Mandy, age 38, was fed up with Tony as he complained all the time about her loss of sexual desire. They had been together sixteen years, and he kept waiting for her to be sexy again like she was before they had any children. They had Patrick, age 15, and Gemma, age 12. She could be sexy for a few days, but then something would upset her and she would turn off. It would be several weeks before she would be feeling sexy again.

Assessment

The therapist helped the couple to see the pattern of behaviour that turned Mandy off. Tony did not realise that he was aggressive when drunk. He thought it was just a bit of fun. He also did not realise, because Mandy had not told him, that Patrick was getting rude and upsetting Mandy, his teacher, and Gemma. The couple began to feel closer to each other as they discussed these things.

Increase Sexual Awareness

For Mandy the whole topic of sex was difficult as she had bad experiences with har family's attitudes in the past. These experiences were preventing her from feeling good about herself, and from feeling OK about sex. The therapist helped her to get over her past, and allow herself to feel sexy if she wanted. Also, it became clear that Tony wanted more sex than she did, because it was the only time he felt close to her.

John and Jane came to see me together. The immediate problem was that Jane, aged 38 years, urgently wanted a baby. John, who was 43, was willing to have a child but was completely ‘off’ sex. They had not had sexual intercourse for more than a year. However, John described himself as being turned on by other women - but he chose to stay faithful to Jane.

Jane’s childhood was spent in a loving family where physical warmth and emotional expression were freely given and received. At school Jane was a high achiever and went on to university after which she made a succesful career as a journalist. In her adolescence Jane's Father, who was a Doctor, developed bouts of intense anger. Jane found this very frightening, although the anger was directed towards her Mother. She remembered that her Mother always gave in to her Father on these occasions.

John’s childhood was more difficult. There were long periods when his Father was absent from home. Emotions were constrained and little physical affection was shown him by his Mother. He, like Jane, was highly successful at school and university where he gained a good History degree. It was at university that John and Jane met. John was very taken with the easy going affection that Jane showed and Jane loved him for his quiet steadiness and attentiveness to her. They were constant companions, sexually excited and satisfied by one another.

Diana, age 31, had a baby girl nine months ago. It had been a difficult birth, and she had very bad Depression afterwards. Her mother had to help with the house and the baby, as Diana could not cope. She had anti depressants, which helped a lot, and got a bit better. When she and Edward started to have sex again, she was not that keen on it. She also had a sharp pain in the back wall of her vagina.

Assessment

Because she could describe the position of the pain so well, the therapist asked her to see her doctor. The doctor pressed on the back of the vagina, and caused exactly the same pain. She referred Diana back to the gyneacologist.

Treatment

The gyneacologist found a little sore tag left over from having the baby. The vagina had healed up, but a little bit was in the wrong place and giving the pain. Under general abaesthetic, the tag was removed.

Afterwards

No more to say. No more pain for Diana. The depression lowered her sexual desire, so she and Edward did not have so much sex as before, but it was OK. Once the depression was past, her desire came back, but not to the level of before the baby. This is normal for many women.

Greg is a 24 year old with a lifelong fear of sexual penetration. Ever since he became aware of his own sexuality he has known that he has not wanted to have intercourse. He says that he is heterosexual and that all his fantasies are about women. He can masturbate to these and has had a series of girlfriends - with whom he has been sexually active. He can achieve penetration, but is aware of a general anxiety that sweeps over him. He says that he prefers his girlfriend to masturbate him with her hand, or that they masturbate themselves in from of each other.

He and his partner Joanna want to get married and start a family. Greg wants to deal with his problem. Joanna thinks that Greg is frightened of being intimate with her, and possibly not wanting to make a commitment to marriage. Greg denies thus, and they have both argued a lot about this before coming to see a therapist.

Peter, age 47, is a highly paid and highly successful journalist, who has noticed a gradual reduction in the hardness of his erections over the past 2 years. Then, 6 weeks ago, after a particularly difficult argument with Edward, his partner of 7 years, he found himself unable to have an erection at all, and his morning erections stopped.

His doctor found he had high blood pressure, which might have caused the reduced hardness, but Peter was told that the sudden change was probably due to psychological causes, and sent him to a therapist.

During discussions with the therapist, Peter began to see that for some time he had been hiding resentment from Edward. He felt that expressing anger was a bad thing in a loving relationship, although Edward had no problem expressing his anger to Peter. This difference had led to a build up of bad feelings, and was the cause of the argument. Because of Peter's belief that expressing anger was wrong, he now felt very guilty, which could easily have caused the loss of erections.

The therapist suggested he discuss the matter with Edward, who was very understanding, and apologised for not realising how hurtful his anger had been. As a couple, they came to an agreement about the most fair way of letting each other know if they were feeling angry or upset.

Susanna is from South America, aged 25, living with her English boyfriend, Peter. She is unable to have intercourse because her vagina tenses up. She has no pain on attempts at penetration, because she never lets it get that far. This is her first sexual relationship, she thinks she is a late starter. They have sexual contact twice a week, but Susanna is terrified of the pain she is convinced she will feel if they have intercourse. There was nothing in her life story to account for her difficulty, so she agreed with me that together we would assess the tension in her vagina at our next meeting.

She felt relieved to have talked and was pleased that there was a way forward. On the couch, to her astonishment, she found she was able to touch her vaginal entrance with no pain, but was afraid to try to insert her finger. I suggested we do more next time. On her third visit, she managed to get one finger into her vagina, but there was no space for anything more. By squeezing and relaxing the muscles at the entrance to her vagina, Kegel's Exercises, she could gradually feel the space becoming bigger. By her next visit, after gently massaging the muscles inside the vaginal opening, she was able to use Vaginal Trainers.

Mandy, age 38, was fed up with Tony as he complained all the time about her loss of sexual desire. They had been together sixteen years, and he kept waiting for her to be sexy again like she was before they had any children. They had Patrick, age 15, and Gemma, age 12. She could be sexy for a few days, but then something would upset her and she would turn off. It would be several weeks before she would be feeling sexy again.

Assessment
The therapist helped the couple to see the pattern of behaviour that turned Mandy off. Tony did not realise that he was aggressive when drunk. He thought it was just a bit of fun. He also did not realise, because Mandy had not told him, that Patrick was getting rude and upsetting Mandy, his teacher, and Gemma. The couple began to feel closer to each other as they discussed these things.

Increase Sexual Awareness
For Mandy the whole topic of sex was difficult as she had bad experiences with har family's attitudes in the past. These experiences were preventing her from feeling good about herself, and from feeling OK about sex. The therapist helped her to get over her past, and allow herself to feel sexy if she wanted. Also, it became clear that Tony wanted more sex than she did, because it was the only time he felt close to her.

Joe was a professional photographer, working for a magazine, when at the age of 44, he became aware of weakness in his arms and legs, and pain in his eyes on occasion. He was devastated, after several investigations, to be told that he had Multiple Sclerosis.

Joe and his wife, Jean, had had an active and good sex life until then. A few weeks after the diagnosis, Joe began to experience either partial erections, or could not perform at all. This was a very embarassing and difficult situation for both. After some months of struggling with the problem, they decided on seeing a sex therapist. Once the therapist had ascertained that Joe still had morning erections, and was aware of feelings of arousal, when wanting to make love to Jean, it was felt that the impotence was probably due more to his anxiety and panic at his diagnosis, and what the future held, than caused by the MS itself.

The therapist placed a ban on penetration for some weeks, and suggested various ways of spending time together, caressing, exploring each other's bodies, and generally relaxing with each other. This brought about the desired effect, removing the pressure to perform for Joe, and he discovered that he had erections while doing the 'exercises' with Jean. Over the ensuing weeks, using a graduated programme, they built up towards full intercourse, and after about 8 weeks, the ban was removed, and Joe discovered that he could perform just as well as before.

Arun, 19, is a car mechanic, who has already built up a successful business, and lives with his 19 year old girlfriend, Mina, in his own home in Essex. They would like to marry, and are expecting their first child in seven months. Arun is referred with his partner because of their destructive arguments, and his occasional violence which is now threatening the whole relationship. Mina says she asks him what he is thinking and he becomes tongue-tied, and she taunts him when he does not reply. Arun says he feels Mina is brighter than he is (she has just started a degree course) and cannot tell her why he gets so frustrated. If she teases him enough, he 'flares up' and becomes aggressive, and he feels even more stupid and 'put down'. Both of them feel locked in a vicious circle and want to learn another way out and are referred to a therapist by their GP.

They see a clinical nurse specialist who is trained in behaviour therapy. They are asked to keep diaries of their rows, which has the immediate effect of reducing the frequency with which they occur. Each agrees to give the other a time to talk when they meet each day, and they sit opposite each other at the kitchen table. This is because they have both said that this is where they feel more comfortable, and safe. They practise their conversations with the therapist, who provides thwm with feedback. Mina learns that she is more sarcastic than she had realised, and Arun learns that he is shouting even when he didn't intend to. Gradually they learn another, more respectful way of asserting themselves that ensures that they are heard, less frustrated, and less likely to argue.

Jo is a twentytsomething gay man living alone in a large bedsit in Edinburgh. He is unemployed but manages his finances carefully and is fully involved with his Housing Association as a Tenants' Representative. He has no partner, but has made many attempts to find one in clubs, through local poltical groups, and in pubs,with no success. He typically meets men he fancies, immediately falls into bed with them, trying desperately to please them in any way he can. He fails, begins an argument, and drives the other person away, sometimes within hours of meeting them. He hates himself when this happens. He believes he tries so hard because he never pleased his parents, especially his father who has never supported him and who does not accept that he is gay.

Jo has had psychotherapy and understands this, but this does not help him when he is in a situation of meeting soembody for the first time. He asks his therapist for some practical help to prevent him always falling into the same trap, and is sent to a Social Skills Groups that provides Assertiveness training for men. He joins a group that has an eight week programme, and learns a whole range of techniques aimed at helping him to relax, building on his strengths, and boosting his self-esteem. He then learns specifically how to talk to men when he first meets them, in ways that do not 'put himself down' but gives them a chance to establish what Jo also would like to try or to do. He leaves the group more confident after he has tried these techniques at a gay bar. He still has no partner, but he has had more fun, and he has had fewer arguments, and reports feeling less depressed.