The PANY Bulletin

Psychoanalytic Association of New York
Volume 43, #2 Summer 2005

Applying Analysis
Psychoanalysis and the Practice of Sex Therapy
by Stephen Snyder, M.D.

It seems odd to be writing about applying analytic ideas to sexuality. Many of Freud's first conceptions about neurosis concerned its relationship to sex, sexual repression, sexual traumata, and childhood sexuality. Very many psychoanalytic patients have symptoms involving sex and physical intimacy. Yet few psychoanalysts have much knowledge about the evaluation and treatment of sexual problems. My own experience has been that a psychoanalytic background is quite valuable in the treatment of sexual concerns. Yet it requires significant modification of technique to apply psychoanalytic thinking to working with sexual problems in clinical practice.

I trained in sex therapy at Mount Sinai School of Medicine here in New York City with Raoul Schiavi and Patricia Shreiner-Engel in the late 1980's. The prevailing model then was brief couples' treatment for sexual dysfunctions, using an amalgam of behavioral and couples' therapy. I spent the next decade building a psychotherapy practice primarily devoted to sexual disorders, while keeping a day job as Director of the Consultation-Liaison Service at Mount Sinai and continuing as a candidate at the Institute.

During this period, my psychoanalytic and sex therapy lives began to merge. I found myself seeing more sex therapy individuals than couples, and found that many of my sex therapy patients did not wish to terminate after brief treatment. I began doing more longer-term psychotherapy, more or less focused on sexual concerns. Now that I have been in full-time private practice for five years, “longer-term sex-oriented psychotherapy” still constitutes the bulk of my practice.

Sex therapy began as an explicitly behavioral therapy, but for most sex therapists today behavioral techniques are a relatively minor ingredient. Helen Singer Kaplan introduced psychodynamics to sex therapy, with the idea that individuals and couples would have specific resistances to doing behavioral exercises, and that these resistances could be clarified and analyzed. I believe most sex therapists today would go even further, and would describe their main work as helping patients understand the activity of their minds with regard to sex and intimacy. Behavioral techniques, when recommended, have a subordinate role.

Helen Kaplan also advanced the useful notion of distinguishing between immediate and remote causes of a sexual symptom. Immediate causes are here-and-now behaviors and thinking patterns. If one succeeds in changing them, sexual symptoms often improve. But changing them is not always easy. Remote causes are disturbances in internal object relations, something that is properly the subject of psychoanalytic investigation. With psychotherapy or psychoanalysis, these can be worked over and softened, but not entirely changed.

For example, a young woman, engaged to be married, complains that in order to climax during sex with her fiancée she requires a fantasy of being raped. She is repelled by this fantasy, and feels ashamed after she uses it. A psychoanalytically oriented investigation will look for disturbances in early object relations, most likely related to some kind of trauma. Unconsciously, sexual climax generally signifies triumph. A traumatized individual may seek to create this triumph in fantasy by reworking the raw material of the traumatic experience, which is now represented as under the patient's magical control. I discover that the patient had serious breathing problems as a child, and would wait panic-stricken for her mother to enter her room and watch over her. Among many other condensed meanings, the rapt attention of the rapist to her body represents the wished-for watchful attention of the mother who has been absent from the room. Many other meanings emerge over time, including the projection of disavowed hostile impulses. But through all this, we are in the realm of remote causes.

The search for immediate causes goes in an entirely different direction. Taking a detailed sexual history, I discover that during sex she becomes quite aroused, but then sometimes just before orgasm suddenly and completely loses the feeling of arousal. Frustrated and angry, it is at such times that she brings in the rape fantasy. According to this here-and-now narrative, the immediate cause of the rape fantasy is what the cognitive therapists would call “catastrophizing” in response to the sudden loss of arousal. It is the same kind of reaction that men have in response to sudden loss of erections. I call her attention to this, and suggest she experiment with a more gentle and inquisitive attitude towards the loss of arousal. She is able to do this, and finds that if she takes her time with it, she can recover her arousal and climax without the rape fantasy.

It is obvious from the above that to neglect either the immediate causes or the remote ones would do this woman a disservice. A psychoanalyst without sex therapy training would certainly deduce the many meanings of the symptom, and in analytic treatment the patient's abandonment issues could be directly experienced, interpreted, and reworked in the transference. But this might take many years, at which point negative experiences in the bedroom might have taken their toll on this young woman's marriage. A sex therapist without psychoanalytic training might discover the immediate cause by taking a careful history, and might succeed in reducing the use of the rape fantasy. But what a missed opportunity to help this woman rework disturbances in object relations that almost certainly will cause her difficulty in other areas. To me the inescapable conclusion is that this kind of patient needs both an analyst and a sex therapist, preferably in the same person.

The opening phase of sex therapy is a complex thing. One must absorb and integrate a wide range of information regarding the patient or couple's psychological, psychiatric, and medical status, all while getting a detailed account of their sexual function and experiences. A sex therapist should know how to listen like an analyst while thinking about urology, gynecology, behavioral and cognitive approaches, psychopharmacologic possibilities, and the local dating scene. Many sex therapy patients turn out to have constitutional vulnerabilities such as mood dysregulation or subtle cognitive dysfunctions. Not infrequently my patients require medication for depression, anxiety, or ADHD. (The relationship between these constitutional vulnerabilities and sexual problems is a fascinating subject, about which very little has been written).

The patient who comes for consultation about a sexual problem is often intensely discouraged. One goal of the initial consultation is to convey an understanding of the problem and an attitude of hope. There is usually a pressure on the therapist to get results quickly, given the patient's acute level of discouragement. I try to clarify immediate causes of the sexual symptom, and to suggest immediate actions to remedy them. My goal is for the patient to leave the office feeling more hopeful and empowered to begin to work on the problem. This is often a tremendously gratifying experience for both the patient and me.

When I began to do this kind of work, I experienced considerable conflict between my psychoanalytic and sex therapist selves over whether the gratification inherent in the opening phase of sex therapy would interfere with later psychotherapeutic work on remote causes. My experience has reassured me in this regard. True, the transference experienced is different than it would be if one were practicing a more abstinent technique. But it can be just as important to understand the patient's reactions to a more gratifying object as to a less gratifying one. Many patients seen in sex therapy practice seem to blossom and grow in the setting of a psychoanalytically-informed but explicitly supportive treatment. After years of self inquiry, I no longer feel ashamed to say that I do “supportive therapy” with patients who have sexual problems.
When Viagra came out in 1998, I thought it would put me out of business. But instead it had the same effect that Prozac had on the practice of general psychiatry. Viagra “cured” many individuals who otherwise might have come for sex therapy. But the patients who remained, whose problems weren't cured by Viagra, tended to be the more complex and interesting ones. I began to see more patients with perversions and with behavioral addictions relating to sex, more patients with sexual dysfunctions for which there still is no medication, such as delayed ejaculation and problems of desire, and more complicated patients with erectile dysfunction whose sexual difficulties were refractory to Viagra.

Viagra divided the sex therapy community into two camps: one opposed to the medicalization of sexuality, and the other bent on being included as an equal voice in the newly medicalized field. As a physician, my own leanings have been strongly with the inclusionists. I have been fortunate to develop close working relationships with several gifted urologists who specialize in sexual problems. From them I have learned much about the biology of sexual function, a field of medical science that is growing rapidly. Andrew McCullough here at NYU invited me in 2003 to co-direct his annual post-graduate course in male sexual medicine. We've now done the course together for two years. Each year I have been stunned by the rapid biomedical advances that have occurred since the year before.

The 2004 course is now available as a video-cast on the web, at www.sexedhealth.com. Nestled among such exotic subjects as Rho-kinase and endothelial function, I have two presentations to which I would invite PANY readers to respond. The first is on erectile dysfunction in the younger man, and the second discusses sexual avoidance in men, women, and couples. It is of course a challenge to adapt psychological ideas to general medical audiences. I'd be interested in your reactions to these lectures, and in any of your thoughts or questions about the application of psychoanalytic thinking to sexual matters.

And you are all encouraged to contribute articles for the PANY Bulletin on how you have been applying analytic knowledge and skills to other areas of your work. Ed.