treatments, this is also controversial. one study found that after a 24-week trial, women taking androgens had higher scores of sexual desire compared to a placebo group. as with all pharmacological drugs, there are side effects in using androgens, which include hirsutism, acne, polycythaemia, increased high-density lipoproteins, cardiovascular risks, and endometrial hyperplasia. alternative treatments include topical estrogen creams and gels that can be applied to the vulva or vagina area to treat vaginal dryness and atrophy. research in modern times, clinical study of sexual problems is usually dated back no earlier than 1970 when masters and johnson's human sexual inadequacy was published. it was the result of over a decade of work at the reproductive biology research foundation in st. louis, involving 790 cases. the work grew from masters and johnson's earlier human sexual response (1966). prior to masters and johnson, the clinical approach to sexual problems was largely derived from sigmund freud. it was held to be psychopathology and approached with a certain pessimism regarding the chance of help or improvement. sexual problems were merely symptoms of a deeper malaise, and the diagnostic approach was from the psychopathological viewpoint. there was little distinction between difficulties in function and variations nor between perversion and problems. despite work by psychotherapists such as balint sexual difficulties were crudely split into frigidity or impotence, terms which acquired negative connotations in popular culture. human sexual inadequacy moved thinking from psychopathology to learning; psychopathological problems would only be considered if a problem did not respond to educative treatment. treatment was directed at couples, whereas before partners would be seen individually. masters and johnson believed that sex was a joint act, and that sexual communication was the key issue to sexual problems, not the specifics of an individual problem. they also proposed co-therapy, with a pair of therapists to match the clients, arguing that a lone male therapist could not fully comprehend female difficulties. the basic masters and johnson treatment program was an intensive two-week program to develop efficient sexual communication. the program is couple-based and therapist-led, and began with discussion and sensate focus between the couple to develop shared experiences. from the experiences, specific difficulties could be determined and approached with a specific therapy. in a limited number of male-only cases (41) masters and johnson developed the use of a female surrogate, which was abandoned over the ethical, legal, and other problems it raised. in defining the range of sexual problems, masters and johnson defined a boundary between dysfunction and deviations. dysfunctions were transitory and experienced by most people, and included male primary or secondary impotence, premature ejaculation, and ejaculatory incompetence; female primary orgasmic dysfunction and situational orgasmic dysfunction; pain during intercourse (dyspareunia) and vaginismus. according to masters and johnson, sexual arousal and climax are a normal physiological process of every functionally intact adult, but they can be inhibited despite being autonomic responses. masters and johnson's treatment program for dysfunction was 81.1% successful. despite masters and johnson's work, sexual therapy in the us was overrun by enthusiastic rather than systematic approaches, blurring the space between "enrichment" and therapy.