Empirically validated treatment for sexual dysfunction

Annual Review of Sex Research, 1997 by Julia R Heiman, Cindy M Meston

Although recent changes in health care management in the United States have increased professional interest in identifying psychotherapies of proven utility, the concern about validated and effective psychotherapy treatments is several decades old (Lambert & Bergin, 1994; Paul, 1967). Compared to treatments for other mental health diagnoses, such as depression and anxiety, sexual dysfunction treatment efficacy has received less critical attention. Sexual disorders have often attracted entrepreneurial and exploratory interventions, with clinical examples, that are often encouraging, but which rarely meet conditions for a well-designed single-case or group-studies series. Our purpose in reviewing validated treatments is to underscore the importance of developing standards of care for sexual dysfunctions.

Overview: Empirical Validation of Sexual Dysfunction Treatments

The American Psychological Association's Task Force (APA, 1995) proposed two categories of empirically validated treatments: well-established and probably efficacious. There are almost no psychological treatments for sexual dysfunctions that conform to all of the criteria of "well-established treatments":

1. group studies by different investigators demonstrating efficacy by (a) showing superiority to pill, psychological placebo, or another treatment, or (b) demonstrating equivalency to an estab lished treatment in studies with adequate statistical power (n = 30/group); or

2. a large series of well-designed single case studies compared to a 1(a) treatment and demonstrating efficacy; with

3. treatment manuals, and

4. clear specification of client samples.

We could locate no studies in which therapists' use of different treatment techniques were compared in a randomized trial.

The APA Task Force's second category of validation, "probably efficacious treatments," uses less stringent criteria:

1. two studies showing treatment is more effective than a waiting-list control group; or

2. studies otherwise meeting the well-established criteria 1, 3, & 4 above; or

3. at least two good studies demonstrating effectiveness but flawed by client sample heterogeneity; or

4. a small series of single-case design studies otherwise meeting the well-established treatment criteria 2, 3, and 4.

There is more evidence for psychological treatments for sexual dysfunctions meeting the "probably efficacious" than "well-established" criteria, as will become evident as the review progresses.

Although we use the APA criteria as guidelines to defining validated treatments, it is clear that these criteria are not without problems and are expected to evolve over time. For example, Wampold (1997) provided a thoughtful analysis of the methodological problems involved in identifying efficacious psychotherapies, and Seligman (1995) argued for effectiveness studies over efficacy studies to establish valid treatments. Nevertheless, the APA criteria offer a relatively clear reference point to define some of the conditions that, if met, will increase practitioners' confidence in identifying where standards of clinical practice have and have not yet been established in the treatment of sexual dysfunctions.

The specific weaknesses in sexual dysfunction research fall into predictable areas. One problem is that treatment manuals are rather uncommon for the treatment of sexual problems, at least in the form we have come to know them. A second reason for the lack of empirically validated treatment is the lack of control groups. Clinical researchers have, for ethical reasons, preferred waiting-list controls over placebos, and reasonably efficacious alternative treatments have not been available for most of the dysfunctions. A third issue is the overwhelming and widespread impact of the Masters and Johnson (1970) text. Never, before or since, has such a large number of individuals (N = 792) with sexual problems been treated with such clearly described treatment techniques, and with a high success rate (overall 15% failure rate), including a 5-year follow-up (Masters & Johnson, 1970). Though methodological problems are clearly present in Masters and Johnson's work, particularly the fact that there was only one therapist-generated nonstandardized item that measured outcome, its impact truly brought sexual dysfunction research into the forefront so that increasingly systematic research might eventually be designed. In fact, more controlled research was delayed by the fact that there were no readily comparable and relatively successful treatments that seemed legitimate to offer as serious alternatives to Masters and Johnson's approach.

An additional issue that has affected the engagement of researchers in controlled outcome studies in sexual dysfunction is the availability of funding for research. Sexual disorders have not been a priority for funding, particularly at the costly level of randomized psychological treatment trials. As a result, projects more modest in size and design complexity dominate the outcome literature.