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chapter 9
Couple Relationship and
Sexuality
Anisha Shah, Rathna Isaac

INTRODUCTION that marital distress actually increases risk for

developing certain psychological disorders
Relationships have certain qualities that influence including depression in women, alcohol abuse
an individual’s life experiences and health in men, higher rates of sexual dysfunctions in
in very special and unique ways. Decades of both sexes, increased behavioral problems in
international psychological researches have children, and conduct disorder in boys.7 This
confirmed the significance of close relationships association is not one way. Long-standing
for general health, mental health, and well- and severe psychological disorders reduce the
being of both men and women. Relationship chances of someone developing a satisfactory
problems are also the most commonly occurring relationship.
presenting problem in young adults seeking Family medicine research also suggests that
help. It is perhaps the most frequently occurring married individuals are healthier, that marital
theme in clinical interviews in India as well. conflict is associated with poorer health,8 and
Moreover, it dominates session process in a large marital conflict is associated with specific
part of individual, couple and family therapy illnesses like cardiac diseases, chronic pain, and
sessions. Marital relationship, in particular, cancer.5 Burman and Margolin also confirm that
happens to be the most prominent relationship the psychological quality of marriages is linked
in the entire adult life span. Thus, theorists, to mortality and morbidity, although the effects
researchers as well as clinicians have contributed are indirect and nonspecific.9 They report that
to professionals’ understanding of this as well as individuals in satisfying relationships are less
similar intimate relationships. vulnerable to major illnesses, and recover better
Specifically, research evidence points when they do become ill. For men, strong links
towards the fact that while a happy marriage are evident between being married and better
decreases the risk for developing a mental health and longevity, thus, suggesting a health
or physical illness, an unhappy marriage buffering effect. However, women with marital
increases this risk.1-4 Marital conflict is definitely conflict are found to be more vulnerable to health
associated with depression, and is also prominent related problems. It appears that relationships
in physical and psychological abuse, alcoholism and marriage affect men and women in unique
in men, early onset drinking, as well as in eating and significant ways.
disorders in women.5 Life events research also Many of the above conclusions explain
points out that after death in the immediate why a large part of research on adult close
family, marital distress and divorce are the relationships has continued to focus on man-
most severe commonly occurring stresses in women relationships in the context of marriage.
adult experiences.6 Research has also confirmed It is interesting that marriage, as an institution,
 Section 2
Sexual Practices
104
owes its stability to sexual needs that were largely control, predict and alter any/all the factors
to be satisfied in a monogamous relationship. associated with this relationship. Over the last
However, the sexual liberation that started in four decades, researches have moved away from
the West in the mid twentieth century, combined study of traditional theoretical concepts to more
with the transformations of traditional notions generic dimensional view of relationships.11
of a family, has greatly altered sexuality in Dominant issues and conflicts can often make
couple relationships. Earlier approaches in these dimensions recede from the conscious
couple therapy dealt with sexual dysfunction region of experience. That is, while couples
Comprehensive Textbook of Sexual Medicine

and couple’s interactions predominantly using may be aware that they have problems, they may
a behavioral perspective. Lately, this alone is not be aware of the location of their difficulties.
not sufficient. Professionals need a broader A better knowledge of these dimensions can
view of changing sexuality and its impact on help in understanding the complex interplay of
relationships. the factors underlying relationship dynamics.
With diminishing importance of marriage Mapping of these dynamics on some of these
as an institution, more and more couples dimensions may often alert professionals to an
live together, or explore all aspects of the individual’s vulnerabilities, and facilitate more
relationship before showing their commitment to sensitive clinical practice.
marriage. In addition, with increasing strength Almeida et al emphasize on the following
of the gay/lesbian movement, professionals dimensional realities of marriages:12
are concerned about unique issues for different ÐÐ economic/financial; determined by each
types of couples. In response to these changes, partner’s characteristics as well as their
many writers have replaced the term marital capacity to jointly create security
therapy with couple therapy. With these issues ÐÐ emotional: (communication, intimacy,
in the background, this chapter presents a broad dependence)
view of dimensions that can be used to map ÐÐ power arrangement: (privileges of men to
relationship quality, and sexuality related issues
partnership versus equality in relationships)
in relationship context.
ÐÐ physical power: ( intimidation; abuse, threats
versus sanctity of the individual)
ÐÐ boundaries: psychological space around the
RELATIONSHIP MAPS couples in connection to friends, family,
In many ways, marriage is a very unique event children, work, religion (tight and controlled
that stresses the individual yet marks a turning versus flexible)
point in life. McGoldrick explains the experience ÐÐ sexuality: sexual intimacy versus sexual
of marriage in these simple lines: “Marriage, objectification,, rape and exploitation
more than any other life transition, is viewed as ÐÐ child-rearing: shared versus viewed as
the solution to life’s problems such as loneliness, women’s responsibility
work/career uncertainty, or extended family ÐÐ chores and leisure activities: home care, food
difficulties….Marriage requires that two people versus priorities for vacation and leisure time.
renegotiate a great many issues that they have These are widely accepted concepts in
previously defined individually or in their marital literature. Some of these are generic
families of origin, such as when and how to eat, concepts, where as others refer to very specific
sleep, talk, have sex, fight, work, and relax”.10 aspects of interactions and behaviors. In India,
The nature of interpersonal relationship and researchers focused on global evaluations as well
the intrapsychic processes of the two partners as a few specific dimensions like roles, decision
not only affect their individual functioning but making, and communication.
also influence other family relationships. This In the following sections, some of the core
prompts researchers to try and understand, dimensions used in India is presented in details.
 chapter 9
Couple Relationship and Sexuality
105
These emerged initially through development of in the context of the relationship, this precludes
a marital quality scale,13 and are expanded and their potential for individual growth. It can also
refined through clinical practice. put a lot of pressure on the relationship to satisfy
all one’s needs.
Understanding: Good understanding has
traditionally been held as the benchmark of Trust: Trust in a relationship refers to the belief
a healthy relationship. But the definition of that the partner is benevolent and honest towards
what exactly constitutes good understanding one.16 This means that the partner is not perceived
tends to vary from person to person. A person as a threat to the self but as self-enhancing. Trust

Comprehensive Textbook of Sexual Medicine

feels understood when the partner’s evaluation increases security in a relationship and reduces
is consistent with the person’s own self- inhibition and defensiveness, thereby fostering
evaluation.14 Thus, understanding denotes not greater intimacy in the relationship. Trust is very
just awareness but also acceptance of the self much a dyadic process in the sense that the more
of the other. This understanding is manifested a person feels trusted in a relationship, the more
in various qualities in the relationship. These they are likely to trust the partner.
include: support for important goals of partner
Affection: This refers to the degree to which
(e.g. maintaining relationship with parents),
feelings of emotional closeness are expressed
awareness of when the partner is upset, ability
by the couple.17 Partners may express affection
to provide comfort, and an appreciation of
the sacrifices and efforts the partner has made verbally, by doing things for the other, and
toward the relationship. Understanding does through physical intimacy. Both styles of
not imply the partners need to be in complete expressing affection and degree of affectional
agreement on issues, but that they accept and need can vary from person to person. As
respect the other’s viewpoint, and can experience with intimacy, these differing styles can be
empathy for each other’s experiences. experienced as demanding or rejecting by the
partner.
Intimacy: Intimacy is closely linked to
understanding. This refers to sharing and Role functioning: When an individual’s status
closeness; giving and receiving of care and changes from that of being single to being in
confidences. This greater sharing of thoughts a relationship, the role demanded of him/her
and feelings requires understanding which in is likely to change. The individual faces new
turn facilitates it. While individuals in most challenges in fulfilling the psychological needs of
relationships are drawn towards each other, the partner as well as accomplishing the various
fears of being hurt or overwhelmed also keep tasks that go into setting up a house and family
people apart. Further, individuals will also need (in the case of cohabitating/married couples).
sufficient separateness to allow for personal While broad roles are often defined by society,
growth. Thus, each individual has a level of in today’s multicultural world, couples have the
intimacy at which they are comfortable. When freedom to negotiate their own role balance.
partners differ in their need for intimacy, this can Though this allows for greater flexibility, it can
be seen as demanding or rejecting by the other. also lead to greater conflict, especially if the
Cohesion: This refers to a feeling of commitment partners have different views on what roles are
to the marriage.15 It is the extent to which couples appropriate for each.
identify themselves with the relationship. Communication: Good communication is a
Cohesiveness can be enhanced through unique facilitator for all aspects of relationships and
activities with special meanings for the partners. couples often experience it as synonymous with
However, it must be noted that too much good understanding. Many of the problems that
togetherness, need not always be a good thing. arise in a marriage today are because of what
When partners create their own identity largely spouses say, how they say it, and how the partner
 Section 2
Sexual Practices
106
interprets this. Misinterpretations of messages spouse is clinically depressed, and stress and
and intentions often arise due to difficulties support in marriage can influence presentation of
with understanding, intimacy and trust. It is depressive symptoms.18 Relationship attributions
particularly difficult to give negative feedback are explanations that spouses make for events
and to resolve conflicts. Hostile, dominant, that occur in their marriage.19,20 Based on the
contemptuous, sarcastic, demeaning or defensive attribution theory, conflicts in close relationships
styles convey rejection. Discussions become have been studied using causal and responsibility
more about attitudes toward the partner than attribution dimensions, voluntariness and
Comprehensive Textbook of Sexual Medicine

issues. The more salient an issue is to one’s self motivation for behavior and unrealistic beliefs
esteem, the harder it is to talk about it. Better about events. Increasing levels of wife’s
communication can facilitate better problem depression are associated with higher levels of
solving and greatly alter the quality of the marital disaffection and disharmony, and also a
relationship. With sexual dysfunction, enhancing tendency to attribute marital difficulties to one’s
sexual communication becomes instrumental in behavior and not to spouse’s behavior.21
decreasing sexual difficulties. Satisfied spouses tend to view their partner’s
positive behavior as a result of stable, internal
Relationship power: This refers to one’s ability
causes and dismiss negative behavior as a result
to influence the thoughts, feelings and behaviors
of the partner. Relationships usually tend to of temporary external causes. This association
create some dynamics around power. However, holds true even when controlling for depressive
when one partner has a disproportionately large symptoms.20,22 Indian studies have also supported
share of the power in a relationship, this can lead these trends for women with depression.18,23
to relationship problems. Such a skewed power Further exploration on this dimension can create
balance often reflects insecurities/anxieties in a highly effective workable explanatory as well
the inner world of both partners. When there as interventional model that explains all types
is less of understanding and intimacy, partners of presenting problems for couples experiencing
find it difficult to share these anxieties. Usually, conflicts. In practice, working on relationship
it is difficult for couples to alter their power belief systems, as well as reattribution work
dynamics from within as it threatens the balance for presenting problems alters marital conflict
in the relationship. They are often not fully significantly.
aware of this struggle, and tend to notice only Stability and commitment is another major
issue-based differences. They can get stuck in determining dimension for the quality of
a tug of war over power that obscures all other relationship. The present understanding from
welfare feelings and relationship issues. Sexual studies on this aspect is that greater commitment
behaviors are often (unconsciously) interpreted enhances the ability to accommodate to partner’s
in the context of power dynamics. Unless sex is negative behavior. Lesser degree of commitment
understood in this context, the full implications has been associated with couples keeping a
of the sexual aspect of the relationship can be short-term perspective of relationships, as well
hard to comprehend. as expecting immediate reciprocation of one’s
Among various marital dimensions examined positive behavior. Uneven levels of commitment
in contemporary research, that of relationship can affect many relationships dimensions
attributions has generated empirical evidence significantly, and increase dissatisfaction with
to create more useful theoretical models that partner behaviors as well as sexual interactions.
explain the association between marital distress Couples with conflict may present with (i) a
and depression. general expression of marital distress, (ii) one
Research shows that depressed individuals partner having major psychological symptoms,
and their spouses consistently report poor marital (iii) child showing problems/symptoms, or (iv)
quality compared to couples where neither sexual difficulties. As part of initial evaluation
 chapter 9
Couple Relationship and Sexuality
107
of the family context, certain inferences can suggests that sexual difficulties often co-exist
be made about the quality of the relationship with specific relationship problems like sexual
between partners. Disclosures about sexual abuse, extra marital affairs, infertility, asexual
experiences are not easy for partners, especially marriages as well as with general marital
since in the Indian context public discourse on distress. Treatments are planned based on
sexuality is usually avoided. Professionals need the strengths of the psychological dyad. Sex
sensitive and skillful approach to establish the therapy techniques are used when the couple is
link between conflict and sexuality. psychologically prepared for the same. Unless

Comprehensive Textbook of Sexual Medicine

the relationship becomes workable, couples are
not always able to apply what they have learnt
NEW CHALLENGES FOR in terms of techniques for improving the sexual
relationship. Thus, while relationship closely
COUPLES’ SEXUALITY affects the quality of sex, sex also affects the
Over the generations, it is noticed that while the quality of the relationship. In this context, sexual
age of sexual maturation has decreased, the age abuse, extra-marital relationships and sexual
of marriage has increased.24 This has lead to an issues in gay and lesbian relationships merit
increased awareness of sexuality as an individual special attention.
phenomenon, even apart from the marital context.
What seems to be becoming more and more
common in couple relationships of persons with
Sexual Abuse
both heterosexual and homosexual orientations is The following examples constitute behaviors that
that partners bring more experience of relationships are considered sexually abusive.25
to new relationships. This is particularly visible ÐÐ Verbal demands for sexual interaction
in urban couples as expected, but is not entirely ÐÐ Threat of force, physical pressure exerted
rare in couples from the rural environment. to get partner to fulfill sexual demands, to
The changing social, economic, information cooperate with demands for intercourse or
technology context may be responsible for other sexual activity
bringing in some kind of uniformity in relationship ÐÐ Verbal/physical demands for the kind of
experiences. This, in turn, seems to explain much sexual activity, with which the partner is
of relationship anxiety that surfaces when a long- clearly uncomfortable
term (often permanent) relationship commitment
ÐÐ Criticism of the partner for being ‘frigid’ or
is to be expressed.
‘impotent’
Marital therapy literature has always
ÐÐ Threats to withhold sex from the partner in
acknowledged the close link between sexual
the future
and other marital problems. In fact, a sexual
ÐÐ Threats to have sex with someone else
dysfunction is not identified as primary, unless
ÐÐ Threats to leave partner
the couple shares a relationship of mutual caring
ÐÐ Very low desire for sexual activity due to
and respect and is able to provide each other
resentment or fear related to coercion used
sensitive sexual pleasuring. Conversely, sexual
by partner for sexual activity.
dysfunctions can also lead to feelings of general
relationship dissatisfaction, fewer expressions of
love or caring and avoidance of communication Violence and Affairs
about sexual matters. Low self-esteem and
depression can be individual outcomes of These two problems always threaten the
such problems.25 When a sexual dysfunction stability of a marital relationship. When there is
is evident, its impact on both partners must be physical violence in a relationship, it is usually
understood. Literature on marital relationship accompanied by sexual and psychological
 Section 2
Sexual Practices
108
violence as well. 26 In some relationships a emphasize influences of: family of origin,
pattern of physical, sexual or psychological dominant versus minority culture, gender
abuse may be used by one partner to exert socialization, and decisions about having
power and control over the other. Extramarital children. Community norms as well as the
affairs (or any cross boundary relationships) are person’s own views affect couple processes
often humiliating experiences for the partner. like committed coupling and monogamy. This
There is a loss of status and a breakdown is particularly so for the gay community where
of trust that can be very difficult to build up sexual experimentation and freedom are the
Comprehensive Textbook of Sexual Medicine

again.27 Many people, especially women, find norms. Lesbian couples are distinguished by
it difficult to acknowledge problems in these their unique arrangements that avoid power
areas. This occurs at the cost of their physical imbalances. It is a well established fact that
and psychological welfare. Often, society/media/ husbands and wives often get caught in power
literature sustains the myth about violence or battles linked to earning capacities Couples
affairs being part of the natural order. Many a where one partner has more control over income
time, when the overt presentation of the case and expenditure tend to be more distressed.29
is a sexual dysfunction, such problems may Conversely, research has also shown that
be underlying. If doctors are not sensitive to working women have to hand over control of
this possibility, victims may get misdiagnosed their pay packets to their husbands, in order to
and further victimized by the medical system. keep the peace at home.30,31 In extreme cases of
Relationship trauma of this nature can lead to power dynamics in couples, this may translate
devastating psychological consequences for the into sexual power games that destabilize the
abused/affected partner including depression, core of the relationship with loss of awareness
anxiety, fearfulness or loss of a sense of self. of one’s sexual boundaries and loss of respect
for partner’s sexuality.
Research in the Western cultures on fusion
Suspicion and intimacy in lesbian, gay, and heterosexual
It is interesting to note that in clinical practice, couples has shown some very surprising
suspicion in a relationship is often accompanied findings. Cultural stereotypes are that lesbian
by decreased sexual activity between the couple. couples seek fusion, and gay couples remain
Many individuals identify the start of major disengaged. However, research has shown
that both lesbian and gay couples tend to have
relationship difficulties with the cessation of an
more intimate, cohesive, relationships than do
active sex life. Even when there are several other
heterosexual couples.10 Another trend identified
problems, such as neglect, violence, discord and
is that money and status define the relationship
fights—it is the sexual relationship that often
along power lines for heterosexual couples.
carries most meaning for these couples. When
Lesbian couples, however, seem to be free to
this is hampered, the resulting insecurity is
grow in the relationship independent of these
expressed as suspicion of infidelity.
issues. One of the speculations is that since
these couples are less bound by traditional
Gay/lesbian couples gender roles, they have more freedom to develop
satisfying intimacy in relationships. In India,
Johnson and Colucci point out how difficult while this seems to enhance the relationship
coupling is for all couples, straight or gay/ quality, non-traditional identity continues to be a
lesbian.28 Yet, there are special issues in gay/ source of conflict and distress. Often, families do
lesbian couples due to same-sex pairing and not accept the relationship, and marginalize these
due to adaptations these couples have to make couples from mainstream social experiences.
to a devaluing larger culture. These writers These are among the many issues regarding
 chapter 9
Couple Relationship and Sexuality
109
homosexual relationships in the Indian context One may safely state that the childhood nurturing
that are yet to be explored by professionals. experiences and relationships contribute greatly
HIV/AIDS issues have also traumatized the towards the growth of a psychologically healthy
gay community tremendously, and their impact young adult. In comparison, experiences in close
on relationships is phenomenal. The biggest intimate relationships in adulthood have impact
challenge for the medical world presently is on well-being in early as well as later years of
that of the HIV/AIDS epidemic. This has direct adult life. Earlier theories tended to look almost
impact on many aspects of close and intimate purely on the effect the woman (particularly the

Comprehensive Textbook of Sexual Medicine

relationships. HIV/AIDS in India is a problem mother) had on the family. Current theories also
faced as much by heterosexual as homosexual examine the effect of the family on the woman.
couples. In fact with transmission of AIDS being Further, there is no doubt that relationships
largely heterosexual and through commercial contribute to an individual’s psychological as
sex workers this disease affects many marriages. well as physical well being. Also, sexuality
Couples where one partner is affected usually influences these experiences at many levels. It
stay together, either for economic, social or arises from the basic human need and transforms
humanitarian reasons. A majority of these patients itself into the web of relationships in the social
are sexually abstinent from the time of diagnosis matrix. Medical professionals dealing with
due to weakness in the patients, decreased sexuality-related issues need to be sensitive to
interest, and fear of contagion. Female patients the complex interplay between sexuality and
reported anger towards their spouses for infecting other relationship aspects. This will create a
them, and therefore, abstained from sexual more holistic and effective practice paradigm.
contact. For them it was possible to take care of
the husband’s health and basic needs for social
reasons, but the emotional and sexual bonds were
severed deliberately. However, some couples
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