Input: Could not generate response.

Response:
Myla felt that men cannot be fully trusted, and she felt that the reason that she was abused by her uncle was that she was "too stupid" not to know that all men want is sex.

She spent years telling herself that, although it was not her fault, she should have known better then to trust her uncle. After being asked to compare her feelings toward her husband with her feelings toward her uncle, Myla realized that her fear of being taken advantage of by a man was preventing her from forgiving her husband. Shortly after this realization, Myla voiced her feeling that she needed to go back to couple therapy before she could address her sexual problems and that her feeling distant from her husband was not something that sex could solve. Given the already established relationship between the therapist and Myla, the couple was referred to another therapist who could address both sexual and relationship problems concerning trust.

This case is not unusual; sexual symptoms often occur as a sign that something is not working in the relationship. Because it is often useless to force a patient to seek a treatment goal different from the one she or he perceives as being the cause of her or his distress, allowing patients to face incongruences between their treatment goals and their 356

behavior can be an effective way to help them redirect their attention toward the real underlying problem. Utilizing a systematic approach to the assessment of the case is very useful; it was clear since the beginning that Myla was not having a problem of sexual desire per se. All measures and interviews pointed to something else brewing under the low desire for sex with her husband. The client was not receptive to directly addressing the relational problem; thus this is an example of client and therapist disagreeing on the best line of action. It would have not been useful to force the client to proceed with the treatment goals identified by the therapist. Instead, we began therapy and utilized the treatment as an opportunity for the client to identify, on her own, the underlying problems that resulted in the low desire.

**Case 2: Louise and Frank**

Louise and Frank were 52 and 58 years old, respectively. Their couple therapist referred them for sex therapy after it appeared that the communication problems they were experiencing were specifically related to sexual matters. Louise was a realtor, and Frank was an engineer working for a small company. They had been together for 10 years and married for 3. Frank was Louises fourth husband, and Louise was Franks third wife.

Louise was highly engaged in art projects and workshops focused on being connected with nature, whereas Frank was more reclusive and liked spending time reading physics books. This difference between them was what attracted them to each other in the first place and what kept them together at the time of therapy. Frank said that Louise brought "color" to his life, and Louise felt Frank was her "rock" when things become too emotionally labile. Their presenting problem was discrepancy in sexual desire, with Louise feeling that she did not want to have sex because it took away from her personal energy and Frank wanting more sex and wanting for Louise to be satisfied during sex, because he felt she was no longer enjoying sex with him. Louise met criteria for hypoactive sexual desire disorder, and Frank did not meet diagnostic criteria for any sexual dysfunction.

During a semistandardized assessment interview, it emerged that Louise and Frank used to have frequent and passionate sex before they decided to get married. Louise mentioned that she had noticed a similar pattern in previous relationships: She felt very passionate when not in a committed relationship, but, as soon as she made a commitment, she became sexually withdrawn.

Louise was open about the sexual abuse she experienced as a child, inflicted by her biological father, and again as a young teenager, perpetrated by her stepfather. Louise was not new to psychotherapy and had seen a number of therapists to work through her traumatic experiences. She had met criteria for depression and posttraumatic stress disorder in the past (age 20–25 years) but denied any present symptoms and did not meet criteria for any other disorders. She was emotionally engaged but not overwhelmed while telling her story, a sign that she had done extensive work on this topic and was now able to be in touch with her emotions associated with the trauma while feeling sufficiently detached not to become overwhelmed. In situations in which a patient has 357

had the opportunity to work extensively on her or his trauma, it may be useful to inquire about the things that helped her or him overcome the difficulties. For Louise, art and spirituality played a large role in her ability to overcome adversities. She found a small artist community composed mostly of women who integrated art and spirituality in their work.

Frank appeared as the prototypical engineer: very practical, attentive to details, very controlled in his expression of emotions. He sat rigidly in the chair during the sessions, and it was not until the third or fourth session that he started opening up and talking about his emotions. He started trusting the therapeutic process after clear treatment goals were set and I had explained the evidence behind the theoretical models we used for the treatment. Frank denied any abuse but described a childhood deprived of emotional support. He did not have any memories of his parents giving him positive feedback. Dinner always occurred in a darkly lit room, and children were not allowed to talk. When he or his brothers were upset about something, they were instructed to go to their rooms and come back after they were no longer "bothered" by their emotions.

At the beginning of therapy, the couple was instructed not to engage in sexual activity, and a series of sensate focus exercises was prescribed to help Louise focus on pleasurable experiences during sensual touch. The couple struggled with the exercises, and, after three sessions spent brainstorming on how to overcome obstacles to practicing the exercises, I reconceptualized the situation as a lack of commitment and readiness for therapy. We moved back to orientation and commitment work, during which we focused on treatment goals. Although both Louise and Frank wanted to increase their sexual pleasure and satisfaction, Louise was having a negative reaction toward this goal. She vocalized the problem as a clash between the goal and her art. She believed that she had a finite amount of energy that could translate to either sexual or artistic pursuits. Engaging in sexual activities meant taking away from her art, which was something she was doing for herself.

Each partner was instructed to complete a writing exercise designed to help them reflect on what a "more satisfying sexual relationship" would be like and the pros and cons of developing such a relationship. It emerged that Louise was concerned about giving up her autonomy and was feeling powerless because she was afraid that her sexual satisfaction was going to be controlled by her partner. Franks main goal was Louises satisfaction, not his own, further fueling Louises fears. Louise felt she no longer had the right to feel "unsatisfied." In the following 2 months our work led to a sexual script that included choosing to not reach an orgasm and taking responsibility for ones own sexual pleasure. Louise felt more in control of the situation and felt freer to express and experience pleasure. Frank did not feel responsible for Louises pleasure, and therefore he stopped worrying about failing her. We resumed the sensate focus assignment, during which it appeared that the couple needed to improve their ability to communicate. Exercises in which they used nonverbal communication were added to the sensate focus. Also, given that communication problems also occurred outside the bedroom, the couple identified projects they could perform together on which they needed to collaborate. The couple started a yard project. With practice, the new sexual script became familiar, and their improved communication skills allowed them to reach 358

greater levels of sexual satisfaction. Also, the frequency of sexual activities was significantly improved (twice a month compared with once every 3–4 months).

This is a case in which knowing how to improve communication is not enough.

Being able to implement efficacious interventions requires full commitment from the clients. The orientation and commitment work that preceded the therapy had a profound effect on the willingness of the couple to fully engage in therapy. Also, the use of a behavioral analysis to identify the reasons for not completing the assignment can cut down on time spent trying to make the couple complete an assignment. A behavioral analysis should attempt to determine whether the assignment was not completed because of lack of motivation, lack of skills, or lack of understanding. In this case, I initially wrongly assumed that the problem was lack of skills and focused on solving the problems for them. An early utilization of a behavioral analysis would have revealed the real underlying problem earlier on.

**CONCLUSIONS**

It is important to include assessment of a history of sexual abuse in all clients presenting with a sexual dysfunction and to ask about sexual function in clients reporting a history of sexual abuse. However, it is equally important to avoid assumptions that a history of abuse will always lead to sexual dysfunctions. Treatment for sexual abuse survivors may be more effective if it includes behavioral techniques such as mindfulness and exposure designed to break avoidance and introduce patients to sexually satisfying experiences.

Finally, therapists should strive to integrate partners in both assessment and treatment, as sexual abuse may have affected the ability to form intimate connections, and the sexual problems may be a symptom of this larger problem.

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192\.

1 Rape was defined as being engaged in unwanted oral, vaginal, or anal sex with someone because he or she (1) took advantage of the person being drunk or high, (2) purposely gave the person drugs or alcohol, (3) blocked the persons retreat, (4) used physical restraint, (5) threatened to physically harm the person.

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**CHAPTER 18**

Infidelity

Stephen B. Levine

**I** nfidelity is not a sexual dysfunction. In fact, it is not a mental disorder. Although infidelity is often described as a betrayal of trust, it is more accurately described as a sexual betrayal whose underlying motivation may be obscure. But when infidelity brings an individual or couple into therapy, it is usually a crisis. Noting that research on infidelity is sorely lacking or plagued by methodological flaws and inconsistencies, Levine exhorts us to listen to the experts, that is, the three people involved. Unless sexual dysfunction was present before the affair, Levine asserts that understanding and working with the couple regarding the meaning of the affair will offer the best chance of restoring sexual intimacy for those couples seeking that outcome. Levines approach is devoid of technique and exercises and focuses on process. He cautions therapists to be aware of "the appearance of an uncharacteristic authoritative voice" and advises us that "our role is to be interested in the persons dilemmas, to clarify the options, to focus on what the person is thinking and feeling about the present, past and future; it is not to tell the person what to do."

**Stephen B. Levine, MD,** is Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine and Co-Director of the Center for Marital and Sexual Health in Beachwood, Ohio. His 40 years of therapeutic experience in individual and conjoint therapy is the basis for his two decades of writing about love and infidelity. In 2005 he was recipient of the Masters and Johnson Lifetime Achievement Award from the Society for Sex Therapy and Research. His most recent book is Barriers to Loving: A Clinicians Perspective.

Happily married people, particularly those with young children and a pleasing family life, find it difficult to imagine that they or their spouses could want to have an affair.

As the children grow older, however, particularly after a spouse has sensed the limitations of marriage and wondered what an affair might be like, a transient dread of being a victim of infidelity may appear. This psychological shift happens at different moments for each partner. A spouse can only hope that the partner remains happy enough or committed enough to resist temptation.

An affair is both an affect-laden event and a process for all concerned. The first unfaithful act immediately creates a set of emotions, a series of thoughts and subtle shifts in identity. These evolve as the sexual behaviors continue. The behaviors create new psychological and social complexities involving the unfaithful person, the partner, and the paramour. The marriage subtly changes. The partner may attribute the change to some other life process, may not notice it, or may not want to consider this unsettling explanation.

What the clinician learns about an affair will depend on which of the three protagonists tells the story. If the couple tells the story together, a fourth version 362

unfolds.

**AMANDA HAS AN AFFAIR**

Adams calm, pleasant, happily married life changed in an instant. He went from unemotional stability to panicky uncertainty as he faced the first major problem in his life. He became suffused with the pain of betrayal and the humiliation of failing as a husband.

The couple appeared to be a physically healthy, athletic, educated pair who had been together for 19 years, almost half of their lives. They said that they had nothing major to complain about. Adam had trusted Amanda implicitly despite the fact that he perceived that they never fully clicked sexually. Amanda never complained about their sexual life.

Each was devoted to the children. Their first son had been a challenge because of his attention, learning, and social problems. Their younger son had been easier to parent.

The couple had friends and cordial relationships with each of their families. Each partner took short breaks from the family to pursue separate interests with friends.

Money was not a concern.

Amanda had been on a stable dose of a selective serotonin reuptake inhibitor (SSRI) since several months after the birth of their first son 12 years before. When she stopped the medication 4 years later, she developed mysterious abdominal symptoms, which disappeared a week after resuming it. Two years ago she took up a new sport. Her skills progressed rapidly under the guidance of an instructor, who previously was teaching her son. Their growing 8-month friendship was transformed by the pros declared wish to kiss her. During these months, she began to think that her husband was preoccupied with his career and seemed distant from her. "Just this once" gradually led to sexual intercourse. Amanda was astounded by how exciting all this was. Sex with her paramour was much more compelling than her quieter, four to six times per month, regularly orgasmic sexual life with Adam, until then her only sexual partner. Guilt led her to end the relationship after 4 months, but she quickly resumed the arrangement for another 7

months.

Amanda and her paramour had no interest in leaving their families, never said they loved each other, and communicated by texting almost daily. They saw each other several times a week at the sports club and had intercourse weekly. Adam began to notice that Amanda frequently seemed to be in a different room when he was home. She often preferred reading in the bedroom. He began to feel alone. After he dreamed that she was having an affair, he checked her cell phone records and confronted her.

She immediately confessed, told him who it was, cried in grave, shameful embarrassment, promised to end the relationship, and said that she wanted to stay married. She apologized repeatedly. She thought that no one else knew about the relationship. The couple agreed to tell no one about this. The next day, Adam visited the instructor, who nervously corroborated Amandas story, apologized, said he would not contact her again, and asked Adam not to tell his wife. After 3 tumultuous days of 363

mutual despair, intense communication, numerous "when," "what," and "why"

questions, and taking turns being overwhelmed in tears, they decided to ask Amandas psychiatrist, whom she saw annually, for a referral for "a marital issue."

I saw them together for an hour three times in the first week and saw her once alone.

Adam was the most distressed person in the room. He said he was devastated, could not sleep, experienced anxiety all day long, felt pressure in his chest, and could not eat. I prescribed a hypnotic for him, which he never took. I asked them to tell me what was important for me to know about their marriage. ("It was fine until the affair," they agreed.) He emphasized how much he loved Amanda because she was sincere, honest, and without pretense. She loved him for his accepting, friendly-to-all nature and kindness. He originally felt much sexual ardor for her, but she was uncomfortable during their early sexual behaviors, so he held himself back. He told himself that keeping her comfortable was required because he loved her. Amanda found sex to be messy and dirty.

After 10 sessions over 4 weeks, including separate ones with each partner, Adam told me that he had recommitted to Amanda. He emphasized that he clearly was, by far, the better man. He felt that he understood as much as could be understood about what happened. He was convinced that she really did love him. He perceived that she was getting over the other man. After refusing to have sex with Amanda for 10 days and then tentatively resuming sex while they were out of town, they eventually had the best sex of their lives after Adam returned from a 5-day business trip.

In this first month I was consistently interested in each of their viewpoints, concerns, and wishes for the future. Adam remained uncommitted about how things would work out until Amanda patiently answered all his questions and maintained a consistent concern about his recurring emotional breakdowns. Initially, he could not understand how she could love him and sleep with another man and why she did not agree that it was a poor idea to continue to take their son for lessons from "this guy." At the end of the month, knowing that "Amanda truly loves me," he concluded that "she had made a very big mistake in judgment to get involved." Still, Amandas reasoning that she should not interrupt their sons progress because of her problem did not sit well with Adam.

Only when the crisis seemed past did Adam speak of his use of methylphenidate for his attention-deficit disorder and previous learning disorders. Amanda also spoke at greater length about her parents divorce when she was a toddler, her mothers cancer death when Amanda was 8, her fathers second wife, and her obsessive–compulsive disorder during high school. She attributed her chronic anxiety to her stepmothers favoritism toward her new biological daughter. Amandas florid symptoms largely disappeared when she went away to college, where she did not have a serious boyfriend until she met Adam. Amanda had been in therapy off and on since her adolescence.

A very calm week ensued, but when I saw Adam alone, he expressed his concern that Amanda seemed too ready to sweep the affair under the rug. She did not want him to mention it. She floated the idea of going to a group class taught by the pro. Adam, still disturbed that she did not think it reasonable to move the family to another sports facility, did not want to speak of this to her yet another time. I gave him an analogy to coping with cancer chemotherapy: Both partners are suffering anxieties but choose to 364

lighten each others burden by not fully discussing their subjective experience. Adam then wondered whether the affair was just the most dramatic manifestation of something else that had been going on for the last few years—that Amanda felt she had the right to do what she wanted. She was far more self-centered than she had been in the past. I wondered whether this was a natural response to their baby growing up—that is, whether she was making up for the period of sacrificing her wishes for the childrens needs. Adam asked whether he should talk to her about his impression of her growing sense of entitlement. I inquired whether he thought that Amandas style of coping with the loss of her mother—pushing it under the rug—was being repeated with her paramour. I told Adam about Freuds concept that an adults sense of entitlement may derive from early life adversity (Freud, 1916). I said that I did not know whether it was a good idea to bring up the subject.

Another calm "normal" week occurred, complete with the couples weekend lovemaking. There was no discussion of the affair, lessons, or entitlement. Each was busy with his or her usual tasks. He said the cancer analogy helped him protect her from his deepest worries. Adam was pleased that Amanda was putting 100% of herself into him and the children again. He worried that the affair was a response to a problem that she felt in the relationship that might cause trouble again in the future. He feared that

"the shadow of another person would always be intoxicating to her." Amanda worried about the meaning of her always having to initiate their sexual opportunities. Adam replied, "Yes, but once you do, everything flows normally and we are both pleased." "But why wont you initiate it?" she asked.

That evening Adam was very sad, had difficulty sleeping, and felt that Amanda wanted sexual things from him that he could not provide. "I only want you to indicate that you really want me sexually!" she told him. They had a long talk. He awakened in the morning feeling better, but she was sad, worried, and confused. "I thought we had made progress, but last night he was like he was a while ago," she told me. After one of Amandas athletic events, she cried in gratitude for his support during this event and the more trying previous 6 weeks. Adam was pleased. Before the athletic event, they had the best sex of their lives.

**MONOGAMY**

An affair is but one of many forms of infidelity. Whether or not they involve physical interaction with a person, online communication, or an intense emotional attachment in anticipation of physical intimacy, all infidelities imply a violation of a prior agreement to be monogamous (Brand, Markey, Mills, & Hodges, 2007). Infidelity is a hidden but much discussed transgression of this internalized value system. The faithful partner often refers to the lingering consequence of infidelity as a "loss of trust." Monogamy is the dominant sexual arrangement in the current Western world. Its violation is the most often cited reason for divorce (Betzig, 1989). Monogamy is not, however, a universal organizing feature of marital relationships (Solstad & Mucic, 1999). Many societies 365

support polygamy. Some individuals organize themselves into social groups that practice consensual nonmonogamy (Anapol, 2010). Because relationships evolve in their sexual, social, economic, and psychological circumstances, every form of sexual arrangement brings its own potential problems.

**Nonnegotiated Nonmonogamy**

The commitment to monogamy is not always made verbally. Some individuals decide to be monogamous and erroneously assume that their partners have made the same decision. Other individuals insincerely agree. Yet others, like Amanda, do not maintain the commitment over time. Clinicians should not assume that every person has an internalized prohibition against infidelity (Solstad & Mucic, 1999). If a person does, however, the clinician can infer that the unfaithful person gave in to a temptation.

Temptations abound in social and work environments. Legal and illegal businesses sell sexual opportunities. Convention cities cultivate the expectation of sexual opportunities.

Power differentials of teacher–student, doctor–nurse, lawyer–client, and supervisor–

subordinate often carry erotic temptations. A long monogamous partnership represents the mastery of numerous mental and behavioral temptations.

Infidelity can occur at any adult age. Homosexual and transgendered persons experience it. Reactions to its discovery range from the poles of devastation, which may create a clinical intervention, to indifference, which usually does not. How the partner regards the unfaithful person before the discovery of the infidelity may be the most important determinant of the reaction. Responses can be overshadowed by one of its complications: pregnancy, an arrest, a sexually transmitted disease, violence, a suicide attempt, or media coverage or by the need to simultaneously deal with a weightier matter—such as a new life-threatening diagnosis, a personal criminal indictment, a suicide attempt, or a bankruptcy.

**RESEARCH FINDINGS**

**Prevalence**

Researchers use personal interviews, telephone or Internet surveys, or questionnaires to study infidelity. Some studies focus on undergraduate students, others on cohabitating individuals, and still others on married couples. Some ask about extradyadic sexual intercourse only, whereas others ask about infidelity in a manner that allows the participant to decide what infidelity is. The questions focus on infidelity in the preceding year, lifetime infidelity within the current relationship, or lifetime infidelity in any relationship. Studies emanate from different countries. As a result of these variations, prevalence estimates range between 1.2% and 85.5% (Luo, Cartun, & Snider, 2010).

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Prior to the 1990s American men admitted to infidelity more frequently than women in a 3:2 ratio. This statistic should not be generalized to other countries, because many cultures are organized around male privilege, and many men (and some women) surreptitiously take this right as their own. In surveys from the 1980s and 1990s, less than half of American men said that they had been unfaithful, but the prevalence varied between 24 and 44% (Weiderman, 1997; Thompson, 1984). In the largest representative sample of Americans from 18 to 59 years old, 20–25% of men and 10–15% of women acknowledged infidelity (Laumann, Gagnon, Michaels, & Michaels, 2001). These figures are usually quoted to the public (Snyder, Baucom, & Gordon, 2007). These data were generated before the Internet gained ascendancy. It is impossible to ascertain the role of lying in research studies (Mark, Janssen, & Millhausen, 2011; Luo et al., 2010). Scientists tend to study the infidelities of heterosexuals. Sexual minority communities may have far different prevalence rates and attitudes toward nonmonogamy.

**Motivation**

In research, motivation for unfaithful acts rests heavily on the correlates of infidelity.

Male gender, low relationship and sexual satisfaction, and opportunity (urban location, and employment) are frequently cited (Havlicek, Husarova, & Rezacova, 2011). Among dating couples, low conscientiousness and neuroticism also predict infidelity (Barta & Kiene, 2005). Among cohabitating couples, infidelity on the part of mens fathers increased the likelihood of the sons unfaithfulness. This was not true for daughters (Havlicek et al., 2011). Some modern studies report a similar prevalence for men and women (Traen, Holmen, & Sigum, 2008; Havlicek et al., 2011), whereas others still find a male predominance (Luo et al., 2010).

The clinical study of motivation is limited by selection bias and the assumptions that a clinician may have about causes (Allen et al., 2008). Brown posits five types of affairs, each with its separate motivations (Brown, 2007). Clinicians rarely have much experience with the infidelities of the poor and of the vast majority of ethnic groups.

Clinical and research findings seem to agree that most womens affairs are associated with their perception of low relationship quality (Havlicek et al., 2011; Mark et al., 2011). I am impressed that there is a particularly high incidence of undiscovered extramarital sexual experience in the 3 years preceding divorce.

To learn about the motives for infidelity, clinicians can usefully focus on the thinking process that occurred prior to a persons stepping outside of monogamy. Although it is important to inquire about motives, clinicians should not expect that the reasons will or can be initially fully revealed. The patient is much more likely than the therapist to know what the motivations were. When a therapist authoritatively explains the motives for the infidelity to the patient, the wrong person is doing the teaching.

**Two Treatment Models**

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Models of treatment are marvels of clinical synthesis. They reduce the complexity of individual characteristics, personal history, interpersonal life, communication patterns, sexual experience, and working-through processes into therapeutic steps. Authors emphasize their models as research-supported, but only a small fraction of the work has been empirically tested. Nonetheless, two models are thought to be helpful to those who are beginning their work with infidelity.

The intersystems approach asserts that infidelity is a relationship issue: Partners suffer together and must heal together (Gambescia, Jenkins, & Weeks, 2003). Conjoint therapy simultaneously focuses on multiple interrelated problems of the individuals and their relationship. This approach aims to optimize the relationship as the couple passes through five phases: (1) crisis of discovery; (2) discovery of the individual and relationship susceptibilities; (3) facilitation of forgiveness; (4) treating the previously identified risk factors; and (5) improving intimacy through communication.

The integrated approach describes three phases of recovery: (1) dealing with the initial impact; (2) developing a shared understanding of the contributing factors; and (3) reaching an informed decision as to how to move on—separately or together (Baucom, Snyder, & Gordon, 2009). This model assumes that infidelity has had a traumatic impact and that recovery is brought about through the promotion of skills and understanding by using both cognitive-behavioral and insight-oriented techniques. Forgiveness may occur even though a decision may be made to end the relationship.

All modern models, however, emphasize individual pathways through the processes of therapy and the importance of empathy. They warn against having a uniform approach (Peluso, 2007). Hertlein and Weeks (2011) have provided an extensive review of the evolution of these models.

**Treatment Outcome**

There are three often-quoted outcome studies of therapy with couples with infidelity.

They have a number of limitations. Sample sizes varied (n = 6, 19, and 145); they were done in three countries; they are missing follow-up data; they are hampered by the inability to ascertain secrets kept from therapists; they lack descriptions of the type and extent of infidelity; and they have limited age ranges and few parameters of measurement. Nevertheless, three findings converge: (1) Unfaithful couples do as well over a 1-year period as couples who present with other marital problems; (2) the affected spouse is more depressed and anxious than the one who has been unfaithful; and (3) infidelity does not invariably end marriages (Gordon, Baucom, & Snyder, 2004) (Atkins, Baucom, Eldrich, & Christensen, 2005) (Atkins, Klann, Marin, Lo, & Hahlweg, 2010). The therapists in these studies had different therapy ideologies. The studies were not designed to compare approaches. Recent reviews of research have concluded that

"There is a large gap between research findings and treatment models" (Hertlein & Weeks, 2011, p. 3) and "There has been an incredible disconnect between clinical reality and research focus" (Kessel, Moon, & Adkins, 2007).

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**CLINICAL CONSIDERATIONS**

**The Type of Infidelity Matters**

The contexts of infidelity vary, and therefore interventions must also (Baucom et al., 2009). The most egregious circumstances of infidelity are excluded from research and model building. A factor analysis of 29 types of infidelity in face-to-face or online emotional attachments and online sexual activities did not conceptualize a partners use of a child or stepchild for sexual gratification (Luo et al., 2010). Such events create the most horrified reactions to relationship infidelity and are typically treated as both crimes and profound moral failings. Other criminal infidelities involve exhibitionistic, voyeuristic, and pedophilic paraphilic patterns, prostitute dependence, and masturbation to child pornography. Such activities make the infidelity per se seem a minor aspect of a more basic problem. They often lead to divorce. In many clinical settings, clinicians hear about infidelities but focus their interventions on the alcoholism, sexual addiction, bipolar disorder, character pathology, or psychosis.

**Expectations for the Clinician**

Clinicians have to be comfortable discussing this topic. Comfort can be attained without any training in sex therapy and requires no particular allegiance to a mental health ideology. Therapists have to act, however, as though they know that infidelity is part of many individuals lives at some time. Some individuals in the midst of infidelity are hesitant to discuss their situation, even when they present for assistance. The comfortable clinician can transform dialogue about mysterious anxiety, depression, or somatic complaints by asking about infidelity. The therapist has to maintain clear boundaries, to provide skillful listening to the feelings and concerns of the individual or the couple, to understand the predicaments that relationships bring (Baucom et al., 2009) and to remain a humble lifelong student of the topic (Levine, 2006b).

It can be difficult to attain these six capacities if strong feelings are stirred up by the patients situation. Private intensely negative or positive reactions increase the risk of therapeutic blunders (Weeks, 2003). Consider the therapists negative affect if his or her marriage has been harmed and restructured by infidelity or if a past personal affair is regretted; consider the positive feelings if the therapist has long participated in a satisfying affair or if infidelity catalyzed a decision to leave an unsatisfying union.

A common boundary crossing is the appearance of an uncharacteristic authoritative voice: Dont have an affair! End the affair now! Your partner is scum! You must divorce!

You should have an affair of your own! Our role is to be interested in the persons dilemmas, to clarify the options, to focus on what the person is thinking and feeling about the present, past, and future; it is not to tell the person what to do. We all must watch our countertransference reactions.

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**Culture and Language**

Although textbooks treat infidelity as a dramatic independent topic, it does not actually stand alone. It is an aspect of the personal lifelong developmental struggle with love, entitlement, and responsibility to others (Levine, 2006a). Infidelity is a ripe topic of gossip between friends and in media outlets. The latter readily become preoccupied with the "inappropriate" sexual activities of the rich, powerful, or famous. Wider ranging, often more profound, perspectives are found in fiction, movies, polemics, biographies, and humor (Kipnis, 2003; Shanahan, 2007).

In the United States the dominant public position concerning marital infidelity is that it is wrong, destructive, and a personal moral failing (Smith, 1994). There is no term for the person who is unfaithful that does not connote a negative social judgment—


Input: Could not generate response.

Response:
cheater, womanizer, adulterer, slut, tart, and so forth. It is easier to employ the term

"infidelity" than "nonnegotiated nonmonogamy," even though "infidelity" has a negative connotation. Because mental health professionals begin their training within a disorders paradigm, problematic behaviors tend to be viewed through a lens of psychopathology that assumes that the behavior is a symptom of individual or relationship psychopathology. Eventually, we come to see that it is a decision that is frequently made in a relationship after balancing the benefits and the dangers.

**Assessment**

Although there are potentially many things to assess when the initial complaint is infidelity, this process is best accomplished by simply letting the individual or couple tell the story. The patient and the clinician notice what the story consists of, how it is told, affects that accompany the narrative, and what questions the therapist asks. Though clinicians may think of the first session as an assessment, we should realize that the patient is also assessing the clinician. Sometimes we flunk our audition; the patient never returns. There is no one correct way to conduct the early process. The goal is have the patient return to continue the discussion based on his or her realistic belief that therapy can be of assistance. Some clinicians see the couple first and then see the partners separately, and others continually see the couple together, but many people come alone to discuss their or their partners infidelity. Seeing the individuals separately poses the dilemma of what to do about a history that a partner does not want to be disclosed. This is one of the major reasons that some therapists only see the couple together in the early phases of working together. Every approach has its advantages and disadvantages. Although some therapists use psychometric testing during evaluation and have a formal process of evaluation before making recommendations, clinicians need to recognize that clients may perceive this as delaying assistance with their painful dilemmas. Baucom and colleagues (2009) use two chapters to discuss assessment, but I am inclined to let the story flow and to allow myself to respond to the concerns that surface.

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**RETURNING TO AMANDA AND ADAM**

**The Crisis of the Betrayed**

The mind of a person who has recently discovered a partners infidelity swirls with questions and disturbing feelings; patients often feel like they are "going crazy." This

"craziness" is merely the struggle to answer four questions:

1\. "What is the personal meaning of the infidelity to me?"

2\. "What is the best way I can respond to it?"

3\. "Will I be abandoned?"

4\. "Why did this happen?"

I listened to Adam struggle with these questions over 6 weeks. At times I rephrased his concerns in terms of a specific question. Various affects accompanied his numerous questions, of course, and I made sure that he labeled them accurately. I did this with him in a relaxed fashion, gently repeating that the answers to the questions and his feelings would evolve.

When he asked, staccato fashion, in Amandas presence, "Does anyone ever get over this? Will I be able to trust her again? Will I be able to ever forget this?" I explained that the Chinese write the character for "crisis" by combining the words "danger" and

"opportunity." I had seen that they were in grave danger. I was there to help them work through the danger in order to create a better life of their choosing. I asserted that many people get over a spouses affair, but that I did not want to mislead them into thinking that there was no possibility of future unhappiness. "Why would anyone aspire to forget that an affair occurred?" I asked rhetorically. I told them that I often dramatically pointed to my patients and accused them of being "meaning makers." "Amandas affair has different meanings to each of you. We all should act as though we know that over time meanings change, behaviors are viewed from a different perspective, and that which is painful can sometimes eventually become discussed more lightly." I neither wanted to trivialize what had happened nor to regard this as the worst possible thing that can happen in life. I certainly did not think that any self-respecting betrayed person should act in some prescribed way.

**The Crisis of the Discovered**

Frequently changing questions and affects dominate the mind of the unfaithful person, too. He or she may also feel unstable and uncertain about what to say. Having already caused intense distress in the partner, the unfaithful person tries to minimize further damage by being discreet about what is revealed. But a dilemma quickly appears. To share more details is to immediately increase pain in the partner and to risk the spouses decision to divorce; to refuse to answer questions is to increase the partners 371

preoccupation with what has transpired. To get annoyed at the questions may inhibit the partner, but it also reflects a lack of empathy for the pain of the betrayed, which can prevent any progress. It is our responsibility to help the person think through the matter (Levine, 2006b). I do this by focusing on the five questions that swirl in the mind of the discovered partner.

1\. "What do I want the outcome of this crisis to be?"

2\. "Can I give up my relationship with the other person?"

3\. "Why did I engage in this affair?"

4\. "Is it wise to explain my motives?"

5\. "What do I privately feel about this experience? Am I regretful? Happy? Justified?

Disgraced?"

Amanda never wavered about wanting to stay married. The possibility that Adam ultimately would choose to divorce her made her sad and frightened. She did not want them to temporarily separate. Although she said she could give up the relationship immediately, she longed to communicate with her ex-lover. I explained to them at the end of the first session that both should realize that, having been involved for over a year, Amanda was quite attached to this man. Grief was to be expected. I didnt expect Adam to be solicitous about her grief. But I thought it was a dangerous mistake to act as though it were not happening. Adam quickly reversed his initial firm position by telling Amanda and her paramour that they could talk in order to help Amanda to end their relationship. The former lovers then spoke briefly on the telephone, texted each other for 2 days, and stopped. When specifically asked, Amanda revealed that she missed her paramour. After 1 month, she reported that she was thinking about him far less and did not miss him during Adams 5-day absence. She missed Adam! This development preceded their passionate weekend of lovemaking during which Adam emotionally reattached to his wife.

Amanda tried to explain why she engaged in the affair. She acknowledged that she had grown comfortable with sex over the course of her marriage and no longer found it to be germ-ridden. She nodded in agreement when I asked her whether their pattern of marital sexual behavior left her somewhat bored despite her dependable orgasms. She was curious what it might be like to be sexually involved with another person. The excitement of this relationship was far greater than she ever imagined—"I loved being pursued!" She told herself that she would be disciplined and discreet, that one day the relationship would end of its own accord and her husband would never know. She was shocked to discover how easy it was for her to conduct the affair. She had thought that she was not the kind of person who would do such a thing. She was mortified that her husband found out and profoundly guilty about the pain she caused him. When she spoke of her shame, she looked ashamed. She worried about whether he could ever be calm again. She had always known him to be centered, quietly confident, and warm toward her. He was anything but these things now. His symptoms lessened session by session. He began to be able to concentrate at work, to stay there longer, and to return to his sport. Amanda was more concerned about him than about answering the painful 372

question of "why."

Amanda told Adam that she was telling the whole truth, but it was apparent to me that she minimized the frequency of sexual contact with her paramour and that she withheld from Adam much of the process of missing her lover.

**SEARCHING FOR NEW LIFE POSSIBILITIES**

Physical and mental illness, treatment of disease, developmental misfortune, or poor intimacy often render a marriage asexual far before old age. What is a spouse to do when a partner becomes sexually incapacitated by any of these forces? Whether it is a wife who deteriorates from amyotrophic lateral sclerosis or a husband with a low sex drive who sticks to his word, without warmth or affection, for a decade that he does not want to have sex again, the more details a clinician is entrusted with, the greater ones interest becomes in what motivates fidelity and infidelity.

When a strongly homoerotic person takes a heterosexual mate, longings to be sexually involved with a same-gender person may recur over time. When a homosexual experience occurs, the person often feels that he or she does not want to or cannot possibly give up such an opportunity. The long-suppressed homosexual experiences feel so natural, exciting, and satisfying, unlike the infrequent and far less passionate marital sex. Although the world is used to hearing about marriages that end because a spouse is gay or lesbian, many such marriages continue (Friedman & Downey, 2010). A therapists role may be to help the couple or simply one of the individuals to negotiate how they are going to deal with this in the future. Will it be surreptitious or open by agreement? Will one or both choose to be abstinent. Will they seek help for sexual addiction or something else? The needs and wishes of the heterosexual partner are of equal importance to those of the homosexual partner. The therapist needs to offer continuing discussions of possibilities until the couple gets beyond their crisis stage.

Then they may be in a better position to decide what to do.

A 60-year-old man, who had had intensifying homosexual desire since his last child moved out, was tempted to engage in homosexual behavior with a new, uneducated acquaintance who he thought might be gay. This would be something he had not done since two drunken episodes in college. Married to an anorgasmic wife who never seemed to like sex, he sought my assistance for depression and anxiety. What he wanted to talk about was his discovery of the Internet gay community and the opportunities this represented for him away and in town. His explorations eventually led to homosexual behavior within several evolving but brief personal relationships.

These delighted him. He and his wife periodically had conversations about his homosexual desire, and she realized he was no longer depressed. He told her that he had had some very enjoyable homosexual encounters. She became distressed during each of these conversations and issued ultimatums. Her distress was assuaged by his reassurance that he was not interested in leaving the marriage or humiliating her at 373

church. He refused to give up his friendships. Several times she agreed to see therapists—including me—but four times she found reasons not to. Their newfound capacity to be married and unilaterally unfaithful lost its equilibrium when he fell in love with a divorced man of his age and educational level. When he acknowledged his wish to live with his paramour, she decided to divorce.

**INFIDELITY AS THE CAUSE OF SEXUAL DYSFUNCTION**

An affair can produce an array of new sexual dysfunctions in either partner. When the chief complaint is a dysfunction that began in the aftermath of infidelity, I try to reprocess the infidelity rather than to focus exclusively on the dysfunction. This works best when the couple was sexually adequate prior to the infidelity. The new empathic psychological intimacy created by the discussion of each partners inner experiences can yield more intense sexual pleasures than the couple ever had. Psychological intimacy is, after all, an aphrodisiac!

In those couples with dysfunctional pre-affair sexual adaptations, the clinician has to deal with the affects related to the affair and recognize their mutual disappointment over their previous sexual life. Before the focus shifts to trying to alleviate the dysfunction, attention should be paid to creating a secure sense of attachment. The dysfunctional person will have a more difficult time improving if divorce is likely to be the consequence of continuing dysfunction. When the empathic reattachment that occurs in a therapy does not improve the dysfunction, specific techniques discussed in other chapters of this book can be judiciously employed, as long as the commitment to each other seems genuine. One should not expect all couples to have a lasting improved sexual life after therapy.

The simplest way of providing help for a man who has been dysfunctional prior to a wifes affair is to provide him with an effective medication for the problem—for example, premature ejaculation. Occasionally the use of a PDE5i will assist a couple whose pre-affair erectile dysfunction was problematic. Long-standing male sexual desire deficiencies are far more difficult. As previously dysfunctional women use the new psychological intimacy brought about during therapy, they may be able to overcome their previous dysfunction or at least have more pleasure in and desire for sex. Some individuals may elect to have individual sessions to focus on their sexual anxieties.

During an initial evaluation for a new sexual dysfunction, clinicians should ask about remote infidelity. The professional should understand that the couple may choose not to reveal it for a host of reasons. The unfaithful partner may not be aware that the spouse knows. The spouse feels it is not in his or her best interest to reveal their knowledge of the past. The couple may have previously dealt with it and does not want to rehash its pain. The couple believes or knows there is another cause of the presenting symptom. If the couple fails to make progress, the topic can be readdressed in individual sessions with each partner to learn about the patients perspective.

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**CONCLUSIONS**

Infidelity is not a psychiatric diagnosis. DSM-5 (American Psychiatric Association, 2013) does not have a category for it. Its assessment and treatment are processes. This chapter does not emphasize techniques, because research and clinical experience converge to suggest that the understanding of the evolving experience of the partners is more vital than an organizing ideology, a particular sequence of assessment, or what a particular therapist may call an approach. The kind, interested, calm, knowledgeable therapist can make a significant difference to the couple by generating a respectful attitude of three people learning together. The therapist may know more about the facts of infidelity, but the betrayed and the betrayer know far more about their background, motivations, and meanings than the therapist does. Therapy is a cooperative venture that is modified imperceptibly session by session.

Although there are degrees of infidelity, even lesser violations may be overwhelming, because people have their own standards for what their partners are permitted to do and their unique coping capacities. New clinicians can quickly grow comfortable with these problems, knowing that dealing with infidelity requires dealing with patients meanings.

Because there is no absolute meaning of infidelity, we witness patients interpretations over time. Many patients can profit from our knowledge, experience, demeanor, and mastery of our countertransference as we attempt to help the parties to absorb, understand, and tolerate their new relationship situation. In helping patients deal with their painful new realizations, we inadvertently help ourselves to mature as clinicians.

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Barta, W. D., & Kiene, S. M. (2005). Motivations for infidelity in heterosexual dating couples: The roles of gender, personality differences, and socio-sexual orientation. Journal of Social and Personal Relationships, 22, 339–360.

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**Medical Problems**

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**CHAPTER 19**

Sexuality and Infertility

Judith C. Daniluk, Emily Koert, and Erin Breckon

**I** nfertility can change the meaning of sex. For many infertile couples, sex is no longer a joyous or intimate connection; instead, it is associated with disappointment or failure. Depending upon ones culture, religion, or upbringing, infertility can challenge ones virility or femininity, not to mention ones marriage. Sex therapists are not usually part of the team of experts that is involved in infertility treatment. Perhaps they should be. Daniluk, Koert, and Breckon argue that sex therapy has an important role to play but that the nature of the intervention will likely depend on the stage of infertility treatment. Early in treatment, sex therapy is directed to helping couples overcome a dysfunction (e.g., erectile dysfunction) that may interfere with achieving a pregnancy or to help increase compliance with timed intercourse. After treatment, couples may want and require interventions focused on restoring pleasure. Above all, Daniluk and colleagues admonish us that "recognition of the common experience of shame, guilt, and inadequacy regarding infertility and sexuality is paramount in providing sensitive support and intervention."

**Judith C. Daniluk, PhD,** is Professor of Counselling Psychology at the University of British Columbia. Her areas of clinical and research expertise include womens sexuality and reproductive health and the psychosocial consequences of infertility and involuntary childlessness.

**Emily Koert, MA,** is a PhD candidate in Counselling Psychology at the University of British Columbia. Her area of clinical practice and research is womens reproductive health. She is conducting research on the psychosocial consequences of permanent, unintentional childlessness for women who delayed childbearing.

**Erin Breckon, BA,** is a masters student in Counselling Psychology at the University of British Columbia. She is interested in exploring the effectiveness of psychotherapeutic interventions for improving quality of life and sexual health for couples receiving medical interventions for infertility.

Infertility is defined as the inability to achieve and sustain a viable pregnancy after 12

months of regular, unprotected intercourse for women under 35 years of age and after 6

months for women 35 and over. It is estimated that approximately 15–20% of both men and women of reproductive age experience fertility problems. These problems in women are generally caused by endocrine imbalances or anatomical impairments such as blocked fallopian tubes, ovulatory difficulties, advanced reproductive age, or endometriosis. Male fertility problems are primarily caused by a deficiency in the number, quality, or motility of sperm. For both men and women, fertility problems are exacerbated with age (Keye, 2006). The assisted reproductive technologies available to treat these conditions include fertility drugs, in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), egg freezing, donated sperm, eggs, or embryos, and gestational or traditional surrogacy. Due to the rapid advances and changes in reproductive technologies, it may be best to suggest that clients regularly visit www.asrm.org/patient_resources for current and accurate information on the latest 378

fertility treatments and family planning options.

The psychosocial impact of infertility and medical treatment is well documented in the literature. Episodes of grief, depression, low self-esteem and diminished self-worth, relationship difficulties, and both episodic and long-term sexual dysfunction and dissatisfaction have been reported for infertile women and men (Daniluk & Tench, 2007; Möller, 2001; Wischmann, 2010). The focus of this chapter is the impact of infertility and related treatment on mens and womens sexual satisfaction and functioning.

**EPIDEMIOLOGY**

A significant body of literature provides evidence for temporary or permanent sexual impairment during and following infertility and related medical treatments (e.g., Marci et al., 2012; Möller, 2001; Nelson, Shindel, Naughton, Ohebshalom, & Mulhall, 2008; Pepe & Byrne, 2005). Sexual concerns are commonly cited by men and women, particularly during the often-invasive and protracted medical fertility investigations and treatments—with estimates ranging from 10 to 60% of couples reporting these concerns (Möller, 2001; Wischmann, 2010).

While in rare cases sexual dysfunction can be the cause of fertility impairments (e.g., vaginismus, dyspareunia, erectile and ejaculatory dysfunction), the preponderance of sexual complaints occur subsequent to a diagnosis of infertility (Hammer Burns, 2006; Leiblum, 1997). For men, common sexual complaints include erectile dysfunction, ejaculatory problems, loss of libido, and decreased frequency of intercourse (Lenzi, Lombardo, Saladone, Gandini, & Jannini, 2003; Shindel, Nelson, Naughton, Ohebshalom, & Mulhall, 2008). In a sample of 244 men with couple infertility, erectile dysfunction and premature ejaculation were reported by one in six men (Lotti et al., 2012). For women, problems with arousal, diminished desire, inability to achieve orgasm, and painful intercourse are the most common sexual complaints (Leiblum, 1997; Keskin et al., 2011; Millheiser et al., 2010).

Some sexual concerns may be the consequence of fertility impairments, as in the case of dyspareunia caused by endometriosis (uterine adhesions and scarring). In others, medical conditions (e.g., diabetes, high blood pressure, thyroid disorders, low testosterone, uterine fibroids, prostatitis, pelvic inflammatory disease [PID]), fertility medications (e.g., clomid, gonadotropins), cancer treatments (radiation, chemotherapy), lifestyle factors (e.g., excessive alcohol and drug use, excessive exercise, poor nutrition or eating disorders, obesity), psychological conditions (e.g., depression, anxiety), relationship distress, or environmental toxins are implicated in the sexual complaints and impairments reported by infertile individuals (Hammer Burns, 2006). In some situations, these sexual concerns can impede successful treatment—such as when erectile or ejaculatory dysfunctions impede a mans ability to produce a fresh semen sample for an IVF cycle or when vaginismus obstructs intrauterine insemination, egg retrieval, or embryo transfer.

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Sexual problems are generally more pronounced for couples whose sexual dissatisfaction and difficulties predate the onset of a diagnosis of infertility, with the reported incidence of sexual complaints increasing among the infertile population with prolonged treatment (Daniluk & Frances-Fischer, 2009; Hammer Burns, 2006; Leiblum, 1997). In terms of comorbidity, sexual complaints are commonly reported secondary to depression and anxiety (Keskin et al., 2011; Lotti et al., 2012; Nelson et al., 2008), although it is not clear whether the incidence of sexual dysfunction is higher for infertile individuals versus their fertile counterparts who have been diagnosed with depression or anxiety. Partner dynamics also play a role, with infertile individuals sexual satisfaction and functioning being highly correlated with those of their partner (Nelson et al., 2008; Shindel et al., 2008).

In terms of gender differences, when comparing mens and womens sexual difficulties during treatment, Lenzi et al. (2003) and Marci et al. (2012) found that men had higher frequencies of sexual difficulties and negative impact on their sexuality than women. However, other research findings (e.g., Nelson et al., 2008; Wischmann, 2010) suggest that women are equally, if not more, affected by sexual problems during infertility and related treatment, especially given that women and their bodies bear the primary burden during fertility investigations and treatments.

Bassons model of sexual desire (Basson, Brotto, Laan, Redmond, & Utian, 2005) helps to explain the way in which mental and physical factors are implicated in and affect sexual desire for women, with intimate contact often preceding the experience of sexual arousal or desire, particularly for women in longer term relationships. Basson and her colleagues (2005) have adapted the model to account for the experiences of infertile women to assist in understanding the sexual sequelae of the diagnosis and treatment of infertility for many women. The stresses associated with fertility treatments reduce a womans motivation and receptivity to sexual intimacy. Depression and poor self-image decrease a womans subjective arousal and subsequent desire response, resulting in diminished desire and sexual satisfaction. There are fewer nonsexual rewards, such as emotional intimacy and closeness; thus the infertile woman is less motivated to repeat the experience. The shift in the purpose of sex from pleasure to procreation and the monthly pairing of sex with reproductive failure further diminishes the infertile womans desire for sexual intimacy and adds considerably to the incidence of sexual difficulties and dissatisfaction reported by infertile women and their partners (Daniluk & Frances-Fischer, 2009; Leiblum, 1997).

Similar models have not been adapted to explain the impact of a diagnosis of infertility on men. However, the prevalence of sexual complaints and episodes of sexual dysfunction reported by infertile men, particularly during the demands of medical treatment (Lenzi et al., 2003; Lotti et al., 2012), would suggest that the burden of being unable to produce a child and the stresses of medical testing and treatment may take a similar toll on the sexual self-esteem, desire, and functioning of men—particularly those diagnosed with male factor infertility (Marci et al., 2012).

What is clear is that sexual difficulties and dissatisfaction appear to persist for many infertile women and men, long after medical treatments have ended (e.g., Lenzi et al., 2003; Sundby, Schmidt, Heldaas, Bugge, & Tanbo, 2007; Wirtberg, Moller, Hogstrom, 380

Tronstad, & Lalos, 2007). For example, in a longitudinal, mixed-methods study of 38

infertile couples following failed fertility treatments, despite increases in positive self-evaluations and perceptions over time, a persistent decrease in sexual satisfaction was evidenced throughout the 33 months following treatment termination (Daniluk & Tench, 2007). Sexual satisfaction was also reported to decline for 101 men and 113

women 5 years following fertility treatments (Schanz et al., 2011). In a 20-year follow-up study of 14 women following unsuccessful fertility treatments, participants reported a persistent negative impact on their sexual desire and satisfaction (Wirtberg et al., 2007).

Nine of these women said that their sexual desire was lost forever subsequent to the diagnosis and treatment of infertility and lamented that mental health support was not made available during or following fertility treatment to address their sexual and relationship concerns. It remains to be determined whether the negative sexual aftermath of infertility similarly persists over many years for men.

**ASSESSMENT AND DIAGNOSTIC ISSUES**

Sex therapists are not routinely included in the initial medical fertility workup, which typically is conducted by a nurse and gynecologist or reproductive endocrinologist.

Although some questions in the medical assessment focus on the frequency and timing of intercourse and previous sexual history (i.e., sexually transmitted infections [STIs], therapeutic abortion), psychosexual assessment or intervention typically is recommended by the medical team only in cases in which a sexual dysfunction is implicated in the couples fertility problem (e.g., inability to engage in intercourse due to impotence or vaginismus) or is impeding fertility treatment.

In Figure 19.1 we present a psychosexual assessment and treatment decision algorithm to guide decision making when working with infertile individuals or couples.

Assessment and diagnosis require assessing the presence, frequency, and severity of an individuals or couples sexual complaint (e.g., vaginismus, dyspareunia, impotence and erectile difficulties, lack of interest/desire) and determining whether a sexual dysfunction is impeding the implementation or successful outcome of fertility treatments. If the sexual problem is impeding fertility or successful medical intervention, it is necessary to consult with the patients fertility specialist and ascertain whether, based on factors such as the patients age and fertility status, taking time out from treatment will reduce their chances of a successful pregnancy. In cases in which the sexual dysfunction is contributing to the couples inability to conceive, a hiatus from fertility treatments is warranted while the sexual dysfunction is addressed only if time permits.1

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**FIGURE 19.1**. Assessment and treatment algorithm for infertility.

If time does not permit taking a break from medical treatment or if the sexual concern is not impeding the couples fertility or successful treatment, it is imperative to ascertain whether the sexual problem is viewed as problematic by the infertile couple (Hammer Burns, 2006; Leiblum, 1997). For many infertile couples, concerns related to sexual satisfaction or functioning are not a high priority when engaged in the all-consuming process of fertility treatments and trying to achieve a pregnancy (Daniluk, 1998). Although early intervention is always recommended (particularly given that sexual problems are very likely to be further exacerbated by prolonged fertility investigations and treatments), unless the sexual dysfunction is contributing to a couples inability to conceive, they may not be willing to invest the time and energy in addressing these problems until after they have terminated, and emotionally recovered from, medical treatment (Hammer Burns, 2006). In these cases, couples should be provided with psychosocial support to help them cope with and to reduce the sexual and performance stresses associated with medical treatment. Couples can be given strategies to manage challenging situations, such as the use of erotic material and partner assistance when producing a sperm sample or the use of visualizations and progressive relaxation to cope with the insertion of a speculum, catheter, or probe. The sexual concern should be monitored on an ongoing basis to assess changes in severity and impact, and if the couple is receptive to the idea, it can be helpful to develop a tentative future treatment plan to address their sexual concern(s) after fertility treatments have ended.

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Psychosexual intervention should be initiated when sexual dysfunctions are impeding fertility or successful medical intervention (if time permits), or when the dysfunctions are having a negative impact on one or both members of the couple or threatening the stability of their relationship and/or are identified as being a high priority by one or both members of the couple. In conducting a thorough psychosexual assessment, it is necessary to ascertain whether the sexual problems are secondary to infertility and whether they are generalized or situation specific (e.g., whether problems commonly occur when having to perform on demand to produce a sperm sample or during times of the month when the woman is ovulating). It is particularly important to determine whether medical conditions or medications are implicated in the dysfunction (e.g., endometriosis resulting in dyspareunia; retrograde ejaculation caused by prostatitis, diabetes, multiple sclerosis or nerve damage or disease; diminished sexual responsiveness and desire due to fertility medications such as clomiphene or gonadotropins; other health conditions such as cystic fibrosis or Turner syndrome).

Mental health (e.g., depression), lifestyle (e.g. alcohol and drug use; use of steroids), and relationship issues should also be included in a thorough psychosexual assessment. With the strong link between fertility and femininity–masculinity in most cultures and religions worldwide, particular attention should be paid to the impact of infertility on the sexual self-perceptions and body image of both members of the couple—factors that can have a considerable impact on reducing sexual responsiveness and desire (Daniluk

& Frances-Fischer, 2009).

In terms of assessing sexual functioning and satisfaction, currently there are no existing assessment measures that have been developed or adapted for specific use with an infertile population. The most frequent measures cited in the research literature examining the incidence or prevalence of sexual distress or dysfunction within the infertile population are the Female Sexual Function Index (FSFI; Rosen et al., 2000), the International Index of Erectile Function (IIEF; Rosen et al., 1997), and the short form of the Derogatis Interview for Sexual Functioning (DSFI-SR; Derogatis, 1997). The Golombok–Rust Inventory of Sexual Satisfaction (GRISS; Rust & Golombok, 1985) might be a good adjunct to these standard sexual functioning measures in that it assesses both the sexual and nonsexual aspects of the relationship between a couple, with scores for both men and women. We also recommend the Comprehensive Psychosocial History for Infertility developed by Burns (1993), which provides a framework for a comprehensive psychosocial assessment of infertile individuals, including questions focused on sexual dysfunction and marital adjustment.

When conducting a sexual assessment with couples who are dealing with infertility, therapists must be acutely sensitive to context and appreciate that through the medical treatment process, infertile men and women have had the most intimate and private aspects of their lives and bodies laid bare and scrutinized. A significant toll will have been taken on each individuals sexual self-esteem, based on the mans "failure" to impregnate his partner and the womans inability to achieve a pregnancy.

Understandably, they will want to maintain what little privacy and dignity they can (Daniluk, 1998). Wischmann (2010) and Daniluk and Frances-Fischer (2009) underscore the value of normalizing the experience of sexual distress and episodic 383

sexual dysfunction during fertility treatments. For example, a man is more likely to acknowledge his difficulties in being able to produce a semen sample "on demand"

during an IVF cycle if he is told that bouts of impotence are extremely common under these circumstances.

It is also important to be very sensitive to gender and cultural differences—

particularly as these are related to beliefs about fertility and masculinity–femininity—

and to infertile individuals levels of comfort in discussing their sexual difficulties, in general and with a therapist of the opposite sex.

**DSM-5 Diagnostic Protocols**

DSM-5 includes a new diagnosis, female sexual interest/arousal disorder (FSIAD). This revision reflects mounting empirical evidence that female sexual desire and subjective sexual arousal overlap—a reconceptualization that more accurately reflects the experiences of many infertile women. Male hypoactive sexual desire disorder addresses the parallel experience of low sexual desire among men—a commonly reported experience among infertile men, particularly in cases of male factor infertility.

DSM-5 (American Psychiatric Association, 2013) omits the diagnosis of sexual dysfunction due to general medical condition. If a thoroughly conducted assessment determines that an infertile woman or man is experiencing sexual difficulties exclusively accounted for by medical or biological factors, then she or he would not receive a DSM

diagnosis. However, under some of the sexual disorders such as female orgasmic disorder, a medical condition may be noted as a differential diagnosis. In this case, the specifier of "with medical factors relevant to prognosis, course, or treatment" should be used. Because short-term sexual problems are common among couples experiencing difficulties conceiving, the recommendation that problems must persist for a minimum of 6 months will be useful in avoiding any inappropriate diagnosis (although treatment should still be made available).

It is important to note that the psychosexual aftermath of infertility is often distressing enough that an additional diagnosis of sexual dysfunction may serve to further damage the sexual self-esteem and agency of infertile men and women (Daniluk, 1998; Hammer Burns, 2006; Leiblum, 1997). As a consequence, such diagnostic labels should be applied with sensitivity and caution.

**EFFICACY OF TREATMENT APPROACHES**

The growing body of literature evaluating psychosocial interventions for infertility-related distress is reviewed briefly here. Within these studies, sexual functioning is also a focus of intervention and measured as an outcome variable, along with variables such as marital satisfaction and psychological well-being (e.g., Haemmerli, Znoj, & Berger, 2010; Tuschen-Caffler, Florin, Krause, & Pook, 1999). Psychosocial treatments frequently 384

include cognitive-behavioral interventions to reduce stress and anxiety, modules on enhancing communication, strategies for accessing social support, and skills for managing work and familial relationships (e.g., Haemmerli et al., 2010; Schmidt, Holstein, Christensen, & Boivin, 2005).

Two large meta-analyses conducted within the past 10 years evaluating the most recent research on psychosocial interventions for infertility-related distress show mixed support for the usefulness of these forms of treatment (Boivin, 2003; de Liz & Strauss, 2005). Boivin (2003) evaluated 25 studies that described psychosocial interventions and evaluated their effect on at least one outcome measure. De Liz and Strauss (2005) examined 22 studies that assessed the efficacy of psychosocial intervention in the reduction of negative affect, depressive symptoms, and pregnancy rates. Overall, Boivin (2003) and de Liz and Strauss (2005) found that psychosocial interventions focused on emotional expression, psychosocial support, and discussion of feelings and thoughts about their infertility were effective in reducing the negative distress related to infertility.

However, there was little unequivocal research support for changes in other areas of psychosocial functioning or interpersonal behavior. According to Boivin, "the way that people related to their partners and other members of their social network was rarely affected by these interventions" (2003, p. 2234). Similar conclusions were reached by de Liz and Strauss (2005) who found that group, individual and couple psychotherapy were effective only in reducing symptoms of anxiety and depression for this population. The effect of these interventions on pregnancy rates was equivocal.

Tuschen-Caffler et al. (1999) conducted one of the few studies of a 6-month cognitive-behavioral therapy group for 17 infertile couples focused specifically on improving sexual functioning and satisfaction, reducing thoughts of helplessness, and enhancing marital communication. The intervention involved the use of daily diaries to track the effect of sex therapy interventions on frequency of sexual intercourse during fertile times. Pre- and posttreatment scores were compared within the treatment group and across a control group. Before the group intervention only 50% of couples in the treatment group were actively scheduling intercourse during their fertile times in the month. Posttreatment, this rose to 100%. However, although the intervention was effective in increasing compliance with the timing of intercourse, levels of sexual pleasure and satisfaction remained low for these couples, even during the nonfertile times of the month. Although dated, this study demonstrates that a planned intercourse schedule can improve couples chances of becoming pregnant when frequency of intercourse is an issue.

More recently, early intervention was found to be effective in somewhat mitigating the negative sexual and relational aftermath of fertility treatments (Vizheh, Pakgohar, Babaei & Ramezanzadeh, 2013). In a randomized controlled study with 100 infertile couples in Iran, 50 couples were assigned to the counseling intervention group consisting of three weekly 60- to 90-minute counseling sessions. The other 50 couples were assigned to the no-intervention group. Those couples who received the counseling intervention demonstrated significantly higher levels of marital and sexual satisfaction when measured 3 months after the intervention compared with those who did not receive the intervention. These findings highlight the impact that medical treatment 385

may have on the sexual and marital satisfaction of infertile couples and underscore the value of early intervention.