SEXUAL LIFE A CLINICIAN'S GUIDE CRITICAL ISSUES IN PSYCHIATRY An Educational Series for Residents and Clinicians Series Editor: Sherwyn M. Woods, M.D., Ph.D. Univers1tv of Southern California School of Medicine Los Ange1es, California Recent volumes in the series: CASE STUDIES IN INSOMNIA Edited by Peter J. Hauri, Ph.D. CHILD AND ADULT DEVELOPMENT: A Psychoanalytic Introduction for Clinicians Calvin A. Colarusso, M.D. CLINICAL DISORDERS OF MEMORY Aman U. Khan, M.D. CONTEMPORARY PERSPECTIVES ON PSYCHOfHERAPY WITH LESBIANS AND GAY MEN Edited by Terry S. Stein, M.D., and Carol J. Cohen, M.D. DECIPHERING MOfiVATION IN PSYCHarHERAPY David M. Allen, M.D. DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis and Treatment, Third Edition Marc A. Schuckit, M.D. ETHNIC PSYCHIATRY Edited by Charles B. Wilkinson, M.D. EVALUATION OF THE PSYCHIATRIC PATIENT: A Primer Seymour L. Halleck, M.D. THE FREEDOM OF THE SELF: The Bio-Existential Therapy of Character Problems Eugene M. Abroms, M.D. HANDBOOK OF BEHAVIOR THERAPY IN THE PSYCHIATRIC SETTING Edited by Alan S. Bellack, Ph.D., and Michel Hersen, Ph.D. NEUROPSYCHIATRIC FEATURES OF MENTAL DISORDERS James W. Jefferson, M.D., and John R. Marshall, M.D. RESEARCH IN PSYCHIATRY: Issues, Strategies, and Methods Edited by L. K. George Hsu, M.D., and Michel Hersen, Ph.D. SEXUAL LIFE: A Clinician's Guide Stephen B. Levine, M.D. STATES OF MIND: Configurational Analysis of Individual Psychology, Second Edition Mardi J. Horowitz, M.D. A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher. SEXUAL LIFE A CLINICIAN'S GUIDE Stephen B. Levine, M.D. Center for Human Sexuality Department of Psychiatry University Hospitals of Cleveland Case Western Reserve University School of Medicine Cleveland, Ohio SPRINGER SCIENCE+BUSINESS MEDIA. LLC Library of Congraaa CBtalagtng-tn-Publtcattan Data ~avlna, Stephen B., 1942- Saxual llfa : a clinician's guide 1 Stephan B. ~evlne. p, em. -- !Critical Issues In psychletryl Includes bibliographical references and Index. ISBN 978-1-4899-0854-4 ISBN 978-1-4899-0852-0 (eBook) DOI 10.1007/978-1-4899-0852-0 1. Psychosexual disorders. 2. Sex therapy. 3. Sex. I. Title. II. Sartes. RC588.~47 1992 616.8'583--dc20 92-26033 ClP 109 8 7 6 543 ISBN 978-1-4899-0854-4 © 1992 Springer Science+B usiness Media New York Originally published by Plemnn Press, New York in 1992 Softcover reprint of the hardcover 1st edition 1992 All rights reserved No part of this book may be reproduced, 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 To Lillian, my wife Foreword There has been great progress in recent years in our understanding of human sexuality, both normal and disordered. Few health professionals, and especially mental health professionals, can spend a day with patients without encountering some form of suffering related to sexuality. Problems vary enormously with respect to nature, severity, and treatment approach. This book addresses the entire range, and does so with great effectiveness. Effective clinical management requires the truly biopsychosocial un derstanding and treatment strategies so clearly presented by Dr. Levine. His approach to patients is simultaneously sensitive, practical, sophisti cated, and comprehensive. His conceptualization of diagnosis and treat ment integrates behavioral, cognitive, and psychodynamic thinking, and always does so with an eye to relevant biological dimensions. I am especially pleased to welcome this book to the series, because it will have an important place in the education of psychiatric residents and other mental health professionals. The depth and quality of the presenta tion, however, make it equally rewarding reading for the most experienced of clinicians. SHERWYN M. Wooos, M.D., PH.D. Series Editor vii Preface It has been almost two decades since I began listening to single and mar ried people talk about their sexual concerns. This privileged position has helped me to better understand my personal development and my role as a therapist and to realize that I have a definable perspective on sexual life. I remain enamored of the opportunities to learn and to help that exist within the roles of clinician and teacher. It never ceases to be a delight to be of assistance to another person or a couple, or to open the door to an understanding of the sexual universe for a student. Always hovering near these pleasures, however, is the awareness of what is not understood. I have come to view genuine expertise as that which exists when a person is acutely aware of the limits of knowledge. I greatly admire those clinicians and behavioral scientists, many of whom are referenced in this book, whose scholarship and research have pushed our understanding of sexu ality a notch or two further or who have cogently articulated the previously inapparent limits of our knowledge. Over the years, I have been encouraged by the interest of mental health trainees in my emerging perspectives. I became sufficiently embold ened to write this book, in part, because of the pleasure of watching these trainees make sense of their patients' sexual concerns using these perspec tives. Sexual Life has arisen from the many stimulating interactions with individuals and couples in therapy, trainees in individual supervision, and groups in the small conferences held three times a week at the Center for Human Sexuality (part of the Department of Psychiatry). I owe an enor mous debt of gratitude to the many persons in each of these categories. It is inconceivable to me that this book could have been written without them. Those who are aware of what the Center for Human Sexuality is, and what it aspires to be, know that none of its therapy, education, or research could have been conducted without the devoted efforts of Stanley Altho£, ix X PREFACE Ph.D., and Candace Risen, L.I.S.W., who have been my teammates since the time when all of us considered ourselves young. To these two talented, wonderful people, in particular, and to the many Fellows in Sexuality who have spent one or two years helping us do our work, I offer my affection and lasting gratitude. Contents Chapter 1 What Is Sexuality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The Meaning of "Sexuality" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The Development of Clinicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 "What Is Sexuality?" Eight Answers . . . . . . . . . . .. . . . . . . . . . . . . . . . 3 Sexuality and the Need for Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 The Tasks of Sexual Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chapter 2 What Shapes Sexual Life? 10 Caveats about Clinical Ways of Knowing . . . . . . . . . . . . . . . . . . . . . . . 10 What Informs the Clinician? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Contexts for Understanding Sexuality . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Thomas-A Case History...................................... 19 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Chapter 3 The Psychological Organization of Our Sexual Selves 24 Sexual Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Sexual Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Sexual Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 An Outline of the Major Pathologies Brought to Clinicians . . . . . . . 34 xi