Transcript 300 Series, Friday, September 23, 2011 at 2:15 PM

AAMFT 2011 Annual Conference
“THE SCIENCE OF RELATIONSHIPS”
Fort Worth, Texas, USA
September 22-25, 2011
AAMFT 2011 Annual Conference
September 23, 2011 at 2:15 PM - 4:15 PM
# 302 - Evidence-Based Principles
for Satisfying Couple Sex
Michael E. Metz, Ph.D.
Meta Associates
821 Raymond Avenue, Suite 440
St. Paul, MN 55114
Voice: 651-641-9317; fax 651-642-1908
www.MichaelMetzPhD.com
Workshop “business”
Slides and clinical handouts:
a) available from AAMFT with audio recording;
b) on my website: www.MichaelMetzPhD.com, at
“resources”, “workshop slides”, “AAMFT handouts
/ Workshop slides”.
Books: Metz books and other recommended books on
Metz website: “books” and “bookstore”.
“Enduring Desire” book Signing: immediately after this
session at Routledge booth.
AAMFT 2011 Annual Conference
September 23, 2011 at 2:15 PM - 4:15 PM
# 302 - Evidence-Based Principles for Satisfying Couple Sex
Learning Objectives:
1.
understand the cognitive-behavioral-emotional environment for
relationship and sexual satisfaction over the life-cycle.
2.
identify 12 evidenced-based features of the Good-Enough Couple
Sex (GES) model for life-long quality sexual satisfaction;
3.
appreciate how research suggests that among committed, longterm, satisfied couples (e.g., average relationship length of 15
years) the quality of sex varies from day-to-day and from verygood to mediocre or even dysfunctional.
What is EVIDENCE BASED PRACTICE (EBP)?
1. “The integration of best research evidence
with clinical expertise and patient values.”
(APA Policy Statement on Evidence-Based Practice in Psychology, 2005).
2. Being anchored in the scientist-practitioner
model.
3. Evidence based practice (EBP) is not to be
confused with evidence based treatment
(EBT) which refers to manualized
treatments that have been researched in
clinical trials.
(Cox., L.M., The National Psychologist. May/June 2011 p.13)
What is Evidence Based Practice (EBP)?
• EBP attempts to identify broader elements
that intersect in practice to produce
excellent outcomes.
• EBP focuses on clarifying, corroborating
and communicating the elements,
variables and processes that help us
replicate excellence… without
oversimplifying a complex process or
stripping clinicians of autonomy, creativity
and judgment.
(Cox., L.M., The National Psychologist. May/June 2011 p.13)
Perspective


Evidence based practice with couples
integrates individual and relationship
research (e.g., physical & mental health, communication,
conflict resolution, couple interventions) and couple
therapy practice evidence.
Partners who are growing in relationship and
sexual satisfaction are growing together as a
cooperative “intimate team” – regardless of
race, nationality, gender, age, mental status,
politics, religious denomination, economic
status, sexual orientation…
Gay, Lesbian, Bisexual, Transgender
(GLBT) and Heterosexual Couples




The relationship and sexual milieu are
essentially the same for hetero and GLBT
couples.
Prevalence of sexual dysfunctions are similar to
heterosexuals.
Variant sexual dysfunctions:
 Men: painful anal intercourse (dyspareunia).
 Women: sexual desire (low desire).
Special features:
 “coming out” issues.
 the burdens from the lack of full societal
support.
Satisfaction is Inherently Subjective

Satisfaction or happiness is “necessarily
subjective and is essentially whatever the
individual defines it to be.” (Seligman (2006);
Lyubomirsky, Sheldon & Schkade, 2005)  “meaning.”

The positive role of general and sexual
well-being is INTENTIONAL , “meaning
making” - inferences from “positive
psychology” and “mindfullness” practices.
The CBE Variables for
Relationship & Sexual Satisfaction


an emotional dimension
-- (i.e., feeling fine, “good,” well, contented),
grounded on the cognitive dimension
– realistic and variable expectations
and positive attributions (i.e., “meaning”)
as an individual and the couple,

about the behavioral dimension
-- i.e., adequate relationship cooperation
and realistic and variable sexual function.
Why we need a new approach to
integrate marital-relationship
and sexual satisfaction:
The “Good-Enough Sex” (GES) Approach
for Couple Satisfaction.
Perspective on “Great” Sex
Michael E. Metz, Ph.D.

The idyllic pursuit of “great” sex is the
source of extensive personal dissatisfaction
(even agony) and relationship distress.



amplifies fears of inadequacy (e.g., penile &
breast augmentations).
predisposes to life-long disappointment.
There is a poignant irony when the pursuit of
“great sex” becomes the cause of
dissatisfying, dysfunctional sex.
Depictions of “Great Sex"
in Popular Magazines.
Menard & Kleinplatz, (2008). Sexuality & Culture,12(1), 1-20.
1.
The prescribed means to achieve "great sex“ most
frequently and overwhelmingly advocated:
1.
2.
3.
4.
2.
technical
mechanical
physical factors
variety
Advice on how to achieve better or "great sex“
tended to promote:
1.
2.
3.
sexual and gender-role stereotypes
enforced narrow sexual scripts
presented readers with contradictory and conflicting
messages
Too often people chase great sex in the wrong
directions, listen to the wrong sources.

Great sex is not magically found in a pill – although
sometimes chemistry can help.

Great sex is not primarily found by making yourself
“beautiful” or handsome” – although that can help.

Great sex is not automatic, nor found by “fortune”.

We too often “bark up the wrong tree” in our pursuit of
great sex.
The Good-Enough Sex (GES) Perspective

The prevalent belief that the quality of sexual
pleasure and satisfaction inevitably declines in ongoing relationships is one of the most toxic and selfdefeating erroneous beliefs.

The therapist, teacher, clergy person, educator,
health care provider has the unique opportunity to
re-educate a partners and encourage them to
challenge this negative belief, and guide them about
the meanings and pleasures of their sex life which
will evolve, deepen, and expand as partners
cooperate as an “intimate team.”
RELATIONSHIP & SEXUAL MILIEU
Good-Enough Sex requires
understanding and appreciating
the biopsychosocial dimensions
and the interactive skills for
relationship and sexual
satisfaction over the life-cycle.
Sexual Health & Satisfaction
Features of the Biopsychosocial Integrative Model
______________________________________________________________________________
DEVELOPMENTAL
lifelong growth stages
PSYCHOSEXUAL
SKILLS
cognitive
behavioral
emotional
RELATIONSHIP
couple identity
cooperation
emotional intimacy
BIOLOGICAL
neurologic
vascular
hormonal
PSYCHOLOGICAL
cognitive
behavioral
emotional
Negative
Positive
Quality
Quality
0
l
25
l
50
l
75
l
100
____________________________________________________________
PSYCHOLOGICAL
COGNITIVE
ASSUMPTIONS
BELIEFS
PERCEPTIONS
ATTRIBUTIONS
BEHAVIORAL
DESTRUCTIVE
CONSTRUCTIVE
EMOTIONAL
NEGATIVE
POSITIVE
EXPECTANCIES
Types of Relationship Cognitions

Assumptions – what each believes people and relationships
actually are like; the set of characteristics typical of a partner.

Standards -- what each believes people and relationships should be
like.

Selective Attention (perception) – what each notices about the
partner, the relationship, and the environment; what an Individual
notices, depending on factors such as the individual’s emotional
state, level of fatigue, prior experiences in similar situations.

“Filtering”; “selective abstraction” (Beck et al., 1979), “negative tracking”
(Jacobson & Margolin, 1979), or “sentiment override” (Weiss, 1980) -- the
selective attention or bias that is commonly unaware to the partners.

Attributions – causal and responsibility explanations for
relationship events; one’s causal explanations for relationship
events, which serve to increase an individual’s sense of
understanding and control over complex relationship events.

Expectancies -- predictions of what will occur in the relationship in
the future; outcomes or efficacy.
(source: Epstein & Baucom, 2002)
The
“Good-Enough Sex”
Approach for
Couple Satisfaction.
How is Good-Enough Sex Great Sex?

Do NOT think we’re encouraging
acceptance of:






Mediocre
Second-rate
Bland
Take-what-you-can-get
Boring sex
The blueprint or GPS for enduring high
quality and satisfying sex – without the
unrealistic “hype” (unrealistic expectations).
Basis: the “Good-Enough Sex” Model
● The Good-Enough Sex model for couple
sexual satisfaction is built on a
continuum model (“more” or “less” ) :
1.
an heuristic model (“replicable approach to direct one’s
attention”) from enduring features of 40 years of
biopsychosocial sex research and therapy;
2.
inferences drawn from multiple empirical studies
of couple sexual function and satisfaction
(biopsychosocial literature: psychology, sociology, social psychology,
marital & family, clinical, biomedical research…).
3.
current clinical observations and outcome
experience of a number of “seasoned” marital &
sex therapists.
Merits of the “Good Enough Sex” Model
The GES model (Metz & McCarthy, 2010a, 2010b; 2008, 2007a;
2007b; 2004; 2003; McCarthy & Metz, 2008a, 2008b)
1.
describes a positive set of principles for satisfaction.
2.
to facilitate couple reflection on the meaning and value of
their general and sexual relationship
3.
which can guide clinicians endeavoring to promote healthy
female, male, and couple sexuality as well as resolve SD.
4.
The model is relevant to all couples who want to enhance
intimacy and sexuality  heterosexual, gay, lesbian,
bisexual, and transgender couples.
Metz, Michael E.
& McCarthy, Barry W.
(in press, 2012).
The “Good-Enough Sex”
(GES) Model: Perspective
and Clinical Applications.
Chapter in P. H, kleinplatz., New
Developments in Sex therapy. New
York: Routledge, 2012.
Michael E. Metz Ph.D.
&
Barry McCarthy Ph.D.
Enduring
Desire:
Your Guide
to Lifelong
Intimacy.
Routledge, NY 2010
x
LIFELONG DEVELOPMENT TASKS
The 12 Core Features of
“Good-Enough Sex” for
Couple Satisfaction.
12 Dimensions of the “Good-Enough Sex” Model
1.
Sex is a good element in life, an invaluable part of an
individual’s and couple’s long-term comfort, intimacy, pleasure,
and confidence.
2.
Relationship and sexual satisfaction are the ultimate
developmental focus and are essentially intertwined. The
couple is an “intimate team.”
3.
Realistic, age-appropriate sexual expectations are essential for
sexual satisfaction.
4.
Good physical health and healthy behavioral habits are vital for
sexual health. Individuals value their and their partner’s sexual
body.
5.
Relaxation is the foundation for pleasure and function.
6.
Pleasure is as important as function.
12 Dimensions of the “Good-Enough Sex” Model
7.
Valuing variable, flexible sexual experiences (the “85 percent
approach”) and abandoning the “need” for perfect
performance inoculates the couple against sexual dysfunction
by overcoming performance pressure, fears of failure, and
rejection.
8.
The five purposes for sex are integrated into the couple’s
sexual relationship.
9.
Integrate and flexibly use the three sexual arousal styles.
10.
Gender differences are respectfully valued and similarities
mutually accepted.
11.
Sex is integrated into real life and real life is integrated into
sex. Sexuality is developing, growing and evolving throughout
life.
12.
Sexuality is personalized: Sex can be playful, spiritual,
“special.”
1
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
☺
Sex is a good, positive element in life,
a “growth goal”  an invaluable part
of an individual’s and couple’s longterm comfort, intimacy, pleasure,
eroticism, and confidence.
Antithesis:
1. sexual shame.
2. Sex negative experiences (e.g., abuse).
3. Sexual perfectionism.
Barriers to Positive Sexual Feelings
1.
SHAME can be evoked:
1.
2.
3.
4.
2.
when sexuality is judged as “bad”…
when one believes she/he should never “fail”.
When she/he believes the partner is dissatisfied.
when there is a “secret” (masturbation, paraphilia, affair,
gender dysphoria…)
HOPELESSNESS & POWERLESSNESS:
when sex performance “fails” again;
when sex function is believed it should be
“automatic” and “autonomous.”
3. fear of sex dysfunction.
4. when partner seems critical or rejecting.
1.
2.
Sexual Self-Esteem

Accepting and affirming one’s sexuality
is the foundation for
1.
2.
3.
4.
sexual self-esteem.
openness & engagement (not avoidance).
sexual self-regulation.
positive sexual interaction with the partner.

“Self-esteem is the reputation you have
with yourself.” (Brian Tracy)

“Self-esteem is that deep-down inside
the skin feeling you have of your own
self-worth.” (Denis Waitley)
Sex is a Positive, Good Element in Life

“These happy people …

found physical pleasure and emotional
satisfaction with their sex lives.

Those who reported themselves more
happy also reported far more frequent
sex.”

(Michael, Gagnon, Laumann, & Kolata, 1994. Sex in America; p.130).
2
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
☺
Sex is inherently relational.
Relationship & sexual satisfaction are the
ultimate couple developmental focus and
are essentially intertwined.
The couple grows as an “intimate team”
Sexuality is Relational

Partners grow to view the partner
as one’s “Sexual Friend.”

Partners view their relationship
as an “Intimate Team.”

Each honors the importance of
sex as only one of a number of
facets of intimacy.

Facets or Kinds of Intimacy
“Relationship Intimacy Assessment” (RIA)
(copies on website:
www.MichaelMetzPhd.com
“resources”)
12 Facets of Intimacy












Recreation:
sharing experiences of fun, sports, hobbies, recreation; sharing ways
of refilling the wells of energy, leisure.
Aesthetic:
sharing experiences of beauty -- music, nature, art, theater, dance, movies;
drinking from the common cup of beauty.
Intellectual:
involves sharing the world of ideas; a genuine touching of persons based on
mutual respect for each others intellectual capacities (reading, discussing,
studying, respectful debating, etc.).
Commitment:
togetherness derived from dedication to a common cause, value or effort
(e.g. working for a political cause).
Work:
sharing common tasks or projects, supporting each other in bearing
responsibilities (raising a family, house/yard chores, cooking together, etc.).
Communication: being open, honest, trusting, truthful, loving; giving constructive feedback;
positive confrontation.
Crisis:
standing together in the major and minor tragedies which persist in life;
closeness in coping with problems and pain.
Sexual:
sensual-emotional satisfaction; the experience of sharing and self-abandon in
the physical merging of two persons; sensual-sexual fantasies and desires.
Emotional:
depth awareness and sharing of significant meanings and feelings; the
touching of the innermost selves of two human beings.
Creative:
helping each other to grow, to be co-creators (not "reformers") of each other.
Conflict:
standing-up with/to each other; "fighting" in non-destructive
(i.e., constructive) ways; facing and struggling with differences together.
Spiritual:
the "we-ness" of sharing ultimate concerns, the meanings of life, philosophies,
religious experience.
Principles of
Relationship Satisfaction.
8 Healthy Relationship
Principles
supported by couple research.
(copies on website:
www.MichaelMetzPhD.com
“resources”)
Principles of Relationship Satisfaction
Michael E. Metz, Ph.D.
1.
The Relationship is the Overall Priority.
2.
Healthy Relationships are Founded in Personal Equity.
3.
There is a Priority on Cooperation.
4.
Each Puts the Other’s Satisfaction First.
5.
There is a Priority on Mutual Emotional & Sexual
Empathy.
6.
Partners Distinguish Feelings & Behaviors.
7.
All Conflict Resolution has as its Goal Mutual Emotional
Satisfaction.
8.
Relationship satisfaction is directly influenced by the
quality of relationship conflict resolution.
Core Research Findings
about Couple Conflict
Relationship Conflict Research Findings
Metz & Epstein, 2002. The role of relationship conflict in sexual dysfunction.
1.
Relationship conflict is normal. The important
factor is how constructively couples resolve their
differences.
2.
Mutual conflict resolution is essential for
satisfaction: the emotional core.
3.
Cognitions are crucial as they strongly influence
satisfaction and communication.
4.
Conflict resolution styles are fundamental.
Couples who address their conflicts with
constructive styles (e.g., assertion, cooperation),
avoid destructive styles (e.g., aggression,
withdrawal), and resolve their conflicts with
mutual satisfaction and equity, are more likely to
be satisfied.
Relationship Conflict Research Findings
Metz & Epstein, 2002. The role of relationship conflict in sexual dysfunction.
5.
Distressed couples display gender differences in
resolution styles.
6.
Satisfied couples blend / merge gender
differences in conflict resolution styles.
7.
Healthy couples are non-aggressive. There is no
empirical evidence that expression of verbal or
physical aggression is ever helpful in an intimate
relationship.
RELATIONSHIP CONFLICT
THE ORDINARY OPPORTUNITY
TO DEEPEN
RELATIONSHIP INTIMACY
(Issue of cooperation)
Conflict as an Opportunity for Intimacy
– and “energy for the bedroom”.
Constructive Conflict Resolution and Intimacy
Conflict presents the ordinary, day-to-day
opportunity for couples to deepen their
emotional and sexual intimacy.
Learn about your partner’s complexity and
uniqueness.
Reinforce respect and admiration for each other.
Develop more confidence that future conflict can
be positively resolved.
Create positive feelings and comfort with each
other that facilitate their sexual desire for each
other.
Develop a greater sense of pride in their
relationship.
Making Some Sense of
Couple Conflict
and Identifying targets
for Change.
The 5 Features of Relationship
Conflict
1. Context:
(a) Geology & (b) Geography
5. Meaning
4. Styles of
Interaction
2. Content
3. Severity
The Conflict Resolution Styles
of the “Styles of Conflict” Model (Metz, 2002)
Engaging
positive
verbal / physical
ASSERTION
AGGRESSION
ADAPT ATION
Avoiding
SUBMISSION
or
YIELDING
Constructive
WITHDRAWAL
DENIAL
Destructive
Empathy is the solid foundation from
which partners resolve conflicts.

When both partners feel good about the
decision, this agreement is self-sustaining: a
win-win strategy.

When your team identity, cooperation,
empathy, and mutually satisfying conflict
resolution are well blended, you’re building
the environment to promote GES and ensure
sexual satisfaction can flourish.
Individuals without a Partner
During periods when she/he may not have a
significant partner, she/he anticipates developing
and “growing” intimacy with a “VIRTUAL
PARTNER”
--> the mental or Imaginary focus of sexual
cognitions, feelings, and behaviors:
 Past relationship (s).
 Present “idealized” relationship.
 Hoped-for future relationship.
 Issue of “reasonable expectations” of
relational sex.
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
3
Dimensions of the Good-Enough Sex Model
☺
Realistic, age-appropriate, accurate
and reasonable sexual knowledge and
expectations are essential for sexual
satisfaction.
Reasonable Sexual Expectations
1.
Partners understand that the commercial
marketing with sex is usually:
1.
2.
3.
►
superficial & simplistic
plays on insecurities or inadequacies
manipulative -- in order to sell products.
Partners learn how his / her person and
sexual body “work:”
1.
physiological 
1.
2.
2.
based on acceptance of lust & eroticism;
based on accurate knowledge of your body;
psychological  emotional integration.
Accurate Knowledge is Powerful
•
Realistic, accurate, age-appropriate
information is crucial
•
because it inspires cognitions (beliefs,
assumptions, interpretations, attributions, and
expectancies) and emotions  the
“meaning” – and
•
essentially distinguishes satisfied vs.
dissatisfied / dysfunctional couples.
What is Distinctive About
Individuals & Couples with SD?

There are individuals and couples with
sexual performance (behavior) deficits
that do not meet the DSM or ICD
diagnostic criteria for SD.

The critical feature in the DMS-IV-R and
ICD-10 classification of sexual dysfunction
is:
“…marked distress or
interpersonal difficulty.”
What is Distinctive About Couples with SD?
#1: Community Availability Sample
Frank, Anderson, & Rubinstein, (1978). Frequency of
Sexual Dysfunction in Normal Couples. NEJM)

Among “normal” (maritally and sexually
satisfied) couples, the prevalence of sex
performance (B) problems is fairly high:
 Sex Dysfunction common:


Sex Difficulties high:


40% men & 63% women.
50% men & 77% women.
Yet, 80%+ were maritally & sexually
satisfied.
What is Distinctive About Couples with SD?
# 2: Community Representative Sample
Laumann, Gagnon, Michael & Michaels, (1994).
The social organization of sexuality.

Despite many men and women (> 50%)
reporting periods of a month or more in the
past year when they experienced one or
another sexual problem, many reported
satisfaction with their sex life (p. 373).
What is Distinctive About Couples with SD?
#3: Community Availability Sample
Byers & Grenier, (2004). Premature or rapid ejaculation: Heterosexual
couples perceptions of male ejaculatory behavior. Arch. Sex. Beh., 2003




Evaluated PE among 150 university alumni couples.
PE was associated with lower sexual satisfaction for men
– but not women – at least in this community sample.
The negative impact of sexual dysfunction is not solely
determined by the behavioral performance deficit but
rather by the significance to the man and notably to his
partner.
Conclusion: “it may be that although partners are
dissatisfied with the time of ejaculation, they have
developed sexual scripts that allow them to
experience sexual pleasure through other forms of
stimulation.” (p. 269).
What is Distinctive About Couples with SD?
#4: Same-Sex Community Availability Sample
Rosser, B. R. S.; Metz, M. E.; Bockting, W. O.; Buroker, (1997).
Sexual difficulties, concerns, and satisfaction in homosexual men.
Journal of Sex & Marital Therapy. 23(1), Spr 1997, 61-73.

A sample of 197 homosexual males (over 18 yrs of age).

Results: Almost all (97%) reported some sexual difficulty over
their lifetime, and more than half (52%) reported a current
sexual dysfunction. A further 25% of the Ss identified other
sexual concerns (e.g., fear of STD).

Despite these figures, most subjects -- whether single,
dating, or in a relationship -- reported average to
above-average sexual satisfaction.
What is Distinctive About Couples with SD?

Such multiple sources suggest realism…

…that sex dysfunction as a clinical
complaint is more complex and more
distinctive

than behavioral function or physical
performance.
A Crucial Variable for Sexual Satisfaction:
Reasonable, Age-Appropriate Expectations

The indispensable variable in
 sexual satisfaction (emotional
dimension) is
 the “meaning” (cognitive dimension)
 of the sexual interaction (behavior) for
the individual and couple.

Satisfaction is influence by realistic,
accurate, age appropriate, reasonable
sexual knowledge.
“The problem isn't that people
know too little,
but that people know too much
that just ain’t so.”

(Mark Twain)
MEN, WOMEN, SEX
Some Sex Behavior Data
Knowledge is Power…

Some sexual behavior data from representative sample studies:
2010 Study:

Herbenick, D., Reece, J, Schick, V., Sanders, S.A., Dodge, B, and
Fortenberry, J.D., (2010). Sexual Behavior in the United States:
Results from a National Probability Sample of Men and Women Ages
14-94. J Sex Medicine, 2010;7(Suppl 5): 255-265
1994 NATIONAL HEALTH AND SOCIAL LIFE (NHSL) Study:


Laumann, E. O., Gagnon, J. H., Michael, R. T., Michaels, S. (1994).
The social organization of sexuality: Sexual practices in the United
States. Chicago: University of Chicago Press. (The National Health
and Social Life study)
Michael, Gagnon, Laumann, & Kolata, (1994). Sex in America: A
definitive survey. NY; Warner.
National Health and Social Life Survey (1994)

Women’s Sexual Complaints (43 %):







Low Desire
Inhibited Orgasm
Sex not pleasurable
Pain with intercourse
Performance Anxiety
Lubrication trouble
Climax too soon
(N = 1,740, ages 19 – 59)
1 in 3
1 in 4
1 in 5
1 in 7
1 in 10
1 in 10
1 in 10
33.4%
24.1%
21.2%
14.4%
11.5%
10.4%
10.3%
National Health and Social Life Survey (1994)

Men’s Sexual Complaints (31%):







Premature Ejaculation
Performance Anxiety
Lacked interest
Erectile Dysfunction
Ejaculatory Inhibition
Sex not pleasurable
Pain with coitus
(N = 1,410, ages 19 – 59)
1 in 4
1 in 6
1 in 6
1 in 10
1 in 11
1 in 11
1 in 33
28.5 %
17.0 %
15.8 %
10.4 %
8.3 %
8.1 %
3.0 %
Some Descriptive Sexual Data of Adults
The National Health and Social Life (NHSL)

Approximate average of 6 sexual partners for men,
and 5 partners for women in lifetime.

> 75 - 80% of men are sexually faithful, and > 8085% women.

Average Couple Sexual frequency is 1- 2 x week.

Sexual dysfunction (SD) is “normal” (average) –
most men (& women) experience a SD by age 40.
Some Descriptive Sexual Data of Adults
The National Health and Social Life (NHSL)

68% of single men and 48% single women
masturbate regularly.

57% of married men and 37% married
women masturbate regularly.

27% of men and 8% women masturbate at
least 1 time per week.

94% of men and 84% of women have sexual
fantasy more than several times per month.
The Appeal of Sexual Practices to Men and Women
The National Health and Social Life (NHSL)
%
%
Men Women
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Vaginal intercourse
Watching partner undress
Receiving oral
Giving oral
Group sex
Lifetime anal intercourse (hetero)
Watching others do sexual things
Stimulating partner’s anus with fingers
Using vibrator/dildo
Anus stimulated by partner’s fingers
95
93
79
77
46
45
40
26
23
22
96
74
73
68
7
55
17
15
17
18
Laumann et al., 1994
NHSL: Frequency of Sex

33% of Americans aged 18 to 59
have sex with a partner as often as
twice a week:
1/3rd = >2x+ week.
 1/3rd = a few times a month.
 1/3rd = a few times a year.

“Sex in America” (NHSL) Findings
●
Duration of intercourse ranges from 2-7
minutes.
●
Orgasm occurs approximately 80% of
the time for men, 30% for women.
●
satisfaction is determined more by
“sexual meaning” than “sexual
performance”
●
The quality of sex varies.
The Role of Sex in Marital Satisfaction

When sexuality functions well, it is a
positive, integral component in the
relationship, contributing 15 – 20%
of satisfying, intimate feelings.

When sexuality is dysfunctional, it
plays an inordinately powerful role,
from 50-75%, draining the
relationship of intimacy and good
feelings.
“Sex in America” (NHSL) Findings
●
“The general picture of sex with a partner in
America shows that Americans do not have a
secret life of abundant sex.” (p. 122)
●
“Contradicting the common view of marriage
as dull and routine, the people who reported
being the most physically pleased and
emotional satisfied were the married
couples.” (p. 124)
●
Virtually all the people who were happy in
general also said they were happy with their
sex lives.” (p. 130)
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
4
☺
Good physical health and healthy
behavioral habits are vital for sexual
health.
Individuals value their and their
partner’s sexual body.
Healthy Behavioral Habits and
Sexual Satisfaction







healthy sleep patterns
moderate physical exercise
eating habits and weight range
alcohol and drugs
smoking
medication management (e.g.,
antihypertensive)
managing chronic illness
Healthy Behavioral Habits and
Sexual Satisfaction
 In healthy, satisfying relationships,
emotional and sexual arousal are
self-regulated.
 The importance of general
cognitive-behavioral-emotional
regulation (e.g., anger, anxiety) for
satisfaction is evident in nonsexual studies. (e.g. Kirby, Baucom, &
Peterman, 2007)
Emotional / Sexual Self Regulation
in Relationship

“If you're not under control, you cannot
have connection.”

“When we lose it, we’re not likable.”

“Calm down, grow up to adult, and
connect.”
(Hal Runkel)
Sexual & Emotional Self-Regulation

Self regulation is at the heart of
developing relationship and sexual
health.

Emotional and sexual arousal
regulation requires self-care and
“sophisticated self-understanding”
Healthy Emotional & Sexual Regulation
© Michael E. Metz, Ph.D.



manage sex behavior (B)
by regulating cognitive (C), and
emotional & sexual drives (E):

Western style: resistance
“Self Control”, discipline.
 Repression / suppression.


Eastern style: acceptance


“Self-acceptance” emotions & sex drive-lust.
Willingness to let it “pass through…”
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
5
☺
Relaxation is the foundation
for sexual function and
pleasure.
1. Physiological: PDE-5 inhibitors.
2. Psychological: balance of anxiety (Barlow).
3. Interpersonal: acceptance of touch,
cooperation  e.g., “sensate focus” (M&J).
4. Developmental  “mellowing”
(e.g., “better quality” of sex among 15 yr
committed couples.)
Relaxation



Relaxation vs. “performance anxiety”.
Relaxation vs. “spectatoring”.
PM and Kegel skills / exercises.

For cognitive relaxation monitoring
Use in premature ejaculation treatment
 Use in erectile dysfunction treatment
 Use in inorgasmia.

The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
6
☺
VALUE SENSUAL TOUCH
& EMOTIONAL PLEASURE AS WELL
AS PERFORMANCE
 need for comfort, acceptance of touch
 research on value of touch for youth,
adults, elderly.
 while sex function is important (especially for
men), pleasure and cooperation are key.
The 6 Kinds of Touch
(Metz & McCarthy, Enduring Desire. NY: Routledge, 2010)
COMFORT
TOUCH
INTERCOURSE
TOUCH
AFFECTIONAL
TOUCH
EROTIC
TOUCH
SENSUAL
TOUCH
PLAYFUL
TOUCH
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
7
☺
Valuing VARIABLE & FLEXIBLE sexual
experiences -- abandoning the “need” for
perfect performance and adapting with
alternate sex scenarios:


inoculates the couple against sexual
dysfunction by overcoming performance
pressure, fears of failure, and rejection.
frames the couple perspective towards
cooperation as an “Intimate Team.”
GES Perspective…
Sex is enhanced by appreciating its
healthy variability.
Researchers (Kleinplatz, Menard, et al., 2005; Lindau,
Schumm, et al., 2007) have learned from older
couples that optimal, exceptional
sexual experiences and lackluster ones
exist in the same very satisfying
relationship.
The Variable Quality of Sex in
Well-Functioning, Satisfied Married Couples
•35 – 45%
Very Good Quality.
•20 – 25 %
Good Quality (at least
for 1 partner).
•15 – 20 %
Okay; Not Remarkable.
•
Mediocre, Dysfunctional.
5 – 15 %
(Sources: Frank, Anderson & Rubinstein, 1978; Laumann, Michaels, Gagnon, et al., 1994)
Basic Components of Sexual Flexibility

Satisfying sex realistically embraces:

5 Basic Purposes for sex --> flexible
sexuality pursues multiple purposes
(pleasure, tension release, emotional intimacy, sexual selfesteem, reproduction).

3 General Sexual Arousal Styles -->
Flexible sexuality blends the multiple
arousal styles (e.g., sexual arousal varies from partner
interaction to entrancement arousal, and role enactment).
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
8
The 12 Core Premises of
“Good-Enough Sex” for Couple Satisfaction
8.
The five general functions or
purposes for sex are
integrated into the couple’s
sexual relationship for
flexibility.
The 5 Basic Purposes for Sex
(Biopsychosocial Functions)
In the order of prevalence:
•
•
•
•
•
Physical pleasure (bio-psych)
Tension / anxiety reduction (bio-psych)
Relationship intimacy (interpersonal).
Self-esteem, confidence (psych)
Reproduction or procreation (bio).
Distressed – Dysfunctional Sex

When the purpose becomes:
 one-dimensional sex over
extended periods of time,
 sexual dysfunction is common:
e.g., infertility protocol
(procreation)
(e.g., Burns et al, 2005).
 e.g., only for intimacy; only for
anxiety reduction.

The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
9
The 12 Core Premises of
“Good-Enough Sex” for Couple Satisfaction
9
Integrate and flexibly
use the three basic
sexual arousal styles.
Arousal Styles: Differences in Focus
(Metz & McCarthy, Enduring Desire. NY: Routledge, 2010)
1.
"Partner Interaction" focus on the partner. Person is
active, eyes open, looking at the partner, talkative (romantic or
"sweet" talk), and energetic. This is the sexual style on TV and
in movies -- passionate and impulsive sex.
2.
Sensual “Self-entrancement” focus on one’s own body.
Person utilizing this style typically closes one's eyes, goes
within, becomes quiet, and looks detached and passive.
Routine and stylized touch help this person to become
aroused.
3.
“Role Enactment" focus on role play, fantasy, variety, and
experimentation, such as dressing in sexy lingerie, role
playing being "tough" or "hard to get," acting out a scene from
a movie or fantasy, having sex in new places (e.g., vacation),
using "toys" (massage oil, vibrator, dildoe) to find excitement
and arousal through sexual playfulness.
What Couples Learn for Sexual Health
Sexual arousal and the issue of
“Sexual Familiarity”
Emotional Closeness and Eroticism
 Traditionally, both professionals and the
public believed that if the couple focused
on increasing loving feelings and
communication that the sex would be
easy and take care of itself.
 This is not just a simplistic myth, it is also
a dangerous one that can subvert quality
couple sexuality. A healthy relationship
involves both emotional intimacy and
sexual eroticism (Perel, 2006).
Emotional Closeness and Eroticism
 They are truly different, although ideally
complementary, dimensions. Closeness is
of central value in establishing couple
identity, communication, and feeling
connected. However, it may not improve
sexual desire and function.
 A real danger is that some couples feel so
close and intimate that it actually smothers
sexual desire: they de-eroticize each other.
They are such good, intimate friends that
there is no space for sexual playfulness or
eroticism.
Perspective… Intimate and Erotic Friends
 The role of emotional intimacy is to
nurture your bond. The role of sexual
intimacy - eroticism is to energize your
bond, specifically to enhance feelings of
desire and desirability.
 Sexuality can contribute 15-20% to
relationship satisfaction when you see
each other as intimate and erotic
partners. It acts as a special relationship
resource that helps maintain vitality and
satisfaction.
Premier Principle
☺
The mutual priority to please the other
in both the everyday emotional
relationship and the erotic sexual
component is the hallmark of enduring
satisfaction.
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
10
10
Individual and gender differences are:
1. respectfully accepted, embraced &
valued.
2. generously accommodated.
3. similarities mutually enjoyed.
4. couple works as an “Intimate Team”
Phases of Male & Female Sexual Response
1.
2.
3.
Physiological (Masters & Johnson couple
model) MALE = “PROCEPTIVE ” drive
model.
Physiological FEMALE = “RECEPTIVE” drive
model.
R. Basson (2001) – “RESPONSIVE” model.
New Model of Female Sexual Arousal - 1
Rosemary Basson, MD:

Women have a lower biological urge for the
release of sexual tension than men.

Orgasm is not necessary for satisfaction
and does not need to occur at each sexual
encounter.

Women’s sexual desire is often a
responsive rather than a biological or
spontaneous event, greatly influenced by
subjective psychological excitement.
Basson’s Model of Female Sexual Arousal - 2
1.
Typically, a woman’s sexual desire develops from her
receptivity to gentle, relaxed sensual touching. This
touching leads to sexual desire and continues to
emotional closeness, affection, sensuality, and eroticism.
2.
Sexual desire can develop after initial sensual contact.
3.
Healthy female sexual response in an established
relationship begins in sexual neutrality, but sensing:
1. an opportunity to be sexual,
2. the partner’s desire,
3. or an awareness of one or more potential benefits that
are important to her and their relationship (for
example, emotional closeness, bonding, love,
affection, healing, acceptance, commitment), she
elects to seek sensual contact and stimulation.
Basson’s Model of Female Sexual Arousal - 3

With beginning physical arousal, she may
become aware at that time of desire to continue
the experience for sexual reasons and
experience more arousal which may or may not
include wanting orgasm. This brings her a
sense of physical well-being with added
benefits such as emotional closeness, love,
affection, and acceptance.

This model acknowledges that sexual desire
for men may be more biologically driven while
for women, more psychological and relational.
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
11
The 12 Core Features of
“Good-Enough Sex” for Couple Satisfaction
11


Sex is integrated into real life and
real life is integrated into sex.
Sex is not an isolated fragment of
one’s life.
Integration of life events into lovemaking
--> Living daily life provides the opportunity
to experience sexual interactions in a subtly
yet distinctively personalized and enriched
way:











sex on vacation.
during pregnancy.
during times of loneliness.
after the wedding of your best friend.
after a parent’s death.
during times of career stress.
after a class reunion.
during periods of success
during periods of failures.
amidst childrearing.
family illnesses.
Integration of life events into lovemaking.
The importance of “regular sex”
Sex is an accepted, consistent part of life.
The healthy sexual couple integrates the daily
events of life and blends this with the partner’s, to
create the couple’s unique, realistic, sexual style.
Sex “fits” real life:
sex fits into one’s daily life; daily life fits into
sex.  sex is commonplace with moments of
tenderness, experimentation, playfulness,
passion, wildness, reflection, transcendence.
Regular Sex…
Couples who permit life’s stresses,
fatigue careers, parenting, or
irritations to override regular sex are
at risk of alienation.
Ongoing, real-time GES sex can
produce benefits like comfort,
diversion, relaxation, trust, pleasure,
cooperation, healing, and emotional
intimacy.
REAL LIFE REGULAR SEX – THE “INTIMACY BLENDER”
(from: Metz & McCarthy, Enduring Desire. NY: Routledge, 2010)
Regular sex ensures that the moods and events of life are brought to your bedroom.
Sexual Environment
▬► Mood Example
● “Spirited Sex” ▬► when you feel full of life and vigorous.
● “Standard Sex” ▬► when life is uneventful, sex is a shared
●
●
●
●
●
●
●
●
pleasure.
“Passionate Sex” ▬► wild, lustful, animalistic, abandoned,
shameless, taking your partner and being taken, rough,
undisciplined, rowdy, raucous, unruly, noisy, boisterous sex.
“Make-up Sex” ▬► after an argument to heal.
“Compassionate Sex” ▬► after the funeral of your close
friend; e.g., intercourse for soothing comfort.
“Bad Mood Sex” ▬► during despondent or glum moments.
“Angst Sex” ▬► sex for tension or stress release.
“Vacation Sex” ▬► on a holiday or escape trip.
“Role Play Sex” ▬► when you’re “stretching”, experimenting
“Transcendental Sex” ▬► sharing sex ”under the stars”,
awareness and appreciation of the ultimate meaning of
life, love, the universe.
© Michael E. Metz, Ph.D.
Regular Sex as Gender Cooperation
1.
2.
3.
4.
5.
Protects the sexual from avoidance due to
mood fluctuation and life events.
Can better balance intimacy and eroticism.
“Tenderizes” the man and promotes
emotional communication.
“Empowers” the woman and promotes
eroticism.
Promotes sexual & emotional cooperation.
Marital / Committed Sex

Rather than “routine,” boring, lethargic, and
perfunctory, healthy sexuality is honest and
realistic; it “fits” your realistic lifestyle amidst
careers, kids, and routines, as well as at times
providing an “escape.”

Satisfying marital sex is respectful, tender,
playful, and occasionally wild &experimental.

Married couples enjoy stable sex with benefits
like comfort, relaxation, trust, pleasure,
cooperation, and emotional intimacy.
12
Core Principles for Couple Satisfaction
☺
Relationship and Sexual
Satisfaction are often personalized:
 idiosyncratic
 spiritual, transcendental,
“prayerful”
 playful, “special.”
What Men Need to Learn for Sexual Health
“Good Enough Sex” is:
Occasionally PLAYFUL
Personalizes the bedroom
Sex as Mature Playfulness

The occasional presence of play is a reliable
indicator of relationship and sexual health,
because for play to occur, certain other
aspects of intimacy must be functioning
well:
trust.
mutual acceptance.
pleasure is more important than
performance.
priority upon the relationship (“special”).
freedom to be oneself.
****************

“A good marriage at age 50 predicted
positive aging at 80. But, surprisingly,
low cholesterol levels did not.”
George Valliant, MD,
Harvard Medical School
Adult Playfulness
“To be playful and serious at
the same time is possible;
in fact it defines the
ideal mental condition.”
(John Dewey, American Educator. How We Think.
Mineola, NY: Dover Publications; 2007).
Couple Reports of Sexual Playfulness
● A 34 year old male lawyer wrote:
●
"We spend time tickling each other which is
sometimes sexual and sometimes not. We will
touch each other `sexually' while doing normal
everyday things. We will 'accidentally' touch
each other. We chase each other in the house. I
will sneak up on her while she is changing. I will
expose myself at times in the house when we are
alone. My wife will give me a sneak peek when
she teases. We take showers together and will
sometimes wash each other with sexual
overtones."
(Metz, ME, (2004). The Role of Adult Play in Intimacy.)
Couple Reports of Sexual Playfulness
● A 32 year old female teacher said:
●
"I love to dress up for my husband in lacy
clothes one time, then my regular underwear
another. I also sometimes beg him in a
playful way (I get down on my knees and BEG
dramatically!) to dress for me in his tuxedo or
leopard skin briefs...that I have to have him
this way... It's a spoof and a tease! But it
really feels like we're willing to please each
other....that's why I think I so love this... I also
prize the way we can giggle and smile
sometimes when we're making love. I feel so
special then...
(Metz, ME, (2004). The Role of Adult Play in Intimacy.)
Mature Couple Playfulness

Play acknowledges:
 the complexity and ambiguity of life
 the multiple levels of reality
 the priority is on interpersonal connection

Play involves unconditional acceptance,
cooperation, team-work, comfort, feeling safe
and secure, trust, union, and delight.

Sexual playfulness enhances and strengthens
intimacy, and respects the capacity of sexuality
as a transcendent or spiritual experience.
Sexuality, Play & Spirituality
●
Deep respect for the capacity of the
human experience of sex.
●
Transcendental experiences with sexuality
 e.g., Roman Catholic “Sacramentality”.
●
Prayer / philosophy and sexuality –
celebrating the meaning of life & death.
Building Blocks Toward Optimal Sexuality
(Kleinplatz & Menard, 2007)

Being present –> “totally absorbed in the moment.”

Authenticity –>

Intense emotional
connection –>
“deeply empathic.”

Sexual and erotic “deep sense of caring for
intimacy –>
one another; generosity.”

Communication –> “comfort with sexual talk and
experimenting.”

Transcendence –>
“feeling free to be oneself.”
“a portal to an alternate reality.”
“Here and there,
now and then;
this is where God
is to be found…”
Frederick Buechner,
Now and Then (1991)
Michael E. Metz Ph.D.
&
Barry McCarthy Ph.D.
Enduring
Desire:
Your Guide
to Lifelong
Intimacy.
Routledge, NY 2010
x
GES Publications / Resources

Metz, M.E. & McCarthy, B.W., (2010). Enduring Desire: Your Guide to Lifelong Intimacy. NY:
Routledge.

Metz, M. E. & McCarthy, B. (2012). The “Good Enough Sex” (GES) Model: Perspective and
Clinical Applications. Chapter in Kleinplatz, P., New Developments in Sex Therapy. New York:
Routledge.

Metz, M. E. & McCarthy, B. (2007). The “Good Enough Sex” model for couple sexual satisfaction.
Sexual and Relationship Therapy, 22 (3), 351-362.

Metz, M. E. & McCarthy, B. W.(2010) .'Male Sexuality and Couple Sexual Health: A Case
Illustration', Journal of Family Psychotherapy, 21: 3, 197-212

McCarthy, B. W. & Metz, M. E., (2008). The cognitive-behavioral “Good-Enough Sex” model: A
case illustration. Sexual and Relationship Therapy; 23 (3), 227.

Metz, M. E. & McCarthy, B. W. (2008). “Eros & aging: Is good-enough sex right for you?”
Psychotherapy Networker, July/August 2008; 55-61

Metz, M.E. & McCarthy, B.W. (2004). Coping with Erectile Dysfunction. Oakland: New Harbinger
Publication.

Metz, M. E. & McCarthy, B. W. (2003). Coping with Premature Ejaculation: Overcome PE, Please
Your Partner, and Have Great Sex. Oakland, CA: New Harbinger Publications.
DISCUSSION…
Thank You
GES motivated
clinical couple
assessment and
treatment
Overview / Illustration of Couple
Assessment / Treatment
GES treatment invariably includes:
1. Thorough assessment of relationship and sexual
behaviors, cognitions, emotions, and partner
interactions.
Multiple assessment sessions involve an initial
couple session, individual psychological/relational/sexual
histories, pencil and paper surveys, and a couple
feedback session to share a new, authentic narrative and
to establish a treatment contract.
 The initial couple sessions establish SD as a couple
issue.
Overview / Illustration of Couple
Assessment / Treatment
 Psychoeducation is a regular component of the
assessment. As issues surface that can benefit from
accurate, realistic information, bibliotherapy is integrated.
 This sets the stage to discuss the concept of personal
responsibility for sexuality and being an intimate and
erotic team.
 History helps each person create a coherent narrative
about his/her sexual beliefs, experiences, and feelings
and elicit hopes and expectations about emotional
intimacy, eroticism, and sexuality.
Overview / Illustration of Couple
Assessment / Treatment
2. Therapist feedback bridges from assessment to
treatment goals.
The structure of this session focuses on a GES
perspective shift, a new, genuine individual and couple
narrative that challenges them to build a new couple
sexual style, and establish an agreement on a therapeutic
plan and goals.
3. Consideration of core features of GES relevant to
this couple and discussing specific growth goals.
Overview / Illustration of Couple
Assessment / Treatment
4. Outlining specific treatment details that include
psycho-educational features, rationale for the treatment
strategies, and psychosexual skills exercises.
5. Specifying the criteria for measuring outcome
(growth goals) and elements that serve as basis for their
relapse prevention plan.
6. Guiding cognitive behavioral sex therapy
homework interventions and exercises.
Overview / Illustration of Couple
Assessment / Treatment
7. Designing an individualized relapse prevention
plan as part of therapy closure.
 Commonly the plan encapsulates 3 to 5 cognitive-behavioral activities
that will continue their progress that are small and achievable such as a
monthly 1 hour pleasuring session without intercourse.
 The couple scheduling six month follow-up therapy sessions over two
years gives a powerful positive message of accountability to maintain
healthy couple sexuality and to continue to grow their intimate
relationship.
 Growth goals can include a minor addition such as trying a new body
lotion during pleasuring or a new intercourse position or it can be a major
change such as taking a couple vacation without children for the first time
in 5 years or trying a role enactment arousal scenario for the first time.
Overview / Illustration of Couple
Assessment / Treatment
8. Follow-Up Session(s)
 The structure of the follow-up session is to:
1. reinforce positive sexuality,
2. problem-solve any sexual issues,
3. set a growth goal for the next six months
4. provide clinician evaluative feedback and
learning.