The new mantra in sex therapy is desire/pleasure/eroticism/satisfaction [1]. Desire is the core dimension, especially for couple sexual vitality and satisfaction. When clinicians addressed desire problems, the traditional focus had been on female desire problems, namely female sexual interest/arousal disorder (FSIAD). However, a little known fact is that when couples stop being sexual, especially after age 50, it is usually the man who makes the decision. He usually does so unilaterally and conveys it nonverbally. The primary cause of male secondary hypoactive sexual desire disorder (HSDD) is loss of confidence with erection, intercourse, and orgasm. He falls into the negative cycle of anticipatory anxiety, performance-oriented intercourse, frustration, embarrassment, and ultimately avoidance. The sexual avoidance cycle becomes self-perpetuating, becoming stronger and more controlling over time. This leads to a nonsexual relationship.

The message of the media and pharmacological advertising is to turn to a biomedical intervention (e.g., Viagra, Cialis, testosterone, penile injections) as a stand-alone approach to restore male confidence. Although pro-erection medications can and do improve sexual function, they are not a “magic pill” as touted by the advertisements. The problem is that men expect a return to easy, totally predictable erections they experienced in their teens and twenties. When this is not the outcome, they feel like “Viagra failures.”

The great majority of men learn sexual response as autonomous; they experience erection, intercourse, and orgasm needing nothing from their partner. Entirely predictable sex function is viewed as the measure of a man and the model for “real male sex” [2]. This model is not appropriate for males as they and their relationship age. Yet peers and the media demand perfect sex performance from men.

Over 90% of male HSDD is secondary, caused by sexual dysfunction, especially erectile dysfunction (ED ) and, to a lesser extent, delayed ejaculation (DE). It is important to note that 8–10% of males experience primary HSDD [3]. Typically, the man denies primary HSDD, saying, “How can I have a desire problem when I have three children?” At the core of primary HSDD is the fact that man does not value intimate, interactive couple sexuality. That does not mean he cannot perform intercourse or have reproductive sex. The typical cause of primary HSDD is a sexual secret. Contrary to the myth that male sexual problems are caused by sexual orientation issues, the most common sexual secrets involve: (1) a variant (atypical) arousal pattern, such as fetishes, cross-dressing, BDSM scenarios; (2) he is confident with masturbatory sex (with or without porn), but is an anxious performer during couple sex; and (3) a history of sexual trauma which has not been disclosed and processed.

The male model of sex is: “A real man is ready and able to have sex with any woman, any time, in any situation.” This oppressive model focuses on individual sex performance, rather than sexuality as an intimate couple experience. The core issue in treatment planning and change goals for HSDD is whether the focus is on totally predictable male individual sex performance or the goal is restoring comfort and confidence with sexuality as a couple process of giving and receiving pleasure-oriented touching using the criterion of Good Enough Sex (GES) [4]. The traditional treatment focus has been an individual, biomedical, performance-oriented approach. This chapter will advocate for a comprehensive, couple biopsychosocial model of assessment, treatment, and relapse prevention of HSDD, with a focus on the couple GES approach rather than on perfect individual sex performance. Regaining and maintaining comfort and confidence with desire, pleasure, eroticism, and satisfaction is the core strategy. As this book is primarily for a medical audience, this chapter utilizes a biopsychosocial framework . However, as psychologists we prefer the strategies and interventions embodied in the psychobiosocial model [5]. What is clear is that successful treatment involves addressing biological/medical, psychological, and social/relational factors. A major mistake made both in the media and by clinicians is the simplistic belief in the efficacy of a stand-alone medication or medical intervention. The reality of male and couple sexuality, especially desire, is that by its nature it is variable and flexible rather than totally predictable [6]. Media advertisements and physician expectations are that the medication will return the man to totally predictable, autonomous sexual function. The message is that when the man takes a pro-erection medication he will experience a 100% predictable erection like he did in his teens. The data, which is not empirically validated, is that successful intercourse occurs in 65–85% of encounters [7]. This is a positive and realistic outcome, but it is not what the man expects. The dropout rate for pro-erection medications and other medical interventions (i.e., testosterone enhancement, penile injections, external penile pumps) is quite high, an estimate of 70% after 2 years [8]. The man is disappointed and frustrated, feels stigmatized, and avoids partner sex. Many clinicians believe that Viagra has caused more nonsexual relationships since 1998 than anything else in history [6]. This is not the drug’s fault as much as it is that no one tells the man (or couple) how to integrate the medical intervention into their couple style of intimacy, pleasuring, and eroticism. In addition, the physician or clinician does not help enable the man or couple to establish positive, realistic expectations for erections and intercourse. Based on media expectations of 100% predictable erection, almost all men are “Viagra failures.”

The reason that psychological and relational factors are so important in treatment of HSDD is they establish a genuine sense of male sexual self-efficacy based on GES expectations rather than on perfect performance. The relational dimension emphasizes that the essence of couple sexuality is giving and receiving pleasure-oriented touch rather than sex as an individual pass–fail test. Couple sex therapy emphasizes an anti-perfectionistic approach. Women accept GES more easily because it is compatible with female sexual socialization and her lived sexual experiences. Few women experience autonomous sexual response and do not feel pressure to be a perfect sex performer. The oppressive performance myth for men is strongly reinforced in porn videos, where the man always has a firm erection and needs nothing from the woman.

GES is much more likely to be accepted in the context of couple therapy than among male peers, with whom the man is unwilling to share sexual questions or anxieties. Male peers judge GES as “wimpy” and “not man enough,” and fear that GES feminizes male sexuality. Clinically, the intervention is to say to the man and couple that “traditional men stop being sexual in their 50s or 60s, whereas ‘wise men’ can be sexual in their 60s, 70s, and 80s” [9]. Wise men turn toward their partner, embrace variable, flexible couple sexuality, accept GES, and value sensual, playful, and erotic sexuality in addition to intercourse. These concepts are congruent with psychological and social/relational perspectives , but stand in stark contrast with traditional male beliefs and the biomedical model of male sex performance. The comprehensive couple biopsychosocial model promotes change and guards against relapse. A key component is to affirm the mantra of desire/pleasure/eroticism/satisfaction, with an emphasis on the core role of desire. This requires the man (and couple) to give up the traditional model of male sex as totally predictable erection, intercourse, and orgasm. Autonomous sex function is the way most males learn sex response and is mistakenly believed to be “natural.” Although this approach might be functional for young adult men, after age 40 and certainly for men in their 50s and 60s this self-defeating approach must be replaced by a positive, realistic model of male sexuality.

Female–male sexual equity promotes emotional and sexual relationships. Hyde [10] found that there are more similarities than differences intellectually, emotionally, behaviorally, and sexually between men and women. The traditional gender split underlies the double standard that it is the man’s role to initiate sex and that sex must involve intercourse. Intercourse frequency and eroticism is the man’s domain. In this gender split, women are to value intimacy, touching, and relational security. The “pop psych” approach to gender differences was illustrated by Gray’s [11] best-selling book, Men are from Mars, Women are from Venus. Although this perspective is clearly described, it is fundamentally lacking in scientific validation . The data is clear that intellectually, emotionally, behaviorally, and sexually, there are many more sexual similarities than differences between adult men and women. This is especially true for adults over 40 and those in married and partnered relationships. Couples who adopt the female–male sexual equity model have a valuable sexual resource [12].

It is crucial to address the conceptual and clinical factors of the biopsychosocial model when trying to assess, treat, and prevent relapse of HSDD. Since secondary HSDD is so much more common than primary HSDD, this chapter addresses secondary HSDD through the use of a case study format.

There is a great need for empirical and clinical research to establish the best treatment approach for HSDD. However, present data and clinical guidelines suggest that a couple biopsychosocial approach is most likely to be efficacious for the man and couple. HSDD is multicausal, multidimensional, and complex; thus, “Sexually, one model never fits all.”

The couple sex therapy approach is likely to be most efficacious because it addresses the core issues underlying HSDD. Secondary HSDD, which is far more common, is typically caused by sex dysfunction, including ED as well as secondary delayed ejaculation (ejaculatory inhibition). The man has lost confidence with erection, intercourse, and orgasm and has fallen into a cycle of anticipatory anxiety, performance-oriented intercourse, frustration, embarrassment, and avoidance. The more he avoids and the more shame he feels, the more chronic and severe the HSDD.

The comprehensive couple biopsychosocial approach to HSDD enables the man and woman to explore and address the causes of the HSDD as well as to utilize all needed biomedical, psychological, and relational resources to rebuild sexual comfort and confidence. Although the man wants an easy answer and a quick sexual fix, his partner is usually aware of the complexity and variability of couple sexuality and encourages him to view intimacy and sexuality as a couple issue. The typical male learning history about desire, spontaneous erections, and totally predictable sex performance interferes with successful treatment of HSDD. The partner’s active role as his intimate and erotic friend who accepts Good Enough Sex (GES) expectations is a crucial factor in successful treatment.

The couple biopsychosocial approach is just as relevant to the treatment of primary HSDD. The combination of high secrecy, high eroticism, and high shame poisons desire for couple sexuality. Usually, the woman is less judgmental of the man’s sexual secret life than he is. Together, they discuss and determine whether acceptance, compartmentalization, or necessary loss is the best strategy to rekindle desire in the relationship.

The clinician (whether medical or mental health) is ideally pro-sexual and pro-relationship, but not anti-divorce. Sometimes HSDD is indicative of a fatally flawed relationship or of the lack of value the man has for couple sexuality. Ideally, the clinician would be empathic and respectful of both traditional couples and sexually nontraditional individuals and couples. Ideally, the clinician would be competent in the assessment of biomedical, psychological, and relational factors and comfortable either treating all necessary dimensions or making referrals to specialists.

The following detailed case study illustrates the couple biopsychosocial approach to assessment, treatment, and relapse prevention of HSDD.

Fifty-four-year-old Brian and 53-year-old Claudia were referred to a couples therapist, with a subspecialty in sex therapy, by their primary care physician. Two years prior to that, Brian had complained about increasing frequency of erectile dysfunction (ED ). The internist conducted an assessment of Brian’s cardiovascular function and checked for diabetes and testosterone status before prescribing Viagra. He scheduled a 6-month follow-up appointment. At the follow-up, Brian reported he was very disappointed in the results of Viagra, and had stopped taking it after 2 months. He reported ED was worsening and causing marital distress. The internist made a referral to a urologist for a more extensive assessment, including an evaluation of whether penile injection therapy was appropriate. Brian attended two appointments, was given a testosterone gel to be used daily and taught to do penile self-injection of a vascular agent in the urologist’s office. Brian did not speak to Claudia about penile injections. He tried this injection three times. The first two attempts resulted in intercourse, but it was not successful the third time. Brian felt quite awkward with the injection procedure and stopped using it without saying anything to Claudia. He continued to use the testosterone gel for 2 more months, but he did not tolerate the side effects of increased irritability (including Claudia’s complaint about his bad temper) and sleep disturbance. Again, Brian discontinued use without speaking to Claudia or his physician.

At the next 6-month appointment, Brian was reluctant to discuss ED with the internist. Instead he expressed concern about Claudia’s unhappiness with him and wondered if, at 54, it was time to put sex behind them. Claudia was also a patient of the internist. Thus, the physician was not surprised when she scheduled an appointment. The internist considered Brian and Claudia healthy people with a stable marriage and family, and not prone to mental health problems. He was reluctant to make a referral for couple therapy. However, he was convinced by Claudia’s evident distress about Brian’s avoidance not only of intercourse but also of any intimate touching. She worried that he no longer loved her and thought that he might be having an affair or keeping some other sexual secret. Claudia wanted to be sure the couple therapist was properly credentialed and that the therapist was pro-marriage rather than someone who promoted opening the marriage to other sex partners. The internist promised to do research on mental health referrals, which he turned over to his secretary. She researched websites for the American Association of Marriage and Family Therapy (www.​therapistlocator​.​net) and the American Association of Sex Educators, Counselors, and Therapists (www.​assect.​org). She found three therapists listed on both sites.

Typically, it is the woman who calls for the initial appointment. The couple therapist utilizes the four-session assessment model, whether the problem is sexual or involves general couple concerns. The four-session assessment model involves scheduling the first session as a couple, followed by sessions 2 and 3 which are individual psychological/relational/sexual histories, and the fourth session is a 90-min couple feedback session which bridges the assessment and treatment phases [13].

By conducting the first session as a couple, they receive a powerful message that intimacy and sexuality are best approached as a couple issue. Often, therapy begins with the woman alone and the man is invited to join the sessions after 6 weeks or even 6 months. In such instances, he enters therapy in the “one down” position, feeling blamed and stigmatized. Most therapy in the USA is conducted as individual therapy rather than couple therapy. The data indicate that couple therapy has a better outcome, especially much lower relapse rates [14]. One of the best predictors of divorce is a woman in individual therapy for marital problems [15]. In the four session assessment model, the man is invited as an equal partner from the beginning. The therapist does not assume that the male is the “bad guy.”

Sexual problems often degenerate into a pattern of blame and counter-blame. This is especially true of desire problems and sexual avoidance. In the initial couple session, the therapist takes the stance that the “desire problem is the joint enemy.” Brian felt the therapist was respectful and empathic, rather than blaming or demonizing him. Claudia also felt listened to and that the therapist was trying to help her as well as the relationship. This approach calmed Claudia’s feelings of panic and distrust. The therapist asked both Brian and Claudia to sign release of information forms so he could consult with the internist. Brian signed a form so the therapist could consult with the urologist. Rather than waiting for a written report, the therapist wrote on the form that he would call next week. Clinicians (e.g., physicians, individual therapists, couple therapists, psychiatrists, ministers) are more likely to be honest and forthcoming during a phone call. Ideally, the therapist discusses the clinician’s assessment and treatment summary as well as future recommendations. If possible, the therapist works in a synergistic manner with other clinicians, but at a minimum avoids an adversarial approach. The internist wanted to be able to share information. The internist indicated a willingness to prescribe medication the therapist recommended. The urologist was clearly irritated that Brian stopped penile injections and suggested he might be a candidate for a penile prosthesis.

An important question to ask in the initial couple session is whether sexuality ever had a positive role in their relationship. Brian and Claudia agreed they had begun, as do most couples, as a romantic love/passionate sex/idealized couple (i.e., limerance phase ) that had lasted a little over a year [16]. Both had positive memories of the limerance phase, especially in terms of desire and frequent, satisfying sex. Brian felt that sex had been a positive factor in the relationship until the past 3–4 years. Claudia agreed that sex had been positive, but better for Brian than for her. Claudia had not resented that difference. Her female peers would joke about their husbands wanting more sex and about touching always ending in intercourse. Claudia noted that there was never just sexual play.

Claudia believed that their sexual relationship changed 7–8 years ago, at which point she felt that Brian began been rushing to intercourse as soon as he obtained an erection. Often, she was not subjectively aroused enough to enjoy intercourse. Traditionally, Claudia was orgasmic during 50% of sexual encounters, either before or during intercourse. However, that had decreased to less than 20% in the last few years. Brian had attributed that to menopause and her decreased libido, but Claudia wondered aloud for the first time whether it was caused by Brian’s rush to intercourse. Brian became defensive, saying he wanted to be sure they had intercourse so that Claudia could have an orgasm. This quickly degenerated into an attack-counterattack pattern, which gave the therapist an opportunity to describe the negative impact of couple power struggles. The issue in a power struggle is not winning, but rather not losing and being labeled the “bad” partner. Sex problems bring out the worst in a couple. The therapist contrasted the good feelings that came from discussing the limerance phase with the bad feelings of whose fault it was when intercourse was not successful. These observations, particularly the fact that Claudia said that neither sex nor talking about sex had been fun in the past few years, caught Brian’s attention. Instead of counterattacking, Brian agreed.

In the first session, it is crucial to explore how each spouse understands the sexual problem and what they have tried to do to address it. The therapist does not want to repeat the same mistakes. Claudia’s objection was that she was not included in any discussion nor was she aware that Brian had used Viagra, injections, or testosterone. Her assumption had been that he denied problems and stonewalled. Her fear was that there was a major sexual secret, namely an affair or worse. Brian was initially offended. He had tried medical means to solve the sex problem and felt like a failure. Brian was demoralized and Claudia was confused.

Claudia was optimistic that they could renew couple intimacy, which Brian heard as a “sexual put-down.” He felt she did not view him as man enough to have “real sex.” Often when couples use the terms “intimacy” and “sex,” they are speaking different languages. The therapist reflected that they were speaking like Democrats and Republicans, using adversarial language and misunderstanding each other. He encouraged them to talk normally to each other, instructing them to “speak English to each other about intimacy and sexuality.” These are not adversarial terms or concepts. Intimacy refers to emotional and sexual experiences of warmth, closeness, attachment, affection, sensual touch, security, and predictability. Sexuality includes intercourse and orgasm, but is much more than that. Sexuality involves sensual, playful, and erotic touch in addition to intercourse. Eroticism involves unpredictable sexual scenarios and techniques, intense emotions and sensations, mystery and creativity, and uninhibited sexuality. Intimacy and eroticism are crucial parts of sexuality for the man, woman and the couple. Both the man and woman can value intimacy and sexuality. They do not need to fall into the traditional gender split in which men value eroticism and women value intimacy. A core issue throughout therapy is integrating intimacy and eroticism to develop a couple sexual style which reinforces strong, resilient sexual desire [17]. Ideally, Brian and Claudia would accept the female–male sexual equity model to replace Brian’s traditional approach to intercourse.

An important question to ask in the initial couple session is: “Are each of you committed to a satisfying, secure, and sexual marriage?” It’s important to directly assess this rather than assume it is true. This was a particularly sensitive issue for Brian and Claudia. Although both wanted these elements in their marriage, Claudia was quite concerned with satisfaction and sexuality. Brian was sexually demoralized and felt ready to give up on the sexual relationship; however, he also wanted marital stability and family and was concerned with pleasing Claudia, wanting her to feel loved and satisfied. The answers to that open-ended question were surprising to each spouse. Brian learned that the core issue for Claudia was not intercourse and orgasm, but rather touching as well as reassurance that he did not have a secret sexual life. Claudia was pleased to learn that Brian still loved her and valued their marriage, but was shocked at how sexually demoralized he was. Speaking the same language about intimacy and sexuality was enlightening for both, but especially Claudia. She was motivated to address issues as a couple. Brian was feeling pessimistic sexually, but better about having Claudia as his intimate ally.

A helpful therapeutic intervention was their reading material between sessions. The therapist never sells clients a book nor asks them to read a whole book, but rather assigns a short reading. In this case, the therapist gave them Chap. 2, “Whose Problem is It? His, Hers or Ours?” from Rekindling Desire [17]. Reading the chapter separately, marking up personally relevant sections, and then discussing it at home and in therapy were surprisingly valuable, especially for Brian. It clarified Claudia’s role as an emotional supporter and erotic ally in addressing HSDD and ED . Brian learned that he had to be responsible for his sexuality. He liked the concept that he deserved sexual pleasure. It also introduced Brian to the value of sexual knowledge, especially regarding ED . In Brian’s individual history session, the therapist told him that no man reacts as positively to Viagra as in television advertisements. Based on the media criterion, all men were “Viagra failures.” This awareness was invaluable in destigmatizing ED and set the stage for Brian and Claudia to read a section of an ED book during therapy [18]. Reading does not cure ED or HSDD; however, it does normalize the problem and creates positive, realistic expectations for change.

The first individual psychological/relational/sexual history was scheduled with Brian. The therapist began by saying, “I want to understand your psychological, relational, and sexual strengths and vulnerabilities both before you met Claudia and since she has been in your life. I want you to be as honest and forthcoming as possible. At the end, I will ask you to identify anything you do not want shared with her. I will not share it without your permission, but I would like to know everything I can in order to help you resolve these problems.”

Typically, the history is conducted using a chronological format, moving from less anxiety-provoking topics to more challenging ones. Open-ended questions are superior to yes-no questions, as the latter make it easy to deny and just say no. Open-ended questions give the therapist the opportunity to explore positives and problems.

It is imperative to find out about educational background generally, and sex education specifically. Following this, open-ended questions about religious background, and specifically religious sex education, are useful. The question about family background and his parents as a marital and sexual model was particularly revealing for Brian. He loved and appreciated them as parents and grandparents, but never thought of them as a marital or sexual model. Brian, like many men, had low expectations of marriage and marital sex. He enjoyed being married to Claudia and having sex, but he had emphasized intercourse frequency rather than satisfying couple sexuality. In later sessions, the issue of parenting was discussed. Brian had been a dutiful father to their son (now 26), but not been emotionally attentive in his parenting. Brian felt badly that the son was much closer to Claudia than he.

In reviewing his psychological and sexual development, Brian labeled it “normal” and gave it little thought. However, with gentle probing, Brian identified the fear that his penis was smaller than average (a fear shared by the majority of males). He also recognized his hatred of being bullied, and believed he had received the message that he was deficit as a male. Brian left home at age 18 for college. When asked what his best psychological, relational, or sexual learning had been before leaving home, Brian answered with no hesitation that being accepted at a prestigious college had reinforced his self-esteem. The therapist then asked, “What was the most confusing, guilt-inducing, negative, or traumatic experience before leaving home?” Brian was very hesitant and embarrassed before admitting to his belief that he was a compulsive masturbator who had a strange pattern of rubbing his genitals against the bed rather than use direct penile stimulation. Brian worried that this might be a cause of his ED . It was clear that Brian, like most men, was not sexually well educated. He was reluctant to ask questions or to read scientifically validated books or articles about sexuality.

In college, Brian did well academically and was sexually active, but not in the context of increased comfort and confidence. Almost all of his sexual encounters involved alcohol. Like most young males, he began as a premature ejaculator, but with experience gained ejaculatory control. Brian had a difficult time identifying his best sexual experiences during college. Without giving it much thought, Brian assumed he would eventually marry and have a family.

At age 24, Brian met Claudia, and they married 2 years later. Claudia was a college graduate and he found her an attractive, engaging partner. Brian was glad he had married Claudia, and felt they were a loving couple. He viewed intimacy and family planning as her domain. Their peer group was getting engaged and beginning to marry, and Brian was swept up in the momentum.

Although he joked about it, he was very concerned about his bachelor party experience. His friends hired two strippers, who took him into a private room and took turns fellating him. In previous experiences with girlfriends and with Claudia, Brian had always functioned autonomously; he had a spontaneous erection, intercourse with his first erection, and was easily orgasmic. Brian had not been sexually self-conscious. However, this stag party experience ended his autonomous sexual function. Brian had a difficult time maintaining his erection, although he did ejaculate easily. Afterwards, he bragged to his friends how good he had been sexually and that the women offered to pay him. However, he felt embarrassed by his performance anxieties and the autonomous sexual function pattern was broken.

Brian felt best about sex with Claudia before marriage. The romantic love/passionate sex/idealization experience (limerance phase ) was the sexual highlight of his life. They were sexual almost every time they were together, and every sexual experience flowed to intercourse and orgasm. Although he recalled the sex as loving and passionate, his focus was on intercourse frequency. Both remembered the limerance phase with positive feelings.

As Brian and Claudia settled into married life with two jobs and household tasks, sex frequency decreased; however, sex function, especially for Brian, was still predictable. Their son was planned and wanted, but the pregnancy signaled a dramatic change sexually. There was almost no sex during the last trimester and for 8 weeks after the birth. Since Brian defined sex as intercourse, other than affectionate touch there was no sexuality. For both Brian and Claudia, the return to intercourse after their son was born was awkward. Claudia was sleep-deprived and much less sexually responsive. Brian was irritated and pushed for more frequent intercourse. They no longer felt they were on the same sexual team.

For the next 20 years, their sexual relationship was functional, especially for Brian. However, it was not special or energizing. They fell into the traditional male–female power struggle of “intercourse or nothing.” Claudia built resentment about Brian’s focus on intercourse frequency. Brian felt Claudia was no longer his sexual friend, but rather that she had power as the sexual gatekeeper.

Brian first experienced intermittent ED in his mid-40s. Like most males, rather than accept variable sexuality as normal and not become anxious, Brian overreacted. This made the ED worse by rushing to intercourse as soon as he became erect. That common self-defeating reaction had two negative impacts. First, it reinforced the cycle of anticipatory anxiety, performance-oriented intercourse, and frustration and embarrassment. Second, it subverted Claudia’s sexual desire and response. She was neither subjectively nor objectively aroused; as a result, intercourse was less pleasurable, and her desire decreased over time. Claudia’s orgasmic response decreased from 80% during the limerance phase , to 40% during the adult years, and then to less than 15% during the erectile anxiety phase. Claudia felt that Brian was a less involved partner and negated her role as his sexual friend. Brian was largely unaware of this pattern, and complained about Claudia’s lack of sexual desire and enthusiasm.

The most difficult section of the history was the exploration of Brian’s attempts to use medical interventions to resolve the ED . Brian thought of ED as an individual performance problem and did not mention sexual desire until the therapist asked him directly. Brian attributed his low desire and sexual avoidance to ED . He stated, “How can I enjoy sex when I fail most of the time?” When asked how often he was orgasmic each month, Brian looked very embarrassed. He initially said less than once a month; however, when the therapist defined being orgasmic as involving any means (i.e., masturbation, intercourse, manual or oral stimulation, with another partner, with the use of Internet material), Brian admitted he was orgasmic 8–10 times a month. It was not true that Brian lacked sexual desire or was incapable of an orgasm; rather, he had desire and valued orgasm, but avoided couple sexuality because he feared intercourse failure. The crucial question when assessing for the presence of HSDD is whether it is generalized or specific to couple sex. Rather than feeling bad or embarrassed, the therapist assured Brian that masturbating to orgasm was normal and a good prognostic indicator.

Like the majority of men, Brian had masturbated throughout their marriage. For the last few years, Brian had been much more confident with masturbation than with couple sex. When asked about his self-efficacy with erections during masturbation, Brian reported firm erections the great majority of time. Neither the internist nor urologist had asked whether he experienced erections and in what context. Equally important was to explore his use of erotic fantasies and materials during masturbation. Like many males, Brian regularly used online porn while masturbating. The key dimensions when assessing porn use are: is it narrow and controlling, or diverse and a facilitator of erotic flow. Although many women label use of porn during masturbation as “porn addiction,” this is usually a misnomer to punish and shame the man. Of men who use porn, 85% utilize porn in a manner that is not harmful to him or his relationship [19]. This was the case with Brian. His masturbation and porn use illustrated his confidence with masturbation and eroticism as well as his lack of confidence with erection and intercourse during couple sex.

Brian had not shared his concerns about erection with Claudia, nor had he spoken with her about his need for manual and oral stimulation to increase his subjective and objective arousal. For Brian, the only criterion was objective arousal (i.e., an erection sufficient for intercourse). Brian was unaware of the concept of subjective arousal, and was therefore surprised when the therapist focused on the importance of increasing subjective arousal as a key resource in rebuilding comfort and confidence with erections. Brian sensed becoming “turned-on” when he masturbated, but in couple sex, his sole focus was on whether he was erect enough to attempt intromission.

When the internist prescribed Viagra, Brian was very optimistic that this would resolve his ED . Brian had told neither Claudia nor the internist that he had purchased a cheap Viagra brand from the Internet; when it did not provide dramatic results, he quickly stopped using it. Brian was confident that the prescription Viagra would provide the dramatic results shown on the TV ads, and was therefore bitterly disappointed when that did not occur. He did not contact the internist; rather, he just gave up and stopped taking it. All of this was unknown to Claudia.

The referral to the urologist was more problematic. Brian did not trust medical specialists and did not feel at ease with the urologist, whom Brian described as detached and uninterested. The urologist used the analogy of male “plumbing” and stated that he treated ED as a plumbing problem. Brian did not understand the reason for penile injections. Brian did not experience any technical problems with the injection and did experience a firm erection. There was no guidance from the urologist about how to integrate the injections into their couple sexuality.

Brian was more comfortable using the testosterone gel. The idea of being “more of a man” appealed to him. Again, Brian was not encouraged to discuss testosterone enhancement with Claudia. In fact, Brian had no desire to share anything sexually with Claudia.

Brian utilized the injection in the bathroom, and he moved to intercourse immediately upon meeting Claudia in the bedroom. Brian was pleased because intercourse was very easy with the injection-induced firmness; however, Claudia was not lubricated and seemed uncomfortable. Brian did not understand why it was difficult for him to reach orgasm, although he eventually succeeded. What caused him to feel awkward and self-conscious is that his erection did not dissipate after orgasm. Although he could sense that Claudia was puzzled, he chose to say nothing and turned away. He had no answers and wanted no questions. The third time he used the penile injection, he was unable to reach orgasm even though he tried as hard as he knew how. His frustration was evident to Claudia, especially since his erection did not decrease even when he felt turned-off. This time Claudia asked Brian what was wrong, and he left the bedroom out of desperation. This was a thoroughly negative experience for both of them.

Brian continued to use the testosterone gel even after he gave up on penile injections. He wondered if testosterone alone would enhance erectile response. Although he felt better with the testosterone, his irritability and sexual frustration increased. It was Claudia’s complaints about his irritability and anger that caused him to stop using testosterone gel. Internally, Brian blamed Claudia for the testosterone failure.

The therapist asked, “What do you make of the lack of success with Viagra, testosterone, and penile injections?” Brian was quite agitated and responded, “I’m a sexual failure and there’s nothing that can help me.” He asked the therapist, “Will Claudia still love me even though we don’t have sex?” The therapist said he needed to hear Claudia’s psychological/relational/sexual history, but wanted to know whether it was in Brian’s perceived best interest to focus on masturbatory sex and ignore intimacy, touching, and sexuality with Claudia. It was clear that Brain had not thought of his approach to Claudia and sexuality in that way. Brian was sensitive to feeling blamed; thus, the therapist was empathic and respectful while challenging Brian’s secrecy and narrow approach to sex. Brian needed to share information and perspectives with Claudia and explore healthy alternatives for him, her, and their relationship. Brian felt sexually at fault and stigmatized rather than positively motivated.

Even though the history is done in a chronological, comprehensive manner, asking open-ended wrap-up questions is strongly recommended. Typically, the therapist attempts to complete the history in one 55-min session. Some clinicians recommend a 90-min history session. Some clients require three sessions and others are finished in 30 min.

The first wrap-up question is either, “What else should I know about you psychologically, relationally, or sexually?” or “What do you not want me to know that I should know?” Often, the client discloses an important sensitive issue in response to one of these questions. Brian said he wanted the therapist to understand how much he loved Claudia and that he did not want a separation or divorce. A second question is, “As you think about your entire life, what was the most confusing, negative, guilt-inducing, or traumatic thing that has ever happened to you?” Contrary to clinical lore, the majority of clients with a history of child sex abuse, incest, or rape report the most negative thing as what is happening at the present. This was true of Brian, who had always thought of himself as pro-sexual; however, sex was now a source of stigma and depressive feelings of failure. A third question is, “Is there anything you have told me that you do not want shared with your spouse?” Brian had a number of sensitive/secret issues: (1) his belief that he had a small penis; (2) his frequency of masturbation and use of porn to masturbate; (3) his use of Viagra, testosterone, and penile injections; (4) his fear that Claudia would leave him: (5) his avoidance of couple sex because of ED . Approximately 80% of clients with sexual problems have sensitive/secret material. The therapist then asks, “What is the positive reason for keeping this secret?” Almost never is there a positive motivation. Secrecy is driven by guilt, embarrassment, or fear of the partner’s reaction. The therapist encourages the client to disclose sensitive/secret material in over 90% of cases and is given permission to do so in over 85% of cases. Unless there is an issue of potential suicide, homicide, or sexual abuse, the therapist does not disclose information without permission. In the great majority of cases, the sensitive/secret material is an integral component of the client’s psychological/relational/sexual narrative. Brian was reluctant to give permission, but the therapist made two cogent points. First, too much of Brian’s approach to sexuality was controlled by secrecy and shame. Second, these materials were integral to his genuine sexual narrative. Brian realized the therapist did not have an agenda to blame or shame him, and gave permission to share all five secrets.