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Sexual and Relationship Therapy

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The Good-Enough Sex model: a case

illustration
a

Barry W. McCarthy & Michael E. Metz

a

American University , Washington, DC, US

Meta Associates , St. Paul, Minnesota, US

Published online: 15 Aug 2008.

To cite this article: Barry W. McCarthy & Michael E. Metz (2008) The Good-Enough Sex model: a
case illustration, Sexual and Relationship Therapy, 23:3, 227-234, DOI: 10.1080/14681990802165919
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Sexual and Relationship Therapy

Vol. 23, No. 3, August 2008, 227234

The Good-Enough Sex model: a case illustration

Barry W. McCarthya* and Michael E. Metzb

Downloaded by [Universidad Evangelica de El Salvador] at 12:32 08 December 2014

American University, Washington, DC, US; bMeta Associates, St. Paul, Minnesota, US
(Received 7 November 2007; accepted 27 April 2008)

The Good-Enough Sex model, grounded on an integrative, couple, psychobiosocial

perspective, intends to replace the prevailing emphasis on sexual performance to the
detriment of sexual quality and satisfaction. Since the introduction of Viagra in 1998,
the professional and lay public focus has been on a medication approach to resolving
male sexual dysfunction, especially erectile dysfunction. This has reinforced the perfect
intercourse performance model of male sexuality. In contrast, the Good-Enough Sex
model advocates for a focus on sharing pleasure and enjoying sex function as variable
and exible. A detailed case illustration describes the clinical application of the GoodEnough Sex model.
Keywords: couples therapy; male erectile dysfunction

Introduction
The great majority of teenage and young adult men learn sex as a highly predictable,
controlled and, most important, autonomous sexual performance involving an easy,
predictable erection and a single orgasm during intercourse. Autonomous means he can
experience desire, arousal and orgasm without needing anything from his partner. In fact,
the main problem for teenage and young adult men is premature ejaculation (PE), which
they typically attempt to deal with by engaging in a second intercourse to try to last longer.
Male sexual socialization emphasizes sexual frequency, highly predictable erections, male
control, perfect intercourse performance and no place for doubts, concerns or questions
(Zilbergeld, 1999).
Although this Perfect Intercourse Performance approach might be functional for the
majority of single, young adults, it does not t mid-life and older adults, especially those
who are married or in long-term committed relationships. Rather, this approach
paradoxically provides the foundation for sexual dysfunction, especially erectile
dysfunction (ED). The unreasonable pursuit of perfect, automatic and autonomous
performance every time becomes the source of personal dissatisfaction and relationship
distress. Likewise, the partner is not immune to the pressures and distress from this
emphasis on performance because any failure on his part is typically experienced by her
as her failure to excite and arouse him. This performance model amplies fears of
inadequacy and predisposes to life-long sexual disappointment. There is a poignant
irony when the pursuit of perfect sex becomes the cause of dissatisfying and
dysfunctional sex.

*Corresponding author. Email: McCarthy160@comcast.net

ISSN 1468-1994 print/ISSN 1468-1749 online
British Association for Sexual and Relationship Therapy
DOI: 10.1080/14681990802165919
http://www.informaworld.com

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B.W. McCarthy and M.E. Metz

Metz and McCarthy (2007) delineated the principles and sources for the GoodEnough Sex model and described its relevance for adult men, women and long-term
committed couples. This model emphasizes a psychobiosocial approach to understanding
sexual function as well as assessing and treating sexual dysfunction (SD). In contrast to the
automatic, autonomous and perfect intercourse performance model, the GoodEnough Sex model emphasizes couple intimacy as a cooperative, interactive process not an
autonomous one; a variable, exible, emotionally intimate approach to sexual pleasure
and function rather than perfect intercourse performance; that realistically 85% of sex
encounters will ow to physically adequate intercourse and when it does not, the couple
transitions to an erotic, non-intercourse scenario or a sensual scenario (i.e. cuddling)
rather than the demand for intercourse each time; when there is ED, the integration of a
medical intervention into the couples sexual style rather than as a stand-alone
intervention; and the crucial importance of a couple relapse prevention program, rather
than treating sex with benign neglect and hoping that ED will not return as long as he
takes his medication.
Clinical issues in application of these two models
With the introduction of Viagra (Goldstein et al., 1998), professional and public
approaches to ED dramatically changed. Although the biopsychosocial approach to
physical and mental health problems was becoming more accepted, sexual problems had
been treated as primarily caused by psychological and relationship factors, with
individual, couple or sex therapy the primary interventions. As a culture, we go from
one extreme to another. The new, mistaken belief is that sex problems, especially ED and
PE, are caused primarily by biological/medical factors and the treatment of choice is a
stand-alone medication (usually prescribed by his general physician rather than a
specialist). Although experienced clinicians urge physicians to engage in sexual coaching
(Perelman, 2005) and, in complex cases where the medication alone has not been
successful, to consult a sex therapist (Althof, 2002), the reality is most men follow the
advice of the marketing ads and feel all they need to do is ask their physician for Viagra,
Levitra or Cialis. The biological/medical approach is currently dominant (Rowland, 2007).
Unfortunately only in the most dicult, complex cases would the physician suggest a
psychosocial assessment and treatment. In this climate, the only role for the woman is to
encourage her male partner to admit to a medical problem and seek a medical solution a
situation which can reinforce the autonomous and perfect-performance model and
paradoxically alienate the partner. In contrast, the psychobiosocial approach begins with
treating the sexual problem as a multi-causal, multi-dimensional couple problem.
Ultimately, sex is an interpersonal process, not an autonomous one. Couple sexuality is
inherently variable and exible rather than clinging to the criterion of perfect intercourse
performance. The mantra in healthy sexuality is the importance of desire, pleasure and
satisfaction (Foley, Kope, & Sugrue, 2002). This approach to couple sexuality has major
implications for treating SD, especially ED (Metz & McCarthy, 2004) and PE (Metz &
McCarthy, 2003). In assessing, treating and relapse prevention of SD, it is crucial to
examine a range of causes and dimensions to ensure that change is genuine and resilient.
Psychological factors involve attitudes, behaviors and emotions and their role in
integrating intimacy and eroticism into individual and couple sexuality (Perel, 2006).
Biological/medical factors need to be carefully assessed, especially the vascular,
neurological and hormonal systems, as well as potential detrimental side-eects of both
prescription and over-the-counter medications.

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Special attention is paid to developing comfortable, functional psychosexual skills.

Relationally, the couples identity, conict resolution skills and capacity for mutual
empathy are examined. Especially important are whether they see the problem as a couple
issue and whether there are past or present secrets. If the therapy is to result in sustainable
change these dimensions and issues need to be addressed in a comprehensive manner. In
addition, there is a major focus in the Good-Enough Sex model on an individualized
relapse prevention program (McCarthy, 2001). Relapse prevention is usually ignored in
the medication/perfect intercourse model.
The couple approach
The Good-Enough Sex model involves each person being responsible for his/her sexuality
and working together as an intimate team to develop a comfortable, functional couple
sexual style. This is a particular challenge for men who value being the sexual expert and
needing to feel totally in control. These men often enjoy receiving manual or oral
stimulation, mainly when they are already aroused. Many men tend to feel vulnerable or
embarrassed asking the woman to help him become aroused. The man is stimulated by the
womans arousal, but worries there is something wrong with him if he needs to piggyback his arousal on hers or feels inadequate if she seems less than passionate. In truth, it
is not easy for the man to accept the concept of sex as a team sport; he learned sex as
totally predictable and under his control.
One of the biggest challenges is to accept couple sexuality as a variable and exible
experience and not feel anxious or vulnerable when the sexual encounter does not ow to
intercourse. The concept of variable, exible sexual response is much easier for the woman
to accept because that is more the reality of female sexual socialization and experiences
(Heiman, 2006). Most women do not experience high desire at each sexual encounter nor
are they expecting to be orgasmic at each encounter. They accept sex being variable both
in terms of physical sensation and emotional meanings. The core concept is the emphasis
on the man and woman as intimate, erotic friends. With the maturing and aging of the
partners and the aging of the relationship, their sexual responses becomes more similar
and they need each other to maintain functional, satisfying couple sexuality.
There are two valuable intervention exercises. The rst involves the man being open to
learning to piggy-back his arousal on hers that an involved, aroused partner is the
major aphrodisiac. The second is to practice transitioning to an erotic non-intercourse
scenario or a cuddly, sensual scenario. He learns to accept that it is normal for 515% of
sexual encounters to not ow to intercourse and to comfortably (without apologizing)
switch to an alternative scenario (Frank, Anderson, & Rubenstein, 1978; Michael,
Gagnon, Laumann, & Kolata, 1994).
To illustrate promoting valuable features of the Good-Enough Sex approach in clinical
practice, consider the case of Paul and Claudia. This couple was treated by the rst author,
involved 18 sessions, as well as a two-year follow-up involving three additional couple
sessions.
Case illustration: Paul and Claudia
When 56-year-old Paul and 53-year-old Claudia appeared for a second opinion/
consultation they were extremely demoralized. Paul had taken great pride in climbing
the career ladder in a large construction company from a laborer to a high-level project
manager position. Along the way, he attained a High School Equivalency Degree and had

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excelled in executive training courses. Sexually, Paul was a mans man. He emphasized
being physically and emotionally strong and in control in all areas of his life, including
sexuality where he viewed himself as pro-sexual and a player.
This was Pauls third marriage and they had been married for ve years. For Claudia,
it was a second marriage; her rst husband was killed eight years before while serving in
the military. Claudia was an attractive middle-years widow with two young-adult sons.
She met Paul when employed in commercial real estate on a building rehabilitation project
his company was completing. Claudias husband had suered from alcohol abuse, traveled
a great deal for the Navy and was a minimally involved husband and father. Claudia was
impressed by Pauls successful career, his extroversion and especially that he was a real hit
with her sons who previously kidded Claudia about the losers shed dated.
Paul and Claudia had a romantic love, passionate sex, idealized courtship, which
unfortunately included the avoidance of talking about sensitive or secret issues. For
example, Paul did not tell Claudia that he used Viagra to ensure his sexual performance
would be perfect in terms of erection and intercourse. In fact, it was not until two years
into the marriage that they talked about their, by now highly problematic, sexual
relationship. Viagra alone was not enough to help Paul and Claudia develop and sustain a
couple sexual style that was comfortable and functional. Pauls erectile anxiety and pattern
of hurrying intercourse as soon as he had an erection was both a turn-o for Claudia and
ultimately increased ED severity. As often happens, a particularly damaging interaction
occurred when Paul lost his erection shortly after intromission. Hed silently rolled to his
side of the bed. Claudia felt confused and abandoned, and asked what was wrong. Paul
felt attacked, and blamed all the sexual problems on Claudia shed pulled a bait and
switch, promising to be pro-sexual, but once married shed become fat, passive and as
sexy as a 16-year-old virgin. Claudia felt wounded and struck back by saying, You
cant deliver the wood thats why your wives left you. He pushed her and she spat at
him, but fortunately it ended there. There is something about being nude, in bed, feeling
vulnerable after a negative sexual encounter that brings out the worst in people. Paul and
Claudia did not appreciate that when a negative sexual experience occurs, they would be
better to get out of bed, get dressed and talk at the kitchen table or on a walk.
Thereafter, Paul and Claudia were stuck in a cycle of anticipatory anxiety, tense and
usually dysfunctional intercourse, with increasing sexual frustration and avoidance. Their
feelings included hurt, embarrassment, confusion and guilt. Unfortunately, rather than
focusing on these vulnerable emotions, it was expressed in an angry attack-counterattack
mode which undermined their marital relationship. Paul had used a number of medical
interventions prescribed by his internist, urologist and so-called specialists at a mens
health clinic. He had tried testosterone injections and gels; Viagra, Levitra and Cialis;
penile injections and the external penile pump. The urologist recommended penile implant
surgery, but Paul said no. The most signicant factor was Paul had gone to each
appointment alone and had not kept Claudia informed of what he was doing or what type
of support he wanted from her. Paul was the Lone Ranger/John Wayne/007 of male
sexuality he would do it himself. Finally, his internist strongly suggested he and
Claudia go at least once to a couple sex therapist.
For Paul and Claudia, the four-session assessment model (McCarthy & Thestrup,
2008) was of great value in increasing their understanding and motivation. The rst session
focused on the circumstances of the couples sexual situation and emphasized that sex is a
couple issue that had to be addressed as an intimate team. This involved Paul changing his
cognitions about erections and seeing Claudia as his intimate and erotic friend; Claudia
taking an active role both in therapy and couple sexual exercises and together developing a

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new intimate, interactive couple sexual style. Initially, the therapeutic focus was on sexual
desire rather than ED. They borrowed Rekindling Desire (McCarthy & McCarthy, 2003)
and were asked as a couple to read the chapter on whether the SD was his, hers or our
problem in order to encourage them to see the diculty as a team. In addition, after his
individual sexual history, Paul was given Coping with Erectile Dysfunction (Metz &
McCarthy, 2004) and asked to read the material on psychosexual skills and how to
integrate these with a pro-erection medication.
Individual sex histories are crucial in obtaining a clear, non-defensive view of each
persons sexual strengths and vulnerabilities and the strengths and vulnerabilities of this
marriage. The focus is on the person, not blaming the spouse. Paul desperately wanted a
medical solution where the outcome was 100% predictable, erections and intercourse. He
found it very dicult to share personal and relationship vulnerabilities. Paul did read about
the Good-Enough Sex model (McCarthy & Metz, 2008) and bluntly said he respected men
who could adopt that, but he was not one of those men. Paul masturbated twice a week
using internet porn whose theme was two or more women engaging in cunnilingus. He
wanted to keep secret from Claudia all aspects of his sexuality including use of medical
interventions, masturbation, porn and erotic fantasies. Interestingly, other than two brief
attempts, Paul had not tried cunnilingus with Claudia. The clinician confronted Paul about
walling o Claudia rather than working with her using the sexual team approach. The
clinician lobbied Paul to give permission to share his sensitive/secret material. Paul was
asked if he had a positive reason to maintain secrecy and it became clear to both Paul and
the therapist there was no positive function. His reason for maintaining secrecy was false
pride and fear of rejection. With ambivalence, Paul gave the therapist permission to share
this material during the couple feedback session.
The couple feedback session is the core therapeutic intervention. There are three
focuses: (1) developing a new, genuine narrative for each persons sexual history, sharing
both strengths and vulnerabilities (including sensitive/secret material), (2) committing to a
therapeutic change plan with the focus on individual responsibility for sexuality and
working as an intimate team, and (3) assigning the rst psychosexual skill exercise to
reinforce the message that much of the therapeutic work happens at home between
therapy sessions.
Paul and Claudia left the couple feedback session with a new understanding of how the
sexual problem had developed and worsened, and a new motivation to address couple
sexuality with a realistic optimism that if they worked as a team and used all their
resources, including medication, they could re-establish healthy desire, arousal, orgasm
and satisfaction (McCarthy & Fucito, 2005).
Paul was open to gaining comfort and condence with erections rst with nonintercourse sex (using manual and/or oral stimulation) and then transitioning to
intercourse. Claudia found the concept that Paul needed her active stimulation to
enhance desire and erection inviting, but she was even more intrigued with Pauls openness
to piggyback his arousal on hers. Concepts such as non-demand pleasuring, using
manual or oral stimulation to high arousal and orgasm and accepting the Good-Enough
Sex model of variable, exible sexual response were more easily accepted by Claudia than
Paul. Claudia very much wanted to be Pauls intimate, erotic friend. Would Paul be open
to joining with Claudia to revitalize their desire, arousal, orgasm, satisfaction bond?
The therapist helped Paul develop a step-by-step approach to create an intimate,
interactive sexual relationship and give up his need for a return to autonomous 100%
predictable erections. Psychologically, the big change for Paul was to view Claudia as his
friend to share pleasure and eroticism rather than to perform for. Also, to accept that the

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key to sexual desire was positive anticipation and embracing the anti-avoidance
approach with non-demand pleasuring and desire exercises. The major psychological
change for Claudia was the realization that her pro-sex attitudes and arousal was integral
to couple sexuality. Physiologically, use of Cialis served to enhance erectile response and
as subjective arousal built, physiological arousal was maintained. Relationally, trust in
being open to mutual stimulation and multiple stimulation without either feeling this was a
competition for ease and rapidity of arousal was benecial. Equally important, Paul
trusted Claudia to initiate and guide intromission at high levels of arousal a totally new
experience which reduced his performance anxiety and spectatoring.
In ongoing therapy, Claudia would usually be open to the clinicians psychosexual skill
exercise approach, but Paul was almost superstitious in wanting to leave well enough
alone. In truth, once erectile anxiety is sensitized, the man cannot go back to
unselfconscious sexual performance. However, he can establish a solid base of erectile
comfort and condence with an awareness of the pleasuring process, develop arousal,
transition to erotic ow and see intercourse as a natural transition at high levels of arousal
rather than trying to force intercourse with a beginning erection. Paul felt much better
about erotic ow when he was stimulating Claudia and she was giving genital stimulation.
Pauls erotic pattern was multiple and mutual stimulation.
It was Claudia who noted how dierent Paul was during intercourse. For Paul,
intercourse had been about thrusting only. His goal was to ejaculate before losing his
erection. Intercourse was a pass-fail test, much less fun and involving for Paul (and for
Claudia also). The most important psychosexual skill exercise was to identify mutual and
multiple stimulation techniques to utilize during intercourse. Claudia was typically
orgasmic with manual or oral stimulation before intercourse and her pattern had been to
be passive during intercourse. Claudia found that when she engaged in mutual stimulation
during intercourse, her pleasure was greatly increased and this amplied the arousal for
Paul. Claudia enjoyed doing testicle stimulation, scratching Pauls back, kissing,
verbalizing pleasurable feelings and especially using intercourse positions other than
man on top. Paul was encouraged to engage in multiple stimulation especially touching
Claudias breasts, verbalizing sexual feelings, allowing himself to enjoy erotic fantasies and
looking at Claudia as he thrust. This facilitated Pauls ability to stay with the erotic ow,
with orgasm the natural result of high arousal, not a desperate attempt to force orgasm.
The second important psychosexual skill exercise involved transitioning to an erotic,
non-intercourse scenario when the sexual encounter did not ow to intercourse.
Emotionally, Claudia was ne with this. Throughout her life, sexual response had been
variable; she did not expect 100% arousal/orgasm at each encounter. The fact that her
arousal/orgasm pattern involved manual and oral stimulation made this transition easier
for Claudia. The idea of an alternative erotic scenario was a hard sell for Paul. He
strongly felt this was settling because he had failed at intercourse. The key to genuine
change is the actual experience of an erotic, non-intercourse encounter. When Paul did not
have an erection sucient for intercourse or lost his erection during intercourse, he would
transition (without panicking or apologizing) to pleasuring Claudia with manual clitoral
stimulation combined with oral breast stimulation, which typically resulted in her being
orgasmic. Paul would then engage in self-stimulation to orgasm with Cynthia holding him
and doing manual testicle stimulation or Claudias preferred scenario to manually
stimulate Paul to orgasm as he lay back and was receptive to her touch and used erotic
fantasies.
Paul and Claudia verbally acknowledged the value of this experience and incorporated
this new cognition of mutual enjoyment of erotic sex. Although Claudia would have been

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open to adding a sensual back-up scenario this was not at all inviting for Paul. They could
agree to take a rain-check for a later sexual encounter.
The key in relapse prevention is to not regress to the cycle of anticipatory anxiety,
failed intercourse and embarrassment and avoidance. This means dealing with a lapse, and
not allowing it to become a relapse. Again, Claudia took an active and positive role. She
accepted the 85% approach to sexual intercourse as a natural, normal part of aging for
males and females. Why shouldnt it be true for us, Paul? Claudia did not want Paul to
be apologetic or put himself down as a sexual man. She was asking him to accept the
reality of being an aging man. This acceptance would form the foundation of being an
intimate sexual couple who could enjoy pleasuring, eroticism and intercourse in their 60s,
70s and 80s. In essence, both Claudia and the therapist were speaking to the healthy part
of Paul and his new awareness of male and couple sexuality. This included acceptance of
the Good-Enough Sex model and to jettison his need for perfect intercourse performance.
Summary
This discussion and case illustration address a core issue in male and couple sexuality as
well as the criterion for sex therapy success and relapse prevention. In the traditional
model of male sexuality, the emphasis was on control, total predictability, autonomous
erections and perfect intercourse performance. This is strongly reinforced by the
marketing of the pro-erection medications (Viagra, Levitra, Cialis). In contrast, the
Good-Enough Sex model emphasizes a couple-centered, pleasure-oriented, psychobiosocial model of assessment, treatment and relapse prevention. A key component is to view
sex as a lifelong maturing process and to develop a variable, exible approach to sexual
function as a positive challenge rather than a loss of masculine condence. Another key
concept is to view pro-sex medications as an important resource to be integrated into the
couple style of intimacy, pleasuring and eroticism rather than a stand-alone intervention.
Perhaps the most crucial concept is to accept that 85% of encounters will ow to
intercourse and to comfortably transition to erotic, non-intercourse or sensual scenarios
rather than demand perfect intercourse performance. Embracing these dimensions
are important features of satised couples and deepen the value of their sexual
relationship.
The Good-Enough Sex model does not claim to be applicable to all sex problems or all
couples. As in all eective therapy, it needs to be individualized to the realities of the
specic couple. What the Good-Enough Sex model provides is a positive, realistic
approach to adapting to sexual function problems by expanding the meaning of their
sexual interactions and addressing relapse prevention in a manner that prevents future
over-focus on performance and relationship distress. The features of this model guide
clinicians to integrate and blend the psychobiosocial realities physiological function,
psychological meaning and relationship intimacy.

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