Can it ever be too late?  Unfortunately, yes.  Some couples wait so long that one partner is already about to walk out the door.  The other will say, wait, let’s go to counseling.  They enter my office, one motivated, one dejected.  If the dejected partner can’t be motivated, if they feel as if they’ve already tried everything imaginable, or if they are so angry and disgusted that they just don’t care any more, yes, it can be too late.  And I have to say, those are the saddest cases that I see in my office.

I can’t say that every marriage like this could have been saved if they had come in sooner; that would be unrealistic.  But what I can say is that the likelihood that the marriage might have endured is increased when there have been fewer years of damage to undo.

How do you know when it’s time to make a call to a sex or couples therapist?  Here are some reasons to call:

• You continually have the same fight about the same topic without any resolution.
• The problem is one that has long roots back into early adulthood or childhood, and you’ve never gotten help for it.
• You don’t talk about the problem, but there is a lot of tension in the relationship.
• You feel unhappy or dissatisfied with your relationship most days.
• You worry that your partner has a mental illness such as depression or bipolar disorder.
• You bicker constantly.
• You dread spending time alone with your partner.
• You fantasize about being single again.
• You’ve contemplated having an affair, or you’ve had or are involved in an affair.
• You have an unusual problem and don’t know where to turn.

There are times when taking a wait-and-see approach makes sense.  If you’ve had a major argument or your partner’s behavior has disappointed you, then time may heal the problem.  Or if you agree to make and implement a change, you may want to have a reasonable time line, such as 6 months, to see if you can remedy things on your own.

Seeing a therapist may be problematic, I know.  Admitting that you have a problem that you haven’t been able to solve, letting someone–a stranger–see you at your worst, and trusting someone is going to give you good value for your money all make going to therapy a tough call.

But consider the alternatives:  Years of arguing, emotional pain, and despair.  Separation or divorce.  The loss of dreams and potential as a couple.

Of course, there is no promise that even if you do contact a therapist sooner rather than later your marriage or relationship will endure.  Sometimes partners hide their motive for coming to therapy, such as making sure that there is someone (the therapist) to take care of their partner if they choose to leave.  Or, they come in so that they can say, “We tried therapy and it just didn’t work out.”  But for most couples, seeing a therapist is the key to staying together–especially if they call before it’s too late.

But before talking about the role of feelings, here is a bit of general information about premature ejaculation (also known as rapid ejaculation).  Often the first question I ask is, “How long do you actually last?”  When a man answers three or four minutes, I tell him that he’s doing fine, because on average men last from three to 10 minutes.  However, the caller is often unhappy with this answer.  Generally, the partner is disappointed because she cannot have orgasm within the time that the couple has intercourse, or he once enjoyed better control but has noticed a change.  Some men have control for a minute or two, if that, which leads to the most frustration.

What to do?  It depends on the cause as well as perspective.  Some people, including many medical doctors, see premature ejaculation as a physical problem.   The thinking goes that a man’s penis and his mental responses to stimulation are overly sensitive, causing ejaculation before the man and his partner want it to occur.  When the medical model is used to explain and treat the symptom, then a medical treatment is used, such as a numbing cream or an antidepressant.  (Antidepressants can have the side effect of delaying ejaculation.)

However, premature ejaculation can also be a psychological problem.  Anxiety and stress are common culprits.  When a man is anxious about how long he will last, whether or not he will please his partner, or about some other aspect of sex, then his brain is primed to react quickly to stimuli.  Stress does the same thing by causing the body and mind to be “keyed up” in high alert, making it difficult to stay focused and manage all the sensations going to the brain.

But feelings can also contribute to premature ejaculation.  If a man is feeling sad, for example, about his relationship, he may find it difficult to last as long as he’d like while being intimate with his partner.  Men often contact me about this problem after the breakup of a relationship.  The problem starts seemingly for “no reason,” but upon reflection, the relationship was actually on shaky ground for quite some time.  Fears about one’s ability to please a woman not just sexually, but emotionally, can be subtle but still create an effect in the bedroom.

Anger can also disrupt a man’s sexual performance, as can feeling exploited or used by his partner.  He may not feel like being close to his partner under such circumstances, even though he mostly wants to please her.  He also may be too distracted by his negative feelings, unable to push them aside.  Though it may be a stereotype, men do tend to pride themselves on their ability to put aside feelings in favor of thought.  But try as a man might, if his negative feelings are strong enough, or if he is under stress or tired, they will make themselves known through various symptoms, including premature ejaculation.

When feelings are absent, there can also be problems.  If a man is with a sexual partner with whom he has little emotional connection, he doesn’t have an incentive to last a long time.  He also may not want to have a long period of intercourse because he doesn’t want to seem or become interested or involved with his partner.  Though there are some men who want to appear as “studs,” able to last a long time under any circumstance, the truth is that feelings do play a role in sex for most men.  After all, men are simply human; they shouldn’t dismiss the important information that their feelings hold for them, including when it comes to sex.

Vaginismus happens for many reasons.  A woman may be highly nervous about having intercourse, particularly for the first time; she may feel shame or guilt about sex, or she may have performance anxiety.  Or, past trauma such as date rape may be to blame.  Repeat infections, such as yeast infections, or dryness during menopause uncomfortable intercourse can also cause vaginismus.  Finally, treatments for gynecological cancers, such as cervical cancer, can also cause vaginal atrophy.

Because it can be so embarrassing, many women fail to talk to a physician about treatment.  Unfortunately, even women that do mention the problem to a doctor often receive a pat on the knee and advice to “just relax.”  Of course, that is much more easily said than done.  There is much more that can be done to help a woman and her partner overcome vaginismus, including the following steps:

1. Find a physician that specializes in sexual medicine.  This is usually a gynecologist or a urogynecologist (a urologist that specializes in women’s problems).  You can ask your own gynecologist or general physician for a referral.
2. Work with a psychotherapist who specializes in problems of a sexual nature.  This may be a sex therapist, or it may be a marriage therapist who has some training in sexual dysfunction.  Identify what makes you fearful, guilty, or shameful about sex, process it, and let it go.
3. Consider a program of dilator use.  A dilator is a cylinder-shaped object that is inserted into the vagina to desensitize a woman to having something “in there.”  Dilators start with a small size and increase to something comparable to a man’s penis.  The physician or sex therapist can give you guidance on how to use them.
4. Try a program of overall physical relaxation.  You can find many relaxation recordings online.  Or do yoga, meditation, or other form of regular relaxation.  Listening to relaxing music can also be helpful.
5. Learn more about sexual pleasure.  You can learn a lot about your own body through self-massage.  Let your partner know what you do and do not like when it comes to touch.
6. Always use lubricant for any type of genital contact.  Water-based lubricants tend to dry out and need to be reapplied, but they can be used with condoms.
7. Don’t give up on sex altogether.  There are definitely couples that have a rich sex life that just doesn’t include intercourse.  (Often it is the wish to become pregnant that brings them into treatment.)

Women with vaginismus shouldn’t give up on the desire to have “normal” sex with their partner.  It may take some time and lots of encouragement, but with the right assistance most every woman can resolve the problem and enjoy sex.

Now I can answer yes.  I’m ready to start serving clients one day a week, on Mondays, in my new office location in Corona, CA, beginning July 12, 2010.  Men, women, and couples in Riverside will no longer need to battle traffic to see me, or skip sessions because they can’t afford to take too much time off from work.  Women with sexual pain problems, men with erectile dysfunction, couples with different levels of sexual desire–you now have a trustworthy, credentialed therapist you can call, closer to your home.

Do you live in Orange County?  My Irvine office is centrally located near the 5, 405, and 133 freeways.  Just give me a call at 800-769-0342 and I’d be happy to tell you if I think I can help, how I work, and schedule your first appointment.

In my view, women who have a problem with orgasm often have one or more of the following issues:

1. They don’t understand their own bodies.  They never masturbate, which is unusual, especially in these times when you can buy a sex toy and a bottle of lubricant at many local pharmacies.  Since they don’t know their own bodies, they can’t communicate to a partner what it is that arouses them and might bring them to orgasm.
2. If they do masturbate, they focus exclusively on their genitals.  They don’t realize that orgasm requires arousal.  They don’t explore their bodies to see what feels good and gets them excited.
3. They often come from a very religious background which puts the breaks on sexual pleasure, so much so that even when married and in a safe relationship, they cannot let go and allow themselves to experience orgasm.
4. They are in denial about stress in their lives or relationship.  Women may not allow themselves to believe that being with a partner who belittles them or abuses them in anyway, who is neglectful, or who has unacceptable behaviors like frequently drinking to excess, can have any effect on their ability to get turned on.

All of these barriers to sexual pleasure can be overcome.  There are many books available on how to achieve orgasm.  The basic approach is the same.  A woman begins by understanding her own body, both how it is made for pleasure and how to generate sexual energy and excitement.  Next, she begins exploring her body.  She needs to become comfortable with sexual touch and to discover what areas of her body bring her pleasure.

Then she begins to explore her genitals.  She can experiment to find out what kind of pressure, where she needs it to be applied, and how sensations travel through her body and mind.  She needs to overcome fears and anxiety about what will happen if she has an orgasm, because she will know that the answer will simply be she will have a sense of release and a warm glow.

If a woman is unable to experiment with these steps on her own, then a qualified psychotherapist with training in sex therapy can help.  Together with the therapist, a woman can discover her mental blocks to feeling pleasure.  She can learn how to relax during sex, not just with her partner, but with herself.  She can gain confidence in her ability to experience her body and learn to communicate her discoveries. And if there are relationship problems or other stress that get in the way, she can work those through and make changes.

Most of all, what she may learn is that orgasm is only a small part of sex.  A woman’s relationship with her own body and an understanding of her mental attitudes about sex are what can make a true difference between being non-orgasmic and orgasmic.

It is a myth that it is always the male partner that has higher sexual desire.  In my sex therapy practice, it is about 50/50 men to women that have higher desire than their partner.  Another myth is that most partners stop having sex once children have arrived.  If couples had a decent sex life before pregnancy, they will figure out a way to regain their sex life.

What causes differences of sexual desire?  The reasons are as varied as what causes differences in participating in different sports or liking different kinds of food.  Some people have a hormonal profile that makes them naturally more interest in sex.  Other people find that sex is a good way to relax, or feel connected, though their partner may not find sex as effective.  Some partners find that their desire to be with their partner never fades, while others discover that their desire diminishes over time.  People differ in how they were raised to view sex.  They also differ in how important it is to them personally.

Differences in sexual desire can cause a lot of friction in a relationship.  What never works is to nag, harass, beg, argue, or avoid the issue.  If you accept that it is okay, even normal, to have those differences and not read too much into them, then you can calmly and kindly discuss how you can both be happy.  Most couples find that simply compromising on how often they will have sex works well enough, while others prefer scheduling so that both know what to expect.  Some couples find that if the high desire partner has his or her needs met regularly, they are happy, whether or not the encounter is romantic or matter-of-fact.

If you can’t seem to resolve your differences, then you might benefit from the services of a sex therapist.  A sex therapist is a psychotherapist with specialized training in sexuality and human relationships.  The sex therapist can help you understand why you are stuck, give you each an opportunity to voice your concerns, and help you work toward a satisfactory solution.  This involves good communication, compassion for your partner, and a willingness to accept differences.

Asperger’s seems to be current vogue disorder.  HBO recently had a documentary on Temple Grandin, the fascinating woman agriculturalist who has written books about her own experience of Asperger’s.  Last year, three movies were released that featured characters with Asperger’s.  Asperger’s, it seems, is everywhere.

But is it? Asperger’s has a short history, because it was only first diagnosed in 1994 by Viennese pediatrician Hans Asperger, the number of people in the U.S. who have Asperger’s is actually unknown.  Many adults may have Asperger’s without knowledge of the disorder.   Today, however, many children are diagnosed sometime in their early childhood.  In any case, Asperger’s is

How does someone know that they or someone they know has Asperger’s, anyway?  People with Asperger’s usually have poor social skills, obsessions, odd speech patterns, unusual posture, and other peculiar mannerisms.  In an adult, the person may have difficulty understanding social behavior that others take for granted, for example, laughing loudly or at inappropriate times.  (One male client with Asperger’s, horribly embarrassed when he told me about his Peyronie’s disease, then went out to the reception area after his appointment and confided so loudly to the receptionist that the entire clinic heard him.)  They may have strange collections, such as one physician with whom I’m familiar who collected all things having to do with bees; even his office was decorated in black and yellow.

When people with Asperger’s speak, they may not make sense, not because they speak gibberish but because they don’t know how to segue into normal conversation.  Generally, they learn how to get along socially by observing and copying others.  Since they don’t do well with change in any case, this only contributes to behavior that may appear strange or robotic.  A common myth about Asperger’s is that everyone who has it is a “genius.”  Not true.  There are people with average intelligence that also have Asperger’s.

Because people with Asperger’s don’t fit in socially, they often apply themselves in school or in their careers.  This makes them stable and dependable, which can be attractive to a partner that is looking to settle down.  Many people who partner with someone with Asperger’s will marry in the belief that feelings and intimacy will grow over time.  While this can happen, more often than not the non-Asperger’s partner becomes disappointed and frustrated.

Sometimes this disappointment and frustration becomes focused in the couple’s bedroom.  While adults with Asperger’s vary, many non-Asperger’s partners find the lover with Asperger’s mechanical and emotionally disconnected during sex.  Even if they have sexual experience, they may not understand what is expected of them, e.g., mutual pleasuring, vocalization, or emotional expression.

Besides misunderstanding social cues and lacking in empathy, the partner with Asperger’s may also be overwhelmed by the sensory experiences of sex.  One man, for example, disliked the smell and feel of his partner’s hair.  Another couldn’t stand the little bumps and irregularities of his partner’s skin and asked her to wear a body stocking when they had sex.  A woman with Asperger’s complained that she felt “completely smothered” by her husband during lovemaking and decided it was better to divorce than to put up with having to have sex.

Is there any hope for couples in which one partner has Asperger’s?  Yes, of course.  If both partners are motivated to change, then they can have a more satisfying sex life, one that makes each partner feel wanted and accepted.  But a satisfying sex life generally starts outside the bedroom.  Partners first need to educate themselves about Asperger’s so that they can understand how it is affecting their intimate relationship.  They need to be able to communicate to each other; both need to develop some empathy for the other’s position.

Sensate focus activities may also be helpful in slowing down both partners so that they can concentrate on what feels good, instead of on performance.  Learning to give verbal feedback about sex without creating defensiveness is another valuable skill.  Being realistic about what may or may not change in the bedroom is another facet of acceptance of the diagnosis of Asperger’s.

You’ll have to wait until January 2011 to read a copy of my book, which discusses how various psychological problems, from addiction to learning disabilities, affect a couple’s sex life, but until then here are some links to resources about Asperger’s that may be helpful to you:

Asperger Adults

WEGO Health on Asperger’s

The National Autistic Society

A word about diagnosis and treatment:  Different people react to a diagnosis of Asperger’s in different ways.  Some people are relieved to discover an identity that answers questions for them.  Others are curious.  Still others are upset or go into denial.  No individual should ever be forced into being diagnosed or treated.  However, therapy can be helpful for people with Asperger’s and spouses or other family members who are trying to understand and give them support.

I understand that some women really do have trouble with blood flow to the genitals.  That’s because for women the brain needs to send a signal that the woman is excited about sex.  Of course, lots of women aren’t very excited about sex. So there’s no blood flow.  Hence, the pill.

Let me share with you some of the many reasons that women are uninterested in sex:

• they worry excessively about things that are unimportant, such as laundry and other chores
• they think of sex as an obligation, instead of a pleasure for themselves
• they don’t communicate what they want to their partner, so they don’t get aroused
• they feel guilty if sex feels good, so they suppress sexual thoughts and feelings
• they don’t take care of themselves–don’t exercise, eat right, or get enough sleep
• they lack education about their own bodies and don’t realize that they may need direct stimulation to the genitals to get blood flow going, leading to orgasm

How will a pill help with such things?  Imagine, if you will, the day that a man and a woman both need to take a pill to have sex with each other.  It’s a New Yorker cartoon waiting to happen.  Now imagine a couple pleasuring each other in a sensual way.  They know if they have intercourse, that’s great.  If that don’t, that’s okay, too.  No pressure, just pleasure.  Think you need a pill if you make love like that?

It’s different for men.  Men do have medical problems that cause erectile dysfunction, such as diabetes or chronic tobacco use.  And I suppose that there is a very small percentage of women that could use a medication to stimulate blood flow, perhaps a woman who has had cancer and radiation treatment.  But those women who commented on the story who are on antidepressants?  No, not likely.  What needs to happen is to get psychotherapy, get off the pills, and then see where things are at, because there are some people that never regain sexual function after antidepressant treatment. But why bother learning how to stop being depressed / anxious / stressed, when you can just take a pill?

Women’s sexual desire is more complex than a man’s.  Especially for women in long term relationships, sexual desire is less driven by hormones, though they do play a role.  What seems to be more important is the quality of the relationship between a woman and her partner; her mood, energy, and stress level; her feelings about herself and her body; and her overall enjoyment of sexual activity.

Also, while men feel horny and then want sex, women in long terms relationships often need some loving before they feel horny.  If a man approaches his wife or partner with his motor on “idle” and gives her some time to warm up without pressure, letting her tune in to her own needs to see if a “no” might become a “yes.”

Another way to help a woman enjoy sex more is to take the time to find out what she enjoys.  If she can’t communicate it verbally, ask if she can show you by guiding your hand with her own.  Encourage her to explore her own body so that she can share what she has discovered with you.

If your wife complains that she doesn’t have any energy, help her out.  If you are feeling amorous, take over a few chores so that she can put her feet up or take a warm bath.  Try doing this regularly, whether or not you are looking for an opportunity for sex.  It’s a fact:  Men that help out have sex more frequently.

There are some rather serious reasons that women may lack desire.  One is that they experience sexual trauma.  Another is that intercourse is painful.  A third would be medical problems, both gynecological and non-gynecological; a woman that has no drive should definitely seek a medical examination.  Problems with depression and anxiety can also interfere with drive.  Finally, changes such as the birth of a child or menopause can have an effect on libido.  These experiences are real and need to be addressed; they just don’t go away on their own.

There is nearly always a reason a woman’s drive goes missing.  Invite your wife to do some detective work with you and then work on the problem together.  If you solve it, great.  If not, perhaps you are both too close to the problem or haven’t considered some of the other many reasons this happens; try using the services of a AASECT certified sex therapist to help you.

Recently, an article in USA Today discussed people that walk down the aisle, even though they know with some certainty that the marriage could fail.  Why do they do it?

• They thought they could make their partner change.
• They just didn’t want to be single.
• There was an unplanned pregnancy.
• They felt pressured by family.
• They wanted financial security.
• They figured they could make it work.

Obviously, for the most part these aren’t great reasons to get married.  Even in the case of an unplanned pregnancy, if there is no love, then there probably shouldn’t be a marriage.

Sometimes a person struggling with the issue of whether or not to divorce a partner because they never felt chemistry nor a connection will decide that they will stay for the sake of the children.  If the person’s partner isn’t drinking, cheating, or being abusive, then that is probably the best decision.  Once the children have grown, they can choose to stay or go, but giving offspring the best possible chance for success can be a sacrifice worth making.

If there are no children involved, then statistically the marriage probably will not last.  While children put a great deal of strain on a marriage–so much responsibility, so little time–they are also paradoxically the “glue” that can hold a marriage together.  Unless someone is very religious, there is little incentive to stay in a loveless marriage.

A loveless marriage is different, though, from a sexless marriage, or a marriage in which sex has never really worked very well.  Love may never be there the way it is portrayed in the movies or novels, but if someone has a decent sex life with their partner (regular, satisfying sex), they may choose to stay in the marriage.  If there is caring and respect, as well as sex, the marriage may survive despite the lack of passion, however that might be described or imagined.

If, however, there are long term sexual issues, even if the relationship is good in other respects, it may not survive the truth:  That one partner has stayed in the marriage out of a sense of duty.  At some point, however, they can no longer tolerate their sexual needs being denied.

I wish I could tell you that in those cases I am always able to help the relationship to heal, to get the couple’s sex life on track so that they can resume the marriage.  Sometimes things don’t work out because there is too much anger and resentment that has built up over the years.  When a partner fails to take responsibility for taking care of sexual problems, the other partner may try to brush it off, reasoning that they aren’t in the relationship for the sex.  But sex and intimate touch are real needs.  Denying them does no good.

What is the remedy?  If you are struggling because you’re not sure you can handle another day of a marriage in which the sex doesn’t work, don’t give up, at least not yet.  Research shows that most couples that attend marital therapy do benefit.  But don’t expect the therapist to do all the work.  Deciding that you are going to give therapy a shot and then showing up without an expectation of having to make a commitment to your marriage and the process isn’t going to cut it.  You’re going to have to work, even if you feel that it’s your partner that “has the problem.”  If your partner has a problem, you have a problem, and you’re going to have to work together as a team.

No sex therapist where you live?  Visit AASECT, click on the map, and find someone in your area.  And remember:  Therapy is way, way, way cheaper than divorce, and the cost of divorce goes way beyond dollars and cents.