The History Of The Sexual Tipping Point® Model


The Sexual Tipping Point® model evolved over the last 40 years, beginning with two decades of collaboration with Helen S. Kaplan at NY Weill Cornell Medicine’s Human Sexuality Program, which she founded at the Payne Whitney Clinic of the New York Hospital. Her first book, The New Sex Therapy (1974), described an outpatient treatment approach, which modified Masters & Johnson’s (1971) two-week pioneering residential program.  As Kaplan’s book became the standard text for most students and medical institutions around the world, it had an impact on where and how people were treated for sexual problems both nationally and internationally. Kaplan brought the principles of multi-determinism and multilevel causality to sex therapy (Perelman, 2014a). Kaplan practiced a therapeutic eclecticism that anticipated current sexual medicine approaches that combine/integrate appropriate selection of medical and surgical treatments with sex counseling, first described by Althof, Leiblum, McCarthy, Perelman, Rosen, Segraves, and Wylie, among others, by the turn of the 21st century.

In Kaplan’s final book (1995), she described a "psychosomatic" dual-control model of sexual motivation emphasizing “inhibition/excitation” processes. Kaplan’s concept was derivative of the work of Kupferman (1991) who wrote, “All examples of physiological motivational control seem to involve dual effects—inhibitory and excitatory—which function together to adjust the system” (p. 751).  In response to that insight, Kaplan wrote, “Control of sexual motivation is no exception and also operates on such a “dual steering” principle… Once again, we can learn from the similarities between eating and sex” (Kaplan, 1995, p. 17).

Adapted with permission from Kaplan HS, The Sexual Desire Disorders. Dysfunctional Regulation of Sexual Motivation. Brunner-Routledge (Taylor and Frances, London, 1995: p. 15 (Fig. 2)

An artist by training, Kaplan had sketched a cartoon in that 1995 book (Figure 2 on the left) that foreshadowed the current digital graphics developed for use in the Sexual Tipping Point® model, all of which can be seen on this website. 

Kaplan’s description and illustration of the dual control elements underlying human sexual motivation and sexual desire dysregulation anticipated Bancroft and his Kinsey Institute colleagues, including Graham, Heiman, Janssen, Sanders, and others. They later provided continuing erudite articulation of dual-control theory, research and related psychometrics becoming the best known of these various models (1999, 2000, 2005, 2009).  Kaplan also foreshadowed the work of James Pfaus’ (2006) concepts of satiation of appetite being related to satiation of sexual desire as a theoretical mechanism to explain Hypoactive Sexual Desire Disorder.

Kaplan dedicated that final book to her two-decade collaboration with her colleagues at Cornell. In 1995, appointed as the next Co-Director of that program, this author found inspiration from Kaplan’s sketch to refine his own mind/body ideas into the Sexual Tipping Point® model. The model’s graphics would provide a visual heuristic for Cornell clinicians that would depict the intra- and inter-individual variability of all sexual function and dysfunction. The Sexual Tipping Point® (STP) is the characteristic threshold for an expression of a given sexual response.

The Sexual Tipping Point® name derived from a concept that was “in the air” at the end of the 20th century. In fact, with the publication of his book in 2000, journalist Malcolm Gladwell made the concept iconic. While Gladwell wrote and lectured about social epidemics and other macro forces, such as viral marketing, the STP was focused on individual uniqueness and the continuous variability of both interpersonal and intrapersonal factors from a biopsychosocial–cultural perspective. Its initial application was for sex therapy; later, it expanded to incorporate all aspects of sexual medicine. To document and distinguish the differences between Gladwell’s exceedingly well-known views and the Sexual Tipping Point® concepts, a trademark registration was sought and awarded by the U.S. Patent and Trademark Office in 2005. 

The Sexual Tipping Point® model easily illuminates the mind-body concept that mental factors can “turn you on” as well as “turn you off”; the same is true of the physical factors. Therefore, an individual’s Sexual Tipping Point® represents the cumulative impact of the interaction of a constitutionally established capacity to express a sexual response elicited by different types of stimulation as dynamically impacted by various psychosocial-behavioral and cultural factors. An individual’s threshold will vary somewhat from one sexual experience to another based on the proportional effect of all the different factors that determine their tipping point at a particular moment in time, with one factor or another dominating while others recede in importance. It illustrates both intra- and inter-individual variability that characterizes sexual response and its disorders for both men and women.

Besides illustrating all etiological permutations, including normal sexual balance, the Sexual Tipping Point® concept is particularly useful for modeling treatment and can easily be used to explain risks and benefits for patients with sexual disorders. The STP model can be used to teach patients where different treatment targets should be focused, depending on diagnosis of their etiological determinants. Typically expressed erroneous binary beliefs can be politely disabused and the patient can be reassured that “No, it is not all in your head,” nor “all a physical problem.” Reciprocally, their partner can be assured it is “not all their fault”! Teaching the STP model to the patient and partner can reduce patient and partner despair and anger, while providing hope through a simple explanation of how the problem’s causes can be diagnosed, parsed, and "fixed” (Perelman & Watter, 2016). In fact, the Sexual Tipping Point® also allows for modeling of a variety of future treatments, including medical or surgical interventions not yet discovered or proven, such as novel pharmacotherapy, genetic engineering or nanotechnology (Perelman, 2011b).  

Some ideas embedded within the STP were first incorporated into the author’s presentations on “Sex Coaching for Physicians” and were also referred to as part of the author’s 1998 Journal of Sex & Marital Therapy commentary on the “Cornell Model.” The author first introduced the “Sexual Tipping Point” term to the professional public in a lecture called “The Role of Sex Therapy, an Overview,” delivered at a CME sexual medicine update course called “Sexual Dysfunction 2001” at Columbia University’s College of Physicians and Surgeons’ Department of Urology. That was also the first time that “Female Sexual Dysfunction” was discussed in that forum, and the STP model was used to illustrate how all the mental and physical factors both implicit and explicit in male sexual dysfunction were also true for disorders and common concerns of women. While obvious to some at the time and to all in retrospect, the profound success of the 1998 launch of sildenafil by Pfizer had overwhelmingly tilted urologists’ attention at the millennium to focus on male disorders with little recognition of the problems and concerns of women.

A number of ensuing presentations and publications described how the STP model could be applied across the full spectrum of specific sexual concerns and disorders. That work led to a presentation at the combined 2008 American Urological Association & Society for Basic Urologic Research summer institute devoted to young investigators interested in the field of sexual medicine. The proceedings of that conference were published in the 2009 Journal of Sexual Medicine, which included the manuscript “The sexual tipping point: a mind/body model for sexual medicine,” thus greatly expanding awareness of the model.

The graphic representation of the STP has evolved rapidly over the past 20 years. Early images of the STP through 2009 were generated from Microsoft Office graphics and, their resolution was modest as reflected in these illustrations below from 2006.

 

In 2012, the first retrospective of the various STP images used over the previous decade was presented to the 15th World Meeting of The International Society For Sexual Medicine (ISSM).  The poster used to supplement that presentation is shown below.

 

In 2013, the STP trademark registration was assigned to the MAP Education & Research Fund, Inc. so that the Fund could distribute STP resources worldwide for free. Today’s more sophisticated and nuanced figures feature “building blocks” that can be used to assemble unique representations of any given individual’s STP at a particular moment in time. A key to those STP images is provided below, although a fully narrated video description of the STP Model may be found on the home page of this website, as well as on YouTube and Vimeo channels. 

maped-graphic.png

In conclusion, it remains critical to advance a model that would help students, professionals and the public alike understand that sex is always both “Mental And Physical.” Greater success will be found within such integrated thinking. All the biopsychosocial-behavioral and cultural models of sexual dysfunction provide a compelling argument for sexual medicine treatments that integrate sex counseling and medical and/or surgical treatments (Perelman, 2008b). Given the choice of so many different biopsychosocial-cultural models, why embrace the Sexual Tipping Point Model®? Perhaps the greatest advantage of the STP model is its simplicity and the ease with which it provides clinicians as well as their patients (and their partners) with a common sense explanation of sexual problems and potential solutions. At Weill Cornell Medicine, when contemplating the clinical need for understanding etiology, diagnosis and treatment, we find the Sexual Tipping Point ® (STP) dual-control model particularly helpful and easy to use. The healthcare professional that can accomplish a patient-centered, holistic view of healing within the context of an integrated treatment will offer the most optimized approach and the most elegant solution. 

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