The popular books on sex make it all sound so simple. One kind emphasizes a careful mechanical approach: a woman is a delicately balanced machine, trickier and more complicated than a man, but capable of control through mastery of anatomical, physiological, and psychological understanding and technique. All factors are taken into account: the calendar, the clock, the lights, the music, the menu, the words, the sighs. The evening is programmed like a giant computer, all systems are "Go," the correct buttons are pushed, and the machine is marvelously in orbit.
When it comes to sex, is all this effort necessary? And if so, is it worth it? The books generally gloss over any functional problems that the man might have. Most of them are written by men, and there is an inescapable suspicion that the author is anonymously bragging about his own success with the ladies, implying: "Do as I do. Just be manly but gentle, and you won't have a bit of trouble." Another kind of book, giving much less space to How To Be a Great Lover, Even Though Married, emphasizes togetherness, communication, sympathy, understanding and mutual consideration. If the husband is amorous, but the wife is tired, anxious, tense, and uninterested, the husband simply sets disappointment aside, summons up a modicum of sympathetic emotional maturity, and the problem is settled.
People who can profit from this sort of advice do not need it. Those who need it generally find the problem more stubborn and complicated than the books will admit, and some will seek professional aid. This is not easy for them: even now, sex is still a taboo subject for polite conversation, and if it is to be talked about at all, boasting is preferred to admission of difficulty, since the latter is often equated with failure or personal inadequacy. People who spend a fortune on their skin and hair, and are very kind to their stomachs, may let their libidos take an awful beating rather than run the risk of being mocked or scolded by revealing a "shameful" secret.
But no-one can brag publicly about anything to do with sex, which in our culture is in a peculiar position. Its importance is openly acknowledged in print, but not in spoken words. If normal sex actually became taboo, advertising would be revolutionized, and products would have to be sold strictly on their intrinsic merits, instead of by association with the sensuous charms of professional models posing as consumers and displaying an almost perverse infatuation with the product. If abnormal sex likewise became taboo, much of the excitement would disappear from the local news, and the papers might be obliged to print more about world events. But the public importance of sex is always officially ignored or denied, playing down in words what is so heartily played up in pictures. Whatever its real importance, it cannot command an air of respectability.
Yet in medical schools very little is taught on sex beyond anatomy and purely automatic functioning, and I do not quite see how the therapist is supposed to learn the rest without study, as his personal sexual experiences are in fact not much different from anyone else's, and the possession of more detailed anatomical knowledge adds little to his capacity as performer or advisor.
I will now specify and describe a few varieties of sexual problems, interpret their possible significance, and outline some ideas about treatment. The problems of a married person impinge continuously on the spouse, affect the total interpersonal relationship, and are affected by it. It is this interpersonal aspect on which I would like to lay particular emphasis.
Another restriction on the topic is that the symptom must be such that one or both members of the married pair consider it a problem for which they may be seeking some sort of help. People often settle sexual problems by compromises that would not appeal to you or me, but as long as they are satisfied with the solution, therapists are not going to hear about them. Let me give an example. Although it has been shown that a substantial number of elderly people retain sexual interest and po
tency into the seventies and some even into the eighties, nobody is concerned that a great many do give up sex after sixty. Now, if a couple in their late twenties decided to give up sex, it would be most unusual, yet if both were really in agreement about it and remained otherwise harmonious and devoted, it would not constitute a problem, and one would only hear about it inadvertently. This couple obviously does have a personal problem, but they have dealt with it (I shall not say solved it) in their own way. As long as the method actually works and does not lead to some kind of disabling symptom, such as anxiety or stress, or psychosomatic manifestations, it is not a therapist's business to insist on change. In the same way, we do not interfere by brute force with phobic or compulsive symptoms, which may represent the best adjustment the person is capable of at the time.
Another example of a "poor" solution to a marital sexual problem is one in which a man deals with frustration or anger at his wife by having affairs with other women. No man is going to seek help about this unless he feels guilty about it, or his wife finds out and is angry, or he becomes involved on some sort of publicly disreputable behavior. Presumably such behavior is based on some kind of a problem in husband or wife or both, but the solution of taking a mistress may be, highly effective, albeit sometimes risky. Many people cope with their sexual problems without seeking advice, or even thinking of it. Some go to lawyers seeking divorce.
Let me summarize by saying that I am going to discuss problems involving the sexual aspect of relationships and activities of married couples which are perceived as problems by one or both partners, or where "solutions" to the problem create social difficulties in the family or community.
I would now like to specify the conditions or broad diagnostic categories under which sexual problems may come to the attention of the therapist. I am considering the problems as symptoms. I cannot emphasize too strongly that although the client may have nothing on his mind but his sexual problem, it should always be considered as one aspect of a potentially more complex situation requiring diagnosis, and not simply as an isolated problem requiring blind treatment. I have made four categories, which I think cover all situations, although a case might come under more than one category. These categories are convenient aids to thinking in the course of taking a history and, if kept in mind, will prevent one from missing the obvious. While the client goes on giving a perhaps too meticulous description of the malfunctioning of his genitalia, the therapist can be thinking, "Could this fellow be psychotic? Has he a neurosis? Does he beat his wife, or vice versa? Or does he really have gonorrhea?" The categories I have chosen are:
1. Symptoms associated with physical disease.
2. Symptoms associated with psychosis.
3. Symptoms associated with neurosis.
4. Symptoms arising predominantly in the framework of a relationship.
Physical Disease: Sexual dysfunction may be associated with physical diseases such as local acute or chronic inflammation, trauma, infection, or tumor; neurological disturbances; toxic, systemic, and metabolic disorders. The preponderance of sexual disorders are psychological and functional in origin, but any concerns that may require medical attentions should be taken to a doctor.
Psychosis: Sexual symptoms, or some alteration of sexual habits, may be early manifestations of a psychotic disorder. Along with fatigue, insomnia, loss of appetite, and general slowing of physical activity, loss of libido is a common symptom of depressive reactions. Not all depressive reactions are psychotic, but it would be important to keep the possibility of this diagnosis in mind, since early discovery and appropriate treatment may forestall more serious developments. A manic or schizophrenic process may be ushered in by an increase in sexual activity or orgasmic capacity, or by peculiar or bizarre ideas about sex or the sex organs. In such cases, diagnosis of the mental disorder can be made on the basis of the mental examination and many other aspects of the history. It should be remembered that bizarre ideas about sex do not necessarily imply psychosis.
Neurosis: In this category I include sexual problems of psychogenic origin which are symptomatic of intrapsychic conflict, but where psychosis is not present or imminent. Obviously people whose problems arise within the sexual relationship also fall within the neurotic category, but I would like to make a somewhat arbitrary distinction here, between cases where the inciting cause lies within the marital relationship, and those where it lies outside it. The latter category would include people with neuroses and personality disorders that might give rise to symptoms in the sexual area. People with personality disorders may not suffer from much anxiety and so may not often seek help spontaneously, but they may come in at the behest of their spouses. If their "abnormal" actions are successfully concealed and if the "normal" sexual role is adequately performed, there is no complaint, and they do not seek help.
Neurotic disturbances such as phobia and anxiety may be manifested by sexual difficulties, and are usually associated with such unpleasant emotions as fear, anxiety, guilt, and shame; they are manifested less by action than the lack of it. In the case of women, anorgasmia and dyspareunia come readily to mind, while impotence and premature ejaculation are chief among such problems in men. These are basically related to emotional immaturity, and the taking of fearful or negative childhood attitudes into adult life. In our culture sex is officially an adult game, like driving, and children are forbidden in no uncertain terms to play it. If they are "sat on" often enough and hard enough, and scared enough into the bargain, they may not realize that they have grown up even when they reach physical and legal maturity, and the fears and taboos may persist despite all logical efforts to dislodge them. Sometimes, of course, this leads to avoidance of relationship or fear of sexual interaction, but commonly such people do marry and some sooner or later discover that they are missing something that others enjoy or that the spouse is disappointed that they do not enjoy. In addition to the persistence of childhood fears, orgasmic impotence or lack of enjoyment may be associated with envy and hostility toward the opposite sex, poor sexual-role identification, or excessive narcissism that precludes actually loving another person.
Let me give some examples of cases in which intrapsychic conflicts gave rise to sexual problems:
1. A young man has had difficulty in breaking away from his domineering but neurotically helpless mother, who uses physical symptoms and "hysterics" to control her children. He marries a more stable woman, but whenever she becomes ill or at all emotional, he suffers anxiety and cannot prevent premature ejaculation. Her actions are not neurotic, but they remind him unconsciously of the complex and disagreeably close relationship with his mother, and although he loves his wife, under such conditions he wants to get out of there fast. Knowing ways to last longer in bed is crucial to every aspect of his psychological health: it is a metaphor for his well-being both physically, emotionally and socially.
2. A woman marries a man somewhat like her father. She becomes anorgasmic whenever her relationship with her husband evokes certain feelings which remind her of an erotically tinged situation with her father, repressed since she was a little girl. Guilt over forbidden childhood sexual wishes prevents her from enjoying her perfectly normal sexual relationship at times.
3. A normally aggressive man encounters unexpected success in his professional work. As a child he had a strong wish to compete with and surpass his father, but he never really expected to do so. Since his field of work is entirely different from his father's, he now feels as though he had won a victory by stealth and anticipates some horrid but unspecified event like a teen-ager who has been caught smoking his father's cigars and drinking his brandy, but whose fate has not yet been decided. After a time, his anxiety culminates in impotence, which irritates his wife.
4. A young woman marries an older man, a widower, and although she is apparently devoted to him she finds sexual intercourse painful and possibly disgusting. Her "devotion" is rather like that of a little girl for a parent, and she actually wants to be treated not as a real wife but like a Princess or a favorite child. She is psychologically too immature to be capable of mature love and sexuality.
5. A man loses his father, with whom he had never gotten along well. He feels as though his failure to, say, contact his father, had somehow hastened his father's death. He feels depressed and has loss of libido out of proportion to the depression. Much of his hostility had been engendered by his father's virtual abdication of family responsibility and his many extramarital affairs. While disapproving of this, the client had unconsciously envied his father's seductive skill and carefree attitude, especially during adolescence.
In most of these cases, the sexual symptoms have not been the only complaints, and I have tried to present them as strictly neurotic problems, in which interference with sexual function or enjoyment is simply one aspect and may or may not be the presenting complaint. Much depends on the attitude of the spouse. In times gone by men hardly complained of a wife's lack of sexual response, but nowadays it is often quite a different story. In the third example, above, where the man first had anxiety symptoms, the later impotence was a response, and for him giving up sexual activity "solved" his internal dilemma nicely. His wife did not like it a bit, however, and nagged him into getting help. If she had been unable to orgasm, or strongly inhibited sexually, or afraid of pregnancy, his symptom might have suited her fine, and he might not have sought help until he himself got tired of being impotent. We must also keep in mind that his impotence might have subsided spontaneously in time.
Neurotic Relationship: The last category of sexual difficulties are those which are related to the neurotic elements in the relationship. In addition to specific strengths, virtues, and other admirable qualities that stir up enough mutual admiration to lead to commitment, each partner or spouse brings to the relationship / marriage his own conflicts, sensitivities, and special needs. Significant incompatibilities may be present, which do not manifest themselves until some time after the marriage has begun, which may appear so insidiously that they are hard to recognize as such until both partners are suffering from profound irritation, and which make adjustment and compromise all the more difficult. Perhaps the state of "being in love" is responsible for much of this, the marvelous self-deception that persuades the young man that he has found the girl of his dreams, and the same for the young lady. Dream girls and boys do not exist this side of the Pearly Gates, yet young people in love insist on attributing the most angelic qualities to each other and expecting the same of themselves, a happy delusion that must somehow be worn away if they are ever to create a workable adult human relationship. Where mutual expectations are unrealistic, the letdown is cruel, and disillusion is painful when couples are confronted too abruptly with each other's frailties.
Some couples attempt to avoid acknowledgment of childish feelings and utilize deficiencies of character to escape the pain of facing these. Instead of living, they try a kind of play-acting. The man may assume the role of the tyrannical husband if his partner will play the hysterical wife. Or vice versa. From his side of the stage, the husband is being the sick little boy, casting his wife in the role formerly occupied by his controlling, aggressive mother. On her side, the wife is engaged in portraying to herself the long-suffering neglected girl, while assigning to her husband the role of her coarse, lazy, incompetent father. Neither is aware that the other is playing a different psychological game, and neither has access to the real list of characters, which shows both of them as overgrown children trying to be adults, unable to escape from their past family relationships and busily and tragically recreating them in the present. The saddest part of all is that each resists maturing tendencies in the other and tries to coerce the partner into truly living the assigned role. If the husband achieves more stature, the wife uses her knowledge of his sensitivities to cut him down to size; if the wife becomes less bitchy, the husband does all he can to provoke her to return to the neurotic status quo.
The actual manifestations of this problem are the same as those mentioned under the heading of neurosis; the difference is that both partners are neurotically involved, and the difficulty lies more between them than within either one. It is somewhat like a folie a deux, in which two people participate in the same psychosis and share the same delusions about people in the outside world. The neurotic couple usually see the outside world clearly enough but have strongly distorted perceptions of each other, which they tend to perpetuate rather than amend.
Let me give an example of a typical complicated interaction involving sex in a relatively normal couple. It begins with a common source of confusion, the normal difference between the sexual urges of men, which are fairly steady, and those of women, which tend to vary with the menstrual cycle. The husband has been away on a trip, feeling a bit sexy, looking forward to fun in bed on his return, and recalls what a delightful time he had with his wife the night before he left, just a week ago. She is very glad to see him back, and they are quite romantic at dinner. They have some wine and are both relaxed, in fact he is quite tired after his long day's journey. She is feeling cuddly but not sexy, but he does not know this, and when he makes a lazy pass at her, she is suddenly revolted. It reminds her of mashers and the lecherous uncle who used to feel her up slyly at family reunions when she was a teenager. She reacts with disgust, and he is quite taken aback, so sudden and unexpected is this turn of events, which was definitely not on his program for the evening. He feels like a child arbitrarily and unjustly cut off in the midst of innocent fun, and he reacts in one of his characteristic ways, by turning away, hurt and pouting. This in turn makes his wife feel anxious and guilty. Her father used to act like this when angry, and she always felt it was somehow her fault. Although she is actually quite angry, she assumes an air of remorse and artificial friendliness and tries in a babyish way to be "nice." This unconsciously reminds the husband of certain contradictory attitudes of his mother, which always used to confuse and bother him, and he now becomes angrier still. At this point either of two things might happen: the husband becomes totally uninterested in sex and retreats nursing a grudge surprisingly reminiscent of an adolescent's feeling of not being understood, thwarting his wife's guilty and highly ambivalent attempts to act loving or sexy; or, alternatively, his anger takes an active form, in which he aggressively shows the little bitch that she is not going to treat him like a kid, and she responds spontaneously to his now ruthless ardor, and they have a fine time, and later recall that they have gotten into this bind on previous occasions. Where honest communication of feeling is possible, unpleasant situations like this can often be resolved in a way that leads to more realistic mutual perception. Where such communication is lacking, a stalemate ensues, often followed by endless repetition of the same dreary sequence.
It sometimes happens that in couples whose attitude toward sex is healthy, difficulty may nevertheless arise as a by-product of conflict in other areas. Sexual passion is frequently aggressive, and the emotion of love lies very close to that of hate. Where one or both partners have strong conflicts about hostility and aggression, sexual activity may have to be kept rather tame in order to prevent the adjacent feelings from getting out of control. A husband who needs such control may be a frustration to a wife who would like him sometimes to be a caveman. If she can communicate her wishes convincingly, they may find common ground; if not, he may merely think that her messages constitute a trap of some kind and remain all the more vigilantly calm.
Treatment
As in all other areas, accurate diagnosis is the cornerstone of therapeutics. Once the underlying disturbance is recognized, therapy can proceed rationally. In the physical category, appropriate physical treatment is of course indicated; however, one must keep in mind that physical disease does not confer immunity against emotional problems, which may either be coincidental or secondary to the disease itself.
With clients in whom psychosis is suspected, psychiatric consultation should be considered, to verify the diagnosis and find what form of treatment is indicated. However, if the situation is chronic and stable, and the amount of social disturbance is slight, it may not be necessary to refer the client elsewhere. Sympathetic support, or modest drug therapy, may provide all the stabilization that is needed. It must be kept in mind that even though the client complains of something - in this case a sexual problem - he may not really want to get rid of the symptom. If the symptom departs, well and good; if it does not, this is no reason to send the client elsewhere or smother him with medicine, unless he is becoming otherwise more disturbed and hard to manage. If he maintains his job and family life and keeps coming to see you, let him complain as much as he wants. The symptom may represent the "ticket of admission" that permits him to maintain therapeutic contact with the therapist.
There are many different ways in which neurotic clients can be treated, depending on the particular case. Simple reassurance as to the benign nature of the symptom may help a great deal. People are always worrying that they might be abnormal in some way, especially in regard to sexual feelings and fantasies. Reassurance and sex education, both by discussion and having the client read a book, may bring great relief from guilt and anxiety. Of course the therapist should be well acquainted with the wide range of what is "normal," which may not coincide with his personal view of what is optimal.
A "talking-out" type of psychotherapy may be very helpful, and this is well within the capacity of the average practitioner in many cases. Clients with bothersome symptoms and relatively healthy personalities are the best motivated for formal intensive psychotherapy and can profit the most from it. Such clients also have the best chance of spontaneous recovery and can be greatly assisted, especially if the problem is a fairly acute one. This is particularly true of male clients, who are aided not only by having a listener but by identification with a mature and healthy male, such as most therapists are. Neurotic female clients with sexual problems are trickier, since some will be prone to develop complex emotional attachments to a male therapist or counsellor in North London and may indulge in highly seductive maneuvers, all of which are difficult to deal with unless you have had special training or happen to be personally skilled in avoiding entanglement without rejecting the client. The most trying developments can be minimized by referring such clients to a female therapist, but since these clients are often very immature, they tend to develop, strong, sticky, dependent attachments that may be equally challenging to deal with, if less alarming.
Clients with neurotic personality disturbances, who translate their conflicts into action (such as "running around") instead of perceiving them as feelings or symptoms, are very difficult clients to treat. Although some may seek psychological help, often they are poorly motivated and are merely complying with somebody's pushing. As in the case of alcoholism, family pushing may be 50 percent pulling. A masochistic wife may foster philandering at the same time that she is complaining of it, to maintain her status as a woman wronged. If you can see the interaction of such people and tell them about it quite bluntly, it may be of some help. Treatment will be of little avail unless the client wants to change.
In the case of dysfunctionally interacting couples, the family therapist may have as good a chance as anyone else in ferreting out the distortions and irrational elements in the relationship. The simple presence of an impartial referee sometimes enables couples to get things off their collective chest and resume normal communication. After talking to both alone and hearing some of the complaints, the therapist might get them together, and say, " have the impression that you're both rather angry at each other, and afraid to admit it. Now why don't we talk about this?" At the same time providing physical presence and moral standards as a reassurance that nobody is going to get maimed in the discussion.
In closing, let me reiterate my "permission" and exhortation to all therapists to read up on the subject of sex, if they wish to be able to help clients who come with such problems. Many clients have sexual problems that they would like help with, except that they wait to be asked about them. Many therapists feel embarrassed asking clients about sex, probably because they do not feel themselves well-grounded in the subject. If the client brings it up, well and good, he has taken the responsibility himself. If the therapist brings it up, the client might become angry or offended. If the client is alarmed, the therapist can usually reassure him that such questions are scientific, necessary, and routine. There is really no reason why sex should not be given an equally important place on the list of pertinent questions.