This article is a description of Barry McCarthy’s Sept. 22, 2013 presentation
to the New Jersey Association of Cognitive Behavioral Therapists
How to Treat Low Sexual Desire
By Lynn Mollick and Milton Spett
.
1. Treatment Concepts for Revitalizing Desire
1. The essence of sexuality is giving and receiving pleasure-oriented touching, not “achieving” erection, intercourse, and orgasm. Touching should be valued for itself and not necessarily lead to intercourse. Touching should occur both in and out of the bedroom.
2. Sexual desire is facilitated by a rhythm of regular sexual experiences. When sex occurs less than twice a month, individuals can become self-conscious and fall into a cycle of anticipatory anxiety, tense and unsatisfying intercourse, and avoidance.
3. Sex should always be voluntary and pleasure-oriented. Sex should never be coerced or used as a reward or a punishment.
4. Desire problems must be treated directly. They can be treated along with other problems, but do not assume that when other couple problems are resolved, sexual desire problems will automatically resolve. Do not wait until other problems are resolved before addressing sexual desire problems.
5. Men and women have different paths to sexual desire. Men experience arousal and desire, then seek out sexual stimulation. Women seek emotional intimacy and then pursue sexual intimacy, which results in arousal and desire.
6. Responsibility. Each partner is responsible for their personal satisfaction and desire, but the couple works together to help each partner experience satisfaction.
7. Personal turn-ons can facilitate sexual anticipation and desire: sharing fantasies, initiating an erotic scenario, sex to celebrate or soothe, etc.
8. External props can also facilitate desire: x-rated movies, vibrators, candles, sex in an unlikely location, etc.
2. Structure of Assessment & Treatment
1. The initial session should be with the couple to assess motivation, couple dynamics, past and present therapy, medication, and medical conditions.
2. Individual sessions should follow to assess sexual and relationship histories and psychological health. Patients are always more forthcoming when they meet with the therapist alone. Confidentiality should be assured.
3. A couple feedback session which lays out the problem, explains the concept of the couple as a sexual team, and assigns the first homework exercise. Couples should do homework exercises two to four times per week.
4. Weekly therapy sessions.
5. Relapse prevention.
6. Booster sessions every six months for two years following termination.
3. Correcting Cognitive Distortions in Low Sexual Desire
Dr. McCarthy noted that when heterosexual couples become asexual (sex less than 10 times/year), 90% of the time it’s because the man has withdrawn from sex. Men avoid sex because they have lost confidence in their ability to meet their own sexual expectations, especially their expectations about their erections. Psychoeducation must correct the unrealistic expectations which create feelings of inadequacy and avoidance of sex.
1. Married couples have sexual intercourse an average of 60 times per year -- about once a week. For couples in their twenties, two or three times per week is average. For couples in their fifties, once or twice a week is average.
2. An average sexual encounter lasts 15 to 45 minutes.
3. The average duration of intercourse is three to seven minutes.
4. Happily married couples with well-functioning sex lives have disappointing sex 5% to 15% of the time. Only 35% to 45% of experiences are “very good” for both partners.
5. Sexuality adds only 15% to 20% to marital satisfaction. Healthy sexuality is not the most important factor in successful marriage.
6. The initial romantic/passionate phase of a relationship lasts only six months to a year. After that couples must find a new style that incorporates intimacy and eroticism.
7. Birth of the first child reduces sexual satisfaction for 70% of all couples.
8. Even when men use Viagra or Cialis, they achieve effective intercourse only 80% of the time.
4. The “Five Gear” Metaphor for Touching Exercises
Non-demand touch is a way to reinforce attachment, share pleasure, and increase sexual desire. Both partners should feel comfortable initiating and refusing touch (and intercourse).
1st gear - affectionate touch, clothed
2nd gear - non-genital, sensual touch, which can be clothed, semi-clothed, or nude
3rd gear - playful touching which mixes genital and non-genital touching, clothed or unclothed
4th gear - erotic touching (manual, oral or vibrator stimulation) to high arousal and orgasm for one or both partners.
5th gear - pleasurable and erotic touch which flows into intercourse
Couples should engage all 5 gears, but most couples operate in only two gears -- 1st and 5th.
5. Exercises for Increasing Sexual Desire
Sexual relations facilitate desire, pleasure and satisfaction. Ideally they celebrate both partners’ sexual individuality, but balance the partners’ emotional needs and practical concerns. Developing and maintaining a sexual relationship that is satisfying for both partners requires work. Here are six sequential exercises that can help low sexual desire couples develop a satisfying sexual relationship (From Sexual Awareness [5th edition], McCarthy & McCarthy, Routledge, pp. 149 – 155):
1. Touching I. In the bedroom, with the couple fully clothed, the woman touches her partner anywhere and in any way she wishes, experimenting with different ways to touch and explore his entire body. If she wishes, she may ask him to remove clothing.
2. Touching II. The man does the same to the woman.
3. Communication: Outside the bedroom, the couple is naked, but sits comfortably and discusses their sexual relationship. They may touch while they talk. What facilitates conversation about sex? What activities do they like and dislike? What are their fondest sexual experiences? They should be open and vulnerable. They should end the exercise with requests and suggestions for improving their sexual relationship.
4. Enhance attraction. (45 minutes to 2 hours) Partners dress carefully, as if they were going on a date. The woman begins by describing 5 to 15 things about her partner that she finds attractive. These may be anything about him, not just aspects of his appearance. Then she makes 1 to 3 requests of specific things she’d like him to change. These may be sexual or may pertain to any aspect of the relationship. When she is finished, the man does the same exercise. The couple discusses maintaining and enhancing attraction to each other. The exercise ends with touching which may lead to intercourse.
5. Discuss trust and intimacy. Do both partners feel that the other “has their back?” If not, what can be done to improve trust? Does the couple have a way to touch each other that enhances trust and makes the partners feel cared for? Experiment with non-demand positions that may enhance trust, intimacy, and sensuality. For example: sitting naked between your partner’s legs and resting backwards on the partner’s chest, lying in the “spoons” position, or breathing together rhythmically.
6. Develop a new couple sexual scenario. The woman describes her ideal scenario first. What is her preferred time for sex? What sets the mood? How does the scenario advance from touching to arousal to intercourse? What is the tempo and how long does it last? What about position, the activity of each partner, sounds, smells and props? Who initiates intercourse? What about each partner’s orgasm? How does the ideal scenario end? The man’s scenario may be different than the woman’s, or much the same. The important thing is to be oneself.
6. Interventions for Low Sexual Desire in Each of the
Four Basic Couple Sexual Relationship Styles
1. Complementary. Partners’ sexual needs are balanced. Each can initiate, refuse, or offer an alternative. Both partners value intimacy and eroticism. This is the most common sexual style. It is so comfortable it can suffer from benign neglect. Intervention - Don’t take sexual desire for granted. Every six months, each partner introduces something new.
2. Traditional. Initiating sexual intercourse is the man’s responsibility. Intimacy and affection are the woman’s. This style is very stable, but the woman may eventually resent “servicing” her partner. Intervention - Respect traditional roles, but make them more flexible. Every six months, the man initiates a sexual encounter that does not lead to intercourse. Every six months, the woman introduces a sexual encounter and she decides whether or not it ends in intercourse.
3. Best Friend/Soul Mate. This is the cultural ideal. It emphasizes intimacy and eroticism that results in feelings of personal validation. This style includes the expectation of mutual pleasure, which may become burdensome and lead to low sexual desire. Also, too much closeness may de-eroticize the relationship. Intervention - The relationship needs to be spiced up with playfulness. The requirement for equal pleasure needs to be challenged. Every six months each partner should initiate a “selfish” scenario.
4. Emotionally Expressive. This is the high energy style where couples experiment and take risks and use sex to heal conflicts and have fun. This is the least stable sexual style. When there are serious problems in the relationship, this sexual style may serve to avoid intimate communication and the healing of wounds. And in the heat of intense sexual moments, partners may say or do harmful things. Intervention - Partners must learn each other’s vulnerabilities and commit to protecting each other from hurt. They must also learn to refrain from high intensity sex when one partner is not emotionally prepared for it.
7. Recovery from Extra-Marital Affairs (EMAs)
In discussing EMAs with patients, it is important not to shame them. Use the neutral terms “involved partner” and “injured partner.”
1. Self-care. Injured partners should slow down, take care of themselves, not act precipitously and hurt the marriage.
2. Understand the EMA. EMAs have meaning to both partners, and each partner must understand the other’s point of view. Recovery requires that the couple develop a shared understanding of the affair’s meaning. Ask the involved partner to write a letter to the injured partner describing their shared understanding of the EMA and acknowledging the injured partner’s hurt.
3. Make wise decisions. Don’t act on the feeling of the moment and leave the marriage because you’re hurt. 70% of marriages recover from EMAs.
4. Ending the affair. Sometimes it is helpful for the couple to meet with the third partner in the therapist’s office to end the EMA together and increase the probability that the EMA will not resume.
5. Finding a new sexual style. Recovery from EMAs requires that the couple does not become obsessed with the affair, but instead finds a new sexual style that is more satisfying than the sexual style that existed before the EMA. Therapists should never assume that couples will want a traditional relationship after an EMA, because 70% do not. Accept whatever arrangement they agree upon as long as it is secure and sexually satisfying for both partners.
6. Relapse prevention. What situations will make the partners vulnerable to future EMAs? They should tell their partner when they encounter these situations and commit to revealing slips within 72 hours.
8. When There is a History of Sexual Abuse
25% of people over 25 report rape, incest, or some other form of sexual assault. 90% report lower level sexual abuse. Childhood abuse causes sexual difficulties because the adult perpetrator’s needs over-ride the child’s, and the child cannot say no. When sexually abused children mature, they do not feel they have control over their sexual lives and they do not believe that they are entitled to a satisfying sexual relationship. Treatment must address these themes so that victims of abuse become “proud survivors” instead of victims.
Barry McCarthy Book Recommendations
The best book for sex therapists
Principles and Practice of Sex Therapy. Fifth Edition, Edited by Yitzchak M. Binik and Kathryn S. K. Hall, Guilford, 2014.
The best book on sexual desire disorders
Treating Sexual Desire Disorders – A clinical casebook, edited by Sandra Lieblum, Guilford, 2011.
The best book about EMAs
Getting Past the Affair – A program to help you cope, heal, and move on – together or apart. Douglas K. Snyder, Donald H. Baucom, and Kristina Coop Gordon, Guilford, 2007.
The best book about women’s sexuality
Sex Matters for Women -- A complete guide to taking care of your sexual self, Second edition. Sallie Foley, Sally A. Kope, and Dennis P. Sugrue, Guilford, 2012.
The best book about men’s sexual health
Men’s Sexual Health – Fitness for satisfying sex, Barry McCarthy and Michael Metz. Routledge, 2008.
The best book for couples
Discovering Your Couple Sexual Style – Sharing desire, pleasure, and satisfaction. Barry McCarthy and Emily McCarthy. Routledge, 2009.
The best book for couples about sexual desire
Enduring Desire – Your guide to lifelong intimacy. Michael Metz and Barry McCarthy. Routledge, 2010.
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