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 CONTENTS

About the Editors xvii

Contributors xix
Preface xxiv
Target Audience xxiv
Purpose and Theoretical Framework xxiv
Chapter Outline xxvi
Changes From the Previous Edition xxvii
Organization of the Text xxvii
Acknowledgments xxxi

SECTION 1
The Basics of Sex Therapy 1

1 What Every Sex Therapist Needs to Know 3

JANE RIDLEY

Introduction: Resilience of the Therapist 3

Sexuality and Sexual Behavior: Social Norms 5
Sexual Minorities 6
The Ageing Population 6
Sexual Abuse, Rape, Domestic Violence 7
Conceptualizing Sexual Difficulties 7
The Anatomy and Physiology of Sexuality 8
The Impact of the Internet 8
The Sexual Response Cycle 9
The Four Phases and Two Physiological Changes 9
Male/Female Similarities and Differences 9
The Significance of Desire 10
The Analytic Contribution 10
Cognitive Behavior Therapy (CBT); Eye Movement Desensitization
and Reprocessing (EMDR) and Mindfulness 11
The Complex Female 11
The Dual Control Model for Men 12
Balancing Medical Aspects of Sexuality 12

vii
 CONTENTS

Conclusion 12
References 13

2 The Current Profession of Sex Therapy 17

P E G G Y J . K LE I N P L ATZ

The History of Sex Therapy 17

Recent Trends in the Field 19
The Medicalization of Sexual Problems 20
Responses to Medicalization 22
Professional Sex Therapy Associations 23
The Personal and Professional Process of Becoming a Sex Therapist 24
Ethical Principles of Sex Therapy 25
Is Sex Therapy a Distinct Modality? The Case for Certifying Professionals 26
Conclusions 28
Resources 28
References 28

3 Toward a New Paradigm in Sex Therapy 32

G E R A L D R . WE E KS AN D N AN CY GAMBE SCI A

The Lack of Integration in Couple and Sex Therapy 32

Traditional Sex Therapy Is Non-systemic 32
The Lack of Theory in Sex Science, Research, and Practice 33
The Lack of Integration in Professional Organizations 34
The Lack of Integration of Sex and Couple Therapy Practice 35
The Intersystem Approach 36
Major Domains of the Intersystem Approach 36
Integrational Constructs of the Intersystem Approach 38
Theory of Interaction 38
Intrapsychic Components of the Theory of Interaction 40
Interactional Components of the Theory of Interaction 40
Triangular Theory of Love 42
Attachment Styles 42
Bringing It Together: An Integrative Paradigm 43
Case Example 44
Intersystem Domains 44
Individual 44
Couple 44
Family-of-Origin 45
External Factors 45
Sternberg’s Triangular Theory of Love Constructs 45
Commitment 45
Intimacy 45
Passion 45
Theory of Interaction Constructs 46
Interpretation 46

viii
 CONTENTS

Definition 46
Prediction 46
Congruence 46
Interdependence 46
Attribution 46
Attachment Style Constructs 47
Suggestions for Moving Toward Greater Integration 47
Envision Sexual Problems From an Expansive, Multivariate Framework 47
Expand the Context of Treatment Beyond the Use of Medications 47
Expand Clinical and Research Realms by the Use of: (1) Comprehensive
Conceptual Frameworks, (2) Theoretical Models, and (3) Metatheoretical
Issues 48
Facilitate Movement Away From Theoretical Purism 48
Conduct More Research on the Interface Between Diversity and
Sexual Problems 49
The Future of Theory in Sex Therapy 49
Note 50
References 50

SECTION 2
Treatment of Specific Disorders 53

4 Male Hypoactive Sexual Desire Disorder 55

K AT H RY N H AL L

Prevalence 56
Comorbidity With Other Sexual Dysfunctions 57
Etiology 57
Individual Medical Factors 57
Individual Psychological Factors 58
Intergenerational Factors 58
Interactional/Relationship Factors 59
Assessment 60
Diagnostic Dilemmas 60
Assessment Tools 61
Treatment 64
Case Vignette 67
Treatment Efficacy—Research and Future Directions 67
References 68

5 Systemic Treatment of Erectile Disorder 72

N A N C Y G A MBE SCI A AN D GE RAL D R. WE E KS

Diagnostic Criteria 72
Differential Diagnosis 73
Prevalence 73

ix
 CONTENTS

The Intersystem Approach 74

Intersystemic Assessment 74
Individual Biological Issues 74
Individual Psychological Factors 75
Intergenerational Influences 76
Environmental Considerations 76
The Sex History 77
Intersystemic Treatment 78
Medical Treatments 79
Noncompliance With Medical Therapies 81
Psychological Treatments 81
Promoting Systemic Thinking 82
Reframing the Symptom 82
Supporting Realistic Expectations 82
Changing Cognitions 82
Reducing Anxiety 83
Correcting Mythology 83
Enriching Communication Skills 83
Psychoeducation 84
Homework 84
Promoting Sensuality 84
Expansion of the Sexual Repertoire 85
Relapse Prevention 85
Avoiding Common Mistakes 85
References 86

6 Premature Ejaculation: An Integrative, Intersystems Approach for Couples 90

S T E P H E N J . BE TCH E N

PE Defined 90
Etiology of PE 91
Individual Biological/Physiological Factors 92
Individual Psychological Factors 92
Couple/Dyadic Factors 93
Family-of-Origin Factors 94
Sociocultural Factors 94
The Treatment Model 95
Assessment 95
Medical/Pharmacological Treatment 96
Sex Therapy Exercises: The Stop-Start Method 98
Uncovering Conflicts: Interactional Level 99
Uncovering Conflicts: Psychodynamic Level 100
Resolving Conflicts 100
Termination 101
Case Study 101

x
 CONTENTS

Future Considerations 103

References 103

7 The Complex Etiology of Delayed Ejaculation: Assessment

and Treatment Implications 107
S A L L I E F O L EY AN D N AN CY GAMBE SCI A

Defining Delayed Ejaculation 107

Physiology of Orgasm 108
The Etiology of DE 109
Prevalence 110
Prior and Current Treatments 110
The Intersystem Approach to Treatment 111
Individual Causes of Delayed Ejaculation—Physiological and Psychological 111
Relational Causes of Delayed Ejaculation and Treatment Approaches 112
Intergenerational Causes of Delayed Ejaculation 113
Sociocultural Factors Affecting Delayed Ejaculation 113
Assessment—Establishing Openness and Safety in Sex Therapy 114
Treatment of Delayed Ejaculation 117
Medication/Biological Approaches and the Individual 117
Sensory Defensiveness or Anxiety Treatments and the Individual 118
Masturbation Flexibility and the Individual 119
Increasing Awareness of Outside Influences 119
Couple Techniques 120
Intersystem Approaches in Three Therapeutic Situations 121
Future Directions 122
Note 122
References 122

8 Definition, Etiology, and Treatment of Absent/Low Desire in Women 125

G E R A L D R . WE E KS AN D N AN CY GAMBE SCI A

Prevalence 126
Definition 126
Models of Sexual Desire 128
Theoretical Model of Treatment 129
Clinical Assessment 129
Individual Partners 130
The Couple 130
The Intergenerational System 130
Environmental Factors 130
Etiology 131
Physical Risk Factors in the Individual 131
Psychological Risk Factors in the Individual 131
Interactional Risk Factors 133

xi
 CONTENTS

Intergenerational Risk Factors Including External Risk Factors 133

Environmental Risk Factors 134
Comprehensive Studies Consistent With the Intersystem Approach 134
Treatment Strategies 135
Indications and Contraindications 135
Addressing Pessimism and Skepticism 136
Using Sensate Focus 136
Maintaining a Systemic Focus 137
Responsibility for Sexual Intimacy 137
Setting Priorities 137
Establishing Treatment Goals 138
Implementing Goals 138
Correcting Unrealistic Expectations 138
Lowering Response Anxiety 138
Addressing Affect 139
Cognitive Work 139
Communication 140
Psychoeducation 140
Systemic Homework 140
Treating Other Sexual Dysfunctions 141
Working With Fears of Intimacy 141
Working With Conflict and Anger 142
Creating an Erotic Environment 143
Family-of-Origin 143
Medical Therapies 144
Relapse Prevention 145
Research 145
Conclusion 146
References 147

9 Inhibited Arousal in Women 152

K E VA N R . W YL I E , DE SA MARKO VI C, AN D RUT H HA LLA M-JONES

Definitions 152
Working Paradigms 154
Individual Biological Components 155
Individual Psychological Components 156
Couple Components 156
Family Components 156
Cultural Components 156
Assessment of FSI/AD 157
Preliminary Assessment 158
Sex Therapy Assessment Activities 158
Case Example (Assessment) 159
Physical Examination and Physiological Assessments (Tests) 160

xii
 CONTENTS

Treatment Options in Couples Sex Therapy 160

Case Example—Continued (Treatment) 162
Conclusion 168
References 168

10 Female Orgasmic Disorder 171

M A R I TA P. MCCABE

Definition and Description of Disorder 171

Intersystemic Etiology 172
Intergenerational Influences 172
Individual Influences 173
Relationship Factors 174
Sociocultural Factors 175
Assessment 175
Treatment 176
Effective Strategies From Previous Research 178
Communication 178
Performance Anxiety 179
Systemic Treatment Framework 179
Research and Future Directions 181
Case Study 181
Client 181
Treatment Program 182
Discussion 186
References 186

11 Painful Intercourse: Genito-Pelvic Pain/Penetration Disorder 191

M A RTA M E A N A, CARO L I N E MAYKUT, AN D EVA N FERT EL

Definition and Description 191

Etiology 192
Individual Physiological Factors 192
Individual Psychological Factors 193
Couple Factors 193
Intergenerational Factors 194
Societal/Cultural Factors 194
Assessment 194
Preliminary Assessment and Consultation 195
Treatment-Integrated Assessment 196
Treatment 197
Initial Stage: Education, Goal Setting, Anxiety Reduction 197
Core Stage of Treatment: Connecting the Dots of Pain, Sex, Self,
and Partner 198
Pain and Physiological Processes 198
Sexual Interactions 199

xiii
 CONTENTS

Individual Proclivities 202

Relationship Dynamics 203
Challenges to Therapy 205
Research and Future Directions 206
References 207

SECTION 3
Contemporary Issues in Sex Therapy 211

12 Sex Therapy With Lesbian and Gay Male Couples 213

A R L E N E I S TAR L E V AN D MARGARE T N I CH OLS

Historical Context of Same Sex Couples 216

The Impact of the Subcultural System on Same Sex Couples 217
Couple Relationship and Family Patterns 220
Lesbian Sexuality and Sex Therapy With Female Dyads 223
Case Vignettes 225
Gay Male Sexuality and Sex Therapy With Male Dyads 226
Case Vignettes 228
Summary and Conclusions 230
References 230

13 Sexual Compulsivity: Diagnosis, Assessment, and Treatment 235

D AV I D L . D E L MO N I CO AN D E L I ZABE TH J. GR IFFIN

Definition and Diagnosis of Sexual Addiction 236

Cybersex 238
Sexual Addiction and Sexual Offense Behavior 239
Sexual Offense Awareness 239
Etiology of Sexual Addiction 239
Individual/Biological 239
Individual/Psychological 240
Intergenerational/Environmental 241
Intersystem Approach to Conceptualizing Sexual Addiction 241
Assessment 242
Initial Screening 242
Sexual Interview/Instruments 243
Physical Issues 244
Psychological Issues 244
Treatment Issues 244
Twelve-Step Support Groups 245
Stress and Anxiety Reduction 245
Relapse Prevention 245
Celibacy (Sobriety) Contract 246
Grief and Loss 246
Trauma 246

xiv
 CONTENTS

Spirituality 246
Sexual Health Plans 247
Systemic Considerations 247
Case Example 248
Summary of Case 249
Research and Future Directions 250
References 251

14 The Interplay Between Mental and Sexual Health 255

K E N N E T H WAYN E P H E L P S, ASH L E Y BL ACKMON JONES, A ND R EBEC C A A NN PAY NE

Depressive Disorders 256

Symptoms 256
Antidepressant Pharmacotherapy 257
Type of Sexual Dysfunction by Medication 258
Bipolar Disorders 259
Symptoms 259
Pharmacologic Treatment of Bipolar 260
Anxiety Disorders and Associated Diagnoses 260
Symptoms 260
Pharmacologic Treatment of Anxiety 262
Type of Sexual Dysfunction by Medication 263
Somatic Disorders 263
Eating Disorders 264
Substance Use Disorders 264
Alcohol 265
Marijuana 265
Opioids 266
Stimulants 266
Other Psychiatric Disorders 267
The Intersystem Approach to Mental and Sexual Health 269
Individual System 269
Couple System 270
Intergenerational System 271
Final Clinical Pearls 271
Work It Up 271
Ask and You Shall Receive 271
Give Me All the Details 271
Let’s Talk About Sex 271
Don’t Hesitate, Collaborate! 272
References 272

15 Sex Therapy: A Panoramic View 276

G E R A L D R . WE E KS, N AN CY GAMBE SCI A, AND K AT HER INE M. HERT LEIN

A Look Behind: Where We’ve Been 276

xv
 CONTENTS

Lack of a Systemic Focus in Sex Therapy 276

Behavioral Concentration in Sex Therapy 277
Bifurcation of Marital and Sex Therapy 277
A Look Around: Where We Are 277
A Shift in Perspective: The Need for Integration in Sex Therapy 277
Acknowledgment of the Interplay Between Biology and Sexuality
in Sex Therapy 279
Medicalization of Sex Therapy 279
Greater Openness Regarding Sexuality and Sexual Problems 280
The Incorporation of Technology into Our Sexual Lives 281
Sexual Compulsivity 281
Special Populations 282
Theoretical Gaps in Sex Therapy 285
Looking Ahead: Future Directions 286
The Effect of Increased Medicalization 286
Infusing Theory Into Practice 286
Developing and Utilizing Integrative Approaches 287
Education/Training Implications 288
New Approaches 289
Research 290
The Way Forward 291
References 292

16 Epilogue: A Personal Note on Being a Sex Therapist 299

G E R A L D R . WE E KS, N AN CY GAMBE SCI A, AND K AT HER INE M. HERT LEIN

Index 301

xvi
 ABOUT THE EDITORS

Katherine M. Hertlein, Ph.D., is an associate professor and the Program Director of the
Marriage and Family Therapy Program at the University of Nevada, Las Vegas. She
received her master’s in marriage and family therapy from Purdue University Calumet
and her doctorate in human development with a specialization in marriage and fam-
ily therapy from Virginia Tech and is an AAMFT Approved Supervisor. Across her
academic career, she has published over 50 articles, six books, and over 25 book chap-
ters. She has co-edited a book on interventions in couples treatment, interventions for
clients with health concerns, and a book on infidelity treatment. Dr. Hertlein has also
produced the first multitheoretical model detailing the role of technology in couple and
family life published in her latest book, The Couple and Family Technology Frame-
work. She presents nationally and internationally on sex, technology, and couples. Dr.
Hertlein has won numerous awards including the 2008 and 2014 Greenspun College
of Urban Affairs Outstanding Teaching Award, the 2010 Greenspun College of Urban
Affairs Outstanding Research Award, the 2013 Supervisor of the Year Award from the
Nevada Association for Marriage and Family Therapy, the 2013 Outstanding Mentor
Award from UNLV’s Graduate and Professional Student Association, the 2014 Nevada
System of Higher Education’s Regent’s Rising Researcher Award, and the 2014 Barrick
Scholar Award from the University of Nevada, Las Vegas.
Gerald R. Weeks, Ph.D., ABPP, is a professor in the Marriage and Family Therapy Pro-
gram at the University of Nevada-Las Vegas. For over 30 years, he has published,
conducted research, practiced, taught, and supervised sex, couple, and family therapy.
Dr. Weeks is a licensed psychologist, Approved-Supervisor, and Clinical Fellow of the
American Association of Marriage and Family Therapy, a Diplomate and Senior Exam-
iner of the American Board of Family Psychology, and a member of the American
Board of Sexology. He has published 20 books, including one or more classic texts in
the fields of individual, sex, couple, and family therapy. Several of his texts are widely
used in Marriage and Family Therapy Programs. In 2009, he was the 16th member
to receive the “Outstanding Contribution the Marriage and Family Therapy” award
from the American Association of Marriage and Family Therapy in its 60 year his-
tory. In 2010, the American Psychological Association awarded “Family Psychologist
of the Year” to Dr. Weeks. One of his major contributions to the field of couple and
sex therapy is the development of a new paradigm of therapy known as the Intersystem
Approach. Dr. Weeks has lectured and conducted intensive training in couple and sex
therapy throughout North America, Europe, and Australia.
Nancy Gambescia, Ph.D., CST, is the Director of the Postgraduate Program in Sex Ther-
apy at the Council for Relationships, Philadelphia, PA. The Program is one of very

xvii
 ABOUT THE EDITORS

few in the U.S. that provides AASECT (American Association of Sex Educators Coun-
selors and Therapists) approved post-graduate training in sex therapy. Also, she is a
clinical associate in Psychiatry at the Perelman School of Medicine at the University
of Pennsylvania. Dr. Gambescia has over 30 years of experience in teaching, supervis-
ing and working with individuals and couples. Dr. Gambescia is a Clinical Fellow and
Approved Supervisor in the American Association of Marriage and Family Therapy
(AAMFT). She is also a Clinical Member, Certified Sex Therapist, and Approved Super-
visor of Sex Therapy in AASECT. Dr. Gambescia is a member of the Society for Sex
Therapy and Research (SSTAR), and a certified sexologist and diplomate of the Ameri-
can Board of Sexology. She has coauthored six books (two in press) that emphasize the
Intersystem Approach to couple and sex therapy and written numerous journal articles
and textbook chapters, which focus on relationship and sexual issues. She has pre-
sented a number of refereed and invited lectures and workshops in The United States
and Europe on couple and sex therapy.

xviii
 CONTRIBUTORS

Stephen J. Betchen, D.S.W., L.M.F.T., is an AAMFT Approved Supervisor and AASECT

Certified Supervisor with a full-time private practice specializing in couples and sex
therapy. He is also a clinical assistant professor in the graduate program for couples
and family therapy at Thomas Jefferson University, and a senior supervisor in the post-
graduate sex therapy program at the Council for Relationships. Dr. Betchen has pub-
lished three books and several scholarly articles on relationships.
David L. Delmonico is a professor at Duquesne University in Pittsburgh, Pennsylvania.
Dr. Delmonico is a graduate of Kent State University’s Counseling and Human Devel-
opment Services Program. He conducts research, consultation, and training on topics
such as cybersex, cyberoffense, and cybersafety. Dr. Delmonico also lectures on topics
such as general Internet psychology and sexually addictive and compulsive behaviors.
Dr. Delmonico is co-author of In the Shadows of the Net, Cybersex Unhooked, Cyber-
sex Unplugged, and his latest book, Illegal Images. He has published numerous schol-
arly articles on a variety of addiction and sexuality topics. Dr. Delmonico is Director of
the Online Behavior Research and Education Center (OBREC) at Duquesne University
and Associate Editor of the Sexual Addiction & Compulsivity journal.
Evan Fertel is a Ph.D. student in the clinical psychology program at the University of
Nevada, Las Vegas. His research investigates the role of self-focus in sexual desire and
arousal and sex differences therein.
Sallie Foley, LMSW is the director of the Center for Sexual Health at the University
of Michigan Health Systems and teaches at the University of Michigan. She has a
private practice in psychotherapy and consultation in Ann Arbor. She is on the medi-
cal advisory board for the Intersex Society of North America and is an AASECT
certified sex therapist. She writes and lectures frequently on the subject of human
sexuality.
Elizabeth J. Griffin, M.A., is a licensed marriage and family therapist with over 27 years
of experience treating individuals with sexually problematic behaviors, especially those
that involve the Internet. She has worked in out-patient, in-patient, military, and prison
settings. Ms. Griffin lectures nationally on the assessment and treatment of sexual
offenders and those with sexually compulsive behavior, as well as issues related to
cybersex. She is currently a consultant for the Minnesota Civil Commitment Program.
She has written numerous professional articles on these topics, and is co-author of four
books—In the Shadows of the Net, Cybersex Unhooked, Cybersex Unplugged, and
Illegal Images. Ms. Griffin is the founder of Internet Behavior Consulting, a company
focused on issues related to problematic online behavior.

xix
 CONTRIBUTORS

Kathryn Hall, Ph.D., is a clinical psychologist in private practice in Princeton, New Jersey.
She has conducted research on a variety of sex-related topics and has presented at national
and international conferences. Her current interest is in the cultural variations in the expe-
rience and treatment of sexual problems. Dr. Hall is coeditor of the Cultural Context of
Sexual Pleasure and Problems: Psychotherapy with Diverse Clients. She is the author of
Reclaiming Your Sexual Self: How You Can Bring Desire Back Into Your Life.
Ruth Hallam-Jones now works as an independent clinician providing sexual and rela-
tionship assessment, psychotherapy, and sexual medicine resources. She uses retreats
based on systemic residential sex therapy. She also provides individual and group
training for professionals. She has worked as a nurse and sexual and relationship
therapist for over 30 years. An experienced and creative clinician, Ruth has gained
her understanding of systemic work with patients with sexual and relationship prob-
lems not just from her training but also from working in community and residential
psychiatry and psychotherapy settings in Sheffield, Rotherham, and the Maudsley,
London, and from the residential sex therapy used by Restoration-Therapy. She has
also worked for ten years in outpatient sexual medicine services. Until recently she
co-ordinated training and was the senior psychotherapist at Porterbrook Clinic,
Sheffield.
Ashley Blackmon Jones, M.D., is a board certified adult psychiatrist. She is an assistant
clinical professor and the director of Adult Resident Outpatient Clinics in the Depart-
ment of Neuropsychiatry and Behavioral Science at the University of South Carolina
School of Medicine. Dr. Jones is also the assistant program director for the General Psy-
chiatry Residency Training Program at Palmetto Health/University of South Carolina
School of Medicine. In professional psychiatric practice she has worked in the areas
of emergency psychiatry, consultation-liaison, outpatient psychiatry, the department
of corrections, and in the division of biological research. She currently supervises an
integrated care clinic in the Department of Obstetrics and Gynecology, which provides
psychiatric care to pregnant and postpartum women. She is a member of the American
Psychiatric Association, South Carolina Psychiatric Association, and American Asso-
ciation of Directors of Psychiatric Residency Training and serves as a board member for
Mental Health America of South Carolina. Dr. Jones is an active presenter in the com-
munity, medical school, and within the Palmetto Health residency programs of psychia-
try, internal medicine, family medicine, and obstetrics and gynecology. Presentations,
lectures, and posters include topics on women’s mental health, resident wellness, psy-
chopharmacology, emergency psychiatry, brief psychotherapies, psychiatric interviews,
and biological-psychological-social formulation.
Peggy J. Kleinplatz, Ph.D., is professor of medicine and clinical professor of psychology
at the University of Ottawa. She is a clinical psychologist, certified in sex therapy,
in sex education, and has a diplomate in and is a supervisor of sex therapy. Since
1983, she has been teaching human sexuality at the School of Psychology, University of
Ottawa, where she received the Prix d’Excellence in 2000. She is currently chair of eth-
ics and former chair of certifications for the American Association of Sexuality Educa-
tors, Counselors and Therapists. Kleinplatz has edited three books, most recently, New
Directions in Sex Therapy: Innovations and Alternatives (Routledge, 2nd edition), win-
ner of the AASECT 2013 Book Award. Her clinical work focuses on eroticism and
transformation. Her current research focuses on optimal sexuality, with a particular
interest in sexual health in the elderly, disabled, and marginalized populations.

xx
 CONTRIBUTORS

Arlene Istar Lev, LCSW-R, CASAC, is a social worker, family therapist, educator, and writer
whose work addresses the unique therapeutic needs of lesbian, gay, bisexual, and trans-
gender people. She is part-time lecturer at the University at Albany, School of Social
Welfare and is the project director of the Sexual Orientation and Gender Identity Project
(SOGI). She is also an adjunct professor at Smith School of Social Work, Empire Col-
lege, Excelsior College, and the Rockway Institute, California School of Professional Psy-
chology at Alliant International University. Ms. Lev is the founder and clinical director
of Choices Counseling and Consulting and The Training Institute for Gender, Relation-
ships, Identity, and Sexuality (TIGRIS), in Albany, New York (www.choicesconsulting.
com). She has authored numerous journal articles and essays including authoring two
books: The Complete Lesbian and Gay Parenting Guide and Transgender Emergence,
winner of the APA (Division 44) Distinguished Book Award, 2006.
Desa Markovic, DPsych, holds the post of program director for psychotherapy and coun-
selling at Regent’s University London. Her clinical practice has spanned over 30 years
and is currently based at Covent Garden Counselling in London where she specializes
in systemic and psychosexual therapy and supervision. After studying clinical psychol-
ogy in Belgrade, Yugoslavia, she continued with post graduate training in systemic
family therapy at Kensington Consultation Centre in London subsequently obtaining
a clinical doctorate in psychotherapy from the University of London. She has taught
on systemic and sexual therapy courses at various institutions including the Institute
of Family Therapy in London and the Porterbrook Clinic in Sheffield. Her most recent
publications and international conference presentations relate to her current area of
interest being the development of a Multidimensional Model integrating systemic
approach and sexology.
Caroline Maykut is a Ph.D. student in the clinical psychology program at the University of
Nevada, Las Vegas. Her research centers on the investigation of how men and women
self-assess their own sexual desire levels and the extent to which these assessments are
related to sexual function and well-being.
Marita P. McCabe, Ph.D., is a professor of psychology and the foundation director of
the Health and Well Being Research Priority Area at Deakin University in Melbourne,
Australia. She is an associate editor for the Journal of Sexual Medicine and Body Image,
and is on the editorial board of the Journal of Sex Research. As well as her clinical
experience, she has over 400 refereed articles and book chapters. Professor McCabe
has obtained research grants and supervised postgraduate students conducting stud-
ies on sexual dysfunction, sex and disability, sexual harassment, sexual abuse, rape,
extramarital affairs, and adolescent sexuality. In particular, she has conducted a series
of studies that have investigated aetiology and most effective method of treatment for
sexual dysfunction. She has recently devised and evaluated an Internet based treatment
program for the treatment of erectile dysfunction and also for the treatment of female
sexual dysfunction.
Marta Meana, Ph.D., is professor of psychology, dean of the Honors College at the Uni-
versity of Nevada, Las Vegas, and is past president of the Society for Sex Therapy
and Research. The author of numerous books, peer-reviewed publications, chapters,
and conference presentations on sexuality and women’s health, her early work was
instrumental in the reconceptualization of dyspareunia as a pain disorder. Her current
research on female sexual desire also seeks to deconstruct traditional notions of desire
and its relationship to behavior. Dr. Meana’s work has been featured widely in national

xxi
 CONTRIBUTORS

and international media, including in the New York Times, the Charlie Rose show, and
the Oprah Winfrey Show. She currently serves on the editorial boards of the Archives
of Sexual Behavior and the Journal of Sex Research and she is a Fellow of the Society
for the Scientific Study of Sexuality. She was also an advisor to the DSM-5 Sexual
Dysfunctions Workgroup and is a licensed clinical psychologist in the state of Nevada.
Margaret Nichols, Ph.D., is a psychologist, sex therapist, and executive director of the
Institute for Personal Growth, a psychotherapy organization in New Jersey specializ-
ing in sex therapy and other clinical work with the sex and gender diverse community.
She has been active in community mental health for many years, helping to start one of
the first shelters for victims of domestic violence in the 1970s and the Hyacinth Foun-
dation, New Jersey’s largest HIV support and service agency, in 1985. She is an inter-
national speaker on LGBTQ issues and author of many articles and papers on LGBTQ
sexuality. Her current primary clinical areas of interest are transgender and gender
nonconforming young people, and those who make up the ‘Q’ in LGBTQ, e.g., kinky,
polyamorous, and queer people. She is also working on developing a queer theory of
sex therapy and sex science.
Rebecca Ann Payne, M.D., is board certified in general and addiction psychiatry. She is
an assistant clinical professor in the Department of Neuropsychiatry and Behavioral
Science at the University of South Carolina School of Medicine. Dr. Payne primarily
functions as a clinician-educator, treating inpatients and outpatients with comorbid
psychiatric and substance use disorders, supervising medical students and psychiatry
residents, and educating the community about co-occurring disorders.
Kenneth Wayne Phelps, Ph.D., LMFT is an assistant clinical professor and outpatient
clinic director in the Department of Neuropsychiatry and Behavioral Science at the
University of South Carolina’s School of Medicine. Dr. Phelps has a doctorate in medi-
cal family therapy from East Carolina University, specializing in treating youth, adults,
and couples navigating medical illness. He is a member of the American Association of
Sexuality Educators, Counselors, and Therapists and American Association for Mar-
riage and Family Therapy through which he has attained the designation of AAMFT
Approved Supervisor. Dr. Phelps completed a predoctoral internship at Dartmouth
Family Practice Residency Program associated with Concord Hospital in New Hamp-
shire. He has presented and published on the topics of sexual health, relational health,
diabetes, tic disorders, autism, and residency education.
Jane Ridley, B.A. PQSW, trained originally as a social worker at the London School of
Economics and at the University of Newcastle and as a mature student at the Insti-
tute of Psychiatry. She ran the Richmond Fellowship training in residential care of the
recovering mentally ill, for 7 years and joined Dr. M. Crowe in 1983 at the Marital
and Sexual Therapy Clinics. She was instrumental in developing the course in relation-
ship and sexual therapy, which offered both MSc and Diploma at the Maudsley and
Institute of Psychiatry. She further developed her work in supervision, running courses
for experienced therapists. She has also been chair of the Family, Marital and Sexual
Section of UKCP and a member of the Governing Board of UKCP. She currently works
privately. Her writing includes joint authorship of Therapy with Couples, a behavioral-
systems approach to relationship and sexual problems (Blackwell Science 2000, 2nd
ed.), and authorship of Intimacy in Crisis (Pub Whurr 1999). In 2007 she contributed
chapters 17 and 18 to The Handbook of Clinical Adult Psychology (eds. Stan Lindsay
and Graham Powell, 3rd ed.).

xxii
 CONTRIBUTORS

Kevan R. Wylie, FRCP FRCPsych FRCOG FECSM, is a consultant in sexual medicine for the
NHS in Sheffield, UK, and leads the Sexual Therapy, Sexual Medicine, and Andrology
(Urology) services. His academic appointments include honorary professor at The Univer-
sity of Sheffield, visiting professor at Sheffield Hallam University, and course director of
the Sheffield MSc program on Sexual & Relationship Psychotherapy. Kevan was awarded
the EFS Gold Medal in 2008 for his work into sexual medicine, sexology, and sex educa-
tion across Europe, has published in excess of 140 peer reviewed papers and 15 book
chapters, and is the current president of the World Association for Sexual Health.

xxiii
 PREFACE

Authors are motivated to write texts because they wish to make a significant contribution
to a field of study or they perceive a theoretical gap in the existing literature. The first edi-
tion of Systemic Sex Therapy represented our attempt to provide a book that would serve
as an introduction to the field of sex therapy from a systems perspective. The first edition
outperformed our expectations and has been adopted in a number of marriage and family
therapy programs in the United States and other countries. We were encouraged by our
colleagues and editors to produce a second edition of this popular book.

Target Audience
There are two target audiences for this book. Graduate students in marriage and fam-
ily therapy programs, who are knowledgeable in systems thinking, wanted a book that
was written from a systems perspective. The other target audience is the many clinicians
who want to progress to a more comprehensive and integrative understanding of sexual
dysfunctions. Some sex therapists have had some training in systems thinking and will
gravitate toward our Intersystem theoretical position. Others, unfortunately, have had
no training in systems thinking and although interested in a systems approach will, by
default, continue to think and practice from an individually oriented framework. One
only has to attend professional sex therapy conferences or read the literature to observe
the theoretical divide that exists within the field. Some of the more senior members of the
field of sex therapy are unfamiliar with systemic thinking and will have limited interest in
changing their theoretical approach.

Purpose and Theoretical Framework

Our objective is to present a highly focused and comprehensive text that promotes under-
standing of the etiology and treatment of sexual problems from a systemic perspective. We
believe that the second edition of Systemic Sex Therapy continues to be very comprehen-
sible, offering descriptive discussions of sex therapy without using a great deal of profes-
sional and/or technical jargon. This edition will be helpful to both graduate students and
practitioners desiring a greater understanding of the current literature in the field of sex
therapy within a systemic framework.
This book’s main purpose is to accomplish what we believe no other book in the field of
sex therapy has ever fully done. It is based on a unique approach to systems theory (called
the Intersystem Approach; Weeks, 1989), one that involves the partner and treats the cou-
ple, rather than the individual, as a unit. Most published books in the field of sex therapy
are behaviorally grounded and/or medically driven. This circumstance is not surprising

xxiv
Another random document with
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double action which pours it into Water, and volatilizes it into Air, and sifts
it to ashes which are Earth. For man can fashion effigies, but the spark of
Life he can neither infuse nor control.

As a sharp sun this man passed across his century, and of the cenotaphs
of his burning, some remain as a shadow of splendour in the streets of his
city, but others have returned whence he gathered them, for the years of
these are many and the touch of kings upon them is as the dropping of
particles of dust.

VENICE AGAIN

Sunday evening, May 23, 1915. A beautiful Sunday evening with the
Lagoon just going purple, and the angel on the tip of the new Campanile
dissolved to a spurt of crocus-coloured flame. Up into the plum-green sky
mount the angels of the Basilica of Saint Mark, their wings, curved up and
feathered to the fragility of a blowing leaf, making incisive stabs of
whiteness against the sky.

An organ moans in the great nave, and the high voices of choristers float
out through the open door and surge down the long Piazza. The chugging of
a motor-boat breaks into the chant, swirls it, churns upon it, and fades to a
distant pulsing down the Grand Canal. The Campanile angel goes suddenly
crimson, pales to rose, dies out in lilac, and remains dark, almost invisible,
until the starting of stars behind it gives it a new solidity in hiding them.

In the warm twilight, the little white tables of the Café Florian are like
petals dropped from the rose of the moon. For a moment they are weird and
magical, but the abrupt glare of electric lights touches them back into mere
tables: mere tables, flecked with coffee-cups and liqueur-glasses; mere
tables, crumpling the lower halves of newspapers with their hard edges;
mere tables, where gesticulating arms rest their elbows, and ice-cream
plates nearly meet disaster in the excitement of a heated discussion. Venice
discusses. What will the Government do? Austria has asked that her troops
might cross over Italian territory, South of Switzerland, in order to attack
the French frontier. Austria! "I tell you, Luigi, that alliance the Government
made with the Central Powers was a ghastly blunder. You could never have
got Italians to fight on the side of Austrians. Blood is thicker than ink,
fortunately. But we are ready, thanks to Commandante Cadorna. It was a
foregone conclusion, ever since we refused passage to their troops." "I saw
Signor Colsanto, yesterday. He told me that the order had come from the
General Board of Antiquities and Fine Arts to remove everything possible
to Rome, and protect what can't be moved. He begins the work to-morrow."
"He does! Well, that tells us. Here, Boy, Boy, give me a paper. Listen to that
roar! There you are, cinque centesimi. Well, we're off, Luigi. It's declared.
Italy at war with Austria again. Thank God, we've wiped off the stain of
that abominable treaty." With heads bared, the crowd stands, and shouts,
and cheers, and the pigeons fleer away in frightened circles to the
sculptured porticoes of the Basilica. The crowd bursts into a sweeping song.
A great patriotic chorus. It echoes from side to side of the Piazza, it runs
down the colonnades of the Procuratie like a splashing tide, it dashes upon
the arched portals of Saint Mark's and flicks upward in jets of broken
music. Wild, shooting, rolling music; vibrant, solemn, dedicated music;
throbbing music flung out of loud-pounding hearts. The Piazza holds the
sound of it and lifts it up as one raises an offering before an altar. Higher—
higher—the song is lifted, it engulfs the four golden horses over the centre
door of the church. The horses are as brazen cymbals crashing back the
great song in a cadence of struck metal, the carven capitals are fluted reeds
to this mighty anthem, the architraves bandy it to and fro in revolving
canons of harmony. Up, up, spires the song, and the mounting angels call it
to one another in an ascending scale even to the star of fire on the topmost
pinnacle which is the Christ, even into the distant sky where it curves up
and over falling down to the four horizons, to the highest point of the
aconite-blue sky, the sky of the Kingdom of Italy.

Garibaldi's Hymn! For war is declared and Italy has joined the Allies!

Soft night falling upon Venice. Summer night over the moon-city, the
flower-city. Fiore di Mare! Garden of lights in the midst of dark waters,
your star-blossoms will be quenched, the strings of your guitars will snap
and slacken. Nights, you will gird on strange armour, and grow loud and
strident. But now— The gilded horses shimmer above the portico of Saint
Mark's! How still they are, and powerful. Pride, motion, activity set in a
frozen patience.

Suddenly—Boom! A signal gun. Then immediately the shrill shriek of a

steam whistle, and another, and whistles and whistles, from factories and
boats, yawling, snarling, mewling, screeching, a cracked cacophony of
horror.

Minutes—one—two—three—and the batteries of the Aerial-Guard

Station begin to fire. Shells—red and black, white and grey—bellow, snap,
and crash into the blue-black sky. A whirr—the Italian planes are rising.
Their white centre lights throw a halo about them, and, tip and tip, a red
light and a green, spark out to a great spread, closing together as the planes
gain in altitude. Up they go, the red, white, and green circles underneath
their wings and on either side of the fan-tails bright in the glow of the white
centre light. Up, up, slanting in mounting circles. "Holy Mother of God!
What is it?" Taubes over the city, flying at a great height, flying in a wedge
like a flight of wild geese. Boom! The anti-aircraft guns are flinging up
strings of luminous balls. Range 10,000 feet, try 10,500. Loud detonations,
echoing far over the Lagoon. The navigation lights of the Italian planes are
a faint triangle of bright dots. They climb in deliberate spirals, up and up,
up and up. They seem to hang. They hover without direction. Ah, there are
the Taubes, specks dotting the beam of a search-light. One of them is
banking. Two Italian machines dart up over him. He spins, round—round—
top-whirling, sleeping in speed, to us below he seems stationary. Pup-pup-
pup-pup-pup—machine-guns, clicking like distant typewriters, firing with
indescribable rapidity. The Italian planes drop signal balloons, they hang in
the air like suspended sky-rockets, they float down, amber balls, steadily
burning. The ground guns answer, and white buds of smoke appear in the
sky. They seem to blossom out of darkness, silver roses beyond the silver
shaft of the search-light. The air is broken with noise: thunder-drumming of
cannon, sharp pocking of machine-guns, snap and crack of rifles. Above,
the specks loop, and glide, and zig-zag. The spinning Taube nose-dives,
recovers, and zums upward, topping its adversary. Another Taube swoops in
over a Nieuport and wags its tail, spraying lead bullets into the Italian in a
wide, wing-and-wing arc. The sky is bitten red with stinging shrapnel. Two
machines charge head on, the Taube swerves and rams the right wing of the
Nieuport. Flame! Flame leaping and dropping. A smear from zenith to—
following it, the eye hits the shadow of a roof. Blackness. One poor devil
gone, and the attacking plane is still airworthy though damaged. It wobbles
out of the search-light and disappears, rocking. Two Taubes shake
themselves free of the tangle, they glide down—down—all round them are
ribbons of "flaming onions," they avoid them and pass on down, close over
the city, unscathed, so close you can see the black crosses on their wings
with a glass. Rifles crack at them from roofs. Pooh! You might as well try to
stop them with pea-shooters. They curve, turn, and hang up-wind. Small
shells beat about them with a report like twanged harp-strings. "Klar sum
Werfen?" "Jawohl." "Gut dock, werfen." Words cannot carry down
thousands of feet, but the ominous hovering is a sort of speech. People
wring their hands and clutch their throats, some cover their ears. Z-z-z-z-z!
That whine would pierce any covering. The bomb has passed below the
roofs. Nothing. A pause. Then a report, breaking the hearing, leaving only
the apprehension of a great light and no sound. They have hit us!
Misericordia! They have hit Venice! One—two—four—ten bombs. People
sob and pray, the water lashes the Rivas as though there were a storm.
Another machine falls, shooting down in silence. It is not on fire, it merely
falls. Then slowly the Taubes draw off. The search-light shifts, seeking
them. The gun-fire is spaced more widely. Field-glasses fail to show even a
speck. There is silence. The silence of a pulse which has stopped. But the
people walk in the brightness of fire. Fire from the Rio della Tanna, from
the Rio del Carmine, from the quarter of Santa Lucia. Bells peal in a fury,
fire-boats hurry with forced engines along the canals. Water streams jet
upon the fire; and, in the golden light, the glittering horses of Saint Mark's
pace forward, silent, calm, determined in their advance, above the portal of
the untouched church.

The night turns grey, and silver, and opens into a blue morning. Diamond
roses sparkle on the Lagoon, but the people passing quickly through the
Piazza are grim, and workmen sniff the smoky air as they fix ladders and
arrange tools. Venice has tasted war. "Evviva Italia!"
 City of soft colours, of amber and violet, you are turning grey-green, and
grey-green are the uniforms of the troops who defend you. The Bersaglieri
still wear their cocks' feathers, but they are green too, and black. Black as
the guns mounted on pontoons among the Lagoons before Venice, green as
the bundles of reeds camouflaging them from Austrian observation
balloons. Drag up metre after metre of grey-green cloth, stretch it over the
five golden domes of Saint Mark's Basilica. Hood their splendour in
umbrella bags of cloth, so that not one glint shall answer the mocking
shimmer of the moon. Barrows and barrows of nails for the wooden bastion
of the Basilica, hods and hods of mortar and narrow bricks to cover the old
mosaics of the lunettes. Cart-loads of tar and planking, and heaps, heaps,
hills and mountains of sand—the Lido protecting Venice, as it has done for
hundreds of years. They shovel sand, scoop sand, pour sand, into bags and
bags and bags. Thousands of bags piled against the bases of columns, rising
in front of carved corners, blotting out altars, throttling the open points of
arches. Porphyries, malachites, and jades are squarely boarded, pulpits and
fonts disappear in swaddling bands. Why? The battle front is forty miles
away in Friuli, and Venice is not a fortified town. Why? Answer, Reims!
Bear witness, Ypres! Do they cover Venice without reason? Nietzsche was a
German, still I believe they read him in Vienna. Blood and Iron! And is
there not also Blood and Stone, Blood and Bronze, Blood and Canvas?
"Kultur," Venetians, in the Rio del Carmine; there is no time to lose. Take
down the great ceiling pictures in the Ducal Palace and wrap them on
cylinders. Build a high trestle, and fashion little go-carts which draw with
string.

Hush! They are coming—the four beautiful horses. They rise in a whirl
of disturbed pigeons. They float and descend. The people watch in silence
as, one after another, they reach the ground. Across the tiles they step at
last, each pulled in a go-cart; merry-go-round horses, detached and solitary,
one foot raised, tramp over chequered stones, over chequered centuries. The
merry-go-round of years has brought them full circle, for are they not
returning to Rome?

For how long? Ask the guns embedded in the snow of glaciers; ask the
rivers pierced from their beds, overflowing marshes and meadows, forming
a new sea. Seek the answer in the faces of the Grenatieri Brigade, dying to a
man, but halting the invaders. Demand it of the women and children fleeing
the approach of a bitter army. Provoke the reply in the dryness of those eyes
which gaze upon the wreck of Tiepolo's ceiling in the Church of the Scalzi.
Yet not in Italy alone shall you find it. The ring of searching must be
widened, and France, England, Japan, and America, caught within its edge.
Moons and moons, and seas seamed with vessels. Needles stitching the
cloth of peace to choke the cannon of war.

The boat draws away from the Riva. The great bronze horses mingle
their outlines with the distant mountains. Dim gold, subdued green-gold,
flashing faintly to the faint, bright peaks above them. Granite and metal,
earth over water. Down the canal, old, beautiful horses, pride of Venice, of
Constantinople, of Rome. Wars bite you with their little flames and pass
away, but roses and oleanders strew their petals before your going, and you
move like a constellation in a space of crimson stars.

So the horses float along the canal, between barred and shuttered
palaces, splendid against marble walls in the fire of the sun.

Printed in the United States of America.

Books by AMY LOWELL

PUBLISHED BY
HOUGHTON MIFFLIN COMPANY

Poetry

WHAT'S O'CLOCK
LEGENDS
PICTURES OF THE FLOATING WORLD
CAN GRANDE'S CASTLE
MEN, WOMEN AND GHOSTS
SWORD BLADES AND POPPY SEED
A DOME OF MANY-COLOURED GLASS
A CRITICAL FABLE

(IN COLLABORATION WITH FLORENCE ATSCOUGH)

FIR-FLOWER TABLETS: POEMS TRANSLATED FROM THE
CHINESE

Prose

TENDENCIES IN MODERN AMERICAN POETRY

SIX FRENCH POETS: STUDIES IN CONTEMPORARY LITERATURE
JOHN KEATS
 *** END OF THE PROJECT GUTENBERG EBOOK CAN
GRANDE'S CASTLE ***

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