Strategic classification and treatment of sexual disorders


Paraphrasing the words of B. Pascal, namely that there is nothing natural that cannot be made artificial and that there is nothing artificial that cannot become natural through exercise, at least two images appear salient if you look at them in relation to the problems of the sexual sphere: on the one hand, that which sheds light on the formidable potential for change inherent in every human being, even more so if based on the very strength of Eros; on the other, that which enlightens us on the natural oscillation, which can turn into contrast, between conscious / rational and instinctive / automatic aspects.

In fact, sexuality, like other vital dimensions such as breathing or nutrition, it is governed by precise neurobiological programs, in that middle between will and spontaneity which at times becomes its intrinsic weakness: the sensations escape precisely because they are pursued too much or because they are avoided altogether. But what do we mean by disturbance in this dimension? Among the many existing definitions, summarizing we can say that it is an anomaly of its functioning, which can involve one or more phases of the sexual response (phase of desire, excitement, plateau, orgasm and resolution).

The whole of Western history has been and is traversed by a marked ambivalence of messages: from the most obscure and completely hidden vetoes of the Victorian era; the whole revealed, shown and incited by the feminist movement and the new age; to the current search for an "experimental" freedom of expression, which at times however seems to become confusing, contradictory and devoid of any reference. Man's interest in everything that pertains to the world of affectivity and pleasure dates back to the beginnings of history, for a long time merging between the meshes of magic, religion and different socio-cultural fashions. It is only around the middle of the 800th century that scientific sexology slowly emerges, freeing itself from philosophical and ecclesial conceptions, to become the object of study of medicine and psychology.

After the war, American society gave new impetus to research through studies on the physiology of the sexual response, on the different orientations of the eros (Reports A. Kinsey, W. Pomeroy and others, 1948, 1953 "Sexual behavior in the human male and female ”; W. Master and VE Jonshon, 1966;) and the great inquiries on sexual habits and behaviors.

Although the WHO has been interested in it since 1974, both studies on the classification and those on the epidemiology of sexual dysfunctions are currently rather scarce, characterized by strong fragmentation, low reliability and considerable variability of results. Elements that reflect an excessive multiplicity of theoretical orientations, methods of evaluation and treatment. The debate is still open and centered on a fundamental question, namely whether some dysfunctions should be considered "diseases" or whether they should be seen as "atypical" in the complex dividing line between the organic / diagnostic and psycho-social sides. To date there seems to be convergence on a criterion, considered essential for a diagnosis of sexual disorder: the presence of a "personal distress", a personal experience of suffering (Cit. Art. By Jan Eardley in "Sex Medicine Review", 2013, 2015).

In the meantime, the DSM-5 (Statistical and Diagnostic Manual of Mental Disorders, American Psychiatric Association, 2013) and the ICD-10 (International Classification of diseases, WHO, 1994), if on the one hand they have been able to offer an important attempt to and synthesis of knowledge, on the other hand the reflections on the risk of pathologization of normal variations of the sexual response and on the possible formation of a standardized conception of sexuality have not been dispelled.

St. Augustine reminds us that "Nno one can live without pleasure". The salience of the sexual sphere can also be transformed into a factor of resentment when it does not work: it causes suffering (the anguish of one inevitably also becomes the other: we can speak of couples of damage and damage of the couple); has profound effects on individual psychology (anguish, depression, anxiety disorders, phobic disorders, eating disorders and Doc); it becomes a cause or contributing cause in separations and divorces, as well as in violent and criminal behavior (in 81% of cases of physical violence and killings against women, 2015 TransCrime Report, Min. Interior and Justice).

A recent survey conducted in Italy by Doxa and TradaPharma (2014), on a significant sample of people (interview and questionnaire), highlights that more than 16 million Italians have sexual dysfunctions, with a prevalence in females compared to males (28/30%, mainly due to hypoactive sexual desire disorder and anorgasmia, versus 25-27% in men, referable with a higher incidence to premature ejaculation).

If it is true as A. Einstein says that “It is the theory that decides what we can observe”, the panorama of current approaches is made up of several souls, converging in two prevailing horizons. The Mechanistic one, mostly medical and partly psychological: clinical sexology, internal medicine, urology and andrology, psychiatry, psychodynamics of Freudian derivation and behaviorism. They all share: a deterministic view (what is named actually exists as an independent entity from whoever invented it); the need to refer to a nosographic diagnosis; a therapeutic imperative that is summarized in knowing in order to change (first I identify the causes of the disorder in the past and then I orient the change with analytical paths, stimulating exercises, the various functions of pleasure at the anatomical-genital level, drugs).

The Anthropomorphic one, to which the constructivist-strategic approaches refer, according to which: there is no valid a priori classification criterion (and even if there were, “the map is not the territory”); it is the solution of the problem that indicates the nature of the problem itself, or rather from the search for the “why” we move on to “How” a system works and how to make it work better; we focus on the identification of persistent and redundant mechanisms that keep and feed the problem to be solved (attempted solutions); the difficulty present in the here and now is framed at the level of self-corrective operative hypothesis, which emerges from the concrete changes that are gradually inserted through specific indications of thought (perceptual system) and behavior (reactive system), in the direction of their solution ( change to know).

Brief Strategic Therapy, according to the research-intervention model applied to thousands of concrete cases in over 20 years of clinical activity, has highlighted sexual disorders two typical and redundant attempted solutions:

  • the most frequent is the voluntary effort to provoke or inhibit reactions / sensations that are natural (relaxation, letting go and abandonment are replaced by voluntary control and excessive contraction). The paradox of "be spontaneous" (P. Watzlawick) governs these moments, transforming pleasure into discomfort, pain or fear; deliberately imposing what is natural and instinctive inevitably takes us further away from finding what we seek.

Think for example of a man who after a normal erective failure, the following times, driven by the fear of repeating the embarrassing experience, begins to focus more and more on himself and on his psychophysiological functions: he falls into the trap in an attempt to escape it, in how much "The desire to become capable prevents one from becoming one". In this case the Strategic intervention will consist in guiding the person, through indirect techniques studied ad hoc (Stratagem of "plowing the sea without the knowledge of the sky"), to give up precisely that control that does not allow him to pleasantly lose control.

“How much time have I lost in trying to make up for lost time” (R. Gervaso).

  • escape from spontaneous sensations / reactions that I cannot resist, that is pleasure is experienced as negatively disturbing, as a sensation from which one must escape as irresistible or fearful. Here, too, a further paradox emerges: “If you allow it you can give it up, if you don't allow it it will become indispensable” (Seneca). In this second case, the Strategic Protocol envisages inducing the person to give in gradually and in small doses to temptations, so that he discovers through direct and concrete experiences that nothing catastrophic or uncontrollable happens. Often this is the situation, for example, of those suffering from a disabling eating disorder such as Anorexia. The attempted dominant solution, that is an excess of control over food and the body so successful that it can no longer be given up, also translates into a snowball effect that becomes an unstoppable avalanche on an emotional level: a progressive and increasingly pervasive anesthesia of sensations primary. The person, closed in his own armor that protects him and at the same time suffocates him, is terrified of letting himself go to pleasure for fear of "feeling" and being overwhelmed by it.

"Sex is the art of controlling the lack of control"(P. Coelho)

The specific strategic treatment protocols for the main male and female sexual dysfunctions currently record an efficacy of 91% of cases (the highest efficacy, immediately after anxiety disorders 95%) and an average efficiency of 7 sessions.

“We don't do anything right, until we stop thinking about how to do it” (W. Hazlitt).


Dr. Marisa Ciola (Official Psychologist-Psychotherapist of the Strategic Therapy Center)


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Ciola, "Affective and sexual education: the strategic approach for children, adolescents and adults", Department of Prevention and Health Promotion, Provincial Health Service Agency of Trento, 2016; “Trainers Training” Course, Strategic Therapy Center, Arezzo 2015.
Ciola, "Sexuality and its dysfunctions: Strategic approach and intervention in the third age", Giornale Unione Apsp, "Civica", Autonomous Province of Trento, 2015.
Ciola, “Emotions and sexuality: a right for everyone or not for everyone?”, Anmic magazine (National Association of the Mutilated and Invalid Civilians), section of Trento, 2012.
Ciola, “Reflections on affectivity and sexuality: between Nature and Culture”, Upipa Conference and the Autonomous Province of Trento, 2010.

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