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Handbook of Clinical Sexuality for Mental Health

Professionals

HANDBOOK OF CLINICAL

SEXUALITY FOR MENTAL

HEALTH PROFESSIONALS

Stephen B.Levine, MD

Editor

Candace B.Risen, LISW

Stanley E.Althof, PhD

Associate Editors

Brunner-Routledge

New York • Hove

Published in 2003 by

Brunner-Routledge

29 West 35th Street

New York, NY 10001

www.brunner-routledge.com

Published in Great Britain by

Brunner-Routledge

27 Church Road

Hove, East Sussex

BN3 2FA

www.brunner-routledge.co.uk

Copyright © 2003 by Taylor & Francis Books, Inc.

Copyright © for Chapter 10, Facilitating Orgasmic Responsiveness,

belongs to the author of that chapter, Carol Rinkleib Ellison, Ph.D.

Brunner-Routledge is an imprint of the Taylor & Francis Group.

This edition published in the Taylor & Francis e-Library, 2005.

“To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of

thousands of eBooks please go to www.eBookstore.tandf.co.uk.”

All rights reserved. No part of this book may be reprinted or reproduced or utilized

in any form or by any electronic, mechanical, or other means, now known or

hereafter invented, including photocopying and recording, or in any information

storage or retrieval system, without permission in writing from the publisher.

Library of Congress Cataloging-in-Publication Data

Handbook of clinical sexuality for mental health professionals/Stephen

B.Levine, editor; Candace B.Risen, Stanley E.Althof, associate editors.

p. cm.

Includes bibliographical references and index.

ISBN 1-58391-331-9 (hbk.)

ISBN 0-203-49032-0 Master e-book ISBN

ISBN 0-203-59350-2 (Adobe eReader Format)

1. Sexual disorders—Handbooks, manuals, etc. I. Levine, Stephen B., 1942–

II. Risen, Candace B. III. Althof, Stanley E., 1948–

RC556 .H353 2003

616.85′83–dc21

2002152844

Contents

About the Editors vii

Contributors viii

Preface

Stephen B.Levine, MD; Candace B.Risen, LISW; Stanley E.Althof, PhD

x

Part 1 Adult Intimacy: Hopes and Disappointments 1

Chapter 1 Listening to Sexual Stories

Candace B.Risen, LISW

3

Chapter 2 What Patients Mean by Love, Intimacy, and Sexual Desire

Stephen B.Levine, MD

19

Chapter 3 Life Processes That Restructure Relationships

David E.Scharff, MD

35

Chapter 4 Infidelity

Stephen B.Levine, MD

55

Chapter 5 Dealing With the Unhappy Marriage

Lynda Dykes Talmadge, PhD, and William C.Talmadge, PhD

73

Part 2 Women’s Sexual Issues 91

Chapter 6 When Do We Say a Woman’s Sexuality Is Dysfunctional?

Sharon G.Nathan, PhD, MPH

93

Chapter 7 Women’s Difficulties with Low Sexual Desire and Sexual

Avoidance

Rosemary Basson, MD

109

Chapter 8 Painful Genital Sexual Activity

Sophie Bergeron, PhD; Marta Meana, PhD; Yitzchak M.Binik, PhD;

and Samir Khalifé, MD

131

Chapter 9 The Sexual Aversions

Sheryl A.Kingsberg, MD, and Jeffrey W.Janata, PhD

153

Chapter 10 Facilitating Orgasmic Responsiveness

Carol Rinkleib Ellison, PhD

167

Chapter 11 The Sexual Impact of Menopause

Lorraine L.Dennerstein, AO, MBBS, PhD, DPM, FRANZCP

187

Part 3 Men’s Sexual Issues 199

Chapter 12 Young Men Who Avoid Sex

Derek C.Polonsky, MD

201

Chapter 13 Psychogenic Impotence in Relatively Young Men

Peter Fagan, PhD

217

Chapter 14 Erectile Dysfunction in Middle-Aged and Older Men

Raymond C.Rosen, PhD

237

Chapter 15 Rapid Ejaculation

Marcel D.Waldinger, MD, PhD

257

Part 4 Sexual Identity Struggles 275

Chapter 16 Male and Female Homosexuality in Heterosexual Life

Richard C.Friedman, MD, and Jennifer I.Downey, MD

277

Chapter 17 Understanding Transgendered Phenomena

Friedemann Pfäfflin, MD

291

Chapter 18 Men Who Are Not in Control of Their Sexual Behavior

Al Cooper, PhD, and I.David Marcus, PhD

311

Chapter 19 The Paraphilic World

J.Paul Fedoroff, MD

333

Part 5 Basic Yet Transcendent Matters 357

Chapter 20 Therapeutic Weaving: The Integration of Treatment Techniques

Stanley E.Althof, PhD

359

Chapter 21 Recognizing and Reversing Sexual Side Effects of Medications

R.Taylor Segraves, MD, PhD

379

Chapter 22 Sexual Potentials and Limitations Imposed by Illness

William L.Maurice, MD, FRCPC

393

Chapter 23 Understanding and Managing Professional-Client Boundaries

S.Michael Plant, PhD

407

Chapter 24 Sexual Trauma

Barry W.McCarthy, PhD

425

v

Chapter 25 The Effects of Drug Abuse on Sexual Functioning

Tiffany Cummins, MD, and Sheldon I.Miller, MD

443

Author Index 457

Subject Index 465

vi

About the Editors

Stanley E.Althof, PhD (Co-editor) is Professor of Psychology in the Department of

Urology at Case Western Reserve University School of Medicine in Cleveland, Ohio and

is Co-director at the Center for Marital and Sexual Health in Beachwood, Ohio

Stephen B.Levine, MD (Editor) is Clinical Professor of Psychiatry at Case Western

Reserve University School of Medicine in Cleveland and is Co-director at the Center for

Marital and Sexual Health in Beachwood, Ohio

Candace B.Risen, LISW (Co-editor) Assistant Clinical Professor of Social Work in

the Department of Psychiatry at Case Western Reserve University and is Co-director at

the Center for Marital and Sexual Health in Beachwood, Ohio

Contributors

Rosemary Basson, MD, MRCP is a Clinical Professor of Psychiatry and Obstetrics/

Gynecology at the University of British Columbia in Vancouver, Canada

Sophie Bergeron, PhD is Assistant Professor in the Department of Sexology,

Université du Québec à Montréal in Montréal, Québec and Clinical Psychologist at the

Sex and Couple Therapy Service at McGill University Health Centre (Royal Victoria

Hospital)

Yitzchak M.Binik, PhD is Professor of Psychology at McGill University and Sex and

Couple Therapy Service at McGill University Health Centre (Royal Victoria Hospital) in

Montréal, Québec, Canada

Al Cooper, PhD is the Clinical Director of the San Jose Marital and Sexuality Centre

in Santa Clara, Associate Professor (Research) at the Pacific Graduate School of

Professional Psychology, and Training Coordinator for Counseling and Psychological

Services at Vaden Student Health, Stanford University in Palo Alto, California

Tiffany Cummins, MD just completed her residency at the Department of

Psychiatry at Northwestern University in Chicago, Illinois

Lorraine L.Dennerstein, AO, MBBS, PhD, DPM, FRANCZ directs the Office for

Gender and Health and is Professor in the Department of Psychiatry at the University of

Melbourne at Royal Melbourne Hospital in Australia

Jennifer I.Downey, MD is Clinical Professor of Psychiatry at Columbia University

College of Physicians & Surgeons in New York

Carol Rinkleib Ellison, PhD is a psychologist in private practice in Oakland,

California and an Assistant Clinical Professor in the Department of Psychiatry at

University of California at San Francisco

Peter Pagan, PhD is Associate Professor of Medical Psychology in the Department of

Psychiatry and Behavioral Sciences at The Johns Hopkins University School of Medicine

and head of the Sexual Behaviors Consultation Unit in Lutherville, Maryland

J.Paul Federoff, MD is Co-Director of the Sexual Behaviors Clinic and Research

Unit Director of the Institute of Mental Health Research at the Royal Ottawa Hospital at

the University of Ottawa in Ontario Canada

Richard C.Friedman, MD is Clinical Professor of Psychiatry at Columbia University

College of Physicians and Surgeons in New York

Jeffrey W.Janata, PhD is Assistant Professor in the Department of Psychiatry and

Director of the Behavioral Medicine Program and University Pain Center at Case Western

Reserve University School of Medicine in Cleveland, Ohio

Samir Khalifé, MD is a gynecologist at the Departments of Obstetrics and

Gynecology At McGill University and Jewish General Hospital in Montréal, Québec, Canada

Sheryl A.Kingsberg, PhD is Assistant Professor the Department of Reproductive

Biology at Case Western Reserve University School of Medicine in Cleveland, Ohio

I.David Marcus, PhD is a psychologist at the San Jose Marital and Sexuality Center

in Santa Clara, California

William L.Maurice, MD is an Associate Professor in the Department of Psychiatry of

the University of British Columbia in Vancouver, Canada

Barry W.McCarthy, PhD is a psychologist in private practice and Professor in the

Department of Psychology at American University in Washington, DC

Marta Meana, PhD is Associate Professor in the Department of Psychology at the

University of Nevada at Las Vegas, Nevada

Sheldon I.Miller, MD is Professor of Psychiatry at Northwestern University School

of Medicine in Chicago, Illinois

Sharon G.Nathan, MPH, PhD, is a psychologist in private practice in New York

Friedemann Pfäfflin, MD is psychiatrist and head of the Department of Forensic

Medicine in the University of Ulm in Germany

S.Michael Plaut, PhD is Assistant Dean for Student Affairs and Associate Professor of

Psychiatry at the University of Maryland School of Medicine in Baltimore, Maryland

Derek C.Polonsky, MD is a psychiatrist in private practice in Brookline,

Massachusetts and is Clinical Instructor in Psychiatry at Harvard Medical School

Raymond C.Rosen, PhD is Professor in the Department of Psychiatry at the Robert

Wood Johnson Medical School in Piscataway, New Jersey

David E.Scharff, MD is Co-Director, International Institute of Object Relations

Therapy in Chevy Chase Maryland and Clinical Professor of Psychiatry, Georgetown

University and the Uniformed Services University of the Health Sciences in Washington,

DC

R.Taylor Segraves, MD, PhD is Chairman at the Department of Psychiatry at

MetroHealth Center and is Professor at Case Western Reserve University School of

Medicine in Cleveland, Ohio

Lynda Dykes Talmadge, PhD is in private psychology practice in Atlanta, Georgia

William C.Talmadge, PhD is in private psychology practice in Atlanta, Georgia

Marcel D.Waldinger, MD, PhD is a psychiatrist in the Department of Psychiatry

and Neurosexology at Leyenburg Hospital in The Hague and is in the Department of

Psychopharmacology at Utrecht University in The Hague, The Netherlands

ix

Preface

Each mental health professional’s life offers a personal opportunity to diminish the sense of

bafflement about how health, suffering, and recovery processes work. Over decades of

work in a mental health field, many of us develop the sense that we better understand

some aspects of psychology and psychopathology. Those who devote themselves to one

subject in a scholarly research fashion seem to have a slightly greater potential to remove

some of the mystery for themselves and others in a particular subject area. But when it

comes to the rest of our vast areas of responsibility, we are far from expert; we remain only

relatively informed.

The authors of this handbook devoted their careers to unraveling human sexuality’s

knots. Their inclusion in this book is a testimony to their previous successes in helping

others to understand sexual suffering and its treatment. Because one of the responsibilities

of scholars is to pass on their knowledge to the next generation, in the largest sense,

passing the torch is the overarching purpose of this book.

We humans are emotionally, cognitively, behaviorally, and sexually changeable

creatures. We react, adapt, and evolve. When our personal evolution occurs along

expected lines, others label us mature or normal. When it does not, our unique

developmental pathways are described as evidence of our immaturity or psychopathology.

Sometimes we are more colloquially described as “having problems.”

Sexual life, being an integral part of nonsexual life processes, is dynamic and

evolutionary. I think about it as having three broad categories of potential difficulties:

disorders, problems, and worries. The disorders are those difficulties that are officially

recognized by the DSM-IV-TR—for example, Hypoactive Sexual Desire Disorder, Gender

Identity Disorder, and Sexual Pain Disorder. Many common forms of suffering that afflict

groups of people, however, are not found in our official nosology and attract little

research. I call these problems. Here are just two examples: continuing uncertainty

about one’s orientation and recurrent paralyzing resentment over having to accommodate

a partner’s sexual needs. Problems are frequent sources of suffering in large definable

groups of the population—for example, bisexual youth and not-so-happily married

menopausal women. Then there are sexual worries. Sexual worries detract from the

pleasure of living. They abound among people of all ages. Here are five examples: Will I

be adequate during my first intercourse? Will my new partner like my not-so-perfect

body? Does my diminishing interest in sex mean that I no longer love my partner? How

long will I be able to maintain potency with my young wife? Will I be able to sustain love

for my partner? Worries are the concerns that are inherent in the experience of being

human.

Sexual disorders, sexual problems, and sexual worries insinuate themselves into the

therapy sessions even when therapists do not directly inquire about the patient’s sexuality.

This is simply because sexuality is integral to personal psychology and because the

prevalence of difficulties involving sexual identity and sexual function is so high.

Unlike the frequency of sexual problems and worries, the prevalence of sexual

disorders has been carefully studied. Their prevalence is so high, however, that most

professionals are shocked when confronted with the evidence. The 1994 National Health

and Social Life Survey, which obtained the most representative sample of 18- to 59-year-old

Americans ever interviewed, confirmed the findings of many less methodologically

sophisticated works. In this study, younger women and older men bore the highest

prevalence. Overall, however, 35% of the entire sample acknowledged being sexually

problematic in the previous 12 months.1

There are compelling reasons to think that the

prevalence is even higher among those who seek help for mental2

or physical conditions.3

Although people in some countries have unique sexual difficulties,4

numerous studies have

demonstrated that the population in the United States is not uniquely sexually

problematic.5,6

To make this point about prevalence and, therefore, the relevance of this book even

stronger, I’d like you to consider with me a retrospective study from Brazil. The authors

compared the frequencies of sexual dysfunction among untreated patients with social

phobia to those with panic disorder.7

The mean age of both groups was mid–30s. The

major discovery was that Sexual Aversion, a severe DSM-IV diagnosis previously thought

to be relatively rare, was extremely common in men (36%) and women (50%) with panic

disorder, but absent in those with social phobia (0%). The sexual lives of those with social

phobia were limited in other ways.

I find this information ironic in several ways. This finding probably would not have

shocked therapists who were trained a generation or two ago because it was then widely

assumed that an important relationship existed between problematic sexual development

and anxiety symptoms.8

Modern therapists, however, tend to be disinterested in sexuality

and so are likely not to respond to these patients’ sexual problems. Adding insult to

injury, the modern treatment of anxiety disorders routinely employs medications with a

high likelihood of dampening sexual drive, arousability, and orgasmic expression.

For most of the 20th century, sexuality was seen as a vital component of personality

development, mental health, and mental distress. During the last 25 years, the extent of

sexual problems has been even better defined, and their negative consequences have been

better appreciated. Mental health professionals’ interest in these matters has been

thwarted by new biological paradigms for understanding the causes and treatments of

mental conditions, the emphasis on short-term psychotherapy, the constriction of

insurance support for nonpharmacological interventions, the political conservatism of

government funding sources, and the policy to consider sexual problems inconsequential.

xi

As a result of these five forces, the average well-trained mental health professional has

had limited educational exposure to clinical sexuality. This professional is

neither comfortable dealing with sexual problems, skillful in asking the relevant

questions, nor able to efficiently provide a relevant focused treatment. It does not matter

much if the professional’s training has been in psychiatric residencies, psychology

internships, counseling internships, marriage and family therapy training programs, or social

work agency placements. Knowledgeable teachers are in short supply. The same paucity of

supervised experiences focusing on sexual disorders, problems, and worries applies to all

groups.

In my community, Cleveland, Ohio, there happens to be a relatively large number of

highly qualified sexuality specialists. Most moderate to large urban communities,

however, have no specialists who deal with the entire spectrum of male and female

dysfunctions, sexual compulsivities, paraphilias, gender-identity disorders, and marital￾relationship problems. Although many communities have therapists who deal with one

part of this spectrum, the entire range of problems exists in every community.

A remarkable bit of progress occurred in the treatment of erectile dysfunction in 1998.

Since then, primary care physicians, cardiologists, and urologists have been effectively

prescribing a phosphodiesterase-5 inhibitor for millions of men. But despite the evidence

of the drug’s safety and efficacy, at least half of the men do not refill their prescriptions.

There is good reason to believe that this drop-out rate is due to psychological/

interpersonal factors, rather than to the lack of the drug’s ability to generate erections. This

fact alone has created another reason for mental health professionals to become interested

in clinical sexuality. Most physicians who prescribe the sildenafil are not equipped to deal

with the psychological issues that are embedded in the apparent failures. The

nonresponders to initial treatment need access to us. But mental health professionals need

to be better educated in sexual subjects. So there are three reasons for developing this

handbook: (1) to pass the torch of knowledge to another generation; (2) to better equip

mental health professionals to respond to sexual disorders, problems, and worries as these

appear in their current practice settings; and (3) to help patients take advantage of

emerging advances in medication treatment by helping them to master their psychological

obstacles to sexual expression.

Stephen B.Levine, MD

YOU CAN DO THIS!

We use this exhortative heading for a reason. “You Can Do This!” is our way of saying

that the handbook provides coaching, encouragement, and optimism and aims to inspire

others to turn their interests to clinical sexuality. Mental health professionals can learn to

competently address their patients’ sexual worries, problems, and disorders.

xii

How We Created the Handbook

Once the editors decided to say yes to the publisher’s invitation to develop a handbook, we

set our sights on creating a unique book. We imagined it as a trustworthy, informative,

informal, supportive, and highly valued volume that would encourage and enable mental

health professionals to work effectively with patients who have sexual concerns. To attain

this lofty goal, we knew that the book would have to be a departure from the usual

excellent book on clinical sexuality.

We created the handbook through seven steps.

The first step we took was to define the intended audience. We quickly realized,

having valued teaching so highly during our careers, that this audience was mental health

professionals with little formal clinical training in sexuality. Although we thought some

readers might be trainees in various educational programs, we envisioned that most of the

readers would be fully trained, competent professionals. We thought that experienced

clinicians would have already had many clients who alluded to their sexual concerns and

might have already perceived how their sexual problems may have contributed to their

presenting depression, substance abuse, or anxiety states. We wanted to help general

mental health professionals think about sex in a way that diminished their personal

discomfort, increased their clinical confidence, piqued their interest in understanding

sexual life better, and increased their effectiveness. We wanted professionals to stop

avoiding their clients’ sexual problems. We also clarified that we were not trying to

create a book that would update sexual experts. We were writing for those who knew that

they needed to learn both basic background material and basic practical interventions.

The second step was to realize that because we were writing an educational text, our

authors would have to be excellent teachers. Excellence as a researcher or a clinician

would not be compelling reason to put a person on the author list.

The third step was to define our strategy for making the handbook unique. We decided

it would be through our instructions to the authors about how to compose their chapters.

We gave them ten instructions:

1. Use the first person voice—use “I” as the subject of some sentences.

2. Imagine when writing that you are talking privately to the reader in a supervisory

session.

3. Reveal something personal about your relationship to your subject—how you

became interested in the subject, how it changed your life, how your understanding

of the subject evolved over the years.

4. Imagine that you are guiding your readers through their first cases with the disorder

you are discussing. Do not share everything that you know about the subject! Try not

to exceed your imagined readers’ interest in the topic.

5. Keep your tone encouraging about not abandoning the therapeutic inquiry, even if

readers are uncertain what to do next.

xiii

6. Discuss your personal reactions to patient care as a model for the appearance of

countertransference. Illustrate how a therapist might use his or her private responses

to better understand the patient.

7. Either tell numerous short patient stories or provide one case in depth. Do not write

a conceptual paper without clinical illustrations.

8. Annotate at least half of your bibliography. Your reference list is not there primarily

to demonstrate your scholarship; it is there to guide the interested supervisee.

9. Be realistic about the reality of life processes and the limitations of professional

interventions. Although we want the readers to be encouraged to learn more, we do

not want to mislead them into thinking that experts in the field can completely solve

people’s sexual difficulties.

10. Be cognizant when writing that you are trying to prepare your reader to skillfully and

comfortably approach the patient, to gain confidence in his or her capacity to help,

and to rediscover the inherent fascination of sexual life.

The fourth step was the definition of relevant sexual topics. We did not want to deal with

uncommon problems—for example, there was not going to be a chapter devoted to

females who want to live as men, to female impersonators, or to serial sex murderers.

This book was to help with common problems, ordinary ones, the ones that are often lurking

behind other psychiatric complaints. This task was relatively easy.

The fifth task was slightly more difficult: to decide what basic information was

necessary as background preparation for dealing with the common sexual problems. After

this, we set about matching authors to the intended topics.

The sixth step was really fun. We had been told that it was often difficult to get people

to write for edited texts and that it might take 6 months or more to complete the author

list. The vast majority of our esteemed colleagues who were asked said yes immediately

and thought that the idea for the book was terrific. A few needed several weeks to agree.

Four pled exhaustion and wished us luck.

The final step—the seventh—involved the review of the manuscripts. It was during

this 5–month process that we, the editors, more fully realized what modern clinical

sexology is. While reading these 25 chapters, we realized that as a group we vary

considerably in our emphasis on evidence-based, clinically-based, or theory-based ideas. All

of us authors, however, speak of having been enriched as we struggled to better

understand and assist people with various sexual difficulties. All of us have seen

considerable progress in our professional lifetimes with our specialty issues. Some of the

chapters are stories of triumphs (treatment of rapid ejaculation, erectile dysfunction,

female orgasmic difficulties), others of disorders still awaiting the significant breakthrough

(female genital pain, sexual compulsivity, sexual side effects of SSRIs). A number of authors

address essential human processes that are part of life (boundaries and their violations,

menopausal changes, love), whereas others are coaching their readers about how to think

of their roles and attitudes (sexual history taking, diagnosis of women’s dysfunction,

transgenderism). Some chapters focus on grave difficulties (aversion, sexual avoidance,

xiv