Dr. Sandra Pertot
Contemporary Sexuality April 2006 Vol. 40, No. 4, 9-13
The early cross-cultural studies by anthropologists such as Malinowski and Mead on sexual practices in non-western cultures were significant landmarks in creating awareness that sexual attitudes, beliefs and expression, even cues for sexual arousal, are influenced by social context (Caplan, 1987; Connel & Dowsett, 1992). Although there are points of difference in the theories on the cultural construction of sexuality proposed by influential figures such as Foucault and the team of Gagnon and Simon (Connell & Dowsett, 1992), there is agreement that "sexuality" is not a static concept but varies across time and place (Villaneuva, 1997). The essential message is that ideas about normal and appropriate sexual behavior, whether these relate to gender roles, sexual identity, or the experience and expression of sexual desires, arise as a result of the interaction of social and cultural forces and do not reflect innate biological imperatives (Villaneuva, 1997).
Although the influence of social factors on sexual expression has been acknowledged for more than a century (Eriksen & Steffen, 1999), sex researchers and therapists have not always recognized the impact of current sexual norms on the way they conduct their own work or formulate their own conclusions. Eriksen and Steffen, in their history of sex surveys in the United States, found that the sex researchers across the twentieth century reflected the sexual values and assumptions of the times in the questions they asked and in the interpretation of their data, and at the same time helped change the cultural construct when they reported on their work, as, for example, the impact of Kinsey’s data on the perception of homosexuality.
Therapists have a long history of recognizing the role of social factors on the sexual problems of their clients but failing to see their own cultural biases. An early example is the work of Freud, who identified repressive societal attitudes as central to the development of adult neuroses, but at the same time he failed to recognize his own socially driven beliefs about female sexuality when he characterized women as mutilated males, and developed his theory of castration anxiety (Freud, 1962).
Similarly, the work of Masters and Johnson into human sexual function and dysfunction can now be seen to have been influenced by the social and political forces of the times (Masters & Johnson, 1970). For example, one of their most steadfast conclusions was that there are no differences of any significance between male and female sexuality, yet this view is now challenged by sex therapists that argue that it hindered the understanding and treatment of female sexual distress (Basson, 2000).
In addition, Masters and Johnson set the paradigm for future sex therapy by their focus on behavioral deficits as evidence of sexual inadequacy (Masters & Johnson, 1970). While ground breaking at the time, it led to the notion that sexual competence was the cornerstone of a good sexual relationship (Eriksen & Steffen, 1999), and this concept of teaching clients to do sex better (as opposed to accepting and/or appreciating what is already happening) has remained the core concept of modern sex therapy.
During the 20th century, sex manuals became a popular method for sex experts to provide information and advice to members of the public who were experiencing difficulties of one kind or another in their sex life. While these no doubt were of benefit to many couples who had been raised in sexual ignorance, the benefits were often tempered by the cultural biases in their views, such as advice to women not to take the initiative in sex (Brothers, 1962).
Today there is a constant flow of information to the public on sexual matters. Books, magazine articles, television talk shows, and the Internet give ready access to ideas about how to solve a sexual problem or just generally spice up a sexual relationship. Much of this information is provided by people with no particular expertise in sexual matters, but sex therapists with a sound educational and clinical background also utilize these forms of media to educate the community about sexual issues.
The examples from the past raise the question of whether, in providing information and advice to the public, today’s sex therapists are themselves influenced by their social context, and therefore present a model of normal and appropriate sexual functioning that contains biases which may operate to the disadvantage of some sections of the community.
Although there are many facets to the interface between sex therapy and the wider society, this paper will focus on self-help manuals as an accessible source that represents the flow of information from sex therapists as a diverse group to the general public.
The message of sex therapy today
On the face of it, the message of modern sex therapy would appear to be inclusive, affirming and liberating; it unequivocally promotes sex as a light hearted, joyous event that both men and women are entitled to participate in and to gain maximum pleasure from without inhibition. Nevertheless, it will be seen that this message rests on assumptions of normal sexual functioning that reflect the current sexual construct of good sex as an intensely passionate, erotic experience that occurs as a consequence of doing sex right, and this should be achievable by all normal-functioning individuals. However, this does not represent the lived sexual experiences of a significant section of society.
Estimates of sexual problems in the community vary. Despite the controversy over their interpretation of their results, the raw data that Laumann, Gagnon, Michael, and Michaels (1994) obtained in their large survey of sexual practices in the United States shows that, for at least several months in the preceding year, 28.5 percent of males reported coming too early, 17 percent felt anxious about ability to perform sexually, 15.7 percent lacked interest in sex, and 10.4 percent had trouble achieving or maintaining an erection; and for women, 33.4 percent reported lack of interest in sex, 24.1 percent were unable to climax, 21.2 percent did not find sex pleasurable, and 18 percent had trouble lubricating.
Bancroft (2003), in response to Laumann’s use of the term "sexual dysfunction", argued that a decrease in sexual functioning was not necessarily maladaptive or dysfunctional because for many individuals "inhibition of sexual interest or response occurs as an appropriate or at least understandable reaction to certain circumstances", and preferred to use the term "sexual distress". He then reported the results of his study of almost 1,000 women that found that 24.4 percent of respondents reported marked distress about their sexual relationship, their own sexuality, or both.
It seems that despite the shift in attitudes to sex and the easy access to sexual information in recent decades, sexual happiness continues to elude a significant section of society. The response to results such as these is to search for factors that might cause disruption to sexual function. Bancroft, for example, found an association between sexual distress and factors such as relationship difficulties and lack of emotional well-being.
Attempts to normalize low order sexual functioning as appropriate given life circumstances are a welcome shift in de-pathologizing a person’s sexual performance, yet, at the same time, they point to the assumptions underlying modern sex therapy. The current cultural construction of sexuality rests on the belief that, if all these
adverse circumstances were not present in a person’s life, the well-adjusted individual would have a regular and persistent desire for sex (emotionally and/or physically based) and experience arousal and orgasm during most sexual encounters: there is implicit in this position an assumed standard of normal sexual functioning, and if you are not meeting these benchmarks, there must be a problem that is causing it.
Bancroft, for example, when referring to low frequency of sexual activity or masturbation, or the absence of orgasm, arousal, genital tingling, enjoyment of genital touching, vaginal lubrication, and experience of pleasure, as "impaired sexual function", does not canvas the possibility that for some women these states may represent their normal level of desire and response. In this case, the women’s distress may not be due to emotional or relationship problems, but to feelings of guilt or inadequacy that they do not meet the current standards for "normal" and that they are missing out, or causing their partner to miss out, on sexual experiences they are entitled to.
Further, while negative emotions such as fatigue and stress may suppress sexual desire and response, if these states reflect normal living rather than unusual life events, there might be less distress if the model of normal sex allowed for a variation on the formula that good sex equates to behavioral performance, and equally promoted the model that emotional intimacy can lead to good sex even if there are behavioral deficiencies.
Unfortunately the model of achievable sex presented by sex therapists to the public assumes that any barriers to passionate and erotic sex can be overcome. Even considered and restrained works, with titles like Coping with Premature Ejaculation: How to Overcome PE, Please your Partner, & Have Great Sex (Metz & McCarthy, 2003) and Getting the Sex You Want: A Woman’s Guide to Becoming Proud, Passionate and Pleased in Bed (Leiblum & Sachs, 2002), send the same message: follow this program and you can have the sex life you want. Lack of emotional well-being, relationship problems or adverse life circumstances are acknowledged, and are obstacles to be resolved before achieving the ultimate goal of doing sex better and therefore gaining more pleasure and satisfaction.
What isn’t discussed also adds to the construct. While, for example, there are many strategies to help the lower libido partner to boost desire, there are few suggestions for partner with the higher libido to contain it; if a couple worry that he may be coming too quickly to bring his partner to orgasm, the pressure is on him to delay ejaculation rather than on her to hurry up or to have orgasm with some other activity. And rarely is the possibility that the suggested program may be useless (it doesn’t help despite best effort) or inappropriate (it requires an educational level or life circumstances that are not part of the individual’s reality) for some people, nor are suggestions routinely canvassed about how to get the most out of a sexual relationship if the target behavior does not change.
No society is homogeneous with respect to sexual beliefs, attitudes and behaviors. The changing nature of the cultural construct of sexuality means that at different times what is regarded as desirable and appropriate in one period can be judged to be dysfunctional or deviant in another. This means that some people "win" and some people "lose" with the process of cultural change. Whatever the prevailing norms, there are always those who go against them even sometimes at great risk to themselves (D’Emilio & Freedman, 1997). Those who don’t fit the new categories of normal may not be distressed by this if they have the self-confidence to act independently and live comfortably with the consequences, but those who lack this self-confidence can find their emotional well-being compromised either by their self-condemnation or by the judgment of others.
The benefits that have occurred as a result of the influence of sex therapy are not in question. The turnaround in attitudes to masturbation and the many good effects that this has produced is but one example. However, in today’s society, the "losers" in the sexual stakes are those who have little or no desire for sex, who routinely ejaculate quickly, who often find sexual touch irritating or boring, who have no interest in activities such as masturbation or oral sex, in short, as in previous times, people who don’t fit the current sexual construct. These are the people ignored or pathologized by sex therapy today.
The flaws in the ‘Great Sex’ model
When sex therapists hold out the promise, either explicitly or implicitly, that they can help any individual achieve the sex life they want, they are ignoring several realities. One is that there is a wide range of individual differences in sexuality, and, by implication, a wide range of sexual abilities. This should be axiomatic for sex therapy, yet, rather than acknowledge and build on individual differences, the effect of sex therapy is to try to blur them and promote sameness. The proceedings of any conference on human sexuality show that sex researchers are more interested in finding the causes and cures of low order sexual functioning than normalizing it and finding treatment options to help individuals and couples have a meaningful sex life not based on behavioural performance.
The classification of sexual disorders as outlined in the DSM-IV acknowledges individual differences in sexual function to the extent that an exclusion by contentment criterion is added to all categories. This criterion allows that if a person is not troubled by their poor sexual performance then they do not have a disorder. Unfortunately, the lure of great sex is hard to resist, and individuals at the lower end of the sexual function range are likely to judge themselves, or be judged by others, as inadequate or dysfunctional.
Further, sex therapists in their discourse in the public arena rarely acknowledge that no treatment program has a 100% success rate, nor are the implications of this spelled out, that is, that some people may not benefit from any treatment option. While sometimes alternative sexual activities are suggested, even these may not be satisfying, and the feelings of disappointment, failure and distress that may arise when none of the suggested strategies are helpful are typically ignored.
Biological imperatives versus cultural construct
If theories about the cultural construction of sexuality suggest that most of what is assumed to be normal sexual expression is culturally derived rather than a reflection of innate biological imperatives, does this mean that there are no biological imperatives that are universally enshrined in codes of normal sexual behavior?
A theoretical exercise of considering sexual constructs across societies to identify commonalities would seem to reduce to some exceptionally basic practices: men should feel desire, achieve an erection, and ejaculate, and women should participate in sex. All other beliefs about the nature of willingness to have sex, normal frequency of any sexual behavior, triggers for sexual arousal, what activities are pleasurable, and so on, develop from social context. This should allow for considerable diversity across groups and between individuals, which has the potential for less sexual distress if variations are given equal value.
Of course, this doesn’t mean that sex should be or could be value-free; societies have the right to protect their members from exploitation and abuse, for example. Nevertheless, sex therapists should acknowledge that at any given time, their beliefs about normal and achievable sexual expression are arbitrary and subject to change. Changes in the understanding of female sexuality (Basson, 2000) are a recent example of the instability of the construct.
Shifts will continue over time: for example, maybe rapid ejaculation will be acknowledged as a normal variation in male response that the couple need to adapt to. What will future generations be amazed or amused by when they learn about sexual practices in early 21st century western civilization?
The following observations are made from a clinician’s perspective:
1. The major source of confusion and hurt in a sexual relationship is no longer ignorance about the physiology of sexual function and sexual technique, but the expectation that sex should be regular, meaningful, satisfying and passionate in line with the portrayal of sex in both fiction and non-fiction.
2. Many individuals and couples who present as distressed about some aspect of their sex lives have no obvious risk factors for sexual dysfunction or suppression, but are living ordinary lives with typical life stresses.
3. The most common worry, even for some couples in loving and mutually supportive relationships characterized by positive communication skills, is that one partner lacks strong physical desire for sex and rarely initiates it.
4. In some relationships, the person who least fits the cultural stereotype for normal sexual function is disempowered, either by the belief system of the partner, the individual, or both.
5. Failure to produce the level of sexual desire and response can be interpreted by the partner as not being attractive or loved by the individual, or as the individual being inhibited, selfish, deliberately withholding, or generally dysfunctional, which may not reflect that individual’s reality but he or she is at a loss to account for their "problem."
6. Failure to improve after trying suggestions in self-help manuals or sex therapy can lead to the interpretations as in 5, and the charge that the individual is not putting in enough effort to change.
7. 7. The belief that the absence of desired sexual behaviors must be caused by a problem of some kind leads to a search for that problem. When a known risk factor is present, it is assumed that it must be relevant, and focus on that may not always be appropriate.
Challenges for Sex Therapy
The sexual construct supported by modern sex therapy seems to be contributing to the sexual distress of some individuals and couples. To address this situation, there are some challenges to be met:
To promote a more inclusive definition of normal sexual functioning and good sex.
The extent of individual differences across the range of sexual functioning for all variables must
be recognized, validated and openly discussed. The variation in individual sexual abilities that
arises from the complex interaction of biological, social and psychological factors needs to be addressed in a way that promotes understanding that people vary in their sexual potential, as they do in weight, height, body shape, sporting ability, academic ability, and so on. This means that sex therapy programs need to help people recognize that however one might wish it, however hard one might try, and however much one might be disappointed, the reality is that they may not get the sex life they want.
Sex therapy needs to abandon the notion of great and passionate sex as the achievable norm for all well-adjusted people, and, to borrow a concept from Winnicott (1964), encourage acceptance of a "good enough" sex life. This means helping a couple recognize that if the rest of the relationship is rewarding in other ways, their best bet for a satisfying life together is to appreciate what is right between them and come to terms with the fact that they might miss out on some sexual experiences that one or both might desperately want.
To develop a broader assessment and treatment model.
The attempts to develop a flexible yet objective set of criteria for sexual dysfunction and enshrine them in a diagnostic classification system (DSM-IV) has not been useful.
An alternative approach is to develop a treatment model that is based on an effects, consequences and possibilities assessment and treatment paradigm. For example, for a male concerned about his time to ejaculation, the effect of his time to ejaculation may be as diverse as his partner is truly upset and dissatisfied, or she is quite content but he worries that he is letting her down, or she may actually prefer rapid ejaculation; the consequence may be that his relationship is genuinely at risk or that his wife would prefer that he stop worrying in order to make sex less stressful for them both. By exploring the key questions, "why is it a problem?" and "what happens if this behavior doesn’t change?", the possible treatment strategies and possible outcomes can be explored. Is a program to help delay ejaculation the most useful and appropriate strategy, or would encouraging the male and/or his partner to alter the belief system be more efficient and effective in promoting sexual harmony for this couple, or a combination of both?
To develop treatment strategies that assist individuals and couples who may already be functioning to the best of their ability.
Shifting the focus of sex therapy from how to do sex better to appreciating a sex life within the limits of an individual’s sexual potential brings with it its own complications. These include the reality that it is impossible for any therapist to be value-free even if that were desirable, so one challenge is to develop treatment programs that at least acknowledge therapeutic biases when assessing a problem and offering solutions. For example, how does the therapist safely identify when an individual is already functioning at his/her optimal level?
The most likely treatment plan to achieve this would be to include a multi-faceted approach, which builds in shifting goals depending on the outcome of each strategy that is tried, rather than a linear model from symptom identification to the goal of removal of symptom.
To broaden the meaning of sexual behaviour.
Probably the most difficult challenge to overcome is to break the current expectation that there is a specific direct tie between emotion and sex, that committed love should bring with it great behavioral sex: if you loved me/found me attractive, you would want sex more often, initiate sex, be more passionate, and so on. There has been a shift to an intimacy-based model of female sexuality (Basson, 2000) but this needs to be extended. The emotional relationship needs to regain at least equal status with the sexual relationship, so that good sex becomes less about what is done and more about valuing what each partner brings to the sexual relationship even if that falls far short of the societal ideal.
To develop "good enough" models of sexuality and associated education and treatment programs.
And then the final challenge will be to develop treatment programs that enable a couple to embrace, with mutual respect and goodwill, this real world approach to the treatment of sexual problems. More research is needed to develop effective strategies using a "different but equal" framework to help couples understand and accommodate individual differences in sexual wants and needs.
Bancroft’s figure that one in four women in his sample reported marked distress about their own sexuality, their sexual relationship, or both, and Laumann’s data that 17 percent of males feel anxious about their ability to perform sexually and 21.2 percent of women do not find sex pleasurable, suggest that sex therapists still have some way to go to develop effective treatment options for the alleviation of sexual distress.
The treatment paradigm based on improving sexual competence has been around for several decades, and the above figures point not only to its limitations but also suggest that it has become part of the problem. Advocacy of "great sex" has become part of the process of the cultural construction of sexuality, to the disadvantage of those at the lower end of the sexual functioning range. The implication that sex therapy has the solution to perceived behavioral deficiencies adds to the stress of those individuals and couples who do not get the promised benefit from a treatment strategy.
Sex therapists need to acknowledge the influence of social context on their own beliefs and practices as sex experts, and given the inevitability of their power to influence community beliefs and practices, to develop more inclusive models of normal sexuality and "good enough" sexual relationships.
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