I. Problems Mainly Affecting the Male

It is convenient to consider sexual problems according to their initial clinical presentation. They fall naturally into problems affecting primarily the male partner and those affecting primarily the female partner. When it comes to dealing with patients, however, it is a fundamental principle that both partners may be concerned in the aetiology of the disorder and both must be involved in treatment. It is a truism that there is no such thing as an uninvolved partner in any marital problem. Diagnosis and treatment rest on prolonged interviews with both partners. Often they are seen separately at first, but eventuaUy the interviews are between couple and therapist. The incidence of sexual disorders in any community is difficult to compute because many remain undisclosed. There is a further difficulty because couples who present for treatment largely select themselves. In some reported series the couples who elect to seek help are the most educated and articulate members of the community. In others, where the cost of therapy is considerable, only the wealthier and thus almost by definition the middle-aged members of society are included. The attitude of society to sexual disorders is also important. Where sexual performance is an everyday topic, couples who think their achievement falls short of the average may seek advice. In other societies where sexual topics are rarely discussed only the most serious problems come to light. Finally the level of expectation is important. For example, in a previous generation in our own society women's expectation of enjoyment of intercourse was very restricted. Personal interrogation of women of middle and working class now aged 50-70 years suggests that few experienced regular orgasm, many never achieved it at all, and none thought it a topic for complaint to a doctor. Today it is rather more likely that a doctor will see at an early stage in a marriage the woman who responds poorly to sexual stimulus and thus achieves little satisfaction from intercourse. Because of these difficulties it is impossible to compare the experience of one school of therapy with another. The patients treated at Masters and Johnson's clinic in St. Louis, U.S.A., for example, differ in culture, education, and financial standing from those referred to my clinic by marriage guidance councillors and family practitioners in the Lambeth district of London. No attempt has been made therefore in the discussion that follows to indicate the frequency of the different disorders. Comments on the technique of management are based largely on personal experience, though the comments of other therapists are interwoven where it appears appropriate. Sexual problems which cause the male partner to seek advice include premature ejaculation, ejaculatory failure, and impotence, which may be either primary or secondary. Occasionally the level of sexual desire in one partner does not match that of the other, but to a surprising extent married couples find themselves well matched. When the woman with a basic dislike of intercourse marries at all, she usually marries someone who is likely to make few demands on her, and the man with a weak sex drive will rarely find himself matched, at least in western society, to a woman with an insatiable sexual appetite. Problems of waning sexual drive are not commonly seen either, because in the majority of marriages this natural evolution occurs in both partners at about the same time.' It is only when there are widely disparate ages, or the sexual performance of one partner is affected by disease or perhaps by such therapeutic ventures