I wrote in Chapter 3 about the differences between sexual drive, sexual desire, sexual arousal and orgasm. To recapitulate:
• Sexual drive is a biologically determined need for sexual release, which is partly based on testosterone, especially in males, and there are differences between men and women in the way that sexual drive is expressed.
• Men seem to be more spontaneous and self-motivated in their sexual needs, and require a regular outlet (perhaps in self-stimulation) if they are not going to be frustrated; while women can enjoy sex just as much, and perhaps more, but can manage longer spells without it if they are not in a relationship.
• Sexual desire, on the other hand, is a desire for a particular sexual experience, maybe with a particular partner or maybe a specific kind of sexual activity, and sexual desire within a relationship is often the mainspring in its development and in its continuation.
• Sexual arousal is best described as biological readiness for a sexual experience. In the man this is usually shown by the presence of an erection, and in the woman by lubrication and clitoral enlargement. Desire and arousal usually happen at the same time, but in some cases of sexual dysfunction, this doesn’t work: for example a man with erectile impotence may not have an erection even though his desire is strong, or a woman whose sexual desire is normal may be unable to be aroused because of anxiety.
• Orgasm is the climax of the sexual process, and involves a feeling of pleasure accompanied by ejaculation in the man, and a similar feeling of pleasure in the woman. This is usually followed by relaxation and satisfaction for both, but women can often move on to a second climax, while this is much rarer in men.
• Mutual orgasm, which some believe that all couples should experience, is not as common as is generally thought, and this is one area where unrealistic expectations can harm an otherwise good relationship.
Many people, both men and women, are shy about talking about their sexual feelings, and often the problems of desire and function get muddled up in discussion. It is helpful to be as plain as possible in discussing sex, but the most important thing is to respect your partner’s sensitivities. Within these limits, a positive approach to talking about a sexual problem, being clear about what exactly is wrong, may do a lot of good and may make the problem much easier to cope with. This may be easy in couples who already have a sympathetic understanding of each other. However, there are some couples whose relationship flourishes on teasing and a combative approach to each other, and for them the move to being positive and sympathetic may be a difficult one. Even if your relationship is of that sort, you may be able to have a constructive talk about sex if you follow the suggestions below.
One of the hardest steps is to raise the subject for the first time. If a couple have a sexual problem, it may be that the one with the problem feels embarrassed to talk about it, and may need some encouragement to do so. It may be easier for the other partner to raise it, but again this has to be done with care so as not to upset the partner with the problem. An exercise may help you to get into this area of discussion.
Exercise
Talking about your sexual problem
• Make sure that you are not going to be disturbed (turn off the radio, TV and music and put the telephone on to ‘answer’)
• Sit comfortably together with the timer on (maybe for ten minutes at first)
• Come with an agenda for what you want to talk about
• Start with a non-threatening issue such as arrangements for the evening or the time you go to bed
• If it feels safe, go on to raise the sexual problem
• Try and tune in to what the other person is wanting
• If you have complaints, put them in the form of positive requests (see Chapter 5)
• Use all the communication and negotiation skills you have learned in Chapter 5
• Use simple language that you both understand
• Remember that non-sexual problems may be interfering with sex, and think about what you might be resentful about in your general relationship
• Don’t go on too long in discussion: if you have not reached a conclusion, put it ‘on ice’ until the next time
Sex is usually better if you can get away from the media-inspired idea that every couple should have a satisfying sexual experience every day, with equal spontaneous levels of desire and simultaneous orgasms. This may happen in films, although the more realistic ones don’t necessarily include this kind of fantasy relationship. However, in most couples sex has to be fitted in with a busy career and/or family life, and is rarely ideal. The aim should be to set your own realistic goals and try to achieve them, bearing in mind that the best experiences will not happen very often.
The pioneers of sexual therapy were the Americans Masters and Johnson. They were the first to treat the couple as the unit for therapy, and they concluded that in many people with sexual problems anxiety was a major factor. They even coined the term ‘performance anxiety’ to describe the anxiety that affects people with a sexual problem whenever they try to make love. In order to get over this performance anxiety they devised an exercise called sensate focus, in which the couple would have a kind of prolonged foreplay together with a ban on sexual intercourse. This tries to overcome the performance anxiety that they both feel when one of them has a problem, by reducing the fear of failure and helping ‘physical communication’, using touch rather than words to get across what each one needs or feels.
In our clinic we have found that it is useful to practise relaxation before doing the sensate focus exercise, so I will give you a guide to that technique at the beginning.
Exercise
Relaxation and non-genital sensate focus
In this exercise the idea is to get used to the feeling of physical closeness and ‘physical communication’ without the pressure of having to ‘perform’ sexually at the end. It involves relaxation and then a kind of prolonged foreplay without genital touching. There is a ban on intercourse and orgasm, at least in the first few times you do it. It is useful for any kind of sexual problem, whether in the man or the woman, and can lead on to more relaxed and satisfying sex.
• You will need at least 40 minutes, so make sure that you choose a time when you have no interruptions or pressures on you (radio and TV off, and the telephone on ‘answer’).
• It is a good idea to prepare for the exercise by having a bath or shower, either separately or together.
• Make sure the room you are in is warm and comfortable, with a good bed or couch to lie on, and maybe some towels on the bed.
• It may help to have soft lights and some quiet music in the background, or you may prefer darkness and silence.
• You may also use body oil as a way of making the experience more sensuous, although some couples prefer talcum powder, and some prefer to use nothing.
• You should be careful to avoid touching any of the erogenous zones, including breasts, penis, testicles, vagina and clitoris, at least in the first few sessions.
The next step is to go to the bedroom together, lie down on the bed with no clothes on, and practise relaxation. This is best done by relaxing your muscles accompanied by deep, slow breathing.
• Lie down on the bed, take a deep breath in, and tense your leg muscles.
• As you breathe out slowly, relax the leg muscles and keep them relaxed.
• Breathe in again and tense the muscles in your buttocks, and then relax them as you breathe out and keep them relaxed.
• Breathe in again and tense the muscles around the base of the penis and the muscles around the vagina, and then relax them as you breathe out (this is the Kegel exercise – see below).
• You then do the same with the muscles in your stomach, relaxing them as you breathe out.
• Your chest muscles will naturally be tense as you breathe in, but as you breathe out you should try and leave them as relaxed as possible.
• You then tense your neck and shoulders, arms and hands, relaxing them as you breathe out.
• Finally you make a face, clenching your jaw and screwing your eyes up, relaxing everything as you breathe out.
• At the end, breathe slowly and try to keep all those muscles as relaxed as possible.
This exercise underlines the way that, in order to get worked up sexually, it is often necessary to ‘work down’ first by relaxing.
You then take it in turns to stroke and caress each other, using the oil or the powder if you want, and only talking about what you are doing or experiencing (not general chat). It doesn’t matter who starts, but for the sake of this description I will assume that it is the woman.
• The man lies facedown, and the woman kneels and explores his body, beginning at the feet.
• Massage the toes, using the oil if you want, asking him how he likes you to do it, and going along with his wishes. Men often prefer a stronger touch, and women a lighter one, but the important thing is to do what your partner likes. Some men are ticklish, and the best way to overcome this is to use a heavier touch.
• Move on to the legs, then the thighs, and then the buttocks. The woman as the active partner should try to enjoy the experience of caressing and touching, while the man should remain passive and receptive, enjoying what is happening, and only commenting if he would like her to use a stronger or lighter touch, or describing his sensations and emotions.
• From the buttocks move on to the lower back and then the neck, the arms and hands, and then massage the scalp, keeping the same touch as before.
Then ask him to turn over, and stroke and caress him on his front, beginning from the feet and moving up the legs.
• Avoid the genital area at this stage, and move on to the stomach, chest, arms and hands.
• Stroke his face with your hands, and if you want to, kiss his face, eyes, ears and mouth (but passionate kissing may be a bit too strong at this stage).
Either of you may become sexually aroused during sensate focus, but you should still observe the ban on intercourse and orgasm. If a man has an erection this does not mean that he must immediately go on and have sex, either in intercourse or in masturbation. Just let the sensation stay or go away, and try not to let it get out of control. (The idea of the exercise is to get away from performance anxiety, and a rush to intercourse may cause the anxiety to rise. On the other hand, it would be all right for the man to ejaculate and for the woman to have an orgasm at the end of the exercise if the urge is too strong.)
The next stage is for the man to be the active partner, and the woman should lie on her front while he kneels.
• He massages her toes and legs in the same way, using oil or powder, asking her what she likes and giving her the kind of touch she requests. Again, men often use a stronger touch than women would ideally like, and should think of it more as caressing than massaging.
• Then he moves to the buttocks, back, arms, hands and neck, and strokes her hair.
• She then turns over, and he caresses her front, beginning with the feet and legs and moving to the stomach (but not the vagina), chest (but not the breasts) and arms, hands and neck.
• Again, he can touch or kiss her face, eyes, ears and mouth, but he should avoid passionate kissing at this stage.
This completes the first sensate focus exercise, and all you do now is turn to each other, and discuss the experience. Did you lose the feeling of anxiety? Did you get to communicate physically? Was it frustrating, for both of you or just for one? Was either of you sexually aroused? What have you both learned? If it is night-time you might then go to sleep, or you may wish to stay awake and talk.
After doing the sensate focus exercise two or three times, and assuming that your levels of anxiety have been reduced by it, you could then decide to move on to the next stage, genital sensate focus. The principle is much the same, but you may now touch the erogenous zones and stimulate each other sexually, but still avoiding orgasm. You should still begin with the sensate focus as described above, but after you have caressed the other person’s front, you could move on to the man’s penis and testicles, and the woman’s breasts, vagina and clitoris. Again, try not to be goal-orientated, but treat it as an exercise in physical communication and anxiety reduction.
Exercise
Genital sensate focus
You should do exactly as you did in preparing for sensate focus, having a bath or shower, making sure the room is warm and comfortable and putting towels on the bed if you wish.
• Start with relaxation, and go on to non-genital sensate focus as before.
• Now, when you come to the front of the body, after the woman has done the non-genital massage on the man, she can touch and caress the penis and testicles.
• In the same way, after the man has done the non-genital caressing on the woman, he can touch and caress the breasts, nipples, vagina and clitoris.
• Again, this is not aimed at achieving an orgasm in either partner, but you should both be using a ‘teasing’ approach, so that when one or other of you becomes sexually aroused the active one can then stop the caressing and move to other parts of the body, or simply stop and you can talk together.
It would be all right at the end of the exercise to have an orgasm if you feel the need, either together or separately, but if it doesn’t happen that is also all right, especially if the problem one of you has difficulty in achieving an orgasm.
I will be giving you quite a lot of information about these problems, so that you will know more about the area before you decide what to do about it. I should emphasize, however, that in many cases a do-it-yourself approach may not solve the whole problem. The complexity of the issues and the need for more thorough investigation of possible medical factors mean that you would not be able to solve many of the problems in a do-it-yourself fashion. You may therefore need to take the problem to your doctor for treatment or referral. There are now a number of sexual problem clinics in hospital psychiatry and urology departments, and in family planning and genito-urinary medicine clinics. There are also psychosexual services in relationship-counselling organizations. There are some very effective treatments available, especially for erectile disorders. For many sexual problems it is therefore well worthwhile asking for professional help. There is, however, a possible advantage in making some efforts to solve the problem yourself first, because it may feel better for you to remain in control of yourself and your sex life rather than asking for external advice straight away.
This is a problem which affects about 10% of the male population, which means perhaps 2 million men in the UK. It is more common in the older age groups.
• It has many possible medical causes, including diabetes, raised blood pressure, spinal cord injuries or interference with the blood supply (for example by pelvic injuries). Some medications can affect erection.
• The most common two causes of erectile disorder are ageing and anxiety.
• Ageing usually causes a loss of sex drive as well as erectile problems, and ageing is the most common reason for erectile problems in older men.
• Anxiety and stress are more common as causative factors in the younger age groups, and the erectile problem in these men is more likely to respond to psychosexual treatment.
• Psychosexual treatment would include the sensate focus approach outlined above, accompanied by helping the couple to communicate better and more freely.
• If you have a positive and enthusiastic partner, the exercises are more likely to be successful.
• A further helpful technique in the treatment of erectile problems is the Kegel exercise. This consists of contracting the muscles around the root of the penis and around the anus, so as to pull up the insides of the pelvis (similar to the movement you might make to stop the flow of urine). You should contract and relax the muscles about ten times in maybe thirty seconds, and you could do this four or five times a day.
• Another related thing to remember is to keep yourself fit, by walking or doing sport, but also by smoking and drinking alcohol as little as possible.
• About 50% of men treated psychosexually recover their erectile function and maintain the improvement, but others go on to need medication (see below).
The treatment of erectile problems has been revolutionized in recent years by drugs such as Viagra and Cialis. These act as potentiators of the erectile process, and are effective in over 80% of men with an erectile disorder, regardless of the exact cause. (Just one thing to beware of is that if you are also on ‘cardiac nitrate’ drugs for heart problems, such as Trinitrin, it would be dangerous to take these at the same time as Viagra or Cialis.)
In those who cannot respond to these drugs, there is the possibility of self-injection into the side of the penis with drugs such as Caverject or Viridal, and also of the use of vacuum pumps. Both these approaches are effective, but need more technical expertise than the Viagra-type drugs.
This is a very common disorder, although, because of difficulties in defining exactly who has the problem and who doesn’t, we cannot be sure exactly how common it is. However, it is likely that it affects between 20 and 30 per cent of the male population. There are no specific medical causes for PE, and in most cases it is probably simply a question of the man being too easily brought to orgasm because of his naturally active reflexes. This may cause distress to the man and his partner, because most women do not reach orgasm as quickly as men. The problem may also be complicated by the development of erectile problems in later life.
• This is through the use of sensate focus exercises (see above). Some men also find that they can last much longer if they ejaculate once and then have intercourse soon afterwards (making use of the refractory period – see Chapter 3). Kegel exercises (see above) may also be useful.
• In addition, it is possible to use the stop-start technique, in which you learn to delay ejaculation first in self-stimulation, and later in mutual sex play with your partner. The idea is that you should approach the ‘point of no return’ (when ejaculation becomes inevitable), but just before you reach that point you should stop stimulating the penis and leave the feeling to subside. You will then find that you can stimulate the penis again and have more control in delaying ejaculation from then on. If this increased control can be brought into your mutual sex-play, a similar technique can be used in intercourse, with both partners stopping their movement when the point of no return is about to be reached, and then continuing after a brief delay when the urge to ejaculate has been controlled.
• Many couples find it quite difficult to master this approach, and there are some other ways of helping those with PE. A ring device called Prolong is available which a man can place around the head of the penis and use in self-stimulation. It has been shown to be useful in increasing control of ejaculation, not only in self-stimulation but also subsequently in intercourse.
• The use of local anaesthetic spray or cream is possible, but ideally should be supervised by a doctor, because it causes numbness and may inhibit ejaculation altogether.
This is a much rarer problem, but is equally distressing when it occurs, because the man is unable to obtain the pleasure of orgasm and often (if the man doesn’t ejaculate at all inside the vagina) the couple have problems with conceiving. There may be reasons for it, such as neurological disorders, spinal cord injury or the effects of some medication (including antidepressants). However, in most cases no specific cause is found, and like PE it is simply due to (in this case) rather sluggish sexual reflexes.
• The treatment of delayed ejaculation is again best done in the setting of genital sensate focus, using so-called superstimulation of the penis (by a very rapid rubbing action using body oil on the hand, either by the man himself or his partner) to achieve a greater degree of excitement and bring the man nearer to the point of no return (in other words the opposite of the treatment of PE).
• The use of a battery-powered vibrator may also be considered, to provide greater amounts of stimulation.
These are not as easily divided up as the male dysfunctions, because for many women there is a combination of desire and arousal problems. Women’s sexuality is more bound up with emotions and their feelings about the partner than men’s sexuality. Many women with a sexual problem will report a general feeling of lack of interest and arousal, although some can clearly state that it is one or the other.
• Treatment approaches reflect this mixture of the two issues, and they are more psychologically focussed than those we use for male problems.
• There is an emphasis on the value of sex education, if possible including the partner in the counselling. It is also important to reduce any unrealistic expectations that the woman and her partner might have, such as the idea that she is constantly ready for sex (see Chapter 3).
• It is often useful for the woman to practise self-exploration sexually, for example lying in a bath and exploring herself with the help of a hand-mirror. This way she may be able to become more comfortable with her own body.
• The use of lubricants (for example Sylk or Sensilube), both in self-stimulation and in intercourse, is often very helpful.
• In working with the woman and her partner, the counsellor will often also recommend the sensate focus approach (see above), which will fulfil some of the needs just mentioned.
This is more common than is generally realized, with perhaps 30% of women in a steady relationship being unable to achieve an orgasm in intercourse (although many of these women can achieve an orgasm with clitoral stimulation). The belief that they should regularly experience orgasm in intercourse is probably one of the most harmful myths in the whole of sexuality. Men should be able to accept that women are different from them in this way, as in many others (see Chapter 3), and the wide variety of sexual expression, including the fact that many women can enjoy sex even without an orgasm, should be seen as a plus rather than a minus.
• It is easier for many women to achieve orgasm in other ways than through intercourse. The most reliable ways are either by self-stimulation or with the use of a battery-powered vibrator.
• The best way to help the couple to be successful in achieving the female orgasm is by the woman teaching the man what to do for her, perhaps guiding his hand or by using the vibrator during foreplay.
• In many couples with this problem, it is also combined with other difficulties such as low desire or lack of arousal, and a general approach is best, including sensate focus and self-exploration as above.
• If the couple can achieve an orgasm for the woman in mutual stimulation as above, they can then try incorporating some of the techniques they have used in intercourse.
This is a specific problem, which like the others may be combined with other difficulties. When intercourse is attempted, although the woman may be sexually aroused, there is a tightening of the muscles around the vagina, and penetration is either very painful or impossible. There is usually also a strong fear of intercourse. On the other hand, sexual desire and arousal may be perfectly normal, and in foreplay or petting it may be quite easy for the woman to achieve orgasm.
• This is not very difficult, although the woman and her partner must be confident and sure of what they are doing.
• Following an internal examination by a doctor which confirms that it really is vaginismus, the woman is given a series of graded plastic ‘trainers’ (or tubes) to pass slowly and carefully into the vagina, using a lubricant and relaxing the muscles while doing so. The plastic tubes ‘train’ the vaginal muscles to relax. The woman will soon find that it gets much easier to take the larger sizes, and she will soon be able to accept the larger tubes quite comfortably. (‘Amielle’ trainers can be obtained from Owen Mumford by mail order, see Useful Address section.)
• It soon becomes possible for the woman and her partner to put fingers into the vagina without difficulty, and then they will be able to have penetrative intercourse.
• Once having been successfully treated, the problem usually does not come back, so this is one of the few sexual problems which can be said to be ‘cured’ after therapy.
I am mentioning this problem only to say that there are many medical and gynaecological causes for it, including pelvic infections, thrush, fibroids and urinary infections (cystitis). Pain during intercourse may also be due to anxiety and difficulty in relaxing, but it would be sensible, if it has gone on for more than a few weeks, to consult your doctor and perhaps get a specialist referral.
In contrast to the problems of function described in the previous two sections, problems of desire are more suitable for the couple to deal with, including the ‘do-it-yourself’ approach. There are many couples with one partner much more interested in sex than the other. In the younger age groups it is usually the man who wants more sex than the woman, and this can be the trigger for many arguments, as well as sometimes leading him to seek outside relationships. It could then be the cause of a separation or divorce.
There are some stages in the relationship in which the problem is more likely to occur. For example, when the woman has recently had a baby, she may be ‘off’ sex for many reasons:
• physical pain following the delivery
• disturbed nights
• the responsibility of baby care
• the fact that breastfeeding offers a different kind of physical and emotional satisfaction
• resentment at the man’s ‘selfishness’.
At other stages of the relationship, there are other sources of tension and anger which can reduce a woman’s interest in sex:
• worry about the children
• competing demands of homemaking and career
• upset over a bereavement.
The relationship itself may be adding to the problems, and in the ‘reluctant woman’ situation this is often because she is overshadowed by the man, who makes all the important decisions and doesn’t allow her to be an equal partner. Sometimes the woman may accept the pressure for sex, but seems not to be enjoying it, and sometimes she will refuse to take part in sex at all. The man may assume, as men often do, that his partner must be ill or disturbed because he believes that women ‘should want and enjoy sex as much as men’ (see Chapter 3). In some couples the woman will accept this theory, and even go to her doctor asking for treatment to increase her sex drive, a treatment which, even if the doctor goes along with it, is unlikely to work.
In coping with this problem, it is very important for you both to agree that neither of you is abnormal, and that each person has his or her own sexual needs. There may be a good deal of progress to be made in having some discussions about the sort of resentments that the woman has. It is also possible to help her to get more enthusiastic about sex by asking her what parts of the sexual experience she enjoys and how it could be made more attractive to her. However, one of the best ways of tackling this problem is for you both to agree on a compromise frequency for sex to take place. It may sound slightly crazy to do this, but if neither of you is abnormal, it makes sense for both of you to give way a little. So, for example, if the man would like sex to take place three times a week and the woman would prefer once every two weeks, you might settle for sex once a week. This is the beginning, but not the end of the story, and you need to be a bit more specific in your planning, as follows.
The agreement on how often sex should take place has the possibility of satisfying both partners. The man may be content that it would provide an acceptable level of sex for his needs, and the woman may be reassured that she would not be overwhelmed by his demands. This compromise, however, does not solve the problem on its own, because there might be a fresh dispute every day as to whether today was the day for sex or not.
• A good way to overcome this problem is for the couple to agree on a timetable (see Chapter 6) determining on which days of the week sex would take place.
• So, for example, it might be agreed that sex would happen on Fridays only, and not on any other days.
• The woman would then know that she will not be pressurized on other days, and the man knows that sex will be happening on a regular basis on Fridays without any conflict.
The disadvantage is that the spontaneity is taken out of sex, and some couples may feel that they cannot use the technique for that reason. However, if you think about the initiation of sex, it is usually only one partner who has the idea, and who then persuades the other one that it would be a nice thing to do. This makes it usually unspontaneous for the second partner, and thus spontaneity is not total or mutual in the first place. It could therefore be something that as a couple you feel that you could sacrifice, for the sake of an arrangement that works and takes the heat out of your conflict over sex.
This might depend on whose side the problem was on. If, for example, the woman is unable to have sex on the arranged day because of her period, she should propose an alternative day. If, however, the man is away at a golf tournament, he should probably miss his ‘sex day’ for that week. You may have to make a set of rules to cover this kind of eventuality.
The timetable may bring so much relief that you feel you want to continue with it for a long time. If it is working well, however, it may have improved your relationship sufficiently for you to go back to spontaneous sex without conflict. A good way to test this is to suspend the timetable for a week or two (again by consultation together) and then see whether it is better to continue with it or to go back to spontaneity again. Some couples have continued with it for months or even years, and see no reason to give it up.
Case example
Leslie (41) and his wife Heidi (39) had been married for 10 years and had a 9-year-old daughter. They had been having relationship and sexual problems for 4 years. These began when Leslie had to change his career after being laid off, and became rather depressed. He went into counselling, but also began to lean on Heidi, and was asking for reassurance more than before. At this time, Heidi began to go off sex (which she had previously enjoyed), partly because of Leslie’s increased dependency on her. He was upset by this, and pressured her for sex on most days. Sex actually happened once a month on average. In therapy they agreed to try a timetable for sex to take place on Wednesdays. They also agreed that Leslie would bring coffee to Heidi on Sunday mornings, and look after their daughter so that Heidi could sleep late. The arrangement was very successful, and some months later they were still using the timetable, with weekly satisfactory sex, and a generally improved relationship.
In the case of Leslie and Heidi above, it is useful to note that we asked him to take over some of the ‘looking after’ that she had mainly been responsible for up to that point, balancing the relationship as well as directly altering the sexual interaction.
This is in some ways the opposite side of the coin, but has things in common with the previous problem. The couple who experience this problem are often older, and the man is possibly entering the stage of life when sex is not an overwhelming priority for him. It may also be a second marriage for him, and his wife may be somewhat younger. In any event, the problem as presented is that she is keen to have sex frequently and he is reluctant. The timetable would be a theoretical possibility, but is not so easily adapted to this situation because, while the woman can allow sex to happen even if she is not completely committed to it, for the man this is more difficult. He would probably worry that he would be unable to get an erection if he were to agree to sex on a particular day of the week. There may be some exceptions, but it is probably better to use an alternative strategy if this is your problem.
We have found in my clinic dealing with couple problems that many men with this problem are diplomatic, unassertive and hate to argue. This is in contrast to their partners, who are often outspoken, emotionally expressive and open. The man is therefore at a disadvantage. He is good at keeping the peace, but he tends to lose most of the arguments when the couple argue, and he may build up some resentment. It is a good example of the ‘attack and withdraw’ couple whom I described in Chapter 4. The problem is at its worst when the couple are arguing about sex. The female partner is outspoken on this subject, blaming the male for his lack of sex drive and initiative, and the quiet man usually agrees that she is right, even though he may have his private reservations. The outcome is that they seldom get around to having sex because he is always somewhat resentful, although he would never admit it. He may also be afraid of her criticism if the process goes wrong, for example if he ejaculates early or if she fails to get the pleasure she expects.
It will be seen from the example given below, that it may be possible to improve the situation by encouraging him to argue a little more strongly, and to help her to understand that her strength in argument can work against her better interests in the sexual area. It is very much like the exercise that I suggested in Chapter 6, in which you sit together and argue about something quite trivial such as the dirty clothes or the toothpaste tube. The important thing to remember in these arguments is that the quieter partner should go on arguing even when he thinks he ought to give in for the sake of peace, and that the more outspoken (female) partner should deliberately encourage him to speak out and ‘hold his own’ in the argument.
Case example
Brian (53) and Stella (51) had been married for 25 years, and their children had left home. The problem was that Stella complained bitterly and frequently that Brian never wanted sex with her, in spite of a previous course of treatment involving sensate focus (see above). Brian was quiet and diplomatic, and never disagreed with Stella. In the third session of therapy, I asked him whether there was any small thing on which he had a difference of opinion with her. After some hesitation he said that sometimes he felt she was too fussy about the toilet seat: he thought it did not matter whether it was left up or down, while she was insistent that it should be left down. They had a lively argument about it, the liveliest argument they had had in their whole marriage. I encouraged him not to give in too quickly, and they finally ‘agreed to differ’. Later in that week they had intercourse at his instigation, and from then on their sex life became more regular, and Stella expressed more respect for him in many other aspects of their marriage.
These arguments are often therapeutic for the couple if they go well and both partners can take part in them in a fairly light-hearted manner. If, however, you have a relationship which is characterized by conflict and there have been violent episodes in the past, it might be safer not to try to have trivial arguments. Alternatively, if you do so it would be better to do it when you are not alone in the house. It would also be wise, in any case, when having these kinds of arguments, to make sure that you have not drunk alcohol or taken other substances on that day: these could reduce inhibitions too much and increase the risk of arguments getting out of hand.
There is much that can be done for the sexual desires outlined above, without resorting to either timetables or arguments.
• You can certainly use the sensate focus approach in both male and female desire problems, and there is no reason why these exercises should not work.
• There is also the idea of simply increasing the openness of your communication (see Chapter 5), which again should help the problem in a general way.
• Any resentments that either partner feels could be explored in a timed discussion, as outlined in Chapter 5, and this should lead to an improvement in the general relationship, which may help the sexual relationship.
• It also helps some couples to watch explicit videos together. This is not necessarily a long-term solution, but it may be able to break the silence and help you to talk about sex in a more constructive way, as well as having an immediate positive effect on sexual interest.
There is never any harm in trying to improve your relationship using the techniques I have outlined in this chapter, and it should probably be your first option whatever you decide to do later. However, sexual desire problems are not always easy to resolve, and many couples have found that they are unable to resolve the situation without professional help. I have given a list at the end of the book of some of the resources available in both couple relationship work and in sexual therapy and counselling. There are several ways to arrange counselling or treatment. If it is a non-sexual problem, or a problem of sexual motivation only, it would be quite sensible to ask for therapy or counselling from a couple counselling organisation or clinic that deals with these problems. If it is a problem of sexual function (for example an erectile problem, vaginismus or dyspareunia) it would probably be best to seek advice first from your doctor, followed by a referral to a clinic that specializes in these problems.
• Sexual drive, sexual desire, sexual arousal and orgasm are all defined.
• Advice is given on how to discuss sexual difficulties.
• It’s important to keep expectations realistic.
• Relaxation and sensate focus exercises are described.
• Advice is given on how to deal with erectile disorder, premature ejaculation and delayed ejaculation.
• Advice is given on how to deal with desire/arousal disorder in women, and with anorgasmia, vaginismus and dyspareunia.
• In couples where the man is keener on sex than the woman, the timetable may be used.
• In couples where the woman is keener on sex than the man, having trivial arguments may be considered.
• In many cases it will be necessary to seek medical help or counselling for the sexual problem.