Specializing in Sex Therapy

From a high point in 1972 when all but six American medical schools gave at least four hours of sexual medicine lectures, there has been a gradual decline in teaching the topic. Aging directors of hospital or medical school sex clinics retired or died; several scholarly sexual journals ceased publication; and support money became nonexistent. Today, few sex therapy specialty programs survive in the United States, yet sexual problems remain prevalent.

So reported Domeena C. Renshaw, M.D., professor of psychiatry and director of the quarter-century-old Sexual Dysfunction Clinic at the Loyola University of Chicago Stritch School of Medicine, in a 1996 article in the Journal of Women's Health.

After her recent return from an every-other-year trip to South Africa, where she goes to teach and visit loved ones, Renshaw consented to an interview with Psychiatric Times. She talked about the dearth of sex therapy programs in the United States, the program she founded at Loyola and the forces that led her to a career in psychiatry.

Born in South Africa, the only daughter in a family of four children, she attended Convent High School, a small all-girls facility housed in Cecil Rhodes' 1880 mansion, which hearkens back to diamond-rush days. "The only science class offered was botany, so we were prepared for marriage rather than medical school while the good nuns prayed we would enter as novitiates," she recalled.

She described her rearing as "highly overprotected and strict," with a message that "girls don't do this, never that and forget the other." One evening when she was 15, she came to a major life crossroad. Hearing that the car of family friends had crashed up the road, she went to the scene with her father. There on the ground was a man moaning loudly that his leg was broken.

"He was very dramatic," said Renshaw. "I looked and saw the whole right leg move as he winced, rolled and groaned."

She calmed him and even made him laugh. And that was when she knew she had to "discover the mind-brain barrier."

"There on the open veld of the plains of Africa, not knowing at all what it meant, I was unable to articulate how I had by common sense and reassurance talked a frightened 6-foot male out of a hysterical somatic reaction," she said. "I had not heard the word psychiatry. I knew there were 'brain doctors'; so therefore I had to go to medical school."

But getting away from home was a long struggle.

"For me, an only daughter, to emancipate from a super-conservative controlling mother and a quietly supportive father was difficult. Threats of disinheritance, never being spoken to again, of being responsible for strokes and deaths prepared me to be a calm, effective therapist," she said.

Nine years after graduating from high school, Renshaw had saved enough salary to leave home to enter the University of Capetown Medical School. Her first year was a "trial by fire" as she struggled with physics and chemistry. She found zoology a delight after getting over her fear of insects. And in 1960, her fifth year of training, she was dazzled by neuropsychiatry, reading the 580-page textbook-Mayer-Gross' Clinical Psychiatry-"as if it were a novel." She did her rotating internship at Groote Schuur Hospital, starting with urology and followed by obstetrics-gynecology and pediatrics. She then applied for and got three months of combined neuropsychiatry.

"I could not wait to get to work and spent endless evening hours on and off duty just listening and listening," she said of those days. "Henry Walton, M.D., was my chief and professor of psychiatry, revered for his wisdom and dignity."

In her last week, she was told by Walton that she "must do psychiatry-it is your specialty." She expressed worry that she was too fascinated by the field and feared she wouldn't be able to detach from patients. Besides, she told him, she planned to do mission hospital work, for which the need was enormous. Responded Walton: "Very well, do that...However, your specialty will catch up with you."

Receiving her medical degree in 1961, Renshaw went to St. Konrad's Hospital, a 255-bed facility where she worked solo for three months.

"It was humbling to realize how much I had yet to learn after medical school," she said. "So I went about gathering my skills and knowledge."

Invited to Children's Hospital in Boston by Paul Dudley White, M.D., a Harvard cardiologist whom Renshaw had met while in medical school, she went there to do a pediatrics residency. She then returned home to do a surgical residency at Livingston Hospital in Port Elizabeth on the Indian Ocean, finishing in 1964.

"I then felt competent to join the husband-wife team of physicians John and Gloria Broeckhaert at the 160-bed St. Mary's Mission Hospital on the edge of Zululand," she said, noting the prevalence there of schistosomiasis, pellagra, tuberculosis and snakebite. "I learned and learned and learned."

In that semitropical bush, Renshaw worked as a general physician-surgeon and after hours saw a steady stream of patients with psychiatric problems, mostly local nuns and priests, some whites and several Zulus and Asians.

"I was reading one page ahead of doing from my well-worn text and a donated shelf-full of leather-bound Jung volumes," she said.

In 1965, Robert Renshaw, Ph.D., an American economist she'd met on her trip to the United States, arrived to marry her. He'd obtained a job as economics professor at Northern Illinois University, which brought the couple to the Midwest, and Domeena became a psychiatry resident at Loyola, and thus, as Walton had predicted, did her specialty catch up with her.

"When I told Bob, he said, 'Sure, do psychiatry, nice easy job for a woman,'" she recalled. "How often have I teased him, when I put in 60 faculty hours a week and fly weekends to teach in Canada, California, etc."

After completing her psychiatric training in 1968, she joined the faculty, where she became assistant chairman of the psychiatry department.

She said her sexual dysfunction clinic began by "geographic accident."

"In the early '70s, the psychiatry department here was sandwiched between gynecology on one side and urology on the other, and we began to get referrals of the anorgasmic ladies from the one side and the impotent men and premature ejaculators from the other side."

Director of the psychiatry outpatient clinic at the time, Renshaw listened each Monday morning to residents present their cases. Hearing that patients with sexual problems were simply being sent home, she realized that she'd have to teach those residents how to treat such dysfunctions. Thus she designed the sexual dysfunction program, which she expected to last only a couple of years.

"I did not go to a committee," she said. "I did not ask for money. These bureaucratic blocks may have strangled all my efforts. I simply began to treat, after designing the elective."

Opening the clinic in 1972, with 20 trainees and 12 couples, Renshaw found her program was an immediate and overwhelming success. Since then, it has trained about 2,800 health professionals and clergy who have come from around the world to take the elective rotation, which includes two weeks of didactic workshops followed by seven weeks of supervised clinical sex therapy with patients. About 1,800 couples have completed therapy at the clinic, with 100 more always on a waiting list.

"There's such an enormous need," said Renshaw, noting that a study of 100 white, middle-class, well-educated couples revealed that more than 70% of the women and 50% of the men reported they had sexual problems. "Ours is a small clinic, in no way able to meet the demand for treatment or training from all who request it. About 80 couples a year are treated. The waiting list is much too long. Couples wait between three and 10 months to come in for therapy, a far from ideal situation."

Given the need, why aren't there more sex therapy programs? Because they are time-intensive and not profitable, said Renshaw, explaining that while former programs had charged thousands of dollars, her clinic charges couples a modest fee of $700 for 35 hours with two therapists plus Renshaw's on-site faculty supervision.

"Our program has a zero budget, and full-time staff members have accepted administrative responsibility for intake, scheduling and necessary support tasks of audiovisuals, billing, etc., with enthusiasm and cheerfulness, despite the long hours the work entails," she said.

Discussing the couples her clinic has treated-130 of whom were in unconsummated marriages of up to 23 years' duration-Renshaw noted that in only 20% were the marriages stable beyond any thought or discussion of divorce.

"A few had already filed for divorce; some had separated but agreed to stay together for the seven weeks of therapy. To threaten divorce unless the sexual problem is resolved is very common. It is extremely difficult to predict which couples will be easy. Some have made unbelievable progress despite years of conflict so severe than the options were only sex clinic or lawyer. Others with good social skills and no admitted conflicts may be tenaciously resistant to changes in their sexual avoidance," she explained.

In only 14% of the persons treated could an individual psychiatric, nonsexual diagnosis be made.

"There may be lifelong character traits, but no definable psychiatric illness," she said. "Whether more personality diagnoses coexisted may be open to debate, but my philosophy is that when an individual's general life adjustment is satisfactory without the use of counseling services, undue psychiatric labeling is inappropriate and unnecessary."

The few patients who show high anxiety are offered medication, and some accept and use low daily doses as needed for about 10 days to good effect.

In the second week of the program, physical causes are carefully sought and excluded. About 3% of patients have sexually relevant pathology such as an intact hymen, pituitary adenoma, varicocele or phimosis. The clinic has also newly diagnosed three cases of malignant melanoma, eight cases of hypertension and other pathologic conditions that needed further care and referral.

"Our technique of brief sex therapy with couples treats the relationship as the patient," Renshaw said. "Although each patient looks at the self and the past, each must also constantly be sensitive to and interact with the other. The process is intensive and directive."

Patients are taught to talk openly for themselves in the first person: e.g., "I don't like it when you don't bathe before sex," instead of the accusatory, "You are smelly." Abundant sex education is given and reinforced by slides and videotapes and also during the explanatory genital examination by a physician in the partner's presence. The behavioral component of the sex therapy takes place in the couple's bedroom and encourages relaxation through mutual sensual pleasuring, with general body massage first and then genital play.

"This method aims to undo coital problems through pleasurable arousal, total body relaxation and orgasm," explained Renshaw. "All are powerful positive reinforcers of newly learned communicative, sensual and sexual skills."

And the therapy works.

"We see 80% symptom reversal, to completed coitus, rated as success," Renshaw said. "This is the objective of sex therapy. In their seventh-week patient evaluations, 80% of the remaining 20% who failed to have coitus subjectively rated improvement. They felt their relationship was closer and their noncoital sexual exchange and enjoyment were satisfactory."

For a small number of couples, sex therapy became predivorce therapy during their last two sessions.

"Greater honesty developed after years of avoidance or denial," Renshaw reported. "Discussion in therapy allowed them to realistically consider separation with less rage, less pursuit of retaliation and perhaps with more mutuality and maturity."

In addition to the couples' program, there are four brief sex therapy options offered through Loyola's psychiatry outpatient clinic. They include individual sex therapy consisting of six sessions, same-sex group therapy for six weeks and a twice-yearly, six-hour Saturday marriage enrichment symposium with slides and videotapes plus a booklet for later use at home.

"This is a community service that is low-cost and totally anonymous for individual or couple attendance," said Renshaw of the symposium. "Many couples on the waiting list or in individual brief sex therapy attend. On mail follow-up eight weeks later, about 30% seem to have managed their sex problem without further help."

The fourth option is "bibliotherapy," the reading of her self-help book which is also available as an audiotape. Called Seven Weeks to Better Sex, it was written at the request of the American Medical Association Consumer Book Division, published by Random House in 1995 and reissued as a paperback by Dell Books last year.

"From anecdotal feedback, this book has assisted couples to improve their sexual exchange and even reverse existing sex symptoms," said Renshaw, who has also written three other books. "Therefore, a physician in practice may suggest that patients read it, then return for a second physician visit with their questions. This stepwise approach was the intent for which the book was written."

To reach consumers, the tireless Renshaw has appeared on radio and talk shows such as "Donahue" and "Geraldo" and been filmed by a New York PBS crew for a segment of a 13-part series on human behavior. To reach medical colleagues, she's published more than 300 articles in medical journals and produced teaching videotapes and audiocassettes, in addition to presenting at professional meetings and lecturing internationally. Alumni of her training program have set up modified programs in Australia, New Zealand, South Africa and Illinois.

Aside from the abundant media coverage of the sex topic and given the present managed care climate, what is her view of the future for both sex therapists and the couples who come to them?

"Well, the future is that whoever is going to do sex therapy, managed care is not going to pay for it. No matter what terms you couch it in. It's going to be perceived as a luxury-they barely pay for depression!

"The reality is that we're going to have to do a lot of this with patient self-pay. That's why we've kept our fee so very low. But we feel the therapy is worth it because the outcome is so good. When the marriage gets better, it's better for all family members.

"Where else can one get an 80% success rate?" she asked. "It's tremendously satisfying work."