Therapist Blog

Aging and Sexuality

Partners in long term relationships often report that after years together, they are emotionally closer and better able to enjoy time together. But for some couples, their enhanced emotional bond is a substitute for shared passion and physical intimacy; and sexual intimacy has become routine, and sometimes, non-existent. Buying into the ageism notion that ‘sex is for the young’ can heighten the complacency that they feel about their sexual life.

The changes, associated with aging, sometimes account for the compromised intimacy between partners. For both men and women, medications and health problems and the medical interventions necessary to treat them, can impact all aspects of a person’s sexual responses. Life changes during the later years, such as retirement, empty nest, and changes in living arrangements, can also have an indirect, but adverse, impact on sexual functioning, particularly when an individual becomes anxious or depressed as they struggle to make necessary adjustments. Changes, specific to sexual functioning, can also play a role. For women, thinning vaginal tissue and diminished lubrication, symptoms associated with the hormonal changes of menopause, can cause discomfort, and even pain, and result in disinterest or avoidance of sex. Declining levels of testosterone, greater variation in erections, and delays in erections are age-related changes that can impact a man’s sexual responses.

Every couple should decide how vital sexuality is to their relationship. Not infrequently, dissatisfaction stirs in one partner. Raising concerns with a loved one is not always easy, particularly, when a couple has not engaged in discussions about their sexual lives throughout their relationship. Additionally, it can trigger feelings of inadequacy and embarrassment. Nevertheless, finding a way to have a frank and open dialogue is critical. It opens the possibility of not only attaining a more satisfying physical connection, but an emotional one, as well.

Discussions about sexuality often involve people clarifying their view of themselves as a sexual being and questioning how consistent their perception is with society’s notions about sexuality. Whereas some feel diminished and hampered by the commonly held view that sex is the domain of the young and beautiful, others enjoy a newfound freedom to enjoy sexual pleasures, bolstered by greater confidence and life experiences. Ideally, an outgrowth of a couple talking about their sexual life will be a decision about the extent to which they want to prioritize it and what measures to take, if any, to improve it. Attending to health or life circumstances may be the first step for some couples; and this may involve contact with a healthcare provider or mental health specialist. Others may need to focus more directly on their sexual functioning. Medical interventions can relieve some of the symptoms that adversely impact sexual functioning, especially when they are integrated into a couple’s love-making. Very often, however, what is needed is a mind-set that appreciates that physical intimacy changes with age and that embraces a variable, flexible, pleasure oriented approach, instead of a performance-oriented style (Sallie Foley, 2004. Sex and
Love for Grown-Ups).

Don’t Be Afraid to Ask

When I’m sitting with a couple, deadlocked over a particular issue, I frequently ask if they discussed this topic prior to tying the knot. Typically, they say they never considered doing so and imagined all would work, given their love for each other. In the short term, failure to have frank talks about issues that are likely to arise in a marriage can help maintain the romance. But over the course of a long term relationship, it can result in hurt, disappointment, and possibly the demise of the marriage. As Eleanor Stanford writes in her March 27, 2016 New York Times article, 13 Questions to Ask Before the Wedding, “what you don’t know really can hurt you.”

I think Stanford’s questions highlight the key issues that a couple needs to consider before making a long term commitment; and I want to share them with you.

1. Did your family throw plates, calmly discuss issues or silently shut down when
disagreements arose?
2. Will we have children, and if we do, will you change diapers?
3. Will our experiences with our exes help or hinder us?
4. Do you know all the ways I say “I love you”?
5. Do we like each other’s parents?
6. What’s the most you would be willing to spend on a car, a couch, or shoes?
7. Can you handle my doing things without you? Having different friends or hobbies?
8. How important is sex to you?
9. Is my debt your debt? Would you be willing to bail me out?
10. How far should we take flirting with other people? Is watching pornography O.K.?
11. What do you admire about me, and what are your pet peeves?
12. How important is religion? How will we celebrate religious holidays, if at all?
13. How do you see us in 10 years from now?

Learning the answers to these questions and figuring out whether differences can be negotiated to a reasonable level of satisfaction prior to marriage is ideal, rather than addressing them when conflicts arise. However, with openness, honesty, and a willingness to sit with the discomfort that comes with taking a long hard look at yourself, your partner, and your relationship, as well as a willingness to compromise, you can navigate differences at any point in your relationship. And who’s to say whether the time invested in your relationship, your shared history, and the humility that comes with age won’t make for a richer discussion that, in turn, will fortify your marriage for years to come!

Book Review: “The Soul of Sex”

Moore, T. (1998). The Soul of Sex: Cultivating Life as an Act of Love. New York: Harper.

The Soul of Sex is no ordinary book about sexuality. In this book, Moore challenges the reader to expand their notions about sexuality. He argues that, rather than being merely a physical act, sex is an experience of the soul. When the soul is integrated with the mind and body, sexuality becomes deeper, richer, and more meaningful. Moore cautions that to attain what can be a sublime state, one must be willing to attend to beauty, sensuality, and pleasure in everyday life, while welcoming emotions and surrendering to the joys of life. By drawing on material from mythology, literature, popular culture, art and religion, he illustrates how to actualize this integration. In so doing, he also reveals the universal nature of human sexuality and its profound mystery.

The Soul of Sex: Cultivating Life as an Act of Love

Assessing Sexual Issues

Sexual difficulties can erode a couple’s relationship and create a personal suffering. And yet, may individuals do not seek professional help because they are uncomfortable sharing information about their intimate life. Adding to feelings of discomfort and shame is the uncertainty about what to expect when seeking treatment from a trained sexuality therapist. To provide greater clarity, this article provides information about the evaluation process.

In assessing sexual problems, a sexuality therapist, most often, considers relational, biological, medical, familial, psychological, cultural, and life style factors. Taking all of these variable into account is necessary because sexuality is complex and affected by many variables. Below are some of the questions, broken down into categories, that a sexuality therapist might explore to better understand sexual symptoms. In gathering this information, the therapist respects the comfort level of the individual and insures confidentiality.

Presenting Problem
How would you describe the sexual problem?
Does the sexual problem co-exist with other sexual problems or concerns?
What does this problem mean to you?

History of the Problem
When did the problem start?
Did the problem come on suddenly or gradually
If the onset was sudden, did it coincide with a traumatic event, changes in lifestyle, or major transition?
If the onset was gradual, has there been an ongoing medical condition?
Have the demands of work or children resulted in sex becoming less of a priority?

Individual History (Individual history is generally conducted separately to encourage openness and comfort)
How did you learn about sex?
Did your knowledge about sex come from family members, peers, or other sources?
What are your family’s attitudes about sex?
Do you have a history of physical or sexual abuse?
What are your perceptions of your body?
What do you consider a healthy sexual life?
To what extent do religious teachings about sex influence your sexual attitudes and behaviors?
To what extent do popular beliefs about sex influence how you define a healthy sex life?
Have you experienced similar sexual problems in previous relationships?
Do you have a past or present medical illness?
Are you taking prescribed medication?
Have you discussed your present symptoms with your physician?
Are you experiencing undue amounts of stress?
Are you using recreational drugs or alcohol excessively?
What is your current emotional and mental state?

Couple Relationship
Are you and your partner presently experiencing general difficulties in your relationship?
How are the sexual difficulties impacting your relationship?
Do you see the sexual difficulties as residing in you, your partner, or within the couple relationship?
How similar are your expectations about a healthy sexual life to those of your partner?
Do you and your partner discuss the sexual difficulties?
How do you and your partner deal with the sexual difficulties?

The information necessary to assess a sexual problem is gathered over multiple sessions. Once the evaluation is complete, the therapist provides feedback and recommendations. If the individual or couple agree with the plan of treatment and wishes to rely on the therapist to help them sort through their difficulties, treatment begins.

Selecting a Partner

Physical attractiveness, shared interests, compatibility, kindness, and sense of humor are common features that people look for when selecting a mate. But societal, cultural, and psychological factors also influence with whom one falls in love and whether that love culminates in marriage. In this article, I will discuss partner choice from a psychological perspective.

In addition to conscious factors, less conscious factors also influence partner choice. Often, recognition that another person possesses some disowned aspects of oneself can draw individuals together. For example, a shy, emotionally non expressive woman may be attracted to a man who is outgoing and emotionally expressive. These individuals complement each other. This pairing may be in the service of development in that it provides an opportunity to grow emotionally and psychologically. In effect, each person can learn from the other new ways of being and interacting. Over time, each person can incorporate the new behavior patterns into their repertoire.

In some instances partner selection is not motivated by growth producing factors. Back in the 70’s, Henry Dicks investigated marital relationships at a London clinic. His findings revealed that attraction to another can result from an inability to tolerate some aspect of oneself. For example, an emotionally reserved man may be drawn to an emotionally expressive woman because he cannot tolerate his feelings. Initially, the man may perceive the woman’s display of emotions as indicative of a vibrant personality. Gradually, he comes to view her emotionality ‘as if” it is his own and becomes intolerant of her emotionality, as well. In turn, he may discount, devalue, or criticize his partner’s emotions. For this union to have taken hold, it requires a woman who was drawn to this emotionally, reserved man. Such a woman initially may have perceived the man’s lack of expressiveness as calming. Eventually, as she comes to view the man’s emotional reserve as her own, she may find his emotional containment unbearable and come to view him as boring or withholding.

In the example provided above, each partner fails to learn from the other. Instead they are at odds with the other and feel frustrated and unfulfilled. As often happens, the very qualities that drew the couple together are the same features that are creating conflict. Such couples may seek relationship treatment to help them sort through their difficulties. Therapy can help each individual understand their contribution to the conflict and develop more fully, rather than look to their spouse to complete them. It takes work, but efforts can not only improve the marriage, but also result in more mature and satisfying functioning for each partner.

Sex Diagnosed: Common Questions About Sex Therapy

Individuals interested in seeking treatment for sexual difficulties may wonder what the process involves. Dr. Caruso addressed some of the common concerns and questions when she was interviewed by a contributing writer of Belle, a Richmond, Virginia based magazine. In the following segment, Dr. Caruso shares her responses which were first was first published in February, 2011.

Belle: As a sex therapist, what are some common concerns that you hear from clients?

Caruso: Women frequently come in concerned about lack of sexual desire or difficulty achieving orgasm. Men commonly seek sex therapy for problems with premature ejaculation and erectile dysfunction. Often times, couples ask for help to deal with differences in their levels of sexual desire.

What should people expect from sex therapy?

I work to understand the problem in the first session and gather more history and define goals with the client in later sessions. I may give individuals or couples assignments to complete at home between therapy sessions to help them accomplish their goals. In subsequent meetings, I have the clients discuss their success or difficulty in carrying out the exercises, as well as other obstacles impeding their progress.

What are some misconceptions about women and sex?

Common misconceptions include views of women as passive, disinterested or less capable sexually than men. Women’s sexual responses are actually varied and complex. Each woman needs to identify and enjoy her patterns and preferences.

What myth would you like to debunk once and for all?

People tend to believe that only women and elderly experience loss of sexual desire. In fact, it occurs in all age groups and in males, as well as females. A loss of sexual desire can be difficult to acknowledge and can put a tremendous strain on a relationship, especially because our culture tells us that everyone should enjoy sex.

Why do you think our culture continues to reinforce such a misleading notion? How can cultural beliefs affect people?

Cultural beliefs around sex are deeply ingrained in us and therefore very difficult to change. Unfortunately, they can limit our potential, create unrealistic expectations, and put pressure on males and females.

What wisdom do you hope clients will come away with from sex therapy?

I want people to know that sexuality is complex. It can be affected by upbringing, experiences, attitudes, cultural values, lifestyle, psychological well-being, and overall health. Understanding these dimensions and building a solid sense of self enhances a person’s ability to fully express their sexuality.

How would someone go about selecting a sexuality therapist?

You might start by discussing your problem with your health care practitioner and asking them for recommendations. The American Association of Sexuality Educators, Counselors and Therapists (aasect.org) also provides names of certified therapists in your area.

Attachment Styles in Couple Relationships

People have different ways of relating, which are called “attachment styles” in the field of human behavior. Beginning in the late 50’s, John Bowlby pioneered the study of attachment behavior. He identified it as a basic human need with an evolutionary basis that insures survival of the species. Which style a person adopts, in part, has to do with what they learned in interacting with early caretakers. Building on Bowlby’s work, in the mid 60’s Mary Ainsworth and her colleagues, developed an experiment, known as the “The Strange Situation.” This study examined the interactions of 1 year olds with their mothers. From her research, Ainsworth concluded that parents who are consistently responsive, attuned, and available to their infants tend to produce children who are securely attached. Caretakers who are emotionally remote and distant promote avoidant children, and parents who hover or are emotionally or physically absent foster anxiously attached offspring.

Many believe that because the attachment styles that Ainsworth identified become encoded in the mind, they endure and impact adult relationships. In other words, early attachment styles serve as the foundation for how adults relate to other adults. Specifically, securely attached children develop into warm, caring individuals who are comfortable with intimacy; those with early avoidant attachment styles later devalue closeness and think it results in a loss of autonomy; and anxiously attached children become adults who worry about their relationships and question whether others love them.

Thinking about attachment styles is particularly interesting when considering couple relationships. Perhaps, the thorniest problems arise when two individuals with opposing styles form a partnership. For example, consider a husband who depends on his spouse to reassure him of her love and a wife who believes that the well being of each partner is their own responsibility. Initially, each partner may have been drawn to the other, intrigued by their differences. However, over time, conflict may arise as the wife views her husband as overly needy and, in turn, withdraws. Her response is likely to increase the husband’s anxiety and intensify his pursuit of her. Then, a vicious cycle may ensue.

Opposing styles of relating may also manifest in a couple’s sexual relationship. Specifically, for anxiously attached individuals sex may satisfy unfulfilled emotional needs and lessen fears of being unloved. This tendency could create a conflict, if such an individual is partnered with a spouse whose need for emotional and sexual distance plays out by infrequent or absent sexual encounters.

Different styles of relating are a frequent complaint that brings couples into treatment. Lessening the conflict begins with each spouse understanding their own, as well as their partner’s, attachment style. Each spouse can then begin to make slight shifts in the direction of their partner. For example, in the case of the couple, described above, the wife may agree to tell her husband she loves him each day and be more welcoming when he initiates affection. The husband may lessen his expectations, take her lack of emotional expressiveness less personally, and appreciate other ways in which she conveys her attentiveness to him, such as preparing a meal he enjoys. Addressing differences in attachment styles and making changes involves a willingness to communicate specific needs to each other and to make changes. It takes work, but can go a long way in improving a marriage.

Book Review: “Rekindling Desire”

McCarthy, B, & Barry, E. (2003). Rekindling Desire: A Step-by-Step Program to Help Low-Sex and No-Sex Marriages. New York: Brunner-Routledge.

Rekindling Desire, a practical guide to getting sex and intimacy back into low-sex and no-sex marriages, is based on a 10 step program. As sex and marital experts, Barry and Emily McCarthy, offer advice in a straight forward, easy to read manner and provide the reader with clinical examples to illustrate the 10 steps. Their book, however, is so much more than a how-to handbook. The authors base their advice on the premise that revitalizing sexual desire is a couple task. To this end, they suggest a team approach that begins with rooting out “poisons,” such as shame, guilt, anger and passivity that can inhibit sexual desire. By helping couples think about the barriers that may interfere with sexual intimacy, the McCarthys sensitively and effectively lay out strategies that not only can spark a more satisfying sexual relationship, but can also rebuild emotional closeness.

Rekindling Desire: A Step by Step Program to Help Low-Sex and No-Sex Marriages