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Not uncommonly, one member of a couple …

will see me in the office with a concern about the sexual aspects of their relationship. Of course many things can go wrong when it comes to sex. We all know about erectile dysfunction since we are bombarded regularly by ads for Viagra and Cialis. Another common problem for women after menopause is pain with intercourse. This is often caused by the lack of estrogen in the vagina and is best treated with estrogen inserted locally, saving the risks of taking oral estrogens.

But another, less often discussed issue is that of low sexual desire. Sometimes the problem of low desire overlaps with erectile dysfunction or vaginal dryness. Other times, low desire exists by itself. To begin our analysis of this issue, we should first turn to several experts who have written about the problem.

“During sex, my wife always wants to talk to me. Just the other night she called me from a hotel.”

“Last night my wife met me at the front door. She was wearing a sexy negligee. The only trouble was, she was coming home.”

—Rodney Dangerfield

“I don’t think I’m good in bed. My husband never said anything, but after we made love he’d take a piece of chalk and outline my body.”

“My best birth control now is just to leave the lights on.”

—Joan Rivers

Sometimes, the problem is that a couple is just not getting along. It’s difficult to want to have sex with someone when you are upset or angry with that person. Another common problem is that the couple is just too busy. They have so many activities, job responsibilities, social obligations, exercise routines, and travel that there is little time left to reconnect physically and emotionally. Having kids underfoot is a big issue for many couples and can hamhelp for old married couplesper their sex life. Older teenagers likely say the same about their parents.

There are other obvious problems that can arise, and one does not need to go to medical school to sort these out. Sometimes one partner is no longer attracted to his or her spouse. Other times, couples grow tired of having sex with the same person after many years.

Doctor: Do you watch your husband’s face during sex?

Patient: I did once & saw anger.

Doctor: Why?

Patient: Because he was watching from the window.

But sometimes, the problem is more perplexing. A couple will report that they are mutually attracted, they are getting along well, the plumbing is working adequately, no one is under major life stress, but that sexual desire remains low.

For readers of a certain age, the team of Masters and Johnson is a household name. William Masters, MD, was a gynecologist who spent his career researching the human sexual response. Along with his assistant, later his wife, Virginia Johnson, they wrote two classic textbooks and pioneered a treatment program for sexual dysfunction. Their program was based on what are called sensate focus exercises. To understand the neuropsychology behind sensate focus exercises and why this works as a behavioral treatment for low sexual desire, we have to explore a bit of the neurobiology of sexual desire itself.

I often tell my male patients to consider this thought experiment: Imagine that the entire squad of the Dallas Cowboy Cheerleaders were out on the street and you could pick the one you liked best and have sex with her. Pretty appealing, right? Now, imagine that you had to sleep with the entire squad, two girls per night, every night of the week for a year. All of a sudden, this is less appealing. Some of those cheerleaders are sorta funny looking. Others have annoying personalities. This is more sex than anyone really wants. Most men would ultimately find the idea very punishing and not at all sexy. Sex would have gone from something enjoyable to an obligation.

Masters and Johnson realized that thhelp for old married couplese best way to spark sexual desire was to forbid the couples they were treating from having sex. The fact that sex is forbidden takes a lot of the pressure off the person with low sexual desire. This is the first step in treatment. They recognized that if one partner in the couple felt he or she were providing sex out of a sense of obligation, this would lower libido. But if sex is “forbidden,” then sexual desire and sexual activity are likely to eventually increase, much to the chagrin of most of the world’s religions.

The next step is to have the couple engage in a series of exercises designed to rekindle their desire and to reconnect as a couple. It is a program which is undertaken over a period of a few weeks. During sensate focus exercises, the couple secures a private time when they will not be interrupted. Lighting candles and a little Nora Jones music is encouraged. Masters and Johnson developed this technique in the sixties, so in the original version, I would suspect that incense and Indian sitar music were used.

“Marriage is a wonderful institution,

but who would want to live in an institution?”

— H.L. Menkin

The couple takes off their clothes if they wish. Some couples start out partially clothed. The goal is whatever is most comfortable to each person. First, one member lies down and the other takes about 20 minutes touching and exploring the partner. The R- and X-rated parts of the body must be avoided, including breasts and buttocks. The person being touched tells his or her partner what feels pleasant. The couple absolutely must communicate during the exercise. Then they switch roles. This is phase one and is done two to three times per week for two weeks. No sex is allowed.

In phase two, the exercises begin as in phase one, but the couple is allowed to touch the other partner’s X-rated parts. I recommend a phase here where there is touching of breasts and buttocks, but no genitals, then proceeding to genital touching after a couple of sessions. No sex is allowed. The goal is not to get anyone to orgasm, but to simply explore and communicate what feels good. This also goes on two to three times per week for two weeks.

In phase three, weeks five and six, the couple again starts out with sensate focus exercises, but they also proceed to have sexual intercourse.

Sometimes I will suggest a certain modification in the basic framework depending on the issues and the severity of the problem. If you Google (or Bing for my Microsoft patients) the term “sensate focus exercises,” you will see many examples and testimonials regarding this effective technique. The goal is a lighter touch, not a massage. Slow touching is generally better than fast motions. Also, touching the face, hands, and feet are an important part of sensate focus. Creating variety in the style of touch can be helpful as well.

Sometimes couples think that the answer to rekindling sexual desire is to explore kinky sex. My view, corroborated by the work of Masters and Johnson, is that kinky approaches are fine for a couple who has a relatively well functioning sex life, but that when their sexual connection needs repair, that sensate focus is the proper way to go.

One of the many benefits of these sensate focus exercises is that they help establish good sexual communication between the partners. Early in their relationship, couples sometimes enter into a “conspiracy of silence” in which they both secretly agree to not talk about sex very much because it can be embarrassing. This decision is often a permanent one, and it can be difficult for many couples to backtrack later on and start speaking openly about sex after many years of avoiding the topic. The problem is that while new couples may have a perfectly fine sex life without ever discussing it, longstanding couples generally need a very open, accepting, mutual dialog to work out issues as they arise over the years.