Infertility: How It Impacts Couple's Sex Lives

I have a friend who has commented about how her mother complains to her about the couple's infertility: she wants grandchildren already! This does nothing to encourage my friend; in fact, just mentioning her mother's remarks seems to "take the air out of her tires." I feel for her predicament. How does the stress of infertility affect a couples sexual relationship?

"Compared with the control group, the patients with infertility had significantly lower scores in the desire and arousal domains and lower frequency of intercourse and masturbation. Sex-life satisfaction scores were significantly lower than those of the controls" (Millheiser et al., 2010).

"Stress related to infertility had a significantly greater impact on their sense of sexual identity than other sources of stress. Sexual complaints are common among women with infertility" (Andrews et al., 1992).

Stanford University's study of infertile women shows the extent to which the problem can impact a couple's sexual life: "Forty percent of infertile women suffered from sexual problems that caused them distress, compared with 25% of a control group of healthy women. They experienced low desire and had trouble becoming aroused. They engaged in sexual intercourse and masturbation less frequently" (Millheiser et al., 2010). As Richards (2012) puts it: "When sex is so fraught with failure, it quickly becomes a casualty."

A few suggestions Richards (2012) offers is to leave the baby-making to the physician. The woman can receive injections of her partner's sperm by her physician, which may alleviate the pressure of "having to perform," and it may revitalize their sex lives. However, such a suggestion may not be assessable or affordable for some couples. For other couples, adoption is another approach which can relieve the couple of the performance anxiety, and "failure syndrome."

References:

Millheiser, L.S., Helmer, A.E., Quintero, R.B., Westphal, L.M., Milki, A.A., Lathi, R.B. (2010). Is infertility a risk factor for female sexual dysfucntion? A case-control study. Fertility and Sterility, Vol. 94, Issue 6, pp. 2022-2025.

F. Andrews, A. Abbey, L. Halman. (1992). Is fertility-problem stress different? The dynamics of stress in fertile and infertile couples.
Fertil Steril, 57 , pp. 1247–1253.

Richards, S.E. (2012). When Sex Becomes A Chore. Doublex Health, Slate, Linfield College.

Post-Retirement Careers: A Future You Can Look Forward To by Nina Bingham

Who Wants to Work After Retirement? Although retirement is traditionally defined as the end of a career and the withdrawal of the worker from the workforce, a significant percentage of retirees want or need to continue working after retirement. How many people choose to go on working after retirement? One third (33%) of the retirees who responded to a survey conducted by the AARP (1993) indicating that they would prefer to work. People have many reasons for wanting to extend their careers, the largest of which may be the need to feel involved and to give back. "As retirees face the developmental tasks of generativity vs. self-absorption and integrity vs. despair, they encounter the challenge of maintaining vital involvement during retirement (Erickson, Erickson, & Kivnick, 1986).

Developing a Post-Retirement Career Plan: "Planning and appraising of one's capacities can help the individual find creative outlet and possibly new work identity" (Harper, Shoffner, 2004). In order to formulate a plan, the individual must have a thorough understanding of their capabilities and aspirations. Assessing a senior's professional capacity could include the following:
1. Physical limitations
2. Psychological limitations
3. Availability for work
4. Compensation: Does the individual expect to be paid or prefer to volunteer?
5. Work environment: Achieving congruence between the individual's values and job environment is of utmost importance.

Post-Retirement Assessment: "With many retirees deciding to continue working after retirement, counselors must be ready to assist retirees in developing poet-retirement career plans" (Harper, Shoffner, 2004). The process of post-retirement assessment is to inventory skills, needs, values, interests and personality style. Some of the tasks included could be:
1. Write a professional biography in timeline form, noting career positions and responsibilities.
2. Take a personality test, or other career-oriented tests to better understand your strengths and areas for growth.
3. Review the Dictionary of Occupational Titles (U.S. Department of Labor, 1991).

Conclusion: Developing a post-retirement career plan now can facilitate a smooth and successful transition to a volunteer or compensated position that will enable you to revitalize your future.

References:

Erikson, E. H., Erikson, J. M., & Kivnick, H. Q. (1986). Vital involvement in old age. New York: Norton.

Harper, M.C., Shoffner, M.F. (2004). Counseling for continued career development after retirement: An application of the theory of work adjustment. The Career Development Quarterly. 52.3

U.S. Department of Labor. (1991). Dictionary of occupational titles (4th Rev. ed.). Retrieved December 13, 2001, from http://www.oalj.dol.gov/libdot.htm

Avoiding Divorce: Dysfunction vs. Abuse, and 4 Keys For Resolution by Nina Bingham

Dysfunctional Patterns: Divorce is a messy word and a painful event. Yet 50% percent of first marriages, 67% of second and 74% of third marriages end in divorce (Baker, 2012). What makes some couples succeed in the game of love, while others fail? How does one avoid becoming a statistic?  "There are two patterns of affect regulation in couples headed for divorce: an emotionally inexpressive pattern that is low in both negative and positive affect (emotion), and an emotionally volatile attack-defend pattern. The emotionally inexpressive pattern will predict later divorcing while the emotionally volatile attack-defend pattern will predict earlier divorcing" (Gottman, Levenson, 2002). This research indicates that a balance of both contact and withdrawl is necessary for a couple's relationship to succeed. It behooves couples to assess what category their inter-personal communication, and conflict-resolution falls into, of the two patterns. Gigy & Kelly's (1992) research confirms these findings: the California Divorce Mediation project found that the most common reason given for divorcing was an increasing distance and isolation between partners, a decay of the marital friendship. And, "The attack-defend mode or avoidant mode couples present the two most common marital problems in therapy" (Wile, 1993).

Critical Periods: There are critical periods in the which relationships typically dissolve. It is important to be aware of what developmental stage the relationship is in. "There are two high-risk periods for divorce in the life course. The first critical period for divorcing is the first 7 years of marriage (Cherling, 1982). The second critical period for divorce is midlife, often when most people have young teenage children. This latter time has been suggested by some investigators as perhaps the lowest point in marital satisfaction in the life course (Adelman, Chadwick, & Baerger, 1996; Orbuch, House, Mero & Webster, 1996; Steinberg & Silverberg, 1987; White & Booth, 1991).

Dysfunction vs. Abuse: Some people would say it's a fine line between a dysfunctional relationship and an abusive one, so let's be clarify what constitutes abuse. Dysfunction is different from abuse. It is important to distinguish one from another. Dysfunction is a dysregulation of: cognition (thought), affect (emotions) or behavior. To a certain degree, we all have minor dysfunctions of the personality. Personality quirks or weaknesses are different than an abusive situation. A dysfunctional relationship can be treated with couple's counseling. Sometimes bibliotherapy is recommended for couples (this would be especially helpful with sexual problems). Even group therapeutic couple encounters can be successful in treating dysfunctional patterns.

However, when abuse is present, the following sign/symptoms may include: Physical violence, isolation from family/friends, sexual abuse, using children against spouse, emotional abuse, economic abuse, threats, intimidation or coercion (Domestic Abuse Intervention Project , 2012). If abuse is occurring, making a safety plan with the guidance of a mental health professional, or domestic violence worker should be the first action step. If children have been endangered in the past and the victim feels it may occur again, taking it seriously by formulating a safety plan to leave must become the priority. A safety plan includes: a safe place for the victim and children to stay (such as a close relative, or domestic violence shelter), economic means for them, and transportation method (to school, work, etc). Counselors and domestic violence shelters or hotlines can  give referrals where the above resources can be found. If the couple is non-abusive, then they should be seen together in couple's counseling.

The following are recommended approaches for changing dysfunctional relational patterns: "For the couple characterized by negativity and volatility, replacing what could be called the "culture of criticism" with a "culture of appreciation" (Gottman, Levensen, 2002). Studies indicate that less negativity can regulate the relational imbalance.

Conversely, for couples who have grown apart and are distant, alienated and have unexpressed disillusionment and disappointment, expressing resentments and regrets with the assistance of a counselor can rebuild the relationship's friendship, "Ending the distance and isolation these people may be experiencing" (Gottman, 1999). "Central to this couple's dilemma is their emotional disengagement from one another" (Gottman, Levensen, 2002). It is the therapist's job to build a bridge between the two, a safe environment where they can meet.

Secure Emotional Attachment: There are various factors which influence the closeness or distance which is experienced inside of a relationship. To explore this idea of emotional attachment, Clymer, Ray, Trepper, and Pierce (2006) researched how attachment impacts couple's sexual functioning. "Secure adult romantic attachments are characterized by emotional safety, trust, and intimacy, while maintaining a certain degree of independence." In regards to maintaining individuality, there are couples who are enmeshed relationally, and these "too close for comfort" couples risk being overly-involved, and as a result, may loose a sense of their independent selves, or individual identities.

"Attachments (adult romantic) is determined by several factors, including an individual's general orientation towards romantic involvements with a partner, including trust, felt security, and emotional affectual bonds" (Clymer, Ray, Trepper, and Pierce, 2006). "Secure attachment style leads to greater relationship satisfaction and quality" (Collins, Read, 1990; Simpson, 1990). To summarize, the attachment style of the couple may be influencing their interactions, leading to mistrust, lack of closeness, lack of intimacy, and lack of satisfaction. Addressing non-sexual aspects of the relationship may be the key to overcoming sexual difficulties in the relationship. Therapists can focus on trust, comfort with intimacy and closeness, independence, and mutual support-all attachment related issues" (Greenberg, Johnson, 1988; Johnson, 2002).

Four Factors Of  A Healthy Relationship: Of the cohesive relational factors, these four stand out as most important: communication skills, trust, improved sexuality, and conflict resolution skills. If these areas of a relationship are healthy, you have a happy couple. I will use an anonymous case study from my work with couples to illustrate these four areas:

Mack was a white construction worker, who kept his feelings well hidden, except his temper. At home he admitted picking fights, and being controlling of, and suspicious of his wife. Anna was a Latina store clerk who had trouble verbalizing her feelings, so she cried through therapy. I could see they were plainly in a lot of emotional pain, and were on the verge of divorce. Their relationship had deteriorated into the attack-withdraw pattern described above, and the only time they interacted was to fight. The more Anna withdrew, the more angry Mack became. Mack was highly suspicious because Anna had been "sexting" other men. This injured Mack's identity as a "good husband," and had rocked their marriage. They both presented saying they had little hope for the future of their marriage.

1. Trust-In order to re-establish trust, I asked if Anna had stopped the sexual flirtation outside of the marriage, and she assured me she had. Mack wasn't so sure. I led them through a process of expressing their resentments and regrets, and then making new agreements about the exclusivity of their relationship. They expressed forgiveness of themselves and one another. Trust is usually a large overarching issue that looms between troubled couples. I like to get it right into the open, to let it be known that re-establishing trust is a process, and truly the goal of couple's therapy.

2. Communication Skills-This couple was not interacting, except to attack and defend. The couple engaged in Skills Training in communications, so they could make requests of one another, and express themselves without having to resort to blaming the other.

3. Sexual problems-This was a young couple, so their sex life could have been vibrant; they had been intensely sexually involved at the outset. I instructed them to re-establish a friendship first: to plan dates, and then report on how it went. Before the sex-life could be re-vitalized, the core friendship and relatedness of these two had to be rebuilt.

4. Conflict Resolution Skills-Fighting fair, or coming to a "win-win" solution was a new concept for them. We discussed the importance of compromise, and coming to agreements in which they each got a little of what they wanted, rather than polarizing.

Conclusion: Troubled relationships can be saved. It is often not what is spoken, but what remains unspoken, or "unfinished business," that can sink a relationship. If you have a troubled relationship, seek intervention before it seems irreparable. If you or someone you know is the victim of abuse, don't wait: waiting never helped anyone. Call a Domestic Violence Hotline and start the healing.

References:

Clymer, S.R., Ray, R.E., Trepper, T.S., Pierce, K.A. (2006). The relationship among romantic attachment style, conflict resolution style and sexual satisfaction. Journal of Couple & Relationship Therapy, Vol. 5, Issue 1, p. 71-89.

Collins, N.L.,&Read, S.J. (1990). Adult attachment, working models, and relationship
quality in dating couples. Journal of Personality and Social Psychology, 53,
397-410.

Simpson, J.A. (1990). Influence of attachment styles on romantic relationships. Journal
of Personality and Social Psychology, 59 (5), 971-980.

Greenberg, L. & Johnson, S. (1988). Emotionally-focused therapy for couples. New
York: The Guilford Press

Johnson, S. (2002). Emotionally-focused couple therapy with trauma survivors. New
York: Guilford Press.

Baker, J. (2012). Forest Institute of Professional Psychology, Springfield, Missouri.

Gottman, J.M., Levensen, R.W. (2002). A two-factored model for predicting when a couple will divorce: Exploring analyses using 14-year longitudinal data. Family Process 41.1, ProQuest.

Gigi, L., Kelly, J.B. (1992). Reasons for divorce: Perspectives of divorcing men and women. Journal of Divorce and Remarriage, 18, 169-187.

Wile, D.B. (1993). After the fight. New York: Guilford Press.

Cherlin, A. (1982). Marriage, divorce and remarriage. Cambridge: Harvard University Press.

Adelman, P.K., Chadwick, K., & Baerger, D.R. (1996). Marital quality of black and white adults over the life course. Journal of Social and Personal Relationships 13: 361-384.

Orbuch, T.L., House, J.S., Mero, R.P., & Webster, P.S. (1996). Marital quality over the life course. Social Psychology Quarterly 59: 162-171.

Steinberg, L., & Silverberg, S.B. (1987). Influences on marital satisfaction during the middle stage of the family life cycle. Journal of Marriage and the Family 49: 751-760.

White, L.K., & Booth, A. (1991). Divorce over the life course. Journal of Family Issues 12: 5-21.

Domestic Abuse Intervention Project. (2012). Power and control pyramid. Retrieved from: www.duluth-model.org

Lesbian Bed Death: Fact or Fiction?

This article is a counseling case study which will describe the following: assessment of a lesbian couple’s sexual problem, the clinical description of the sexual disorder as related to the sexual response cycle, and the inter-personal dynamics of the couple. Further, treatment approaches for lesbian sexuality and the subject of ‘Lesbian Bed Death’ will be explored.

Case Study Assessment: Sara was referred to counseling by her gynecologist because she is currently experiencing a lack of desire in a sexual relationship with her partner Amy. The couple state they have lived together for a year and are both in their thirties. Sara is white and Amy is black, both are in good health and employed. They agree they are in love, and happy to be together. However, when Sara lost her well-paying corporate job, she took two jobs to make ends meet, and works long hours. When she comes home, she is so exhausted she has no desire for sex, and Amy is feeling rejected, frustrated and sad about the loss of physical intimacy. As a result, when Amy initiates sex, they fight because Amy raises her voice. Several hours later they can talk again, but the problem remains unresolved. The couple has sex twice a month on average, and Sara expresses enjoying being close to Amy and achieving orgasm over 50% of the time. Sara does not masturbate, and admits refraining from showing affection to Amy, because she doesn’t want it to lead to sex. Amy states she came to counseling at Sara’s request but feels it is, “Her problem.” Sara states she wishes she would desire sex more often because it’s having a negative impact on their relationship. When asked about their families, Sara says she is cut off from them, since they are religious and believe that homosexuality is immoral. Her family also believes that inter-racial dating is immoral. Amy’s family is also moderately religious, but recognizes their relationship.

Clinical Diagnostics: In the Case of Sara and Amy, disruption in their relationship is being caused by Sara’s lack of sexual desire. Though they are sexually functional because they are having infrequent sex, the degree of sexual functionality for Sara’s partner Amy is not sufficient to meet her needs. The Diagnostic and Statistical Manual of Mental Disorders (DSM-1V-TR, American Psychiatric Association, 2005) lists sexual dysfunctions as, “A disturbance in the process that characterize the sexual response cycle…” and lists: desire, excitement, orgasm and resolution as the healthy sexual cycle. Sara has a dysfunction of the desire cycle, “This phase consists of fantasies about sexual activity and the desire to have sexual activity” and is an “Acquired Type,” (DSM, 2005, p. 536), indicating the onset of the problem developed only after a period of normal functioning. This condition is described as, Hypoactive Sexual Desire Disorder (HSDD) in the DSM (2005). This is distinguished from Sexual Aversion Disorder: “In hypoactive desire there is a lack of desire for something that in itself can be experienced in a positive manner, whereas in sexual aversion, negative emotions (e.g. anxiety, disgust) play important roles” (Both, Laan, Schultz, 2012). Sara admits enjoying sex in the past, so she can be ruled out for aversion to sex, and her lowered sexual desire (HSDD) is a common theme in couples therapy. “One of the most common presenting problems in the practice of sex and couple therapy; approximately 20% of men and 33% of women are affected by low or absent sexual desire” (Laumann, Palik & Rosen, 1999). “Recent epidemiological data and clinical experience clearly indicate that approximately 1 in 10 women may receive a diagnosis of HSDD” (Shifren et al., 2008). The negative feelings associated with decreased sexual interest include: feeling less feminine, feeling like a sexual failure, low self-esteem, insecurity, inadequacy and letting the partner down (Dennerstein et al., 2006; Leiblum et al., 2006). An even higher percentage of women with low sexual desire feel: frustrated, concerned, unhappy, disappointed, hopeless, troubled, ashamed and bitter as compared to women with normal desire and the distress is worse if a current partner is present (Rosen et al., 2009). “While HSDD is prevalent, it is also among the most difficult sexual problems to treat because it can be caused by a number of biopsychosocial factors” (Weeks, Hertlien, Gambescia, 2009). When diagnostics are approached from a holistic perspective, meaning the clinician takes into account the multiple biopsychosocial factors at play, biological causes must be discussed and ruled out before attempting to address the psychological and cultural factors. Biological causes such as: androgens which can cause hypothyroidism, depression and anxiety can disrupt the sexual response cycle. “Women reported that feeling depressed or anxious decrease their interest in sex” (Lykins, Janssen, Graham, 2006). In this case, Sara may be experiencing depression over having lost her corporate job and anxiety about starting two new positions.

Inter-Personal Dynamics of the Couple: This lesbian couple agrees on being in love and having been very happy for the year they have been together. They are showing a willingness to make an investment in their relationship by attending couple’s counseling. Amy is feeling rejected, frustrated and sad, but also anger. Her feelings of rejection are reinforced when she initiates sex and is refused. Sara may be feeling guilt and frustration with both her partner and herself due to her inability to “measure up” to Amy’s expectations. Sara may be feeling like she is “the problem,” because Amy has stressed that she is. Understanding the etiology of the sexual dysfunction is of utmost importance in assisting the clients to resolve the issue. Sara has recently lost her corporate job and now works two jobs which require long hours. Amy works at one job in a potentially less-stressful environment. My first hypothesis as to the etiology of the dysfunction would be the level of stress and fatigue that Sara has been experiencing: “The potential effects of stress or fatigue could be explained by the fact that stress or fatigue factors may have caused some women as much or greater stress than HSDD, which may diminish a sense of distress as a result of lack of sexual desire. As expected, the women in our HSDD registry had low Female Sexual Function Index total scores, low levels of sexual desire, and the majority reported frequent to always experiencing personal distress related to their lack of desire. The strong influence of a patient’s age, ongoing stress or fatigue, the patient’s perception of her partner’s desire levels, and oral contraceptive use should be considered or evaluated in each case ” (Conner et al., 2011). Though these clients are not pre-menopausal women, further inquiry into Sara’s stress level and fatigue (environmental causes), whether she takes an oral contraceptive or could have low androgen levels (biological cause), and her perception and feelings about Amy’s reactions to the problem (inter-personal cause) should be investigated. If Amy yells when she is denied sex, and they have been fighting because of it, Amy’s negative and blaming reaction may be reinforcing Sara’s tendency to avoid sex, exacerbating the problem.

Lesbian Sexual Response and ‘Lesbian Bed Death’: “One of the most challenging sexuality issues within the lesbian community and among professionals who treat lesbian women is the presenting problem of hypoactive sexual desire disorder or, colloquially speaking, lesbian bed death” (Nichols, 2004). Early studies showed that of all couples, lesbian couples have sex less frequently than any of the other couples (Blumstein & Schwartz, 1983), and they practice fewer sexual techniques than other types of couples (Jay & Young, 1977). In a meta-analysis of sex research indicating gender differences (Peplau, 2003), lower libido, lower rates of sexual activity in general, and less assertiveness around sexuality were found in women. Therefore, two women together have been theorized to be less sexual than a heterosexual couple because of the absence of ‘a male force’ to drive sexual contact (Nichols, 2004). Popular culture has perpetuated the belief that diminished sexual frequency among lesbian couples makes sense, since there is no man in the relationship to ensure initiation of sex (Angier, 1999; MacDonald, 1998; Nichols, 1987; Schreurs, 1993; Schwartz, 1998). Specific to lesbian couples, clinical journals refer to this problem as, “Inhibited Sexual Response” (ISD), citing, “Current understanding of lesbian cultural realities suggests that gender-specific sex role socialization profoundly affects female dynamics and that lesbians are subject to ISD as the direct result of societal expectations of them both as women and as homosexuals” (Post, Avery, 1995). However, some sex therapists (Nichols, 2004) believe this type of thinking represents a simplistic use of gender socialization theory. Nichols (2004) points out differences in lovemaking when heterosexual and homosexuals are compared: “Masters and Johnson's research (1979) in which lesbian, gay, and heterosexual couples' sexual behavior was compared found that heterosexual couples were more performance-oriented and preoccupied with orgasmic attainment. Lesbian couples took more time having sex, with sexual interaction beginning with whole-body contact and proceeding with kissing, hugging, touching, and holding before breast or genital contact was made. In heterosexual couples, "Rarely more than 30 seconds to a minute were spent holding close or caressing the total body area before the breasts or genitals were directly stimulated" (Masters & Johnson, 1979, p. 66). The point is that it may not be socialization of women which causes less frequent sex among lesbians. Instead, it may not be the quantity, but the quality of sexual relations which accounts for less frequent, but longer and more emotionally intimate sexual relations between lesbians. Defining healthy lesbian sexuality by sexual frequency may be short-sighted: “Rather than using sexual frequency as a measure of the sexual health of a relationship, some have shown that lesbians spend more time on the average sexual encounter than do heterosexuals. Using this criterion of sexual time spent together, lesbians may have lower frequency but would appear ‘healthier’ than heterosexual couples” (Iasenza, 2002). Other researchers dispute ‘lesbian bed death’ as myth: “Another view of ‘lesbian bed death’ is that it is a myth based on insufficient data, and that sexual frequency in lesbian couples is comparable to that of heterosexual couples (Iasenza, 2002). Mathews et al., (2003) found no differences in sexual frequency rates of heterosexuals vs. lesbian women. In fact, Iasenza (1991) found lesbians as compared to heterosexual women tend to be more sexually arousable and more sexually assertive” (Nichols, 2004). 

Conclusion: This couple is unique in that they are a three-way minority: females, lesbians, and biracial. Imposing on them a male standard of sexuality, a heterosexual standard, or a Caucasian standard will be 

ill-fitting, or worse: insulting to their unique place in the world. I propose that clinicians take into careful 

consideration the clients they have before them, and tailor their treatments accordingly. Sexuality is not a 

one-size-fits all proposition. With an openness and willingness to learn from the client’s individual perspectives, 

the astute clinician is in the best possible position to tailor a treatment plan that fits just right, and leave the 

myths and stereotypes behind.

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