Clinical Case: Woman Experiencing Low Sexual Desire in a Non Sexual Marraige

Mary, a teacher in her late 30s, phoned requesting an appointment to address her lack of sexual desire for her husband of 15 years, Herb. She explained that for the past three years, she had had no sexual desire for him. Now, Mary reported feeling desperate because Herb was saying that unless she fixed her sexual problem, he intended to leave the marriage. I suggested that even though she was experiencing the low sexual desire, it was best to treat the sexual problem as a couple issue and for both of them to attend the first appointment. Mary agreed to ask Herb to accompany her and booked an initial appointment.

STEP 1: Identify the cause of the low sexual desire

In Step 1 an assessment is conducted to identify the cause of the low sexual desire. This involves an assessment of the nonsexual aspects of the marriage, the sexual functioning of both partners as individuals, and the sexual relationship of the couple. Generally, this assessment reveals both an "originating" and "maintaining" cause of the low sexual desire. A therapeutic alliance is formed with both partners, which helps partners to talk openly about their sexuality. This Step concludes with both partners committing to the goal of revitalizing their sexual relationship as an intimate team.

In the first session, Herb, a 38 year old real estate salesman, described how he loved Mary but was feeling rejected sexually. He stated how romantic and passionate their sex life had been when they had met at university, and how he longed to recover this. Mary indicated that she loved Herb and their life together as a family with their 15 year old daughter, but that in the last three years she had lost sexual desire for him. She noted that sex occurred infrequently, about four times a year, whenever she caved in to Herb's pressure and her own internal guilt.

An exploration of the nonsexual aspects of their marriage indicated that they had a good relationship. Both conveyed respect and trust for each other. Both agreed that they liked each other's company, enjoying a variety of outdoor and cultural activities together. Although they had occasional conflict, they recovered quickly by talking soon after the argument. They seemed relieved when I suggested that the most common pattern of nonsexual marriages is the couple that has a good relationship, but struggles with low sexual desire. Because it is very difficult to revitalize sexual desire when respect and trust are missing, they also found it reassuring that their respect and trust for each other was an important ingredient for revitalizing sexual desire.

An exploration of their sexual functioning as individuals indicated that they both functioned normally. Herb reported that he got and maintained firm erections, that he wasn't concerned about ejaculating too quickly, that his orgasms were satisfying, and that he had a strong appetite for sex. Although his preference was partner sex, he admitted to self-stimulating to typical fantasies about three times a week. Mary indicated that with the right stimulation and enough time, she could experience subjective arousal (feeling turned on) and objective arousal (vaginal lubrication), and achieve orgasm. She denied any pain associated with sex, except mild discomfort when Herb
penetrated her before she felt aroused sufficiently. She reported that she didn't bother asturbating. She was aware of sexual thoughts and fantasies, and responded with mild arousal to sexual stimuli on TV or in literature. What puzzled her was her lack of sexual urges for her husband, Herb. As much as she thought she should feel sexual desire for him, she didn't.

Mary appeared a bit disappointed when I suggested that her low sexual desire appeared to be psychogenic (related to psychological causes) rather than biogenic (related to physical causes). She had read an article about how testosterone helps women with low sexual desire, and was hoping that it would help her. I explained that an absence of sexual thoughts, fantasies, and arousal to sexual stimuli would point to a physical cause, but that this was not the case for her.

In order to understand the psychological etiology of her low sexual desire, I explored their marital sexual history. Mary and Herb had me in the last year of universtiy. Premarital sex had been exciting, adventurous, and frequent. Herb in particular recalled how gratifying it had been to experiment sexually both in the bedroom and in outdoor settings. Mary recollected how several years into the marriage, sex had become brief and routinized, with a focus on intercourse. Typically, they would engage in about five minutes of touching and kissing before Herb entered her. He would climax after five to ten minutes of intercourse. Although occasionally he would bring Mary to climax manually, typically she would say it wasn't going to happen for her and they would stop love-making. Both would then fall asleep with little contact. Herb remarked that for him sex early in the marriage had been good but less frequent than he had wanted. It surprised him that Mary painted such a bleak picture of their sex life at that time.

Both agreed that there had been a gradual decline of sexual frequency and quality over the years, until in the past three years they had had sex about four times a year. I suggested that they had shifted gradually from a low sexual marriage to a non sexual marriage.

As this decline had occcurred, Herb had blamed Mary increasingly for denying him sex. Although feeling guilty about this, Mary expressed increasing resistance to feeling pressured into sex that she didn't find gratifying.

I suggested that the "originating" cause of their non sexual marriage was falling into an inflexible, truncated sexual script early in marriage that was overly focused on performance and intercourse rather than on pleasure. In addition, I suggested that the "maintaining" cause was the negative pursue-avoidance cycle that characterized their sexual interactions. Although Mary had lost interest in sex originally because of their inflexible sexual script, their non sexual marriage was now maintained by a negative cycle characterized by his pursuit and her avoidance.

I validated them for having the courage to seek professional help to revitalize their sexual relationship, indicating that the longer a couple avoids sexual contact, the harder it is to get back on track because of increased levels of resentment and bitterness. I noted that these feelings may become a greater threat to the marriage than the sexual problem itself.

I suggested that it was unrealistic to recover the sexual passion of premarital sex, but that it was possible to create a new marital sexuality based on intimacy, pleasuring, and eroticism. I indicated that there was no quick fix or magic formula, but if they were willing to commit to a process of change as an intimate team over ten to 20 sessions, they could revitalize their marital sexuality.
Although apprehensive, both Mary and Herb indicated they were willing to try.

STEP 2: Interrupting the pursue-avoidance cycle that maintains low sexual desire and fostering intimacy

In step 2, awareness of the pursue-avoidance cycle is heightened by exploring this cycle in detail. Interventions drawn from Emotionally Focused Couples Therapy (EFT) are used to interrupt this cycle. The negative cycle is framed as a mutual enemy requiring their efforts as an intimate team to overcome.

When I asked Mary and Herb to describe what happened typically between them sexually, Herb indicated that he had mostly given up initiating sex because he was tired of feeling rejected. Occasionally, when he thought Mary might be receptive, he would ask if she wanted to make love. Typically, Mary would decline with an excuse or rationalization. Herb would then accuse her of not keeping her part of the marital bargain which included sex. Mary would respond defensively, stating she wasn't going to have sex if she didn't want to. Herb would then exclaim in frustration, "You never want sex", to which Mary would reply, "I can't help it if I don't want sex. Leave me alone!" Fortunately, Herb did not then become coercive by insisting that if she didn't give him sex, there would be negative consequences for her (intimate coercion increases bitte ness and alienation). Instead, both would drop the issue, but feel distant from each other for the rest of the day.

I suggested that it was understandable that Herb felt frustrated and deprived sexually and would want to blame Mary for withholding sex. I suggested that it was also understandable that Mary would avoid sex when she felt pressured and wasn't feeling sexual desire. Although they perceived that they weren't having an impact on each other, I pointed out that they were having enormous impact on each other. Herb's pursuit of Mary for sex evoked her avoidance; Mary's avoidance evoked his pursuit. I suggested that the pursue-avoidance cycle was their well-intentioned but misguided attempt to reestablish their marital sexuality. Peter's blame was his way of protesting the loss of the vital sex they had once had. Mary's avoidance was her way of holding out for marital sex that was more gratifying for her. Their challenge was to see the pursue-avoidance cycle as an enemy that stood between them and a revitalized marital sexuality, and to defeat it working together as an intimate team.

Following Emotionally Focused Couples' Therapy (EFT) approach to interrupting negative fight cycles by accessing deeper feelings underlying the fight cycle (see the clinical case of EFT ), I began to explore Mary and Herb's deeper feelings. When I said to Herb, "I'm wondering if under your frustration and anger toward Mary for avoiding sex you're feeling unwanted and unloved," he nodded affirmatively. When in a low, soft voice, I asked him what this was like, he indicated that it was painful to feel unwanted sexually. When I directed him to say this to Mary, he stated, "I feel so undesireable when you don't want me sexually. It's painful for me." Mary responded supportively, saying "I'm sorry my not wanting sex is so hard for you. I don't mean to hurt you. I just don't know how to respond to you when I don't feel desire."

I then explored Mary's deeper feelings underlying her position of avoidance in the negative cycle. When I said I wondered if under her defensiveness and guilt she was feeling besieged and inadequate, she replied, "Yes". When I asked Mary what it was like to feel inadequate sexually, she stated, "I've always felt inadequate when it comes to satisfying Herb sexually. I could never do it right or enough for him". When I directed her to say this to Herb, he started to respond defensively. I interrupted, stating it was important that he struggle with what Mary was telling him. With my support, he replied, "I didn't realize you were feeling so incompetent sexually with me. I don't mean for you to feel this way."

When I asked Mary to tell Herb what she was wanting from him sexually, she stated, "I'm not sure. But it would help if you would stop pressuring me and if you would just be with me. I want to feel close rather than like I have to perform for you." Herb felt apprehensive about what Mary was asking of him, but said he was willing to try.

I validated both Mary and Herb for their willingness to be more open and vulnerable regarding their sexuality, rather than accusatory and defensive. I indicated that this increased responsiveness and emotional intimacy is what would be required as they worked together as an intimate team to rekindle their marital sexuality.

STEP 3: Creating responsive desire through pleasuring

In step 3, pleasuring touch is introduced as an incentive for responsive desire. As the couple engages in exercises of sensuous touch, they are encouraged to "go with" feelings of arousal and desire rather than blocking themselves. A temporary ban on orgasm and intercourse reinforces that pleasuring touch is valued for its own sake rather than as a pressure or demand for sex.

Although Mary wanted to feel sexual desire for Herb, she didn't know how to feel desire for him . I indicated that if she waited for spontaneous sexual urges for Herb, she would likely wait a long time. What she didn't know was that it is common for the low desire partner to lack spontaneous sexual urges for their partner. The alternative to waiting and hoping to feel spontaneous urges again was to create responsive desire. I explained that this is the desire one feels in response to engaging in sensuous touch or pleasuring. Pleasuring is the incentive for sexual desire. If one engages in pleasuring and feels the positive sensations that emerge rather than blocking them, one will experience increasing levels of sexual arousal and desire.

Mary seemed intrigued about feeling sexual arousal and desire again through pleasuring, but wondered how this would work. I suggested that what would be required from her was the willingness to start from "neutral", without preexisting sexual urges, using a special type of touch called "nondemand" pleasuring.

I explained that nondemand pleasuring is touch that is valued for itself, that is not a pressure or demand for sex, but rather is a way of maintaining physical contact, feeling connected, and sharing pleasure. Nondemand pleasuring would help them learn how to pleasure each other and to keep the "demand" out of sex. It would help them to replace foreplay, which is goal-oriented, with a broad-based sexuality oriented toward pleasure rather than performance. Nondemand pleasuring would not only help to create responsive desire, but would also inoculate their sexual relationship from deteriorating in the future.

I then suggested an exercise involving nondemand pleasuring that they could do at home. I instructed Mary and Herb to begin by showering together, noting that cleanliness promotes comfort. Next, they were to retire unclothed to their bedroom, which they had already organized with candles, incense, and their favorite music to create a romantic mood. With Herb leaning against the headboard and Mary lying against his chest, Herb was to begin in the giver role by caressing and touching Mary's head, neck, and shoulders as tenderly and sensously as possible. When he was ready to caress the front of her body, Mary was to take his hands and guide them over her body, in whatever way and pace she preferred, communicating verbally and nonverbally what she liked and wanted more of. When Mary was finished, they were to reverse roles, with Mary becoming the giver and Herb the receiver. In the giving role, the task was to experience as much pleasure as possible in giving touch. In the receiving role, the task was to focus with eyes closed on the sensations and feelings of being touched. Finally, I explained that the purpose of the exercise was to enhance sexual communication and pleasure, and not to turn the partner on. It was important that the exercise not lead to orgasm and/or intercourse.

Knowing that couples are reluctant to engage in touching because it is easier to avoid than to try again, I explored what they were telling themselves about engaging in the pleasuring exercise. Mary's thoughts were, "He doesn't want to touch me, just to have sex", and " This exercise won't work for me. I won't feel anything." I suggested that Mary was having a negative thought process which if " listened" to would limit her ability to benefit from the exercise. Using a procedure from Voice Therapy, I instructed Mary to say these thoughts in the second person, "You", as if someone else was addressing her (see the link, "Approach to Counselling" for more information). Mary said, "He doesn't want to touch you, just to have sex", and "This exercise won't work for you. You won't feel anything." Mary was surprised by how negative and against herself these thoughts sounded when she said them in this way. When I instructed her to counter these negative thoughts or voices in the 1st person "I", from her healthy point of view, she stated, "I know Herb likes to touch me. I trust that if I open myself to pleasuring touch, I will experience positive feelings." Countering the voices helped her to feel more confident about benefiting from the exercise.

When I asked Herb what he was telling himself about the nondemand pleasuring exercise, he remarked, "This exercise is for her, not for me. I will be bored. What's the point." Expressing these thoughts as "voices" in the 2nd person, "You", Herb said, "This is for her not for you. You will be bored. What's the point." When Herb countered these voices in the 1st person, "I", he stated, "I know that I too can benefit from the exercise. I want to be open-minded and see." Herb realized that "listening" to his negative thought process would undermine his benefiting from the experience.

I suggested that before, during, and after the pleasuring exercise, they would likely both have a negative thought process. The challenge was to be aware of any negative voices, to separate them out in the 2nd person, and to refocus on the experience of giving and receiving touch. If at any point the negative voice was too "loud", or if they felt uncomfortable for any reason, they were to stop the exercise, assume a trust position by holding and looking at each other, and talk about their experience until they felt ready to resume touching.

Mary and Herb reported that they found the exercise artificial but helpful. Herb noted that he felt more comfortable in the giving than the receiving role, but that he could see the value of learning to enjoy touch. Mary noted that without the pressure of touch leading to sex, she had been able to relax enough to experience some pleasure in both roles. Both commented that they had been aware of a negative thought process during the exercise, but that they had not allowed these thoughts to interfere with the experience.

Over the next few months, Mary and Herb engaged in further experiences of nondemand pleasuring on three levels: 1) affectionate touch while clothed (e.g., hugging, kissing, holding hands), 2) sensual touch while nude or semi-clothed (nongenital touch such as massage, bathing together), and 3) playful touch (a combination of genital and nongenital touch such as "fooling around" on the couch, in bed, or in the car). Mary, to her surprise, reported feeling considerable sexual arousal and desire. Herb commented that often he felt so aroused that he had a hard time not "breaking the rules" and having intercourse.

I congratulated them both on pushing through their resistance to nondemand pleasuring, and staying with the experience of pleasuring long enough to reap the benefits of arousal and desire. I indicated that pleasuring was not only a bridge between intimacy and
eroticism, but also a means of sustaining their sexual relationship throughout the life cycle (as people age, they require more stimulation to feel aroused).

STEP 4: Increasing arousal and sexual gratification through eroticism

In step 4, couples experiment with erotic techniques and scenarios in order to heighten arousal and experience orgasmic sex. Inhibitions to erotic techniques are overcome or significantly reduced where possible.

Although intimacy and nondemand pleasuring are necessary for sexual satisfaction, they are not sufficient. For heightened arousal and orgasm, eroticism is required. Eroticism refers to sexual thoughts, fantasies, and behaviors that turn a person on. Eroticism includes intercourse, but is not limited to it. It includes erotic scenarios and techniques such as sexual fantasy, manual and oral stimulation, various intercourse positions, and multiple stimulation before and during intercourse (e.g., kissing, caressing, breast and testicle stimulation).

Herb was enthusiastic about augmenting the pleasuring phase of love-making with erotic scenarios and techniques, while Mary seemed less enthusiastic. She was afraid that the pleasuring phase of love-making that she had been enjoying so much would be lost. She seemed reassured when I stressed that eroticism requires arousal which is best fulfilled by pleasuring. I suggested as a useful guideline that they both be between 3 to 5 on an 11-point arousal scale (where zero represents no arousal and 10 orgasm) before transitioning from pleasuring to erotic stimulation.

In order to increase their eroticism, I suggested that both write down erotic techniques and scenarios that they would like to incorporate into their sex life. To compile their individual lists, I recommended they reflect on behaviors they had found arousing in the past, behaviors they found arousing currently but wanted more of, and behaviors they had never asked for. Finally, I instructed them to rank the behaviors from the most arousing to the least arousing.

Mary's most arousing erotic request was for Herb to perform cunnilingus (oral sex). Because she knew that Herb didn't like to give her cunnilingus, she had given up wanting this early in the relationship. In exploring Herb's inhibition to cunnilingus, it became apparent that Herb had developed this inhibition in young adulthood when attempting to give oral sex to a girlfriend who not only had poor hygienne but also was critical of his efforts. When I asked if Herb was willing to challenge this inhibition, he said that he was willing to try because he knew cunnilingus was important to Mary's eroticism. I suggested that they experiment with a gradual approach involving practice, feedback, and validation, in which Mary's support was crucial (sex is a team sport, in which partners win or lose as a team). First, Herb became comfortable with the scent of Mary's fresly bathed genitals. Then, he experimented with kissing and licking the area around her vulva. Finally, he kissed and licked her clitoris. Once Herb accomplished this, he was surprised to find himself becoming turned on by Mary's response to receiving cunnilingus. I commented that the partner's arousal is the best aphrodisiac.

Herb's most arousing erotic request was for Mary to role play the sexual fantasy of a high class escort. Herb found the fantasy of picking up an escort, and having her talk dirty to him during sex, extremely arousing. Although he utilized this fantasy during partner sex, he felt guilty about doing so. I suggested that it is common for people to use fantasy during partner sex to heighten their arousal, and that it is okay to do so providing they do not lose connection with their partner. He had never shared this fantasy with Mary because he felt embarrassed by its unusual elements. He seemed relieved when I indicated that most peoples' sexual fantasies have unusual elements, and that it is these very elements that give sexual fantasies their charge.

Mary was okay with his having this fantasy, but didn't want to act it out. I said that it was important that she not do anything that she felt uncomfortable with, but wondered if she would be willing to try role playing some of the elements of Herb's fantasy. Knowing this was important to Herb's eroticism, she agreed. When I asked what elements she thought she could act out, she indicated that she could wear the lingerie of an escort, and act submissively. What she didn't want to act out was "talking dirty". Herb was pleased with Mary's willingness to respond to him. Before engaging in this role play at home, I reminded Mary that she could ask Herb to stop at any point and to assume a "trust position", by holding her until she felt secure enough to resume. After experimenting with this fantasy several times, Mary reported that she was beginning to feel aroused not only by Herb's arousal but also by playing a submissive role. On reflection, she realized that submission was an element in her own sexual fantasies.

Over the next several months, Mary and Herb continued to incorporate erotic scenarios and techniques into their sex life. This was not done at the expense of the pleasuring phase of love-making. They continued to enjoy affectionate, sensuous, playful, and erotic levels of touch. Mary was surprised that she was anticipating sex with Herb positively. Both were experiencing more satisfaction after sex in the form of "afterplay". Both enjoyed holding each other and basking in the warm after-glow of sex.

I validated Mary and Herb for persisting in the process of revitalizing their sex life, even though this had neither been easy nor without set backs. I congratulated them on creating a new, broad-based sexual script that included positive anticipation, invitation (not demand), pleasuring, eroticism (including but not requiring orgasm and intercourse), and satisfaction (after play).

STEP 5: Maintaining a rekindled marital sexuality

In step 5, couples are encouraged to be proactive in maintaining their treatment gains so as to avoid regression. In order to maintain their rekindled marital sexuality, I provided Herb and Mary with a number of guidelines. First, I suggested that they maintain a regular pattern of sexual contact. This would require their investing the necessary time and energy as an intimate team
in both planned intimacy dates and spontaneous encounters. Second, I advised that they anticipate that about 5 to15 percent of their sexual experiences would be mediocre. Having a realistic view of marital sexuality would help them to take mediocre experiences in stride without over reacting or becoming demoralized. Third, I recommended occasional pleasuring encounters that didn't lead on to orgasm and/or intercourse. Doing so would help them to remember that marital sexuality is more than orgasm and intercourse.

Conclusion

Revitalizing marital sexuality in a low sexual or non sexual relationship in which one of the partners experiences low sexual desire is a challenging process requiring considerable motivation. By working as an intimate team to interrupt the pursue-avoidance sexual cycle and foster intimacy, by creating sexual desire through nondemand pleasuring, and by heightening arousal through erotic techniques and scenarios, couples may build a flexible, broad-based marital sexuality based on intimacy, pleasuring, and eroticism.