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THE TREATMENT OF CHRONIC FRIGIDITY SYSTEMATIC DESENSITIZATION

ARXOLD A. LAZARUS,

PHD.'

BY

The term "frigidity" is associated with a wide range of conditions, most of which refer to female hyposexuality. Frigidity need not necessarily imply deficient sexual feeling or desire per se, since some women who are completely frigid in all heterosexual situations are capable of orgastic experience during masturbation. Apart from organic factors (which are responsible for a minority of symptoms in young women) frigidity may generally be regarded as a learned pattern of behavior, although some females are probably genetically unequipped to respond erotically. Frigid women may be pIaced on a continuum extending from those who basically enjoy coitus but fail to reach orgasm, to those for whom all sexual activities are anathema. Acute but shortlived episodes of frigidity are not uncommon during or .after pregnancy and lactation, defloration, physical illness, and during periods of psychological stress. Mild or temporary frigidity may also be due to faulty sex technique and a variety of misconceptions which majr usually be corrected by appropriate instruction and information. The present paper deals with the treatment. of recalcitrant and persistent cases of frigidity, many of which had failed to respond to the usual run of psychiatric techniques. While the present discussion desk with frigidity as a specific psychosexual aberration, it must be understood that several psychopathological conditions are often heraIded by or result in impaired sexual functioning (e.g., endogenous depression, schizophrenia). The patients discussed in this paper were IGtwatersrand University Medical School, Johannesburg. South Africa. ' Department of Psychiatry and Mental Hygiene,

selected from numerous cases of frigidity in our records. Excluded from the present survey are all cases in whom varying degrees of frigidity were present as a minor part of a much broader neurotic or psychotic spectrum. The 16 patients who comprise the present sample all complained of frigidity as a monosymptomatic or primary disturbance. Of the present series, five patients had been referred by general practitioners, three were referred by gynecologists, one was referred by a psychiatrist, and seven had been recommended by previous patients. Cases were only accepted for therapy when medical reports excluded organic pathology. All were married. Their mean age was 24.6 years with a standard deviation of 3.8. Of the 16 women, nine had been married for two years or less, five had been married for approximately four years, and two were married for more than ten years. The majority had always found coitus to be meaningless, somewhat unpleasant or utterly repugnant. The educational level of these patients varied considerably and ranged from three professional `women (a doctor, a lawyer and a grades teacher) to several housewives with only two or three years of secondary schooling. The patients were reasonably homogeneous with regard to socio-economic status and may be described as fairly typical of middle class, urban, white South African women. Two of the women stated that they had been highIy promiscuous pre-maritally. They both claimed, however, that they had never derived any sexual satisfaction whatsoever. One of these patients had also been fairly active extramaritally. A previous therapist had convinced her that these sexual exploits were a search for erotic sensa-

Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 136, No. 3, March, 1963

Copyright, 1963, The Williams 6 Wilkins Co. All rights reserved

SYSTEYITIC

DESESSITlZATIOS

OF FRIGIDITY

273

tions which had always eluded her. This the latter dimension. She was consequent.ly knowledge made no appreciable difference enabled to have a sall?ingectomy and subseto her condition. The remaining patients quently experienG& sexual s&faction for main taintd that their sexual activities had the first time in her life. been confined to their marriage partners. The sexual reluct.ance of one patient foilowed a severe monilia infection which In atteltlpting to delineate reasonably clt+ar-cut areas of causation, it was found flared up during her honeymoon. She had that the basic etiological factors were vkry irrationally attributed her illness to sexual diverse. In Sony. cases, the problem seemed participation and was disinclined to expose to emanate from faulty at.titudes and mis- herself to the risk of further infection. It is pl:icetl sesual emphasis in childhood, which worth noting that she had other mild obresulted in conditioned avoi,Jance responses vious hypochondriacal tendencies, which to sexual activities. Many patients showed were treated concurrently with her sexual c\*idence of early or recently acquired feel- problems. ing5 of hostility and resentment towards The following excerpt, taken from a frigid mCn in gencr;iI and!or their husbands in paGent's notes, provides a graphic descripp:trticular. i)nl_v in one case was there evi- tion of the attitudes of one of the most sedencc of a traumatic etiology. A few pa- vere cases: Ii I hate every single man on this earth, tient*: n-ercbcomplctcly unable to offer any csplanation for their symptoms. In some, bitterly. I think they are all pigs-some the basic reasons were apparently uncoverdd smaller, some bigger. When one looks at me during therapy (these insights, although in the street I could shoot him with a water conlforting, appeared to bear little relation- pistol full of vitriol. I hate women who ship to tllcrapeutic outcome:), whereas in enjoy sex. I think they are just animals. otlIcbr5, the pattern of causality remained I hate sexy books; they are filthy. I hate to spcculati\-c or enigmatic. In one case, the see people kissing; it makes me feel sick. I entire problem amounted to a hypersensi- don't want to become one of them. tivity to extraneous auditory stimuli and "I hurt my husband's feelings whenever a high degree of distractibility. During sex- I can. I think he is a pig too. I don't want ual intercourse this patient would be exces- to have children. I would feel too much like sivclv ul)sct by the sound of a distant. motor an animal. I have nightmares about men. car, an imagined footstep, a leaking tap, or in my dreams they are just pigs and anithe like, whereupon she would experience mals. I hate sex and everything that goes violent dyspareunia. with it. "When I have intercourse I feel like spit-4 direct fear of pregnancy appeared to be the underl?ing cause of chronic frigidity ting. I can't stand my husband's hands on in yet anotller ca&b. "The so-called safe me. N'hen I have to go to bed with him and period is a myth . . . no contraceptive is in- there is no way out I feel trapped like an fallible and I refuse to play around with animal about to be slit open with a knife. hormones . . . I have a rheumatic heart and I could strangle fiim and kick him. I hate doctors have warned me not to have any to see him look at other women. I want to children, so I regard sex as a prcttr risky shout at him `Animal, animal.' Men are all bu&zss." M-hen the therapist suggested that the impasse might be remedied by was developed by Dr. Joseph Wolpe (12, 13). It consists of presenting carefully graded situations, mc3ns of surgery, the patient revealed a which are subjectiveIF noxious, to the imagination basic phobia of tloct~r~, hospit& and ant'+ of a deeply relascd patient until the most persontllctic?. and rcrluirclcl dt5ensitizntior? along ally distressing events no longer evoke any ansiety.

`Systematic dcscnsitizntion is a tcchniclue which A hricf account of this technique is provided in the section on therapy. '

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ARXOLD A. LAZARUS

pig5; my father, my brothers, the WhOIe curative mechanism would then depend on unlearning the primary neurotic stimulus lot !" On studying the life histories, psgchodiag- configuration. The desensitization procedure (12, 13.J nostic test profiles and similar detailed information which was routinely obtained in has proved high!y effective in treating dieach case?it became ob\-ious that the pa- verse neurotic reactions where specific tients were not a honiogeneou~group with re- ratlrcr than "free-Aoating" anxiety is presgard to temperament or personality makeul). ent l.5,~.This technique has also been used Marked indilvidual differences and maria- in groups t.7) and adapted for child therapy tion,; in background, training and tempera- programs (6, 8 t . Bond and Hutchinson (1 ,J ment u-we clearly noted. There xas suggc+ have successfully employed systematic descwitization in the treatnlent of exhibitiontivc evidence, however, that the introwrted patients (i.e., persons with an E score of kin, and Lazovik and Lang ( 10 1 have scrutinized the value of dc~cnsitization therap! 1~s than 15 on the Naud&y Personalit) In\.entory [3] l generally displayed straight- under controlled laboratory conditions. forsvard a~ricty reactions to sexual situa- Rachwan ( 11.1has provided an account, of tion+--" as soon as my husband approache+ a 24-year-old female n-ho had a phobia for me in that n-ay I literally feel tense if not injections, a fear of using internal sanitary terrified" --whereas the highly extroverted pads: and who experienced pain and anxiety patients (i.e., those with an E score of 35 in sexual situations. The elimination, by or more) tended to complain of vaginismus desensitization, of her sanitary pad anxiety and similar reactions of a probable hgsteri- and the injection phobia effected an ilnprovenlent in her sexual adjustment, cal variety. Briefly, the dcscn~itization method in-411 patients had received sonle form of the treatment for t,heir condition before consult- vol\-es the following three separate sets of ing the writer. Five had received detailed operations: 1 I The patient is taught the essentials of intitruction from their family doctors concerning sex technique. Three were treated Jacobson?c (4) progressive relaxation. Thi:: by weans of hormonal injections and topical relaxation training program seldom extends ointments. Three other patients had con- o\*cr niorc than six interviews. (During the sulted marriage guidance counselors n-ho past ywr, ho\vcvcr, the writer has rclicd exhad embarked on a course of reassuring tcnGwl\- on a long playing l~honogral~l~ discussions with both husband and n-ifc. record of which he iti the co-author f93.I 21 Gratl~~cllists arc dran-n up of all the suplknxntcd by a reconuncndcd list of books on ses hygicnc. One of the patients definable tlwnw into which the patient's anxictics may be grouped. This construction had undergone four years of l~sychonnaly&. Two 1~1 visited psychiatrists -at n-tckiy of anxiety hierarcliic~ iinplic,~ that. a11iininterval3 for al~proxinnitel~ six months? and portant thcinatic clcnwnt~ which engender the rennknng two patients had been treated neurotic anxiety in the patient will be idenby clinical lx~chologkt~ for one yar, and tificd and prolwly ranked according to the fi1.c months respectively. dtgrcaclof subjccti\e disturbance aroused. 3r The anxiety-evoking items from the THER.WIhieritrcll~ are prcwntcd wrbally to the The present thcralwutic lwogrt~n WE iniagination of the deeply relaxed patient, b:i~cd on the as5uinl)tion tlntt frigidity is coniinencing with the "weakest" stimuli and USU:tll!result of liabits of ans- grwdu;tliv lwocecding up the hierarchy to c icty relating to .wiual particil>ation. AS in progreA~*ely "stronger" anxiety-arou$ng chewy effccti\*e system of tlwraly, tlw bask situations. Sew items arc introduced onl?tllr lC?i\l*IlC.Yl

SYSTEMATIC

DESEX3ITIZATIOK

OF FRIGIDITY

275

when patients are able to picture their pre- peared to have consolidated her marriage ceding scenes without experiencing anxiety. and according to her husband, "saved a It is impressed upon patients that, if any worthwhile marriage in the nick of time." The patient whose sex life was underitem proves upsetting or disturbing they mined by real or imagined extraneous must raise their left forefinger. The easiest cases to handle were those in sounds responded well to desensitization which the normal erotic interchange be- methods. While hypnotically relaxed, she tween male and female constituted the es- was asked to imagine increasingly disturbsential anxiety component. "3ly mother ing sounds while conditions for sexual relawarned me to keep away from boys so often tions became less and less ideal. (As an exthat I even feel guilty when my husband ample : "I want you to imagine that you kisses me." A patient who depicted less and your husband are in Cape Town on generalization along this theme said, "I holiday. While having intercourse you can actually quite enjoy kissing and necking, clearly hear people walking and talking in but when it gets more serious than that I the hotel corridor.") After 14 desensitization just feel myself freezing up." Desensitiza- sessions she reported that she was able to tion in these cases proceeded along a hier- "get lost in sex." At the time of writing, she archy of more and more intimate physical has not experienced dyspareunia for over and sexual interchanges. In the most severe fifteen months. cases, the graded repertoire of noxious situA more detailed case presentation should ations had to commence with the most lend greater clarity to some of the points casual and innocent contacts between the outlined above. sexes. The thought of a flirtatious glance-or Mrs. -4, aged 24 years, had been married an ephemeral embrace initially produced for two and one-half years, during which observable anxiety reactions in two of the time she claimed to have had coitus on less patients. The "mildest" case along this than two dozen occasions. She always exdimension was a patient who could accept perienced violent dyspareunia during intercoitus in the "normal" position, but whose course as well as "disgust and anxiety at husband's erotic gratification depended on the whole messy business." She could tolervarying the sexual positions. "Frankly, I ate casual kissing and caressing without think that my husband needs treatment. He anxiety and at times found these experibehaves just like an animal." ences "mildly pleasant." The background to \ This patient's aversion to postural varia- her problem was clearly one of puritanical tions during coitus apparently emanated upbringing, in which much emphasis was from feelings of fear and disgust when, as a placed on the sinful qualities of carnal de-young girl on the farm, she had on occasion sire. Mrs. A's husband had endeavored to been forced to witness animals copulating. solve their difficulties by providing his wife She reported that ever since then, t.he sight with books on sex techniques and practices. of "animals doing it in the street" upset her Mrs. A had obligingly read these works undufy. Systematic desensitization was ac- but her emotional reactions remained uncordingly administered along dimensions of changed. She sought treatment of her own distance and size-the nearer the animals accord when she suspected that her husband the worse; the larger the animals the worse. had developed an extramarital attachment. After diagnostic interviews and psychoAs soon as she became impervious to sexual activities in animals, her own behavior metric tests, systematic desensitization was underwent a change. She became free from administered according to the following unnecessary inhibitions which had upset her hierarchy (the most disturbing items being sexual relationships. Significantly, this ap- at the head of the list):

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AXNOLD A. LAZARUS

.

Having intercourse in the nude whiIe sitting on husband's lap. 2) Changing positions during intercourse. Having coitus in the nude in a dining room or living room. 4) Having intercourse in the nude on top of a bed. Having intercourse in the nude under the bed covers. 6) Manual stimulation of the clitoris. 7) Husband's fingers being inserted into the vagina during precoital love play. Caressing husband's genitals. Oral stimulation of the breasts. Naked breasts being caressed. Breasts being caressed while fully clothed. Embracing while semi-clothed, being aware of husband's erection and his* desire for sex. _ 13) Contact of tongues while- kissing. 14) Having buttocks and thighs caressed. 15) Shoulders and back being caressed. 16) Husband caresseshair and face. 17) Husband kisses neck and ears. 18) Sitting on husband's lap, both fully dressed. 19) Being kissed on lips. 20) Being kissed on cheeks and forehead. 211 Dancing with and embracing husband while both fully clothed. Variations in the brightness of lighting played a prominent part in determining the patient's reactions. After four desensitization sessions for instance, she was without anxiety able to visualize item 14 (having her buttocks and thighs caressed) if this was occurring in the dark. It required several additional treatments before she was able to tolerate this imagined intimacy unr der conditions of ordinary lighting. The therapist asked Mrs. A's husband to make no sexual overtures to his wife during the period of treatment (to avoid tesensitization). Mrs. A was desensitized three times a week over a period of less than three months.

When item 7 on the hierarchy had been successfully visualized without anxiety, Mrs. A "seduced" her husband one evening and found the entire episode "disgustingly pleasant." Thereafter, progress was extremely rapid, although the first two items were slightly troublesome and each required over 20 presentations before the criterion (a 30-second exposure without signaling) was reached. A year later Mr. and Mrs. A both said that the results of therapy had remained "spectacularly effective."

BESULTS

Of the 16 patients, nine were discharged as "sexually adjusted" after a mean of 28.7 sessions. (The mean time was somewhat inflated by one patient, who required more than 40 sessions.) - The remaining cases were regarded as failures. Patients were usually seen once a week, so that the average time period for successful therapy was just over six months. The majority of patients listed as failures usually terminated therapy on their own initiative after less than six sessions.It can safeiy be said that treatment was successful for every patient who underwent more than 15 sessions. The nine recoveries were all cases in whom reasonably clear-cut areas of inhibition could be discerned, while the seven patients who reported no improvement were nearly a11 individuals in whom abstruse, pervasive. or extreme attitudes prevailed. Some of them-were inadequately motivated for therapy. Others, although evidently eager to overcome their sexual difficulties, were unable to produce sufficiently vivid images-an essential prerequisite for effective desensitization. It is worth noting that all the successful cases were undoubtedly dysthymic in character (i.e., having high scores on neuroticism and low scores on extraversion 121.) The criterion for "cure" was an affirma-

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