Great Expectations
An expert looks at our changing notions of a satisfying sex life and the role of couples therapy
April, 2004
Fifty years ago, we knew little about the female orgasm, and women were afraid to assert their sexual needs. Now many women want to keep their libido in working order, and they may be distressed by a decrease in desire or sexual enjoyment.
"Women today feel guilty or depressed if they suddenly become uninterested in sex or have difficulty reaching orgasm," says Philip Sarrel, MD, a noted researcher and sex therapist, who is Professor Emeritus in the Department of Psychiatry at Yale University Medical School in New Haven, CT. "This represents a major shift in our sexual values."
Forty-three percent of American women between the ages of 18 and 55 currently report some form of sexual dysfunction. A landmark study in The Journal of the American Medical Association1 linked a variety of complaints, from low libido, sexual pain, and the inability to climax not just to aging and certain health conditions but also to psychological and social stress.
Women whose income suddenly dropped by more than 20 percent were twice as likely to have sexual problems. Single women were more likely to have difficulty than married women due to the stress of trying out new partners alternating with stretches of not dating.
Still, says Sarrel, "the outlook is much better for women now than it was for their counterparts just a generation or two earlier." Physicians have a better understanding of female sexuality, he says, and couples have greater access to sex counseling and sex therapy.
Sarrel is in a unique position to provide an overview. He and his wife, Lorna, trained as sex therapists with Masters and Johnson in the 1970s, wrote groundbreaking columns on sex for Glamour and Redbook , taught seminars in England, Australia, Denmark, and Sweden, and founded the Yale Sex Counseling Service. The Service has helped over 10,000 patients in the last 35 years.
Our managing editor, Valerie Andrews, recently spoke with Sarrel about the revolution in female sexuality — from Masters and Johnson to the present — and the role of couples therapy today.
Let's start with a historical perspective: How did we get our first insights into the nature of female sexuality?
Alfred Kinsey actually observed more than 1,000 couples having sex in their homes in Indiana in the late 1940s. But when he discussed his research at professional meetings, he swore the audience to silence. He brought a ceramic black cat to his lectures, and when he put it on the podium, it was a signal that this information could not be repeated outside the room. Shortly before his death in 1956, Kinsey sealed his files because he felt the world was not ready to hear what happened when two people engaged in sex.
When the gynecologist William Masters was starting his program on human sexuality at the University in St. Louis in the early 1950s, he went to Kinsey and asked for his advice. "First," Kinsey said, "you've got to look at the biology."
Freud was a dominant influence at the time, and it was like turning an ocean liner around to focus on the physiological aspects of sex. But that's what Masters did. Eventually, he even used a mini-cam to take pictures inside the vagina and document the female sexual response. On their first day at the Masters and Johnson clinic, all patients got a physical exam. Post-menopausal women were started on a combination of estrogen and androgen that very night.
Masters was among the first to identify the importance of hormones in women — especially the issue of hormone inadequacy at mid-life. In the Journal of Clinical Endocrinology, he addressed estrogens and androgens and the complementary effects they have on sexual response and desire.
The average age of the women who came to his clinic was 49, so it was very easy to make the diagnosis that these women were hormone-deficient. Masters also brought in Virginia Johnson to help him address the couples' communication issues, and this was the beginning of sex therapy as we know it today.
What are its guiding principles? And how did women fare?
Sex therapy is based on the notion that sex is a natural function, and there is no such thing as an uninvolved partner.
There are two basic skills Masters and Johnson set out to teach: One was self-assertion — getting people to say, "I need, I want." This was especially important for women a generation or two ago since they were taught to be passive sexually.
The other was self-protection — getting people to say "ouch" when something is physically or mentally uncomfortable. Over time, hurt leads to angry outbursts. When suppressed, it leads to depression. The goal is to keep people from getting into these unhealthy states.
Sex therapists still rely on these principles today. Whether dealing with lesbian or heterosexual couples, we want to get pain out of the picture and to give partners the confidence to say, "Stop, this doesn't feel right."
To eliminate the situations that trigger fear or anxiety, at the beginning we restrict any kind of vaginal penetration. A woman can do things that are pleasurable for her and her partner, but the idea is for her to approach sex and find out what she likes — without the goal of intercourse.
How can a goal-orientation hamper a woman's sexual enjoyment?
Masters and Johnson described the phenomenon of "spectatoring," the anxious, non-erotic, performance-oriented observance of the self during sex. They helped couples to stop being so self-conscious and to stop worrying about "what happens next."
There's a scene in the movie Annie Hall, where Annie leaves her body and watches herself perform with Woody Allen on the bed. It's important for couples to understand that this is a kind of disconnect and that spectatoring gets in the way of natural sexual response.
And so the therapist will ask, "When you are beginning to engage in sex, where's your mind? What are you thinking or feeling?" Is there another track that takes energy away from what's happening in the moment?
What kind of time do people invest in couples therapy?
Masters and Johnson designed a co-therapy approach that is both elegant and efficient. A male therapist represents the man, and a female therapist represents the women. Both sides have an advocate who understands their point of view and can encourage them to express their needs.
The advantage of the co-therapy is that it takes fewer hours overall. It involves an investment of approximately 18 hours for each partner. Masters and Johnson saw couples every day for two weeks, including Saturdays and Sundays. At Yale, we commit a similar number of hours to sex therapy, but spread out over nine weeks.
By comparison, individual therapy might take six months. Another advantage to the Masters and Johnson co-therapy model: It's often easier to address certain sensitive subjects in a foursome rather than when you're working one-on-one.
Can unmarried women work with surrogate sex partners during therapy?
In the early days of the clinic, Masters and Johnson would allow a man to work with a surrogate — a person hired by the program. This was useful if the patient was unmarried, or if his wife was uninterested in sex therapy. One of their surrogates was a former nun who was working as a kindergarten teacher. Others were psychologists and nurses.
But women always had to come to the clinic with a mate or with a partner of their own choosing. The argument, mostly Virginia Johnson's, was that a woman would not be able separate her sexual response from the context of her relationship. In the 1950s and 1960s, that was integral to feminine psychology. It was felt that to just set a woman up with a stranger was not going to be helpful. Over the next 50 years, our values have changed dramatically. While it's not common in sex therapy, a single woman might work with a surrogate today.
Thirty-five years ago, Masters and Johnson estimated that roughly half of all couples in America experience some form of sexual dysfunction. Is this still true?
Yes, at least half. Couples today have the same physical complaints as those in the past. In moving through the life cycle, the vast majority will encounter one problem or another, from flagging libido and pain with intercourse to various forms of impotence.
What has changed is not the diagnosis but our attitude and our expectations of sex. In the 1970s, when sex therapy was in its infancy, the majority of women felt that they were not supposed to enjoy themselves, sex was for procreation, and this activity should stop with menopause. Today woman come for help because they've had satisfying sex for most of their lives and are distressed by the loss of it. They feel it's good to be responsive and have pleasure.
A national Gallup poll in 2001, indicated that 64 percent of post-menopausal women have a problem with vaginal dryness. And 25 percent of these women complained of pain with intercourse, but only 50 percent were sexually active. This was a national sample that crossed all the ethnic groups.
By the average age of 57, these women had stopped having sex for different reasons but when asked, "Is there anything you can do about this dryness problem?" 90 percent of them had no idea there was something they could do to reverse the dryness and take care of the pain.
Do women react differently to these changes in their sexuality?
There is some variation. The study done two years ago found an old-fashioned stoicism in Asian-American women. They turned out to be similar in their values and complaints to the patients we saw in the 1970s. These women try to tough it out and rarely ask for medical attention or any kind of counseling. The same study also revealed that of all ethnic groups, African-American women are most angry about any decline they experience in their sexual function.
One thing is true for everybody: Problems with sexual desire and comfort generally increase with age. In one of my own studies, I reported that 86 percent of women who come into a menopause clinic had sexual complaints. Among the general population the figures are a bit lower.
Lorraine Dennerstein recently reported that 88 percent of women have problems with desire in the first five or six years post-menopause. That's a dramatic jump up from the 40 percent who are concerned about a downshift in their desire before menopause.
How has our attitude toward menopause shifted in the last 30 years?
In 1965, I was working with a generation of women for whom sex was an unmentionable word. That changed with the women's movement in the 1970s and the advent of "the pill." But though sexuality was now out in the open, menopause was not.
In 1976, when we started our menopause program at Yale, the average woman did not mention "the change" to her closest friends. She didn't talk about hot flashes or sleep disturbances. That reluctance is hard to imagine in today's society.
Our attitudes toward sex and aging have changed profoundly, too. In the early 1970s, Dr. Harold Lief of the University of Pennsylvania made a documentary film about human sexuality. On camera a medical student admits, "I would never ask an old person about sex."
"What's old?" Lief asks. "Anyone 42 or over," the student replies. If a woman was sexually active over 40, she was looked at as an oddity. It took 30 years to change that perception.
What about post-menopausal sexuality?
A few years ago, a practicing gynecologist called me for advice. His grandmother had come to him and asked what to do with grandpa who wanted sex every day. She was 84, and her husband was 86.
I told him sexuality doesn't disappear with age. In fact, for older people sex can become more important — it's a way of maintaining a human connection, and some people need this kind of touch and contact into their 90s and beyond.
I encouraged the physician to advise his grandmother about vaginal lubrication. And I tell physicians that it's important to ask their patients if they are sexually active, no matter what their age. Every woman who comes to our menopause clinic fills out a questionnaire asking about vaginal dryness, pain with intercourse, and decreased sexual desire.
What do women need to know about sexuality and aging?
Masters and Johnson were the first to dispel the myth of the vaginal orgasm in 1966. Yet many women still believe that the vaginal orgasm is the most important criterion for a satisfying sex life.
This week a patient came to me and complained that she could no longer achieve orgasm in this manner and to the same degree. She was very upset. We looked at diagrams of the female sexual response, and she was able to pinpoint her distress; she said she no longer had a certain kind of feeling during muscle contraction.
I explained that her diminished capacity to develop muscle tension probably meant that she didn't have enough androgen. A blood test showed her bioavailable testosterone to be at the bottom of the normal range. I asked her to start taking a combination of estrogen and methyltestosterone in a tablet each evening after dinner. She is scheduled to return in six weeks, and by then I expect an improvement in her sexual response.
I also reminded her than an orgasm can involve other parts of the body, not just a particular set of muscles. As an illustration, I told her about a woman who could only have an orgasm when her partner was stroking the right side of her neck. So much of sexuality has to do with the mind — and with our psychological associations.
How do we develop this "personal map" of our sexuality?
All through our lives, we attach meanings to sex. As children, we see how the body is dealt with in our families, how we deal with nudity, the role of touch in parental affection, and in our contact with our peers at play. Later we have to deal with changes that take place in our bodies during puberty and adolescence, and the changes in attitudes of the church and other authorities toward our physicality.
We also develop a map of pleasure based on our own intimate experiences and associations. None of it gets "deleted."
We also have techniques that will enable us to look at the brain and see what happens neurologically during sexual arousal and orgasm. This opens up an exciting avenue for future research. Kinsey originally reported on the discharge from the hippocampus during orgasm. I wrote a paper in '70s about using an electroencephalograph to monitor sexual response. But there is much more to be learned.
We also need to know, for example, how SSRI antidepressants affect brain activity and interfere with sexual response. This should be a high priority since complaints about sexual function lead to a high discontinuance of these medications especially among women.
What it the best source of information about sexual response and sex therapy?
Primary care physicians should be able to provide accurate sex education, but they may not have the time. In this case, the clinician should refer a woman to a local sex educator or therapist. Another good source of referrals is the American Association of Sex Educations, Counselors and Therapists (www.aasect.org) .
Couples can also learn a great deal just from reading. I recommend For Yourself: The Fulfillment of Female Sexuality by Lonnie Barbach, PhD, Male Sexuality by Bernie Zilbergeld and Analysis of Human Sexual Response by Brecher and Brecher. These are all available in paperback.
More information on female sexuality can be found on the following web sites:
Notes
1 Laumann, et al, 1999
This article is for educational purposes only and is not intended as a substitute for medical advice. Please consult with a clinician to review any current symptoms and address your medical concerns.
