At Harmony Place Monterey, the most common sexual problems we treat are desire phase disorders.

Masters and Johnson wrote very little about their approach to desire phase disorders. When I was a therapist with them for many years, I co-wrote an article in 1977 to conceptualize how we treated Inhibited Sexual Desire. In that article, Dr. Masters and I co-wrote that desire phase difficulty often result from intimacy issues in an individual or between a couple, and it is necessary to identify contributing factors before intervention makes sense. For example, if a man is hypogonadal (doesn’t produce normal amounts of testosterone), hormone replacement therapy is necessary before initiating therapy. Similarly, if the same man has a history of being enmeshed with his mother, sexual abuse, or other experiences that interfered with sexual unfolding, they might also emerge as a disturbance of desire. The treatment would and should be directly related to the cause. Factors contributing to an individual presenting with Inhibited Sexual Desire are listed in Table 1 and are self-explanatory.

Additionally, since individuals frequently choose partners with similar issues, the couple often produces more complicated problems, mainly because when one person says no to sex the other can feel unloved. Therefore, Masters and Johnson believed that there is no such thing as an uninvolved partner when treating sexual difficulties. The focus was on the “relationship.”

The most obvious and frequent problem contributing to sexual dysfunction, then and now, is ignorance. Most couples don’t know how to make love effectively.

Additionally, if two individuals work long hours with no time to relax or play, they may also not take sufficient time to enjoy sex. Couples often require skill training in communication, managing anger and conflict, and problem-solving, rather than just focusing on sex.

Masters and Johnson devised sensate focus as a tool to expose couples to close physical interaction and see what blocks “pop-up” that interfere with love-making. In sensate focus, the emphasis is on nude touching of each other in a mindful way without regard for sexual response or pleasure for oneself or one’s partner.[6, The aim is to increase personal and interpersonal awareness of self and the other’s needs and to take the pressure off of performance. Each participant is encouraged to focus on their own varied sense experience, rather than to see orgasm as the sole goal of sex.[4][5]

Typically, the blocks that emerged in sensate focus were multiple and complex, both characteristic of the individual and the couple.

As Helen Kaplan, MD, PhD, noted, the problems most often related to deeper issues of psychopathology and intimacy disorder. Bernie Applebaum ( ) described the Masters and Johnsons approach as “entitlement or paradoxical permission not to be sexual.” In sex therapy, the therapist might say to the client, “It is understandable that, given what happened to you, and what you’ve done to yourself as a result, and the destructive influence on your choice of partner, and the relationship you both created, you would not feel sexual.” Sensate focus would catalyze the stuck points interfering with the individual’s erotic development and the couple’s connection and affectional system.

Tables 1 and 2 are conditions necessary for an individual and a couple to feel entitled to experience sexual desire. If two healthy people love each other, become close friends and are physically healthy, the sexual response should be unimpeded. It is a congenital response, a birthright. At Harmony Place Monterey, we remove the roadblocks to sexual desire, allowing the natural desire to emerge. “Sex is a natural function” was the cornerstone of the Masters and Johnson philosophy.

In the early days of sex therapy, the most common issue behind low sexual desire was a history of sexual trauma in one or both individuals, and techniques for resolution were not yet clearly established. Today post traumatic stress related to sexual trauma can be efficaciously treated, yet treatment of PTSD is rarely sufficient to reverse sexual desire difficulties. Why?

As mentioned earlier, couples’ issues are often superimposed on the individual’s issues (such as sexual trauma) which compounds the problem. Sexual difficulties in adulthood are more a reflection of unfinished business than expressions of lack of commitment, caring, love or friendship. Unfinished business is an emotional reaction guided by strong feelings based on past anxiety. Unfinished business can dictate pivotal portions of our adult life. Who we bring into our life, major life decisions such as career and lifestyle, how we interact with important people, and the emotional closeness or distance we need to feel safe and loved are all shaped by unfinished business (Freeman 1972).

The diagnosis of inhibited sexual desire remains high — as many as one out of 10 women do not enjoy sex with their partner. Successful treatment requires artful skill as it combines behaviorally based relational therapy, sex therapy and PTSD work. Effectiveness depends on uncovering the root causes, maximizing the couples’ dynamic, and the therapist competency. In our experience, the short-term, time-limited intervention is still the most effective, but insurance companies are unlikely to support this type of intensive work. Harmony Place Monterey.