Some 20 or 30 years ago, it was assumed that 90 percent of erectile problems were caused by psychological or relational factors. But since our culture tends to veer wildly from one extreme to another, the majority view today is firmly in the opposite camp: faulty physiology is widely assumed to be the culprit. Luckily, there’s been a neat, little remedy on the market since 1998: Viagra. Today it seems that the entire North American population not only knows about Viagra, but devoutly believes in its miraculous powers to restore the lost sexual vigor, and rigor, of youth.
Unfortunately, for the majority of middle-aged and older men experiencing problems getting and/or maintaining their erections, the drugs being promoted in the media are hardly a panacea. We’ve found that helping couples deal with erectile problems and other sexual realities brought on by the aging process has as much or more to do with their psychological and relational lives as it does with their physiological capacities.
Like the great majority of males, Bill learned from his first experience of sexual intercourse in his late teens that sex was powerful, self-validating, and completely predictable—desire, erection, intercourse, and orgasm followed each other as regularly, quickly, and easily as clockwork. Even more important for his masculine pride, his sexual response seemed entirely autonomous: his entire physical mechanism worked perfectly, almost regardless of the help or enthusiasm of his sexual partner.
Fast forward 33 years. Bill is 51 years old and has been married for seven years to 48-year-old, perimenopausal Cynthia (a second marriage for both). He’s finding that his equipment is definitely performing below par. Like half of men by age 50, Bill has begun experiencing occasional difficulties getting an erection.
He’d experienced a similar problem once before, during his divorce 10 years ago. But when he met Cynthia in his mid-forties, the romantic love, idealization, and passionate sex recharged his batteries, and erections clipped along with the same dependable regularity that they had previously.
His distress over the renewal of his erectile difficulty was made even worse when Cynthia wondered out loud if it meant that he didn’t love her or wasn’t attracted to her anymore. So he began working harder to get hard, in a determined effort to show his wife that he found her to be the same sexy dish he always had. However, the attempt to will a great sexual performance brought a negative cycle of anticipatory anxiety, tense intercourse, more “failures,” increased frustration, embarrassment, and, finally, avoidance of the whole miserable business. For Bill, sex was a pass-fail exam, and he was on the wrong side of the grading curve.
Believing, as many American men do, that a little pill would do the trick, Bill went alone to his internist to get some Viagra. His doctor made sure he had no systemic medical problems and then prescribed the medication without recommending any additional medical, psychological, relational, or sexual interventions. The doctor assumed that the pill, all by itself, would bring back the frisky, confident potency Bill had enjoyed earlier in life.
In fact, Viagra did improve Bill’s erections, and he and Cynthia resumed intercourse. But the results were oddly disappointing. Because he wasn’t entirely sure of the longevity of his new chemically-induced erection, he was in an anxious “use it or lose it” mode, and rushed to intercourse as soon as he got aroused. Good-sport Cynthia didn’t want to add to his anxiety, so she didn’t object to the speediness of the proceedings, but she found penetration, if not painful, at least uncomfortable when her body hadn’t had time to “get into it.”
Although Bill managed to achieve intercourse and ejaculate intravaginally about 70 percent of the time when taking Viagra regularly, the thrill was gone. Disconcerted and disappointed, within a few months, he stopped taking the pill and, once again, avoided sex completely. To Cynthia, he began to seem more emotionally aloof, as well—spending more time brooding alone. This is the outcome for a significant number of men. They feel like “Viagra failures” because their results didn’t live up to the high-octane marketing hype that fills the media.
Unsurprisingly, the marriage itself began heading south. Cynthia became increasingly irritable and depressed, and the two engaged in an unhelpful series of attacks and counterattacks on the subject of who’d killed their sex life. Eventually, Cynthia called Barry McCarthy, a couples therapist she’d found on the Internet who had a subspecialty in sexuality. He suggested starting with a four-session assessment process—an initial session for the couple, an individual session for each, and a feedback session involving both spouses. This seemed a logical and sensible way to proceed, and Cynthia convinced Bill to come to the first session.
In the preliminary session with the two of them, it was clear that, in spite of their sexual woes, Bill and Cynthia loved each other and wanted a satisfying, stable second marriage. But Bill’s no-sex rule was draining the vitality out of the relationship by subverting its intimacy and emotional satisfaction. Unfortunately, he didn’t think there was any solution to the problem: he’d seen the doctor and taken his Viagra. What else could he do? At this point, he thought that Cynthia should accept the fact that he just wasn’t the man he used to be, they should get on with their (sexless) marriage, and she should quit nagging him.
This didn’t seem like much of a plan to Cynthia, who felt emotionally rejected, sexually abandoned, and completely blindsided by the deterioration of marital sex and their entire relationship. In truth, they were both demoralized and caught in that most classic of couple’s routines: the pursuer-distancer dance choreographed to a blame-counterblame rhythm.
In this initial couples session, Bill and Cynthia played out their roles to perfection. He said he loved her and would remain loyal, but insisted that she must accept the unalterable fact that he couldn’t perform sexually in a way that would satisfy her. He also hinted that she was to blame—her pressure made him so anxious that it was no wonder he couldn’t do the job.
Cynthia countered by pointing out that he not only avoided intercourse, but any physical intimacy or touching. Both looked sullen and defensive at this point in the session. They didn’t project any sense that they belonged to the same intimate team, although they’d have to work together as a team if they wanted a sexually satisfying marriage.
Teaching the Concept of Sexual Teamwork
At heart, the problem was the disabling, but very common, belief held by both Bill and Cynthia that sex was zero-sum game, a win-lose athletic performance, measured entirely by the “success” or “failure” of the male arousal-intercourse-orgasm sequence. So the first step was to educate the couple to the amazing possibility that they could develop a new sexual style, replete with desire, pleasure, and mutual satisfaction—one that completely bypassed the old up-in-and-out model of sex that Bill (and, implicitly, Cynthia) believed was normal.
The advantage of the individual assessment sessions that followed is that they provided an opportunity to take a detailed sex history, which helped reveal each person’s emotional and sexual strengths and vulnerabilities. Cynthia valued the special bonding and energy generated during sex. She missed this now, but felt powerless to influence Bill to reengage. The most striking thing revealed in Bill’s individual history was how narrow his view of sex was.
The couple feedback session that came next offered a chance to help Bill and Cynthia create a new relational and sexual narrative based on a good-faith commitment to a sexual life focused more on intimacy, pleasure, and satisfaction than on intercourse per se. We gave them a psychosexual exercise to take home—a playful touching experience involving both nongenital and genital stimulation—saying that intercourse wasn’t allowed for the time being. This introduced a new approach to lovemaking. Cynthia was enthusiastic when she heard about it, but Bill was dubious. He said he wanted intimacy and touching back in their marriage, but continued to be dominated by fear of intercourse failure.
Psychosexual Skill Exercises
Good Enough Sex (GES) therapy doesn’t attempt to have the couple talk through their sexual impasses. Instead, it uses psychosexual skill exercises designed in session to eliminate performance demands on each partner: in this case, for Bill to get an erection and for Cynthia to get him hard.
In therapy, Bill and Cynthia learned how to build comfort with touch, both inside and outside the bedroom, how to take turns being stimulated, how to make verbal requests of each other, and how to “let their fingers do the talking.” They explored Cynthia’s patterns of receptivity and response. They created opportunities for Bill to “piggy-back” his arousal on Cynthia’s—a totally new experience for him. At each session, they discussed the exercises they’d done at home and then helped formulate one or two additional psychosexual skill exercises to be tried as a team that week.
Like all men with erectile dysfunction we’ve seen for sex therapy, Bill disliked the idea of doing exercises that not only permitted but required him to lose his precious erection—to let it wax and wane—while he and Cynthia focused on pleasuring skills. But once the performance anxiety was removed in this way, he grew to enjoy the playfulness of sex and learned not to panic if his erection “took a break.” He came to realize that if he stayed relaxed and open to sensual stimulation, his erection would generally return within a few minutes. Both Cynthia and Bill found the emphasis on intimacy and giving each other sensual and erotic pleasure to be a positive experience, which helped them feel like an intimate team again.
Because most men consider sex a highly predictable course of events—erection, intercourse, and orgasm—they often find it hard to get comfortable with a more flexible approach, and Bill couldn’t have done it without Cynthia’s support. Like most women, she’d learned a model of sexuality fundamentally different from that of men: viewing sex as an intimate, interactive, variable process. She and Bill were, in effect, learning together to practice a more traditionally integrated, balanced, “female” style of sexuality, which would age far better than his young-stud approach.
Seeking Good Enough Sex
As it turned out, the biggest challenge for Bill, as with most men, was to accept the GES approach and to understand that it’s normal in men his age for 85 percent of sexual encounters to follow a somewhat slower trajectory. Instead of a fast, urgent format common among younger people, sex among experienced and older men is more successful and enjoyable when it proceeds from anticipation (thinking about and looking forward to a later encounter, maybe hours away), to comfort (approaching sex without anxiety or tension, and feeling open to whatever happens), pleasure (enjoying physical touch and emotional stimulation), arousal (increased blood flow, heart rate, and erection and feeling turned on and fully engaged emotionally), erotic flow (high levels of subjective and objective arousal and willingness to let go physically and emotionally), and intercourse as a natural extension of the pleasuring/eroticism process. He had to learn that life wasn’t over when sex didn’t end with intercourse: he could be happy and comfortable with an erotic, nonintercourse scenario, sensual cuddling that ended in sleep, or a request for a “rain check.”
Bill found that once he learned he didn’t have to prove himself, he could enjoy a range of sensual and erotic encounters and be comfortable taking a “rain check” for intercourse. Then over the next couple of days, when he felt rested, awake, and fully alert, he could enjoy sex the “old” way—erection leading to intercourse with orgasm. Having on hand at least one, and preferably all three, alternative scenarios (erotic, sensual, or “rain-check”) establishes a sense of sexual and emotional resiliency in a couple and “good enough” sex becomes more than good enough.
The focus in the GES approach is on changing and blending attitudes, feelings, and behaviors of the partners. Although in treating erectile dysfunction, the focus is more on changing the man’s thoughts, behaviors, and feelings, the woman’s role is integral to the model. Most women we’ve seen not only accept this approach, but welcome it because it’s congruent with female sexual socialization and experiences. The model is congruent with mature male sexuality, too (unlike our culture at large, and particularly pop culture, which essentially exalts uncontrollable adolescent male sexuality as the only kind worth having). It honors sex as a means for the couple to use their bodies for pleasure, mature playfulness, closeness, and affirmation, while promoting feelings of desire and desirability and energizing their intimate bond.
The Quality of Sex Is Inherently Variable
To achieve satisfying, mature sex, it’s vital that both men and women understand that the quality of sex in a committed relationship is inherently variable. Sex is an interpersonal process, not an autonomous one, and is dependent upon all the emotional complexity and flux of any connection between two distinct personalities. In any relationship, therefore, sex will exhibit as many moods, colors, flairs, and profiles as the relationship itself.
Among healthy sexual couples, fewer than 50 percent of encounters are considered satisfying in the sense that both partners experience high levels of desire, arousal, orgasm, and satisfaction. Even more important, it’s normal for 5 to 15 percent of sexual encounters to be dissatisfying or dysfunctional. Even in happy, satisfied couples, the quality of sex varies from experience to experience—from exceptional to good to mediocre, even to downright lousy, on occasion. The resilient couple can revel in the great times, take some pleasure from the mediocre times, and accept with equanimity the times of distinctly ungreat sex. Therefore, the most realistic approach for couples seeking a happy sex life is to focus on establishing an overall pattern of desire, pleasure, and satisfaction, and not to expect peak sexual performance on every occasion, or even on many occasions.
Accepting sexual variability and flexibility as the healthiest model for men over 50 (and under 50, for that matter)—a realization that “wise” women often integrate into their sexual styles more comfortably—helps couples become intimate, erotic friends who approach sexuality as a team. Clinical experience has taught us that sexual problems arise when one or both spouses have rigid and conflicting ideas about the purpose for sex, when either or both misunderstand the different styles of sexual arousal, and when men and women become overly concerned about sexual boredom. Healthy couples accept that sexual complexity, variability, and flexibility are the keys to enjoying sexuality into their fifties and later through life.
Fortunate couples, or those who’ve been educated about mature, committed sexuality, learn what might be called the five main, interconnected goals of sex: (1) to share pleasure and enjoyment; (2) to deepen intimacy and satisfaction; (3) to reduce or alleviate the emotional stresses inherent in sharing a life with someone; (4) to reinforce and even enhance each partner’s self-esteem and confidence; and (5) to fulfill the traditional biological function of procreation.
Realizing and accepting that it’s normal to have sex for multiple and fluctuating purposes, and that many times each partner may have a different “agenda,” can reduce a couple’s conflict and promote cooperation. A couple can avoid the arguments that can arise when one or both have conflicting, one-dimensional, or restricted ideas about what sex is “for” or what it “should mean”—for example, that it “should” always be romantic and soul-stirring or that it “should” only be for procreation. With a more realistic and flexible attitude toward sex, each partner can enjoy various roles, accept each other’s differences, and appreciate the range of meanings that sex has at different times.
Sexual variability and flexibility allow partners to integrate the three basic styles of arousal arising from the person’s focus of attention: (1) on the partner (partner–interaction arousal); (2) on one’s own physical pleasure and sensual/sexual sensations (self-entrancement arousal); and (3) on fantasy and playing out erotic scenarios (role-enactment arousal). Youthful sexual response is usually based on partner interaction arousal, but, with experience and age, men and women often expand their sexual style to include self-entrancement arousal and/or role-enactment arousal.
Crucial Factors in Healthy Sexuality
We’ve found that the following 10 attitude shifts and actions can help men and women develop more realistic and rewarding attitudes about sex, and help couples establish a strong and resilient sexual relationship that will last well into old age.
1. Value sex in one’s relationship as intrinsically good and humanly indispensable. This means accepting that sex is more than being sexy or performing perfectly: it’s an integral part of one’s attitudes, behaviors, and emotions.
2. Commit to developmentally integrating one’s maturing sexuality into self-esteem as a man and a woman. Realize that one’s sense of “manhood” or “womanhood” doesn’t rest on the sexual behavior and characteristics exhibited by an 18-year-old.
3. Ground sexual expectations on accurate knowledge about sexual physiology, psychology, and relationship health.
4. Make intimacy the ultimate sexual focus, while valuing the joys of physical sex.
5. Value sensual and sexual pleasure above sexual performance.
6. Self-regulate sexual drive and arousal.
7. Incorporate flexible sexual arousal in lovemaking, rather than demanding total, predictable sexual performance.
8. Value cooperation in intimacy, viewing the partner as your intimate, erotic friend.
9. Integrate sexuality into daily life through a range of emotional and relational experiences, rather than compartmentalizing it into a separate event.
10. Embrace the GES model.
Bill and Cynthia After 70
Let’s imagine Bill at 74 and Cynthia at 71. Two of three couples have stopped being sexual at this age. The decision is almost always made unilaterally and nonverbally by the man, because he’s lost confidence in erections, intercourse, and orgasm. But not Bill and Cynthia, who take great pride in beating the odds and maintaining a satisfying sexual relationship.
Cynthia says “I enjoy sex more now than I did 20 years ago, because I know Bill needs me sexually, and our sexual relationship feels more human and genuine.” Bill agrees with his wife that sex is more intimate and interactive, but he also emphasizes how flexible their erotic scenarios are. He still prefers being orgasmic during intercourse, but he’s become open to erotic, nonintercourse scenarios, particularly enjoying mutual manual stimulation to orgasm and having Cynthia orally stimulate him to orgasm.
Partner interaction—being turned on by the give-and-take of partner stimulation— is still Bill’s preference, but he enjoys self-entrancement arousal, which allows them to take turns sexually rather than having all encounters be mutual. He’s found to his surprise that his erections are more reliable when he practices relaxing self-entrancement arousal.
Healthy sexuality develops over a lifetime. A challenge to males (and couples) is to stop clinging to the “perfect-intercourse” model and replace this with positive, realistic physiological, psychological, and relational expectations of oneself, one’s partner, and one’s relationship.
A particularly reliable indicator of Good Enough Sex is valuing sexual playfulness. For sex to be occasionally and genuinely playful, other aspects of intimacy must be functioning well, including trust, mutual acceptance, sharing pleasure, freedom to be yourself, and deep valuing of your intimate relationship. Intimate sexuality respects and accepts the complexity and ambiguity of human relationship, the multiple levels of reality, the spiritual dimension of life, and the importance of sex as a bonding agent.
Case Commentary
By Gina Ogden
Michael Metz and Barry McCarthy’s carefully crafted “Good Enough” program offers a range of skills crucial to helping couples like Bill and Cynthia move through midlife sexual performance crises. The program is based on several precepts invaluable for both clients and therapists: that sexual intimacy is an integral part of relationships throughout life; that it’s normal for couples to experience difficulties with intercourse as they grow older; and that Viagra and other performance-propping drugs aren’t the panacea pharmaceutical companies would have us believe. When Bill loses erectile confidence and consults his internist, he’s following a path traveled by countless midlife men (and women) who seek sexual help. Unfortunately, few physicians are trained to treat patients beyond writing a prescription.
The purpose of GES therapy is to help couples embrace relational complexity, introduce nondemand sensual pleasure, and teach a kind of “mature” teamwork to help open up erotic flow. Metz and McCarthy’s sequence of taking a sex history, education, and home-play reads like the best of Masters and Johnson, updated for the 21st century. Through this approach, Bill and Cynthia ultimately learn to value a new intimacy over their old routines, and to appreciate each other’s unique and changing arousal styles.
One strength of this gentle approach is that it demystifies sex therapy for both clients and clinicians. Yet embedded in it are assumptions that might undermine a couple less motivated than Bill and Cynthia. For instance, the program centers on the notion that a man’s changed consciousness will revive a couple’s flagging sex life. I believe the program would be strengthened by including a psychoeducational component on the sexual complexities specific to midlife women, such as body image, shame, guilt, and the hormonal anomalies of low libido. There’s the stated premise that “health” means heterosexual and committedly coupled. However, single adults constitute a growing percentage of midlife Americans, with many forming new and socially diverse relationships: gay, lesbian, and polyamorous, for starters. Finally, I’d welcome hearing how the authors might adapt their program to introduce flexibility and pleasure in resistant couples with messy histories of disappointment, abuse, clandestine affairs, ongoing fights about money, teenagers, aging parents, and on and on. These are the ones most likely to appear in our therapy offices.
Authors’ Response
Gina Ogden’s raises several important issues that give us an opportunity to elaborate on important features of the Good Enough Sex (GES) model. There’s a poignant irony that the pursuit of “great sex”—a goal for both men and women—becomes the cause of dissatisfying and dysfunctional sex. The idyllic pursuit of great sexual performance can be the source of personal dissatisfaction (even agony), relationship distress, fear, and feelings of inadequacy. GES shifts the expectation that sex should always be a perfect performance to one that it should be an adaptable, real-life, “intimate team” activity, with the goal of sharing pleasure.
Positive, realistic sex expectations include the realization by each partner that mature sex involves variability and flexibility, which itself inoculates couples against sexual dysfunction and alienation. Our perspective does center on the notion that the man’s changed consciousness fundamentally benefits a couple’s sexual satisfaction, because when couples stop having sex in midlife or older, it’s almost always the man’s decision to avoid any sexual touching to ward off anticipated failure of totally predictable erections, intercourse, and ejaculation.
When a man adopts the GES approach, he can not only free himself for pleasure, but alleviate the distress caused by body-image anxiety, shame, guilt, and low libido, all of which Ogden notes are felt by women at midlife. GES removes the performance pressures on both women and men, and invites personal and couple sexual acceptance and cooperation.
One advantage of teaching, self-entrancement and role-enactment styles of arousal, rather than total dependency on partner-interaction arousal, is to liberate women and men from rigid sex roles and expectations. They become more an intimate team, sharing pleasure and enhancing sexual function.
Our case illustration focuses on the male because it’s most often men who cling to the performance demands of their youth. We believe the GES model is relevant to couple dynamics for straight and gay couples. It can serve as a lifelong “compass” for female, male, and couple satisfaction.
We agree with Ogden that resistant couples are particularly challenging. Messy histories, abuse, affairs, ongoing conflicts, and/or major life stresses must be addressed as they are the milieu within which a sexual relationship is grounded. Realistic, reasonable cooperation as an intimate sexual team is a microcosm for the larger relationship requirements for both traditional and nontraditional couples.
Michael Metz, Ph.D., is a licensed psychologist and marital therapist practicing in St. Paul, Minnesota. Barry McCarthy, Ph.D., has a diplomate in clinical psychology and practices at the Washington Psychological Center. He’s a professor of psychology at American University. They’re the coauthors of Coping with Erectile Dysfunction and Coping with Premature Ejaculation. Their latest book is Men’s Sexual Health.
Gina Ogden, Ph.D., is a licensed marriage and family therapist, sex therapy diplomate, and researcher who lives in Cambridge, Massachusetts. She conducted the first national survey on integrating sexuality and spirituality, and is the author of The Heart & Soul of Sex; Women Who Love Sex, and most recently, The Return of Desire.
