed on the frenulum, located on the interior (ventral) surface of the circumcized penis, and the first and second fingers are placed on the superior (dorsal) surface of the penis in a position immediately adjacent to one another on either side of the coronal ridge. Pressure is applied by squeezing the thumb and first two fingers together for an elapsed time of 3 to 4 seconds.
The PC Technique
David B. Marcotte and Daniel S. Weiss (1976) believe that the pubococcygeus muscle plays a vital role in the stimulation of the male. They agree that the Seman’s technique reduces tension in the pelvic girdle, albeit indirectly, and this relaxation is what inhibits male orgasm. Their approach involves a relaxation exercise that can be learned in a short period of time and can be used without interrupting intercourse without calling for cooperation from the partner. This is obviously derivative of the techniques of the Taoists (Chang, 1977), and can be very effective.
Coital Positions
Sex therapists recommend the couple start with the female-superior position, with the female remaining motionless at first. After the man becomes accustomed to intravaginal containment in a relaxed, non-threatening manner, he initiates thrusting. If the man is able to maintain control, the female begins thrusting as well. If the man feels his sexual excitement is getting too high, they can stop or decrease the amount of stimulation.
The lateral position is suggested next. It provides a good compromise between the need for male ejaculatory control and the need for his partner to express her own sexual feelings. Masters and Johnson (1980) found that their couples voluntarily chose this position 75 percent of the time.
The male-superior position is the most difficult one for the man to maintain ejaculatory control and couples are advised to avoid it in the initial stages of learning. In my clinical experience, however, it can still be used (with one modification) in cases when the male has performance anxiety. That one modification is that the male must raise his torso up enough so that the female can manually bring herself to orgasm. Alternately, the male can provide the manual stimulation. In this way, the male can fill his need to satisfy his partner without placing the entire burden on his penis. It also allows the male to gain a different perspective on sex: 1) He can observe his partner visually, which can be difficult in other positions, and 2) he can share his partner’s climax while he is in a more relaxed state. This difference in perspective tends to broaden his appreciation for lovemaking, which in turn helps him to feel more at ease.
Therapeutic Results
Masters and Johnson, Kaplan, and Zilbergeld all report high levels of success in reversing the symptoms of premature ejaculation. The following paragraph is typical (Masters and Johnson, 1980):
“In the past 11 years, 186 men have been treated for premature ejaculation. There have been 4 failures to learn adequate control during the acute phase of therapy. Adequate control is defined as sufficient to provide orgasmic opportunity for the sexual partner during approximately 50 percent of the coital opportunities. The failure rate is 2.2 percent.”
Masters and Johnson discovered that 23 of the 186 couples they treated had a brief period of secondary impotence just before or shortly after the ending of the acute phase of therapy. The reason for this is simply that once the problem of premature ejaculation has been removed, couples tend to significantly increase their sexual frequency and sometimes the man can’t meet the demand. Therefore, it is suggested that the therapist warn the couple of this possibility so they won’t get overly alarmed and have new performance fears develop (Masters and Johnson, 1980).
Couples who have completed the intensive portion of therapy are encouraged by Masters and Johnson to maintain an active sex life. Inactivity could lead to a resurfacing of the symptoms. They are also encouraged to use the squeeze technique at least once a week during the first six months after treatment.
Conclusion
Contrasting the Psychological Factors
In terms of the causes of premature ejaculation, there appear to be three prevalent theories. First, there are the interactive theories and systems theories. Second, there are behavioralist theories. Finally, there is the psychodynamic approach. Even though there are other theories, these three are the most widely accepted.
It is interesting to note that while there is disagreement concerning the causative factors, there is considerable agreement concerning the multi-dimensional treatment model. This raises the question: “Should the theory and the treatment be more than one-dimensional?” The therapist may often have a one-dimensional viewpoint, yet the treatment modalities represent many different approaches. Therefore, it appears we have a long way to go in finding one cohesive theory for this problem’s causative factors.
In comparing the interactive theories with the psychodynamic theories, I feel they share their outlook on the role played by the client’s response. In the psychodynamic theory, the person who creates the anxiety in the client is a primary person from the client’s past, for example, his mother. In the interactive theory, the client’s anxiety results from an intimate interaction with a person who is currently active in the client’s life. Therefore, whether the interactions were from the past or present, the client’s anxiety relates to intimate relationships with another person.
In contrast, the behavioralists suggest that the client’s premature ejaculation is simply a learned response and has little to do with a past or present intimate emotional contact. It is my opinion that in an uncomplicated case of premature ejaculation a psycho|logically well-functioning man could become anxious and begin to have premature ejaculation patterning in which behavioral strategies could be very helpful.
I feel that Kaplan’s intrapsychic approach, which establishes the premise of a dominant mother, and Pomeroy’s approach to the client’s ambivalence towards women, reinforce my own clinical experiences concerning this disorder.
Contrasting the Treatment Approaches
While the theorists are in disagreement as to the causes of premature ejaculation, many of them agree that the treatment strategies mentioned above are effective. My impressions of the various techniques are as follows:
Sensate Focus
In my clinical experience, one of the most effective behavioral strategies has been on the sensate focus, which helps the man stay in the moment at the plateau stage, whether he is engaged in foreplay or intercourse.
Masturbation
One of the few differences in opinion exists regarding masturbation. Master and Johnson point out that a man might be able to postpone his ejaculatory urge during masturbation, but that this is so different from sex with a partner that this control will not be translated to better control during intercourse. I believe Zilbergeld’s masturbation exercises have some merit, but I agree with Masters and Johnson that ejaculatory control learned during masturbation is probably valuable for its attitudinal rather than behavioral significance.
The Start-Stop Method
The advantage of the start-stop method is that it can easily be incorporated into the couple’s sexual repertoire. For some couples, this pattern can lead to a relaxed and pleasurable interaction.
The Squeeze Method
I have found that some clients consider the squeeze method to be a disruptive inconvenience. If the penis is not squeezed firmly enough the man may ejaculate anyway. Other men I have worked with felt very uncomfortable withdrawing the penis from the vagina in order that their partner may squeeze it. I have had some women suggest to me that they are afraid to squeeze the penis because they fear hurting the man. All these factors can discourage the couple from continuing to work on the problem.
The PC Technique
Masters and Johnson contend that the squeeze technique is not effective if done by a man himself. In the event that the female cannot be counted on as a partner in the therapy, in my opinion, the PC technique would be better suited.
Coital Positions
My clinical experience supports Masters and Johnson’s findings that, after working initially with the female-superior position, most couples prefer the lateral position. The use of different coital positions extends even beyond therapy. Once the couple has used therapeutic positions during treatment, their normal lovemaking can include a wider variety of positions, depending on whether the male or female feels more aggressive.
The choice of technique, therefore, is based on the dynamics, comforts, and needs of the client. Now that we have discussed the theories and treatment modalities, I will describe excerpts from the case of a client, using a multi-dimensional treatment approach to the problem.
Professional and Personal Insights and Developments
This clinical area has the potential for creating strong transference and counter-transference feelings. I will discuss counter-transference in the next section on the Development of My Clinical Skills and Self-Awareness.
Sexual material is so very personal a client may easily feel emotionally exposed by sharing his sexual inadequacies. For example, the male ego is so tied up with feelings of being sexuality adequate, the client fears being seen as less powerful, interesting, and attractive by a female therapist. In the course of therapy, I as the clinician need to help the client understand and accept these difficult feelings and also help the client feel accepted and understood. Because this material may arouse sexual feelings towards me as the therapist, I must be aware of potentially seductive interactions with the client. It is, therefore, my responsibility to discuss the feelings, but to keep these feelings within boundaries appropriate to the clinical issues.
As I have previously commented, my family background did not help me develop comfortable sexual feelings. It became apparent that not only did I not experience the normal maturation of sexual feelings as a child, I was also discouraged by my parents from expressing or exploring any of these feelings.
In my training at the Julia Ann Singer Center and in Dr. Fleming’s parenting seminars, it was revealing to me that parents showed a great deal of concern about how to deal with their children’s sexuality. Second, in the work I did with young children between the ages of three and five years old, it became evident that children have a great deal of curiosity about their own sexuality and about the sexuality of others. It was also interesting for me to note from the reports of parents and my own observations in the therapeutic nursery school that some children would openly and comfortably masturbate. In reading the literature and training with young children, I learned how age-appropriate this behavior is. I think that if I had demonstrated any open sexual behavior of this sort my parents would have discouraged it.
I also remembered that when my father would try to show normal affectionate and sexual overtures to my mother, she would discourage him. Her behavior gave me the feeling my father was doing something wrong or bothering her. Therefore my mother was not a good female sexual role model. My parents did not educate me or convey to me that they saw me as a sexual being. Between this unsexual self-image and my basic shyness, I found it difficult to develop relationships with other adolescents. Being isolated from those of my peer group who were more comfortable socially and sexually, I learned very little about my own sexuality. It wasn’t until my early twenties, through my own personal therapy, that I developed an understanding of my patterns from my childhood, and through this process, I was able to develop the necessary comfort and understanding to become a fully-developed sexual adult.
Development of My Clinical Skills and Self-Awareness
I agree with Helen Singer Kaplan that we must carefully understand how the intrapsychic issues are to be resolved before we can effectively utilize behavioral techniques. Clients are coming in with more and more complex cases, and we as mental health professionals must be able to tailor our therapy to the needs of the client.
A good illustration of the importance of the intrapsychic approach was the case of John Rogers, a 27-year-old professional man who was an MSW. He felt he understood his premature ejaculation well enough to suggest that what he needed was a behavioral treatment approach. Part of the job of the therapeutic treatment team (of which I was a member) was to help the client see that his premature ejaculation was more involved than he initially admitted. As we took his case history, John described his relationship with his mother (a very controlling and domineering woman), his mistrust of women in general, and his inability to express anger directly. It became apparent that simply using behavioral techniques would not deal with his underlying psychological problem.
Through this work, I was impressed by the value of using an intrapsychic approach as a way of helping a client deal with these complex dynamics. After nine months of intrapsychic work, he was able to begin to use some of the behavioral techniques, such as sensate focus and the start-stop techniques in resolving the initial presenting problem.
In this section, I will discuss and describe the development of the learner’s clinical skills and self-awareness. I will describe some of the clinical problems and progress through the case excerpts. These excerpts have been taken from the session after the major portion of the intrapsychic therapy was completed. I will demonstrate through the clinical characteristics the development of the following clinical skills:
- Counter-transference
- Clinical Process
- Building a trusting relationship with the client
- Behavior intervention strategies
- Self-awareness
Case Excerpts
Case Excerpt 1
One of the things I noticed as I worked with the client was my tendency to feel overly protective and maternal. I tended to see John little-boy-like instead of as a grown man. I became aware through supervision and my own clinical self-awareness that I was talking to the client in a maternal tone of voice. Even though the client felt given to on a certain level I began to see I wasn’t modeling an appropriate female-to-male interaction. Also, I was reinforcing John’s dynamic of not feeling like an adequate man, which was a core issue for John in his therapeutic development. Therefore I changed my treatment approach to a supportive and much less maternal attitude and the client then started relating to me in a more appropriate male-to-female manner, rather than child-to-parent. This experience helped me see how my own counter-transference could block effective work with a client.
Case Excerpt 2
We taught John to manage his premature ejaculation problem with behavior methods by using a sensate focus technique. He had been feeling very happy for a number of sessions because this treatment approach had been very successful in dealing with premature ejaculation. Subsequently, he came in feeling very anxious because he began to experience failure in this area again. In the session during the exploration of what went wrong for John, it became clear that because of some of his prior performance anxieties he felt unsuccessful because of these new failures. I noticed as we were reviewing the use of the techniques he seemed discouraged and had a hard time listening to the behavioral strategies. Dr. Fleming also sensed this, and said, “John, it appears that this is hard for you to hear right now. I wonder if we are being too practical in discussing behavioral techniques.” John then agreed, saying, “I feel so lousy about this.” Picking up the cue from Dr. Fleming I said to John in a strong but empathetic way, “John, this must be really hard that this is happening to you again.” After we talked about John’s feelings and he received our support and understanding, he was able to listen to the behavioral strategies and try them again. This helped me pay attention to what the client is feeling, rather than using behavior techniques in a mechanical way.
This exchange also showed Dr. Fleming’s willingness to look at his own part of the interaction with the client. When I reinforced Dr. Fleming’s point by further empathizing with John’s feelings, I feel this demonstrated my clinical self-awareness. The development of clinical process and clinical self-awareness reinforces the trusting relationship with the client.
I was also able to demonstrate my ability to teach the client how to use behavioral strategies effectively. After listening to John describe how he used the sensate focus technique, I realized he had not implemented it the way we had discussed. I redescribed the technique to him, and he was able to see and accept how in the moment during intercourse, he was not focussing strongly enough on the sensuous feelings he was having at that time with his partner. Once he realized this was the problem, John felt encouraged that he could regain control.
Conclusion
I feel that I have demonstrated my clinical self-awareness through the use of the clinical characteristics in the case excerpts. In writing this paper, I have demonstrated the balance of theory, practical, and critical assimilation.
Addendum
While studying the major theories of human sexuality, I was struck by the similarities and differences between the intrapsychic and behavioral approaches. The intrapsychic viewpoint, represented by Freud, puts forth the idea that man’s sexual problems are based on two major premises: repressed sexual conflict and unconscious ambivalence towards one’s sexual partner. Masters and Johnson, on the other hand, represent the behavioral viewpoint with their conjoint therapeutic techniques.
Other examples of the behavioral viewpoint can be found in the rational-emotive approach of A. Ellis, who, like Masters and Johnson, attempts to modify the sexual dysfunction with direct prescribed procedures. Kaplan’s psycho-sexual theories of behavioral psychodynamics and systems theory take both viewpoints into account.
I found it interesting to examine the work of the pioneers in the field, such as H. Ellis’ theories of sexual dysfunction, and the studies by Kinsey. I also sensed a similarity between Kinsey’s work and that of Hite’s in that both had an impact on the way we viewed sexuality. Kinsey made it possible and even acceptable for people to discuss sexual dysfunctions and to seek help for them. The Hite Report gave us greater insights into the sexual feelings and attitudes of the average American woman and contributed greatly to our understanding of female sexual response.
I studied the theorists’ positions on the physiological and psychological principles of human sexuality including male and female anatomy; chromosome patterns; hormonal, structural, and reproductive functioning of the male and female; and the secondary sexual characteristics (breasts, buttocks, etc.).
In Masters and Johnson, we studied human sexuality response phases (this area was one of special focus), sexual dysfunction, impotence, the inability to maintain an erection, retarded ejaculation (the narcissistic and sado-masochistic aspects), a general study of orgasms, vaginismus (the painful spasms of the vagina that prevent coitus), dyspareunia (painful sexual intercourse for women — usually caused by lack of lubrication — which can be a symptom of fear or the absense of desire), with a special emphasis on intimacy and sexuality using such books as Lonnie Barbach’s “Shared Intimacies,” Masters and Johnson’s “The Pleasure Bond,” etc.
I interacted with my peers and tutor in seminars and supervision and defended conclusions I reached about the clinical assessment of theory, practice, and critical assimilation, from the studies and writings in human sexuality. We debated and discussed the theories and practice of human sexuality. For example, one of the areas we discussed was the emergence of behavioral techniques that have advanced our profession. At other times, I defended the idea that there is a place for the understanding and use of psychodynamic thinking. In contrast, some of my peers felt Kaplan had a bias towards the intrapsychic approach because of her clinical orientation.
I met with my tutor twice a week for supervision, and once a week during seminars. I was given oral examinations that challenged my understanding of principles and concepts of human sexuality, such as the normal and abnormal psychological and physiological development of males and females.
Through my work in this field, I confirmed the need for a multi-dimensional treatment approach to human sexual dysfunction.
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