SEX COUNSELLING AND THERAPY FOR SINGLE PEOPLE
Frank G. Sommers, B.Sc., M.D., F.R.C.P. (C)
Department of Psychiatry, Faculty of Medicine
University of Toronto
This is the third in a series of reports.1, 2
“Single” in this discussion is a person, male or female, who has never married, is separated, widowed, or divorced. This paper is based on clinical experience with approximately 100 such patients who presented with a sexual problem.
Looking at our society today, it is not unreasonable to conclude that perhaps a majority of us can expect to spend as much, or more, time in the “single” state than married. Consequently, examining the sexual functioning of the “single” person has considerable relevance and priority.
In our times, in particular, due to a number of factors, such as improved birth control technology, greater privacy, the Women’s Movement, rising general level of education and parallel disinclination to adhere to authoritarian or dogmatic prescriptions for moral behaviour, life-long, monogamous sexual unions appear to be on the wane. As the ship of marriage is buffeted from all sides, the operative question for so many becomes: “How long did it last?” And this is not meant as a double entendre.
For many singles who present with a sexual dysfunction, the trauma of uncoupling involves a painful recovery period which, at times, shakes them to their foundation. Their precarious sense of self-esteem can enhance their vulnerability to an episode of sexual malfunction, which, under happier circumstances, would impact them much less severely. The problem of the long-married person becoming single again can be equally critical.
A 57-year-old school principal who lost his wife to cancer. I quote:
Nine months after my wife died, I invited a lady out for dinner. She was someone I had worked with for seven years and a friend of my wife, although younger than both of us. (She was 41.) I respect and like her very much, but found it difficult to get into the routine of asking someone out. However, having taken the initial step it was a very enjoyable evening. We talked until three in the morning. I took her out several times. I don’t recall exactly how many, but anyway, after a time we went to bed. I must admit I was rather surprised in that I did not expect that she would find me interesting in that our ages were fairly wide apart.
Things were going great in bed until we reached the point where she took hold of my penis for insertion and I ejaculated. My reaction and feeling at the time? Complete and utter devastation. I guess even humiliation; certainly failure. Here was someone I cared a great deal about, stimulated to a high pitch and disappointed. Since that time I have not on subsequent tries been able to get a full erection and have ejaculated. In this respect I guess it has gotten worse. How do I feel about the problem? It is the most debilitating thing I have ever tried to cope with. It has badly affected my self-confidence. It has made it difficult for me to communicate verbally with her. It is on my mind most of the time and affecting my concentration at work and my emotional stability — which I think has always been considerably high. Sometimes when by myself I simply break down and cry.
Thinking about the root causes of this problem, and dealing with the possible connection with his long, faithful marriage, or perhaps a moral inhibition about casual sex, both of which he discusses, he states:
I felt such a failure after the first disastrous experience that now I am afraid of failure and I guess the best way to avoid failure is not permit the situation where failure is likely to occur, to happen. That is, if I don’t get an erection, I can’t fail. This ends up in a dog-chasing-its-tail situation.
The media-created image of the “swinging single” adds to the burden. One is forced to live up to a mythical standard of happy, carefree times and easy sex.
The pressure to establish “credentials” as it were, that one is a skilfull, capable, knowledgeable “sexual technician” tends to transform, especially the initial sexual contact into a performance — almost a “rite of passage.” This kind of “hidden” agenda does little to encourage a relaxed atmosphere, so essential for the creative use of one’s senses in the service of deepening the emotional aspects and satisfaction of sexual interplay.
The main diagnostic categories of presenting patients cover erectile dysfunction, with or without inhibited sexual desire; premature ejaculation, or retarded ejaculation; and first or second degree anorgasmia. A few present as virgins in their third or fourth decade and a few have confused sexual identities. A question frequently asked is with respect to ability to relate socially. While this is a problem for some, the majority have little or no difficulty in this area. In fact, many are attractive, well-educated, productive members of their community who readily attract potential dates and mates.
A little-known fact is that sexual dysfunction is an illness that can lead to death. While figures are not available in the literature, a number of our patients have attempted suicide as a consequence of their hopelessness secondary to their sexual failure experience.
This patient was referred following a suicide attempt on New Year’s Eve for which he was hospitalized. He was a 27-year-old factory worker out for an evening of fun. He had attempted intercourse with a few women since age 18 and would lose his erection prior to penetration. He stated:
This New Year’s Eve I spent in my friend’s place. We had a few drinks and started to dance. As I danced with one of the ladies, I smelled her hair. I don’t know why, but I got an erection. But this erection was much weaker than I remember years ago.
Frightened that he was going downhill sexually, and as he had tried to get help before with no positive results, he thought:
I don’t know what I should live for. I know this problem is ruining my life. My life now is work eight hours a day, buy food, and watch TV. This is my daily program. On my day off I watch TV from morning ’till midnight. Is this life? I don’t want to live all my life in a closed apartment and alone. I want to have girlfriends, maybe later a wife and kids. I am scared how I’m going to live the next 27 years. There can be a hundred people around, but I still feel alone with my problem. You can say “try to find a girlfriend,” but no way. If I’m gonna find a girlfriend there is going to be a day when I have to have sex. What I’m gonna do then? I failed so many times I don’t want to go over that again.
Sometimes the presenting complaint is not directly a sex problem, as in the case of the 45-year-old Irish Catholic male:
I cannot maintain eye contact with people, even with men I have worked with for the past 22 years. I blush when I am introduced to people and when I talk with people. If I blush at a social gathering the blush stays with me for hours. If I am in a situation where attention is focused on me after I start blushing, I lose control of my facial muscles. When this happens I have to cover my face with my hands. The same thing happens when I enter a crowded room, like the lunch room where I work. I’ve had this problem since I was about 20 years old.
When questioned about his sexual history, he stated:
I had my first intercourse when I was about 26. It was with a prostitute and I was intoxicated. I had intercourse about five times since, intoxicated each time. These were the only times I had intercourse.
When questioned about the origins of his blushing, he said:
I believe my problems have something to do with sex. I first had the blush when I was engaged in sex play with a close female relative. After my visit to the prostitute in my twenties, I had a feeling of self-confidence that I had not had before or since then. Instead of going back to the woman, I went back to Confession.
Stories like this are not unique except in degree, but not in kind. Time and again, one becomes aware on history taking of the crucial importance of early sexual attitudes and values. Almost all these patients come from homes where sex was not even talked about. Most did not have as models parents who hugged and kissed and stroked in front of the children, and in many cases neither did they provide much affection to them. At an early age, children would be set on a course that would not equip them to deal with their emerging sexual curiosity, needs, and thirst for information. The roots of habits that will hold them for a lifetime can be found in this early period of socialization.
An extreme example is a man in treatment now who grew up in a wealthy home of five children, where no affection was dispensed. Mother and father slept in separate rooms on different floors and the children had to dress for dinner and call their father “sir.” This man, an executive, flits from bed to bed, unable to satiate his hunger for deep affection that his constant sexual hunting covers up.
Many of these patients have an interesting inability to fantasize. I would postulate this is due to two factors, at least:
- They have not accumulated or incorporated sufficient experiences or stimuli at a crucial early part of their development that would form a healthy base for later elaboration of sexual/sensual material.
- They act as willing self-censors of any image, thought, or feeling that they might feel guilty for experiencing. Here, of course, thinking or imagining is often confused with action or experience, and self-doubting, shame, and disgust become the accompanying effects. One could legitimately theorize that the most devoted advocates of censorship, whether of movies or books — incidentally, an affliction particularly rampant in Ontario — are the very people most adept at self-censorship.
On the basis of the above, it could also be argued that the widespread availability of quality erotica (a term much preferable to “porn,” as it implies an emphasis on the aesthetic and the sensual), could be a public health measure. It could help supplement or enrich fantasy life and contribute to the establishment of a milieu which fosters, rather than arrests, sexual growth and development.
In this connection, it is interesting to also note that totalitarian societies act, regardless of professed ideology, to suppress or ban porn and erotica. The oligarchies in charge find their people’s tradition-bound self-censorship to their liking. When a person censors his or her own thoughts, state-induced thought control is much easier. And when a person gives up, willingly, sources of innate, positive human pleasure — that person and their society become more easily controlled and manipulated in other directions as well. According to Professor John Money,3 sexual democracy and political freedom go hand in hand. Thus, we all must carefully guard our sexual rights and those of sexual minorities. A healthy society tolerates diversity, and does not use its criminal code to control sexual behaviour between, or among, consenting adults. Dr. Money made, in my opinion, a powerful analogy between the religious heretics burned at the stake in the Middle Ages, and the sexual heretics of today who are hauled off to court if their behaviour does not conform to some mythical, unmeasured and unmeasurable, community norm.
The discovery that many sexual problems can be treated by brief directive methods is a great step forward in the healthcare field. The essence of these methods is the breakdown of the sexual response cycle into small, manageable components and dealing with each in turn. It’s like building a home, I say to patients. We must lay a foundation and build gradually from the ground up. In this process, the usual genital preoccupation vanishes, as the person re-learns to use and pay attention to each of his or her senses. This also induces a sense of being alive, and a sense of awareness of the present that promotes taking responsibility for each thought, feeling, and action.
It would be untrue to say that old habits are easy to change. But well-motivated patients are eager to learn and to gain release from suffering. This is one reason that sex therapy is a gratifying discipline. Though it’s not easy. In fact, I would agree with Dr. Helen Singer Kaplan4 that psychosexual therapy is a more accurate term for what the majority of patients need. Thus, to approach a patient without a good grounding in diagnosis and management of the range of psychological problems and an ability and willingness to see these problems through to their proper resolution, in addition to specific, supervised training in sex therapy, is offering patients less than what they need in my view.
During the ten to fifteen session course of therapy, patients learn to tune into their senses, to stay in the present, and to give up their performance anxiety. The learning in the sessions: the sensate focus exercises, films, relaxation and imagery training, is supplemented with bibliotherapy, and homework exercises. With our help and guidance, the person is encouraged to begin dating again in an attempt to generalize what is learned in a specific situation. The patient now is “learning success,” and in a way undergoes the inverse of the process that lead to his or her illness. As confidence blossoms, a new set of values and beliefs become adopted, now congruent with one’s adult needs and wants. Spontaneity and creative sensuality are encouraged and the carry-through to other aspects of the patient’s life is often remarkable.
Here are the words of a male patient, 25, who was treated for impotence of four years’ duration:
I’m very happy with my progress. Now every time I’m holding a woman I get an erection. The urge is stronger and stays with me longer. I learned how to be in touch with people more, to communicate more, to be open. Before, I was blank, kept to myself. I’d used to say “forget it.” When I was in elementary school I was overweight and kids would leave me out of plays and called me “fatso.” I feel this therapy helped me get control of myself; I’ve done something.
Here are some thoughtful comments from another patient who, at the age of 26, presented as a virgin with fairly severe secondary depression:
I feel that my therapy program has been successful to the extent that my basic goal of discovering my sexual potency has been realized. Although I was never supposed to be “goal-oriented,” the basic rationale for entering such a program was to regain this potency, and this was achieved. I thus no longer feel in “isolation” or that I had missed out on something that everyone else my age had experienced.
There are several goals that I have yet to achieve. I am still tremendously disappointed that this potency is partial — to the degree that the mind-penis connection has not re-established itself. I had always assumed that if I made love once, that entire “paralysis” would be removed from my mind and my potency would return to its teenage level, where any erotic thought or visual stimulation produced an immediate physical reaction. This has not been the case, and I doubt that it ever will be.
As is clear from the above, learning goes on after the therapeutic sessions end. But the emphasis is on the patient’s ability to apply the principles learned over and over again to his or her new experiences.
A 25-year-old woman knows exactly how she wants to proceed. She said:
Most of all, I would like to be rid of all the shame and guilt that is so strongly tied to sex (at least in my mind). After my problem is cured, I would love to be able to sleep with lots of different men and be able to enjoy sex just for itself, no strings attached! Of course, ultimately, I would like to get involved with a man and have a deep emotional relationship as well. What I really want is to be able to feel free and to really feel that I have the option to sleep with someone just for the sake of it, if I want to, and not suffer all these added anxieties or, at least learn how to cope with them.
In conclusion, it is worth it to cast another glance at the apparent causal factors for sexual dysfunction.
It appears that children raised in a sex-negative home, or even a sexually-neutral one, are more predisposed to sexual dysfunction than those raised in a sex-positive home. Thus, Dr. Alayne Yates’5 message for parents to instill in their infants “penis pride” and “clitoral consciousness” ought to be heard far and wide, if we are interested in primary prevention of sexual disorders.
Further, the excessive preoccupation of religion, some more than others, with sexual functioning, can easily engender a sense that sex and the body are dirty. The mind-body split is thus re-enforced, and recovery can be very arduous, indeed, especially since the belief system that a “pure life on earth” can be the guarantee of all that is good in the hereafter, is a most difficult one to totally relinquish.
Sex educators appear to need much better training, along with doctors and other health and counselling personnel, in the field of human sexuality. “Primum non nocere” — first of all, do no harm, applies, or ought to apply, very strictly in this field, especially since one’s sexuality appears to be such a vulnerable area. A number of patients have presented with a sexual problem dating from a sex education class in high school, when the teacher talked about impotence as a male problem. Up to then the patient had assumed that everything just worked reflexively on its own. Other patients have been told by their doctor not to worry, that they’ll outgrow their problem, or it will go away when they meet the right partner. One urologist, who should have known better, berated his patient after telling him that he had a low sperm count, casting aspersions on his manliness and suggesting that he adjust to a life of rare or no sex.
With respect to professionals working in this field, we clearly need to get our own sexuality together, our own body-mind integrated, our own attitudes and values re-assessed prior to advising others.
Finally, a word about the economy. We live in a tough, competitive, goal-obsessed, produce-to-consume, materialistic society with an emphasis on youth, superficial glamour and instant gratification. It is folly to think that a person obsessed with reaching visible goals all the time can easily shift gears into a person-oriented, inner-directed existence. Yet for sexually dysfunctional patients this transition is essential, and forms a turning point in their therapy and their lives. As they learn to lose themselves in the pleasures of the moment, giving themselves permission to abandon the thinking, evaluative, observing self for the playful child within, delighting in all the senses as they play with a consensual partner of their choosing, sex becomes much more than penis in vagina. Now sex is in a look, a touch, or a sigh. It is no longer a performance but a delightful union where there is no observer and no performer. Just human beings dancing the oldest dance there is.
Were this to happen globally, then one can perhaps be forgiven for fervently wishing that neuropsychologist James Prescott’s work on “Body Pleasure and the Origins of Violence”6 were borne out.7 Then, perhaps, our small planet would not be in danger of annihilation, but would contentedly purr along in space to the rhythm of people making love, not war.
1. Sommers, F.G. “Treatment of Male Sexual Dysfunction in a Psychiatric Practice Integrating the Sexual Therapy Practitioner.” In Medical Sexology. Littleton, Mass.: PSG Publishing, 1978.
2. “Some Considerations on the Psycho-dynamics of the Psychiatrist and Sexual Therapy Practitioner (Surrogate) Relationship in Modern Sex Therapy.” Paper presented at the Fourth World Congress of Sexology, Mexico City, December 1979.
3. Money, John. “Sexual Dictatorship, Dissidence and Democracy.” Paper presented at the First Annual Conference of the Centre for Human Freedom and Sexuality, Toronto, Canada, October 1978.
4. Kaplan, Helen Singer. The New Sex Therapy. New York, N.Y.: Brunner/Mazel, 1974.
5. Yates, Alayne. Sex Without Shame: Encouraging the Child’s Healthy Sexual Development. New York, N.Y.: William Morrow, Inc., 1978.
6. Prescott, James W. “Body Pleasure and the Origins of Violence.” The Futurist, April 1975, pp 64-74.
7. In a nutshell, his research shows that the more body pleasure is permitted in a society, the less violent it is likely to be.