I had a letter published recently in Therapy Today that commented briefly on the previous month's edition of the same journal that contained several articles pertinent to psychosexual work. It was as if the mysteries of psychosexual therapy had hit the big time and had made it to mainstream print in the counselling and psychotherapy press. Not before time might I add. But these professional journals are for exactly that, professionals, who have a sense of the workings of therapy per se (even if by all accounts they might not dare to mention sex in the consulting room!). What about the layman, the un-initiated, the ordinary man and woman who contemplates the idea that they might have a problem that involves sex and begins wondering who to turn to for help and what that help involves? In my experience clients who seek me out, even those who don't mention explicitly the nature of the sexual concern in the first phone call, have registered my specialization and are relieved to talk about more intimate personal matters than perhaps originally envisaged. The majority have a specific sexual concern, say erectile dysfunction, genito-pelvic pain/penetration disorder, a relationship problem that involves sex or a sexual compulsion; none of these are exclusive by the way, they can exist in varying forms and combinations with each other. So for example penetration disorder can be part of a couple's sexual and relationship concerns. Invariably however clients tend to focus initially at least on their genitalia as if it were not a part of their holistic selves; so it is very common for men with rapid ejaculation to expect that focus will be primarily on their penis for the duration of treatment and that there will be an outcome of cure. Those men that realise that perhaps their initial expectations were a little too high are those that engage in a profound sense to confront their anxiety and thus their confidence. And couples say who have not had sex in years soon realise that confronting the sexual concern needs to be 'attached' to an increased understanding of the functioning of the relationship!

So I hope that I have clarified something here for those considering help with psychosexual concerns. Sex, by its importance in our lives and therefore discussing it when it's not working properly can be the powerful catalyst that releases the unconscious material that is often holding us back. If your concerns seem to be primarily sexual ones but you have a feeling from what you know of yourself and your life that there might be a 'bigger picture' i.e not just about your penis or vagina then sex therapy can be an extraordinarily potent path to growth, excitement and FUN!

One of the facets that distinguishes sex therapy from traditional talking therapy can be the inclusion of homework, practical exercises and relapse prevention plans for example. Positive outcomes inform me that this integration is the essence of psychosexual work.

What are the symptoms?

The pain experienced by women with vestibulodynia is very individual. The main problem for women with this diagnosis relates to hypersensitivity on light touch to the vestibule, such as during intercourse and on insertion of tampons. The degree of pain is variable. Some women have pain but are able to tolerate penetrative sex. For others any pressure to the vestibule area causes symptoms of soreness and tenderness, including tight clothes and even light touch to the area. Itching is not usually a feature of the condition.

Vestibulitis was the former term for vestibulodynia. This term is out of date now (Vestibulodynia itself now comes under Genito-Pelvic Pain Disorder/Penetration Disorder in DSM-5). It is slightly misleading as it implies that the vestibule is inflamed – hence the term vestibulitis. It is not believed that an inflammatory process in the skin is to blame for symptoms. An excessive sensitivity of the nerve fibres and even, on occasions, overgrowth of the nerve fibres in the area is believed to be responsible for symptoms.

Although the pain on light touch is the main symptom it is wrong to think that this is a skin condition. When sex has been painful for some time there are inevitable effects on your sex life. Tension in the lower pelvic floor muscles during attempted sex can lead to increased pain and subsequent avoidance of sex. If communication breaks down between a couple then this can lead to further disharmony. In some couples where the symptoms have been present for many months or years, provoked vulvodynia can alter sexual function and a referral to a psychosexual counsellor is necessary. For further information contact the VPS.

What is there to see on examination?

Vestibulodynia is a very real physical disease. Often on examination of the vestibule there is tenderness to light touch. There can be red areas at the site of tenderness, but frequently the findings are normal. Just because your doctor cannot see anything does not mean that there is nothing present.

What tests should be done?

Vestibulodynia should be diagnosed by a doctor who should rule out infections and vulval skin conditions which may cause similar symptoms. Many doctors, however, are unaware that the condition exists and often regard the condition as ‘thrush’. Your doctor should listen to your symptoms, examine the vulval area and refer you to a specialist where necessary. This specialist would be either a gynaecologist, dermatologist or a genitourinary (GUM) physician. If thrush is suspected by your doctor then it should be confirmed by performing a vaginal swab. Repeated vaginal anti-thrush treatments make the condition worse so insist on oral treatment instead, with Diflucan or Sporanox, for instance.

How is it treated?

As there is no obvious cause for symptoms, it is difficult for many women (and some doctors) to understand the condition. There are many conditions that it is not! It is not infectious, it is not related to cancer, it will not spread to other parts of your body and you will not pass it on to your partner.

The treatments available for this condition are very variable. Different doctors treat the condition in different ways but below are a selection of suggested treatments. Not all doctors will use these methods, but you can discuss the different options with him or her. Some treatments will help some women and not others. Treatments range from local anaesthetic creams or gels, vaginal dilators and pelvic floor muscle physiotherapy, to psychosexual counselling and sometimes surgery (vestibulectomy).

You can read more about the surgical option, but please remember always to ask for a second opinion. Surgery is very much a last resort and you should explore every other option first.

Be careful of using non-prescribed creams on the vulva as some can cause vulval irritation. Remember the strict vulval hygiene measures that you should practise.

What causes it?

It is likely that a number of factors cause vestibulodynia, but often no identifiable cause can be found. Some women have a sudden onset of symptoms following a specific event: a commonly recognised event is a severe attack of thrush followed by anti-thrush treatment. Once the attack of thrush settles following treatment, soreness and burning may persist as vestibulodynia. Some women complain of vestibulodynia following childbirth, or the use of certain bubble baths and soaps or with the use of antiseptic in the bath, e.g. Dettol. Where symptoms have gradually occurred over some time, even years, then it’s difficult to identify a cause. Some women with interstitial cystitis also suffer from the condition. The reasons why the two conditions are connected remain unknown.

Treatments available from your doctor

Local anaesthetic gel is a water-based gel which contains a weak amount of a local anaesthetic such as lidocaine (lignocaine). The anaesthetic can ‘numb’ the nerves in the skin temporarily and may be used safely on a regular basis. Many women have gained considerable benefit using the treatment, particularly with vestibulodynia when the gel is used half an hour prior to sexual intercourse. They find it helpful to rub the gel into the tender areas – this helps numb the skin and also can help overcome tension in the pelvic floor muscles. The gel can now be bought over the counter. Make sure that you use a test dose first on a small area of the vulva as around 10 per cent of women can have a skin reaction to it.

Vaginal dilators can be inserted to relax the muscles around the entrance to the vagina and to gently stretch the area. These can be helpful to overcome the tension in the pelvic floor muscles that can occur in vestibulodynia.

Tricyclic antidepressant tablets may be useful if the pain that you have is more constant in nature. These are used in low dosages to treat pain directly at the site of the nerve endings in the skin.

Summary

Vulvodynia (unprovoked pain) Spontaneous pain Pain is burning and sore in nature Itching not usually a problem Can be generalised around the vulva or localised

Vestibulodynia (provoked pain) Pain with light touch eg tampon use or sexual intercourse Usually no symptoms at other times Can be generalised around the vulva or localised

2013 DSM 5 Definition of Vaginismus
Vaginismus is newly defined in the latest edition of the 2013 DSM 5 (formerly known as the DSM V) as a “Genito-Pelvic Pain Disorder/ Penetration Disorder” which attempts to bring together the concepts and full spectrum of painful vaginal penetration.

This replaces the definition that has been in use since last published by the 2000 DSM IV. DSM-5 is the fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, generally acknowledged as the definitive reference by which disorders can be categorised in the medico/psychological professions. Though this new term of “Genito-Pelvic Pain Disorder/Penetration Disorder” seems to be a complex one, it brings together the spectrum of dyspareunia (painful sex) to vaginismus (severe pain with penetration, or penetration is impossible) and also accounts for other penetration difficulties such as tampon use, finger penetration, difficulty with gynaecological examinations and of course intercourse.

As such this diagnosis becomes part of the following spectrum of vaginal penetration disorders that are also defined as:

• Pelvic Floor Muscle Dysfunction
• Vaginal spasm
• Sexual pain disorder
• Inability to consummate
• Vulvodynia
• Vestibulodynia

I see many men of all ages and sexual orientations struggling with sexual compulsivity. This is predominantly manifested in online activity through chat rooms (including those where men exchange porn or home movies and stills – sometimes involving unwitting spouses), viewing porn and web cam activity. Traditional compulsivity that includes visits to sex workers and ‘massage parlours’ is also still very much alive as well as chronic sexual liaisons with strangers (in the case of gay men hook-ups via Grinder) or female colleagues met through work.

When men meet me for the first time they have usually been found out by their spouse or partner and there has followed a devastating impact on the relationship, usually one in which he has been kicked out or about to be. Occasionally the spouse or partner is unaware of the behaviour and he knows he has a problem because sex in the relationship has ceased (or if it is continuing he may be at risk of passing on a disease or STI) and his behaviour is escalating by risk factor, expense, warned at work, etc, and he feels more and more ashamed of himself. Despite the shame and guilt there is denial; ways of minimising the behaviour and consequences and telling himself that it won’t happen again. But it does and a vicious cycle ensues.

Sexual compulsivity is common amongst gay men that come to my practice; often comorbid with chemical (drug) and or alcohol compulsivity.

It is well documented in the treatment of sexual compulsivity and addiction that group work with fellow sufferers is the strategy for on-going and long term support. I always let my clients know this and provide information such as that below from SLAA. Usually however this first step can seem daunting; perhaps its a denial of the very serious nature of what has happened and thinking that it could never happen again. Or its a fear of exposure in a group and feeling ashamed of having to admit “I have a problem”. So what I do is invite men to a series of one to one sessions to tackle the behaviour with the view that this could lead to SLAA in the longer term. Within this confidential behavioural programme we will draw up a Relapse Prevention Plan together.
Sex and Love Addicts Anonymous (S.L.A.A) is a Twelve Step, Twelve Tradition oriented fellowship based on the model pioneered by Alcoholics Anonymous.

The only qualification for S.L.A.A. membership is a desire to stop living out a pattern of sex and love addiction. S.L.A.A. is supported entirely through the contributions of its membership and is free to all who need it.

To counter the destructive consequences of sex and love addiction, we draw on five major resources:

1. Sobriety. Our willingness to stop acting out in our own personal bottom-line addictive behavior on a daily basis.
2. Sponsorship/Meetings. Our capacity to reach out for the supportive fellowship within S.L.A.A.
3. Steps. Our practice of the Twelve Step program of recovery to achieve sexual and emotional sobriety.
4. Service. Our giving back to the S.L.A.A. community what we continue to freely receive.
5. Spirituality. Our developing a relationship with a Power greater than ourselves which can guide and sustain us in recovery.

As a fellowship S.L.A.A. has no opinion on outside issues and seeks no controversy. S.L.A.A. is not affiliated with any other organizations, movements or causes, either religious or secular.

We are, however, united in a common focus: dealing with our addictive sexual and emotional behavior. We find a common denominator in our obsessive/compulsive patterns, which transcends any personal differences of sexual orientation or gender identity.

We need protect with special care the anonymity of every S.L.A.A. member. Additionally we try to avoid drawing undue attention to S.L.A.A. as a whole from the public media.

ALCOHOLISM AND ADDICTION IN HOMOSEXUALS
ETIOLOGY, PREVALENCE & TREATMENT

Roy Young, J.D., M.S.W., L.M.S.W.[1]

There is a good deal of alcoholism and addiction in the gay community, but newer studies suggest that the incidence among younger homosexuals may be no greater than in the population at large. This article suggests that gay liberation in the 1970’s may have spared male homosexuals now under 30 some of the misunderstanding, discrimination and hatred that drove older homosexuals to drink and drugs. It also suggests that older homosexuals may abuse drink and drugs to dull the pain of aging in an especially youth-oriented, beauty-driven homosexual culture.[2]This article discusses some of the treatment issues specific to homosexuals who abuse alcohol and drugs, and suggests the use of gay special-interest 12-Step groups to assist in treating internalized homophobia and in making some of the lifestyle changes beneficial to homosexuals in recovery .

Substance abuse[3] is endemic in the homosexual[4] communities in the United States. Although the etiology of abuse in any given individual can be complex, there are certain themes which are frequently seen in the gay or lesbian addict, and require specialized treatment in recovery. Awareness of these special risk factors increases the chances of successfully treating a lesbian or gay addict. The author has chosen this topic because he is both homosexual and in long-term recovery from alcoholism.

Etiology

American Psychiatric Association (1994) (the DSM-IV) lucidly groups all addiction to and abuse of substances into a single chapter: Substance Related Disorders. There is no single theory which accounts for why some people abuse substances and others don’t (Straussner, 1993), but the presenting picture is essentially the same regardless of the substance.

In all probability, addiction (like so much mental illness) has a multifactorial etiology. Thus it must be viewed in a biopsychosocial framework. Straussner (1993) concludes that,

It may be best to view substance abuse as a multivariate syndrome in which multiple patterns of dysfunctional substance abuse occur in various types of people with multiple prognoses requiring a variety of interventions (p. 11).

Here are some of the predisposing factors:

1. the possibility of a biochemical or genetic factor in intergenerational transmission;

2. familial factors such as early separation from one or both parents early in life; inadequate parenting during childhood; physical or sexual abuse, or growing up in a family with multigenerational abuse of substances;

3. all of the psychological theories posit psychological factors in the development of addiction. For all the “insight” provided by these theories, none of them leads to any more effective intervention than the others. In fact, those willing to be straightforward on this subject admit that psychotherapy of any ilk is largely ineffective in treating active addiction. If the proof of the pudding is in the eating, it is then apparent that the following classic psychological bromides are wrong and/or irrelevant:

The addict uses the substance:

• as a substitute for unacceptable sexual or aggressive drives, as a substitute for the primal addiction to masturbation, or as a defense against homosexuality;
• as the result of a fixation in and a regression to the oral stage of development;
• in response to an underlying neurosis based on the conflict between dependence and anger, or
• as slow suicide (Straussner, 1993).[5]

Other more modern theoretical perspectives focus equally ineffectively on poor ego development, pathological narcissism, or a deficiency in the sense of self (Straussner, 1993).

More useful theories for treating an individual in later-stage recovery[6] suggested that,

• the addict attempts to medicate emotional problems such as depression, anxiety and anger;
• express dependency needs;
• compensate for feelings of inferiority and powerlessness, or
• relate to such things as low frustration tolerance, high level of impulsivity, or the inability to endure even low-level anxiety (Straussner, 1993).

Learning and behavioral theorists see addiction as a conditioned response; it produces a pleasurable high (perhaps very pleasurable in some, making them more willing to accept the negative consequences of indulgence) or relieves pain (as suggested above). Because children raised by addicted non-biological parents are at a higher risk of alcoholism than children raised by non-addicted non-biological parents, expectancy, modeling, imitation and identification may also predispose to substance abuse (Straussner, 1993).

4. environmental and cultural factors in general can play a role in the etiology of addiction, such as:

• availability of the substance (e.g., many soldiers became addicted to heroin in Vietnam because of [1] the high stress of war, and [2] the availability of the substance, but upon return to civilian life a large proportion of them ceased to have problems with drugs and alcohol);
• lack of rewarding alternatives in life (e.g., lack of decent living conditions or opportunity to earn an income, as might be experienced by persons living in a minority ghetto),
• influence of mass media, or
• social or peer acceptance of use of the substance.

Finally, regardless of the theory of addiction or the predisposition of the person to addiction, almost anyone who takes a mood-altering substance in large quantity for a long enough time will experience physical and/or psychological dependence (Straussner, 1993).

Etiology of alcoholism in homosexuals

People with a homosexual orientation are, of course, subject to all of the multiple risk factors for addiction discussed above. They also have some psychosocial predisposing factors common to all hated minorities, and some unique to the homosexual population. There are many different types of alcoholics; there are many different types of homosexuals, and there are even more types of alcoholic homosexuals (Nardi, 1982).

Common to all hated minorities is the damage done to self-image by the internalization of that hatred. Erikson (1959) asserts that it is impossible for any member of a hated minority to escape that internalized hatred.[7]

Homosexuals are subject to unique stressors, as well. Starting in youth, sometimes as early as school age, sometimes before the homosexual himself[8] is aware of any sexual orientation, he learns some of the dangers of being homosexual:[9] public derision (“Joey is a fagot!”), discrimination (“We don’t want a queer on the baseball teem”), and physical harm (“Hit the sissy again!”). The child may be rejected by her family implicitly (Mother overheard: “I’d rather my daughter be dead than be one of those lez-bines.”) or explicitly (Father overheard: “You are a homo, you are not my son. Get out of my house.”) (Savin-Williams, 1994). In later life he will face discrimination in the workplace and the possibility (only today less prevalent) of arrest and imprisonment for “unnatural acts.” Rosario, Hunter & Rotheram-Borus (1992) note,

. . . the experience of being gay or bisexual in our society overwhelms any potential differences in social categories involving age, ethnicity, race, social class or geographical region of the country (p. 19).

The homosexual is unique among minorities in facing hatred and discrimination in that she usually has no role model, no positive example in her family, no loving parent who has gone through the same experience, to support her in her pain. Those discriminated against because they are (for instance) Jewish or African-American usually have families or communities for which this is a common problem. But gay youths are all too often rejected even by their families (Savin-Williams, 1994) and too seldom have yet found their supportive peers and communities.

Facing this external view of herself, no wonder that the homosexual internalizes this hatred and has difficulty with accepting her identity, building self-esteem, and expressing her sexuality. About 65% of all homosexuals seek therapy and give as a reason depression which is a result of adjusting to their homosexuality; of these, 50% started therapy between the ages of 18-21 (Diamond-Friedman, 1990).

In turn, these difficulties lead some to increase their consumption of alcohol or other drugs to aid in the coming-out process, or to medicate the anxiety or depression associated with concealing their identity or facing rejection from family and friends, discrimination in employment and housing, physical assault, arrest or imprisonment.

Colcher (1982) hypothesizes that homosexuals use substances to dull the pain of feeling “different and alone,” to reduce “sexual inhibitions” relating to internalized homophobia, and to reduce the stress of the keen competition for good-looking sexual partners.

Nardi (1982) hypothesizes that homosexuals are more at risk of drinking to the point of addiction because the gay life style often revolves (or revolved in 1982) around gay bars, which have a history of permissiveness and protectiveness:

The absence of significant subculturally valued alternatives to drinking settings . . . contributes to the dependency on alcohol as an acceptable solution to feelings of anxiety, alienation and low self-esteem (p. 21).

Prevalence

Various older[10] studies indicate that about one-third of all homosexuals will have a problem with substances at some time in their lives (Diamond-Friedman, 1990). In a more recent study, however, McKirnan & Peterson (1989) come to a strikingly different conclusion. Based on their very large (n=3,400) and well-controlled study, they criticize earlier studies as being biased for several reasons, not the least of which is that they were made in gay bars of the bar-going population. McKirnan & Peterson (1989, p. 549) found the following percentages of homosexuals reporting alcohol problems:

General Homosexual Population Sample

 Age Men Women Men Women
Group
18-25 29 16 26 24
26-30 25 7 25 23
31-40 16 8 24 25
41-60 7 4.5 19 15
(overall) (16) (8) (23) (23)

Significantly, up to age 30 the homosexual men in the study show no higher incidence of alcoholism than men in the general population (although homosexual women show significantly higher levels).[11] But after age 30, the high incidence of alcohol problems declines much less in the homosexual population than it does in the general population.

Why are older homosexuals at greater risk of alcoholism? The author has found no sufficient explanation in the literature. McKirnan & Peterson (1989) suggest that psychosocial or cultural variables in the homosexual population might be responsible for increased alcoholism in the later years. They hypothesize that homosexual men and women do not typically enter traditional marriages or childbearing roles as they age, are often not in mainstream occupations, and do not typically adhere to traditional sex roles, all of which encourage control of drinking. The author suggests that more significant than “encouraging the control of drinking,” the functions of childbearing and childrearing may have a significant part in the emotional happiness and stability of the parents, being biologically ego-syntonic which, in turn, could relieve feelings of loneliness and lack of fulfillment which give impetus to drink.

Author suggests several other explanations as to why today’s older gays have a higher rate of alcoholism:

Today’s older homosexuals faced a more closeted life in their young years, with a much higher prevalence of the stressors discussed above. Gay liberation had not yet struck. They began drinking heavily earlier and, addiction being a disease most frequently progressing into middle age before being addressed,[12] were addicted by their middle 30’s. Thus, the higher rates of alcoholism in those over 30 shown by McKirnan & Peterson (1989) may be caused by an even higher incidence of alcoholism in the pre-liberation group, which is now in its 30’s, 40’s and 50’s. That male homosexuals under the age of 30 should show no greater incidence of addiction may be a testament to the positive effects of gay liberation.

Another untested hypothesis which occurs to the author is that many older homosexuals (say, over 35) are faced with the daunting task of competing for lovers, friends, and sexual partners in the unrelentingly youth-oriented, beauty-driven gay culture.[13] One of the major tasks of middle age for homosexuals is to reach acceptance that they are no longer able to compete for lovers or sexual partners on the basis of beauty (of which youth, in the homosexual population, is ordinarily a requisite), and accept that their sex and love lives may be substantially less fulfilling, or fulfilling in different ways, than when they were younger. Many homosexuals as they pass 35 turn increasingly to drugs and alcohol for solace and companionship.

Treating Addiction in Homosexuals

General Considerations

Addiction is like a fire; once started it becomes self-sustaining, and the first order of business for the fire fighter is to put out the blaze. Only later comes the search for the match. Similarly, treatment of the addict in early recovery is largely behavioral and cognitive: daily attendance at AA meetings provides (among other things) a support system and teaches the addict a number of techniques to avoid drinking/using, break old habit patterns of action and thinking, and reduce or manage the inevitable pain of withdrawal and recovery. Even psychodynamically oriented therapists now agree that focusing on the underlying causes of active addiction in an individual does not work to halt the addictive behavior (Colcher, 1982). Thus initially the sexual orientation of an addict is largely irrelevant to his treatment (Colcher, 1982), except (1) as it may cause legitimate concerns as to the treatment he may receive at the hands of a homophobic treatment staff, or may fuel his alcoholic denial that even an unbiased staff could help him, and (2) that the homosexual because of his lifestyle may be at special environmental risks to continued sobriety.[14] In these cases, an addict should be referred to a gay-sensitive rehabilitation program,[15] or to one of the gay special-interest groups of the 12-Step programs.[16]

Treating Homosexuals

Internalized homophobia is common in gay alcoholics, and often a source of considerable pain and dysfunction. In the author’s experience, addiction is most often initially driven by pain; thus it is important in recovery to reduce pain and stress wherever possible in the recovering alcoholics life and thus reduce the temptation for the alcoholic to self-medicate.

The alcoholic may be self-medicating anxiety, anger and depression relating to the internalized homophobia. In addition, a homosexual who has been taught by parents, church, school and society in general that homosexual lovemaking is forbidden, sinful, bad, sick, disgusting, and perverted,[17] may use alcohol to medicate the anxiety which these negative thoughts provoke in him and thus allow him to engage in sex at all. And to the alcoholic contemplating abstinence, the prospect of not being able to have (or function in) sober sex can be a motivation to and justification for not staying sober.

Gay special-interest 12-Step programs[18] (and, perhaps gay group therapy) can help the recovering alcoholic consciously work through internalized homophobia, and understand and reject for himself the destructive myths[19] about homosexuality:

Most of these myths are counterproductive . . . since they are based on assumptions that all gay males are identical, are fixated at regressive levels, and can never achieve a “whole” and satisfactory life. Examples of these myths are: gay males are hysterical and dramatic, especially in dealing with conflict; gay male sex is compulsively driven sex;[20] the treatment objective is a dyadic, long-term relationship; gay males are basically narcissistic; gay sex is basically masturbation; gay males are immature (fixated at pre-Oedipal stages, fixated at adolescence, manifesting the Peter Pan syndrome); gay men are totally sexually liberated; “something” will always be missing, in comparison with heterosexuality; gay intimate relationships cannot last and cannot mature; gays are “sad young men”;[21] casual sex is empty sex; gay men are psychotic; gay men cannot obtain relatedness; and so on (Smith, 1982, p. 55).

In addition, strange though it might seem, in the gay special-interest meetings of 12-Step programs, gay men and women can learn (perhaps for the first time) to relate to other gay men and women in non-sexual ways, thus building healthy relationships based on other common interests.[22] This may be especially important for older homosexuals, for whom the earlier, sexualized relationships may be undesirable, unfulfilling, and unavailable.

Conclusion

Whatever the etiology of an individual’s addiction, successful long-term recovery requires him to come to terms with himself and his homosexuality, and to learn to cope with life. In the treatment of the gay alcoholic, the therapist must not only keep perspective on the client as an addict, but also as a homosexual, with all that may mean to that person in his biopsychosocial setting. This includes being aware of the special challenges discussed above of internalized homophobia and the related low self-esteem, a lifestyle in which alcohol, drugs and gay bars may be central, and the particular problems of aging in the homosexual community. Especially, older gay men need information and encouragement to find the joys which can be contained in the second half of life (Smith, 1982).

The therapist must be sensitive to the gay subculture and to subcultural changes. The therapist must also be aware of the developmental tasks, as described by Erikson (1959), that gay men face throughout their lives. For instance, the stage of generativity can involve more than just parenting. Twelve-Step groups give ample opportunity, through 12th-Step work[23]for mentoring and nurturing others, and for utilizing that most noble of the ego defenses: altruism.

References

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association.

Colcher, R.W. (1982). Counseling the homosexual alcoholic. Journal of Homosexuality, 7(4). 43.

Diamond-Friedman, C. (1990). A multivariant model of alcoholism specific to gay-lesbian populations.Alcoholism Treatment Quarterly, 7(2). 111.

Erikson, E. (1959). Identity and the Life Cycle. New York: Norton. 30. Quoted from Greene, R. & Ephross, P. (1991). Human Behavior Theory and Social Work Practice. New York: Aldine de Gruyter. 97.

McKirnan, D.J. and Peterson, P.L. (1989). Alcohol and drug use among homosexual men and women: epidemiology and population characteristics. Addictive Behaviors, 14. 545.

Nardi, P.N. (1982). Alcoholism and homosexuality: a theoretical perspective. Journal of Homosexuality, 7(4). 9.

Rosario, M., Hunter, J., & Rotheram-Borus, M.J. (1992). HIV risk acts of lesbian adolescents.Unpublished manuscript, Columbia University. Quoted from Savin-Williams, R.C. (1994). Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: associations with school problems, running away, substance abuse, prostitution and suicide. Journal of Consulting and Clinical Psychology, 62(2). 261.

Savin-Williams, R.C. (1994). Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: associations with school problems, running away, substance abuse, prostitution and suicide. Journal of Consulting and Clinical Psychology, 62(2). 261.

Smith, T.M. (1982). Specific approaches and techniques in the treatment of gay male alcohol abusers.Journal of Homosexuality, 7(4). 53.

Straussner, S.L.A. (1993). Clinical Work with Substance-Abusing Clients. New York: The Guilford Press.

Premature ejaculation (PE) occurs when a man ejaculates sooner during sexual intercourse than they or their partner would like. As long as it happens infrequently, it's no cause for concern. However, if you regularly ejaculate sooner than you and your partner wish—such as before intercourse begins or shortly afterward it can become a frustration.

Premature ejaculation is a common sexual complaint and, although estimates vary, as many as 1 out of 3 men may be affected by this problem at some time in their lives.

There is no sole cause for this issue as both psychological and biological factors can play a role in premature ejaculation. Although many men feel embarrassed to talk about it, premature ejaculation is a common and treatable condition.

Psychosocial techniques are proving especially adept at improving sex for men with PE.

Common Symptoms of PE:

Ejaculation occurs much sooner than both partners wish, resulting in stress or concern. The problem may occur in other sexual situations such as masturbation.

Classifications of PE:

Lifelong (primary) premature ejaculation is characterized by the following:

• Ejaculation that always or nearly always occurs within one minute of vaginal penetration
• The inability to delay ejaculation on all or nearly all vaginal penetrations
• Negative personal consequences, such as stress, frustration or the avoidance of sexual intimacy

 Acquired (secondary) premature ejaculation is similar to the primary but with one key difference:

• Secondary ejaculation develops after you've had previous, satisfying sexual relationships without ejaculatory problems

When to Seek Professional Help:

Discuss with your therapist if you are experiencing and are concerned with the above symptoms. Although you may feel you should be able to fix the problem yourself, you may need special treatment in order to achieve a satisfying sex life. For some men, however, a conversation with your therapist may be one of reassurance; the discussion could be one that convinces you that your occasional premature ejaculation is normal—or possibly not even premature as the average time from the beginning of intercourse to ejaculation is generally about five minutes.

Causes:

Whether it is alone, with a partner or a combination of both, PE is generally considered to be a psychological concern and a sex therapist will do a thorough assessment to rule out any physical or biological factors that may be contributing to PE.

Psychological Causes:

Some doctors believe that early sexual experiences may establish a pattern that can be difficult to change later in life, such as:

• Situations in which you feel rushed to finish or are obligated to hurry
• Guilty feelings that increase your tendency to rush through sexual encounters

Other factors that can play a role are:

Erectile dysfunction: Men who are anxious about obtaining or maintaining their erection during sexual intercourse may form a pattern of rushing to ejaculate, which can be difficult to change.

Anxiety: Many men experiencing premature ejaculation have problems with anxiety—either specifically about sexual performance or related to other issues.

Relationship problems: If you have had satisfying sexual relationships with other partners in which premature ejaculation happened infrequently or not at all, it's likely that interpersonal issues between you and your current partner are contributing to the problem.

Treatments and Medication:

Treatment options for premature ejaculation include sexual therapy, medications and psychotherapy and are very effective.

Medications: Certain antidepressants such as PRILIGY is used to treat premature ejaculation. Although PRILIGY is not specifically approved by the Food and Drug Administration to treat premature ejaculation, it can be used for this purpose but although increased 'staying power' is reported generally, there can be side effects and most men do not want to be dependent on an antidepressant for PE.

Psychosocial cures: A hand-held battery operated stimulating device called PROLONG has also shown promising results in scientific research. PROLONG is an adaptation of the "Stop-Start" technique first used to help men with PE; instead of hand masturbation the vibrating device is held against the underside of the head of the penis. The literature specifies that this is ideally a programme of treatment and suggests therapy such as CBT/Sex therapy to run concurrently. I agree with this approach as men often need help in mastering techniques and giving feedback about the exercises; remember that underlying PE is anxiety and therefore it's predominantly a psychological concern that can be very helpful to talk through. For more information on this treatment and premature ejaculation visit http://www.prolongshop.com.

The College of Sexual and Relationship Therapists (COSRT) is a national charity which has been established for over thirty years. Until recently it was known as the British Association for Sexual and Relationship Therapy (BASRT).

Our 750 members provide sexual and relationship therapy for thousands of people every year who are suffering from very personal difficulties in their closest relationships. COSRTmembers offer a range of treatments encompassing sex therapy, psychosexual therapy and relationship therapy. These are all talking therapies where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. Together they will identify factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact. You can find out more about our therapy from our website www.cosrt.org.uk

COSRT sets and maintains professional standards for the profession, through the accreditation of practitioners, the approval of training courses, a Code of Ethics and Complains Procedure, thus offering protection to the public. We also offer continuous professional development through seminars, conferences and our international, peer-reviewed journal. On our website you can find lots more information including a list of therapists.

Vision

We believe in healthy, satisfying and rewarding relationships.

Mission

We exist to develop and maintain high standards of professional practice, through regulation, training, research and dissemination of knowledge, to enable sexual and relationship therapists to provide the most effective therapeutic treatments to the public.

COSRT has a number of different membership categories but Accredited status means the following:

Accredited Member

This category gives members a title that can be advertised. This level of membership gives the highest level of protection for the public as accredited members have met rigorous standards of training and are licensed on an annual basis. They must continue to meet set standards with regard to supervision, minimum practice hours, insurance, continuity of practice and CPD. They sign up to our Code of Ethics and Principles of Good Practice.