What kinds of sex problems do clients bring to marriage counsellors ? Classification is difficult, as each client presents the precipitating problem in a different way. I shall use six case histories to illustrate the vast range of problems and then consider the impact of detailed knowledge of sexual physiology on the masses of cases these six illustrate. In particular, sex after fifty can be problematic.
An introductory word about the philosophy of marriage counselling may prove helpful. In non-technical terms, counselling can be thought of as the process of helping someone (hopefully, the engaged or married couple), to come to grips with any difficult phase of adjustment in their interpersonal relations. It is usually fairly short-term help. Many clients, in fact, can obtain what they want in a series of six to ten visits. "There is no logic," Franz Alexander has pointed out, "in assuming that only a misfortune can have a permanent effect on one's personality. A single, equally intensive, beneficent experience can also leave its mark." A counselling interview is designed to be such an experience. Often a series of interviews may extend over a period of weeks or months, but rarely over years.
With respect to sexual problems, the counsellor's usual goal is to help a client recognize his own and his partner's real feelings about sex, their relation to reliable information, and to the sexual capacities of both individuals. Often this involves accommodations by each partner, and an acceptance of the impact of the cultural pattern in which each partner was raised. In addition to encouraging accommodation, acceptance and understanding, however, counselling may also significantly modify sexual attitudes and behaviour, as the cases below will illustrate.
Abraham Maslow spoke of "self-actualizing people"; self-actualizing people have both the power to love and the ability to be loved. They can love freely and easily and naturally, without getting wound up in conflicts or threats or inhibitions, and they can find intense enjoyment in their sexuality. Few of the clients who come to marriage counsellors are self-actualizing in this sense. There is evidence that some of them come at least a little closer to the Maslow concept at the conclusion of counselling.
The six cases fall under four major headings:
(1) Difficulties in sexual adjustment which reflect inadequate information. Frequently there are couples who are having a difficult time early in marriage with respect to sex, or couples whose marriages were at first so satisfying in other ways that they are just now beginning to feel that their sexual life is not all it should be, or older couples who have failed to understand the natural changes in sex needs felt by both men and women as they age physiologically. In many such cases, where the overall relationship between husband and wife is sound, additional information may, by affecting sexual attitudes, profoundly affect marital satisfactions.
Mr. and Mrs. A are a case in point. Mrs. A reported that she had been very happy in every way - except that she "didn't react normally to sex no matter how patient and careful her co-operative husband was." Both partners had as a result become highly apprehensive and disturbed, feeling that Mrs. A was incapable of orgasm during sex. Her orgasm, they felt, should take place in the "right" position (man above, woman on back with legs straight). And they felt that Mr. A's ejaculation should end the intercourse.
An explanation from the counsellor of the physiology of orgasm indicated clearly to Mrs. A that clitoral stimulation by some means was almost always essential to attain full female orgasmic response. Authorities were cited who stated that a wide variety of methods of stimulation were in common use and within the "normal" range. Present teachings, she was told, indicate that any method acceptable and helpful to both partners is suitable to them. This mention of variation made it possible to explain easily that a number of positions are used by many couples, and that attitudes of experimentation, spontaneity, and playfulness produce variety and refreshment. It was stressed that sexual sharing can be fun and relaxing - a spiritual as well as physically creative act.
Mrs. A was astonished. Relieved from unnecessary guilt and literally bursting with new ideas, she could hardly wait to tell her husband. She made another appointment for two weeks ahead "because you have helped me so much." A letter received before appointment time told the counsellor it would not be necessary for her to come in again as "everything was simply wonderful and all it should be. We feel as if we had entered a new world and that we owe it to you."
(2) Sex difficulties as part of a total marital difficulty. Frequently couples with sexual problems come with questions about divorce or separation. It is only when they begin to consider what they might do to make a go of their marriage that the sexual component of their problem is brought up for discussion.
Mrs. B, for example, was referred by her doctor because of her complaint that she had not had sexual satisfaction during the twelve years of her marriage and now no longer had "any use for it." As Mrs. B and the counsellor talked about her situation it developed that Mrs. B had sought help in the sexual area because her husband had told her he would have legal grounds for divorcing her and gaining custody of their three children if she continued to refuse his sexual demands. Mrs. B's feelings about sex were further complicated by the fact that her marriage had been entered into in the first place only because she was pregnant and thought she had no alternative.
As Mrs. B and the counsellor explored these areas together, Mrs. B began to see her situation more clearly. The focus of her need for help changed; she now wanted help around a decision about a divorce.
Mrs. B came in for a second interview, during which she decided that she had long since passed the point where she was able to put anything more into any area of her marriage. Divorce, she decided, was the solution she wished to consider. In additional interviews Mr. B also was seen, and the couple was helped to explore as constructively as possible the various steps necessary to begin divorce proceedings. The couple was referred to reliable legal assistance.
Often clients themselves recognize that the sexual part of their marriage is not a thing apart but rather just one area among many which reflect the difficulties they are having in their total marital relationship. In these cases, as the client begins to work out the other difficulties, the sexual difficulties often work out too, without special counselling in the sexual area.
Mrs. C, for example, came for help in deciding whether to get a divorce. She did not mention sexual problems until she and her counsellor were discussing a printed schedule, used only during interviews, on which a number of questions were asked, including "Do you want help with your sexual adjustment?" She replied quite simply that she did not feel that would be necessary, for if she could work out other matters with her husband, she was sure that would take care of itself.
Mrs. C, it later developed, had not had intercourse with her husband for five years, though before that she had always experienced orgasm. Her husband, she reported, was as overbearing in that as in other matters. She had refused to continue intercourse because of the emotional pain that his attitude caused her.
Both partners came in and worked on the general aspects of their relationship; and at the end of a series of interviews there was a shift in their general behaviour towards each other. Almost casually, during her last interview, Mrs. C told the counsellor that she and her husband were sharing the same bed again, and had been having sexual intercourse frequently for several weeks. "Mr. C is much more friendly in bed," Mrs. C commented with an air of satisfaction.
(3) Sexual problems regarded as the focus of marital difficulty. "Our life is perfect in every other way." Often the marriage counsellor hears this comment on sexual maladjustment, but almost always further exploration reveals that it is mistaken. The client has ignored maladjustment in many other areas of the marriage, and has transferred his or her disturbed feelings to the sexual part of the relationship. Sex used in this manner can be the deadliest of all weapons. In many of these cases, the other partner responds in kind with the result that the marriage becomes in reality a bitter duel.
The D's are an illustration. Mr. D was referred by his physician; he was, very much disturbed because he had become increasingly incapable of carrying sex to completion. For the last six months, indeed, he had been practically impotent. As a result his wife seemed even more unresponsive and tense; this further enhanced Mr. D's anxiety. He had been treated during this period by two urologists, but his symptoms had remained. His fear that his condition might be permanent was affecting his work as well as his family relationships. "I am," he reported, "scared to death."
Because Mr. D's fear was so acutely-focused on his sexual problem, the early interviews were spent in discussing this and in checking sexual adjustment. It soon became apparent that in spite of his college education, Mr. D had a really abysmal ignorance of female sexual anatomy, physiology, and psychology. Mr. D. came rapidly to the realization of how inept and unimaginative he had been, and he seemed relieved and hopeful at the new possibilities opened up. The importance of gaining his wife's co-operation was stressed by the counsellor.
Mrs. D came in for her first appointment a few days later. She was very tearful and upset and expressed considerable resentment towards her husband. She complained that his job took them from town to town, and that the repeated moving made her feel isolated. All this had its effect in the sexual area, of course. As she put it, "If you aren't loved, you can't give yourself."
At his next interview, Mr. D reported he had been able to have intercourse with his wife the night after his last visit. And after his wife's visit to the counsellor, "they had had the most beautiful time they had ever had." Mrs. D verified this later. "I didn't let myself go before," she stated, "because I thought there would be no sexual satisfaction and that would only make it harder for me. I now feel so much more relaxed and better."
Subsequent interviews - six for Mr. D, four for Mrs. D - enabled each of them to discuss former relationships with their parents and with friends, as well as their experiences with and attitudes towards sex as they were growing up. These discussions, which allowed the expression of many and varied feelings, helped them to perceive their own and each other's needs more realistically, and to meet their present situation more understandingly and freely. As some of their intense anxiety and fear about their sexual problems waned, they were able to communicate and to work on other aspects of their relationship.
Eleven months after his last counselling interview, Mr. D again sought help. He no longer had sexual problems; indeed, he reported that "our sexual adjustment is excellent." Both partners, it appeared, were achieving complete satisfaction, and Mr. D was particularly pleased that he was able to continue sex for fifteen or twenty minutes after penetration. Mrs. D, too, had regained much of her old sparkle. But something else had now come to the surface. During an earlier interview, the counsellor had brought up the question of fear. Mr. D had not thought much about fear before, but now he felt it was having a definite effect on other things in his life. He had just been offered a challenging new job - and he was afraid. "The whole business of this sexual adjustment," he explained, "has been so amazing to me and so completely successful that it makes me feel like going at my fear and doing something about it." Mr. D had 8 further sessions of therapy.
(4) Complex problems. Often a marital problem is neither purely sexual nor purely non-sexual, but a complex amalgam of disturbed interpersonal relationships, lack of adequate sex information, and ignorance of sexual technique. Once tensions in other areas have been relaxed or resolved to some degree, the client may be freed to ask for and respond to information and suggestions about sexual problems.
Mr. E, a college graduate, had been married over eight years and "he had agreed with his wife that he ought to talk to someone." He himself focused his concern on his inability to find a congenial job. He had earnestly tried a number of different fields and was about to change jobs again. His wife had been so upset at his last shift that she had sought therapeutic help for more than six months. A period of military service, including war separation and the uncertainties of his military assignment, had added to the anxieties of both Mr. and Mrs. E.
Over a period of two, months Mr. E was seen weekly. He discussed with the counsellor his feelings about jobs, his relationship to his father and mother, his difference in background and life philosophy from his wife, his admiration for his wife's abilities, his children, their meaning to him and his wife. He came back throughout to the ways in which he disappointed and irritated his wife. He felt that the "sore spots" which caused the worst family conflicts were his irresponsibility about keeping commitments at the times scheduled, his deep feeling about wasting anything, and his wife's spending what seemed to him excessive amounts on clothing and household effects. In particular, he felt that his passivity and general easy-goingness irritated his wife.
In the sixth interview, Mr. E described a very recent episode in which his wife had completely lost her temper and struck him. He admitted being scared by the intensity of her feeling, but he could not answer her back. In the seventh interview he quoted his wife as saying what bothered her most was his taking her attack "sitting down." He was then able to tell his wife he would "spank her good and hard if she ever hit him again," which made them both laugh. Up to this point, Mr. E had not discussed sexual problems.
When he did come to discuss sex, his presentation reflected his general lack of assurance and aggressiveness, and his wife's control and domination. Mrs. E, he reported, had never achieved orgasm. Her lack of enjoyment, and her rejection and criticism of him had made Mr. E almost unable to perform and hardly able to enjoy intercourse.
Further discussion of this, and of its probable connection with his general relationship with Mrs. E, seemed to have great significance to Mr. E. Instead of repeating his great admiration for his wife's abilities and rehearsing his own shortcomings, he was now able to express a great deal of negative feeling towards her, and fear. At this stage, too, it appeared that neither Mr. nor Mrs. E understood even the simple fundamentals of female or male sexual physiology or response. He was able to get definite information from the counsellor and supplement it by reading - and to put this new information to constructive use with his wife. He was also able to persuade his wife to come in for an interview with the counsellor.
Mrs. E had three interviews, oriented around her "anger" and the couple's sexual problem. She was able to use these interviews to obtain information and to reorient her attitude towards sex and her role as a marriage partner. Following his wife's first visit, Mr. E reported, in his last interview, happy experimentation with mutual response and satisfaction for both. In his own words, "talking is much more helpful than books. Books give you something, counselling something else. But written material must be general enough to cover a wide range of possibilities so that individual differences cannot be discussed. On the other hand, a counsellor who knows this subject can say where the individual fits into the general picture and help them with their specific problem."
Mrs. E put it this way in her last interview: "It is amazing what a difference the books and the sessions here make. This approach of having a good time in the process of sex is quite new to me. I used to think it just a business to get through with. Actually, I find the whole business of sex quite changed by being mentally prepared. All this has released a lot of energy for my husband. His new knowledge gives him confidence. It opens a new world to us both which he is initiating me into. I have had orgasms during sex several times and really enjoyed them."
One further example of a complex cluster of problems, sexual and seemingly non-sexual, will round out this review of cases. The F's came to because of their concern over the deterioration of their sexual relationship. Mr. F wrote initially to inquire about the fee "for diagnosis" of his wife, who he stated was "frigid." He added he did not feel anything could be done to help her. Later Mrs. F came in for an appointment. Her attitude was, 'Yes, here I am; change me if you can!' She tried to prove to the counsellor that she couldn't do anything about the way she was. She complained bitterly about her husband's sexual behaviour; but when she was asked if Mr. F acted in the same sort of way in other areas of their life, she tearfully assured the counsellor that their marriage was ideal in every other respect.
The counsellor, in offering the possibility of another appointment to continue their discussion, shared with Mrs. F her feeling of doubt as to Mrs. F's ability to use the service. So far as the counsellor could see, Mrs. F was leaving the interview just about as she was when she came in. "But I've gotten a lot," Mrs. F herself insisted. "I now know that I want to do something about my condition."
Mrs. F then shifted ground. She told the counsellor that her problem was actually physical. She was referred to a doctor; the examination showed that she was anatomically normal; but her vitality was so depleted that medical treatment seemed indicated. After medical treatment was started Mrs. F began to show a slight interest in sex; and she now persuaded her husband to come to discuss his sexual behaviour.
During the first interview, the counsellor helped Mr. F to talk about his other marital difficulties. He described their early married life as reasonably satisfactory in all areas until he was dismissed from a job that not only paid fairly well but also gave his family prestige in the community. This last meant much to Mrs. F because she had come from an under-privileged family herself. Then, as Mr. F's income dwindled with each succeeding job and as their position in the community declined, Mrs. F's interest in sex decreased to the point where any sexual advance from her husband was more than she could bear. They had not had intercourse for over a year now.
After several interviews, Mr. F began to see a possible connection between these two problems. He responded to it as to a fresh revelation and made arrangements to come in for more interviews to see if he could work out his relationship with his wife. Of his own accord he undertook to tell her what he had "learned," and to ask her to come in to discuss the same thing with the counsellor.
Mr. F spent most of his subsequent interview time discussing the various jobs he had held during his marriage, his disappointment that Mrs. F was dissatisfied with him, and his deep personal need to feel that his work would improve the world. Then he began to feel that maybe in the long run he could help the world more if he did the most he could do to help his own family.
He now began to have an increasing awareness of the difficulties their meagre income made for Mrs. F. He wanted to know, in turn, how he could get his wife to be more understanding of his problems. With much encouragement from the counsellor Mr. F began to talk over his plans with his wife while he was making them rather than after they had been put into effect. Mr. and Mrs. F discussed his salary and decided together that he should ask for a raise - an unusual form of interaction in this family. He did ask, and both of the F's were most pleased at the increase: he was given a raise and he felt good because not only because of the extra money but also because it showed the value his employer placed on his services.
During this time, Mrs. F also came in and with the counsellor's help began to accept the fact that her husband would never be more than a modest provider. She relieved anxieties and guilt, enormous significance at the appropriate stage in the counselling process. In this process the attitudes and atmosphere represented by the counsellor are of the utmost importance. Often the counsellor is perceived by the client as an authority figure in the culture. Here then is another human being, a father or mother substitute, who can emphasize with the conflicts and inhibitions of the client, who indicates that it is constructive and permissible to experiment with sexual activity desired but long repressed. This relationship, together with new ideas based on reliable information, makes first steps in new approaches possible and supports their continuation.
Fourth, the above may prove true even in cases where it seems clear that the sexual problem is only incidental, or is secondary to broader disturbances in the marital relationship.
Fifth, an effective marriage counsellor needs much more than knowledge, of course; but he needs all the knowledge he can get. Clinical research in marital sexual adjustment will prove of continuous value through the decades ahead in helping counsellors to help their clients.
Finally, it is to be hoped that as research findings seep down in various ways from the professional to the non-professional level they will have a directly beneficial effect on the majority of men and women. All who have engaged in marriage counselling can believe the abysmal ignorance of various aspects of sex which can still be found among some intelligent, literate people!