Working with Erectile Dysfunction (a book review)

A book review by Michele O’Mara, PhD

Weeks, Gerald R and Nancy Gambescia (2000). Erectile Dysfunction: Integrating Couple Therapy, Sex Therapy, and Medical Treatment. New York, NY: W.W. Norton Company, Inc.

Thirty-nine percent of 40 year old men and sixty-seven percent of men who are 70 experience erectile dysfunction (ED).   While there are many books available today on the topic of erectile dysfunction, Weeks and Gambescia have separated themselves from the pack by presenting “an integrated approach that examines both the organic and psychological factors contributing to erectile dysfunction (ix).” In a book directed specifically to clinicians and physicians, rather than the actual man who is experiencing ED, this book reveals itself as a clearly charted, no-nonsense, guide for professionals who wish to offer hope and relief for the man experiencing ED.   What appeals to me most about this program is that the target of this treatment is not just him; this program addresses his relationship at large which inadvertently slowly takes the focus off of him, and eventually narrows in on the relationship itself.

By introducing the DSM-IV early in the book, the authors establish the difference between psychological ED and organic or medically-based ED. Because the client is actually the couple, not just the man, the authors note that they “frequently find that the couple is struggling with at least two distinct but interrelated problems.” When research suggests that 48% of women have difficulty getting sexually excited, 33% have difficulty maintaining excitement, and 46% were unable to have an orgasm, it stands to reason that the partners of men with ED might also be a part of the problem and the solution.

Getting a man into treatment is the first step. According to the authors there are plenty of reasons he may be hesitant, not the least of which is actually finding a provider that offers such help. As seems to be the case in all books related to sex, there is a good deal of myth-busting that must occur just to level the playing field to the facts. The authors have come up with 18 common misconceptions that serve as a great resource for educating the client. Among my favorite of these is the myth that “Every time a man has an erection, he must have sex” (11). The authors reassure their clients that, “a man can sustain an erection and choose not to have an orgasm without risking physical or psychological damage” (11).

After explaining the physiology of an erection, and the role of the central nervous system, the vascular system and the hormonal system, the reader is primed to learn about the medical influences on erectile dysfunction. Starting with age-related issues, the authors note that “the most important factor in the age-related decrease in sexual desire is the reduction in the production of testosterone…beginning about the age 40” (19). With age also comes a longer refractory period. Later in the book we learn that some men misdiagnose these natural changes in their sexual behavior as a problem, thus activating a psychological anxiety around performance that exacerbates an otherwise natural decline in desire and performance.

The author’s take great care to educate the reader about the various medical assessments involved in the diagnosis of a ED. Included is a review of the physical examination, the lab tests and electrocardiogram, the rectal exam, sleep monitoring to determine nocturnal penile tumescence (NPT), penile blood pressure, urology tests, neurological testing of the penis, as well as others. A generous amount of information is also provided about the various medical treatments available for men with ED, ranging from the penile implants which were introduced in 1966 to the ever common Viagra that introduced in 1998.

Not surprisingly one of the largest chapters in the book is on the psychological aspects of ED. Performance anxiety, or the excessive concern over attaining and sustaining erections (42), is the leading symptom of erectile dysfunction. Also of concern are good ole life stressors which may include:   divorce, relationship difficulties, addictions, depression, affairs, inability to problem solve or deal with conflicts, unresolved childhood abuse, or even negative cultural messages. Another concern is the presence of other sexual dysfunctions. For example, according to Masters and Johnson (1970) 50% of the men who experienced erectile problems were premature ejaculators (45).

Chapters four and five offer the provider a concrete place to start treatment: the initial phone call. The authors literally walk the provider through the necessary steps involved in assessing the psychological risk factors, including the questions to ask and the importance of taking control of the conversation by asking questions in a direct manner.   In a similar fashion, the book outlines the steps involved in the initial session, offering strategies to establish therapeutic rapport. Therapy is, by nature, an experience in vulnerability if one chooses to self-disclose, and it strikes me that the authors make a very good point when they highlight the importance of the first call as a starting place for treatment. There is no way to ease into the issues when you are seeking help for an erectile dysfunction. The request itself immediately renders the client vulnerable before he has a chance to assess the safety of the provider and his feeling of confidence in the process.

Thus it also makes sense that much of the initial process is about tending to the client’s need to feel safe, to feel reassured, and to be given a sense of hope that this can, and will, get better. One of the strategies the authors favor is that of reframing. The reframe is how the therapist is able to control the structure of the session, and literally crafts the stage on which this problem will be defined, and the solution will be found. The reframe is the process of teaching the clients to think about the problem differently (70).

Once clients begin to discuss the actual sexual problems it is important to determine if the man is describing an erectile dysfunction or if instead there is a desire problem. Similar to Cervanka’s message in her book, “In the Mood.” You can’t fix what isn’t broken, so you must first determine where the breakdown is.   Key questions to help determine this are offered, and the authors suggest that “answers to two important questions about nocturnal erections and masturbation can give you reliable indicators” (72). These questions relate to whether or not he awakens from sleep with an erection and the tumescence of that erection if so, and whether or not he has erectile problems when masturbating (72).  The answers to these questions serve as a sort of litmus test. When functional erections occur in sleep or while masturbating it is no longer deemed a medical concern.

With whole chapter dedicated to the basic techniques used with couples, my greatest criticism is the absence of information about imago therapy, a personal favorite when it comes to working with couples. The use of education (bibliotherapy), and a well-considered list of book suggestions, combined with some cognitive and behavioral strategies, are all solid approaches to any couple.   The best part, though, is the attention given to the sensate focus exercises initially developed by Masters and Johnsons.

Once the assessments are made, the rapport is built, and the couple is stable enough to do the work, Weeks and Gambescia suggest that it is time to use get to the heart of this treatment. The authors introduce sensate focus in a very user-friendly format, including the purposes behind this strategy. Particularly helpful is the emphasis on how to follow-up with the clients once their homework is given, and the importance of doing so. The authors indicate that, “tracking this aspect of treatment requires great consistency on the part of the therapist” (133).

In some cases, the authors literally provide scripts for how to communicate the homework to the clients, which is a useful tool for the novice therapist who may not yet be confident in doing so.   The clients are encouraged to identify where they would be most comfortable beginning a sensual experience. While I understand the value in having couples participate in this, it seems to contradict the otherwise directive nature of the therapeutic process so far. It seems that a key part of this program is in the hand-holding, in reassurance that “this is the path to recovery,” and fostering the confidence of clients that they are going to experience success, and that we know how to lead them there.

An alternative to how they approach this could be to create a check list for each partner to complete, without the other seeing, that indicates where he or she is most comfortable touching. Then the therapist takes these and decides from this where to direct the clients to start (using the lowest common denominator as the deciding factor).

The next step, sensate focus-II, is also clever in that the goal is to help the man now achieve an erection, but this goal is to never be stated – which makes sense, so that performance anxiety does not return.   The final step is the most interesting and offers me the greatest insight to the treatment, and that is the strategy of teaching him to actually lose his erection. While counter-intuitive at first, this makes perfect sense in that the authors are encouraging psychological strength here, rather than physical achievement.

Also of note is the importance of working with couples who do have medically induced erectile dysfunction. Because the medically-based dysfunction can initiate a psychological dysfunction it is wise to intervene at any point – to be sure he stays on the right course from the start, or to get the couple back on course if they find themselves exacerbating their dysfunction with the addition of psychological stressors.

After reading this book by Weeks and Gambescia, it seems reasonable that a skilled clinician with a solid understanding of the sexual response cycle, the physiology of an erection, and experience working with couples, could successfully implement their treatment protocol. It is noted that finding a local urologist to enlist in the care of patients with ED is also important, so perhaps this legwork is important to do first. However, the nuts and bolts of treatment are described with great care, and offer very detailed roadmaps to anyone interested in providing this type of service.

The book is very well written and organized. The authors set out to provide a guide for other clinicians and medical professionals interested in the care of men experiencing erectile dysfunction and they seemed to have hit the nail on the head with this book. Except for possible updates to assessment technologies and medical treatments, this book offers a timeless approach to the treatment of erectile dysfunction.   Any clinician who provides care for men with ED can benefit from this book, even if their role is not to provide psychological interventions. Understanding the bigger picture, the relational picture, of erectile dysfunction is invaluable and seems to be a key ingredient to their successful interventions.

While the jury is still out whether or not I will be actively promoting myself as a clinician for men with ED, I am happy to add this book to my bookshelf. Because the statistics of men who experience ED are so high, I am certain that I find myself face to face with couples who are dealing with this issue, and thanks to this book I will have a much better sense of how to proceed.





Increase, Reawaken, and Rekindle Desire (a book review about)

A book review by Michele O’Mara, PhD

Cervenka, Kathleen A. (2003). In The Mood Again: A Couple’s Guide to Reawakening Sexual Desire. Oakland, CA: New Harbinger Publications.

In 1964 the Righteous Brothers wrote a song titled, You’ve Lost that Lovin’ Feeling. Ultimately it climbed to the number one hit single in the United States, ranking 34 of the 500 Greatest Songs of all Time by Rolling Stone magazine.   This, I am sure, is no surprise to Dr. Cervenka who has built her career, and this book, around helping couples find that lovin’ feeling again.

According to Cervenka, the contents of this book represent “the exact process” that she takes clients through in couples therapy (5).   The basic assumption is that almost all couples at some point in their relationship are affected by a diminished libido in one or both partners. In order to establish a foundation on which to build her treatment protocol, Cervenka starts with a review of the Tri-Phasic Model developed to describe the human sexual response cycle created by Helen Singer Kaplan in 1974. Briefly, the three stages are desire, arousal (excitement), and orgasm.

In order to accurately assess issues of desire, it is important to identify the phase in which the dysfunction occurs. Cervenka is clear to state that her treatment process is designed only for issues of desire and that in order for successful treatment to occur, the problem must first be accurately identified. Educating her clients on the function of desire is central to her initial treatment protocol.  Relying on Kaplan’s research, she reviews with clients the notion that our desire starts in a small area of our brain called the hypothalamus which contains tiny sexual drive centers. She then explores with couples the common motivators for sexual desire. Cervenka reviews our five senses and how to interpret sensations as erotic, going into detail about various erotic pleasures associated with touch, smell, sight, sound, and taste.   After encouraging increased awareness of what variety of sensations will activate your own sex centers, Cervanka asserts very clearly that there is only one person in control of your sex center, and it isn’t your partner! It is you.

Anyone who has ever fallen in love knows the feeling of what Cervenka calls euphoric lust.   Readers may benefit from a more thorough explanation of this phase of attraction which can be found in the book, Why We Love: Nature and Chemistry of Romantic Love, by Helen Fischer. Cervenka does not expand on the biological explanation for the often obsessive, usually passionate, intensely pleasurable and naturally intoxicating stage of attraction. However, she does acknowledge the limited time in which most couples are able to enjoy this phase, which helps couples normalize the natural decline in this intense state of desire.

She also explains that when the inevitable happens and euphoric lust fades, we are faced with a decision to commit to enduring love, or seek a new partner with whom we can activate a new round of euphoric lust. For couples choosing enduring love, she empowers each partner to take ownership of his own power to turn on and off his sex centers.

After an adequate education is provided on the topic of desire and personal power and control over desire, Cervenka turns her attention to the couple’s relationship, and more specifically to what she terms the couple boundary. She explains that “A couple boundary is an invisible circle that surrounds the two of you” (39). This boundary is an essential safeguard for couples who may otherwise be negatively penetrated by well-meaning parental intrusions which often involve advice giving, demands on the couple’s time, and the insistence on maintaining and participating in the family tradition.

Cervenka encourages couples to set clear and firm boundaries with their families of origin, which will naturally lead to a tighter connection and enhanced functioning as a team.   In therapy, I suspect Dr. Cervenka has the ability to offer additional support and skills in learning exactly how to communicate these changes and deal with the emotional ramifications that accompany the metaphorical cord cutting ceremonies by these couples. It is less clear, however, how the reader who is not in counseling secures these skills or deals with the emotional fallout that will likely occur when the cord cutting begins.

Another observation about this chapter is that boundaries are a very broad topic that extends well beyond the demands of family and friends. Work, hobbies, drugs, volunteering, cleaning, exercising, gambling, video games, shopping, and more are other examples of drains on the couple relationship. This chapter could offer readers a broader understanding of how to protect their relationship and create a more accurate inventory of where their energy – sexual and otherwise – is going. The emphasis on family is certainly relevant, but it does not seem comprehensive.

Rounding out the chapter on boundaries is a brief summary of three different types of couples with various boundary issues, and the related impact on sexuality. The disengaged couples are leading parallel lives without much desire, and consequently a lacking sex life. The enmeshed couple occurs when both partners are more concerned about who they think the other wants them to be than they are concerned about who they actually are and how they actually feel. This is another killjoy for sex and leads to a sibling-like relationship. Luckily, there is also the healthy couple. This partnership involves two independent people who are able to maintain their own identity while maintaining concern and care for the other.

Now it is time for the fire extinguisher. Cervenka explains that “A fire extinguisher is an interrelationship obstacle that has the potential of turning off your sex centers.” Also of importance to note is her insistence that “a lack of sexual desire is not simply an individual problem, it’s a relational one.” This chapter involves an exploration of various fire extinguishers, including flirtatious behavior, computer sex, infidelity, having a libido discrepancy, inability to engage in sexual fantasy, good old stress, a poor body image, boring sexual techniques, and lastly, but certainly not least important is unpleasant sexual techniques.

Many of these seem to be fairly obvious contributors to the slamming of doors in the sex centers, however, I find myself in slight disagreement about the vehemence with which Cervenka speaks about flirting. She states that “Individuals who flirt might as well wear a neon sign around their neck that reads, ‘I am insecure; please pay attention to me.” While I agree that flirting can be taken to extremes and ultimately lead to dangerous outcomes for couples, it seems to me that flirtation can also be an innocent expression of non-sexual affection and playfulness. Cervenka, however, describes flirting as having “only one motive: to solicit and receive sexual attention” (53). This inclines me to think we simply disagree on the definition of flirting, as I would agree that any behavior that is designed to solicit and receive sexual attention is not user-friendly behavior for monogamously committed couples unless of course, they are flirting with one another.

In addition to relational behaviors such as those discussed above, Cervenka also points out the possibility that desire can be affected by psychological, pharmacological, hormonal or medical issues as well. A brief review of some of these includes alcohol and substance abuse, depression, abnormal hormonal levels, poor physical health, and simply aging and all that accompanies getting older.

Chapter seven is my favorite chapter. Here Cervanka introduces the concept of power in relationships, and how power works as an aphrodisiac. Cervenka did a great job teasing the reader with this golden nugget earlier in the book, and I have to agree that this concept offers the most important message of the book. In this chapter, we learn about the concept of genuine power, and that essentially this power stems from “possessing a quality that most people find influential, impressive, convincing, and sexy” (78). She cautions that power can be toxic too, and this occurs when “those with toxic power use their voice, opinions, influence, persuasion, sexuality, and authority to manipulate, dominate, and control others” (79). This, she explains is one-sided and unequal, moreover, it is not reciprocal. When our sense of personal power is strong, our need for toxic power disappears. Thus it would seem that like attracts like, toxic low self-esteem attracts toxic misuse of power. Healthy high-self-esteem attracts a healthy expression of personal power.

In relationships, it is necessary to tend to the intersection of each partner’s personal power. Cervenka introduces the phrase, “power reciprocity,” and describes this as “using your own individual power to empower your partner, while your partner will use his or her own individual power to empower you” (81). Power reciprocity requires that you understand your own feelings, listen carefully to what your partner says, and connect to your partner on an emotional level. Without a sense of personal power, and a sense that your partner has reciprocal power, you can not turn on your brain’s sex centers.   Cervenka is confident about the role of power, stating boldly that “Power is the best mental aphrodisiac known to mankind” (87).

Like Cervenka, I too find this concept very helpful in understanding the core of sexual shutdowns in otherwise functional relationships. If we perceive (a keyword that Cervenka emphasizes here) that we are powerless, voiceless, unimportant, devalued, or otherwise insignificant to our partner, why would we want to have sex with him or her, or vice-versa? This just makes sense.

In a list of characteristics needed to develop individual power, Cervanka lists the following: integrity, humor, empathy, assertiveness, emotional awareness, autonomy, decisiveness, financial balance, and self-observation. She also offers an exercise which allows couples to take an inventory of where they stand with each character trait, and how they see themselves and one another.

Expanding on the concept of reciprocity, Cervanka states that in a nutshell, “reciprocity is that you give to get” (124). She also details the importance of several behaviors that each partner can engage in to improve the power exchange which all seem to all hinge on a more conscious awareness of oneself in relationship to partner.   She states that “you must be conscious of how your partner is seeing and hearing you when you are engaged in connected conversations” (127). Among her list of strategies are basic concepts such as know your partner, intend to connect meaningfully, maintain powerful body language, check your facial expressions to avoid unwanted responses, use a powerful (not whiney) voice, and become persuasive.   She also suggests that the reader be sensitive to one another’s style of processing, noting that some people process quickly and others slowly, as well as to recognize that there are differences in how men and women express themselves. Lastly, she encourages that partners’ acknowledge one another’s strengths.

Also, a chapter is dedicated to that trusty old four letter word that ends in “k.” Talk. Cervenka calls this “verbal intercourse” and compares the benefits of verbal intercourse with sexual intercourse. She states, “In order to totally restore your sexual desire to the highest level possible, you must possess individual power and exchange that power within a connected conversation” (148).   Here she offers another list of characteristics that expands on what connected communication includes: self-disclosure, courage, trust, understanding, validation, interest, being present, affection, empathy, and authenticity. Three pitfalls to avoid are criticism (voice complaints about behaviors, not attacks about character), withdrawal or a total shutdown, and mind reading.

Bringing the book to a close, and her therapy process to an end, Cervanka suggests a final exercise that involves both couples learning more information (which is provided by Cervenka in the book) about the specifics of each of the three phases of the sexual response cycle.   After information is provided for each phase, she then offers a series of questions that both partners are to answer. With questions such as “What are your favorite sexual fantasies?” and “Do you masturbate?” couples are encouraged to open to one another through intimate conversation, and learn more about what one another desires. This is repeated with additional information and questions for the next two phases, arousal, and orgasm, as well.

This exercise is my favorite of the many offered in the book. Because of the guided nature of this exercise, couples are given permission, and in fact, encouraged to talk about topics from which they may otherwise shy away. In some ways, this may be more effective than doing so in counseling, depending on the level of comfort one or both partners have with talking about their personal fantasies in front of a third party. This also stands to strengthen trust and intimacy simply by talking about their fantasies, likes, and dislikes.

In summary, Cervenka has a created an easy-to-follow, no-nonsense road map guiding couples back to a place of desire. The assumption, of course, is that couples were once in a place of desire. It is unlikely that this book will be effective for the couple who never had a strong desire in the beginning. An exercise to determine the strongest level of desire achieved (a baseline of sorts) may be helpful at the start of the book in order to create a realistic picture of what is possible. For example, if I went through this program with a random person to whom I never had a strong attraction; it is quite unlikely I would find myself passionately glued to them by the end of this book.  Some couples who are married or partnered grew their relationships from friendship and never experienced strong desire from the start. Think, thirty-five-year-old woman meets a willing man to marry and she wants a baby but doesn’t feel intensely drawn to him.  Or imagine the gay man who marries a heterosexual woman to avoid dealing with his sexuality. Perhaps some desire issues predate the commitment, and unearthing this seems equally important.

This is a helpful resource for the struggling couple who is working on issues at home, and it is also a great resource for the therapist seeking guidance on how to help couples who present with issues of desire. The information is helpful, specific, and rooted in the basics of the human sexual response cycle.   Couples who are not struggling with desire may also find this book a helpful resource to keep that lovin’ feeling alive!

The Myth of Monogomy (a book review)

A book review by Michele O’Mara, PhD

Barash, David and Judith Eve Lipton (2001). The Myth of Monogamy: Fidelity and Infidelity in Animals and People. New York, NY: Owl Books.

“Aspiring monogamists are going against some of the deepest-seated evolutionary inclinations with which biology has endowed most creatures” (1), according to Zoologist David P. Barash, and his wife Judith Lipton, a psychiatrist.   And this book is determined to illustrate exactly why this is true. In a sometimes humorous, sometimes seemingly self-indulgent exploration of animal behavior that is mostly focused on birds and insects, the authors cite numerous research studies to illustrate their theory that humans, like animals, are predisposed to extra pair copulations (EPCs). This is the fancy scientific term for having sex with someone other than your mate.

As the authors prepare to unfold their observations about how human monogamists are climbing an uphill battle, they clarify that this book is designed to illustrate what is natural, not what is right or wrong.   The exploration throughout this book is not about what should be, it is simply about what is.

Thanks to DNA fingerprinting, the lens used to observe animal behavior has significantly improved and animals previously thought to be monogamous are not so. Monogamy is divided into two categories: social and sexual. Social monogamy exists “if they live together, nest together, forage together, and copulate together” (8). Sexual monogamy requires sexual fidelity, also known as intra-pair (or in-pair) copulation (IPC).

The currency of evolutionary success is based on successful reproduction. To understand how this relates to males and monogamy, the authors introduce various associated strategies employed by males throughout the animal kingdom such as:   sperm competition, frequent copulations, mate guarding and parental investment.

Sperm competition speaks to the effort put forth by males to secure a female whose egg he can fertilize, leading him to reproductive success. Endless sperm and limited eggs create an unbalanced picture – basic supply and demand dictates the inherent competition among men to get their sperm to fertilize eggs. The authors provide many examples of how males compete to copulate with a given female.  For obvious reasons, frequent copulations increase the chances of reproduction, and it is theorized that this contributes to the frequent desire to copulate among males.

Mate guarding is another strategy used by males to improve the odds that they are successful in fertilizing their female, and furthermore to guarantee that the offspring they are raising are their own! This tactic prevents his mate from straying, as well as preventing other males from gaining access to her.   An interesting side note about mate guarding that is correlated with human behavior is the notion that “poor-quality males are generally more concerned with mate-guarding than are their high-quality counterparts, and for good reason, since females whose mates are less desirable are more inclined to seek EPCs” (35).

When it comes to parental investment, there are many variations among animals and humans. Resources such as time, energy, risk taking, childcare, protection, beauty, skills, strength and more are combined to determine one’s value. This makes just as much sense with humans too. The greater your strengths, resources, and beauty, the more leverage you have to attract a similarly valuable partner. As for sperm which is readily available in large quantities, however, its value pales in comparison to “the big, fat, energy-rich mother lode of nutrients called an egg” (17). The authors suggest that because of this, males are positioned to compete with one another for access to the much rarer eggs, hence the sperm competition.

Interestingly, “the greater the male’s secondary sex characteristics, the less his contributing” (50).   The authors go on to say, “It is as though desirable males know they are desirable, and so they are likely to shop that desirability around; by the same token, those ‘lucky’ females who get to mate with such studs find themselves less lucky when they are stuck with most of the household chores” (50). The comparison is drawn to less desirable men, and it is suggested that those less endowed with good looks actually make better fathers.

Before we get too carried away with all of this male gallivanting, let’s be clear that females are none-too-innocent themselves.   For a long time, females were considered the opposite of males, and evolutionary biologists envisioned females desiring monogamy.   However, “evidence has been accumulating, fast and furious, that females are not nearly as reliably monogamous as had been thought” (58).

If reproductive success is the fundamental biologically-based motivation for males to stray, what’s the motivation for females? The authors suggest a handful of reasons including: fertility insurance, to avoid inbreeding, a predilection for quality, and to maximize the benefits of sperm competition, material rewards, recruit care and protection of offspring, to gain toleration of young when different troops interact, and possibly to pave the way to a stronger prospective pair-bond.

Fertility insurance is a simple concept. The more sex she has, the more sperm she’s exposed to, and the stronger the likelihood that she will reproduce.   In order to avoid inbreeding, the authors suggest females may seek out strangers that are less likely to have any genetic association, thus reducing the possibility of inbred offspring. The search for quality sperm is thought to be the motivation for multiple mating, and it involves not only the search for the most attractive, healthiest, and strongest male, but it also takes incorporates what is called the “last male advantage.” The female may mate with her partner, along with many others and typically the last male she copulates with has the greatest advantage for a successful fertilization. This also allows her to maximize the sperm competition, pitting the strongest of the strong males against one another, and saving her the effort of having to determine for herself which one is the best. The notion behind this is thought to be that the one who succeeds is going to help her create offspring that will be as successful in doing the same so that her reproductive success, and quality, remains high for years to come.

Material rewards are another suggested motivation for multiple pairings. The authors cite a study of Red-billed gulls, stating that “Females who are well fed during courtship resist all EPC attempts, and they also remate with their partner the following year; on the other hand, females who had been poorly provisioned are especially likely to divorce in the future and are more likely to submit to EPCs” (91-92).   It is thought that some females seek multiple EPCs so that they can cast a wide-net of protection for their offspring, leading many males from all over to question whether or not the offspring is his, and thereby increasing the odds of protection, and at a minimum reducing the odds of harm.

The pursuit of a stronger pair-bond is another motivation suggested for females who engage in EPCs. Because there is an advantage of having two parents over one, the argument that a female would seek an alternate pair-bonding to improve her social situation certainly makes sense.

Why, the authors query, does monogamy occur at all? Their conclusions are varied. One suggestion is that monogamy leads to better and more effective parenting. Another thought is that it may be a response to sperm competition by males, so that they can reduce the risk that another male will fertilize his female’s egg.   They also suggest the possibility that monogamy is a solution to men fighting over women. Monogamy may be the result of men negotiating how to divide access to women. In general it appears these arguments lead toward the suggestion that monogamy was greatly influenced by the “cultural homogenization that came with Western imperialism and the Judeo-Christian ethic of monogamy” (146).   In the end, however, the author admits that with the question of why monogamy exists at all, “the short answer is that no one knows” (132).

The book also reports some interesting facts about monogamy and the double standard for men.   G.P. Murdoch cited 238 different human societies around the world, and monogamy was enforced as the only acceptable marriage system in just 43. Gwen Broude researched 116 different human societies and reports that 63 permit extramarital sex by husbands, and only 13 permit it for wives.   However, Kinsey and colleagues discovered that slightly more than 25 percent of adult females in the United States were unfaithful. Given this double standard, it is ironic that in terms of sexual capacity, women are physiologically capable of having more sex than men.     Furthermore, a woman can be impregnated without experiencing a hint of pleasure, whereas it is likely (though not necessary) for a man to orgasm upon ejaculation, thereby rewarding him for his efforts with pleasure.

The last, and possibly shortest, chapter of the book draws a relatively simple conclusion that while all of the evidence points to why humans are biologically oriented to polygamy/polyandry, we humans are gifted with a large, discerning brain that allows us something all of the animals cited in the book do not have: choice.

In summary, this book was very informative; at times entertaining and it introduced me to some new and valuable perspectives on the evolutionary imprints on our sexuality. The first several chapters were weighted with very detailed research on animals.   For a layperson such as me, it is hard to make the connection between the sexual behaviors of a fruit fly and those of a much more complex creature such as a human.   This perhaps is more my weakness, than the books, however.

I appreciate the authors’ goal to simply observe the evolutionary trail and impact on human sexual behavior as it relates to monogamy, and to set out to do so without judging the outcomes as right or wrong.   In this way the author succeeded. I would imagine this book has some cross-over appeal for the mental health community as well as zoologists and social scientists. It covers a lot of bases (no pun intended).

However, it was very disappointing to see the observations limited to male-female copulations. The fundamental premise of this research was reportedly to unearth the myth of monogamy.  Specifically, however, this body of work only explains the sexual behavior and evolution of heterosexual monogamy, not sexual monogamy in general. The inclusion of same-sex pair-bonding between animals such as penguins, whiptail lizards, dragonflies, and others who are known to engage in same-sex pair bonding, would lead to a more accurate and informed view of our whole evolutionary history.

In the final chapter, the conclusion emphasizes the ability of humans to make choices. Unfortunately, this chapter seems to propose only two choices: to be monogamous or to be unfaithful. The reality is that we live in a culture that includes a multitude of coupling arrangements, some of which include the expressed desire to engage in a polygamous arrangement whereby partners support and encourage EPCs as an option for one, both, or all partners to the relationship. Because animal research relies on observation and interpretation, I would think it is nearly impossible to determine the motivations, and expressed agreements (or lack thereof) among these animals about their copulation.   Humans, however, are easier to study in this way, yet there is no discussion about the choices humans makes to engage in multiple-pair arrangements and how successful or not those are. There is no mention, in fact, that this is a choice some humans do make. This seems a significant oversight in a book determined to dispel the myth of monogamy.

At the end of the day, this book has offered very interesting perspectives that provoke much thought about human sexual behavior and issues of monogamy, while simultaneously remaining judgment-free about exactly what to do with this information. That has been no easy feat.

She Comes First (a book review about oral sex)

A book report by Michele O’Mara, PhD

Kerner, Ian (2004). She Comes First: The Thinking Man’s Guide to Pleasuring a Woman. New York, NY: HarperCollins.

One of the many ironies of heterosexual sex is that according to Kinsey, 75 percent of men ejaculate within two minutes of vaginal penetration and most women require at least fifteen minutes of partner stimulation to orgasm.   Adding further insult is the fact that the clitoris is 2 to 3 centimeters above the vaginal opening, which typically prevents the penis from stimulating the clitoris all together during intercourse. Quoting Shere Hite, author Ian Kerner shares, “Intercourse was never meant to stimulate women to orgasm” (8). Luckily though, Ian Kerner has found the perfect solution for couples who face this age old dilemma.

In this ode to cunnilingus, Kerner makes a strong and compelling case for oral sex with women. Moreover, he emphasizes the postponement of male orgasm in order to facilitate the maximum enjoyment from sexual activity for both parties involved. The title says it all, “She Comes First.” Kerner starts with some basic facts about female anatomy and statistics on arousal and female orgasms.   Then he points out that in a study of 98 wives in happy marriages, eighty-two percent of them rank cunnilingus as the most satisfying sexual activity. During intercourse only 25 percent of the women reached orgasm whereas 81 percent of the time women reached orgasm with oral sex (9).

Early in the book, the reader is introduced to the clitoris. As the central hub of sexual pleasure for women, Kerner spends adequate time familiarizing the reader with all of her parts, taking special care to provide accuracy and in some cases myth-busting, or news-flashing, information. For example, Kerner points out that the clitoris extends well beyond the eye’s view, and includes three important components with comparable parts to the male penis (head, shaft and base) which makes sense given that both are made from the same embryonic tissue.

“The shaft extends north from the head toward the mons pubis for about three quarters of an inch before forking and dividing like a wishbone into two thin crura (or legs) that flare downward along the path of the inner lips and surround twin bulbs of erectile tissue, known as the clitoral bulbs” (50).

Unique to any other body part, the clitoris serves only one function: pleasure. This is not true for the penis which has very practical functions including fertilization and urination.   “The clitoris is the sexual epicenter, an orgasmic powerhouse in which no sensation goes unnoticed” (26). Highlighting the reality of this, Kerner points out that one in five thousand women are born with vaginal agenesis, which means they are literally born without a vagina. Because the external genitals are in tact, however, these women are able to experience sexual pleasure and orgasm because they also have a fully functional clitoris.

In “She Comes First,” Kerner provides a relevant education about a woman’s female anatomy, with accurate terminology and useful descriptions of each part. He makes a point to draw the distinction between the commonly used term, “vagina,” and the more accurate term “vulva,” to describe the network of lady parts “down there.” He covers the all of the major parts involved in pleasing a woman, and provides an explanation of where each is located. There are helpful pictures that accompany his descriptions too, which makes it easy to learn these parts.

Kerner touches briefly on the topic of female ejaculation and lubrication before moving into the heart of his book where he begins discussion about the “journey through sexual response,” which he refers to as: foreplay, coreplay, and moreplay (61). Starting with foreplay, Kerner offers a succinct breakdown of what happens to a woman’s body during the initial stages of arousal. Then he moves into a description of coreplay where he describes the tension and release that occurs upon stimulation to orgasm. Lastly, he explains the resolution phase, which he calls moreplay.   Kerner suggests that for women “it takes longer for the genitals to return to their normal state, at least five to ten minutes” (65).

By making frequent reference to the ever-popular book, The Elements of Style, Kerner draws subtle, yet persistent attention to the importance of style, accuracy and details when it comes to cunnilingus. While I found these frequent detours into the land of linguistics distracting, his point was not lost. By combining a crash course in female anatomy with a user-friendly guide to the female process of arousal, these early chapters of the book stand alone as an excellent resource for anyone wishing to understand women’s anatomy and arousal.   Admittedly, this information might also serve as useful to high school graduates as The Elements of Style which, by the way, has had a total sales exceeding ten million copies since 1959.

Would a book on oral sex be complete without a Cunnilinguist Manifesto? Apparently not. Kerner encourages that all cunnilinguists offer the Three Assurances:

  1. Going Down on her turns you on; you enjoy it as much as she does.
  2. There’s no rush; she has all the time in the world. You want to savor every moment.
  3. Her scent is provocative, her taste powerful; it all emanates from the same beautiful essence (78).

Unfortunately, however, there is no solution for the reader who is not a fan of oral sex. Kerner is clearly targeting readers who are lovers of cunnilingus (or those eager to become so), and there are no reassurances or alternatives provided for the reader who is not prepared to take an oral trip down yonder. To be fair, Kerner does offer supplements to oral sex that serve as appetizers and condiments to this main course. He includes the importance of sex toys, vibrators, as well as the use of fingers. With statistics on his side (81 percent of women reach orgasm with oral sex), it’s easy to understand, though, why Kerner touts oral sex as the pathway to a woman’s pleasure.

Peppered with interesting research findings, She Comes First offers random insights to women, such as “women tend to fantasize in ways that are more situational and narrative, whereas men’s fantasies tend to focus more on specific physical and graphical elements of sexual encounters” (88). He also offers practical and specific resources, including book references, terms and definitions, tips about various lubricants, and important warnings such as: “Blowing into a woman’s vagina may cause an embolism and lead to death” (111). Who knew?

Kerner is also quick to point out common mistaken beliefs, stating that “there are a few positions better suited to porn films than to prolonged clitoral stimulation” (99). Here he is referencing positions such as 69’ing, SOMF (sit on my face), and up against the wall. In fact, Kerner also offers men the information necessary to know whether or not his partner is actually aroused and orgasmic. Caution to any women who have ever faked an orgasm by arching your back – do not buy this book for your partner if you wish to maintain your cover because Kerner points out: “When a woman is aroused and comfortable, her back will find itself flat, without an arch, and her genitals will be tilted slightly up toward your mouth, rather than driving downward – in short, the opposite of what we see in porn” (102).

By chapter twenty-five, Kerner is ready to provide specific instruction on how to deliver oral sex. Starting with the” First Kiss” unlilke many how-to-guides, Kerner has embedded his with a seemingly authentic passion, as he builds one small chapter on top of the next, leading the reader through the various stages of arousal. He adds important reminders such as savoring the experience and reinforcing the Three Assurances.   Kerner includes a variety of kisses, including the protected kiss (safe sex), the scarlet kiss (on her period), the virgin kiss (first time cunnilinguists) , and the pregnant kiss which cover the unique variables of these respective scenarios. Next he moves into building a rhythm, with a “flat still tongue pressed softly, later firmly, into her vulva” (115), with an adequate interval, to create a rhythm such as “long, slow lick/flat, still tongue; long slow lick/flat still tongue” (116). The instructions are easy to understand, and explicit.

After this, he moves gracefully into the importance of building tension.   Again, providing a step-by-step guide to how this is done, while adding the use of hands, fingers and a “teasing thumb.” Increasing the tension more, Kerner introduces new tongue strokes, including: horizontal strokes, diagonal strokes, cat licks, and more. Next comes the escalation, with the “come hither” description of doing a manual stimulation to the clitoral cluster. Often referred to as the G-Spot, Kerner encourages the reader to think of this a cluster of “unseen ‘roots’ of a flower that wind their way through the ‘soil’ of erectile tissue and the pelvic bone “(131).

Still building tension, Kerner highlights the importance of constant pressure against the area of her clitoral head as “probably the single most important element in helping her reach orgasm” (143). Finally reaching a point where the signs of arousal are visible, Kerner offers eight indicators of as well as helpful suggestions for brining her to a happy ending. Lastly, he shares with the reader what to expect once she has had an orgasm, in great detail. “Her vagina and uterus will contract, on average, ten to fifteen times, with each contraction lasting approximately eight tenths of a second… the average female orgasm lasts anywhere from ten to twenty seconds” (165).

There are plenty of books available that address female orgasm and pleasure, such as: The Elusive Orgasm: A Woman’s Guide to Why She Can’t and How She Can Orgasm by Vivienne Cass Ph.D. Ph.D.; Becoming Orgasmic: A Sexual and Personal Growth Program for Women by Julia Heiman ; and I Love Female Orgasm: An Extraordinary Orgasm Guide by Dorian Solot. However, none that I know of, are as specific and focused on a single strategy, oral sex, with as much depth of knowledge as Kerner offers, or written by a man.

While Kerner indicates this book was written primarily for “those guys of the world who crave the knowledge to become better, more sensitive lovers…” I would propose that this book is also a great read for any woman who wishes to better understand her own body and capacity for sexual arousal, as well as for female lovers of women who wish to perfect the art of oral sex.  It is specific, clever, and educational, with accurate language, accessible descriptions of female anatomy, and enjoyable lessons in oral sex and the female sexual response from arousal to orgasm. All of this is wrapped with a beautiful bow on the top because of way Kerner so passionately delivers this important information with such a palpable reverence for the power of pleasing a woman.

Lesbian Sexual Frequency Dissertation References

This is a dissertation by Michele O'Mara, PhD on the topic of Sexual Frequency and Relationship Satisfaction Among Lesbians.  Tap here to read the entire dissertation in a pdf format.



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How Often Should Lesbian Couples Have Sex?

This is a dissertation by Michele O'Mara, PhD on the topic of Sexual Frequency and Relationship Satisfaction Among Lesbians.  Tap here to read the entire dissertation in a pdf format.




The purpose of the Frequency vs. Satisfaction Survey was to determine the correlation between sexual frequency and relationship satisfaction among lesbians. This researcher was successful in achieving this goal, and also revealed the following information in the process: the sexual frequency of lesbian couples in the twenty-first century, a contemporary definition of lesbian sex according to lesbians themselves, the sexual behaviors in which lesbians regularly engage, and the satisfaction levels with sex as it relates to sexual frequency.

This researcher hypothesized that there is not a strong correlation between sexual frequency and relationship satisfaction among lesbians. Based on findings from the Frequency vs. Satisfaction Survey, this researcher concludes that while there is a correlation between sexual frequency and relationship satisfaction, the correlation is not strong. To determine the correlation between sexual frequency and relationship satisfaction for lesbians, four key questions had to be answered. These questions were the following: “How do lesbians define sex?”, “What are contemporary lesbians doing sexually?”, “How frequently lesbians are lesbians actually having sex?”, and, “How satisfied are lesbians with their relationships?”

The first question answered in this research was, “How do lesbians define sex?” The results of the Frequency vs. Satisfaction Survey revealed that how lesbians define sex has become more inclusive over the last thirty years. Lesbian sex was most commonly defined by the respondents in the Frequency vs. Satisfaction study as one of three behaviors between women: oral sex, vaginal penetration, or clitoral stimulation. The older the respondent, the more likely she was to include non-genitally focused activities in her definition of sex. The younger the respondent, the more likely she was to include anal stimulation in her definition of sex. The majority of contemporary lesbians also agree that an orgasm is not a requirement when defining lesbian sex.

Next, this researcher answered the question, “What are contemporary lesbians doing sexually?” Not only has the definition of sex expanded to include more activities, but the actual sexual behaviors of lesbians also bring more diverse experiences to the 21st century lesbian than the 20th century lesbian. While foreplay and kissing during sex continue to be the most consistent ingredients in the sexual repertoire of lesbians, penetrative sex with a vibrator/dildo and oral sex have increased in popularity over the last three decades.

Masturbation rates have remained stable over the past few decades; lesbians masturbate roughly three to four times per month. The majority of lesbians (84%) experience orgasms when they have sex. The research also revealed that the most common technique used by lesbians during sex is clitoral stimulation (finger sex), followed by penetrative sex. Oral sex is the least common of the top three behaviors considered “having sex” by lesbians. Lesbians also reported that they like to take their time when they have sex, with seventy-nine percent having engaged in sexual sessions that characteristically lasted thirty minutes or longer.

With answers to how lesbians define and practice sex, this researcher next answered the question, “What is most important in a relationship for lesbians?” The most important aspects of a relationship for lesbians are a strong emotional connection and a strong intellectual connection. Among the various relationship characteristics evaluated in the Frequency vs. Satisfaction Survey, sexual frequency surfaced as least important to lesbians.

Lesbians who placed the greatest value on sexual frequency were those partnered for three to five years, and those who lived together with no children. The majority of women (55%) reported that sex was not the issue that caused their relationships to end, and of those who cited sexual issues as the motivation for their relationship’s demise, twenty-eight percent indicated that it was caused by a difference in desired sexual frequency.

The next question this researcher answered was, “How frequently are lesbians having sex?” When compared to research dating back to the 1980s, the findings in the Frequency vs. Satisfaction Survey suggest that the frequency of lesbian sex has not increased. In fact, when compared to some studies, the rates of lesbian sexual frequency have experienced a slight decline.

Finally, this researcher then answered the question, “How satisfied are lesbians with their relationships?” In lesbian relationships, the least satisfied couples were those who were partnered between six and ten years. This is valuable information for the clinician who strives to normalize the various phases of relationship development, offering clients affirmation that they are not alone in their relationship struggles. This information is also useful in promoting the importance of greater attention to lesbian relationships during these years, as the lower satisfaction rates may lead to more breakups if appropriate interventions are not made during these years.

Unlike heterosexuals, lesbians do not have clear roadmaps to guide the development of their relationships. Even if heterosexuals reject the traditional paths that are socially prescribed for relationship development (dating, engagement, marriage, children, etc.), there is, at least, a point from which to consciously deviate. Lesbians, however, are left to trial and error. There is little information available to guide lesbians as they seek to understand the dynamics of their own relationships.

While analyzing the data provided in the Frequency vs. Satisfaction Survey, it became apparent that the number of lesbians who are raising children together is increasing, and the average length of a lesbian relationship is longer than it was decades ago. This makes sense in the context of increasing societal acceptance of lesbian relationships. With acceptance comes a higher level of family support, which is important for creating lasting partnerships and families, regardless of sexual orientation. Another benefit of social acceptance for lesbians is the likelihood that lesbians will have a greater respect for their own relationship.

Prior research has emphasized the comparison of sexual frequency between the various couple dyads, inferring that lesbian sexuality is somehow impaired because of the consistently lower rates of frequency that result from this comparison. This researcher believes there is no need to compare frequency rates between couple dyads, and that the rate of sexual frequency is not central to the health or success of lesbian relationships. This researcher rejects the assumption that heterosexuals represent the healthy standard by which lesbians must be compared. By rejecting this comparison, it is easier to see relationships created between women as a unique and separate experience, and this allows for the comparison of apples to apples, rather than apples (lesbians) to oranges (heterosexuals).

According to the Frequency vs. Satisfaction Survey, lesbian couples experience a relatively dramatic decline in sexual frequency after they have been partnered for only six months. The most significant decrease in sexual frequency is found among lesbians who live together, regardless of whether or not children are living with them. Lesbians between the ages of twenty-one and thirty years old report the lowest rates of decline in their sexual frequency. This is also the most sexually active group of lesbians in the Frequency vs. Satisfaction Survey based on age. The highest drop in frequency occurs with lesbians who are fifty-one to sixty years old. The most commonly reported reason for a decline in sexual frequency is stress, and only twenty percent of the Frequency vs. Satisfaction sample denied a loss of sexual frequency in their relationships.

This leads to the big question on which this research is based. Do the lower rates of sexual frequency, and the rapid declines in sexual frequency, impact the overall relationship satisfaction for lesbians? Ironically, lesbians in the Frequency vs. Satisfaction Survey rated sexual frequency among the least important variable of their relationships, yet they report this is also what they are least satisfied with in their relationship.

The Frequency vs. Satisfaction Survey suggests that a slight change in sexual frequency in either direction appears to have no serious consequences on lesbian relationship satisfaction. However, when sexual frequency is not fully satisfying, the negative impact on overall relationship satisfaction is not as great as the positive impact of a fully satisfying rate of sexual frequency. In a lesbian relationship, an emotional connection has a much stronger impact than sexual frequency does. This applies equally to negative and positive changes in the emotional connection that lesbians share.

After analyzing the data of the Frequency vs. Satisfaction Survey, this researcher reached several conclusions. First, lesbian relationship development follows a strong, consistent pattern for the majority of lesbian couples. The pattern starts when lesbian couples partner with a particular emphasis on the emotional attraction, which is prized more highly than any other aspect of the relationship throughout the course of their relationship, no matter how long their relationship lasts. Sexual connection between lesbians is strongest at the start of the relationship, and dramatically declines after the first year lesbian couples are partnered. Lesbians experience the greatest decline in relationship satisfaction between years six and ten, and lesbian couples who make it to their eleventh anniversary begin to experience incremental improvements in relationship satisfaction as their relationship continues.

Another conclusion this researcher reached is that sexual frequency does influence relationship satisfaction; however, it appears the power of its influence is unidirectional. Higher sexual frequency correlates with higher relationship satisfaction. The reverse, however, is not true. Lower sexual frequency does not correlate with lower relationship satisfaction.

Couples who experienced a slight decrease in sexual frequency were still fully satisfied ninety percent of the time, and couples who experienced a slight increase in sexual frequency were also fully satisfied ninety-percent of the time. The groups who most frequently reported that their relationship was not satisfying were comprised of the following: those who stopped having sex (24%) and lesbians who reported a significant increase in their sexual frequency (13%).

Lesbians who ceased all sexual activity had relationship satisfaction ratings that were distributed fairly evenly among the three levels of satisfaction. Thirty-four percent were fully satisfied, forty-two percent were moderately satisfied, and the lowest group was twenty-four percent who were not fully satisfied. Of the lesbians who reported a significant decrease in sexual frequency, fifty-three percent indicated they were very satisfied with their overall relationship, forty-one percent reported they were moderately satisfied, and only six percent reported they were not satisfied.

There is no discernible pattern in satisfaction ratings that indicates a strong correlation between sexual frequency and overall relationship satisfaction. Many of the reported changes in sexual frequency (slight increase, slight decrease, moderate increase, no changes, and significant increase) do not seem to greatly impact the overall relationship satisfaction of lesbians.

The changes in sexual frequency that are associated with the lowest satisfaction ratings (significant decrease and stopping all together) do not elicit strong negative responses from lesbians in terms of their overall relationship satisfaction. Interestingly, the two categories that draw the strongest negative ratings for overall relationship satisfaction are women with a significant increase in sexual frequency (13%) and women who have stopped having sex all together (24%).

A moderate increase in sexual frequency does not pose any harm to relationship satisfaction. Ultimately, it appears that any amount of sex is important to lesbians, and even though lesbians generally want more sex than they are having, the absence of sex does not decisively detract from relationship satisfaction.

Ninety percent of lesbians who are fully satisfied with their sexual frequency are also fully satisfied with their overall relationship. This suggests that when sexual frequency is satisfying, there is a strong possibility that the relationship in general will be satisfying. However, when looked at from the opposite perspective, lesbians who report that they are not fully satisfied with their sexual frequency still state they are fully satisfied with their overall relationship thirty-nine percent of the time, and moderately satisfied thirty-three percent of the time. This means the majority of lesbians (72%) do not identify their overall relationship as not fully satisfied regardless of how infrequently they are having sex.

Only twenty-eight percent of lesbians with unsatisfactory sexual frequency report they are not fully satisfied with their overall relationship. When sexual frequency is not fully satisfying, the negative impact on overall relationship satisfaction is not as great as the positive impact when sexual frequency is fully satisfying. Therefore, the positive impact of satisfying rates of sexual frequency is greater than the negative impact of unsatisfying rates of sexual frequency for lesbian couples.

In conclusion, sexual frequency bears more relevance to relationship satisfaction than this researcher anticipated. However, the data analyzed in the Frequency vs. Satisfaction Study does not support a relationship between sexual frequency and relationship satisfaction that is strong enough to assert that there is a correlation. Thus, the formal conclusion of this research is that while sexual frequency has the power to positively impact a lesbian relationship, infrequent sexual activity among lesbians does not necessitate the likelihood of lower levels of relationship satisfaction.

Challenges with the Study

There were some challenges with the Frequency vs. Satisfaction study. The sample from which the data was drawn included primarily white lesbians (77%), resulting in a racially homogenous pool of survey respondents. Another concern with the sample was the disproportionate geographic representation. Although eighty-four percent of the U.S. cities are represented in the Frequency vs. Satisfaction Survey with at least one respondent from each state, the majority of the sample (61%) is from the researcher’s home state, Indiana. The imbalance in geographic representation may overemphasize the attitudes, beliefs, and feelings of lesbians in the Midwest, which is commonly believed to be more conservative. This geographic bias may skew the survey results.

Another concern about the sampling process results from the outreach method used. Because the research was conducted by a psychotherapist who specializes in the care of lesbian individuals and couples, the survey outreach may have included a disproportionate number of lesbians who are in therapy. This also has the potential to bias the survey outcomes, assuming that lesbians in therapy may present with more concerns about their relationship than lesbians not in counseling.

A third concern with the study relates to the use of self-report to gather data. In some cases, lesbians were asked to rely on their memory of a relationship that was terminated up to six months ago. The greater amount of recall that is required, the greater margin of error there is in the ultimate findings. Additionally, lesbians who were recounting their experiences of a prior relationship may have a biased perception of that relationship depending on how it ended. If the relationship ended poorly, they may experience negative recall, which could influence their thoughts about relationship satisfaction, or even their feelings about the frequency of sex and other variables explored in the Frequency vs. Satisfaction Survey.

Areas identified for future research

Several additional questions surfaced while researching the topic of sexual frequency as it correlates with relationship satisfaction. One of the findings in the Frequency vs. Satisfaction Survey, as well as Lever’s Survey (1995), shows that no matter how much sex lesbians are having, they generally report the desire for more. This particular dichotomy of infrequent sex by lesbians who state a wish for more seems to be at the heart of the lesbian sexual dilemma. Further research may prove helpful in answering this question: What is preventing lesbians who report a desire for more frequent sex from having more sex?

Another unanswered question that surfaced during this study is, “How does perceived relationship security influence sexual frequency in lesbian relationships?” This is not a topic that was addressed in the Frequency vs. Satisfaction Survey, nor is it a topic that this researcher came across in her research. However, it seems that relationship security, or more specifically, the feeling of safety that one’s relationship is strong and stable, appears to be a valuable characteristic to lesbians, and one that is supported by a strong emotional connection. This researcher theorizes the possibility that the greater the perceived relationship security for a lesbian couple, the lower the rate of sexual frequency.

Other areas of interest for further research relate to the universality of lesbian sexual frequency. How do rates of lesbian sexual frequency in the United States compare to other countries, particularly in more progressive countries that provide rights and protections for lesbian relationships? Is there a cultural influence, or even a geographical influence, on sexual frequency among lesbians? Perhaps a study comparing lesbians from selected larger cities such as New York City, New York and Los Angeles, California could be compared to lesbians from smaller cities in the Midwest such as Indianapolis, Indiana and Columbus, Ohio. The correlation of race and sexual frequency among lesbians is also a valuable topic to explore.

This worker concludes that the next step in the quest for greater understanding about lesbian sexuality will be best achieved through qualitative research. The most accurate picture of lesbian sexuality will likely require a detailed, longitudinal, qualitative study that tracks the nuances and dynamics of a lesbian couple’s relationship from the initial stages of courtship throughout the course of their relationship. This would allow for new information to surface that has not yet been hypothesized, and for lesbians to give voice to their experiences as they are happening, rather than the subjective nature involved in recalling the events of one’s relationship.

What is most clear to this researcher is that sex between women is uniquely lesbian and without comparison. When juxtaposed with heterosexual or gay male relationships, lesbian sexuality is out of focus, blurred by what is perceived to be “normal” when in fact, lesbian sexuality has no established baseline behavior of its own. As research continues on lesbian sexuality without preconceived notions about how it “should” look or what it “should” entail, interesting and important discoveries will likely be made. Ultimately, lesbian sexuality is already valuable in its own right for its own nuances. Unfortunately, it is not yet well understood. In time, lesbians will be equipped to define their own sexual health through greater understanding of lesbian sexuality as a whole, and when that happens, needed progress will have been made.

Read Chapter Nine

Dissertation References