Historical Revolutions in Sex Therapy: A Critical Examination of Men's Sexual Dysfunctions and Their Treatment

Abstract

History, recent and ancient, presents innumerable methods intended to ensure or restore male sexual performance. Although these methods have regularly claimed to be “revolutionary,” they have often been remarkably similar, and of questionably efficacy. This article provides a critical account of key historical trends in the treatment of male sexual dysfunctions in order to contextualize and critique the current treatment field. The author uses historical analysis to contextualize contemporary sex therapy techniques, arguing that even clinically verified contemporary revolutions, such as the advent of Viagra and similar drugs, may not present broadly efficacious standalone cures. Using critical historical analysis to illustrate the limitations of single-method treatments, the article argues for the value of comprehensive, biopsychosocial therapy methods. A common tendency—to seek a ‘magic bullet’ solution to sexual dysfunctions—is apparent throughout history, the author argues. While Viagra differs biomedically from historical treatments, it may appeal to the same logic, raising the question of whether it constitutes a truly revolutionary development in treatment. The article concludes with a set of recommendations regarding the implementation of biopsychosocial practice in sex therapy.

Notes

How we come to define certain variations in sexual performance as dysfunctions, in terms of history and in the present context, is an important point for future research, and central to the debate about diagnostic standards, which currently focuses on the impending publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (Brotto, 2010; Segraves, Balon, & Clayton, 2007; Waldinger & Schweitzer, 2007).

This project examines the treatment of men's sexual dysfunctions specifically, by virtue of research design. It is apparent that, especially in light of increased emphasis on the development of pharmacotherapies for women's sexual dysfunctions, research on the history of women's sexual problems, and their treatment, is an equally important area. The interested reader would be well-advised to familiarize him- or herself with the pivotal work of Basson and colleagues (Basson & Brotto, 2009; Basson, Wierman, Van Lankveld, & Brotto, 2010) and Tiefer (2010a, 2010b) in examining women's sexual dysfunctions and their treatment.

The biopsychosocial paradigm explicitly focuses on dysfunctions as multifaceted; in this system, the cause and the symptom-structure of a dysfunction entail some combination of biological, psychological, and social factors.

Ancient Greek and Roman societies provide a particularly useful source of knowledge about ancient medicine in general, and sexual dysfunctions and their treatment specifically, as their treatment practices reflected the broader and preceding bodies of knowledge about treatment, and they were among the first civilizations to meticulously document their treatment methods.

Medieval societies’ metaphysical accounts of impotence, however, could implicitly be an attempt to address the psychological facets of men's sexual dysfunctions, through the power of suggestion, an issue worthy of further research.

For Nefzaoui, men's sexual dysfunctions were primarily caused by physiological factors. Their treatment, he posited, was almost exclusively physical. Thus, he wrote:

Men whose impotence is due either to the corruption of their sperm owing to their cold nature, or to maladies of the organs, or to discharges or fevers and similar ills, or to their excessive promptness in ejaculation, can be cured. They should eat stimulant pastry containing honey, ginger, pyrether, syrup of vinegar, hellebore, garlic, cinnamon, nutmeg, cardamoms, sparrows tongues, Chinese cinnamon, long pepper, and other spices. He [sic.] will be cured by using them (Nefzaoui, 1886, p. 199).

Although a detailed account of Freud's theories on psychosexuality is beyond the scope of this article, it bears mention that Freud's most important contributions include the following: the Oedipus complex, the Madonna-Whore tension, and the idea of triphasic (oral, anal, and genital stages) sexual development.

Freud examined issues relevant to men's sexual dysfunctions in the Three Essays on the Theory of Sexuality (1961c) touched on the issue in “On the Universal Tendency to Debasement in the Sphere of Love” (1961a), and wrote, in the preface to Steiner's The Psychical Disorders of Male Potency:

The sexual function is liable to a great number of disturbances, most of which exhibit the characteristics of simple inhibitions. They are classed together as psychical impotence…In men the chief stages at which the inhibition occurs are shown by: a turning away of the libido at the very beginning of the process (psychical-unpleasure); an absence of the physical preparation for it (lack of erection); an abridgement of the sexual act (ejaculatio praecox), an occurrence which might equally well be regarded as a symptom; an arrest of the act before it has reached its natural conclusion (absence of ejaculation); or a non-appearance of the psychical outcome (lack of the feeling of pleasure in orgasm). Other disturbances arise from the sexual function becoming dependent on special conditions of a perverse or fetishistic nature. (1961b, pp. 345–346)

This statement is, conceptually, remarkably similar to current diagnostic symptomatology, a likeness that is probably not a coincidence in light of Freud's pronounced influence over psychological and psychiatric science.

This type of critique dovetails well with Tiefer's work, which aims to analyze the medicalization of sexuality, in light of contemporary constructions of sexuality and gender. In addition, the interested reader is referred to Fishman and Mamo's sociocultural analyses of sexual medicalization (Fishman & Mamo, 2001; Mamo & Fishman, 2001, as cited in Tiefer, 2006).

More longer term follow-up studies on the real-world effectiveness of Viagra, especially in the treatment of psychogenic sexual dysfunction, are required. Experts have suggested that high rates of discontinuance generally correlate to patient dissatisfaction with these drug treatments, which are often rooted in a disjuncture between patients’ expectations and the actual effects of the PDE5i drugs (Althof, 2006; Perelman, 2005).

The recommendations provided herein are preliminary and intended to serve as a departure for further, more detailed work addressing how these, and other suitable strategies, can be realistically implemented.