Application: Family Life-Cycle Stages

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Male Sexuality and Couple Sexual Health: A Case Illustration

MICHAEL E. METZ Meta Associates, St. Paul, Minnesota, USA

BARRY W. MCCARTHY Department of Psychology, American University, Washington, DC, USA

Male sexual problems are common and offer exceptional oppor- tunities for clinicians to not only relieve distress but enhance individual and relationship satisfaction. However, limited clini- cal focus on sex behaviors alone often overlook this opportunity. With more comprehensive approaches, clinicians are able to both facilitate improved sexual function and to promote positive, realis- tic principles for healthy and satisfying male and couple sexuality. Approaches such as the Good-Enough Sex model provide clinicians with crucial elements to resolve common male sexual problems and promote sexual health and couple satisfaction. This article sum- marizes realistic features for men’s (and women’s) sexual health including promoting the positive value of sex, promoting realis- tic expectations, supporting pleasure as well as physical function, promoting sexual flexibility by integrating 5 basic purposes for being sexual and 3 arousal styles, appreciating the variable qual- ity of sex, building relationship cooperation as an “intimate team,” and integrating sex into one’s real life. Such features promoting healthy, satisfying sexuality are illustrated with a case example.

KEYWORDS sex problems, sexual health, sex dysfunction, couple therapy, couple satisfaction, cognitive therapy, couple conflict resolution, Good-Enough Sex model, male sexuality

Address correspondence to Michael E. Metz, Baker Court Office Building, Suite 440, 821 Raymond Avenue, St. Paul, MN 55114, USA. E-mail: [email protected]

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THE PREVALENCE AND COMPLEXITY OF SEXUAL PROBLEMS

Prevalence studies using multiple populations verify the common occur- rence of male (and female) sexual problems. For example, Kinsey (Kinsey, Pomeroy, & Martin 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953) using a sizeable availability sample and other nonrepresentative reports over the past 50 years (e.g., Ende, Rockwell, & Glasgow, 1984; Metz & Seifert, 1993; Schein et al., 1988; Spector & Carey, 1990) indicate sexual dysfunction (SD) for men, women, and couples ranging from 10% to 95% prevalence over the life cycle. Masters and Johnson (1970) estimated that at any moment in time, approximately 50% of couples suffered SD—described as personal and/or relationship distress due to the inability to perform intercourse with satis- faction. These distresses include problems with low or absent sexual desire, arousal or excitement (erections or lubrication), orgasm (rapid, delayed, or absent orgasm), or painful intercourse. The classic study by Frank, Anderson, and Rubenstein (1978) reported sex dysfunction in 40% to 45% of couples while nearly 80% experienced other nonfunction difficulties (e.g., conflict over frequency, preferences, or styles). The best representative study con- ducted in the United States reported that approximately 45% of couples at a given time suffer a male (31%), female (43%), or couple (combined 45%) SD that commonly create relationship distress (Laumann, Paik, & Rosen, 1999).

Public and professional awareness of SD has increased in recent years with the marketing of phosphodiesterase 5 (PDE-5) proerection medications (Viagra, Levitra, Cialis). At the same time, clinical experience demonstrates that SD and other problems with men’s sexual health are rarely simple problems with a simple cure in spite of people’s longing for “quick fixes.” Recent developments in sexual medicine to improve male SD (better erec- tion devices, medications for ejaculatory control) and increased attention to women’s SD offer distressed couples increased hope for sexual func- tion. However, in the last decade, there has developed an imbalance in the approach to treating SD with an inordinate emphasis on a biomedi- cal approach to physical function, especially to male sexuality. The failure of biomedical technologies to benefit many couples (Brock et al., 2002) as well as the suggestion of significant psychological placebo benefit with medications (Hatzichristou et al., 2005) highlight the oversimplification of human sexuality by focusing on sex performance and often disregarding the overall well-being and important meaning to couple sexual intimacy and satisfaction.

A sexual issue is commonly a profound human relationship problem that involves emotional suffering, distress, even agony. Sometimes SD is the secondary manifestation or symptom of other personal (e.g., depression, anxiety disorder) and/or sexual and relationship problems (e.g., unresolved couple conflict; Levine, Risen, & Althof, 2003; Metz & Epstein, 2002). In addition to SD, other sexual problems—often concealed—are a common

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reason that individuals and couples seek therapy. Approximately 18% to 24% of married men and 16% to 20% of married women have an extramarital affair (Allan et al., 2005). In addition, studies estimate that of the 20% of “netizens” (Internet users) who engage in some sort of online sexual activity as high as 17% of these have online compulsive or “addictive” problems (Cooper, McLoughlin, & Campbell, 2000; Cooper & Marcus, 2003) sometimes described by the client as erectile dysfunction or low desire (resulting from compulsive sex) and potentially undermining relationship cohesion.

THE PROBLEM TREATING MEN WITH SEXUAL PROBLEMS

Sex problems are usually multicausal and multidimensional and have mul- tiple effects on the person, the partner, and the relationship. Effective treat- ment ought to integrate suitable medical, pharmacological, psychological, and relational aspects for adequate sex function and ensure relational and sexual satisfaction (e.g., Althof et al., 2005; Levine et al., 2003; Metz & Pryor, 2000). Satisfaction with one’s sexual life is fundamentally grounded on real- istic physical, psychological, and relationship expectations. Unrealistic con- cepts precipitate frustration, a sense of failure, and distress (Boul, 2007). The prevailing societal emphasis on perfect sexual performance is self-defeating and needs to be replaced with realism such as the Optimal Sexuality descrip- tion (Kleinplatz & Menard, 2007) or the Good-Enough Sex (GES) model (Metz & McCarthy, 2007a), which identify the value of realistic expectations and the inherent variability of couple sex. Sex problems offer an excep- tional opportunity for the helping professional to relieve distress, to promote individual and relationship satisfaction, and to promote quality of life.

However, when clinicians have only limited behavioral goals—such as to stop premature ejaculation; erectile dysfunction; or detrimental male sex- ual behavior such as misusing Internet pornography, soliciting prostitution, or engaging in affairs—quality of life promotion may be undervalued, and sometimes treatment may unintentionally set the stage for relapse and disillu- sionment. Limited approaches minimize sexual satisfaction by only focusing on performance when there is an SD or eliciting compliant and marginal promises to change when there is a sexual disorder such as compulsive sex. The man needs to be accountable not simply for his sexual behavior but for his sexual maturity, honestly addressing the reality of his sexual being; pro- moting positive, confident sexual health; and blending his sexuality with his partner’s in a manner that promotes intimacy, mutual pleasure, and sexual satisfaction.

The complexity of psychological and sexual satisfaction expands beyond the individual. Interpersonal therapies (e.g., Levine et al., 2003; Snyder, Castellani, & Whisman, 2006; Yeh, Lorenz, Wickrama, Conger, & Elder, 2006) that focus on couple understanding and interventions are

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valuable in formulating and clinically working with the complexity of men’s sexual health. Consider that a man’s sex problem, which on the surface seems an individual function problem (e.g., erectile dysfunction, exces- sive masturbation, rapid ejaculation), is inevitably a relationship problem whether because of cause or effect. Even a man who is seen in individ- ual therapy—because he has no partner, he refuses to involve her, or he has a partner who is unwilling to participate in couple work—inevitably his problem involves relationship dimensions. He has a “virtual partner” in his mind—his current real partner or an imagined partner, a partner from the past or one imagined in the future. Understanding and working well with the complexity of a man’s sexual issues warrants an interpersonal, interac- tional, relationship perspective. Although some individuals and couples may resist such systemic context promoted by the therapist, they will deepen their awareness and acquire insulation against future disillusionment should function-only efforts later relapse (McCarthy & McCarthy, 2003).

THE NEED FOR A NEW COUPLE APPROACH: THE GES MODEL

The ultimate purpose of the multiple medical and psychological treatments now available to address sexual problems should be the well-being of the couple (Snyder et al., 2006). The GES model (Metz & McCarthy, 2003, 2004, 2007a, 2007b; McCarthy & Metz, 2008) describes principles that can guide clinicians endeavoring to resolve male sex dysfunction and to promote healthy male and couple sexuality. This heuristic model is grounded in the more than 40 years of traditional sex therapy (Kaplan, 1974; Leiblum, 2006; Masters & Johnson, 1970), classic psychotherapeutic notions of realistic stan- dards (e.g., Winnicott, 1964) for the individual and couple, and the marital and sex therapy experience of seasoned clinicians and couples (Kleinplatz & Menard, 2007).

The GES approach is also consistent with the recent progress in research on positive psychology (e.g., Lent, 2004; Seligman, Rashid, & Parks, 2006; Seligman, Steen, Park, & Peterson, 2005; Turkington, 2006) as the GES model emphasizes how positive dimensions can improve one’s coping with sexual problems and promote aspects of happiness (e.g., Lyubomirsky, Sheldon, & Schkade, 2005). In the GES model, sexual meaning and self-understanding are crucial. For example, sex is not viewed as an isolated fragment of one’s life but rather seen integrated into the individual’s and couple’s daily life— and daily life is integrated into their sex life. Living daily life provides the opportunity to experience sexual interactions in a subtly yet distinctively personalized and enriched way. The GES model was developed for long- term committed couples who experience SD as a positive set of principles to guide sex therapists in their creative design of individualized cognitive- behavioral sex therapy and to facilitate couple reflection on the meaning

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and value of their sexual relationship. This approach is relevant to serious couples who want to enhance intimacy and sexuality as well as for gay and lesbian couples.

THE GES APPROACH: COGNITIVIE, BEHAVIORAL, EMOTIONAL, AND COUPLE CLINICAL FEATURES

Features that characterize the GES model include cognitive, behavioral, emo- tional, and relational factors that promote couple cohesion, cooperation, and intimacy (Epstein & Baucom, 2002). Examples of cognitive dimen- sions include a positive attitude toward sex and a deep commitment to mutual sexual health and taking personal responsibility for pursuing devel- opmental (“lifelong”) sexual growth. Emotional features include accepting and expressing one’s honest feelings about sex and body and distinguish- ing feelings from behaviors. Behaviorally, couples cultivate cooperation to ground their sexual pleasure on physical relaxation and learn sensual self- entrancement and role enactment arousal. Especially important is that the couple cooperate as an “intimate team,” prioritize mutual emotional empa- thy, forgive each other for prior disappointments, and view their sexuality as an essential relationship forum and opportunity for cohesion.

There are six crucial cognitive, behavioral, emotional, and interpersonal features that men (and women) adopt for sexual health that merit emphasis. These are open-ended qualities that offer the clinician principles and clinical “tools” to assist men and their partners to enhance their sexual health, inte- grate them into their personal lives, and serve as a directional course or map for sexual growth (e.g., McCarthy & Metz, 2008). Healthy men and women increase their understanding and integrate these concepts throughout their lives. In sex therapy, whether the clinician uses traditional sex therapy inter- ventions (e.g., “sensate focus”) or creatively designs individual and couple exercises, GES piloted interventions promote affirmation and acceptance of the man and woman and their relationship. During the process of therapy, the man and his partner confirm, or improve in, a number of cognitive, behavioral, emotional, and relational dimensions.

1. Positive value of sex: Essential to the GES approach is to intentionally value sex as inherently good. Men who develop sexual problems usually lack a positive value of their sexual body, lack mature sexual confi- dence, underestimate the power of their sex drive, and minimize their desires for emotional intimacy (Cooper & Marcus, 2003). Often negative cognitions (Boul, 2007; Fichten, Spector, & Libman, 1988) link sex with embarrassment, even shame, and compartmentalize sex from real life. Sex-positive therapy (Kleinplatz, 1996) facilitates acceptance of men’s sex- uality and honors sex as a means for a couple to use their bodies for fun,

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pleasure, affirmation, and closeness. Developing sexual self-esteem— the antithesis of shame—requires accepting and affirming his sexuality, respecting honest sexual feelings, regulating sexual behaviors, and pro- moting overall self-esteem (Cooper et al., 2000). Sometimes promoting sexual self-esteem requires his partner to become more understanding, accepting, and respectful of his sex drive and desires.

2. Sex is relational: As well as valuing sex, he and his partner accept that sex is inherently relational (Harvey, Wenzel, & Sprecher, 2004). He can view his partner as his “sexual friend” and their relationship as an intimate team (Levine et al., 2003), and they cooperate to achieve constructive con- flict resolution and mutual satisfaction (Metz & Epstein, 2002; O’Farrell, Choquette, Cutter & Birchler, 1997; Weis, 1980). Rather than a source of bitterness and alienation, conflict presents daily opportunities for the couple to address issues cooperatively, understand and appreciate differ- ences, and deepen emotional intimacy (Eldridge, Sevier, Jones, Atkins, & Christensen, 2007; Jacobson & Christensen, 1996). Sexual health and satisfaction are more likely to occur when partners work together—as an intimate team—to achieve intimacy, comfort, pleasure, stress reduc- tion, self-esteem, and joy in and out of the bedroom (Johnson, 2008). Partners recognize that relationship disagreements are a catalyst for inti- macy. When couples deal well with conflict, each partner feels respected and special in the other’s eyes. When these feelings of trust and coop- eration come into the bedroom, they generate a loving environment that fosters long-term, healthy sexual functioning. Sexual health and satisfac- tion are directly influenced by relationship cooperation, shared empathy, and mutual conflict resolution (Metz & Epstein, 2002).

3. Sexual pleasure is valued as much as sex function: Another important feature of GES is that the sexually healthy man progresses beyond the youthful preoccupation with sexual performance and increases his enjoy- ment of touch for affection and sensual pleasure (Kleinplatz, 1996). He and his partner come to appreciate that an initial focus on touch and relaxation is the foundation for sensual response and pleasure the foun- dation for heightened eroticism (Aanstoos, 1991). This is a challenge for men and couples in our culture because performance expectations and anxious associations are intense—worrying about penis size, ensuring his partner has an orgasm, and performing like a porn star. The clinician bal- ances the “hype” and unrealistic performance expectations promoted in movies, television, and magazines with information about sexual function (performance) with realistic and accurate expectations and appreciation of sensual pleasures.

4. Sex drive is self-regulated: Learning to value sensual pleasure is pro- moted by his learning to regulate his natural sexual drive and arousal. Men’s (and women’s) bodies have “lust” (Buss, 1995), a “biological imperative” (Fisher, Aron, Mashek, Li, & Brown, 2002), or an “urge to

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merge” (Rolheiser, 1999). Healthy men and women accept and respect the power of these urges. Men whose sexual behavior creates indi- vidual and relationship distress invariably underestimate sex drive and the importance of sex drive regulation. The importance of general cognitive-behavioral-emotional regulation (e.g., anger, anxiety) is evident in a number of nonsexual studies (e.g., Kirby, Baucom, & Peterman, 2007). For most men, lust is not just a youthful stage (Blum, 1998; Fisher et al., 2002) but continues throughout life. Because male sex drive is more specific and “object focused” than female sex drive (Buss, 1995; Hamann, Herman, Nolan, & Wallen, 2004), men have a special responsibility to regulate and manage their sex drive wisely, just as they manage their desire for food, sleep, and exercise. For sexual health, men learn to bal- ance sex drive through several regulatory learning tasks. For most men, this regulation is cultivated through strategies such as conscious cognitive management (Boul, 2007; McCarthy & Metz, 2008) and impulse control by limiting exposure to sex stimuli so as not to provoke or incite the bio- logical sex drive. When in an appropriate sexual situation, then, he can reverse the sexual regulation and freely engage in and enjoy heightened sex excitement.

An important regulatory task is to develop emotional sophistication. Emotions such as loneliness, anxiety, or shame can be misunderstood as sexual feelings with an urge to assuage them by sex (Adams & Robinson, 2001; Cooper & Marcus, 2003; Leeds, 2001). Although tension reduction is a common and healthy use of sex, the unwitting sexualizing of nonsexual emotions may fuel problematic sex behaviors such as making excessive demands of the partner, affairs, or misuse of pornography. Sexual health involves becoming aware and comfortable with nonsexual emotions and healthy strategies to deal with them.

It is important to note that perhaps as many as 10% of men expe- rience low sex desire (Laumann, Gagnon, Michael, & Michaels, 1994). The cause for some is a sexual secret such as a variant arousal pat- tern (e.g., fetish), preference for masturbatory sex rather than partner sex, a poorly processed history of child sex trauma, and conflict regard- ing sexual orientation. The more common cause of an acquired sexual desire problem is SD, especially erectile dysfunction. The man has lost his confidence with arousal and orgasm and avoids couple sex out of embarrassment. Unresolved relationship conflict is also a common cause of acquired inhibited sex desire.

For these men, promoting sex desire involves mutually resolving chronic relationship conflicts and developing self-confidence and a sex- positive attitude. For men with sexual repression, therapy addresses reducing emotional or physical fatigue, ensuring realistic expectations of his body and emotions, and directing his attention to healthy sexual fan- tasy and erotic images. Use of erotic fantasies is one of the most sensitive

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and controversial components of male and female sexuality. It is normal to have “abnormal” fantasies. Erotic fantasies can serve as a bridge to sex- ual desire as well as a bridge to arousal and orgasm during couple sex. Two examples of the destructive use of fantasy is when the combination of secrecy, eroticism, and shame result in a compulsively controlling fan- tasy and when fantasy serves as a “wall” that creates disengagement from partner sex.

When a man’s sex drive is well managed, lust does not create prob- lems and he can freely enjoy sex. When overregulated, it can suppress desire. Poorly regulated sex drive can cause a variety of personal, sexual, and relationship problems by leading him to pursue mechanical sex and compulsively act out (Adams & Robinson, 2001). Conversely, repressing sex drive and depriving him of pleasure and passion causes personal and relational problems. Self-regulation is not self-castigating but rather demonstrates self-respect. With good physical and emotional health, sex- ual drive continues his entire life and he integrates physiological sexual drive, psychological well-being, and interpersonal cohesion.

5. Healthy sex is flexible: One of the most fundamental features of the GES approach is learning flexible sexual arousal. Flexibility in the bedroom promotes the couple as an intimate team but can be blocked by (a) differ- ing, conflicted, or rigid purposes for being sexual; (b) misunderstandings about the different styles of sexual arousal; and (c) concerns about sexual overfamiliarity (“boredom”). Learning sexual flexibility involves integrat- ing three features: (a) accepting that there can be five general purposes for sex, (b) blending three basic arousal styles, and (c) appreciating the inherent variability of couple sexuality.

Purposes for being sexual. It is vital for partners to accept that they can be sexual for multiple and varying reasons and to cooperatively blend their sexual agenda. The five main purposes for sex are pleasure, stress reduction, self-esteem, intimacy, and reproduction. When the focus becomes invariably singular or rigid—for example, sex only for romantic intimacy or for conception among couples in infertility treatment (Burns, 2006)—sex can become distressing and dysfunctional. The relative impor- tance of these five purposes varies for different people and at different times. For example, one partner may engage in sex primarily for physical pleasure or stress reduction, while the other may be focused on self- esteem and love. The potential for conflict exists as partners feel this difference in “agenda” and may interpret it as alienation. Acceptance of differences and partner cooperation promote cohesion and satisfaction.

Styles of sexual arousal. Flexibility also involves appreciating and blending three sexual arousal styles. The three styles of arousal (Metz & McCarthy, 2003; Mezzich & Hernandez, 2006; Mosher, 1980) are (a) partner interaction arousal, which is focused on partner interplay and visual stimulation; (b) self-entrancement arousal, which is focused on

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relaxing the body and being receptive and responsive to touch; and (c) role enactment arousal, which is focused on role play, fantasy, variety, experimentation, and unpredictability. Many young men rely primarily on partner interaction arousal, while older and more experienced men can expand their arousal pattern to include the self-entrancement and role enactment arousal styles. Some men (and women) utilize all three arousal styles and others only two. Sexually healthy men can comfortably blend arousal styles. Different purposes for a sexual encounter and dif- ferent styles of arousal can complement each other and result in flexible, satisfying sexual experiences. The man and woman accept they are not clones of each other nor do they need to be on the “same page” to have a positive sexual encounter. An example of flexibility is the man focuses on the goal of orgasm as a tension reducer while the woman enjoys being the giving partner and the powerful feelings of being needed and con- trolling the sexual scenario.

Variability of sex quality. A vital aspect of the GES approach is the candid recognition that among sexually well-functioning and satisfied couples, the quality of sex varies. Studies support the association of rela- tionship satisfaction with regular sexual frequency and an appreciation of the variation in the quality of sex (e.g., Frank et al., 1978; Laumann et al., 1994). Although satisfied couples are “regular” in frequency (e.g., one to two times per week), the sexual experience has “very good” qual- ity about 20% to 25% of the time, “good” quality about 40% to 60% of the time, “fair” but unremarkable 15% to 20% of the time, and dissat- isfying or dysfunctional 1% to 15% of the time. These expectations of regular sexual contact with variable quality engender sexual acceptance and serve to inoculate the couple from sexual problems, especially with aging.

6. Regular sex is integrated into daily life: Integrating such GES features can culminate in the partners integrating sexuality into daily life and daily life into their sexuality (Metz & Lutz, 1990). Whether due to biology or socialization, sex for many younger men is compartmentalized with the focus on physical pleasure and orgasm. As a man matures, he increas- ingly integrates sex into his real life. Valuing his partner’s emotions and sexual health helps to create the couple’s unique sexual style (McCarthy & McCarthy, 2009).

Examples of life phases that can shape sexual experiences are pregnancy, times of loneliness or disappointment, a sibling’s wedding, vacation, a friend’s death, career stress, a class reunion, times of suc- cess and achievement, unemployment, illness, raising children, business travel, military service, adjustment to the “empty nest,” aging, and retirement. Any and all of these events can influence the functions, mean- ings, and quality of sex. One time, sex is for anxiety release through orgasm, another time for escape and fun, another time for emotional

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healing, another time for romance and intimacy, or another time sex is a spiritual experience such as having gentle intercourse while sharing sad- ness about a parent’s death weeks earlier. Sharing life provides the opportunity to experience sexual interactions in a subtly yet distinctively personalized and enriched way.

A prerequisite for blending real life events and sex is a regular rou- tine of touch and sex. Rather than being routine, boring, lethargic, or perfunctory, sex on a regular basis in the context of a committed rela- tionship can be honest and genuine, adapting to the rhythm of life. Sex can be respectful, passionate, tender, playful, and experimental. Couples who permit life’s stresses, fatigue, careers, parenting, or irritations to over- ride regular sex are at risk of alienation. Ongoing, real-time sex produces benefits like comfort, diversion, relaxation, trust, pleasure, cooperation, and emotional intimacy. For many couples, deep respect for the human experience of sex includes transcendental, spiritual experiences that cel- ebrate the meaning of life and death.

A reliable indicator of quality sex is the occasional presence of play- fulness. Playfulness involves more than a trivial role in sexual health (Metz & Lutz, 1990; Tulman, Dornbush, Gilner, Kolodny, & Tullman, 1981). In order for play to occur, other aspects of intimacy must be functioning well—trust, mutual acceptance, focus on pleasure, freedom to be oneself, feeling safe, and deeply valuing the relationship. The idiosyncratic nature of couple sexual playfulness (such as affirming teasing or “nicknames” for sexual body parts) adds uniqueness to sexual experiences and “per- sonalizes” the bedroom. Further, playfulness is a way to acknowledge the complexity and ambiguity of life, the multiple levels of reality, the spiritual dimension, and the value of interpersonal connection. Sexual playfulness enhances and strengthens intimacy and facilitates partners feeling “special.”

CASE ILLLUSTRATION: DANIEL AND KAY

Daniel and Kay exemplify some of the important elements of the GES approach, which provided the “context” or milieu for their sex therapy.

Background

Daniel was a very demoralized 49-year-old man in a second marriage of 2 years’ duration with 50-year-old Kay (this was her third marriage). Daniel bragged about his youthful sexual escapades and the easy sex of the early years of his first marriage. Daniel fantasized about those experiences, and they took on an almost mythical meaning for him. After Daniel’s first wife was diagnosed with bipolar disorder and psychiatrically

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medicated, she told Daniel that their “wild” sex life was a manifestation of her disorder. She was “healthier” now and was unwilling to engage in the high emotionally and erotically charged sex of their early years. Daniel’s off-hand comment that he liked sex better when she was “crazy” contributed to an escalating downward cycle that both caused and resulted in decreased sexual frequency and increased emotional conflict. Daniel felt this was unfair and used masturbation to Internet porn as his sexual outlet. During their separation/divorce process, Daniel found it easier to use escort services, massage parlors, and masturbation rather than re-engaging in dating relationships. In the ensuing 3 years, he had four short-term sexual relationships, and five one-night stands but did not find this as exciting as previous sexual experiences.

Daniel and Kay met at work and started as friends (a good way to begin a new relationship). They respected each other’s professionalism and enjoyed meeting for coffee and going to lunch. It was Kay who took the emotional risk to introduce a romantic touch component to their relation- ship. She invited Daniel to her home for a special dinner with wine and dancing. Daniel liked the idea of being seduced and by the next weekend they were a sexual couple.

Kay was a sexually sophisticated woman who had experienced men with erection and ejaculatory inhibition problems, so she was sure that with love and support Daniel and she could enjoy a satisfying sexual relation- ship. However, 2 years into the marriage, Kay felt emotionally and sexually rejected and increasingly hopeless about the viability of the marriage. Daniel felt Kay had pulled a “bait and switch” and blamed her for the low-frequency dysfunctional sex. He felt justified returning to Internet porn as his sex- ual outlet. Sexual conflict, alienation, and avoidance were draining loving feelings from the relationship.

GES Features in Treatment

At Kay’s insistence they consulted a couple therapist with a subspecialty in sex therapy. After an initial couple session followed by individual psycholog- ical, relational, and sexual histories, the couple was given feedback during which the clinician recommended a 6-month “good faith” effort to develop a satisfying couple sexual style. This meant breaking the blame–counterblame cycle and approaching sex with the goal to develop as an intimate team. The most important challenge for Daniel was to accept Kay as his intimate, erotic friend rather than unrealistically compare marital sex as an almost 50- year-old man to youthful sex. The core issue was to accept the GES model rather than cling to the totally predictable erection and perfect intercourse performance model.

When Daniel masturbated to porn, he had predictable erections and orgasms relying on the novelty of the erotic visual stimuli (heightened partner interaction arousal style). When Kay tried to sexually seduce him,

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Daniel experienced anticipatory anxiety (fearing he wouldn’t get an erection without heightened erotic stimuli and viewing intercourse as a pass–fail test), as well as concern he would not be able to ejaculate and instead lose his erection. For Daniel, couple sex was frustrating and embarrassing. Better to avoid and be the “master of masturbation.”

The therapeutic plan was not only to relieve the distress of their alien- ation but to promote reasonable and reliable erections and ejaculation and a new, healthier sex life. Cognitively this involved providing them with the GES schema and coaching the couple in select features of the approach that were relevant to their situation. As a perspective for more reliable (but not perfect) sexual function, the couple intentionally embraced the global sex- ual focus on intimacy and satisfaction. While ensuring Daniel that he would learn how to have reliable erections and redevelop his sexual confidence, the clinical focus endorsed pursuing sensual, emotional, and sexual pleasure as valuable as sexual function. Kay and Daniel discussed with the therapist the value to be gained by learning flexible sexual arousal and the variability of sex quality. They would cooperatively integrate sexuality into their daily life and daily life into their sexual relationship.

Behaviorally, this involved putting a computer block on the porn sites (not to shame Daniel but as an aid to self-regulation); agreeing to engage in masturbation only when feeling sexual desire and when Kay was not available; using Cialis both as a placebo and to enhance vascular efficacy; and beginning by focusing on playful and erotic, nonintercourse sex with Kay. Both Kay and Daniel understood the rationale for the therapeutic plan but found the explicitness and degree of transparency awkward to accept. Daniel was afraid that without porn he would have no desire.

It was very helpful for Daniel and Kay to appreciate the different pur- poses for sex and how they vary from time to time and how having multiple bridges to sexual desire integrated into couple sexuality. It was especially useful for Daniel to learn about the three basic styles of arousal. From youth, he had relied on partner interaction arousal to perform, then the “wildness” of sex with his first wife, then the raucous images of porn. It was a powerful unburdening for him to learn through couple psychosexual skill exercises that his erections were “easier” and more reliable grounded in “sensual self- entrancement” arousal. Kay also felt relief that his arousal was not so focused on her body (she worried about her aging and weight gain).

Positive, realistic information and adopting new sexual cognitions was of great value, but most motivating was designing psychosexual skill homework to facilitate positive sexual experiences. During their second play-oriented sexual exercise, Kay was very aroused and orgasmic. Daniel found her excitement highly arousing. At the next therapy session, the clin- ician emphasized the psychosexual skill of the man “piggybacking” his arousal on the woman’s. At their next sexual exercise, Kay was again aroused, which was arousing for Daniel. He was receptive/responsive to Kay’s manual and oral stimulation to orgasm.

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In subsequent therapy sessions and psychosexual skill exercises, Daniel with Kay’s support learned to accept that couple sex is more variable/flexible and less predictable than masturbatory sex. However, it is more human, genuine, and bonding. Giving up porn was a loss for Daniel, but a “necessary loss” if sexuality was to play a 15% to 20% role in energizing their marital bond rather than draining it. Learning that his erections could be more reliable with relaxed pleasuring and “self-entrancement arousal” was a confidence builder. In addition, learning to rely on Kay’s support, cooperation, patience, and attention were crucial to their growing as an intimate team.

A big challenge for Daniel and Kay was to learn to transition to inter- course at high levels of arousal rather than Daniel pushing intercourse as soon as he became erect. For a period of time Kay agreed to take the role of intercourse initiator and to guide intromission so Daniel did not fall into the “self-conscious spectator” trap. In addition, they engaged in multiple stim- ulation during intercourse to enhance erotic flow. If arousal did not flow to intercourse or intercourse did not flow to orgasm, Daniel learned, with- out apologizing or panicking, to transition to an erotic, nonintercourse or a cuddly, sensual scenario.

Using the GES template as the framework for the changes they made in treatment also served them well in designing their relapse prevention plan. Accepting GES and valuing each other as intimate and erotic friends would inoculate Daniel and Kay against sexual problems in their 60s, 70s, and 80s.

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Althof, S. E., Leiblum, S. R., Chevret-Measson, M., Hartman, L., Levine, S. B., McCabe, M., . . . Wylie, K., (2005). Psychological and interpersonal dimensions of sexual function and dysfunction. Journal of Sexual Medicine, 2, 793–800.

Blum, D. (1998). Sex on the brain: The biological differences between men and women. New York, NY: Penguin Books.

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