In memory of William H. Masters.

The death of William H. Masters, M.D. in Tucson, Arizona on February 16, 2001, at age 85 marked the passing of one of the giants of the field of sexology in the twentieth century.

William H. Masters graduated from Hamilton College in 1938 and from the University of Rochester School of Medicine in 1943, following which he began a long-standing affiliation with the Washington University School of Medicine when he came to St. Louis for post-graduate training. A member of the Department of Obstetrics and Gynecology from 1943 until his death, Dr. Masters earned a unique place in medical and cultural history with a multi-dimensional career the likes of which has rarely been seen.

After establishing credentials of an impeccable academic nature in his early professional years in the fields of infertility, gynecologic surgery, and research on estrogen replacement therapy in postmenopausal women, Masters then turned to the field that he had planned to study from the outset. Obtaining permission to launch a research program in human sexuality in 1954 from his department chairman, the dean of the medical school, and finally, from Washington University's Chancellor, Ethan Shepley (who took the matter to the Board of Trustees of the university for a vote of approval), Masters spent a number of months planning how to ensure maximum confidentiality for such work, recognizing its potentially incendiary nature. Ultimately, he recruited an advisory board made up of the St. Louis Police Commissioner, the publisher of The St. Louis Globe Democrat (one of the two daily St. Louis newspapers at that time), several of the area's preeminent religious leaders, and Ethan Shepley. This group convinced the press to keep an absolute embargo on news about his research program for the next 12 years.

Masters' initial sex research, during 1955 and 1956, was done exclusively with prostitutes around the country. Masters felt that by conducting interviews with prostitutes and observing them at work, he might learn things that were not in the scientific literature. He also believed that prostitutes would be more amenable to participating in laboratory studies of sexual response than other populations, and so viewed this preliminary phase of his investigations as an opportunity to devise proper instrumentation and recording techniques as well as to get instructive feedback from laboratory subjects. This work was never published because Masters recognized that the study population was unrepresentative demographically, psychologically, and medically; it was, in fact, just a preliminary step toward the work that he had envisioned for more than a decade.

Dr. Masters had the foresight to recruit a professional partner, Virginia E. Johnson, to conduct a pioneering decade-long systematic study of observational laboratory research in the anatomy and physiology of human sexual response that had never been attempted before. This work, begun in the Department of Obstetrics & Gynecology at Washington University in late 1956 and moved in 1964 to the Reproductive Biology Research Foundation adjacent to the medical school (later renamed the Masters & Johnson Institute), attracted an astonishing degree of worldwide attention with the publication in 1966 of Human Sexual Response, which became the first and only medical text to climb to the top of the New York Times best-seller list.

Human Sexual Response provided definitive laboratory evidence regarding the origins of vaginal lubrication (disproving the notions that either the cervix or Bartholin's glands were the primary source of vaginal lubrication), documented the typical vaginal and uterine changes that occurred during sexual arousal and with orgasm, demonstrated the existence of multiple orgasms in women (at a time when most medical authorities disputed the existence of this phenomenon), and provided concrete data on the general changes that aging produced on sexual responsiveness in both males and females. (Later, Dr. Masters often stressed to interviewers that the laboratory work showing that a full range of continued sexual functioning was possible in the geriatric years--given, as he liked to phrase it, "a good general state of health and the availability of an interested and interesting partner"--was arguably the single most important aspect of his physiology work.) In Human Sexual Response, Masters and Johnson also quantified the timing dynamics of orgasmic contractions in both sexes, reported on cardiac and blood pressure responses during sexual arousal, and described dozens of differences and similarities between the sexual response patterns of males and females. The work entailed not only simply laboratory observation and peripheral monitoring of human subjects, which would have been startling enough to the world, but also intravaginal cinematic photography that clearly showed the processes of vaginal lubrication, the formation of the orgasmic platform, rhythmic contractions of the orgasmic platform (and vaginal interior) during orgasm, and similar photographic documentation of changes in the breasts, the labia, and the clitoris. (There was no similar photography done at the time of male sexual responses due to at least two issues: a paucity of research funds and lack of instrument miniaturization to allow intraurethral or intrarectal photography.)

Although this fundamental research elucidating the nature of human sexual response would have, by itself, been enough of an achievement to insure Masters and Johnson's place in history, this visionary research team went on to develop a revolutionary approach to treating a broad range of human sexual dysfunctions and disorders based in part on what they had learned from their laboratory studies. The Masters and Johnson approach, which took the scientific world completely by surprise when it was unveiled in 1970 with the publication of Human Sexual Inadequacy, provided a short-term, highly efficacious clinical model with an overall success rate of more than 90% for problems that had previously been treated with years of therapy with abysmally high failure rates. Notably, the meticulous planning of Dr. Masters and his sense of what it would take to convince other health care professionals of the long-term efficacy of this method had led him to wait until 5 years of 5-year follow-up data were gathered on the couples who had undergone therapy, a virtually unheard-of degree of research rigor at that time.

Today, it is hard to envision how startling the unveiling of the Masters and Johnson model for sex therapy was in 1970. Many psychiatrists and psychologists were outraged over what they viewed as impossible results. Accusations were made in many quarters that the Masters and Johnson therapy could, a priori, only address superficial sexual symptoms rather than deep-seated psychological problems, and would thus have no chance of achieving sustained results; others dismissed their approach as mechanistic, formulaic, and simplistic. But none of the early critics had actually observed Masters and Johnson's methods, and the truth was considerably more complex than these erstwhile reactions allowed. As Fritz Redlich, M.D., Professor of Psychiatry at Yale University School of Medicine, remarked after spending several weeks at the Reproductive Biology Research Foundation in the mid-1970s listening to cases, both live and on tape, "Masters and Johnson treated sexual problems more swiftly and effectively than anyone in psychiatry recognized. They have turned the tables on Freud and exposed the weak underbelly of his theories about sex." People such as Raymond Waggoner, M.D., Chairman of the Department of Psychiatry at the University of Michigan School of Medicine, and Emily Mudd, Ph.D., a noted marriage and family therapist who had founded the Marriage Council in Philadelphia, had worked with Masters and Johnson extensively from the late 1960s on and were highly enthusiastic advocates of their approach.

In actuality, the sex therapy program that Masters and Johnson devised was a sophisticated short-term intensive psychotherapy process for couples that used an eclectic mix of behavioral tasks, dyadic work on communication patterns, cognitive techniques, and other elements in combination with practical sex education, permission-giving, and attention to individual and couple issues that went far beyond what most professionals envisioned it to be. While it was primarily directive rather than interpretive, it certainly entailed considerable effort on the part of the therapists to help each member of the client couple achieve insights into the factors causing or maintaining their sexual and relationship difficulties. (Unlike most psychotherapy that had been done before, clients were also thoroughly evaluated for medical factors that might play causal or contributing roles to any sexual problem that was being treated with both complete physical exams and full clinical laboratory work-ups.) In a typical case, less than 20% of the time in therapy was actually spent discussing sex at all: Considerably more time was spent dealing with such matters as emotions, intimacy, personalities, the vagaries of male-female communications, body image, problem-solving skills, resistances, ego defenses, and everyday hurdles to couples finding personal satisfaction, not done in a formulaic way but done based on the needs of each client-couple.

Among the most important elements in Masters and Johnson's approach, and certainly one that helped catalyze the entire process, was their invention of a set of seemingly simple exercises that they termed sensate focus which provide a framework for couples to approach their sexual interaction in new and relatively unfettered ways while also providing diagnostic feedback to the therapists. The sensate focus exercises, which were always to be done by a couple in privacy (never in view of the therapists), began typically with a counterintuitive ban on any form of direct sexual stimulation or activity which served dual purposes -- largely eliminating the spectre of performance anxieties from the couple's immediate interaction and allowing the partners to approach physical intimacy as a form of unstructured exploration with an emphasis on sensory awareness. Gradually, the instructions for sensate focus were shifted day by day to allow these exercises to encompass exploration of the breasts and genitals and then typically to progress to intercourse; along the way, fears of performance and the attendant role of spectatoring (which Masters and Johnson were the first to describe and name) could be dealt with therapeutically. Today, the notion that people caught in the vise of sexual anxieties are apt to be distracted from the fundamental flow of touching and being touched, developing personal closeness and comfort, and relaxing during a sensual encounter is hardly earth-shattering, but in the 1950s and 1960s therapists had largely ignored this issue or addressed it only in abstract ways.

Few scientists will ever achieve what Masters and Johnson did: found an entirely new specialty with their work.

Through the next quarter century, Masters and Johnson devoted considerable time and effort to training and educational work, providing instruction for residents and fellows from the Departments of Psychiatry and Obstetrics and Gynecology at Washington University as well as for physicians and other health care professionals from around the world. The Masters & Johnson Institute also conducted a broad range of research on the sexual effects of a wide variety of medical problems and published the highly acclaimed Textbook of Sexual Medicine (Kolodny, Masters, & Johnson, 1979), as well as the Textbook of Human Sexuality for Nurses (Kolodny, Masters, Johnson, & Biggs, 1979), and a college textbook that has gone through 5 editions since 1982. In addition, under Dr. Masters' leadership, the Institute spear-headed a national effort to devise ethical guidelines for sex researchers and sex therapists, with the Institute paying virtually the entire expense of bringing dozens of acclaimed experts from the field of bioethics and the leading organizations involved in sexology together in this work which spanned a period of 4 years.

Dr. Masters frequently expressed his frustration over two disparate matters. He was unhappy that relatively little work had been done unraveling the neurophysiology of human sexual response. He was also personally dismayed that sex researchers and sex therapists had not managed to forge a united field in the face of the HIV epidemic and had thus simultaneously missed an opportunity to foster interdisciplinary and inter-institutional cooperation and synergies and to demonstrate to the scientific community at large how valuable our field's multidisciplinary contributions could be.

Dr. Masters was the ultimate scientific pioneer who had a combination of remarkable vision, scientific fervor, and willingness to work against the odds to reach his goals. Although he was attacked harshly and personally at many points in his career, he always handled such situations with remarkable restraint and class. He was a leader and a doer; it is safe to say his likes will not be seen again for quite some time.