Review of Chinese sex attitudes & applicability of sex therapy for Chinese couples with sexual dysfunction.

As the most populated country in the world with an enduring history of cultural development, China has long been concerned with issues of sex and procreation. Attitudes toward sex and sexual behavior among Chinese people have evolved over thousands of years and have been influenced by ancient Chinese philosophies as well as contemporary political and sociocultural changes. With an increasingly liberal political and economic environment in the recent decades, sex has become less of a taboo subject in China. However, with insufficient sex education within the country, folk beliefs prevail. People with sexual dysfunction are reluctant to seek help from experts of sex therapy. Rather, many Chinese people with sexual dysfunction tend to attribute their problems to somatopsychic origins and use folk medicines or tonic treatments. This paper reviews contemporary studies of Chinese sexual attitudes and behaviors, examines the applicability of Western psychosexual intervention on Chinese couples, and suggests adaptations needed for effective sex therapy with the Chinese.

The influx of Asian immigrants into the United States and other Western countries in the recent decades has raised the need for clinicians to become more familiar with the cross-cultural validity of psychological therapies. According to Kim, Atkinson, and Yang (1999), Asian Americans born overseas constituted over 50% of the Asian American population in the United States. The 7.2 million Asians born overseas also made up 25.5% of the foreign-born population in 2000 (U.S. Bureau of the Census, 2001), with China being one of the most common countries of origin. Kim et al. (1999) pointed out that even when Asian American clients are familiar with English, they vary in their degrees of acculturation of American values and behaviors. Therefore, clinicians working with Chinese or Chinese American clients may find this article helpful in enhancing their understanding of Chinese sexual attitudes and behaviors.

SEXUAL BEHAVIOR AND DYSFUNCTION IN CHINESE

Renaud and Byers (1997) investigated the sexual relationships of 424 married Chinese men and women living in Beijing and Shanghai, China. The results indicated that in general, married Chinese men and women were moderately satisfied with their overall relationships and their sexual relationships with their spouses. Their physical affection was mostly expressed within the context of sexual activity and they had a narrow repertoire of affectionate expressions. Chinese couples, especially those in the older generation, were taught that love should be kept within one's heart, rather than expressed overtly through affectionate behaviors such as hugging, kissing, and cuddling. However, the study found that more frequent physical affection was related to higher relationship satisfaction and higher sexual satisfaction. The expression of physical as well as sexual affection between the couple enhanced the marital relationship.

Two thirds of Renaud and Byers' (1997) sample indicated that they had experienced at least one sexual problem recently. The most frequently experienced sexual problems for women were trouble getting sexually excited and inhibited orgasm, whereas the most frequently experienced sexual problems for men were premature orgasm and maintaining sexual arousal.

Wen (1995) analyzed the 216 letters written to the "Mailbox for Sexual Problems," a weekly medical column in Taiwan. Nearly half of the male enquirers presented sexual dysfunction such as erectile difficulties and premature ejaculation, and one third presented "sex-related anxieties" (p. 225). Of those with sex-related anxieties, around 52% focused on masturbation, mainly worrying about whether masturbation would cause shenkui, that is, energy or kidney deficiency resulting from an excessive excretion of semen (Wen & Wang, 1980). Concerns about the size and appearance of their genital organs consisted of 28% of the sex-related anxieties among the male respondents. On the contrary, nearly half of the female respondents presented sex-related anxieties in regard to virginity, premarital sex, and coital behavior (p. 225). About one fifth of them were concerned with problems related to pregnancy and contraception, and only less than one sixth were concerned with problems of sexual dysfunction. These figures suggest that Chinese men were more concerned about their performance during sexual intercourse, while Chinese women were more concerned about sex ethics such as virginity, pregnancy, and premarital sex.

CHINESE VIEW OF SEX

Although Chinese people manifest similar sexual problems as those in the West, they may have different understanding of these problems. Despite the significant steps in modernization and sexual liberalization in recent decades, the Chinese view of sexuality has strong roots in its cultural heritage and traditional folk concepts.

Taoist Concepts of Sex

Historically, the Chinese saw the world in dualistic terms and looked to the inherent unity of the opposing forces. Sexual behavior in ancient China was regarded as an indispensable activity done in order to reach harmony with the universe through the unity of the two opposing forces: yin and yang (Dikotter, 1995). Yin was thought of as the female, the cold, the negative aspect of nature, while yang was conceived of as the male, the hot, and the positive component. An imbalance of yin and yang led to illnesses (Bhugra & de Silva, 1995; Ruan, 1991; Tan, 1980). Regulation of sex life was one of the major ways to promote health.

Taoism, China's major indigenous religion, particularly stressed the importance of using sexual techniques for individual benefit. Taoist doctrine holds that appropriate sexual methods are a means of achieving personal immortality. A set of Taoist theories on sexual techniques--The Art of the Bedchamber--was gradually developed (review by Liu, 1999; Ruan, 1991). Taoist handbooks on sex encouraged prolonged sexual intercourse and intercourse with multiple sexual partners for obtaining more nourishment from the female essence. Male's seminal essence was deemed highly precious and avoiding its loss through emission could lead to longevity and immortality. Masturbation was strongly denounced, and the life-giving seminal essence was reserved for procreation. Hence, the aim of sexual intercourse for a male was to give the female an orgasm while avoiding ejaculation. Each time a man had intercourse he should try to absorb as much as possible the woman's yin without giving up his own yang. By collecting such yin, he could then impregnate the wife from whom he wanted to have a child (Bhugra & de Silva, 1995; Evans, 1995; Ruan, 1991). Therefore, most sexual prescriptions were male-oriented, while the female took a passive role as a means for procreation (Bullough, 1976).

Contemporary Chinese Attitudes Toward Sex and Sexuality

Government-backed ideologies had brought major changes in Chinese attitudes toward sex and sexual behavior in the past few centuries. Around the 17th century, government-initiated asceticism became predominant as part of a more general effort to combat all forms of extramarital sexuality and to enforce male and female chastity. Sexual taboos and modesty became the ethos (Zhang, Li, Li, & Beck, 1999). Such ideas prevailed throughout the Qing Dynasty (16441911 A.D.) until the early 20th century.

The political changes in modern China in the 20th century also impact on the public discourse on sex. After the establishment of the People's Republic of China in 1949, there was official repression of many forms of sexual expression in China. Throughout the 1950s, principles of hard work, frugality, and collective enthusiasm for the "new China" dominated images of marriage and family life. As sexuality was promoted only for reproduction and the enhancement of the family and society, seeking sexual pleasure was frowned upon (Pan, 1993). Women in particular were not expected to derive pleasure from sex, and their sexual desires were thought to be dictated by their capacity to bear children (Evans, 1995; Pan, 1993). During the Cultural Revolution (1966-1976), a kind of gender neutrality in hairstyle and dress, based on the defeminization of female appearance and its approximation to male stereotypes, became the socialist ideal (Evans, 1995: Zheng, 1997).

Approaching the end of the 20th century, the Open Door Policy and economic reforms in China were accompanied by more attention to individuals' freedom of choice, rights, and interests. Sexual attitudes and behaviors have now become recognized as an individual's decisions, resulting in increasing diversity of sexual behavior (Ruan, 1991: Zhang et al., 1999).

Premarital sex has become more widely accepted among Chinese young people, as suggested by a number of studies. Pan (1995) reported that the percentage of Beijing's urban population who approved of premarital sex rose from 50% in 1986 to 70% in 1990. In 1990, around 80% of a sample of young women were found to have had sex before marriage, which increased to 95% in 1992. Among a group of college students, 40% showed their approval of premarital sex as long as "they have fallen in love" and 35% approved if "both sides want it" (Pan, 1995).

Liu, Ng, Zhou, and Haeberie (1997) conducted a nationwide survey of 20,000 men and women in China between 1989 and 1990. About 66% of the 372 college student respondents had their first sexual intercourse between the ages of 17 and 22. Among the married couples in the study, who were less educated than the college students, more than 60% had their first sexual intercourse on their wedding day. Also, the younger and more educated the couples were, the more likely it was that they had had premarital sex.

Around 6% of the respondents in Liu et al.'s (1997) national study reported having extramarital sexual partners, while 53% of the city dwellers and 43.9% of the villagers deemed extramarital sex understandable in the case of a poor relationship with one's partner. However, women were generally less tolerant of extramarital sex than men.

Married couples have begun to pay more attention to the quality of their marriage, rather than its stability alone. From 1982 to 1994, the divorce rate in China increased annually by more than 10% (Pan, 1995). About 30% of divorced people attributed their break up to sexual difficulties. Liu et al. (1997) also found that sexual disharmony as a cause for divorce had been increasing in recent years.

In Hong Kong, a more westernized and cosmopolitan city, the younger populations also hold accepting attitudes toward premarital sex. In a survey conducted by the Family Planning Association of Hong Kong in 1996 (FPAHK, 2000a) with 964 young people aged 18 to 27 years who were out of school, 31% had experienced premarital sex. The female mean age at first premarital sex decreased from 19.3 years in a similar study in 1991 (FPAHK, 1995) to 18.2 years in the 1996 study. Around 68% of the male respondents and 50% of the female respondents indicated acceptance of sex between a single man and his partner when they were planning for marriage, compared with only 50% of the males and 33% of the females in 1991. Among the married respondents, more than one third had cohabited with their spouses before marriage.

Sexual Knowledge and Satisfaction

The above review reveals greater flexibility and openness in the contemporary Chinese attitudes toward sex and sexual behavior, but sex education and information on sexual issues in China appear to remain limited. Under stringent political and social sanctions in the mid-20th century, sex was not usually mentioned in public. When sex education was first initiated in China in late 1980s, teachers and parents expressed strong opposition against it. They worried that sex education would stimulate sexual interests in the youngsters. Not until the late 1980s had a few books been published in China for the purpose of public sex education. They were The Knowledge of Sex, The Essentials for the Newlywed, Handbook of Sex Knowledge, and Sexual Medicine (Liu et al., 1997). More than 60% of Liu et al.'s (1997) city respondents and more than 70% of their village respondents had read books of this nature. Recreational sex books or movies are still rare in China and are denigrated as immoral. Many people seem to be reluctant to come into contact with them. In Hong Kong, although sex education is included in the secondary school curriculum, the focus is on physiology and hygiene with little attention given to the relational aspects (FPAHK, 2000b). Similar parental resistance is encountered and teachers are ill-prepared to cover topics beyond biology.

Studies have suggested that knowledge of sexual terminology is rather limited in China. For example, in Xu's (1997) survey of 3,205 wives (with a mean age of 39 years) and 2,828 husbands (with a mean age of 41 years) from urban and rural areas of China, 50% of the respondents had no knowledge of the term "sexual orgasm." More than 67% of those respondents who were above 50 years old were unfamiliar with the term. Among those under 30 years old, 43.1% had not heard about the term.

The insufficiency of sexual knowledge may have an important impact on sexual pleasure and satisfaction. In Xu's (1997) survey, 11.8% of the city couples and 23% of the village couples engaged in intercourse without foreplay. As high as 40% of the women had never or only rarely felt sexual pleasure, while less than 20% reported feeling sexual pleasure often or every time they had intercourse. Among the city respondents in Liu et al.'s (1997) survey, 2.6% reported frequent pain during sexual intercourse and 39.2% reported occasional pain; the corresponding figures of village respondents were 2.2% and 34.4%.

In the rural regions of China, where people are less educated and more conservative, sex is seldom talked about even between married couples. Among the village respondents in Xu's (1997) survey, 31.7% of those over 50 years old reported communicating with their spouses about sex, and 66.6% of those below 30 years old did so. Overall, only 4.6% of the villagers often shared their sexual feelings with their spouses.

Studies on Chinese sex life and sexual attitudes may be affected by the conservatism of the respondents. In the analysis of the responses to the Chinese Minnesota Multiphasic Personality Inventory in Hong Kong, Cheung (1985) observed that most of the items left unanswered by more than 10% of the college students were related to sex. Such item endorsement patterns may reflect the respondents' reluctance to discuss and disclose their sex lives and attitudes. Sometimes, even the investigators appear to hold a conservative view about research on sex. Xu (1997) reported that the rural-based investigators who participated in his survey appeared to be embarrassed about the topic of the survey and had little confidence in obtaining information from the respondents on such a private and forbidden issue.

Folk Beliefs

In the absence of comprehensive and pervasive sex education in China, a large proportion of Chinese people obtain sexual knowledge from informal sources. These range from pornographic books, magazines, movies, and television programs to jokes and casual communication among peers (Evans, 1995; Lieh-Mak & Ng, 1981). This allows room for folk beliefs to flourish and perpetuate.

Tseng et al. (1993) conducted a survey on 173 college freshmen in Taiwan. Of the male group, 19% believed that semen was a precious substance needing careful conservation: 29% considered that a person needed to reduce or avoid masturbation so as to preserve physical vitality; and 47% thought that sexual intercourse promoted yin and yang exchange, and thus was helpful in maintaining health. In the female group, only 12.3%, 4.1%, and 26% agreed with those three statements, respectively. These results reflect the impact of the male-oriented Taoist beliefs on the respondents' sexual attitudes. Even though the taboo about masturbation may be found also in other cultures, such as the Judeo-Christian tradition, the taboo as conceptualized in the Taoist tradition denounced masturbation not so much due to its moral implications as to its disturbance of the yin-yang balance.

The health concern is supported by Tseng et al. (1993), who found that, when compared with nonclinical male students, a significantly higher percentage of male patients suffering from sexual dysfunction believed that a person needed to reduce or prevent masturbation (51%), that excessive masturbation would cause shenkui (62%), and that intercourse with menstruating women caused illness in men (53%). Lieh-Mak & Ng (1981) also reported that their patients with ejaculatory incompetence had an overriding concern with ejaculation in relation to health. There appears to be a close relationship between sexual dysfunction and folk beliefs about sex that associate unrestricted sex with health risks.

These folk beliefs may be traced back to the Taoist sex doctrines that value semen as a source of vitality and emphasize the importance of semen conservation. The Taoist teachings were originally meant to promote the idea that a man must learn to find the right interval of ejaculation to suit his age and physical condition in order to find greater pleasure. However, it has been interpreted in isolation, particularly by individuals with sexual dysfunction, to say that semen is essential to health and longevity and must be conserved at all costs (Lieh-Mak & Ng, 1981). Today, sayings such as "one drop of semen is derived from ten drops of blood and each drop of blood is derived from the ingestion of ten grains of rice" are still widely believed among the Chinese (Gwee, 1968; Lieh-Mak & Ng, 1981; Tan, 1980; Zhang et al., 1999). In the daily newspapers in contemporary Taiwan, it is easy to find advertisements for traditional medicine that promote the concept that excessive waste of semen is the usual cause of developing naoshenjing shuairuo (i.e., a group of loosely defined symptoms such as poor concentration, memory disturbance, dizziness, insomnia, etc.; Wen, 1995), or shenkui ("kidney deficiency"). Such medical advertisements may reinforce traditional views and distort understanding of modern sexual knowledge (Tan, 1980; Wen, 1995).

Folk beliefs may also contribute to sex-related anxieties. For example, under the influence of folk beliefs, young men who practice masturbation may perceive their behavior as wrong. They may become anxious, remorseful, self-incriminatory, and frightened whenever they engage in the practice (Wang, Zhao, & Tan, 1956).

Culture-Bound Sexual Disorders

A number of culture-bound syndromes (Yap, 1974) have been associated with sexual dysfunction in the Chinese cultural context. These patterns of behavioral aberrations can be understood in the context of the characteristic norms and beliefs about sexual behaviors.

Nao-shenjing shuairuo or brain neurasthenia. According to Wen (1995), nao-shenjing shuairuo or brain neurasthenia is characterized by poor concentration, memory disturbance, dizziness, blurring of vision, difficulty concentrating, and insomnia. This condition may be related to exhaustion of the brain due to excessive study or chronic anxiety. However, if a traditional doctor is consulted, excessive masturbation may be considered the cause.

Shenkui or shen-k'uei or sex neurasthenia. Shenkui literally means "energy or kidney deficiency". In classical Chinese medicine, shen (kidney) is the reservoir of vital essence in semen (i.e., the positive yang), and kui means deficiency. An excessive excretion of semen means excessive loss of the yang force. It is believed that if a young man indulged in excessive nocturnal emission, masturbation, or sexual activities, he would develop shenkui (Wen & Wang, 1980). Symptoms include dizziness, backache, fatigability, general weakness, insomnia, frequent dreams, and complaints of sexual dysfunction (such as premature ejaculation and erectile dysfunction).

Frigophobia. This condition is characterized by a patient who becomes excessively sensitive to coldness or has fears of catching cold. This is commonly explained in traditional medicine as a symptom of excessive loss of the positive yang force as resulting from excessive masturbation or promiscuous sexual relationships.

Suoyang or koro. Suoyang arises from the belief that retraction of the sexual organs (including penis, breasts, and nipples) into the body leads to eventual death (Cheung, 1998). Patients experience overwhelming apprehensiveness and anxiety, fear of death, and coldness, followed by body weakness and dizziness. They also feel coldness or tremor in their genitals, which appear to contract into their bodies. Tseng et al. (1992) found that a koro attack is a psychologically induced anxiety-panic condition, and the presence of an intensive belief in the culturally related concept of koro renders the person vulnerable to the attack.

HELP-SEEKING BEHAVIOR

From the above review of Chinese sex attitudes and beliefs from the past to the present, it appears that contemporary Chinese people are more tolerant of various sexual behaviors. Despite these changes, sex myths and folk beliefs as well as male-dominant gender roles still prevail, especially among less educated Chinese couples and those who live in more rural areas. The indigenous understanding of sex and sexual dysfunction may have affected the patients' help-seeking behavior.

In Renaud and Byers' (1997) sample in which a majority reported having a sexual concern or problem, fewer than 2% of respondents had sought counseling for sexual problems. Wen (1995) conducted a survey in 1982 on 58 male patients with sexual dysfunction in Taiwan. Most of the patients used various treatment modalities, including traditional Chinese medicine (58.6%), visiting a pharmacy for over-the-counter-medication (24.1%), and visiting Western-style medical clinics (63.8%). Services offered by mental health clinics were not frequently used (15.5%). According to Wen (1995), these figures suggested that the concept of sexual dysfunction as psychosomatic disorders was rarely endorsed, whereas somatopsychic concepts compatible with yin-yang theory and shenkui were favored.

Many Chinese people with sexual dysfunction or psychiatric disorders tend to label their problems as neurasthenia, a broad and vague term. Even in Hong Kong where psychiatrists have adopted the Western diagnostic nomenclature, the term is still used frequently for communication with patients. In Rin and Huang's (1989) survey, about half of the outpatients in four psychiatric clinics came to seek psychiatric treatment for their self-diagnosed illness of neurasthenia. According to Cheung (1989), the term neurasthenia may provide a more socially acceptable means for indicating the presence of sexual disorders. Erectile dysfunction and other sexual dysfunction may be presented in the forms of shenkui (for males) or irregular menstruation (for females), which constitute common symptoms associated with neurasthenia. Neurasthenia destigmatizes the expression of sexual and psychiatric problems. Also, neurasthenia is attributed to somatic depletion, overwork, irregular lifestyle, and extended intellectual activities. It is an acceptable pretext for seeking medical treatment. Its broad range of associated symptoms as well as its ambiguous references allow for a subtlety in communication which leaves room for face-saving (Cheung, 1989).

In Cheung's (1989) review of popular Chinese books on neurasthenia, several forms of treatment were generally recommended, namely rest and exercise, development of personality and positive attitude, healthy diet supplemented with tonic medicines or nutritional foods, and physical treatment and medication. Review of the catalogue of Chinese herbal drugs showed that treatment of symptoms associated with neurasthenia was indicated in 10 patent drugs of Chinese herbs. Breathing exercise and acupuncture have also been recommended as a treatment for some of these symptoms (Bhugra & de Silva, 1995).

In recent years, extensive studies have found sildenafil citrate (Viagra) successful as a treatment for sexual dysfunction in the West (e.g., Benatov, Reznik, & Zemishlany, 1999: Berman & Berman, 2000; Pallas, Levine, Althof, & Risen, 2000). Nonetheless, few studies have examined the use of Viagra in the Chinese communities. Lira et al. (2002) studied the drug efficacy in a multi-ethnic population in Singapore and found Viagra more efficacious for Chinese men with erectile dysfunction than their Indian and Malay counterparts. Low, Zulkifli, Wong, and Tan (2002) studied women's perceptions of Viagra in the Malaysian multicultural society. They viewed the possibility of their husbands starting to take Viagra with suspicion, mistrust, and tear. Due to their concern about the negative aspects of Viagra, the Chinese and Malay traditional methods of treatment were commonly mentioned.

GENDER ROLE STEREOTYPES AND ATTITUDES AMONG THE CHINESE

From the feminist perspective, gender roles play an important role in sexual relationships. Chinese culture and family system is basically patriarchal. In a traditional Chinese society, women served an instrumental and supportive role in managing the home and supplying male heirs (Koo, 1985). Male descendants were necessary for the lineage to survive, whereas raising a daughter was considered a luxury or even a money-losing business.

In a recent Social Indicators Survey in Hong Kong, Chu (1997) noted that a wife was typically responsible for most of the household chores as well as the majority of parenting duties. If she was employed, her involvement in the parenting duties remained high. More than half of the 200 female respondents agreed that "if a wife is employed, it is better for her to do more housework once she leaves work." This shows that the wife has a double concern for both her work and her domestic responsibilities. The survey also confirmed the stereotypic perception that the career world is still ultimately a man's place, whereas the family is the place where women should concentrate their efforts.

Within the family, including the marital relationship between Chinese couples, men still assume the dominant and powerful role. In Liu et al.'s study (1997), most husbands took the initiative in sex. Rarely did the wives report taking the initiative, especially among rural wives who reported that they felt too shy to take the initiative, even though they might want to do so.

However, it appears that young women are beginning to "reject their traditional role as 'asexual' beings or passive sexual objects at the mere disposal of men" (Zhang et al., 1999, p. 585). Surveys about women's sexual behavior in China suggest that more young women--even though they are still in a minority--become more active in sex than they were in the past (Xu, 1990).

Increasingly, women who are dissatisfied with their sex lives, especially those with higher education levels, will initiate extramarital relationships or divorce (Zhang et al., 1999). Among the young people ages 18 to 27 in the FPAHK's study (2000a), 54% of females and 45% of males felt that it was not shameful for women to remarry after divorce.

Although Chinese city-dwellers have generally become more open sexually, gender imbalance in power and relationship dominance still exists. In a survey on 1,511 women in Hong Kong (FPAHK, 1997), over 82% of the married women agreed that wives should be able to reject their husbands' sexual requests, whereas only 67% of the husbands agreed that their wives had the right of rejection. Another survey showed that male respondents are more tolerant of men having casual sex, such as with commercial sex workers, than of women having casual sex (FPAHK, 2000a). According to Liu et al.'s (1997) survey, more female than male respondents felt that their relationship would not be affected if they found out that their fiances had prior sexual relationships with somebody else. On the other hand, more male respondents anticipated irreparable damage in their relationships if this happened with their fiances. Hence, the traditional attitude emphasizing female chastity still prevails.

APPLICABILITY OF SEX THERAPY WITH CHINESE COUPLES

Sex therapy aims at helping the couples develop a more satisfying sexual relationship, with an emphasis on mutual sexual enjoyment rather than on performance. According to Wincze and Carey (2001), the treatment methods that tend to be therapeutically useful for most sexual dysfunction include education, stimulus control, cognitive restructuring, sensate focus, and communication training.

As discussed earlier, Chinese people manifest similar sexual problems as those in the West, although they may have different understanding of these problems. Their attitudes towards sex reflect a mixture of traditional folk concepts and contemporary gender role stereotypes and may vary with different socioeconomic subcultures. Studies on family therapy with Chinese families have highlighted the need for cultural sensitivity. While a family systems approach may be beneficial, Chinese families generally expect a didactic approach (Ma, 2000). The focus on individuality, equality, and freedom in Western therapy may be discordant with the hierarchical collectivistic values in Chinese culture (Cheung & Chan, 2002). This section investigates the applicability of the Western sex therapy to Chinese couples and discusses whether modifications are needed for sex therapy to be effective among Chinese couples.

Education

Education serves as an essential first step of psychological treatment for sexual dysfunction. Information regarding physiology, anatomy, and sexual function and dysfunction is provided in sex clinics in the West in the form of didactic teaching using anatomical pictures, slides, and books. Myths and misunderstandings are corrected in the process of open discussions between the therapist and the couple.

To increase sex knowledge in Chinese communities, some Chinese sex therapists suggest that education may be similarly promoted on both public and individual levels. Ng (1993) noted that sex education programs on television were in great demand in Hong Kong and that serious viewers found the programs useful.

Apart from public sex education, didactic education for Chinese couples suffering sexual dysfunction can form part of psychotherapy. When delivering sex education to Chinese couples, some difficulties may be encountered. First, discussing sex with the therapist is likely to be a completely new and perhaps embarrassing experience to Chinese couples. Chinese women may be particularly anxious about discussing such a private issue with a male stranger, given their rather conservative and repressive sexual attitudes. More traditional women may even consider sex obscene or immoral. Thus, sensitivity to the cultural context on the part of the therapist is of utmost importance. For example, for many patients, therapy may be more effective if the therapist incorporates the patient's somatic symptoms into the discussion so that sex is contextualized as part of the medical treatment. Also, the patients may be more responsive if the therapists maintain a flexible attitude in regard to treatment and do not discourage patients from using traditional Chinese medicine (Hong, Lee, & Lorenzo, 1995).

A second difficulty relates to the content of education on sexual physiology, which is often taught in the framework of the four stages of sexual response: excitement, plateau, orgasm, and resolution. Such distinction between stages may appear obscure and unfamiliar for those couples who often engage in painful intercourse without foreplay, thereby missing the first one or two stages of sexual response. Lieh-Mak and Ng (1981) attributed the lack of adequate sexual stimulation or foreplay to inadequate sexual knowledge rather than shyness. For Chinese couples, therefore, the therapist may refer to the difficulty in intercourse as a lack of synchronization in the couple's stages of sexual responses. The therapist may then present the stages of sexual response as a progression through stages, emphasizing the importance of foreplay in facilitating sexual intercourse.

Third, common sex myths and folk beliefs in the Chinese culture may affect the patients' sexual functioning. Thus, therapists may first explore possible misconceptions in relation to folk beliefs and dispel sex myths by providing authoritative medical evidence. For example, the patient may believe that masturbation would result in the loss of vital energy and cause shenkui, or that masturbation and ejaculation during intercourse would lead to illness or death (Wen, 1995). Many Chinese patients with sexual problems tend to attribute their dysfunction to somatopsychic problems such as yin-yang imbalance rather than to purely psychological lectors.

Therapists may also borrow from the folk medical concepts in their communication with their patients. Some modern sex therapists have made use of Taoist sexual teachings as a way to treat premature ejaculation and other sexual dysfunction. For example, Lieh-Mak and Ng (1981) referred to the original Taoist texts during discussions with Chinese men with ejaculatory incompetence. They helped their patients to recognize that their fear of health impairment due to the loss of semen might have originated from a common misinterpretation of the teachings of Taoist sexology, and reinterpreted the teachings to show that conservation of semen is not essential to health and longevity. Clarifying and correcting sex knowledge in the context of folk beliefs are likely to be helpful to these patients.

Fourth, roadblocks in sex therapy may be the result of not only the client's discomfort, but also the therapist's own uneasiness with the topic. For some health service professionals, the primary reason for avoiding discussion of sexual matters is their own discomfort in talking about these issues with their clients (Hospital Authority Rehabaid Centre, 1998). This may be related to their insufficient knowledge of sex therapy and their inadequate skills in delivering it. Therefore, training for these professionals is especially important.

Stimulus Control

In Western sex therapy, stimulus control refers to efforts to establish a pleasant and relaxing environment that is conducive to healthy sexual functioning, thereby minimizing interfering circumstances. Couples may be asked to set aside a time for sexual expression, to arrange for a babysitter, to create a romantic and sensual atmosphere, etc. These are ways to help the couples set the mood and environment for sexual activities.

Considerations should be given to the social situation in present-day China. In Chinese villages, families live together with their relatives in the same house. Given the close-knit unit of the household, attempts to have privacy may be difficult. In modern urban cities such as Hong Kong, scarcity of space in the household limits privacy for the couple. Many couples share the same room or even the same bed with their children. The pace of work also leaves little leisure time for the working couple, especially for women in paid employment. Despite a rising trend of women's participation in the labour force, the women's homemaker role is still firmly ingrained in the gender schemas of both men and women (Cheung, 1997). Under the tension from domestic and occupational responsibilities, women with children, in particular, are left with little emotional and physical energy for sexual enjoyment. To some women, demand for sex from their husbands may be seen as a chore.

In view of these practical difficulties, stimulus control for the Chinese couples is embedded in the broader context of gender roles. Simple discussion of the superficial and concrete aspects of stimulus control is unlikely to be meaningful or useful to the Chinese patients. In such cases, the discussion may include gender relationships and a more balanced allocation of domestic duties between the couple.

Cognitive Restructuring and Behavioral Interventions

Negative attitudes towards sex and interfering thoughts during sexual activity can present impediments to sexual expression and enjoyment. Cognitive therapy challenges false assumptions, identifies errors in the patient's thinking, and decatastrophizes negative outcomes. This intervention technique offers an alternative conceptualization of sexual dysfunction to the somatopsychic view that the Chinese couples may hold. Leung and Lee (1996) reviewed the research literature on psychotherapy for Chinese people and considered the outcome of the studies on the efficacy of cognitive-behavioral therapy to be generally "positive and impressive" (Leung & Lee, 1996, p. 449). Employing cognitive-behavioral techniques in sex therapy, Li and Yan (1990) treated 21 couples with erectile disorder and reported a remission rate of 61.8%. Lieh-Mak and Ng (1981) treated 12 Chinese men with ejaculatory incompetence using a modified version of Masters and Johnson's (1970) techniques such as education and sensate focus, which included education on Taoist sex doctrines. They reported that 7 out of the 12 patients recovered.

A number of psychotherapy studies suggested that ethnic Chinese clients displayed a lower tolerance for ambiguity, a greater respect for authority, and a stronger preference for practical and immediate solutions to problems (Sue & Kirk, 1972; Sue & Sue, 1990; Vernon, 1982). They expected the therapy process to be directive and authoritarian (Arkoff, Thaver, & Elkind, 1966; Tan, 1967; Yuen & Tinsley, 1981). In Waxer's (1989) study, Chinese clients opted for Ellis' directive style of rational-emotive therapy and least preferred Rogerian non-directive therapy. Therefore, it is likely that cognitive therapy with behavioral assignments would be a beneficial approach for treating Chinese clients with sexual dysfunction.

Sensate Focus

Sensate focus is a treatment method that was developed by Masters and Johnson (1970). The most important principle of sensate focus involves helping couples develop a heightened awareness of sensations rather than focusing on performance. Through gradual exercises of sensual touching, from nongenital massage to sexual intercourse, the clients become less anxious about sex. During the treatment, concepts of performance anxiety and "all-or-none" thinking (i.e., sex is equated with intercourse) are discussed.

The sensate locus paradigm invites the couple to pay attention to the sensations derived from sexual behaviors. This focus challenges the traditional Chinese view that sex, especially for women, is intended for procreation. Furthermore, in the sensate focus exercises, both the man and the woman play an active role in stimulating each other towards mutual enjoyment. This calls for a shift from the traditional male-active/female-passive model of sexual behavior. However, for both Chinese men and women, the rights of a woman to enjoy sexual pleasure may not be assumed. The "good" woman should not take the initiative or an active role in sexual behavior. Sensitivity to these cultural beliefs will increase the effectiveness of the sensate focus paradigm. In Li and Yan's (1990) report on sex therapy for couples with erectile disorder, the female therapists taught the wives how to guide their husbands and to experience sexual pleasure in the sensate focus exercises. They found a significant increase in the wives' sexual activities alter therapy. These changes were due not only to the improvement in the husbands' erection, but also to changes in the wives' sexual attitudes, as well as increased bodily contact during the couples' home assignments (Li &Yan, 1990, p. 110).

Communication Training

Sexual communication may be facilitated by focusing on general communication training. Through training, couples may practice using a number of communication skills and are encouraged to discuss their sexual relationship and sexual problems. More direct forms of sexual communication may be possible when couples begin to accept reciprocity in their sexual relationship. The therapist may also encourage couples to express their preferences for different forms of stimulation or sexual activities.

As discussed earlier, open communication about sex is uncommon among Chinese couples, especially among rural couples (Xu, 1997). To reduce embarrassment in communicating about sex, Li and Yan (1990) instructed Chinese couples to read sex education literature aloud in the presence of their partner and therapists at the clinic, and asked them to read erotic materials and talk about sex before going to bed. They found that the wives who had improved sex lives after therapy held less conservative attitudes toward sex. The authors speculated that the wives with an enlightened attitude toward sex might cooperate better with the therapist and their husbands during treatment.

Expanding Repertoire of Sexual Expressions

In sex therapy, couples are often asked to expand their repertoire of expressions of affection, as more frequent physical affection is related to higher relationship satisfaction and higher sexual satisfaction (Renaud & Byers, 1997). With liberalization of sexual attitudes in the Chinese community, overt expressions of affection are better accepted than they were in the past, especially among the younger generation. However, Chinese couples are found to engage in fewer sexual activities and report a lower level of sexual pleasure than American couples (Xu, 1997). Also, Chinese couples have a narrow repertoire of affectionate expressions (Renaud & Byers, 1997). Chinese women may also find unconventional or unfamiliar sexual behaviors obscene and repulsive, especially if the initiative is not mutual. Therefore, therapists should be sensitive to the clients' traditional beliefs and inhibitions and consider assigning these tasks at a gradual pace.

CONCLUSION

Sexual functioning and dysfunction are, to a large extent, universal. Similar forms of sexual difficulties and issues in sex therapy appear in many cultures. However, the unique contents of indigenous folk beliefs and sex attitudes illustrate the specific manifestations of these problems and how they may be addressed in the Chinese cultural context. Understanding the expectations and dynamics of the counseling relationship for Chinese clients would also sensitize the therapist to process issues in the Chinese context. The importance of integrating universal and indigenous approaches and not taking Western theories and practice for granted has been emphasized in the developments of cross-cultural psychology in the recent decades (Berry, 1990: Sue, 1983). Indigenous constructs provide more culturally sensitive frameworks to understand the phenomenology of human experience in different cultures (Cheung, Leong, & Ben-Porath, 2003). Cheung (2000) postulated that counseling takes place in a cultural context. For counseling to be meaningful and relevant, the problem conceptualization and the therapeutic approach should be deconstructed in the specific cultural context in which it is offered. The cultural context provides a better understanding of the problem and its solutions.

In this article, we outlined the concepts and commonly used techniques of sex therapy and described specific cultural considerations for Chinese couples. It is suggested that, with appropriate adaptations, many of the basic sex therapy techniques can be applied to the Chinese couples. In view of the culture-specific beliefs, gender role expectations, and social contexts in Chinese communities, we hold that adaptations are required for the efficacious delivery of sex therapy to Chinese couples. Also, it would be important for therapists working with Chinese couples to be aware that there are individual and subcultural differences among the Chinese Diaspora in terms of education, gender, geographic location, economic circumstances, and acculturation. Given this diversity, the deconstruction of the cultural context of sex therapy, like any form of psychotherapy, may be undertaken not only across societies, but also within societies where ethnicity, gender, social class, and other subcultures interact (Cheung, 2000). The integration of traditional Chinese concepts of health and illness, gender roles, sex attitudes, and marriage in the reformulation of the treatment approach would enhance the effectiveness of Western-based sex therapy among Chinese couples.

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Manuscript accepted June 14, 2004

Ho-wai So

Kwai Chung Hospital, Hong Kong

Fanny M. Cheung

The Chinese University of Hong Kong

Address correspondence to H. W. So, Department of Clinical Psychology. Kwai Chung Hospital, 3-15, Kwai Chung Hospital Road, New Territories, Hong Kong, HKSAR; e-mail: [e-mail].