Vol2No1

Vol. 2 No. 1 March 1981
Hypnosis And Sex Therapy The Difficult Art Of Deciding Which Patient (Client) Should Be Rejected By The Hypnotherapist.
Derek Richardson, Medical Practitioner
Sydney, New South Wales

ABSTRACT
A Hypnotherapist's decision of when to refer and when to treat a client is often fraught with difficulties - particularly so with sexual problems where correct diagnosis and assessment is crucial in deciding on the course of treatment which would be most therapeutic for the client. The purpose of this paper is to develop a systematic approach that may minimize the difficulty in deciding when to refer.

1. INTRODUCTION
About twenty years ago if you asked people who were involved in the caring professions, the general belief was that most, if not all, sexual problems were "in the head". They arose (according to Freud and the psychoanalytical school), because of penis envy or castration anxiety. (1) (2).

Sometimes, psychological trauma occurring during the formative years cause a sexual "suppression" and Wilhelm Reich talks of this in his book on Sexual Morality (3). If these statements had been completely true, there would have been far fewer failures in people with sexual dysfunction treated by psychotherapy and hypnotherapy over the years.

We have come to realise with the passage of time, that this view is a mistaken one, and work coming from the United States during the past few years has suggested that in fact 15% of all clients presenting with sexual problems have got a basic underlying medical problem, and that in males over 30, the percentage is considerably higher. During recent years, as the medical profession has become more aware, and been willing to investigate more extensively, the numbers who have been found to have organic disease appears to have risen, but this increase is more apparent than real. It is most important that these cases are detected, and appropriate medical or other measures are undertaken to remedy the cause before sex therapy is undertaken.

The main purpose of this paper is to discuss in a systematic way, the types of problems that are being looked for, and where most of the accepted forms of therapy are likely to be unsuccessful - whether it be behaviour modification, sensate focus, systematic desensitization, psychotherapy, hypnotherapy, education or even explanation I It is probably appropriate to mention here the PLlSSIT Model for therapy which was first described by Jack Anon (4).

Here,
P stands for PERMISSION GIVING,
LI is for LIMITED INFORMATION,
SS for SPECIFIC SUGGESTION, and
IT for INTENSIVE THERAPY.

The form that PERMISSION GIVING takes may vary. Sometimes it is just permission to talk about sexual matters, being told that it is not wrong to sensually touch and explore your own or somebody else's body, or to discuss or indulge in such "forbidden" practises as masturbation or premarital intercourse. The LIMITED INFORMATION includes the description of the anatomy and physiology of physical, sensual and sexual inter-reaction between two people. Both PERMISSION GIVING and LIMITED INFORMATION should be within the scope of everyone who undertakes any form of counselling or relationship caring. SPECIFIC SUGGESTIONS may be given by people with some knowledge, but only if they are completely at home and at ease with their own sexuality. Only a few people should be undertaking INTENSIVE THERAPY, because such therapy may produce a whole series of other problems, difficulties and crises. The type of condition is envisaged that would give rise to anxiety; patients who are psychotic may have their condition worsened or an attack precipitated by inappropriate therapy, and if the therapist is not prepared for, and able to cope, with these manifestations when they come, then the therapist should not go out of his depth and tackle these cases.

A mnemonic to help one to remember the organic or medical causes of sexual difficulty is the word IMPOTENCE. Professor Arthur D. Smith of the University of Minnesota Medical School, describes the use of this mnemonic to assist in assessing the causes of partial erectile failure (5), but it also may be used as a schemata to try and find a medical cause for all sexual problems.
I Inflammatory
M Mechanical
P Post Surgical
O Occlusive Vascular Disease
T Traumatic
E Endurance
N Neurological
C Chemical
E Endocrine
On reading this list, some of these categories are self-explanatory - we can hardly expect intercourse or sex play to be particularly enjoyable when we have got an infection - whether it be from monilia (eg. vaginal thrush), orchitis (enlarged painful testicles - a frequent complication of mumps in adult males) or cystitis. Mechanical causes too, need little comment, diseases such as Peyronie's Disease (which may cause angulation of the penis) or an imperforate hymen or a septate vagina, obviously are going to lead to major problems. One must also bear in mind the mechanical problems such as arthritis, amputations and other physical causes which mechanically make the act of intercourse difficult. Here, our skills must be used to assist the people concerned to adapt to their disabilities. An example of this, is that the lateral scissors position for intercourse puts little strain on the back or hips and involves very little in the way of physical effort, so it is suitable for use by both those physically handicapped by arthritis or with a bad back and by those with endurance problems.

After a surgical operation there may be major changes in the body structure due to excision of the bowel or bladder for cancer - uterus or prostrate gland for either dysfunction or disease. In women, mastectomy can change the whole sexual self image, and the effects of a painful episiotomy scar can have long lasting effects on arousal patterns and the ability to achieve orgasm with intercourse.

Occlusive vascular disease is a fairly common problem and may be seen in people who are suffering from hyperlipidaemia (where an excessive intake of animal fats or a defect in body metabolism causes a rise in the serum cholesterol and serum triglycerides), diabetes or hypertension, occlusive arterial disease is aggravated by heavy smoking, and in the male, can give rise to partial or complete impotence due to a reduction in the blood supply to the penis. In the female, however, diabetes appears to have no demonstrable effects on sexuality, either as measured by libido or orgasmic response, according to Professor Max Ellenburg of Mount Sinai School of Medicine, New York (6).

Trauma can affect sexuality in a number of ways. Initially the body tends to go into a state of surgical shock, with blood being diverted to the brain, heart and vital tissues, and away from the skin and sex organs. Consequently, sex drive and performance become, temporarily, non-existent gradually, as the body recovers, there is a recovery, but multiple burns, fractures or lacerations, can lead to a period of weeks, or even months when libido is very low, and the injured person can rarely experience orgasm. Another example of the effects of trauma would be the results of a fractured pelvis with damage to either urethra or vagina.

"Endurance" covers a large range of problems: lack of physical fitness, fatigue, heart failure, respiratory failure (eg. emphysema), or renal failure. Heart failure is due to weakness of the myocardium or heart. muscle due to damage produced by a heart attack (myocardial infarction) or excessive strain on the myocardium itself, caused by the muscles having to pump the blood around the body at high temperatures in sufferers from hypertension, or when the muscles are attempting to overcome the effect of leaking heart valves (secondary to childhood rheumatic fever). The history the patient gives may lead one to expect emphysema - this is the condition where the parenchyma of the lung is damaged and replaced by scar tissue, and the diagnosis may be suspected either from the present symptoms, or from a history of previous recurrent attacks of bronchitis, or the knowledge that the patient or client has worked for long periods in a dusty or polluted atmosphere which is likely to damage lung tissue. Similarly, renal failure may be a result of the abuse of analgesics, especially the compound tablets which for many years were freely available over the counter in pharmacies and corner stores, or it could occur as a complication of acute nephritis suffered months or years before.

Neurological problems, too, are by no means rare, whether the disease be multiple sclerosis, a peripheral neuritis due to diabetes, or a spinal cord injury such as paraplegia to name just a few.

Chemical causes are legion - starting from what is probably one of the commonest causes of sexual malfunction - alcohol, ranging through drug abuse n. marijuana, LSD, narcotics, to the medically prescribed drugs such as the tranquillisers (eg. Valium and Serepax). "Go home and take some Valium and relax" - whilst it may sound reasonable advice - especially for people under tension, rarely solves any sexual problems, and may in fact promote iatrogenic disease. Hypotensive drugs used in the treatment of blood pressure, anti-convulsants for epilepsy and many other medications prescribed by the medical profession, can cause worsening or even initiate the problems. The anti-depressant drugs are a more doubtful issue; depression itself produces sexual problems - initially loss of libido, and this commonly progresses to impotence or anorgasmia so it is a chicken and egg situation, because the anti-depressant drugs themselves do have an effect on sexual performance and the difficult situation is to decide whether it is the depression or the medication which is causing the difficulty. The list is endless and there is no point in trying to catalogue all the drugs which may create difficulties.

Finally, one must mention the endocrine or hormonal diseases such as diabetes (and remember that this produces peripheral vascular disease as well as peripheral neuritis, and that unstable diabetics are unlikely to be performing well sexually). With these possible effects, one realises what a major problem diabetes is. Another area of hormonal difficulty comes when there are tumours of pituitary, thyroid or adrenal glands, or of the ovaries or testicles.

The most important decision for anyone trying to help those with sexual problems is when to treat - and when to refer on. The greatest and probably the most serious error anyone can commit, is to tackle tasks for which they are not adequately trained. Any medical practitioner will need the help of many colleagues - both medically qualified and from other fiends. It may be that assistance will be needed from the gynaecologist, the endocrinologist, the urologist, the psychiatrist, the physician or the pathologist, or from several of these. In other fields, help may be required from lawyers, the religious, the academic, the psychologist and the hypnotherapist. It appears that in the interest of the "client", everyone must work together as a team, and NOT try to hold on to patients. Naturally, there will be over laps in the skills available, and at times people will be working in each others areas, but basically it must be accepted that everyone's responsibility is to complement each other.

Perhaps, fortunately(l), knowledge of sex and sexuality are not yet totally scientific, and it really is a difficult art deciding who is suitable for treatment, and knowing what each one of us is capable of achieving. This article will (it is hoped), offer a few insights to assist in the selection of those to whom it is appropriate to offer treatment and help, and those whom it would be best if therapy was refused until the cause has been elicited.

REFERENCES
Sigmund Freud - Three Contributions to the Therapy of Sex (Chapter 2). Harper & Row, 1976.
Sigmund Freud - Totem and Taboo (Chapter 4. Section 3). Harper & Row, 1976.
Wilhelm Reich - The Invasion of Compulsory Sex Morality. Harper & Row, 1976.
Jack Anon - The Behavioural Treatment of Sexual Problems: Brief Therapy. Harper & Row, 1976.
Medical Aspects of Human Sexuality (New York) Vol. 14, No. 4 April 1980
page 10.
Medical Aspects of Human Sexuality, Vol. 14, No. 10, October 1980 pg. 66