Sex Made Simple: Clinical Strategies For Sexual Issues In Therapy

When sex therapy first developed, the assumption was that by increasing sexual function problems would disappear. In fact, the core sexual dimension is desire. Although arousal and orgasm are highly valued, this alone does not promote sexual desire.

The mantra for healthy sexuality is desire/pleasure/eroticism/satisfaction. Desire is the major dimension for relationship satisfaction and security. The role of healthy sexuality is to energize the couple bond and reinforce feelings of desire and desirability. Healthy individual and couple sexuality has a small, integral (15-20 percent) role for the person and relationship. The paradox is that unhealthy sexuality has an inordinately powerful negative role, destabilizing the person and relationship. Although sexual conflict and dysfunction is disruptive, the main problem is sexual avoidance. The non-sexual relationship subverts attachment feelings and threatens relationship stability.

Psychologically, the most important factor for sexual desire is positive anticipation. In the same way the person anticipates going to their favorite restaurant, sports game, music performance, cultural event, the individual and couple can look forward to being sexual. A second dimension is that the person deserves sexual pleasure in her life and relationship. Deserving sexual pleasure is not contingent on everything being perfect. The woman deserves sexual pleasure if she is 20 pounds overweight, her marriage is stressed, their child is experiencing academic or social problems, or her job is boring. An important factor for desire is freedom and choice (especially for the woman). Freedom includes valuing sensual, playful, and erotic scenarios rather than the pressure that all sexual play must result in intercourse. Instead of enjoying her partner’s erection, she views it as pressure for sex. Freedom and choice, with a focus on sharing pleasure, promotes sexual desire. Unpredictable sexual scenarios facilitate desire. This can involve a range of scenarios—a surprise transition from pleasuring to eroticism, a different pleasuring position, switching intercourse positions 2 or 3 times, a different rhythm of multiple stimulation during intercourse, or a new afterplay scenario. Desire is facilitated by playfulness, taking emotional and sexual risks, experimentation, and unpredictability.

Psychologically, what subverts sexual desire? Desire is surprisingly easy to divert and kill. Factors include anticipatory anxiety, performance anxiety, anger, coercion, and routine. The healthy cycle is positive anticipation, pleasure-oriented touching flowing to eroticism, intercourse, and orgasm, as well as a regular rhythm of touch and sexual connection. The negative cycle is anticipatory anxiety, performance-oriented intercourse, frustration, embarrassment, and eventually avoidance. Ideally, both partners embrace the challenge of creating strong, resilient sexual desire.

Biologically, anything which is good for his physical body is good for his sexual body. This includes maintaining health and healthy behavioral patterns of sleep, exercise, and eating. What subverts sexual desire is not aging; rather, illness and the side-effects of medications. If it’s bad for her physical body, it’s bad for her sexual body. Smoking and alcohol/drug abuse reduce sexual function and eventually desire. Sleep problems, lack of exercise, and unhealthy eating subverts sexual function and desire.

Relationally, the challenge for the couple is to be intimate and erotic allies. Intimacy and eroticism are different dimensions, but can be complementary. They are not adversarial or incompatible. In long term relationships a secure, intimate attachment is vital. Intimacy includes warmth, loving feelings, open communication, feeling accepted, trust in the relationship, confidence the spouse “has your back,” and valuing intimacy and security. Eroticism is a different dimension—eroticism involves taking emotional and sexual risks, creativity and mystery, being playful or lustful, not being “politically correct.” Sex can be mutual or asynchronous, and they enjoy unpredictable sexual scenarios. Eroticism and intimacy are integrated to promote sexual desire and satisfaction.

Either extreme can subvert desire. When there is a sole focus on intimacy, attachment, loving feelings and mutuality this can burden desire and result in de-eroticizing the spouse and relationship. A sole focus on eroticism can result in sex being a performance to prove something to the partner. In this situation, creating an erotic charge requires high intensity and breaking boundaries. Ultimately, performance-oriented sex kills desire. The challenge for couples, married and partnered, straight and gay, is to integrate intimacy and eroticism into their relationship.

The DSM-5 (APA, 2013) term for males is hypoactive sexual desire disorder (HSSD) which emphasizes a biological/medical approach to the desire problem. The new term for female desire problems is sexual interest/arousal disorder (SIAD) emphasizing that the core issue involves psychological and relational factors. A comprehensive approach to identifying psychological, biological, and social/relational dimensions which facilitate and inhibit desire is the most clinically useful.

There are a range of possible factors which inhibit desire. The operational definition of a non-sexual relationship is being sexual less than 10 times a year or less than once a month (McCarthy& McCarthy, 2014). Approximately one in five married couples and one in three partnered couples who have been together 2 years or longer are non-sexual. ISD is the sexual problem that most negatively impacts relational satisfaction and stability.

Most couples begin with a romantic love/passionate sex/idealized relationship. This is the “limerance” phase which is very powerful, but fragile, typically lasting 6 months-2 years (Tennov, 1999). Many couples never make the transition to a couple sexual style which promotes desire/pleasure/eroticism/satisfaction. Instead, they fall into a predictable routine that any sexual contact leads to intercourse. Even if the sex is functional, it is not necessarily inviting or energizing.

Rates of ISD are higher for women than men. However, when couples stop being sexual it is almost always the man’s decision. To better understand this paradoxical data, what inhibits desire for women includes predictable sex, losing her “sexual voice,” her sexual feelings and preferences being ignored, side-effects of medication, role overload, anger, self-defeating behavioral health habits, and disappointment in the spouse and marriage (Meana, 2010). However, if the male continues to initiate she will go along with the intercourse routine even if it is not desired by her. Many women, once sexually involved, will experience arousal and orgasm, although this does not by itself enhance desire.

The major cause of ISD for males is sexual dysfunction, especially erectile dysfunction and ejaculatory inhibition. When the man has lost confidence with erections, intercourse, and orgasm sex becomes controlled by anticipatory and performance anxiety (McCarthy & Metz, 2008). Intercourse is the male pass-fail test. He experiences frustration, embarrassment, and eventually sexual avoidance. He says to himself, “I don’t want to start something I can’t finish,” so avoids sensual and playful touch. Even if the woman has ISD, his avoidance is demoralizing. She misses touch in their relationship.

Psychologically, the causes of ISD include anger, anxiety, alienation, depression, boredom, history of trauma, distracted by parenting, work, extended family, financial issues, stress, and that touching does not serve as a bridge to desire.

Biological/medical causes include vascular, neurological, or hormonal factors, side-effects of medications, poor sleep, exercise, or eating patterns, alcoholism or drug abuse, depression, diabetes, and other illnesses.

Socially, the prime causes of ISD are the fact that the culture does not value marital sex nor does it value sex and aging. Relational causes of ISD include de-eroticizing the spouse, sex has become a power struggle, not having a couple sexual style, believing that each sexual encounter must be intimate and mutual, splitting intimacy and eroticism, feeling, “I love him, but I’m not in love with him,” conflict over family planning, an extra-marital affair, conflict about porn or internet sex, or disappointment in the partner or relationship.

A couple comprehensive psychobiosocial assessment, including individual psychological/relational/sexual histories, is vital in assessing causes of ISD.

In most cases, couple sex therapy is the preferred treatment for ISD. Couple treatment can be intermixed with individual sessions. The theme is that sexuality is a couple issue. The task is to develop a couple sexual style which promotes desire/pleasure/eroticism/satisfaction. If there is a specific arousal or orgasm dysfunction (most commonly premature ejaculation, erectile dysfunction, or ejaculatory inhibition for males and non-orgasmic response or sexual pain for females), these need to be directly addressed. However, changing arousal and orgasmic response will not be enough to create strong, resilient sexual desire. The psychosexual skill exercises of comfort, attraction, trust, and developing a preferred sexual scenario are often necessary to change desire problems (McCarthy& McCarthy, 2012). In addition, biological/medical and social/relational factors which subvert sexual desire have to be addressed and resolved.

The couple is given the following sexual desire guidelines to facilitate understanding and change attitudes toward sexual desire.

GUIDELINES

REVITALIZING AND MAINTAINING SEXUAL DESIRE

1) The key to sexual desire is positive anticipation and feeling you deserve sexual pleasure in your intimate relationship.

2) Each person is responsible for his/her desire with the couple functioning as an intimate sexual team to nurture and enhance desire. Revitalizing sexual desire is a couple task. Guilt, blame, and pressure subvert the change process.

3) Inhibited desire and conflicts over desire discrepancies are the most common sexual problems, affecting one in three couples. Desire problems drain intimacy and good feelings from your relationship.

4) One in five married couples has a non-sexual marriage (being sexual less than ten times a year). One in three non-married couples who have been together two years or longer has a non-sexual relationship.

5) The initial romantic love/passionate sex/idealization relationship phase lasts less than two years and often only six months. Desire in an ongoing relationship is maintained by developing a comfortable, functional couple sexual style.

6) The essence of sexuality is giving and receiving pleasure-oriented touching. The prescription to revitalize and maintain sexual desire is intimacy, pleasuring, and eroticism.

7) Touching occurs both inside and outside the bedroom. Touching is valued for itself and does not always lead to intercourse.

8) Couples who maintain a vital sexual relationship can use the metaphor of touching consisting of “five gears” (dimensions). First gear is clothes on, affectionate touch including hugging, kissing, holding hands. Second gear is sensual touching. Sensual touch includes non-genital body massage, cuddling on the couch, and touching while going to sleep or on awakening. Third gear is playful touch which intermixes genital and non-genital touch, can be clothed or unclothed, romantic or erotic dancing, touching while in the bath and shower, whole body massage, playing strip poker or Twister. Fourth gear is erotic touch (manual, oral, rubbing, or vibrator stimulation) to high arousal and orgasm for one or both partners. Fifth gear integrates pleasurable and erotic touch that flows into intercourse. Intercourse is a natural continuation of the pleasuring/eroticism process. Intercourse is not a pass-fail sex test.

9) Both the man and woman value affectionate, sensual, playful, erotic, and intercourse experiences.

10) Both the woman and man are comfortable initiating touching and intercourse. Both feel free to say “no” and suggest an alternative way to connect and share pleasure.

11) A key strategy is to develop “her,” “his,” and “our” bridges to sexual desire. This involves ways of thinking, talking, anticipating, and feeling that invite being sexual.

12) Sexuality has a number of positive functions for your relationship—a shared pleasure, a means to reinforce and deepen intimacy, and a tension reducer to deal with the stresses of life and the relationship.

13) The average frequency of sexual intercourse is from four times a week to once every two weeks. For couples in their twenties, the average is two to three times a week, and for couples in their fifties once-twice a week.

14) Personal turn-ons (special celebrations or memories, feeling caring and close, erotic fantasies, anniversaries or birthdays, sex with the goal of pregnancy, initiating a favorite erotic scenario, being playful or spontaneous, sexuality to celebrate a career success or soothe a personal disappointment) facilitate anticipation and desire.

15) External turn-ons (R or X-rated videos, music, candles, sex toys, visual feedback from mirrors, being sexual outside the bedroom, a weekend away without the kids) facilitate anticipation and desire.

16) Non-demand pleasuring can be a way to reinforce attachment, a means to share pleasure, or a bridge to sexual desire.

17) Intimate coercion is not acceptable. Sexuality is neither a reward nor a punishment. Sexuality is voluntary, mutual, and pleasure-oriented.

18) Realistic expectations are crucial for maintaining a satisfying sexual relationship. It is self-defeating to demand equal desire, arousal, orgasm, and satisfaction each time. Realistically, 35 to 45 percent of experiences are very good (mutual and synchronous). Twenty percent are very good for one (usually the man) and fine for the partner. Fifteen to 20 percent are okay for one and the other finds it acceptable. Be aware that 5-15 percent of sexual experiences are dissatisfying or dysfunctional. Couples who accept occasional mediocre or dysfunctional experiences without guilt or blaming and reengage when they are open and responsive have a vital, resilient sexual relationship. Satisfied couples use the guideline of Good Enough Sex (GES) to promote positive, realistic sexual expectations.

19) Contrary to the myth that “horniness” occurs after not being sexual for weeks, desire is facilitated by a regular rhythm of sexual experiences. When sex is less than twice a month, you become self-conscious and are in danger of falling into a cycle of anticipatory anxiety, tense and unsatisfying intercourse, and avoidance.

20) Healthy sexuality plays a positive, integral role in your relationship with the main function to energize your bond and reinforce feelings of desire and desirability. Paradoxically, dysfunctional, conflictual or nonexistent sex plays a more powerful negative role than the positive role of good sex.

Establishing positive, realistic expectations for sexuality and desire motivates the couple toward change. A good example is that although 85-95 percent of sexual encounters are positive, less than 50 percent are mutual and synchronous (Frank, Anderson, & Rubinstein, 1978). Often, the sex is better for one partner than the other, usually males before 50, and often females after 50. It’s normal that some experiences are functional, but mediocre. A crucial understanding is that among happily married, sexual functional couples 5-15 percent of encounters are dissatisfying or dysfunctional. This little known reality makes clear that the Good Enough Sex (GES) model of variable, flexible couple sexuality is a better fit than the traditional individual sex performance model of erection and intercourse for men and orgasm (preferably during intercourse) for women. GES recognizes the range of roles, meanings, and outcomes of the sexual encounter for the man, woman, and couple.

A crucial therapeutic strategy for treating ISD is “bridges for sexual desire.” Rather than waiting for mutual, spontaneous desire, the reality is that the majority of sexual encounters are planned or semi-planned. Couples who do well are those who have “his,” “hers,” and “our” bridges to desire. Each partner has his or her preferred way to initiate a sexual encounter. Couples develop sensual, playful, erotic, and intercourse scenarios as well as special scenarios which ensure sexual vitality.

Perhaps the most important psychosexual skill exercise involves the five dimensions of touch (“gears of connection”).

GUIDELINES

THE CRUCIAL COUPLE SEXUAL DIALOGUE: FIVE DIMENSIONS OF TOUCH

The core psychosexual skill exercise is to increase awareness of each partner’s preferences for gears (dimensions) of touch. The majority of couples only use two gears-affection or intercourse. They fall into the trap of believing that sex=intercourse. This results in lower levels of both touch and intercourse.

This psychosexual skill exercise focuses on five gears of touch:

First gear: Affectionate touch-this usually involves clothes-on touching such as holding hands, hugging, or kissing. Affectionate touch is not sexual, but it provides the crucial base for intimate attachment.

Second gear: Sensual touch-this involves non-genital touch (also called non-genital pleasuring) which can be clothed, semi-clothed, or nude. Sensual touch can include a head, back, or foot rub; cuddling on the couch while watching a DVD, a trust position where you feel safe and connected, cradling each other as you go to sleep or wake in the morning. Sensual touch is an integral part of couple sexuality. It has value in itself as well as serving as a bridge to sexual desire at that time or later.

Third gear: Playful touch-this intermixes genital (also called genital pleasuring) with non-genital touch while semi-clothed or nude. Playful touch can include touching in the shower or bath, full body massage, seductive or erotic dancing, playing games such as strip poker or Twister. What makes this inviting is the sense of sharing pleasure and playful unpredictability. Playful touch is valuable in itself or can serve as a bridge to sexual desire.

Fourth gear: Erotic touch-this is the most challenging gear. Erotic, non-intercourse touch can include manual, oral, rubbing, or vibrator stimulation. Erotic scenarios and techniques are an integral part of couple sexuality providing a sense of vitality, creativity, and unpredictability. Erotic touch can be mutual or one-way. It can proceed to orgasm or transition to intercourse.

Fifth gear: Intercourse—there are two crucial concepts in integrating intercourse into the approach of gears of connection. First, intercourse is a natural continuation of the pleasuring/eroticism process, not a pass-fail sex performance test. Second, transition to intercourse at high levels of erotic flow and continue multiple stimulation during intercourse.

We suggest each partner fill out this chart separately. Then discuss feelings and preferences with your partner.

Touch Type	Current Percentage of Touch	Percent of Touch Desired
Affectionate touch
Sensual touch
Playful touch
Erotic touch
Intercourse touch

The essence of couple sexuality is sharing pleasure- oriented touch. You develop a common language to facilitate connection and embrace a variable, flexible approach to intimacy, touching, and sexuality.

So many couples only have two gears (dimensions) of touch-affection and intercourse. Most couples define sex as intercourse, with the traditional male-female power struggle about whether they will have intercourse or not. Sex becomes a struggle about intercourse frequency. The concept of gears of connection confronts this power struggle and identifies five gears (dimensions) of touch, like a five-speed stick shift car. Affectionate touch involves holding hands, kissing, hugging-typically clothed. Affectionate touch is not sexual, but serves to keep the couple connected (attachment). Sensual, playful, erotic, and intercourse touch are all accepted as sexual. This is a crucial change in the couple dialogue and understanding. This concept provides the clients a broader, more realistic model for the roles and meanings of touch and sexuality.

The clinician teaches the couple to identify subjective arousal on a 10 point scale where “0” is neutral and “10” is orgasm. This makes it easier to describe the dimensions of touch and implement the concept that sexuality is much more than intercourse.

2) Sensual touch involves non-genital touching, including head or back rubs, touch couples engage in before going to sleep or on awakening, cuddling on the couch watching a DVD. Sensual touch helps the couple transition from 1 to 3 on the subjective arousal scale.

3) Playful touch mixes non-genital and genital touch and can include teasing touch in the shower or bath, full body massage, seductive or erotic dancing, “making out” while semi-clothed. What makes playful touch fun and special is its unpredictability. Playful touch facilitates subjective arousal from 4-5.

4) Erotic touch can involve manual, oral, rubbing, or vibrator stimulation. This can proceed to high levels of arousal/erotic flow and orgasm or more commonly transition to intercourse. In terms of subjective arousal this involves 6-10.

5) Intercourse touch is an integral part of the pleasuring/eroticism process rather than a pass-fail sex test. Most couples find intercourse more involving and pleasurable when they transition to intercourse when they “should” (at 7-8 subjective arousal) rather than when they “can” (4-5 subjective arousal). Use of multiple stimulation (giving and receiving erotic stimulation, including erotic fantasies) during intercourse rather than a sole focus on thrusting promotes sexual responsivity.

The broadening of what is perceived as sexual and the emphasis on the couple sharing pleasure and eroticism promotes desire rather than intercourse as a pass-fail individual performance test.

Just reading or talking about dimensions of touch is not enough. The couple takes the handout home, marks up relevant parts, discusses trying it, and what to focus on. The most important dimension is actually implementing the exercise and experiencing sensual, playful, and erotic touch as a valuable experience for itself not just as a way to build toward intercourse. Many couples find all five dimensions of touch to be motivating while others find 3 or 4 are most valuable. The most challenging dimensions are playful touch and erotic stimulation to orgasm (rather than transitioning to intercourse). Don’t let the couple be “politically correct.” Reinforce what is comfortable and valuable about dimensions of touch for the individuals and couple.

The breakthrough concept in female sexuality is “responsive sexual desire.” Basson (2002) challenges the male model of spontaneous erection, erotic fantasy, and desire for orgasm as the “natural” definition of desire. Basson introduced the concept that the adult woman in a married or partnered relationship who has responsibilities of children, work, and community often begins a sexual encounter at 0 (neutral) subjective arousal. In response to touch, partner connection, and awareness of her feelings she becomes receptive and experiences subjective arousal of 2 or 3. It is then that she experiences sexual desire. Desire is responsive to touch and emotional connection rather than spontaneous desire or wish for orgasm. Responsive desire is not the only type of desire the woman experiences, but for many women it is the most common. Basson (2007) more fully described the female desire model, including the woman’s feelings of freedom and choice. She need not feel pressured by the man’s erection or desire for intercourse. When she feels desire and subjective arousal, she has choices of how the scenario plays out. The socially desirable outcome is a mutual, synchronous sexual encounter where both partners experience desire/pleasure/eroticism/satisfaction. However, if this is the only acceptable option it will subvert desire because of performance pressure. Having a range of positive scenarios promotes female and couple desire. Alternative scenarios can include:(1) enjoying a mutual sensual encounter, (2) the traditional scenario of intercourse where it is a 10 for the man and a 4-6 for the woman, (3) enjoying a mutual or asynchronous erotic scenario to orgasm for one or both partners, (4) she pleasuring him to orgasm, (5) she holds him while he stimulates himself to orgasm. Female sexual desire requires not allowing sexual scenarios that are destructive for her or their relationship.

A second breakthrough concept is that female sexuality, including desire, is first class-not second class to male sexuality (Brotto & Woo, 2010). Female sexuality is more variable, flexible, complex, and individualistic—and first class. The woman and man approaching their sexual relationship as equitable sexual friends promote pleasure/eroticism/satisfaction. Most important, it promotes strong, resilient sexual desire.

Rather than an attack on male sexuality, the concept of responsive desire and accepting his partner as a first class sexual woman is good for male and couple sexuality. The concept of responsive sexual desire can be motivating and empowering for male sexual desire and function, especially after age 50. Rather than needing a spontaneous erection or totally predictable sexual response, the man being open to his partner’s sensual, playful, and erotic touch promotes male desire. The key to sexual desire with middle years and older couples is touch, not visual stimuli. This message is more easily accepted by females, but is empowering for males.

The traditional male approach to sexuality was simple and one dimensional. The message was “a real man is willing and ready to have sex any time and any situation.” The “natural” sexual response is a spontaneous erection, going to intercourse on his first erection, and totally predictable orgasm. The most important, and most destructive, assumption is that autonomous sexual response is the measure of first class male sex. Female sexual desire and response was viewed as inferior. The man pressures the woman for more sex. The “sophisticated” man is loving, encouraging, giving manual and oral stimulation to turn her on and enhance sexual responsivity. He is especially attentive to her arousal and orgasm. The “traditional” man would like her to be more sexual and orgasmic, but assumes women don’t enjoy sex as much as men. Both the sophisticated and traditional approaches subvert female and couple sexual desire.

The traditional male-female power struggle over intercourse is a major social/relational inhibitor of sexual desire and a prime reason for low intercourse frequency. When it’s intercourse or nothing it’s not surprising that nothing is the usual outcome.

The man accepting that female sexuality is first class is good for her, him, and them. Recognizing the validity and first class status of her sexual voice facilitates embracing an equity model of female-male sexuality and implementing the dimensions (gears) of touch model which values sensual, playful, erotic, and intercourse touch to promote sexual desire.

GUIDELINES

FEMALE-MALE EQUITY

The most intimate and stable relationship between a woman and a man is marriage. Although elements of the equity model are relevant to a range of relationships including friendships, parenting, work, and other social and family relationships, it is most crucial in marriage. The following are guidelines for equity between the sexes.

1) Relationships between women and men are based on respectful attitudes that promote, and even demand, equity.

2) Develop open and flexible attitudes toward female-male roles.

3) Be accepting and secure about your femininity or masculinity. You do not need the approval of others, nor are you intimidated by rigid sex roles.

4) Be aware that intellectually, behaviorally, emotionally, and sexually there are more similarities than differences between women and men.

5) Encourage personal and professional friendships with the opposite sex; resist the pressure to sexualize these relationships.

6) Be comfortable and confident in your femininity or masculinity so activities and interests which have traditionally been labeled as belonging to the opposite sex can be integrated into your life.

7) An intimate sexual relationship is more satisfying if both the woman and man can initiate, say no, make requests, and value sexual pleasure and eroticism.

8) Conception, contraception, and children are as much the responsibility of the man as the woman.

9) A respectful, equitable, trusting, and intimate sexual marriage is the most satisfying.

10) A communicative, sharing, and giving relationship promotes emotional and sexual satisfaction.

This facilitates more ways to stay sexually connected and leads to enhanced pleasure and intercourse. This is not to be “politically correct,” but to free the woman and man to enjoy multiple roles and meanings of sexuality and facilitate sexual desire.

The core treatment strategy for ISD is to directly build sexual desire by implementing the desire psychosexual skill exercises of comfort, attraction, trust, and each partner’s preferred sexual scenario (McCarthy & McCarthy, 2012). Although all four exercises are important, the preferred sexual scenario exercise is most impactful in illustrating the validity of honoring each person’s feelings, preferences, and initiation patterns. Partners are not clones of each other. Embracing each person’s bridges to sexual desire and preferred scenario is validating and enhances desire.

EXERCISE

PREFERRED SEXUAL SCENARIO

When a relationship is new, there is strong anticipation of being sexual even if the quality is not particularly good. Sex serves as an affirmation of your desirability and desire to be a couple. Romantic love and passionate sex energize a new relationship and make it “magical.” There is the thrill of sexual exploration as well as the energy that goes into making your relationship exciting and erotic.

After the initial romantic love/passionate sex has dissipated it takes most couples 3-6 months to develop a couple sexual style that is intimate, functional, and satisfying. Part of the process is crafting sexual scenarios, the focus of this exercise. As a reminder, you are not a machine, so it is normal in the best of couples to occasionally have mediocre or negative sexual experiences. A sign of healthy couple sexuality is your ability to accept this and not overreact to negative experiences.

What do you most value in a sexual experience? Each individual develops an inviting sexual scenario. Let the woman introduce her scenario first. At a different time the man can create his.

When is your best time to be sexual? When waking up? After the morning news? At noon? Before or after a nap? Before dinner (sex as an appetizer) or after dinner (sex as dessert)? In the evening? Most couples have sex late at night, but interestingly few people say that is their favorite time.

How do you set your preferred sensual and sexual mood? Do you listen to music, go for a walk, talk, light candles, drink wine, take a bath, have 15 minutes of time alone and then come together, meet your partner at the door and lure him into the bedroom? As a prelude to being sexual some couples enjoy doing together things like shopping, working in the garden, going for a run, or sharing feelings. Many couples start touching and playing in the living room or den and do not move to the bedroom until both are turned on. Others prefer to start in the privacy of their bedroom. What is your favorite way to begin a sexual encounter? Remember, there is no right or wrong-what is your preference?

Once the scenario is under way, what is your favorite script? Do you like to take turns or do you prefer mutual stimulation? Do you verbally express sexual feelings or would you rather let your fingers do the talking? Do you prefer a slow build-up or would you rather begin intercourse as soon as you are aroused? Do you like multiple stimulation or one erotic focus at a time? Do you make use of all your senses- touch, taste, smell, hearing soft moans, smelling an erotic perfume, feeling sexual movement? Develop the scenario in your unique way. Your partner is open to your guidance.

How do you transition from pleasure/eroticism to intercourse? Some people prefer to begin intercourse at moderate levels of arousal, but many prefer not transitioning to intercourse until they are highly aroused. Do you want to initiate the transition or do you want your partner to? Who guides intromission? Do you prefer multiple stimulation during intercourse or a sole focus on thrusting? What is your preferred intercourse rhythm and type of thrusting (short, rapid thrusting; slow up-and-down thrusting; circular thrusting; changing intercourse positions)? Do you prefer being orgasmic during intercourse or do you feel greater pleasure being orgasmic during erotic, non-intercourse sex?

How would you like to end the scenario? Afterplay is the most neglected element of the sexual experience. Your needs and desires are important here too. Do you like to lie and hold each other, sleep in your partner’s arms, engage in playful tickling, have a warm kiss, take a walk, read poetry, nap and start again, talk and come down together?

When it is his turn to create a sexual scenario, he is free to design his own, which could be similar to or totally different from hers. Many men fall into the trap of trying to outdo their partner. Sex is neither a competition nor a performance. Be yourself; develop an initiation, script, and afterplay scenario that is intimate, erotic, special, and satisfying for you.

CASE STUDY

STUART AND DANIELLE

Stuart and Danielle were one of the nicest couples I have ever treated. They are a powerful example of the corrosive effect of ISD. Their meeting, becoming a couple, and marrying was a wonderful romantic love/passionate sex dramatic story. Stuart was viewed by his many male and female friends as a wonderful human being who would “give the shirt off his back” for someone in need. However, he was painfully shy, especially with women he was romantically interested in. When Stuart was introduced to Danielle he was struck with how beautiful and social she was. He quickly put her in the friend category because he felt there was no way he could be romantically involved with this quality woman. Danielle welcomed Stuart’s friendship—she was tired of men coming on to her.

Danielle told Stuart that her student visa would soon expire and she would have to leave the US and return to Romania. That is not what she wanted. She was scheduled to depart in less than a month, and friends were planning a large going away party.

The next Friday a group met after work to play darts and have drinks. Stuart was an excellent dart player and teamed up with Danielle-showing her techniques to improve her game and was impressed by how quickly she learned. After two more drinks, Danielle leaned on his shoulder and said he was a wonderful friend, there was no one like him in Romania. Stuart said he would do anything to help her. Danielle blurted out “marry me” and gave him a big kiss. Stuart was stunned—this was his greatest dream. He was babbling, but finally said he would love to marry her.

Could this really work? Should they fly to Las Vegas? Would the INS accept this as a “real marriage?” Before either of them raised practical questions, their friends jumped on the fast moving bandwagon. On Monday a friend arranged a consultation with an immigration attorney who instructed them on how to organize a wedding which would meet INS standards. Twelve days later, Danielle and Stuart were married in a church with 30 family and friends attending.

With all the drama and excitement, sex had a special erotic charge, something Stuart had never experienced. Danielle was clearly more sexually experienced and sophisticated than Stuart. She was grateful to him for rescuing her from having to leave the country. Sexual quality was the last thing on her mind. Instead, she went with the loving feelings and was sure that with time sexual quality, especially his ability to please her, would naturally improve. For Stuart, this emotional and sexual relationship was a dream come true.

The romantic love/passionate sex/idealization (limerance) phase lasted about four months. When it ended, it was very dramatic—incredibly hurtful for Stuart and disillusioning for Danielle. Danielle’s naive assumption was that sexual quality would become better with practice. Instead, she became increasingly frustrated with the sexual routine Stuart had fallen into. After an encounter that he thought was great and she found boring, they were lying nude in bed. Danielle complained that Stuart was an unimaginative lover—why wasn’t he more involved and experimental? Stuart reacted in an extreme manner—he felt like a “sexual loser” and burst into tears. At first Danielle felt badly but when he didn’t stop crying, she was angry and increased her vehemence that he did not know what he was doing sexually.

The worst time to talk sex is in bed, nude, after a negative sexual experience. People say and do destructive things. Even when she later apologizes or says she didn’t mean it, the negative emotions dominate. The best time to talk sex is in the therapist’s office, on a walk the day before being sexual, or on the porch over a glass of wine or cup of tea. Sexuality is a very emotionally-laden topic. It is easy for the dialogue to break down in destructive ways. Particularly important is being respectful, empathic, and making suggestions for change as a request, not a demand.

Sadly for Stuart and Danielle their sexual relationship quickly degenerated. Stuart tried very hard to perform for Danielle and please her sexually, but both became highly self-conscious. There is nothing more anti-erotic than self-consciousness. Within two weeks, they were stuck in the negative cycle of anticipatory anxiety, tense performance-oriented sex, and embarrassment which eventually led to avoidance of any type of touch except affection. Once into an avoidance cycle, this takes control and builds on itself.

Stuart felt like a total failure as a spouse and lover. Danielle “split” her image of Stuart—a good guy, successful professional, good friend, but a terrible disappointment as a sexual partner. Stuart’s continual apologizing and trying to compensate for sexual problems made it much worse—she began to view him as pathetic.

Attempts at seeking help made the psychological, marital, and sexual problems much worse. His internist prescribed Viagra. A friend suggested Stuart consult an individual therapist who focused on Stuart’s learning to express anger. A referral to a couple therapist backfired as he explored the hypothesis that because of immigration issues surrounding the decision to marry that this was a “fatally flawed” marriage.

Stuart urged Danielle to begin an EMA (extra-marital affair) so her sexual needs could be met. She urged Stuart to hire a prostitute to improve his sexual skill and confidence. Stuart and Danielle were an example of how a sexual problem can destabilize people’s lives and marriage.

When they arrived for couple sex therapy there were a number of issues to address with this demoralized couple. The sex therapist needs to focus on building a new couple sexual style to promote desire/pleasure/eroticism/satisfaction as well as confronting the “poisons” which subvert sexual desire. The individual psychological/relational/sexual histories gave a clear picture of how different Danielle and Stuart’s strengths and vulnerabilities were. No wonder it was so hard for them to dialogue about sexuality.

The couple feedback session was the turning point in motivating them to begin addressing the sexual desire problem as intimate and erotic allies. Particularly important, Stuart had to stop apologizing for himself sexually and trying to prove something to Danielle. Danielle needed to accept responsibility for her own desire and eroticism. The biggest challenge for Danielle was to build trust in an intimate, secure marriage. Her lack of belief that she could have a satisfying, secure, sexual marriage was a major vulnerability. Interestingly, intimacy and valuing a secure marriage was a strength for Stuart. The essence of a healthy marriage is positive influence—being in the marriage brings out healthy parts of the person. Sex therapy and rekindling desire was a team effort. They needed to apply the positive influence approach.

In focusing on building sexual desire the two most valuable psychosexual skill exercises were attraction and the preferred sexual scenario. It was affirming to realize there were so many aspects of Stuart that Danielle found attractive. She made three requests of him: 1) accept her apology for their devastating fight and see her as his sexual friend, 2) be open to touching her and being touched by her inside and outside the bedroom, 3) stop trying to turn her on—desire and arousal was her responsibility. Stuart heard these as requests, not demands. He readily accepted the first two and modified the third to emphasize sharing pleasure. Stuart had only one request of Danielle—to join with him in developing a new couple sexual style which would energize their marital bond. She enthusiastically accepted.

Danielle’s preferred sexual scenario resulted in a major breakthrough. She tied Stuart’s hands so he couldn’t stimulate her manually, used rubbing stimulation to heighten her arousal, was open to his oral stimulation when she was in an erotic flow, and guided his penis into her. He was highly excited to see her be orgasmic with both oral stimulation and during intercourse. Perhaps the most important learning involved her untying his hands, cuddling during afterplay, and Danielle affirming she loved him and knew they could be an intimate sexual team. The fact that Stuart’s preferred sexual scenario was quite different than Danielle’s reinforced the message that they weren’t sexual clones of each other. Each partner’s sexual preferences add to the vibrancy of couple sexuality. For Stuart the prime sexual learning was to share intimacy, pleasuring, and eroticism. For Danielle, the prime learning was to value a genuine satisfying, secure, sexual marriage. They had grown individually and as a couple. Sexuality had the 15-20 percent role of energizing their marital bond and reinforcing feelings of desire and desirability.

They agreed to schedule six-month check-in sessions during the next two years to reinforce gains and continue to build their Complementary couple sexual style. Sexuality cannot be taken for granted nor treated with benign neglect. Put energy into the sexual relationship so it remains vital and satisfying.

Sexual desire is the core issue in couple satisfaction and security. Sexual desire problems, especially ISD and desire discrepancies, are best addressed as a couple. Emphasize the personal responsibility/intimate sexual team approach. Sexual desire can be rekindled and reinforced. A key concept is discovering the couple sexual style which promotes strong, resilient sexual desire. The couple deal with desire directly through the psychosexual skill exercises of comfort, attraction, trust, and preferred sexual scenarios. Just as important, confront and change psychological, biological, and relational factors which subvert sexual desire.

A key to sexual satisfaction is positive, realistic sexual expectations promoted by the Good Enough Sex (GES) model. Desire is resilient when the couple value both mutual and asynchronous experiences. When there is dissatisfying or dysfunctional sex, they turn toward each other rather than avoid. This includes being sexual in the next one to four days when they feel open and receptive. The couple reinforces the key concepts in sexual desire—anticipation, deserving, freedom, choice, and unpredictable sexual scenarios.