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SHOW 209 TRANSCRIPT
Who Needs Sex Therapy?

HOW'S your sex life? Would you like to make it better? Can we even agree on what "better sex" means? Talking about sex used to be off limits; now there's surely more talk, more obsession, but possibly less pleasure and fulfillment. Can sex therapy help? Who is in need of sex therapy? Not too long ago, sex therapists were dealing with odd problems of few people. Today, sex therapists work with normal problems of many people. But what is a "normal" problem when it comes to sex? And what sort of measures do professional sex therapists recommend? There seems to be surprising consensus. 

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PARTICIPANTS 
Dr. Paul Abramson, a leading authority on human sexuality at UCLA, is the author of With Pleasure: Thoughts on Human Sexuality. Paul describes male-female roles in the context of evolution; he also deals with sexual trauma.

Dr. Vern Bullough, a professor of medical history at California State University, Northridge, has written many books about sex, including Sexual Attitudes: Myths & Realities. Vern critiques the poor practices of unprofessional sex therapists and points out that historically love and sex have been separate matters.
Dr. Sherwin (Shep) Nuland, author of How We Die and How We Live, teaches medical history and bioethics at Yale. Shep believes that our sexuality is central to our humanity, and he describes aesthetic, altruistic and psychoanalytic aspects of love and sex. 

Dr. Clifford Penner and his wife, Joyce Penner, R.N., are sex therapists and marriage counselors with a long-standing practice in the Christian community. Cliff and Joyce emphasize that intimacy and communication are fundamental to a successful sexual relationship and that there are profound differences between male and female sexuality. They also describe how sexual counseling works, and why women should take the lead in bed.

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ROBERT: Joyce, as a sex therapist, and as coauthor with Cliff of such books as What Every Wife Wants Her Husband to Know About Sex, can you describe some of the common problems your clients face? 

JOYCE: The problems we're treating are becoming more complex, because nowadays more self-help books have become available. 

ROBERT: Now that people can solve the simple problems themselves, they save the tough ones for you. 
JOYCE: Yes. Most commonly we deal with the lack of sexual desire--surprisingly widespread in both men and women, though it's more characteristic of women than men. 

ROBERT: Lack of sexual desire seems paradoxical in our sexually open society. 

JOYCE: And then pain for women, pain that interrupts the pleasure--

ROBERT: Physical pain?

JOYCE: Yes, physical pain. Often caused by destructive relationship patterns that manifest themselves in the sexual relationship. The most common example of such a destructive pattern is the one set up by an insecure, sexually demanding male. 

ROBERT: Paul, you're one of the leading scientists in sexual research. This is not a silly question: Why is sex so pleasurable?

PAUL: From an evolutionary perspective, sex is a simple but exquisite mechanism for motivating human beings to engage in those behaviors likely to lead to conception. The propagation of the species is the ancient biological force behind sex. 

ROBERT: Cliff, with the increasing openness of sex in society, are the sexual problems that you encounter changing?
CLIFF: Many more people now believe that they should find deeper fulfillment in sex. They are seeking more exquisite satisfaction. And so problems arise, I would say, when realizations don't meet expectations. 

ROBERT: Shep, as a medical doctor, you have a chapter on the act of love in your best-selling book How We Live. How important are sexual function and dysfunction in normal human relationships?

SHEP: Sexual function is the primary center of everything we are as human beings. Sexuality is the core of our personality; its powers focus our ability to love, to enjoy a heightened sense of our surroundings. It's moonlight, it's roses, it's poetry. If this sounds too Freudian, I won't retract a word of it. Sexuality empowers us to express everything that is within us. And that's one reason we often think of sex as a release.

ROBERT: Modern scholars criticize Freud for precisely your grand view--eloquently expressed--that sex is pandemic in its power over human thought and behavior. Do you agree with this Freudian maximal position of sexual influence and control?

SHEP: I think sex is the sum total of what we are as biological, sentient creatures. What we must come to consider is sexuality as an aesthetic. What we must come to appreciate is the true romance in sex. What we must come to understand is the altruism in sexual love. And it's this grander notion of the aesthetics of sex that can be lost in our need to understand the mechanics of sex. True sexual fulfillment means satisfying another person as well as satisfying oneself.

ROBERT: Vern, you've written or edited dozens of books about sex, such as "How I Got into Sex"--the personal stories of people who make their living dealing in one way or another with sex. As a keen, longtime observer of the sexual scene, can you tell us about some of the common mistakes that sex therapists make?

VERN: It's dangerous to generalize about sex therapists. They vary tremendously; there are good ones and there are bad ones, and the difficulty is that you don't know which is which. Choosing a sex therapist can be like stepping into the water and finding out that it's scalding hot, but you're already in deep and already getting burned. Unfortunately, many practicing sex therapists pay little attention to current research. They just don't follow the literature; they wing it. 

ROBERT: Sex therapy is a field that lends itself to intuitive practitioners setting themselves up as armchair experts, even though they're not professionally trained and can't comprehend the latest research. Sexuality is something that most people think they instinctively understand--common sense alone can supposedly provide an effective prescription. But in the highly complex world of human sexuality, instincts and common sense may point in the wrong direction. Worse, some sex therapists are like partisan fanatics, propounding their own peculiar views, which often do more harm than good. No one thinks of "winging it" where nuclear physics or neurosurgery are concerned, but there's little reluctance to spout untrained advice in sex therapy--just as in diet and nutrition, to pick another favorite field of intuitive practitioners. 

VERN: Yes, that's all true. The difficulty with sex therapy is that there are no professional standards regarding specific training. Where do you go to become a qualified sex therapist? Many come into the profession through clinical psychology--but you can be a marriage and family counselor, or you can be a used-car salesman, or you can be any number of things [that don't require certification]. All you need do is put up a sign and instantly you're a sex therapist. 

ROBERT: Let's get back to pleasure. Does an emphasis on pure pleasure, which is becoming more prevalent in sexual discourse, decrease personal intimacy?

JOYCE: I don't think so. Pleasure can lead to intimacy just as easily as intimacy can lead to pleasure. If pleasure is just satisfying a physical need, if personal enjoyment is expressed only as physical gratification, then pleasure can counteract intimacy. But if pleasure means two people enjoying each other's bodies, delighting in each other, and feeling good sensations of being together and sharing that moment, physically and emotionally, then pleasure can actually enhance intimacy.

ROBERT: Since sex in society has become so readily available--for example, on the Internet--doesn't it become more difficult to generate pleasure through intimacy rather than pleasure through isolation? Certainly, pleasure through intimacy takes more work than typing "www.xxx.com."

JOYCE: This is true particularly for men. When men go to the Internet to get a quick fix, so to speak, rather than going to their wives to have those moments of intimacy and connection, which is much more meaningful to women, then there's a progressive deterioration of the relationship. The sad irony is that such men don't end up happy, either, even though at the moment it feels good.

ROBERT: Paul, you've investigated sexual trauma in its many forms and variations. Do you see any change in recent years? 

PAUL: Sexual trauma and sexual victimization have always been pervasive, but two kinds of changes have emerged in recent years. First, society has taken these matters more seriously; we now give the victims more credence. In the past, credence was a problem, because sexual abuse was often perpetrated by people in positions of considerable authority--husbands, fathers, police officers, priests, and so on. Second, society is much more sympathetic to the victim, because sexual victimization is so pervasive, touching all social and economic circles. Today there's a great deal more support and sympathy available, in a social structure designed to deal with sexual trauma--the therapeutic community, the forensic community, the criminal justice system. Many district attorneys' offices have sexual-abuse units, which target such crimes. 

ROBERT: Let's go to the counseling situation itself. Cliff, Joyce, you obviously work together as a therapy team. Perhaps the fundamental operating principle that informs your counseling techniques is that there are marked differences between male and female sexuality. What are these differences, and how do they affect your counseling?

JOYCE: Who should begin?

ROBERT: I'm not going to decide; I don't want trouble.

JOYCE: One of the clear differences between male and female sexuality is pace. We deal with this all the time. Normally, we teach the man how to slow down and learn to enjoy the scenery as he takes his trip.

ROBERT: How much time do you need?

PAUL: That's a particularly male kind of thing to say.

JOYCE: Go for the goal--just go a little slower.

ROBERT: Go a little slower and you'll get there a little faster?

CLIFF: A man gets his greatest pleasure from experiencing the joy of a woman's response. There's nothing that turns on a man more than a turned-on woman. And when a male experiences a female turn-on, when a woman is really able to get with her own sexuality, when a male can take in a woman's sexuality, then they both end up satisfied. 

JOYCE: But all too often the man doesn't know any of this. He comes into sexual therapy complaining about the woman and her lack of responsiveness, not realizing that his satisfaction can come out of getting with her and allowing her to express herself sexually. If a man is more focused on "She never meets my needs" than he is on "How can I meet her needs?", he's the one who needs therapy the most. When such a man comes to our office, and many do, we encourage him to realize that getting with his mate and her complex sexuality--relating to her emotional needs and to everything that's going on with her--will be the key to opening her up sexually. And once she does open up, then she wants to be with him sexually and even takes the initiative by inviting him--and he's excited, because he feels affirmed and desired, and they both end up fulfilled and happy. It's a win-win situation.

ROBERT: Paul, if there are these differences between males and females, what do you think is the underlying cause?

PAUL: When you have such pronounced differences and you see them so consistently, you have to start asking whether these reflect some real fundamental differences between men and women. One idea that has been floating around recently is that these male-female differences represent true reproductive strategies across the genders. The old adage "Mother's baby; Father's maybe," conveys a biological truth. The woman is always sure of her maternity, so that female sexual strategy should be restrictive and protective. But because the man never can really be sure of his paternity, the male sexual strategy should be more permissive. If these fundamental differences are true, then sexual therapeutic solutions have to take them into account. So maybe fast-paced sex is all right at times because it reflects a male perspective. Good sex therapy has to negotiate solutions to reflect both male and female patterns of sexual behavior.

ROBERT: Joyce, you've asked a rather provocative question in your books: Who should lead in bed? 

JOYCE: The woman.

CLIFF: We always emphasize that it's the woman who should lead. Female leadership in sexual activity goes against what traditionally has been taught. But because women are so much more complex--because so much more has to happen for women in the sexual experience--when the woman can lead sexually from within herself and the man can follow that lead, then they usually both end up being more satisfied.

VERN: I think what you both are emphasizing--and this is the sign of a good therapist--

CLIFF: Thank you, Vern.

ROBERT: I want to hear what Vern says before we endorse it. I may not agree with him.

VERN: --is that good therapists should always develop a whole series of data before they try to offer any therapy. They offer therapies to help their clients, not to change their clients. The key is to listen to the patient, going beneath the superficial. When the husband says, "Well, she never responds to me," it's vital to find out what he really means by that. Until you do, you can't really be a good therapist.

ROBERT: Good sex therapists should not seek to change patients to their own sense of perfection.

SHEP: Joyce, how do you deal with the fact that many husbands are threatened by the thought of allowing their wives to take the lead in sex? That many men feel, whether for cultural or other reasons, that they should be the ones to take the lead?

JOYCE: Men should be the authority; they should know how to turn their wives on, so that their wives will then initiate sex.

SHEP: But how do you change such ingrained perceptions? How do you get men to do that?

JOYCE: First of all, as Vern just said, a therapist has to really understand the man, getting with him, finding out where he's coming from. Does he feel a lot of anxiety because he's unable to satisfy his wife? Ultimately, even though he's pointing the finger at her, he's really saying, "I'm inadequate--

CLIFF: "--I'm failing--"

JOYCE: "--I'm failing--I'm not satisfying her." That's when we can take the pressure off him and say, "Hey, she's going to keep changing every minute. There's no way you're ever going to figure her out. You know, it's as if she had an itch someplace on her back where you can't reach it and she has to tell you exactly how to scratch it. You're not going to know where the itch is and when it's there."

PAUL: Maybe I'm a nonconformist, but I like the idea of fast women, women who like to take the lead in sex. I think the way these things play themselves out in relationships depends on how we're embedded into specific roles. And I suspect that you'll find generational differences here. I don't think that the issue of masculine control, masculine initiative, and so on comes up very much with teenagers and young adults today. Gender parity in sexual relations is common now. 

JOYCE: Not in bed. Not in bed.

ROBERT: Joyce, are you perpetuating a stereotype?

JOYCE: I don't think so. Gender differences are a big dilemma for most of the couples I see, and in our practice we work mainly with couples in their twenties. 

VERN: One of the primary challenges in therapy is to facilitate communication about sex between the man and the woman. Often, communication difficulty is a male problem, but one of the big hurdles is getting the female to tell the male what satisfies her and what makes her happy. 

JOYCE: I'll say it again: The female must take more responsibility in sex, absolutely!

VERN: Facilitating communication is the key, and that's what a good therapist should do.

PAUL: I think that if sexual relations are modeled strictly on male and female roles, then one would expect homosexual relationships to be void of these sorts of dysfunctions. But we know that gay relationships, lesbian relationships, have their own dynamics that interfere with fulfilling sexual expression. These relationships play themselves out in ways that aren't specific to gender roles. 

ROBERT: Paul, do I sense that you're a little troubled by the specificity that Joyce and Cliff are suggesting, in terms of male and female type-casting?

PAUL: We may be referring to different population samples; the Penners may have a more limited sample of individuals who come to them for counseling. 

CLIFF: There's no question. We're talking about the people we see in our office.

ROBERT: Joyce, Cliff, about how many couples have you counseled in your career?

JOYCE: Large numbers. Cliff?

CLIFF: I'd say between a thousand and two thousand.

JOYCE: In addition, about three weekends each month, we teach sex seminars for audiences of up to five hundred people. 

ROBERT: It's real data, but it's still a relatively small sample, compared to the general population. More significantly, it's obviously not a random sample.1

{FOOTNOTE}1 The first sampling bias is "couples seeking professional sex therapy," and the second sampling bias is "couples within the evangelical Christian community." Such biases mitigate taking the results as a generalized reflection of the entire population. On the other hand, the Penner's substantial number of clients seem significant for portraying "couples in the evangelical Christian community who seek sex counseling."

VERN: I'll raise a delicate question for Joyce and CLIFF: Have you ever counseled gay couples and lesbian couples? 

CLIFF: Most of our clients are married, mainly because we work in the Christian community. And so I would agree; our sample is biased. 

PAUL: The concern I was raising is that we shouldn't truncate the application of sexual therapy to the very limited domain of married couples or individuals on that track. Sexuality is embraced by everyone. There is a rainbow of diversity in the way people couple and express their sexuality. 
JOYCE: People are sexual persons from birth--they don't become sexual persons when they marry. But in our sexual therapy practice, we particularly work with heterosexuals.

CLIFF: And we'd say that we work with the general masses. We don't work with groups on the edges. That's just how our practice is.

ROBERT: Joyce, let's talk about a specific counseling situation. A couple comes to you and they say they're having some problems. What's your procedure? Do you interview the wife? Does Cliff interview the husband? Do both of you work with both of them in a group? How do you counsel?

JOYCE: We usually begin by going through a three-hour process. In the first hour, I meet with the woman and Cliff meets with the man. 

CLIFF: In the second hour, we reverse roles. I have an hour with the woman, while Joyce has an hour with the man. 

JOYCE: And then the two of us meet with the two of them.

ROBERT: All on the same day?

CLIFF: All on the same day, and our goal during that time is to make a very thorough assessment, mainly because we see people who have already been seeking help from other places. We try to define, as narrowly as we can, specifically what the issues are. And very often these issues turn out to be quite different from what our clients first report.

ROBERT: What's an example?

CLIFF: An example would be a sexually insecure male who comes in saying that his wife is not responsive to him, that she lacks sexual desire. What's really going on, in fact, is that he gets much of his affirmation as a person from her response to him as a sexual being.

ROBERT: So a superficial sexual denial becomes a deep personal insult?

JOYCE: Right. Another scenario might occur on the honeymoon. Husband and wife are both excited about starting their marriage and--usually--their sexual relationship. Often she's eager for sex, expecting that they'll have sex once or twice a day. And so they do have sex, and the sex is good, but perhaps one time when he approaches her she isn't ready. And so his insecurity rises instantly and his self-assessed value as a person tumbles.

ROBERT: Insecurity is the only thing that rises, right?

JOYCE: Yes, that's right, insecurity is the only thing that rises. And now he starts getting anxious about whether she's ever going to be interested in him sexually again. So he starts evaluating her, watching her, making comments. This kind of behavior can go on for a year or so before they come into to our office, both of them complaining about her lack of sexual desire--because now it's no longer coming spontaneously, from inside. Instead, she's feeling on trial--observed and evaluated.

CLIFF: And she's trying to respond to him, but can't.

ROBERT: Both thought that she was the cause of their problems, when in fact it was his actions that stunted her sexual desire.

PAUL: It reminds me of the scene in Annie Hall where Woody Allen is talking to his male psychiatrist and says, "You know, we never have sex--only two or three times a week." And then you see Diane Keaton complaining to her female psychiatrist, "We have sex all the time, two or three times a week."

CLIFF: So the data may be the same, but the perception can be very different.

JOYCE: That's the one question a therapist always asks in counseling couples--"How often are you having sex?"--and you compare their answers. Then you ask, "How often do you think your spouse would want to have sex?"--and again you compare their answers. These comparisons are often very interesting and instructive.
ROBERT: What about all the increasing technology enhancing or openly offering sex--from Internet cybersex to chemical enhancers like Viagra? Are these sexual technologies affecting your practice?

CLIFF: That's a complex issue. For example, Viagra can greatly reduce the length of time it takes to treat impotence. We can concentrate on the emotional and relational aspects, because the physical side is resolved in about seventy percent of the men. 

ROBERT: But Viagra can also alter the psychosexual status quo. Some older men may suddenly desire a higher level of sexual activity, and such demands may be uncomfortably intesnse for their spouses. Other men may feel intimated by the new pressures to perform. Likewise, internet cybersex can be addicting and distracting to some people, while stimulating and reinvigorating to others.

VERN: Many men take Viagra thinking it's going to cure all their sexual problems, because suddenly they're able to perform physically. But their wives, or their companions, are not prepared for this. 

JOYCE: That's right. She's complaining, "I thought it was over!" 

CLIFF: She thought his sexual demands were history, part of their past, and now, all of a sudden, he's back pressuring her about sex again.
SHEP: Where is love in all of this? You're Christian therapists, and in the Judeo-Christian tradition we say, "Cast your bread upon the waters, and it will return ere many a day." It seems to me that the lesson you're giving us is that the essence of sex is mutuality, and that it's love that enables sex to engender fulfillment. So, why don't we talk more about love? Let's go back to your clients on their honeymoon. Here are two people who have just gotten married, for God's sake! They must be desperately in love. We should ideally--as I am sure you do--appeal to exactly that. Love in some ways is self-generating, self-replicating--at least, temporarily--although it needs constant refurbishment. Love is the essence of everything we feel for another person, and we express it, or try to express it, with sexuality, which, as counselors and therapists, you help us to do.

JOYCE: Sometimes, when a couple starts having sexual problems, the first question that arises in their minds is "Did I marry the wrong person?"

CLIFF: Or "Maybe I'm not in love." This is a very common question--one of the questions they come into counseling to answer.

ROBERT: Is such fundamental insecurity common in sexual dysfunction? When something goes wrong in the bedroom, husbands and wives question their love?

CLIFF: That's right.
JOYCE: And we really have to help them sort this out. 

SHEP: In your experience, do people realize that sex in the evening is a reflection of what has happened during the course of the day? Or do they think of sex as a kind of event, on a timetable? "Here I am--it's Thursday." Too often it's--

JOYCE: It's the male-female difference again. The woman says, "You came home from work, or we came home from work, we put the kids to bed, we had dinner, you went and watched TV, you didn't have any interest in me at all, we got into bed, you flipped off the remote control, you slapped your hand over me, and now you're ready for sex? Now you're interested in me?" 

PAUL: But that's a plain failure of communication and intimacy. 

JOYCE: Yes, that's right. 

ROBERT: I don't know anybody who hasn't experienced that.

PAUL: What counts is how we partition our time. 

JOYCE: How you stay connected.

PAUL: And also the impact of children on one's sex life. 

ROBERT: Someone once said that the frequency of sex is inversely proportional to the number of diapers. 

JOYCE: Yes, and that "Sex makes children, but children don't make sex."

PAUL: I thought you were going to say, "Insanity's inherited--you get it from your kids." 

ROBERT: To what extent is love necessary for sex? For enhancing a long-term relationship, we should want love and sex to be intimately intertwined. But is our tradition of connecting sex and love a universal requirement? Each one of these words--sex, love, intimacy, pleasure--maintains its own separate existence. There's no perfect correlation between any of these terms, but I think what you're all saying is that the more correlated they are, the stronger the total satisfaction.

SHEP: What sort of pleasure are we looking for? Sometimes we talk in terms of this involuntary, mechanical reflex, this wonderful tickling sensation, this orgasm. But of course the ultimate pleasure is the pleasure of love. The pleasure of experiencing another human being and giving to that human being that which is entirely you. And if people thought more in terms of this kind of other-person-centered love and less in terms of the self-centered, mechanistic kind of sexual pleasure, which is only part of a larger pleasure, we might do a lot better. 

CLIFF: You're talking about the sex beyond the orgasm, aren't you?

SHEP: I'm talking about a larger view of sexuality, but I would like to ask Vern [Bullough], What's the relationship between sex and love, historically?

VERN: They're not very closely related. In many societies, marriages were arranged, and it might become love afterward. Marriages were arranged for various reasons--economic, say, or political. Romantic love is a rather late invention. It begins in the fourteenth and fifteenth centuries, but it doesn't really become a major factor until the nineteenth and twentieth centuries. So, love and sex are something we are trying to wed, so to speak, because love and sex were traditionally separate. Historically, you usually got married because you intended to reproduce. 

SHEP: I would argue that love and sex are linked both biologically and culturally, and that in previous ages we didn't recognize that.

JOYCE: That's a good way of putting it.

PAUL: But what's the biological basis of love?

SHEP: You should read my book [How We Live]. Love is an expression of psychological harmony, symmetry, and unity, which I think the human organism requires in order to fight off the sense of chaotic disaster and death that goes on within us and that we are on some level, whether consciously or not, aware of.

ROBERT: I'd like to discuss sexual behavior from a different angle. Vern, let's talk about sex and old age. Give us your take on this sensitive subject. Most people can't imagine their parents having sex, much less their grandparents. I hope it's a fallacy that men reach their sexual prime at nineteen.

VERN: Even if we peak at a young age, we can coast along at a high plateau for many years. 

JOYCE: The older you get, the more creative you become.

ROBERT: The more creative you have to become.

VERN: As a sexually active male past seventy, I can give personal testimony that sex does exist and is a very important part of life. But, again, it depends on communication. Older couples for whom sex is no longer important have lost something valuable. If the wife says, "Thank God, I'm past the menopause, and sex is over," that's a real problem in the marriage--not a problem of sex per se, but of the marriage. 
JOYCE: It's a problem for the older women personally, too, because she hasn't yet accepted her sexuality and her sexual needs.

VERN: Well, the older man still feels a great desire--witness the popularity of Viagra. Previously it was all the plastic penile inserts, and so forth. Wives would sometimes tell me, "He didn't ask me before he went and got that piece of plastic. I didn't care about all that--I'd like something else." 

ROBERT: What about sexual addiction? We hear about it at all levels of society. Is sexual addiction a real illness or a clever excuse?

CLIFF: Whether we call it an addiction or not, there are people who are hooked in their behaviors--compelled to look for sexual gratification outside their normal relationship. Sex controls them; they don't control sex. This is what makes the behavior look like an addiction.

PAUL: "Sexual addiction" is probably more a misnomer than a legitimate illness, because true addictions presume a physiological dependence, for which we have no evidence in the case of sex. What we're basically dealing with is compulsive sexuality, which is detrimental to individuals and destructive to their relationships.

ROBERT: In any medical procedures, there are misdiagnoses. What happens when patients are misdiagnosed in sexual counseling? What are some examples?

JOYCE: Early in our practice, before there was general awareness of sexual addiction, compulsion, or abuse, we missed some of these diagnoses.

CLIFF: Yes, we missed many cases of abuse. We didn't understand why a woman reacted as she did, because we were not taking the abuse in her past seriously. Now we do.

JOYCE: As another example, because of what we now understand physiologically about hormonal regulation, we're now treating conditions we didn't treat previously. We're working much more with the medical profession than we were in the past. New information changes the sexual therapy process.

SHEP: Is sexual abuse a one-way street? Or is there some mutuality here? Does the abused person have a need to be abused? Do they somehow, on an almost conscious level, find each other?

CLIFF: Well, what we're talking about is a situation in which a five-year-old, say, is abused by an adult.

SHEP: Oh, about children--that's something completely different. I was referring to something like chronic sexual dissatisfaction, in which one of the partners is obviously very much at fault and therefore the other partner, in a sense, is being abused. Is there any mutuality there?

CLIFF: There's always this relational issue to consider, absolutely. Often the abuser came from a situation of abuse and is now reliving it, hoping to make things come out all right. 

ROBERT: How often do you face sexual abuse within marriages? 

JOYCE: That's hard to define. Are the behaviors simply perceived as abuse, or are they actually abuse? It's often difficult to determine, because an action can feel like abuse to the wife--particularly if she was abused as a child--in situations where the husband may not have been abusive at all. His actions may constitute normal sexual behavior patterns, but because of her past abuse, what he's doing feels like abuse. The solution largely depends on the man in this case. He has to change his behavior, even though it's not truly abusive, until she heals; because as long as she perceives what he's doing as abuse, it is abuse. And it won't work.

PAUL: Abuse is not limited to the sexual arena. Complaints about abuse are really more often about psychological abuse--domination and intimidation and issues like that are typical goals of abusers. 
JOYCE: That's right.

SHEP: So, once again, it's the relationship that's the important thing. 

VERN: Understanding the relationship is the key to good sex therapy.

JOYCE: One of the key points in our book What Every Wife Wants Her Husband to Know About Sex is, how do you negotiate? Good negotiations between husbands and wives about sexual matters sustain a robust relationship. 

ROBERT: I have a question for the Penners. Cliff, Joyce, you are a sex therapist couple. So I assume that many of your patients would like to know, but are too polite to ask, whether you guys ever have problems when your bedroom doors are closed? 

CLIFF: That's private [with a smile].

ROBERT: I promise not to tell.

JOYCE: Sure we do; everyone has problems. Fortunately, we function very well together and have for over thirty-five years. Sex has been a vital part of our lives, personally as well as professionally. Sex is important for me, and I appreciate Cliff for following my lead in the bedroom, allowing me to express myself. We have fun with our sexuality, and we negotiate our differences. 

CLIFF: I was just going to say the same thing.

JOYCE: One of our key points in our book, What Every Wife Wants Her Husband to Know About Sex, is, how do you negotiate? Good negotiations between husbands and wives about sexual matters sustain a robust relationship.

ROBERT: Allow me to get a little more personal--I'll be your sex therapist for a moment. Joyce, what percentage of the time do you take the lead in initiating sex?

JOYCE: I would say….

CLIFF: Joyce, what do you think?

ROBERT: No checking; no communications. Cliff, Joyce, write down your numbers -- "What percentage of the time does Joyce initiate sex?" No peeking.

JOYCE: I wrote seventy percent.

CLIFF: I wrote seventy-five percent. 

ROBERT: That's pretty close; I'm impressed. 

CLIFF: One of the reasons our relationship works well is that Joyce has a higher sexual drive than I do. At least she seems to express it more frequently. Joyce has a greater need for sex than I do, and that has been true all along. 

JOYCE: I was fortunate to have grown up extremely naïve; I was never taught a thing about sex. I then went to nursing school where I was taught a very clinical, very positive approach to sexuality. I have always been a good student; I took down every note; I studied sex avidly.

CLIFF: And then she lived it out for the last thirty-five years.

ROBERT: Joyce, are you faster than he is? 

CLIFF: Sexually, or just….

ROBERT: You may interpret my questions as you like. 

JOYCE: Sex is not a race.

ROBERT: Joyce, when you initiate sex--seventy percent of the time as the whole world now knows--do the sexual behaviors differ from when Cliff initiates sex? Or are your sexual patterns pretty much the same no matter who makes the first move?

JOYCE: There is a difference. 

ROBERT: So, what is it? Don't worry; we're still private here.

JOYCE: I think that when sex starts with me, it has more intensity.

CLIFF: I agree. And when sex starts with me, it is more about meeting my needs--but Joyce is not really there and it is not quite as good. 

JOYCE: But I can get there.

CLIFF: Yeah.

JOYCE: And I do.

ROBERT: We're ready for a prediction. In a hundred years, will there be a greater or lesser need for sex therapy?

JOYCE: I'd say, "greater." And not just behavioral sex therapy, but intimacy training as well. 

ROBERT: That's a good business decision for a sex therapist. But do you really believe it?

JOYCE: In a hundred years, I don't think it will matter to us.

CLIFF: Because our sexual world is getting more complicated, people are going to need more help in a greater variety of areas. And one topic we haven't dealt with here is the whole issue of commitment. It's a key issue in building relationships. Maintaining commitment is a struggle in society these days, and unless we get that worked out, we're in for trouble. 

PAUL: Like rock 'n' roll, sex therapy is here to stay. The kinds of societal pressures that disrupt couples and attenuate their ability to stay close and communicate will increase, so there's going to be a continuing need for sex therapy. 

VERN: I don't think there will be a need for sex therapy in a hundred years, but I do think there will be a need for therapy to encourage intimacy and conversation. I hope we'll have learned all the techniques of sex by that time, so we shouldn't call it sex therapy anymore--we should call it intimacy therapy.

JOYCE: We hope that encouraging intimacy would always be a part of sex therapy. 

VERN: Then I think it shouldn't be called sex therapy. 

JOYCE: You're right--"intimacy therapy" might be a better term.

SHEP: I'd call it estrangement therapy. As our society grows more mechanistic and distancing, what we'll need is therapy to strengthen relationships, out of which will grow appropriate expressions of sexuality. 

JOYCE: This is what the best sex therapy is already more concerned with.


ROBERT: CONCLUDING COMMENT

WE all agree that seeking sexual fulfillment is a natural need of human beings. We all believe that sex therapy can play a useful role in improving the sex lives of normal people. Where some may disagree is in the nature of the therapies. Is pleasure the crowning achievement? Or does intimacy take top honors? Must there be a higher purpose? Pleasure is important, to be sure, but as we have seen, it may diminish without intimacy. Delving a little deeper into controversy, how do we compare male and female sexuality? Do the genders respond similarly? Or are there fundamental sexual differences between men and women? A failure to appreciate some of these differences, it seems, may lead to frustration, even irritation. Much as we may hate to admit it, we all probably need some lessons. Optimal sexual fulfillment doesn't come quite so naturally. But its achievement is surely worth it. Admissions like these are what bring us closer to truth.

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