On call: Wife’s disinterest in sex

On call

Wife’s disinterest in sex

Q.My wife and I, who both read your column, have
always enjoyed our intimate relations. Since she went through the change last
year, however, she’s lost interest in sex. She’s only 53, and although I’m 8
years older, I’m as amorous as ever. Do you have any suggestions for us?

A.We’re glad to have you both as readers; in many
households, after all, it’s women who watch over men’s health.

Doctors have learned a lot about the male sexual response in the Viagra era,
but there is less information about female sexuality. Menopause signals an
abrupt drop in female hormones such as estrogen and progesterone, but that
shouldn’t affect the female sex drive. In fact, libido depends on
testosterone, the male hormone, in both men and women.
Testosterone levels are very much lower in women than men, but they drop even
lower as menopause approaches, then remain stable during and after menopause as
the adrenal glands continue to produce small amounts of male hormones. Still,
some women are testosterone deficient and might benefit from testosterone
therapy. Unfortunately, however, data are scant, and much more research is
needed to learn if testosterone is safe and effective — and if it is, which
women should receive it and what dose and preparations are best. At present,
those answers are a long way off; in fact, the same questions about testosterone
replacement remain to be answered for men.

Another area for research is the use of Viagra for women. An early trial
found the drug safe but not beneficial for healthy postmenopausal women. More
research is under way, and other drugs are being developed for sexual
dysfunction in both genders. The FDA has already approved a hand-held
battery-powered clitoral stimulator for women with sexual dysfunction. Your
wife’s problem, though, may be a good deal simpler. Postmenopausal women who do
not take hormone therapy (and with research showing more harm than good, most
should not) develop vaginal dryness, which can make intercourse unpleasant or
even painful. So a simple place to start would be a nonprescription vaginal
lubricant such as Replens. If that doesn’t help, your wife should ask herself if
she might be feeling subtle stress or unhappiness or if she may be reacting to
personal, marital, or family conflicts. Her doctor may be able to help her sort
out possible physiological and psychological issues.

Discuss the problem with your wife frankly, but be patient and supportive,
always looking for mutually satisfactory ways to achieve intimacy and express
love and affection.

How To Spice Up Your Sex Life

Since the dawn of time, people have looked toward elixirs and potions to
improve their sex lives. Why else, after all, would one consume ground tiger
penis, horny goat weed and Spanish Fly?

Perhaps because nearly one in five men in the U.S. suffer from erectile
dysfunction, according to a recent study in the American Journal of
Medicine. Some researchers have estimated that as many as 40% of U.S. women
have low libido or inability to reach orgasm. Most quick fixes simply don't
work, and some, like Spanish Fly, a supposed aphrodisiac derived from beetles
that can cause kidney damage, are harmful.

In Pictures: Thirteen Steps To Better Sex

But modern medicine has found ways--both proven and experimental--to improve
your sex life. One place to start: old-fashioned remedies, which some say work
best. Regular exercise can actually improve erectile function in
most men, says Andrew McCullough, a urologist at New York University Medical
Center--and we're talking jogging, not the acrobatic feats found in the back of
a magazine. Not particularly athletic? Therapists say that paying attention to
your feelings is as important as any pill, nose spray or cream.

"Have a really wonderful role-play with your partner, have a really great
dinner out or watch a romantic movie together," says Robert Dunlap, who has
researched aphrodisiacs at the Institute for Advanced Study of Human Sexuality
in San Francisco. "The greatest aphrodisiac is your mind."

Hope In A Bottle

But that's not stopping the $600
billion global pharmaceutical industry from trying to think up new sex drugs.
Viagra, the little blue pill Pfizer launched a decade ago, brings in $1.7
billion in sales every year. Cialis, the longer-acting imitator made by Eli
Lilly, rakes in another $1 billion, with several hundred million more for
Levitra, from Bayer and Schering-Plough. Other remedies increase blood flow,
like the penis injection Caverject, and bring in $30 million more.

A product that could improve women's sexual function might bring in even more
money, if it were truly effective. So far, though, companies have been
unsuccessful. Viagra failed in tests on women. Procter & Gamble tried to
push a testosterone patch for female sexual dysfunction through the Food and
Drug Administration (FDA) but in 2004 the agency balked, citing a lack of
long-term safety data.

Now the idea of using testosterone as a sex-booster for women is being pushed
by Lincolnshire, Ill.-based BioSante Pharmaceuticals, Inc. Its LibiGel is rubbed
on the upper arm daily, delivering testosterone, which is thought to increase
libido, to the bloodstream over time. The company just began late-stage trials,
and, after discussions with the FDA, will start a big safety trial before
submitting data to regulators in 2009.

Palatin Technologies, of Cranbury, N.J., is trying to get in on the game,
developing a nose spray, called bremelanotide, to treat men and women with
sexual dysfunction. Applied 10 to 15 minutes prior to sex, it travels through
the central nervous system to increase blood flow in the penile or vaginal
tissue. The company hopes to get FDA approval for men in 2009 and women around
2011. "On the female front, we've got a chance to be first to market," says CEO
Carl Spana. "People wonder how many women will come in for treatment, but my gut
tells me they will come in."

What Really Works
Right now, the treatment available for
women with female sexual dysfunction that has been reviewed by the FDA is a
handheld vacuum that can be used with a doctor's prescription to increase blood
flow to the clitoris. Called Eros Therapy, it is made by NuGyn of Minnesota.
Devices such as this go through fewer hurdles than drugs; the Eros device has
been tested in several dozen people, compared with hundreds for a pill such as
Viagra.

Joy Davidson, a Manhattan-based certified sex therapist, worries that all
this technology may cause some people to ignore important cultural factors that
can cause sexual dysfunction. "There are agendas here that are not health-based,
they're profit-based," she says. "If you're not looking at these elements--the
emotional, psychological and cultural--then giving somebody a so-called magic
pill is not going to solve the problem."

Future Fixes
Meanwhile, drug researchers keep coming up
with even more out-there approaches. For instance, a gene therapy, which seeks
to fix erectile function by altering the DNA of cells in the penis, then
injecting them back in to the patient. It should work for six months, according
to inventor Arnold Melman, the researcher at New York's Albert Einstein College
of Medicine. He has co-founded a tiny biotech, Ion Channel Innovations, to
develop the product, which even he doesn't expect to reach the market before
2012. No gene therapy has ever been approved.

"People always say gene therapy doesn't work, but at one point it will," says
Melman. "We think this is the one."

Aphrodisiacs That Really Work

For as long as humans have been having sex, they've been trying to get in the
mood--or get their partners in the mood. And if necessity is the mother of
invention, it's no surprise that humans have developed a wide variety of creative
solutions for the old "I've-got-a-headache" problem.

The most recent solution, of course, is Viagra. But in ancient India, a young
man who proved passionless in the sack might have tried goat testicles boiled in
milk. Oysters are another common turn-on; the Roman satirist Juvenal was the
first to note their seductive qualities. In medieval times, honeyed mead was the
equivalent of Bud Lite for loosening up carousing swains.

Fresh snake blood is still revered as a stimulant in parts of Asia, as are
bat blood, reindeer penises, shark fins and ground rhino horns. And what
sad-sack hasn't at least contemplated Spanish Fly? It's not a fly at all,
actually, but the dried remains of beetles, which irritate the male urogenital
tract, causing a prolonged erection--and potentially causing serious discomfort
and even death, according to the Food and Drug Administration.

In
Pictures: Ten Aphrodisiacs That Work

Beyond their collective exoticism, the only thing the above have in common is
that they don't work. Named for Aphrodite, the Greek goddess of sex and beauty,
an aphrodisiac is just about anything that awakens or increases sexual
desire--be it your own, or the object of your desire's. In reality, however,
most aphrodisiacs are folklore at best and hazardous to your health at worst. As
the Food and Drug Administration has declared: "There is no scientific proof
that any over-the-counter aphrodisiacs work to treat sexual dysfunction."

But there is still some hope for those seeking a libido boost. The herbal
supplement Ginkgo
Biloba is being studied by the Office of Dietary Supplements, a subsidiary
of the National Institute of Health, as a treatment for erectile dysfunction.
The FDA has called animal studies of yohimbine "encouraging." Derived from the
bark of an African tree, yohimbe has been used as a sexual stimulant for
centuries. But the FDA notes that animal studies can't be used to prove
effectiveness in humans.

Even when aphrodisiacs do show promise, they don't always work for everybody.
Sexual desire is rooted in the mind more than the genitals. One person's fantasy
could be another's turn-off. "We're all unique individuals, and we all respond
differently to different things," says Dr. Beverly Whipple, a professor emerita
at Rutgers University and author of, most recently, The Science of Orgasm.

At the root of human sexual desire is the "core erotic personality"--a.k.a.
"sexual template"--which, in a nutshell, is whatever gets you off. "Everyone has
in their mind an image of someone or thing they find sexually desirous,"
explains Dr. William Granzig, dean of clinical sexology at Maimonides University
in North Miami Beach and president of the American Board of Sexology.

That image might be a person of specific age, race or hair color, or it might
be every person. It could be a fondness for a particular style of dress, objects
such as women's shoes or fur-lined handcuffs, or behavior such as cross-dressing
or exhibitionism. Whatever it is in particular, the sexual template is believed
to develop early on during a childhood erotic experience--perhaps as early as
age three or four--and it sticks with you for life.

The difficulty of maintaining sexual desire over the long term, of course, is
that if your partner falls outside of your sexual template--or you fall outside
theirs--sooner or later one of you could lose interest. "Many people whose
template is not, say, age-specific, can have great sex throughout their lives,"
notes Granzig. "But if you're only attracted to 20-year-olds, once your partner
hits 30, your desire will decrease. Unless, of course, you can figure out some
ways to spice things up."

Spicing things up is where sex gets complicated, because men and women
sometimes have wildly divergent desires. For men, a sexy photo is often enough to get blood flowing in the right direction. For
women, pornography can be a major turn-off. Orgasms are also less central to
women, who sometimes need full body stimulation, not to mention mental
seduction, in order to achieve climax. "There are just so many variables that go
beyond the physical in sex for women," says Dr. Janice Epp, a clinical
sexologist at the Institute for Advanced Study of Human Sexuality in San
Francisco.

There are also a host of external nuisances that weigh heavily upon sexual
desire--and that may dampen the mood. Studies routinely rank American culture as
one of the most sexually repressed in the world thanks to its forbidding
Judeo-Christian origins, high incidence of sexual problems and dysfunction, and
a lingering Puritan discomfort with the very topic of sex.

And while Europeans take mandatory month-long vacations, Americans routinely
work 60-hour weeks, and stretch their ten vacation days over the entire year.
With the demands of our modern day technological society, it's little wonder the
search for aphrodisiacs continues. "I see a lot of highly evolved, highly
skilled people who are losing desire because they have such an overriding focus
on their profession," says Epp, who works in Silicon Valley. "For them, the
temptation to believe that there's a magic pill that will make them desirous of
sex again is very strong."

Inspired by the phenomenal success of Viagra, which rang up over $1.6 billion
in sales for Pfizer in 2005, it's perhaps not surprising that there has been a
recent push to find more pharmaceutical remedies for flagging sexual desire.
It's a focus that throws many in the sex field into apoplexy. "The idea that you
can just give someone a pill, and they'll be interested in sex is like putting a
band-aid on a tumor," says Epp.

In the end, the only truly effective aphrodisiac seems to be that's been
working for humans all along. "Your biggest sex organ is the one between your
ears," says Dr. Granzig. "What is desire, after all, other than the hope that
you can fulfill your sexual fantasies? And that's all in your mind."

Sex and Your Psyche

You know the cliche: a woman is so uninterested in sex that she makes a
shopping list while making love. Jennifer and Laura Berman see such women all
the time, and it's frustration—not boredom—that brings them to the Bermans' new
clinic at UCLA.

"I was talking to a woman earlier today about her low libido, which was a
result of the fact that she can't reach orgasm," says psychologist Laura Berman,
Ph.D., who with her sister, urologist Jennifer Berman, M.D., is a founder and
codirector of the Center for Women's Urology and Sexual Medicine clinic.
"Because she can't reach orgasm, sex is frustrating. She feels a hopeless,
fatalistic complacency about her sex life. When she's having sex, her partner
picks up on that and feels rejected and angry, or notices she's withdrawing.
Then intimacy starts to break down. Her partner feels less intimate because
there's less sex, and she feels less sexual because there's less intimacy. The
whole thing starts to break down."

Acknowledgement of sexual dysfunction in America is booming. But with all the
attention on Viagra and prostate problems in men, most people would probably
never guess that more women than men suffer from sexual dysfunction. According
to an article in the Journal of the American Medical
Association, as many as 43 percent of women have some form of difficulty in
their sexual function, as opposed to 31 percent of men.

And yet female sexuality has taken a back seat to the penis. Before Viagra,
medicine was doing everything from penile injections to wire and balloon
implants to raise flagging erections, while female sexual dysfunction was almost
exclusively treated as a mental problem. "Women were often told it was all in
their head, and they just needed to relax," says Laura.

The Bermans want to change that. They are at the forefront of forging a
mind-body perspective of female sexuality. The Bermans want the medical
community and the public to recognize that female sexual dysfunction (FSD) is a
problem that may have physical as well as emotional components. To spread their
message, they have appeared twice on Oprah,
have made numerous appearances on Good Morning
America and have written a book, For Women
Only.

"Female sexual dysfunction is a problem that can affect your sense of
well-being," explains Jennifer. "And for years people have been working in a
vacuum in the sex and psychotherapy realms and the medical community. Now we are
putting it all together."

No single problem makes up female sexual dysfunction. A recent article in the
Journal of Urology defined FSD as including
such varied troubles as a lack of sexual desire so great that it causes personal
distress, an inability of the genitals to become adequately lubricated,
difficulty in reaching orgasm even after sufficient stimulation and a persistent
genital pain associated with intercourse. "We see women ranging from their early
twenties to their mid-seventies with all types of problems," Laura says, "most
of which have both medical and emotional bases to them." The physical causes of
FSD can range from having too little testosterone or estrogen in the blood to
severed nerves as a result of pelvic surgery to taking such medications as
antihistamines or serotonin reuptake inhibitors, such as Prozac and Zoloft. The
psychological factors, Laura says, can include sexual history issues,
relationship problems and depression.

The Bermans codirected the Women's Sexual Health Clinic at Boston University
Medical Center for three years before starting the UCLA clinic this year. At
present, they can see only eight patients a day, but each one receives a full
consultation the first day. Laura gives an extensive evaluation to assess the
psychological component of each woman's sexuality.

"Basically, it's a sex history," Laura says. "We talk about the presenting
problem, its history, what she's done to address it in her relationship, how
she's coped with it, how it has impacted the way she feels about herself. We
also address earlier sexual development, unresolved sexual abuse or trauma,
values around sexuality, body image, self-stimulation, whether the problem is
situational or across the board, whether it's lifelong or acquired." After the
evaluation, Laura recommends possible solutions. "There is some psycho-education
in there, where I'll work with her around vibrators or videos or things to try,
and talk about addressing sex therapy."

Afterward, the patient is given a physiological evaluation. Different probes
are used to determine vaginal pH balance, the degree of clitoral and labial
sensation and the amount of vaginal elasticity. "Then we give the patient a pair
of 3-D goggles with surround sound and a vibrator and ask them to watch an
erotic video and stimulate themselves to measure lubrication and pelvic blood
flow," Jennifer says.

The identification of FSD has been called everything from the final frontier
of the women's movement to an attempt by the patriarchy to shackle women's
sexuality. But given the success that drugs such as Viagra have had in reversing
male sexual dysfunction, the Bermans found an unexpected amount of criticism
from their peers. "The resistance we got from the rest of the medical community
early on was surprising to us," Laura says, explaining that the urological field
in particular has been dominated by men.

Clearly, the Bermans will need hard data to win over their critics. Their
UCLA facility is enabling the Bermans to conduct some of the first systematic
psychological and physiological research on the factors that inhibit female
sexual function. One of their first studies suggests that the pharmaco-sexual
revolution that helped some men overcome their sexual dysfunction may prove less
effective for women. Their initial study of the effects of Viagra on women found
that Viagra did increase blood flow to genitalia and thereby facilitate sex, but
women who took the drug said it provided little in the way of arousal. In short,
subjects' bodies might have been ready, but their minds were not.

"Viagra worked half as often in the women with an unresolved sexual abuse
history as in those without it," Laura says. "So it's just not going to work
alone. Women experience sexuality in a context, and no amount of medication is
going to mask psychologically rooted, or emotionally or relationally rooted
sexual problems." Laura believes the results of the Viagra study counter those
who contend that FSD is simply a tool of pharmaceutical companies to
"medicalize" female sexuality.

"I'm less concerned about it, because I'm aware that it won't work," she
says. "And in some respects, pharmaceutical companies are closing the divide
between the mind and body camps of FSD. Clinical trials of new drugs for FSD are
requiring psychologists to screen participants, and that is an acknowledgement
that an accurate assessment of a drug's efficacy requires a consideration of the
test subjects' feelings about sex. So these physicians who may not be motivated
to bring on a sex therapist are now motivated to participate in a clinical
trial, and then that model becomes the norm."

Currently, the sisters are working on MRI studies of the brain's response to
sexual arousal, the place where mind and body meet. And although there is a lot
more research to be done on FSD, identifying it as a problem has already made a
significant impact on how women perceive their sexuality. "Women now feel more
comfortable going to their doctors, and they're not taking no for an answer, not
being told to just go home and have a glass of wine," explains Laura. "They feel
more entitled to their sexual function."

His & Hers: How To Have Them

Hers: a female orgasm can be frustratingly evasive. While about 85 to 90
percent of women are capable of having an orgasm, according to Beverly Whipple,
Ph.D., vice president of the World Association for Sexology, only about
one-third have had one during intercourse. That said, it's important to remember
that orgasm should never be the goal.

"In goal-oriented sexual interactions, each step leads to the top step, or
the big "O"—orgasm," says Whipple. "Goal-oriented people who don't reach the top
step don't feel very good about the process that has occurred. Whereas for
people who are pleasure oriented, any activity can be an end in itself; it
doesn't have to lead to something else. Sometimes, we're very satisfied holding
hands or cuddling. There would be a lot more pleasure in this world if people
would just focus on the process."

Whipple also points out that the psychological ramifications of dissatisfying
sexual interactions are not often suffered alone; they can cause distress in
both partners. "If one person in a relationship is goal-oriented and the other
is pleasure-oriented, and neither is aware of their own orientation, they don't
communicate that with their partner," she explains. "A lot of relationship
problems can develop. In my workshops with couples, I help them be aware of how
they view sexual interactions and then communicate this with their partner."

Types of Orgasm

Clitoral Orgasm

The most common, they result from directly stimulating the clitoris and
surrounding tissue. What many people don't realize is that the majority of the
clitoris is actually hidden inside the woman's body. Recently, Australian
urologist Helen O'Connell, M.M.E.D., studied cadavers and 3-D photography and
found that the clitoris is attached to an inner mound of erectile tissue the
size of your first thumb joint. That tissue has two legs or crura that extend
another 11 centimeters. In addition, two clitoral bulbs—also composed of
erectile tissue—run down the area just outside the vagina.

O'Connell's findings, published in the Journal of
Urology, show that this erectile tissue, plus the surrounding muscle
tissue, all contribute to orgasmic muscle spasms. With so much tissue involved
in a clitoral orgasm, it's no wonder they're the easiest to have.

Pelvic Floor or Vaginal Orgasms

These occur through stimulating the G-spot, or putting pressure on the cervix
(the opening into the uterus) and/or the anterior vaginal wall. Located halfway
between the pubic bone and the cervix, the sensitive G-spot—named after its
discoverer, German physician Ernest Grafenberg—is a mass of spongy tissue that
swells when stimulated. Because it's difficult to locate, experts have developed
a few guiding techniques:

1. Lying on her back, the woman tilts her pelvis upward so that
   her vulva presses flat against her partner's pelvic bone. According to the
   Bermans, this allows the penis to make contact with the G-spot, simultaneously
   stimulating the clitoris. Putting pillows beneath her buttocks makes angling her
   pelvis easier.
   
2. Whipple suggests placing two fingers inside the vagina and
   moving them in a beckoning motion. The fingertips should stroke the frontal
   vaginal wall, just where the G-spot is located.

The Blended Orgasm

This can be attained through a combination of the first two.

Her Benefits

1. Pain relief: Orgasms help alleviate menstrual cramps. In
   addition, studies have shown that a woman's pain threshold increases
   substantially during orgasm.
   
2. Enhanced mood: According to University of Virginia
   researchers, orgasms boost levels of the female sex hormone estrogen, which in
   turn betters your mood and helps ease premenstrual symptoms. They also release
   endorphins, the body's natural painkillers and depression fighters.
   
3. Increased intimacy: Oxytocin, a hormone that promotes
   feelings of intimacy, jumps to five times its normal level during climax.
   
4. Easier rest: Oxytocin also induces drowsiness. For women,
   sleepiness comes about 20 to 30 minutes after orgasm. Men, on the other hand,
   usually drift off after only two to five minutes.
   
5. Less stress: Stress in women is highly correlated with
   arousal difficulties, lack of libido and anorgasmia, the inability to reach
   orgasm, according to one 1999 study in the Journal of the American Medical
   Association. Just 20 minutes of intercourse, however, releases the
   lust-enhancing hormone dopamine, triggering a relaxation response that lasts up
   to two hours.

Physiologically speaking, male and female orgasms are surprisingly similar.
The related problems men and women experience, however, are distinctly
different.

"There are men who can't orgasm, but I think it's less than I percent of
men," says Jed Kaminetsky, M.D., a professor of urology at New York University
and director of the school's male sexual dysfunction clinic. "That's a much less
common problem than premature ejaculation."

A study published in the Journal of the American
Medical Association found that premature ejaculation is even more common
than erectile dysfunction, especially among younger men. As with most
sex-related problems, it affects both partners—some studies suggest that nearly
30 percent of couples report premature ejaculation as the most prevalent sexual
problem in their relationship. One major obstacle to treating it is simply
defining the problem to begin with.

"It depends on the relationship," Kaminetsky explains. "If a woman takes an
hour to orgasm and the man can last 40 minutes, that's premature ejaculation for
that couple." At the other extreme, one minute is too short an amount of time
for most couples. "Not too many women are going to climax within a minute."

Kaminetsky also sees truth in Whipple's assessment of goal-oriented versus
pleasure-oriented interactions. "Men are very goal oriented; they see a task and
they want to successfully perform that task," he says. "Often that task is to
make their partner have an orgasm. If the woman knows that, she feels like a
laboratory animal—it's not a very sexy thing. That's why women fake orgasms,
which is a sign of lack of communication in a relationship."

Premature Ejaculation

Rarely a physiological problem, premature ejaculation can result from
over-excitement, positioning or rate of intercourse. "The roots of it go back to
the way men learn to orgasm, which is typically through masturbation," suggests
Kaminetsky. "A lot of young boys masturbate quickly, because they don't want
their mom to walk in on them. It becomes a trained behavior." To treat premature
ejaculation, experts suggest changing positions, breathing deeply, thinking
about something other than sex or simply stopping for a moment. Here, Kaminetsky
offers two additional techniques for delaying orgasm:

1. Practice this before reaching "ejaculatory inevitability,"
   the point when ejaculation cannot be stopped; most men recognize it as a
   sensation of deep warmth or pleasure: Squeeze the head of the penis for about
   four seconds or until the sensation subsides, then resume.
   
2. During intercourse, the man should press his pelvic bone
   against the woman's and rock rather than thrust his body. "It won't be as
   stimulating for him so he'll last longer, and it may be more stimulating for the
   woman."

His Benefits

1. Long life: Men who have two or more orgasms a week tend to
   live significantly longer than do those who have only one or none, according to
   research at Cardiff University in Wales.
   
2. Less cancer: Breast cancer is rare in men, but once
   developed, the mortality rate is high. Fortunately, a study published in the
   British Journal of Cancer found that men who have more than six orgasms a month
   are significantly less likely to develop breast cancer than are those who have
   less frequent sex.
   
3. Healthy hearts: A study of 2,500 men at the University of
   Bristol and Queens University of Belfast found that men who have at least three
   or more orgasms a week are 50 percent less likely to die from heart failure or
   coronary heart disease.
   
4. Good health: Having sex once or twice a week also fights off
   the flu and other viruses by strengthening the immune system, psychologists at
   the University of Pennsylvania recently found.
   
5. Youthful looks: A study of 3,500 aging people at the Royal
   Edinburgh Hospital in Scotland found that those who looked the youngest also had
   the most vigorous sex life. The effects were even greater if the subjects were
   emotionally satisfied as well.

Getting Close And Personal

Bee, 25, Copywriter

Masturbating is the easiest way for women to learn how to have an orgasm.
Women who masturbate will be a lot more likely to have an orgasm during sex. I
think it helps you learn the actual mechanics of what turns you on, where things
need to happen.

Because the guy isn't going to know that; there's no reason he would. Every
woman is different. Also, the bonding that goes on during sex seems most extreme
with an orgasm. It's kind of like one or both people have gone completely over
the edge; they're suspended in the other person's grasp, and they're completely
surrendered to it. That intensifies any connection.

Gabriel, 25, Musician

There are guys who don't get a rise out of giving a woman an orgasm and would
just prefer not to have someone else there. I've even heard some guys say they
have better orgasms during masturbation than sex. The mere thought of it
astounds me, but it makes sense if a guy has a fear of intimacy or, even more, a
fear of performing. It probably takes away from his own orgasm if he's overly
concerned with his sexual performance or whether or not she's having one. It's
ironic, because an orgasm during sex is enhanced when it's with someone you
truly care about.

Getting Close and Personal

Kamara, 27, Musician

I'm amazed when I talk to anyone who claims to have never had an orgasm,
probably because I just can't imagine not having them or not being able to have
them. At the same time, it doesn't surprise me: I was raised in a very
conservative religious atmosphere that actually called masturbation "self
abuse," and all sexuality—not to mention orgasms—was beautiful and good only if
it happened in a marriage bed. It takes awhile to expel the load of guilt that
piles up around your sexuality if you're raised in that kind of culture, and I'm
sure some people never do. But there was no way I wasn't going to aim for the
prize once I knew what it felt like. Maybe it depends on your sexual drive—for
me the drive was strong enough that I could never feel guilty about an orgasm
for long.

Steven, 28, Veterinarian

Some guys think sex has to include an orgasm. Orgasms are great, but there's
so much more to sex. An orgasm is more of a physical experience; I guess there
is an emotional aspect, but it's over in a second. I think anybody can give you
an orgasm, but it's the person there after the orgasm that matters. But I think
I'm the exception.

Does Orgasm Equal Sex?

Our ever-changing definition of sex may hinge more on the climax than on the
act itself; Psychologist L.M. Bogart, Ph.D., gave Kent State students a list of
scenarios in which "Jim" and "Susie" engaged in vaginal, anal or oral
intercourse and either did or did not achieve orgasm. Vaginal intercourse was
considered sex 97 percent of the time, followed by anal intercourse (93 percent)
and oral sex (44 percent). Researchers were surprised to find that orgasm
occurrence dictated whether or not the activity was considered sex. Although the
woman was more likely to label vaginal intercourse sex if neither partner
climaxed, when it came to oral sex, the recipient was more likely to consider it
sex than the partner performing the act, especially if the recipient achieved
orgasm—because the stimulator was unlikely to achieve orgasm. For anal sex, it
was more likely to be called sex if Jim had the orgasm, but it was sex to Susie
regardless of whether she achieved orgasm. In general, the lack of orgasm for
women was less likely to affect her labeling the act sex. Although most sex
therapists argue against using orgasm as an end-all definition of sex, Bogart's
study indicates that orgasm is still an important gauge by which we measure
sexual activity.

Lust For The Long Haul

When my husband and I started dating, we quickly became one of those
obnoxious couples who couldn't keep their hands off each other. We kissed every
time we stopped at a crosswalk -- in New York, that's a lot. At Starbucks we
were so grotesque -- staring into each other's eyes, stroking each other's arms
-- that when the branch removed its tables and converted to carryout, we
wondered if we were the reason. Once, during a protracted public goodbye, a
group of teenagers actually screeched at us to get a room.

We did more than that. We got married. Like most couples in the throes of
passion, we were smug, convinced that all the cliches about things slowing down
described partners who weren't meant to be together in the first place. But
slowly, things did cool off. We still loved one another, still held hands. But
the crosswalk kissing and the subway platform clinches faded away. Instead of
long weekend mornings in bed, we started getting up early and going to the
gym.

I couldn't help (a) noticing, and (b) torturing myself about what it meant.
You'd have to be hiding under a rock for the last decade not to know that half
of all marriages now end in divorce, and that sexual difficulties are one of the
leading complaints of unhappy couples. Was this how it begins?

It's some consolation that many other Americans face the same question. In
the benchmark survey of desire, roughly one-third of all adults reported having
some kind of sexual problem during the previous year. Some pundits blame gender
politics, job stress and cultural changes. Others, more cynical, point to the
monotony of marriage. But these plausible (and socially acceptable) explanations
obscure a more disquieting truth. Sex, and more importantly, intimacy, are
grown-up skills, and most of us, metaphorically speaking, are still in junior
high. We're still clinging to the idea of romance, when real intimacy requires
something a lot more difficult: pushing past your own limits to become a more
fully developed human being.

Conventional wisdom holds that an intimate couple thinks pretty much the same
way about most things. You connect seamlessly -- especially in bed. But
according to the radical ideas of the marital and sex therapist David Schnarch,
we've got it all backward. "Sex is inherently based on intimacy. The problem is
that most people have a very misguided idea of what intimacy means," he says.
"There's this idea that your partner is going to make you feel good and validate
you." It's our cultural template for "true" love. Think Tom Cruise in Jerry
McGuire declaring his love for Renee Zellweger: "You complete me," he says,
with trembling lip.

Except that no one has a marriage like that. What's more, says Schnarch, no
one should. Sure, the you-complete-me stuff works fine in the beginning. It's
even fun. Like two people cinched together for a three-legged race, there is
satisfaction in getting the groove of operating side-by-side with perfect
fluidity. But when you try to keep those tethers on indefinitely, reality
intrudes. Two people aren't going to agree on every move. And they'll get tired
of always accommodating the other -- by keeping quiet, by moving the same way,
by propping the other one up.

Sooner or later, a lot of these three-legged marriages wind up in gridlock:
Each partner is increasingly frustrated by the other's apparent unwillingness to
get on the same page -- and each becomes increasingly annoyed and worried about
it. It's in this juncture, where the conflict between real intimacy and wishful
thinking rears its head, that many of us notice the sex ain't what it used to
be. But while we fear that this is the beginning of the end, Schnarch says it's
often when things finally start to go right. It means marriage is beginning the
relentless process of doing what it's supposed to do, nudging us away from the
Renee-Tom model of partnership and forcing us to figure out who we are as
individuals.

Real intimacy is frightening. It requires a kind of openness, honesty and
self-respect that most of us aren't used to. But Schnarch's 30 years of
counseling couples has convinced him that it's worth it. A truly intimate
connection between adults is less volatile, because couples aren't ticked off
about what their partner is or isn't doing to prop them up. It's more solid,
because it's based on reality. "Ultimately, you get through gridlock and get to
a place of more honest self-disclosure, where the focus is on being known,
rather than being validated," he says. Best of all, the sex often becomes more
relaxed, creative and connected. Literally and figuratively, no one's hiding in
the dark anymore.

Learning the Language of Sex

When couples do try to address their sexual problems, they often focus on
mechanics: Viagra, lingerie, trying out new positions. But sex -- even terrible
sex -- isn't engineering, says Schnarch. It's a language, and its content is
everything else happening in the marriage. The woman who doesn't say a word but
barely opens her knees for her husband is actually speaking volumes. Ditto the
man who is so intent upon pleasing his unpleasable wife that he frequently loses
his erection. "Even the way couples avoid having sex is a window into who they
are together," he says.

Often, sexual disconnect has a similar refrain: I can't show you who I really
am. People's mistaken ideas about intimacy have made them overly reliant on a
partner for their own sense of self. You demand that your partner approve of
you, and you begin to count on him or her to reassure you that you're normal and
that your feelings are valid. This makes it difficult to be completely open or
honest with each other anymore. One or both of you begins to feel suffocated,
and the intense vulnerability of sexual passion that was so easy in the early
days becomes impossible.

Tammy, 36, and her husband, Jack, 34, struggled for years with mismatched
sexual desire. Jack wanted to have sex all the time. Tammy avoided it. "I pretty
much didn't care if I never had sex again," she says now. For her marriage's
sake, she'd tried supplements and testosterone cream to increase her desire.
They hadn't worked. Nor had a therapist who'd advised Tammy to try a little
novelty -- like running a hairbrush all over her husband's body. "I already
didn't want to have sex," says Tammy, still irritated, "and I definitely didn't
want to do that." By the time they wound up at Schnarch's office, they were
inches away from divorce.

Through three intensive days in therapy, it became obvious that Tammy's
problem wasn't biological. Jack was needy, emotionally, and looked to Tammy to
make him feel better, in and out of bed. Tammy, like many women, played the
caregiver role to the hilt. She was a teacher, she had two small children, and
she was even contemplating a new career as a nurse.

They began to realize, with Schnarch's guidance, that although they felt
estranged from each other, they were in fact completely interdependent. Jack
didn't know how to soothe himself when he was feeling anxious. He looked to
Tammy, and to sex, for that. For her part, Tammy had no idea how to take care of
her own feelings, or even what they were. Nor did she have the energy, because
so much went to propping up Jack. In some unconscious way, by avoiding sex with
him, she was saying no more.

For their relationship to survive, each needed to take a step back and change
how they individually dealt with their own emotions, rather than leaning on --
and resenting -- the other. Jack had to learn to deal with his neediness on his
own, and recognize that he couldn't expect his wife to do it for him. Tammy had
to figure out who she was and what she wanted, or live her life without really
ever knowing herself -- much less getting to be known by anyone else. And she
had to speak up when she disagreed, rather than keep quiet in order to not rock
the boat.

A year later, Tammy and Jack are utterly honest with each other. No hiding.
"Before we would just not talk about any of our problems because we didn't want
to get each other upset," Tammy says. Now, she says, they always say what they
are thinking or feeling, regardless of the reaction they anticipate. "It can be
very uncomfortable," she admits. "And I'm still working on tact." But in their
case, she says, it changed everything. Over the course of several months spent
learning to be themselves together, Tammy's sex drive returned. They're happier
than they've ever been, she says: "We just renewed our vows in Vegas."

How Sex Makes Grown-Ups

Schnarch's way of thinking about the interdependence of sex and intimacy is a
big shift from the traditional focus on anxiety as a primary cause of sexual
difficulty. Problems in the bedroom are too often seen as distinct from the
emotional struggles of marriage and partnership. But Schnarch -- and a few other
therapists -- have developed an alternative view, one that puts partnership at
the heart of sexuality and puts both sexuality and intimacy at the center of
human development. Sexual difficulties are a kind of emotional Rorschach test
that offers a glimpse into not just the dynamics of the relationship, but the
continuing agenda of growing into a fully autonomous human being.

Schnarch says that what happens with many troubled couples is analogous to
what happens in children as they mature emotionally. A key developmental task of
adolescence is to form separate and unique identities from our parents. (That's
what the dismissive remarks and the skin piercings are all about.) We assume
that by the time we're married, we're past all that. Not true, says Schnarch.
We've merely switched our focus from our parents to our spouses. Temporarily,
some of us adopt joined-at-the-hip intimacy as an archetype of marriage. But the
rebelliousness, the need to separate ourselves, kicks in again. You know it,
Schnarch says, when you begin to find yourself more at odds with your partner
and less sexually attracted to each other than you used to be.

Or you know it when you engage in something he calls arguing about reality.
That is, you both experience an event -- a movie, or a remembered moment from
your past together. But you see it in entirely different ways, and you can't
stop arguing until one of you caves in. Schnarch describes one couple's memories
of the birth of their first child. The wife thought it was the closest moment
they'd ever shared -- but her husband remembered being nauseated by the blood.
Their contradictory views of this event became part of a bitter argument that
surfaced again and again. Because neither of them would accept the other's point
of view, they felt that they were drifting apart. In Schnarch's view, this
difference of opinion was normal, not an indication that their relationship was
falling apart. They are, after all, two different people.

Schnarch's treatment usually involves intense four-day sessions, and doesn't
lend itself to quick tips. All the same, there are basic behavioral shifts that
he finds can benefit many unhappy couples. They all involve the same process:
Each partner takes responsibility for his or her own emotions and learns to
tolerate the idea that his or her partner is not a spiritual twin. That means no
longer expecting a partner to validate you -- so that he or she can admit that
sometimes your ideas are half-baked, rather than always reassuring you that
you're right. You examine your own behavior and see what you expect others to do
for you that you could be doing on your own -- for example, learning to feel
good about yourself without requiring someone else's praise and compliments.

But don't expect your partner to applaud when you tell the truth about
yourself. Learn to lick your own wounds -- it's not your partner's job to soothe
you, it's yours. Try to tell the truth for the right reason. Being honest
doesn't mean being vindictive. "The idea is that you are telling each other the
truth, even when it is difficult, out of caring and commitment, not because
you're pissed off and want to carve each other up," he says. The irony, says
Schnarch, is that rather than increasing conflict between couples -- as you
would think might happen -- emotional honesty has the opposite effect. The issue
is no longer about what your partner does or doesn't do: You can accept that
they, like all people, have their own limitations and failings. Instead, the
focus shifts to you, and whether you're being a grown-up -- or not.

The Joys of Adulthood

Schnarch is still something of a maverick in the field of sex therapy. Talk
to 10 sex therapists (I did), and you'll get 10 strong opinions. Some think he's
done the sex and marital therapy version of cracking the code of DNA. Others
find his ideas interesting, but don't believe that they apply to all couples.
Many say they incorporate a little of what he preaches into their practice --
like a spice in a tomato sauce." The Atlanta-based marital therapist Frank
Pittman, author of a self-help book called Grow Up: How Taking Responsibility
Can Make You a Happy Adult, is one whose approach resembles Schnarch's.
"What he's doing is teaching people the joys of adulthood," he says, "of the
wonderful things that can happen in a relationship when you take responsibility
for yourself, whether you've got your pants on at the moment or not."

The reward for all of this hard work, say Schnarch, Pittman and others, is a
kind of intimacy that helps you be more of the person you want to be and
supports an intense lifelong bond. In return you are seen, known and understood
-- truly -- for who you are. And loved and desired, to boot. It's a rare thing,
perhaps the most powerful connection we can hope for.

With this outing of yourself, so to speak, goes a greater freedom in bed.
You're no longer pretending. Schnarch considers the ability, for example, to
look into your partner's eyes while engaged in a sexual act or in the midst of
orgasm to be the height of intimacy. It's an act of mutual self-revelation that
cannot be matched almost anywhere else in life. "Once people try it, they
totally get what real intimacy is about," he says.

Eye-to-eye sex is not for the faint of heart. Even Schnarch's wife,
psychologist Ruth Morehouse, who now works with him as a marital and sex
therapist and uses his techniques, confesses to having had her doubts. At the
time that her husband was developing his ideas in the 1980s, she says, she
wasn't crazy about them. She describes herself at that time as fairly reliant on
others to give her great feedback about herself, personally and professionally.
She wasn't too keen to grow up, in the way her husband advocated. And the
eyes-open thing, well. "At first, I was mad at him for even suggesting that this
is something that people were supposed to do," says Morehouse. "It was a stretch
for me. At first, I literally couldn't keep my eyes open. After a couple of
times, I was able to do it, and it made sex more emotional and meaningful. It's
now a routine part of my sex life."

Does this mean that all sexual issues can be solved this way? Probably not.
Growing up won't do a lot for a faulty blood vessel that's contributing to an
erection problem. Or for the couple who are genuinely exhausted from chasing
small children around all day. But it maps out some promising new territory,
where personal growth and existential concerns become as much a part of sexual
therapy as do anxiety and pathology. Schnarch is creating a new way of thinking
built on growth and possibilities. Making relationships, and sex, better. How
could anyone not be fascinated by the potential?

As for me, I suspect I still have a lot of growing up to do. (Arguing about
reality? Guilty.) And I haven't dared bring up the idea of eyes-open sex with my
husband yet, for fear he'll take me up on it. I have a feeling I'd have to keep
my eyes open with pliers. But I am intrigued. And now, as I stand on subway
platforms or street corners, watching couples who really ought to get a room
groping one another without shame, I don't feel as if I've been banished to the
land of slippers and ratty bathrobes. Because according to Schnarch's model, in
which sex only gets better as you get older and wiser, I'm ahead of the game. Or
at least those couples. And that makes me feel smug all over again.