Input:
1. Q: What is the main text in the field of Principles and Practice of Sex Therapy?
A: The main text in the field of Principles and Practice of Sex Therapy is the book Principles and Practice of Sex Therapy.
2. Q: When was the first edition of Principles and Practice of Sex Therapy published?
A: The first edition of Principles and Practice of Sex Therapy was published in 1980.
3. Q: What is the guiding principle behind the book Principles and Practice of Sex Therapy?
A: The guiding principle behind the book Principles and Practice of Sex Therapy is the integration of current research with clinical practice.
4. Q: Who are the authors of the chapters in Principles and Practice of Sex Therapy?
A: The authors of the chapters in Principles and Practice of Sex Therapy are internationally recognized experts who synthesize the often separate worlds of sex research and clinical practice.
5. Q: Who is the target audience for Principles and Practice of Sex Therapy?
A: The target audience for Principles and Practice of Sex Therapy is aspiring students as well as seasoned clinicians and clinical researchers wishing to keep current with innovations in the field.
6. Q: What is the main focus of the fifth edition of Principles and Practice of Sex Therapy?
A: The main focus of the fifth edition of Principles and Practice of Sex Therapy is to provide evidence-based treatment approaches to the common, challenging, and/or complex sexual issues facing individuals and couples today.
7. Q: What is the structure of the fifth edition of Principles and Practice of Sex Therapy?
A: The fifth edition of Principles and Practice of Sex Therapy is structured into three sections: Section I focuses on sexual dysfunction, Section II focuses on other sexual disorders, and Section III focuses on therapeutic challenges for sex therapy.

1. Q: What are the changes in the DSM-5 diagnoses that are reflected in the fifth edition of Principles and Practice of Sex Therapy?
A: The changes in the DSM-5 diagnoses that are reflected in the fifth edition of Principles and Practice of Sex Therapy include the omission of sexual aversion disorder, the combination of female sexual arousal disorder and hypoactive sexual desire disorder into one category called 'sexual interest arousal disorder,' and the collapsing of the categories of vaginismus and dyspareunia into one new diagnosis called 'genito-pelvic pain/penetration disorder.'
2. Q: What is the relationship between sexual dysfunction and the other sexual disorders in Principles and Practice of Sex Therapy?
A: The relationship between sexual dysfunction and the other sexual disorders in Principles and Practice of Sex Therapy is that they are all grouped together under the heading of sexual disorders in the DSM-5, although they may not all be related to sexual functioning.
3. Q: What is the role of sex therapy in the treatment of gender dysphoria and paraphilias?
A: The role of sex therapy in the treatment of gender dysphoria and paraphilias is not well defined, as these disorders are typically treated by other mental health professionals such as endocrinologists, surgeons, and psychiatrists. However, the problem-solving skills and achievement of comfort involved in talking about sexual and relationship issues that are required for sex therapy may be useful in dealing with these disorders.
4. Q: What are the therapeutic challenges for sex therapy addressed in the third section of Principles and Practice of Sex Therapy?
A: The therapeutic challenges for sex therapy addressed in the third section of Principles and Practice of Sex Therapy include dealing with specific groups such as LGBTQ clients and clients from non-Western cultures, as well as issues that affect all psychological problems and therapies such as culture, trauma, infidelity, illness, and aging.
5. Q: What is the aim of the book Principles and Practice of Sex Therapy?
A: The aim of the book Principles and Practice of Sex Therapy is to offer a means for all practitioners to deepen their knowledge and enhance their skills so that they can provide effective treatment for the sexual problems of their clients.

Response:
**Principles**

**and Practice**

**of Sex Therapy**

**FIFTH EDITION**

Yitzchak M. Binik

Kathryn S. K. Hall

Editors

THE GUILFORD PRESS

New York London

2

Epub Edition ISBN: 9781462513895; Kindle Edition ISBN: 9781462513901

© 2014 The Guilford Press

A Division of Guilford Publications, Inc.

72 Spring Street, New York, NY 10012

www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher.

Last digit is print number: 9 8 7 6 5 4 3 2 1

The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication.

However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the authors, nor the editors and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information.

Readers are encouraged to confirm the information contained in this book with other sources.

Library of Congress Cataloging-in-Publication Data is available from the publisher.

ISBN 978-1-4625-1367-3

3

**T** his book is dedicated to the memory of our friend and colleague Dr. Sandra R.

Leiblum. Sandy, as she was affectionately known, was an unabashed advocate for sex therapy, and her enthusiasm for the discipline is reflected in her vision and editorship of four editions of Principles and Practice of Sex Therapy. This book embodies the scientist-practitioner model that Sandy herself exemplified. She was a talented sex therapist and a skilled sex researcher. Her writings (both empirical and clinical) remain seminal contributions to the field. In both her professional and personal life Sandy was engaging, entertaining, energetic, and effervescent. Her quick wit, her high energy, her crackling intelligence, and her ebullient smile made her a captivating speaker and teacher.

Sandy thought her greatest talent was finding, encouraging, and promoting the talents of others. She employed this skill in her numerous collaborations, as well as in her teaching, mentoring, and supervising of sex therapists and researchers. Principles and Practice of Sex Therapy was Sandys way of creating a community in which knowledge could be shared and ideas could inspire. We are honored to continue the tradition that Sandy started, and we proudly dedicate this fifth edition of Principles and Practice of Sex Therapy to her memory. We miss her greatly.

4

About the Editors

Y **itzchak (Irv) M. Binik, PhD** , is Professor in the Department of Psychology at McGill University and Director of the Sex and Couple Therapy Service at McGill University Health Center in Montreal. Dr. Binik is a Fellow of the Canadian Psychological Association and a Diplomate of the American Board of Sexology. He was a member of the DSM-5 work group on sexual and gender disorders. Dr. Binik is a recipient of the Distinguished Contribution to Professional Psychology Award from the Canadian Psychological Association and the Masters and Johnson Award for Lifetime Achievement from the Society for Sex Therapy and Research (SSTAR). He has published

more

than

100

refereed

articles

in

the

areas

of

health

psychology/psychosomatics and sexuality. His main research interest is sexual dysfunction, with a particular interest in genito-pelvic pain/penetration disorder.

**Kathryn S. K. Hall, PhD** , is a clinical psychologist in private practice in Princeton, New Jersey. She began her career in sex therapy working with Drs. Sandra R. Leiblum and Raymond C. Rosen at the Sexual Counseling Service at the University of Medicine and Dentistry of New Jersey (now Rutgers Biomedical and Health Sciences). She has conducted research on a variety of sex-related topics and has presented at national and international conferences. Her current research interests include desire in arranged marriages and cultural variations in the experience and treatment of sexual problems.

Dr. Hall is coeditor of The Cultural Context of Sexual Pleasure and Problems: Psychotherapy with Diverse Clients; author of Reclaiming Your Sexual Self: How You Can Bring Desire Back into Your Life, winner of the SSTAR Consumer Book Award; and book review editor for the Journal of Sex and Marital Therapy.

5

Contributors

**Marc E. Agronin, MD** , Medical Director for Mental Health and Clinical Research, Miami Jewish Health Systems, and Affiliate Associate Professor of Psychiatry and Neurology, University of Miami Miller School of Medicine, Miami, Florida

**Stanley E. Althof, PhD** , Executive Director, Center for Marital and Sexual Health of South Florida, West Palm Beach, Florida, and Professor Emeritus, Case Western Reserve University School of Medicine, Cleveland, Ohio **Sophie Bergeron, PhD** , Associate Professor of Psychology, University of Montreal, Montreal, Quebec, Canada **Yitzchak (Irv) M. Binik, PhD** , Professor of Psychology, McGill University, and Director, Sex and Couple Therapy Service, McGill University Health Center, Montreal, Quebec, Canada

**Erin Breckon, BA** , masters student in Counselling Psychology, University of British Columbia, Vancouver, British Columbia, Canada

**Lori Brotto, PhD,** Head of the Division of Gynaecologic Specialties and Associate Professor of Gynaecology and Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada **Nicola Brown, PhD** , staff psychologist, Gender Identity Clinic for adults, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

**Rebecca P. Cameron, PhD** , Professor of Psychology, California State University, Sacramento, California **James M. Cantor, PhD** , Associate Professor of Psychiatry, University of Toronto Faculty of Medicine, and Senior Scientist, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

**Judith C. Daniluk, PhD** , Professor, Counselling Psychology, University of British Columbia, Vancouver, British Columbia, Canada

**Paul Enzlin, PhD** , Associate Professor of Sexology and Program Director, Institute for Family and Sexuality Studies, Department of Development and Regeneration, KU Leuven, and Head of the Sex Therapy Team, Context: Center for Couple, Family and Sex Therapy, UPC KU Leuven, Leuven, Belgium **Thomas M. Facelle, MD** , resident in urology, University of Medicine and Dentistry of New Jersey, University Hospital, Newark, New Jersey

**William A. Fisher, PhD** , Distinguished Professor, Department of Psychology and Department of Obstetrics and Gynaecology, University of Western Ontario, Waterloo, Ontario, Canada

**David Goldmeier MD, FRCP,** Clinical Lead, Jane Wadsworth Sexual Function Clinic, St Marys Hospital, London, United Kingdom

**Cynthia A. Graham, PhD,** Senior Lecturer, Department of Psychology, University of Southampton, Southampton, United Kingdom; Research Fellow, Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University; and visiting Research Fellow, Rural Center for AIDS/STD Prevention, Indiana University, Bloomington, Indiana

**Kathryn S. K. Hall, PhD,** clinical psychologist, Princeton, New Jersey

**Stephen Holzapfel, MD,** Director, Sexual Medicine Counselling Unit, Family Practice Health Centre, Womens College Hospital, and Associate Professor, Department of Family and Community Medicine and Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada

**Martin P. Kafka, MD** , Clinical Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts, 6

and Senior Clinical Associate, McLean Hospital, Belmont, Massachusetts **Peggy J. Kleinplatz, PhD,** Professor of Medicine and Clinical Professor of Psychology, University of Ottawa, Ottawa, Ontario, Canada

**Emily Koert, MA,** PhD candidate in Counselling Psychology, University of British Columbia, Vancouver, British Columbia, Canada

**Stephen B. Levine, MD,** Clinical Professor of Psychiatry and Co-director, Center for Marital and Sexual Health, Case Western Reserve University School of Medicine, Cleveland, Ohio

**Mijal Luria, MD,** Director, Center for Sexual Health, Hadassah Mt. Scopus Medical Center, Jerusalem, Israel **Marta Meana, PhD** , Professor of Psychology and Dean of the Honors College, University of Nevada, Las Vegas, Las Vegas, Nevada

**Martin M. Miner, MD,** Director, Mens Health Center of The Miriam Hospital, and Clinical Associate Professor of Family Medicine and Urology and Co-Director of the Mens Health Center, Warren Alpert Medical School, Brown University, Providence, Rhode Island

**Linda R. Mona, PhD,** Director of Psychology Postdoctoral Training, VA Long Beach Healthcare System, Long Beach, California

**Margaret Nichols, PhD,** Founder and Executive Director, Institute for Personal Growth, New Jersey Psychotherapy Center, Highland Park, New Jersey

**Lucia F. OSullivan, PhD,** Professor, Department of Psychology, University of New Brunswick, Fredericton, New Brunswick, Canada

**Vickie Pasterski, PhD,** Research Psychologist, Department of Paediatrics, Addenbrookes Hospital, University of Cambridge, Cambridge, United Kingdom

**Michael A. Perelman, PhD,** Clinical Professor of Psychiatry, Reproductive Medicine, and Urology, Weill Medical College, Cornell University, and Co-Director, Human Sexuality Program, Payne Whitney Clinic of the New York Presbyterian Hospital, New York, New York

**Caroline F. Pukall, PhD,** Associate Professor, Department of Psychology, and Director, Sex Therapy Service, Psychology Clinic, Queens University, Kingston, Ontario, Canada

**Elke D. Reissing, PhD** , Professor, School of Psychology; Director, Human Sexuality Research Laboratory; and Supervisor of sex therapy training, Centre for Psychological Services and Research, University of Ottawa, Ottawa, Ontario, Canada

**Alessandra H. Rellini, PhD,** Associate Professor, Department of Psychology, University of Vermont, Burlington, Vermont

**Natalie O. Rosen, PhD,** Assistant Professor, Department of Psychology and Neuroscience, Dalhousie University, and cross-appointed, Department of Obstetrics and Gynaecology, IWK Health Centre, Halifax, Nova Scotia, Canada

**Raymond C. Rosen, PhD** , Chief Scientist, New England Research Institutes, Watertown, Massachusetts; and former Co-Director, Sex and Marital Therapy Center, and former Chief Psychologist and Director of the Human Sexuality Program, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, Piscataway, New Jersey

**Hossein Sadeghi-Nejad, MD,** Professor of Surgery/Urology, New Jersey Medical School, Rutgers, The State University of New Jersey, Piscataway, New Jersey; Chief of Urology, VA New Jersey Health Care System, East Orange, New Jersey; and Director, Center for Male Reproductive Medicine (private practice) at the Hackensack University Medical Center, Hackensack, New Jersey

**Sabina Sarin, MS, MPhil,** PhD candidate in Clinical Psychology, McGill University, Montreal, Quebec, Canada **Eric T. Steiner, PhD,** Department of Psychology, National University, San Diego, California **Maggie L. Syme, PhD, MPH,** Research Assistant Professor, San Diego State University, San Diego, California **Moniek M. ter Kuile, PhD,** Associate Professor, Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands

**Michael W. Wiederman, PhD,** Professor of Psychology, Columbia College, Columbia, South Carolina 7

**John P. Wincze, PhD,** Associate Director, Mens Health Center, The Miriam Hospital, and Clinical Professor, Department of Psychiatry and Human Behavior and the Department of Psychology, Brown University, Providence, Rhode Island

**Kenneth J. Zucker, PhD,** Psychologist-in-Chief and Head of the Gender Identity Service for children and adolescents in the Child, Youth, and Family Program, Centre for Addiction and Mental Health; and Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada

8

Preface

**S** exual problems are ubiquitous. We know that thanks to large-scale national and multinational epidemiological surveys. Furthermore, community and clinical samples verify that sexual dysfunction and dissatisfaction are widespread. And yet, clinical training programs in psychology, psychiatry, family therapy, and related fields give at best passing attention to this area. Moreover, to adequately address sexual problems, clinicians now need to be cognizant of advances in sexual medicine as well. It is not surprising that many of us in the field feel a need for more education and training on how to conceptualize and treat sexual problems. This book offers just that—a means for all of us, seasoned, novice, and student practitioners alike, to deepen our knowledge and enhance our skills so that we can provide effective treatment for the sexual problems of our clients.

Since the first edition was published in 1980, Principles and Practice of Sex Therapy has been the major text in its field. It has succeeded because of its adherence to a basic guiding principle: the integration of current research with clinical practice. This fifth edition continues and expands upon this principle and tradition. All chapters are authored by internationally recognized experts who synthesize the often separate worlds of sex research and clinical practice. As a result of these syntheses, each chapter presents empirically validated clinical interventions for the sexual disorder under consideration.

This volume will be an invaluable aid for aspiring students as well as seasoned clinicians and clinical researchers wishing to keep current with innovations in the field.

What you will find in this fifth edition is a multidisciplinary perspective designed to provide evidence-based treatment approaches to the common, challenging, and/or complex sexual issues facing individuals and couples today. Because reconciling the differing views in practice can be challenging, most chapters include an assessment and treatment algorithm, a GPS as it were for the current clinical terrain.

The timing of this new edition is not arbitrary. In the 7 years since the publication of the previous edition, sex therapy has undergone unprecedented growth and change.

This has been prompted by an explosion of sex research fueled, in part, by the pharmaceutical industrys quest to find the next Viagra, and by new technologies that can more precisely measure physiological sexual responses. Unpredictably, sex therapy and sexual medicine are rather companionable bedfellows. Often sexual medicine interventions aid function (provide blood flow for an erection, hormones for desire), while sex therapy provides the opportunity and context to be sexual. Removing the 9

psychological barriers to sexual pleasure, dealing with relational issues, and providing cognitive-behavioral interventions for sexual dysfunction continue to be the mainstays of sex therapy. In addition, sex therapy has always addressed the important connection between mind and body, and continues to incorporate new techniques, most recently mindfulness meditation.

The timing of the publication of this fifth edition of Principles and Practice of Sex Therapy also coincides with the newly released DSM-5. Whereas DSM-IV had one chapter on sexual disorders, there are now three separate DSM-5 chapters, one on sexual dysfunction, one on gender dysphoria, and one on paraphilia. This suggests a major theoretical shift in recognizing that there exist three distinct categories of pathology. For sexual dysfunction diagnoses, there are notable changes that reflect long-standing concerns about the adequacy of Masters and Johnsons triphasic model and its underlying assumption of parallelism in sexual response between men and women.

These changes and the implications for clinical practice and research are critically reviewed in this volume.

The structure of this edition reflects the changes that have transpired in the practice of sex therapy. The first section, a third of the book, is devoted to updating and incorporating new research and treatment for sexual dysfunctions, while the second section deals with the expanded scope of sex therapy in providing treatment for other sexual concerns, including hypersexuality (often referred to as sexual addiction), nonviolent paraphilic sexual interests, pedophilia, persistent genital arousal in women, and gender dysphoria. The final section of the book deals with new challenges for sex therapy in terms of its expanding clientele. Adolescents, aging adults, ethnic and sexual minorities, disabled individuals, and those dealing with sexual trauma, chronic illness, and sexually transmitted infection are presenting for sex therapy with increasing frequency. We are fortunate to have expert authors who have written sensitively on the ways that sex therapy can be adapted to be more inclusive.

This volume reflects the basic idea that sex therapy should no longer be the sole domain of a small, highly specialized group of clinicians. While Principles and Practice of Sex Therapy is the definitive text for expert clinicians and researchers, we hope this book will encourage others to enter the field.

We are extraordinarily grateful that many of the leaders in sex research and therapy contributed chapters to this book. We were aided in our editing duties by several very able assistants, including Caroline Maykut, Jackie Huberman, Marie Faaborg-Andersen, and Tanya DAmours. Dr. Sandra Leiblum first brought the idea of Principles and Practice of Sex Therapy to The Guilford Press in 1978. She edited and coedited this book through its first four editions, setting the standard for excellence. Those of you who knew Sandy and her work will recognize her imprint and influence in almost every chapter. We thank Guilford for continuing to believe in this volume, and we especially thank Senior Editor Jim Nageotte for his wisdom, his advice, and his guidance in moving this book forward to publication.

10

Contents

Title Page

Copyright Page

Dedication Page

About the Editors

Contributors

Preface

Introduction. The Future of Sex Therapy

Yitzchak (Irv) M. Binik and Kathryn S. K. Hall

**PART I. SEX THERAPY FOR SEXUAL DYSFUNCTION**

**Desire and Arousal**

**1**Sexual Interest/Arousal Disorder in Women

Lori Brotto and Mijal Luria

**2**Hidden Disorder/Hidden Desire: Presentations of Low Sexual Desire in Men

Marta Meana and Eric T. Steiner

**3**Erectile Dysfunction: Integration of Medical and Psychological Approaches

Raymond C. Rosen, Martin M. Miner, and John P. Wincze

**Orgasm**

**4**Orgasm Disorders in Women

Cynthia A. Graham

11

**5**Treatment of Premature Ejaculation: Psychotherapy, Pharmacotherapy, and

Combined Therapy

Stanley E. Althof

**6**Delayed Ejaculation

Michael A. Perelman

**Pain**

**7**Genital Pain in Women and Men: It Can Hurt More Than Your Sex Life

Sophie Bergeron, Natalie O. Rosen, and Caroline F. Pukall

**8**Lifelong Vaginismus

Moniek M. ter Kuile and Elke D. Reissing

**PART II. SEX THERAPY FOR OTHER SEXUAL DISORDERS**

**9**The Paraphilias: An Experiential Approach to "Dangerous" Desires

Peggy J. Kleinplatz

**10**"Gold-Star Pedophiles" in General Sex Therapy Practice

James M. Cantor

**11**Gender Dysphoria

Kenneth J. Zucker and Nicola Brown

**12**Persistent Genital Arousal Disorder

David Goldmeier, Hossein Sadeghi-Nejad, and Thomas M. Facelle

**13**Nonparaphilic Hypersexuality Disorders

Martin P. Kafka

**PART III. THERAPEUTIC CHALLENGES FOR SEX THERAPY**

**Specific Groups**

**14**Therapy with LGBTQ Clients: Working with Sex and Gender Variance from a

Queer Theory Model

Margaret Nichols

**15** Culturally Sensitive Sex Therapy: The Need for Shared Meanings in the Treatment

of Sexual Problems

Kathryn S. K. Hall and Cynthia A. Graham

12

**16**Body Image and Sexuality

Michael W. Wiederman and Sabina Sarin

**17**The Treatment of Sexual Dysfunctions in Survivors of Sexual Abuse

Alessandra H. Rellini

**18**Infidelity

Stephen B. Levine

**Medical Problems**

**19**Sexuality and Infertility

Judith C. Daniluk, Emily Koert, and Erin Breckon

**20**Sexuality in the Context of Chronic Illness

Paul Enzlin

**21**Sexuality and Disability: A Disability-Affirmative Approach to Sex Therapy

Linda R. Mona, Maggie L. Syme, and Rebecca P. Cameron

**22**Suppose They Gave an Epidemic and Sex Therapy Didnt Attend?: Sexually

Transmitted Infection Concerns in the Sex Therapy Context

William A. Fisher and Stephen Holzapfel

**Lifespan Changes**

**23**Sexual Problems in Adolescents and Young Adults

Lucia F. OSullivan and Vickie Pasterski

**24**Sexuality and Aging

Marc E. Agronin

Conclusion. Sex Therapy in Transition: Are We There Yet?

Marta Meana, Kathryn S. K. Hall, and Yitzchak (Irv) M. Binik

Index

About Guilford Press

Discover Related Guilford Books

13

**INTRODUCTION**

The Future of Sex Therapy

Yitzchak (Irv) M. Binik and Kathryn S. K. Hall

**O** nce characterized by a clearly defined set of procedures designed to treat a narrow list of sexual dysfunctions, the scope of sex therapy has significantly broadened.

This new edition of Principles and Practice of Sex Therapy reflects the tremendous growth that has taken place in the field and challenges previous perceptions of what sex therapy is and what a sex therapist does. The sexual dysfunction chapters take up only a

third of the book and are located in the first section, "Sex Therapy for Sexual

Dysfunction." Most of the current edition is organized into two new sections titled "Sex

Therapy for Other Sexual Disorders" and "Therapeutic Challenges for Sex Therapy."

These sections replace the section in the fourth edition called "Special Issues," which dealt with a variety of topics ranging from the paraphilias to childhood sexual abuse. In our view, these topics are no longer "special" but part of a sex therapists everyday work.

Despite these significant changes from the previous edition, the organizing principle has not changed. Since its first edition (Leiblum & Rosen, 1980), Principles and Practice of Sex Therapy has been unique for its sophisticated synthesis of up-to-date research with clinical practice. Its goal has been and remains to critically review the available research with a view to informing and directing the clinician. In fact, the choice of editors for this edition reflects this goal. Although both editors would consider themselves clinician scientists, Kathryn S. K. Hall spends most of her time as a private practice clinician, whereas Yitzchak M. Binik is chiefly an academic researcher. We hope that both clinicians and researchers will benefit from our collaboration.

**SEX THERAPY FOR SEXUAL DYSFUNCTION**

The eight chapters in the first section reflect the "bread and butter" work of traditional sex therapy, that is, the assessment and treatment of sexual dysfunction. For better or worse, sexual dysfunction has been defined, at least in North America, as those dysfunctions listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). Despite some name changes, most of these sexual dysfunctions date from the publication of DSM-III-R

14

(American Psychiatric Association, 1987), and most sex therapists still treat premature (early) and delayed ejaculation, erectile dysfunction, low desire, vaginismus, and orgasmic dysfunction.

Despite this continuity, there are some notable changes in DSM-5 (American Psychiatric Association, 2013) and, as a result, in this edition. Sexual aversion disorder does not appear in DSM-5 nor as a chapter in this edition. The rationale for this omission is fairly simple. Based on available statistics, sexual aversion disorder was rarely diagnosed, and there was a minimal research literature on it (Brotto, 2010).

During the DSM-5 development process, when the American Psychiatric Association asked for public and professional feedback about this potential deletion, no one who responded seemed to mind. In fact, it was hard to reconstruct why sexual aversion disorder had ever become a DSM sexual dysfunction. One theory is that it was due to the important influence of Helen Singer Kaplan (1987), who wrote a book on this topic, Sexual Aversion, Sexual Phobias, and Panic Disorder. Although few would deny that there are patients who are phobic or disgusted about various aspects of sexuality, it seemed unlikely to the DSM-5 committee that these reactions exist as a distinct and valid diagnostic category. In our view, the appearance and disappearance of this diagnosis reflects both poorly and well on the field. On the one hand, exciting new ideas are welcomed and integrated; on the other, such ideas should be carefully vetted before entering the canon. How to balance these opposing tendencies remains a challenge for the field.

Another notable change is the omission of female sexual arousal disorder (FSAD) as a separate diagnostic category. This problem has not disappeared, but its diagnosis has been combined with hypoactive sexual desire disorder (HSDD) in women into a new category called "sexual interest arousal disorder." The rationale for this change is discussed in detail by Brotto and Luria in Chapter 1.  Although few mourned the passing of sexual aversion disorder, there has been a storm of controversy about the amalgamation of FSAD and HSDD (Clayton, Derogatis, Rosen, & Pyke, 2012). For the moment, there does not seem to be a lot of concern about the loss of female sexual arousal disorder as a separate category; what is motivating the controversy is the disappearance of HSDD as a distinct category in women. Historians and sociologists will ultimately sort out the meaning of this controversy, but it is tempting to speculate that the interest in preserving low desire in women as a distinct and separate category is motivated, in part, by the pharmaceutical lobby and the impending appearance of drugs for low desire. The good news is that controversy often breeds interest and new research leading to treatment innovation. This will be welcome, as we are currently stalled pharmacologically and psychologically concerning the treatment of difficulties of desire and arousal in women.

This kind of controversy is not reflected in the chapters concerning arousal or desire problems in men. However, Meana and Steiner, in Chapter 2, propose a very controversial hypothesis for many men diagnosed with HSDD. They suggest the tantalizing idea that many men diagnosed with low desire actually have desire, but not for their partners. Whether this reflects a true gender difference or our lack of knowledge about low desire in men remains to be seen. Not surprisingly, no one is 15

currently suggesting amalgamating the diagnosis of low sexual desire in men with erectile dysfunction. In fact, in Chapter 3, Rosen and colleagues outline the enormous progress made in understanding the biological mechanisms of erectile disorder. Despite this progress, the authors make it clear that traditional and new sex therapy interventions are necessary for up-to-date treatment.

The final major change in DSM-5 (American Psychiatric Association, 2013) classification is the collapsing of the categories of vaginismus and dyspareunia into one new diagnosis called "genito-pelvic pain/penetration disorder." This descriptive mouthful of a name reflects the significant overlap in symptomatology between the disorders and the many conceptual difficulties in defining them (Binik, 2010a, 2010b).

Despite our conceptual agreement with the change in DSM, we have opted to keep two separate chapters concerning these dysfunctions. The main reason is that recent and exciting clinical innovations concerning the treatment of vaginismus (defined as the womans inability to have desired intercourse) suggest a strong divergence from the treatment of dyspareunia (defined as pain experienced during intercourse), even if the diagnoses merge. These treatment innovations are spelled out by ter Kuile and Reissing (Chapter 8) and are based on the "fear/avoidance" model of pain rather than on the traditional vaginal spasm model. Bergeron et al. (Chapter 7) summarize the continuing progress in research and clinical intervention for genital pain (dyspareunia) while emphasizing couple interactional aspects and their effect on this pain. We have asked each author in this section to critically evaluate the DSM-5 changes.

These DSM-5 changes reflect the diminishing importance of gender parallelism in our understanding and treatment of sexual dysfunction. As discussed earlier, the conceptualizations and interventions for desire and arousal in men and women have almost totally diverged. Dyspareunia was defined in DSM-IV (American Psychiatric Association, 1994) as a diagnosis for both women and men, despite the fact that it was rarely applied to men. In DSM-5 (American Psychiatric Association, 2013), male dyspareunia is not a formal diagnosis because of the lack of sufficient data and research.

Paradoxically, there is a small but growing body of research on urological chronic pelvic pain syndrome (UCPPS) in men, which suggests that a diagnosis similar to male dyspareunia may have a future (Davis, Binik, & Carrier, 2009). Bergeron et al. review this work in Chapter 7. The ultimate fate of gender differences in diagnoses is not clear and will probably evolve with gender politics, theory, and clinical practice.

There has been little gender controversy, however, about premature (early) and delayed ejaculation. Although surveys suggest that "premature orgasm" may be a problem for some women, this issue seldom comes to clinical attention (Laumann, Gagnon, Michael, & Michaels, 1994). The diagnostic criteria for premature (early) ejaculation have undergone a major overhaul in DSM-5 by the inclusion of a specific time specification of approximately 1 minute or less. This change, however, does not greatly affect Althofs recommendation (Chapter 5) that clinicians carefully consider a

"combination therapy" (psychotherapy and pharmacotherapy) approach. This combination approach does not simply target time as the solution to premature (early) ejaculation; it considers ejaculatory latency in the context of the couples relationship and the males feelings of masculinity. A similar approach is taken by Perelman in 16

discussing delayed ejaculation (Chapter 6). Perelman expands his discussion to also include the whole range of ejaculatory/orgasmic problems for men (e.g., anejaculation; painful ejaculation; retrograde ejaculation; reductions in volume, force, sensation of ejaculation; postorgasmic illness syndrome).

The last "traditional sexual dysfunction" reviewed in Part I is female orgasmic disorder. Graham (Chapter 4) points out that "directed masturbation" continues to be the mainstay of treatment for this problem because it has shown to be highly effective.

In fact, it is the only sex therapy technique that is acknowledged by current standards to be efficacious, at least for lifelong anorgasmia (Heiman, 2002). Although it is wonderful to have such an efficacious treatment, we cannot help wondering whether the success of this treatment has hindered further research concerning the nature and function of female orgasm. We still do not fully understand the tremendous variability in womens ability to experience orgasm.

Overall, the single most important influence on the practice of sex therapy for the traditional DSM sexual dysfunctions is the continuing development of sexual medicine.

As a result, we requested that each author in this section review the relevant sexual medicine research and discuss how such work can be integrated into practice. Most authors recommended a multidisciplinary or interdisciplinary assessment and treatment model. As a result, we asked them to reify this model with an assessment and treatment algorithm. The net result is a far cry from the solo sex therapy practitioner model that was the standard 20 years ago.

Many will argue that such multidisciplinary models are a luxury affordable only in developed countries, and even there only in major centers. Although this may be true, it is important to differentiate between what is possible and what may be necessary or ideal. Even when resources are available, the question of how to integrate multiple disciplines effectively is a continuing health care management problem.

**SEX THERAPY FOR OTHER SEXUAL DISORDERS**

The relationship between sexual dysfunction and the other sexual disorders might be best characterized as a DSM-arranged marriage. Paraphilia and gender-dysphoria clinicians and researchers have usually not been sex therapists. Yet in the view of previous DSMs and most of the North American mental health community, all sexual and gender issues are alike. The net result is that the sexual dysfunctions, paraphilias, and gender identity disorders have all been thrown into a single DSM chapter. This is not true in the World Health Organization (WHO) International Classification of Diseases (ICD) classification..

Whether sexuality is an important defining characteristic for gender dysphoria is a matter of some controversy. Brown and Zucker (Chapter 11) point out that autogynephilia—that is, sexual arousal to the idea of oneself being a woman—may be a crucial mechanism in male-to-female gender dysphoria and that this "erotic location error" is considered by some as a sexual orientation. This theory has aroused bitter 17

controversy, as evidenced by the recent brouhaha between J. Michael Bailey of Northwestern University and some militant gender activists (see special issue of Archives of Sexual Behavior, June 2008). Brown and Zucker also review the intervention literature and summarize the substantive changes in the DSM-5 diagnosis.

The difficulty in classifying problems as sexual or not is also exemplified by the discussion of persistent genital arousal disorder in Chapter 12.  This problem was originally referred to as persistent sexual arousal disorder. This name change suggests an obvious change in conceptualization. Goldmeier and colleagues argue that the presence of persistent physical genital symptoms of arousal is not sufficient to define a problem as sexual. Nonetheless, sex therapists will often treat such problems because they interfere with sexual and relationship functioning; most other health professionals will avoid such conversations. This same controversy exists with respect to hypersexuality, or, as it is popularly known, sexual compulsivity/addiction. Kafka points out, in Chapter 13, that the jury is still out in deciding whether this problem is a sexual one or whether it is better characterized as an attachment or obsessional disorder. Despite the growth in clinical and popular interest in this problem, it is not classified as a sexual disorder in DSM-5. Whether this disorder will ultimately become part of the canon or go the way of sexual aversion disorder remains to be seen.

The conceptual and clinical issues involving the paraphilias are somewhat different.

There is little doubt that unusual or alternative objects of sexual arousal/desire are the key defining features; there is, however, much doubt about whether such symptoms are indications of psychopathology, the result of unfortunate developmental outcomes, or the failure of societal tolerance. Whatever the origin, clinicians are often faced with problems in dealing with the legal system and public opinion, in addition to the welfare of their clients. Kleinplatz, in Chapter 9, and Cantor, in Chapter 10,  suggest very different intervention strategies for dealing with paraphilic attractions and behaviors.

Kleinplatz advocates an existential psychotherapy approach to effect deep personality change, whereas Cantor describes a community containment model that aims to control rather than change pedophilic attraction. These differences in approach not only reflect basic theoretical differences but may also reflect different therapeutic strategies for dealing with the potential societal and legal implications resulting from the coercive versus noncoercive paraphilias.

Although the somewhat unhappy arranged marriage among sexual dysfunction, gender dysphoria, and paraphilias has lasted for many years, it appears to be ending.

DSM-5 appears to have arranged a "legal separation" (i.e., separate chapters) in an attempt to coordinate the metadiagnostic structures of the next WHO classification (ICD-11) and DSM-5. This will no doubt facilitate international collaboration, though it does not really solve the conceptual issues of whether these categories are really similar or not. Whether there will be a reconciliation or a full divorce in the future remains to be seen.

The modern sexual medicine movement has not been heavily involved in the treatment of paraphilias and gender dysphoria, but physicians always have.

Endocrinologists and surgeons are often required for the management of gender dysphoria, and psychiatrists are often called upon to prescribe sex-drive-reducing 18

medication for the "chemical castration" of convicted sex offenders. Whereas psychologists have often been heavily involved in the treatment of sex offenses and gender dysphoria, sex therapists have often shied away from these groups. We have, therefore, asked each of the authors in Part II to address the role of sex therapy directly.

Clearly, the problem-solving skills and achievement of comfort involved in talking about sexual and relationship issues that are required for sex therapy will be very useful in dealing with the paraphilias and gender dysphoria.

**THERAPEUTIC CHALLENGES FOR SEX THERAPY**

The chapters in Part III address the clinical and research challenges facing sex therapy today. Some of the issues (e.g., culture, trauma, infidelity, illness, aging) affect all psychological problems and therapies. They are, however, so frequently encountered in sex therapy practice that it is, in our view, necessary to deal with them directly and specifically in any sex therapy text. This reflects our view that traditional sex therapy, as exemplified by Masters and Johnsons cognitive-behavioral type interventions, is no longer sufficient to characterize actual practice. Considering what we now know about the long-term efficacy of traditional sex therapy interventions, it is perhaps not surprising that this is the largest section of this edition.

We have organized these "therapeutic challenges" into three different subsections.

The first is the most varied and deals with groups for which standard practice must often be adapted to the nature of the group. Obvious examples include sexual minorities

—lesbians, gays, and bisexuals (LGBs)—as well as individuals from non-Western cultures. In fact, LGBs are characterized by Nichols in Chapter 14 as coming from a different sexual culture than the typical heterosexual sex therapy client. For many years, LGBs avoided heterosexual and institutionally based treatment environments because of their antigay biases. It is our strong impression that both the "institutional" and the LGB

communities have changed. Although non-gay-friendly therapists still exist, their number is diminishing; in most public and many private health institutions, homophobia is also greatly reduced. It also appears to us that LGB treatment seekers are changing. Not so long ago, they felt compelled, often for good reason, to limit their therapist choices to members of their own community. Today, the frame of reference appears to be enlarged to "who will be the best therapist for me," independent of his or her sexual orientation. The LGB community has expanded and welcomed transgender, questioning, and queer individuals, so the moniker now frequently reads LGBTQ.

Transgender clients have often felt misunderstood by mainstream therapists, physicians, and sex therapists. Nichols points out that the role of therapists is shifting from

gatekeepers of medical/surgical intervention to advocates. Hall and Graham (Chapter

15) extend this theme of adapting standard practice into a multicultural and

intercultural context. They point out that the cultural context of the client (couple) and the culturally unique meaning of the sexual problem are crucial to understand in order to implement effective intervention with respect to sexual issues.

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Two "new" chapters for this volume concern infidelity and body image. These are not new issues for sex therapists, who often receive referrals for sexual dysfunctions such as lack of desire or arousal in which the underlying issues may be infidelity or body image.

Most sex therapists will opt to deal with the underlying issues in conjunction with the sexual dysfunction. How to do therapy in this way is not immediately obvious, because the research literatures related to infidelity and body image are not well developed and often not linked to practical clinical intervention. Wiederman and Sarin (Chapter 16)

connect the growing social psychological literature on body image to clinical reality by pointing out that it is body image specific to sexual situations, not global measures of body image, that are the best predictors of sexual functioning. Levine (Chapter 18)

points out that a therapeutic understanding of the ongoing experience of partners who are living with infidelity is more crucial than adoption of a particular treatment model or set of techniques.

Chapter 17 addresses the long-standing issue of how to deal with sexual abuse. Rellini integrates the available research data and cautions the clinician about making unwarranted causal assumptions linking the abuse to sexual dysfunction. She also presents useful therapeutic insights into how to practically deal with a history of abuse that is, in fact, interfering with current sexuality.

The second subsection within Part III is titled "Medical Problems. " Sex therapists are often called on to consult and treat individuals suffering from the sexual effects of an illness, accident, or medical situation. It is often hard to disentangle the effects of chronic illness from age, as these are highly correlated. It is also often tempting to attribute sexual difficulties to the direct effects of a particular illness. Enzlin (Chapter 20) provides us with a general model for explicating the interaction of chronic illness and sexuality. This model differentiates between the direct, indirect, and iatrogenic effects of chronic illness on sexuality. Enzlin also provides us with a "stepped-care" approach for dealing with the ensuing problems. Sexually transmitted infections (STIs) constitute an instance of illness that requires a special chapter (Chapter 22). This special case is important because of the enormous influence of HIV on society and because STIs, as opposed to most other illnesses affecting sexuality, disproportionately affect younger populations. Sex therapists should now be able to educate their clients about STI risks and to treat couples in which one member is affected. In their chapter, titled "Suppose They Gave an Epidemic and Sex Therapy Didnt Attend," Fisher and Holzapfel point out how sex therapy has failed to take up this task.

One of the legitimate criticisms of previous editions was that they failed to differentiate adequately between illness and disability. Disability is no longer conceptualized as a solely medical condition. Mona and colleagues (Chapter 21) point out that individuals suffering from disabilities constitute the largest minority group in the world and that disability must be seen as a "multicultural variable." This reconceptualization has dramatic implications for treatment models.

Chapter 19 deals with a specific medical/interpersonal issue: infertility. Although sociocultural changes and modern advances in contraception have decreased the interdependence of sexuality and reproduction, modern technological advances in infertility treatment have made sex therapists key members of infertility treatment 20

teams. In Chapter 19,  Daniluk and colleagues point out that couples, prior to a diagnosis of infertility, do not have higher rates of sexual dysfunction than the general population.

However, the psychological and medical stresses following such a diagnosis take their toll. The authors present assessment and counseling strategies appropriate to each stage of the infertility treatment, including invaluable guidelines for the therapist working in this area.

The third subsection within Part III represents a new direction for Principles and Practice of Sex Therapy. It emphasizes a developmental/lifespan view of sexuality. In our sex therapy training years, we rarely saw clients younger than 25 or older than 50. In todays world, clients under 20 and over 70 are not uncommon. OSullivan and Pasterski (Chapter 23) point out that our conceptualizations of sexual problems and our treatment strategies are still based on 25- to 50-year-olds and that there are no systematic treatment studies of sexual dysfunction for individuals under 18. They nonetheless provide case examples to guide clinicians until more information is available. Agronin (Chapter 24) deals with a similar lack of information about aging populations. In addition to the "normal" changes in sexuality experienced with healthy aging, he discusses the interpersonal and ethical issues raised by individuals and couples attempting to continue their sexual lives when faced with memory loss and institutionalization. Finally, in the previously discussed Chapter 11, Brown and Zucker discuss children and adolescents with gender dysphoria, who are now raising many ethical and treatment questions about when it is appropriate to start hormonal and medical treatment. Although dealing with the sexual problems of 25- to 50-year-olds continues to be challenging, we believe that the field must expand to take into account the reality of sexual behavior throughout the lifespan.

**THE FUTURE OF SEX THERAPY**

The different editions of Principles and Practice of Sex Therapy, starting with the first in 1980, reflect the history of our field. We hope this new edition also will foreshadow future developments. The immediate future of sex therapy depends on new blood and new ideas. Fortunately, we have been able to recruit several relatively junior but highly accomplished clinicians and researchers (Beckon, Facelle, Koert, N. O. Rosen, Sadeghi-Nejad, Sarin, Steiner) who are forcing the field to confront the new realities of the 21st century. In addition, there are a relatively large number of established professionals who are first-time contributors to Principles and Practice of Sex Therapy (Agronin, Brotto, Brown, Cameron, Cantor, Daniluk, Enzlin, Fisher, Goldmeier, Graham, Holzapfel, Kleinplatz, ter Kuile, Levine, Luria, Meana, Miner, Mona, OSullivan, Pasterski, Pukall, Reissing, Rellini, Syme, Wiederman, Wincze, Zucker). Last but not least, we have induced some of our past stars (Althof, Bergeron, Kafka, Nichols, Perelman, R. C.

Rosen) to either update their 4th-edition chapters or write new chapters. The net result is that the majority of the content of the book is new or written from a new perspective.

Our author list probably also reflects some of the ongoing professional trends. Five 21