January 19, 2004 Health
The Power of Love
How does our love life shape us--mind, body and soul? Let us count the ways
By Jeffrey Kluger

One thing you can say about lust, it sure shows up early. Talk all you want about the honey-sweet face of an innocent newborn, the fact is, from the moment we appear in the world, we're not much more than squalling balls of passion. Our needs aren't many: to sleep, to eat, to be held, to be changed. Satisfy these, and there won't be any trouble. Fail to, and you will hear about it.

Of all the urges that drive us, it's the passion to be held that makes itself known first. If a baby is startled fresh from the womb, German pediatrician Ernst Moro discovered in 1918, its arms will fly up and out, then come together in a desperate clutch. Holding is good, and floating free is bad—a lesson that's not so much learned after birth as preloaded at the factory. In fact, doctors have long known that babies who aren't held simply fail to thrive. Not surprisingly, it's a need we never outgrow. In one way or another, we spend the rest of our lives in a sort of sustained Moro clinch.

Physical contact—the feeling of skin on skin, the tickle of hair on face, the intimate scent drawn in by nose pressed to neck—is one of the most precious, priceless things Homo sapiens can offer one another. Mothers and their babies share it one way, friends and siblings share it another, teams and crowds in a celebratory scrum share it a third. And of course lovers share it in the most complex way of all.

Of all the splendidly ridiculous, transcendently fulfilling things humans do, it's sex—with its countless permutations of practices and partners—that most confounds understanding. What in the world are we doing? Why in the world are we so consumed by it? The impulse to procreate may lie at the heart of sex, but like the impulse to nourish ourselves, it is merely the starting point for an astonishingly varied banquet. Bursting from our sexual center is a whole spangle of other things—art, song, romance, obsession, rapture, sorrow, companionship, love, even violence and criminality—all playing an enormous role in everything from our physical health to our emotional health to our politics, our communities, our very life spans.

Why should this be so? Did nature simply overload us in the mating department, hot-wiring us for the sex that is so central to the survival of the species, and never mind the sometimes sloppy consequences? Or is there something smarter and subtler at work, some larger interplay among sexuality, life and what it means to be human? Can evolution program for poetry, or does it simply want children?

If there's indeed much more than babies involved in the reasons for sex, we're clearly not the first species to benefit from that fact. Even among the nonhuman orders, sex appears to be regularly practiced for a whole range of nonreproductive reasons with a wide range of community-building benefits. How else to explain the fact that homosexual behavior occurs in more than 450 species? How else to explain kissing among bonobos, nuzzling among zebras, literal necking among male giraffes? How else to explain the fact that some sexually active animals seem to avoid reproduction quite deliberately, mating at times that are unlikely to produce young or picking partners that are unable to do so? From 80% to 95% of a species of sea lion rarely or never reproduce, though they continue to couple. And so of course do many of us, chasing sex as passionately as the most prolific of breeders.

"How many times in your life do you think about being sexual," asks clinical psychologist Joanne Marrow of California State University, Sacramento, "and how many of those times are you thinking about reproduction?"

So what gives? And don't say simply that sex is fun. So are gardening and traveling and going to the movies, but when was the last time you woke up in the middle of the night with your heart pounding and your breath catching because of a dream you were having about a trip to Barcelona? Just as there's more to sex than babies, there's also more to it than fun.

Part of what makes touch—and by extension, sex—such a central part of the species software is that hedonism simply makes good Darwinian sense. It's not for nothing that hot stoves hurt and caresses feel nice, and we learn early on to distinguish between the two. "All creatures do things that feel good and avoid things that feel bad," says J. Gayle Beck, professor of psychology at the University of Buffalo. "The individuals who learn that best live the longest."

But mastering even so basic an idea can be a slow process, often too slow when survival is on the line. And so nature provides us with a head start. Before we have a chance to practice our first little Moro grab—before we leave the womb, in fact—our pleasure engine is humming. "Little boys can have erections from the day they're born, sometimes even in utero," says Marrow. "Both sexes get pleasure from touching themselves without having to be taught."

Once we're in the world, both nature and experience reinforce that need for physical contact, turning us into full-blown tactile bacchanalians. Nursing alone is a powerful reinforcer. The mechanics of animal nursing can be a utilitarian business, with wobbly-legged newborns standing up to drink from Mom as if she were a spigot. Human nursing, by contrast, requires flesh-on-flesh cuddling. What's more, a mother's metabolism ensures that this contact occurs more or less all day long. Anthropologist Sarah Blaffer Hrdy, professor emeritus at the University of California at Davis, points out that human beings produce very dilute breast milk, which necessitates frequent nursing sessions and therefore provides loads of opportunities for mother and child to touch.

The whole-body rapture found in Mom's arms lasts only through infancy, but children become expert at seeking the same security as they grow older, and good parents have a sixth sense about what the priorities are. A wailing child with a cut knee gets a long hug first, even though it's the bleeding wound that needs attention. In uncounted thousands of such tactile transactions, kids learn to use touch as a means of connection at least as expressive as—and certainly more satisfying than—anything so detached as speech. With the pump thus primed, they are ready for the next, exponentially bigger step: the moment, at age 12 or so, when the glands engage, the hormones flow and a childhood of simple physicality becomes a lifetime of sexuality.

From the moment the bodies of boys and girls are able to conceive, nature is very clear that it wants these mere babies to go about making babies of their own, and so it makes the impulse almost irresistible. There's a reason for the fabled sexual stamina of teens: the more frequent the pairings, the more likely the offspring. What's more, the pleasure of sex can often lead to long-term bonding, something else nature wants if babies and children—with their long years of dependency—are going to survive into adulthood.

But even at this unsophisticated stage of sexual maturation, there's more going on in kids than simply developing an exquisite reproductive itch and learning the wonderful ways it can be scratched. "More and more in our field, we don't even talk about sex anymore," says anthropologist Gil Herdt, director of the Program in Human Sexuality Studies at San Francisco State University. "We talk about sexuality. It's something that involves the entire person, the whole life course, not just the sexual acts."

Marrow agrees and takes the notion even further with the belief that human sexuality is a form of communication as much as it is of procreation. Nearly all creative acts are at least in part communicative. Songs are written to be sung to somebody else; pictures are painted to be hung for somebody else. Is it any surprise that sex—an act infinitely more intimate than any type of art—is also a creative way of communicating complex ideas and deep feelings? "The biologists think the biology comes first," Marrow says. "I think consciousness is the first part of sex, and exploring that consciousness with another person is one of its purposes." If Marrow is right, it's no wonder that poetry and music are often included in the business of romance, if only to make that message richer.

Of course, artistry—even something as small as a well-chosen greeting card or a romantic setting for dinner—may open the sexual door, but something else must keep it from closing again. What sustains a physical relationship after the early romantic rounds end is something more nuanced than seduction and more enduring than passion. Often it's something as wonderfully ordinary as stability. Partners who maintain a robust sex life are simply more likely to remain partners than those who don't, something almost any couple knew long before the sex researchers thought to quantify it. If it is hard to be physical with a mate you've stopped loving, it can be equally hard to get to that cold point with a person with whom you still share the intimacy, exclusivity and, especially, vulnerability of sex. This is particularly true as the intoxication of a new relationship begins to fade and partners start to notice flaws they were too romantically tipsy to see before.

Not only does the relationship benefit from a steady sex life, but so can the physical and emotional health of the partners themselves. Research suggests that married people may live longer than singles, that happily marrieds do best of all, and that couples who remain at least somewhat sexual, even into their dotage, report a better level of satisfaction both with their relationships and with their lives as a whole. Certainly, it's hard to say if people who start off happy and satisfied simply have more sex or if it's the sex that makes them happy and satisfied. Whatever the answer, it's clear that human beings would not be fully Homo sapiens—at least not as we've come to understand ourselves—without the great, mysterious, preposterous pageant of our sexuality.

The Chemistry of Desire
Everyone knows what lust feels like. Scientists are now starting to understand how it happens
By Michael D. Lemonick

Eight years ago, after she had a hysterectomy at age 42, Roslyn Washington was left with an unexpected side effect. Her doctors, who had recommended removing her ovaries as well as her uterus because of fibroid tumors and an ovarian cyst, had warned her about a lengthy recovery period. But, she says, "I was not aware of the fact that there would be a decrease in my sexual life." That's something of an understatement. Washington, an office manager from Silver Spring, Md., who is married and has a teenage daughter, says that after the surgery she felt no sexual desire whatsoever. "I didn't think about it," she says. "I didn't get that urge from a glance or a look or a touch." It was a profound loss. "Without that connection, without the sexual aspects, you feel in some instances like you're really less than a woman," she says.

Then several years later Washington heard a radio ad seeking women like her for a study of testosterone patches. People usually think of testosterone as a male hormone, but women have plenty in their systems too, and researchers have reason to believe that the hormone is involved in the female sex drive. About half of women's testosterone is produced in the ovaries, so the patches were an attempt to replace what had been lost through surgery. Washington signed up and was one of 75 women accepted for the study out of 50,000 who applied; clearly she was not alone in her misery. Twice a week for the next year she affixed a thin, clear patch onto her abdomen, alternating sites over where her right and left ovaries used to be.

Washington didn't know whether she was receiving transdermal testosterone or a placebo. She did know that things were very different. "I hadn't felt like that in years," she says. "I felt stimulated. It was like, 'Oh, yeah, I'd forgotten that's what it feels like.' It was good." Alas, when the trial ended, her desire ebbed.

It's tempting to conclude that Procter & Gamble, manufacturer of the testosterone patch, had found the elusive chemical key to female desire. The study, published in 2000 in the New England Journal of Medicine, reported that many of the women who, like Washington, were on real testosterone had more sexual fantasies and more sex and masturbated more than they had before. But so, albeit to a lesser extent, did women who wore patches with no testosterone at all. For women suffering from lost libido, the placebo effect was almost as strong as that of the hormone. In short, the mere belief that the treatment would rekindle sexual desire was often enough to turn up the heat.

This finding illustrates the promise and the perplexity of research into the biology of human sexuality, where mind, body and experience are endlessly intermingled. People find themselves turned on in obvious situations—slow-dancing together, seeing someone with a sexy body, finding a member of the opposite or same gender to be excitingly sharp-witted or funny. But carnal longings strike at surprising times too—in the wake of a victory by your favorite team (for men, anyway) or at times of fear or even after a tragedy, like the death of a parent.

No matter how lust is triggered, though, sex, like eating or sleeping, is ultimately biochemical, governed by hormones, neurotransmitters and other substances that interact in complicated ways to create the familiar sensations of desire, arousal, orgasm. By understanding how that happens, scientists should in principle be able to help people like Washington for whom sex just isn't working. And indeed, over the past decade or two, scientists have identified many of the pieces of this complex puzzle. It clearly involves testosterone, along with other hormones, including estrogen and oxytocin, and brain chemicals such as dopamine, serotonin and norepinephrine. And there are numerous other bodily chemicals that turn us on, ranging from the commonplace, nitric oxide, to the obscure, vasoactive intestinal polypeptide.

Scientists have also learned that the old notion that 90% of sex is in the mind is literally true: the parts of the brain involved in sexual response include, at the very least, the sensory vagus nerves, the midbrain reticular formation, the basal ganglia, the anterior insula cortex, the amygdala, the cerebellum and the hypothalamus.

If all this sounds complicated, it is. Researchers are still struggling to understand how these pieces fit together and how they might be different for men and women. It's not clear which chemicals of desire are unleashed and under which circumstances, because setting and mood, as women know better than men, can make all the difference between arousal and annoyance.

Nevertheless, scientists are light-years ahead of where they were in the 1920s and '30s, when estrogen and testosterone were first identified, and they know a great deal more than they did in the 1940s, when Alfred Kinsey, followed by the research team of William Masters and Virginia Johnson in the 1960s, published some of the first scholarly studies of human sexuality. Those studies concluded that sexual response proceeds in distinct stages, beginning with excitement—erection in men, engorgement of vaginal and clitoral tissue in women—proceeding to orgasm and finally to "resolution," in which tissues return to their normal state.

They didn't delve into biochemistry, though, and it turns out they probably didn't get the stages right either. In the 1970s psychiatrist Helen Singer Kaplan, who founded the Human Sexuality Program at New York Weill Cornell Medical Center, pointed out that before you get physically aroused, you have to feel sexual desire—a statement that seems pretty obvious. It's also pretty obvious to anyone who has been in a heterosexual relationship that men and women tend to experience sexuality somewhat differently. So where Masters and Johnson saw sexual arousal as a linear progression toward orgasm, researchers like Dr. Rosemary Basson of the University of British Columbia argued in 1999 that women, at least, operate in a more circular pattern. Desire can precede stimulation or be triggered by it. Satisfaction is possible at any of the stages. And orgasm isn't necessarily the ultimate goal.

Stimulation, moreover, can take all sorts of forms. Says Dr. Jennifer Berman, a urologist and director of the Female Sexual Medicine Center at UCLA: "Women experience desire as a result of context—how they feel about themselves and their partner, how safe they feel, their closeness and their attachment." Men, says Berman, "tend to be more visually directed and stimulated than women are." Thus Playboy and Hooters and the estimated $10 billion-a-year mainly male-oriented pornography industry.

But the reasons for that difference may be as much cultural as they are physiological. Dr. Julia Heiman, a psychologist and director of the Reproductive and Sexual Medicine Clinic at the University of Washington Medical School, is one of a growing number of researchers who think it's misguided to see men as simple and linear and women as complex and circular. "I don't think we've taken the time to talk to men about what desire is," she says. "If they are emotional about their sexuality, they don't feel in step with other men."

Women who don't fit stereotypes don't fare much better, says Jim Pfaus, a psychologist at Concordia University in Montreal who studies behavioral neurobiology. "What is a woman who expresses arousal in response to blatantly visual sexual cues? I hope we've moved beyond calling her a slut while calling a man who does the same a stud." But the cultural prejudice behind those labels persists, he says.

Research by Meredith Chivers at the Center for Addiction and Mental Health, affiliated with the University of Toronto, shows that women do respond to sexy visual stimuli. In fact, in a study recently presented at a Kinsey Institute conference on female sexuality, Chivers found that women show physical signs of arousal in response to a wider variety of images (including films of bonobo chimps mating) than men do. But unlike in men, this physical arousal is not closely paired with a subjective feeling of being turned on. In short, physical arousal for women can come before or even in the absence of conscious desire—doubtless a source of much confusion between the sexes. Arousal and desire can also happen at once.

But while arousal and desire are intimately intertwined and probably involve all sorts of feedback between brain and genitalia that have yet to be untangled, at least some of the underlying biochemistry is becoming clear. Here is a catalog of some of the key chemicals of love:

—LETTING IT FLOW

Desire is complicated. Arousal, by contrast, is pretty straightforward: fill the penile arteries with blood or divert blood to the vagina and clitoris, and you're there. "Once the brain gets turned on—however it gets turned on—it's a relatively simple concept to increase blood flow," says Dr. Alan Altman, a specialist in menopause and sexuality at Harvard Medical School. In men, a chemical that facilitates the flow is vasoactive intestinal polypeptide, a hormone that also directs the expansion and contraction of smooth muscles in the gastrointestinal tract.

But the primary chemical in charge of that function is nitric oxide. It's a vascular traffic cop, activating the muscles that control the expansion and contraction of blood vessels. If the mind is in the mood—or when you pop a nitric-oxide-boosting drug such as Viagra or Levitra—the body responds. Men tend to be more focused on genital stimulation than women, so they are more likely to perceive an increased blood flow to the genitals as arousal, while women may be unaware of it. That may be one reason why trials of Viagra on women have been disappointing.

—FUELS FOR LUST

If there's one substance that ultimately makes it possible to get turned on in the first place, testosterone is probably it. "When testosterone is gone," says UCLA's Berman, "for whatever reason—aging, medication—men experience erection and libido problems." Restore the testosterone, and you usually fix those problems.

Women too seem to have problems getting interested in sex when their testosterone levels are too low, which is why Procter & Gamble is experimenting with testosterone patches. Says Altman: "When women are having normal menstrual cycles in their prime reproductive ages, their ovaries make two times more testosterone than estrogen." A few days before ovulation, triggered by surging levels of testosterone—along with other hormones including progesterone and estrogen—sexual desire peaks, according to new research by Martha McClintock of the University of Chicago that dispels a long-held theory that fertility precedes desire.

But for women, at least, estrogen may also be crucial. "Give estrogen to women with decreased desire," says Pfaus, "and you don't restore desire. Give them testosterone alone, and you get a little increase in desire. Give them estrogen and testosterone together, and you get a whopping increase." Why? Some research suggests that testosterone's role in women is diversionary: it attaches to so-called steroid-binding globulins in the blood that would otherwise latch onto estrogen molecules and render them inert. The testosterone is taken away to the liver, while the estrogen is free to make a lust-inducing dash for the brain.

Pfaus argues further that estrogen may be the ultimate love hormone for men as well. "A lot of studies on rats and birds," he says, "show that brains are like giant ovaries, in the sense that testosterone and other androgens are converted into estrogens in the hypothalamus. And this conversion appears to be critical to the expression of male sexual behavior."

—THE FEEL-GOOD CHEMICAL

Both testosterone and estrogen trigger desire by stimulating the release of neurotransmitters in the brain. These chemicals are ultimately responsible for our moods, emotions and attitudes. And the most important of these for the feeling we call desire seems to be dopamine. Dopamine is at least partly responsible for making external stimuli arousing (among other things, it's thought to be the pleasure-triggering substance underlying drug addiction). "Being low on dopamine," says the University of Washington Medical School's Heiman, "correlates with being low on desire." And in men dopamine-enhancing drugs (including some antidepressants and anti-Parkinson's medications) can increase desire and erections. So can apomorphine, a Parkinson's drug that latches directly onto the dopamine receptors in brain cells and turns them on.

Another neurotransmitter almost certainly involved in the biochemistry of desire is serotonin, which, like dopamine, plays a role in feelings of satisfaction. Antidepressants like Prozac, which enhance mood by keeping serotonin in circulation longer than usual, can paradoxically depress the ability to achieve orgasm. But "dopamine and serotonin," says Heiman, "appear to interact with each other in a complicated way to impact desire."

So, researchers suspect, do the neurotransmitters epinephrine and norepinephrine, whose usual job is to pump up our energy when we're in danger. Blood-plasma levels of both chemicals increase during masturbation, peak at orgasm and then decline, and by-products of norepinephrine metabolism remain elevated for up to 23 hours after sex. It's not yet clear, though, whether this is a cause or an effect of arousal.

—THE CUDDLE HORMONE

Endocrinologists have known for years that oxytocin, released by the pituitary gland, ovaries and testes, helps trigger childbirth contractions, milk production during nursing and the pelvic shudders women experience during orgasm (and possibly the contractions during male orgasm as well). The hormone is believed to play a vital role in mother-child bonding and may do the same for new fathers: oxytocin surges when a new dad holds his bundle of joy. Some researchers also think of oxytocin as a cuddle chemical. Preliminary studies by psychiatrist Kathleen Light at the University of North Carolina have found that oxytocin levels rise after couples hold hands, hug or watch romantic movies. It also may be what makes you want to stay with your partner until the morning after sex. Those who can relate to Billy Crystal's "How long do I have to lie here?" scene from When Harry Met Sally might question whether oxytocin affects both genders equally.

But there's increasing evidence that oxytocin is also involved in deeper bonding. It certainly plays that role in a much studied little rodent called the prairie vole, which is famous for its fidelity to its mate. The critter's brain releases a rush of oxytocin as it bonds with its beloved. Block the chemical, and voles fail to make a connection. Inject more of the hormone, and they fall for each other even faster.

A similar kind of imprinting might take place in humans. "Oxytocin release may help us bond to certain features in our partners," says Pfaus. "It's probably part of the mechanism that generates the template of what we find attractive." The next time you see your partner or someone like your partner, he theorizes, "the oxytocin is activated. It doesn't mean you have to be aroused. You just think, God, what a beautiful woman"—which might explain why we're attracted to the same type over and over.

—ATTRACTIVE AROMAS?

Probably the most controversial issue in the chemistry of sexuality is the role of pheromones. In 1971 the University of Chicago's McClintock, then a Wellesley undergraduate, proved scientifically what women in dorms had known for decades: menstrual periods become synchronized when women live together. It's probably because of pheromones, she said—olfactory chemicals that we can detect even though we're not aware of them. In 1998, she did experiments that proved this hypothesis, but, unlike animal pheromones, no human versions have been isolated.

Because menstrual cycles and sexuality are part of an overall system, it's possible that pheromones could trigger desire. Perfumemakers that market pheromone-based scents have latched onto this notion. It's plausible, says Altman, "but I don't think the science is very good on it." Pfaus agrees: "I hope it's true. Totally on faith, I believe it. The problem is that the scientist in me says, 'O.K., but what are these pheromones, and who has shown it?'"

—A DOUBLE SHOT OF LOVE

A newly identified substance that has captured Pfaus's interest is alpha melanocyte polypeptide, also known as melanocyte-stimulating hormone (MSH). In clinical trials, this pituitary hormone had the dual effect of giving men erections and heightening their interest in sex. Pfaus is studying a synthetic version for Palatin Technologies of Cranbury, N.J., which is developing it as a nasal spray. "It's astonishing that you have a little peptide that has such a big, specific effect," he says. It interacts with dopamine, but how, precisely? "We don't know," he says.

Like all substances that promise to increase desire and performance, whether they are prescription drugs or folk aphrodisiacs sold next to the cash register at the quick-stop store, MSH is tough to investigate because of the placebo effect. As Procter & Gamble discovered with its testosterone-patch study, arousal and desire are so entangled with one's state of mind that it's tough to figure out cause and effect. Says Altman: "If you're in a tribal society and taught that something is an aphrodisiac, it probably will be. But someone in Los Angeles taking the same thing probably won't get the same effect."

Maybe that's just as well. For those who suffer from a lack of interest in sex, like Roslyn Washington, it's great to have a treatment that works. But like the women in the testosterone study who responded to a placebo showed, the real point is to create a sex life that works. Feeling is believing, and vice versa. We experience attraction and sexual desire as a sort of magic, a phenomenon filled with delightful mystery. And if scientists continue to be overwhelmed by the complex interplay of dozens of substances percolating from mind to body and back, that keeps the mystery nicely intact.

— Reported by Sonja Steptoe/Los Angeles

The Marriage Savers
Does couples therapy really work? The divorce rate says no, but a new breed of therapists offers hope
By Richard Corliss and Sonja Steptoe

The cynic Ambrose Bierce defined love as "a temporary insanity, curable by marriage." It's truer to say the first blush of love is a vacation from reality; marriage is the job you return to. You may like your job, even love it. But you have to work to keep it.

In modern America, there's no shortage of professionals ready and willing to pitch in with the task. In fact, over the past 40 years, the couples-counseling business has exploded. In 1966 there were only about 1,800 experts practicing in the field, according to the Department of Health and Human Services. In 2001 the American Association for Marriage and Family Therapy listed 47,111 marriage and family therapists in the U.S. and estimated that they treat 863,700 couples a year.

Yet how many were helped? The growth of the marriage-industrial complex has not done much to slow the national divorce epidemic. In 1965 the divorce rate was 2.5 per 1,000 people; it reached a high in 1979 and 1981, with 5.3 per 1,000. Today the figure hovers at about 4.0, pretty much where it has been for five years. In some quarters, the suspicion has lingered that the therapist's job is to validate a patient's complaints and act as ministers in reverse, putting couples asunder. "The idea of therapist neutrality often came down to support for breaking up," says William Doherty, director of the Marriage and Family Therapy Program at the University of Minnesota. And therapists weren't appreciated for it. In a 1995 Consumer Reports poll, couples seeking therapy gave marriage counselors low grades for competence.

Lately, however, a new breed of therapist and "marriage educator" is shaking up the profession. These therapists reject the passive, old-style therapies that emphasize personal growth over shared commitment and take a more aggressive, hands-around-the-neck approach to saving marriages. "They feel therapists have been too quick in calling an end to relationships and having people move on," says University of Chicago sociology professor Linda Waite. The new breed also advocates premarital skill training and early intervention in problems--learning the ropes before tying the knot. "It's like a vaccination," says Waite, "instead of having to do surgery when something goes wrong."

The new, pro-marriage generation "is young, far more conservative and more religious" than traditional therapists, says Doherty, author of Take Back Your Marriage. "This generation has seen the fruits of the divorce revolution. And they don't think they have to be value-neutral about it." They also tend to be pragmatists. Many of them favor short-term, low-cost interventions based on methods with a record of proved success.

These qualities have drawn the support of religious leaders and conservative politicians, including First Husband George W. Bush, who would like to make marriage education for young couples part of welfare reform. "This is a social movement," says Doherty, "that involves government, church, professional and lay people." How do these therapies and lessons in connection work? A look at some methods of the movement:

--GOING TO "PREP" SCHOOL

Prep, short for prevention and relationship Enhancement Program, aims to be the industry leader in research-based couples education. Its tenets, which emphasize structured communication, are ingredients in a variety of programs for teens, pre-marrieds and long-marrieds.

Rod Grimm Lewis and his wife Victoria paid $400 to attend a two-day PREP seminar in Los Angeles in a final attempt to save their 28-year-old marriage. "I think this will help," says Victoria, the more eager of the two. "I think of it as chemotherapy." Rod figures he's being a good sport. "I came because she asked me to," he says. "I'm about 5% of the problem, and she's 95%." Marc Sadoff, the workshop leader, says, "It's good to hear that you can acknowledge you're 5%. So many people can't see any role in the problem."

Positive communication, like Sadoff's comment, is the backbone of PREP, developed in the 1980s by psychologists Howard Markman and Scott Stanley, co-directors of the Center for Marital and Family Studies at the University of Denver. In developing it, Markham spent years taping couples having arguments and devising ways to break bad habits. The method, which relies partly on videos of other couples using the technique, is continually tweaked in light of new research, says Stanley. "The idea was to build a program for couples that was based on sound research," he says, "rather than armchair clinical speculation."

Sadoff, a clinical social worker trained in PREP, explains the method to the Lewises and a younger couple sharing the session. They are to agree to set aside a time each week to talk over their problems. These discussions must follow certain rules, which can be posted on the refrigerator door. "The word I is allowed," Sadoff says. "You is not." The partners take turns talking, without interruption. The speaker makes brief statements, which the listener must paraphrase to show he understands what was said. There are also time-outs, which allow one partner to leave the room for an emotional break. That's a scary notion for Victoria, who says that since childhood she has never felt she could leave a heated discussion without repercussions. "Where would I go?"

Rod and Victoria give it a try. While Victoria is speaking, Rod interjects to ask a question. That's not allowed, he's told. Later he doesn't correctly paraphrase what she said. Rod tries again. When he gets it right, Victoria smiles and says, "Yes! That's good." For a moment they have connected. But Rod is struggling to remember his role, and Victoria still feels unnatural: "Does anyone really talk like this?'' Sadoff assures her she will get better with practice. He explains that, although artificial, the technique provides a safe way for couples to talk about thorny issues. "We're after progress, not perfection," he says.

Six months after the first session--and despite follow-up therapy with Sadoff--problems linger. "We tried, but the techniques just don't take care of the deeper issues," says Rod, who is thinking of ending the marriage. "The future of our relationship doesn't look good."

But many evaluators award PREP high marks. While two studies did not find it more effective than other methods, two others, involving a total of 210 couples, found that those who take PREP, either before marriage or after, have lower rates of breakup and divorce than couples who took a different training class or did nothing. Also, seven studies involving about 500 couples concluded that PREP participants had less negative communication for up to five years after the course. Men are particularly partial to the method.

Such results have made PREP popular around the world and in a wide range of settings, including U.S. military bases and churches. Oklahoma has embraced it as part of a $10 million government initiative to reduce divorce. That's how Shelitha and John Coleman Jr. came to PREP in November, in a Christianized version offered free at their church, G.A.P. [God's Apostolic Prophetic] Restoration Tabernacle in Oklahoma City. The Colemans' marriage of nearly two years was doing fine, but John's parents didn't seem to think so and were interfering. "They wanted me to have the same kind of marriage they had, where I'm the man and I run the whole show," explains John, 28. He and Shelitha, 29, needed a way to declare their independence without sounding rebellious.

PREP techniques helped them do that while improving their own communication. John's parents, says Shelitha, "were having trouble letting go. Our talk revealed some things about how they feel about seeing their children grow up and live on their own. Now all four of us are using PREP methods." The religious aspect of the program was important to the couple. "We make the word of God part of the foundation of our marriage," says John. "In terms of communicating, it shows up in principles about being honest with your partner about everything. When a difficult problem comes up, you shouldn't hide."

--LESSONS FROM THE LOVE LAB

Heinrich Heine called marriage "the high sea for which no compass has yet been invented." John Gottman figures he has found the compass. At the Gottman Institute in Seattle, a husband and wife sit in sensor-loaded chairs with wires strapped across their chests, taped to their fingertips, clipped to their earlobes. The wires are connected to an array of computerized measuring devices that will track physiological data about them. As the couple discuss a glitch in their marriage, a technician in the next room monitors the data: heart rate, sweaty palms, the speed of blood flow. Another technician watches them on a video screen, recording facial expressions, calibrating emotional vital signs of couples during actual marital conflict. Survivor, Fear Factor--that's kid stuff. This is true reality TV.

Gottman, a clinical psychologist, has essentially distilled the art of love and war--a.k.a. marriage--into a kind of science. After 30 years of such studies inside his physiology lab, nicknamed the Love Lab, Gottman's group has developed a model that he claims can assess whether a couple are on a path to dysfunction. Now when Gottman wires up therapy clients and videotapes them, "in the first three minutes of the conflict discussion," he says, "we can predict if a couple is going to divorce." He and research partner Robert Levenson of the University of California, Berkeley, found that during arguments, couples in stable relationships have five times as many positive factors present as negative ones. "In relationships that were working, even during conflict, there was a rich climate of positive things, such as love, affection, interest in one another, humor and support. Couples in unstable unions had slightly more negative factors than positive."

Conflict is endemic in a relationship, Gottman says, but adds--with peculiar precision--that "only 31% of conflicts get resolved over the course of a marriage. The other 69% are perpetual, unsolvable problems." His insight: don't bother trying to fix the unfixable. Spend your energy on selecting a mate with whom you can manage those inevitable annoyances, then learn how to manage them. To admit some problems can't be solved is the first step toward finding a larger solution. Says Gottman: "We try to build up the couple's friendship, their ability to repair conflict and to deal with their gridlock."

The Gottman technique usually involves a $495 two-day workshop, followed by nine private therapy sessions costing $1,260, which Gottman recommends as a supplement. These attempt to conquer the four most common, corrosive negative factors in unstable unions: criticism (You never ... You always ... ), defensiveness (Who me? I'm not defensive), contempt (You're too stupid to realize how defensive you are) and stonewalling (I'll just let it blow over). Gottman says 85% of stonewallers are men.

Gottman fiercely protects the privacy of his patients and does not provide names of couples to be interviewed. He says his five-year follow-up study shows that after one year, about 75% of the treated couples are happier, "[though] we haven't been able to help the other 25% calm down. They stay irritable, cranky and contemptuous."

--LET'S GET SCHNARCHED!

That cranky quarter of the peace-seeking married contingent may find a sympathetic soul in David Schnarch, author of the book Passionate Marriage and creator of the Crucible Approach to marital therapy, which upends nearly all the conventional tenets of couples counseling. He says he is the therapist of last resort for many couples who go to his Marriage and Family Health Center in Evergreen, Colo., for an intensive four-day session: "The worse shape your marriage is in, the more this is the approach of choice." Nor does he recommend that a warring couple break up--that's just "one way therapists can bury their errors."

Schnarch argues that the main issue for most troubled couples "isn't their lack of communication skills. If spouses aren't talking to each other, they are still communicating. They each know they don't want to hear what the other has to say. But communication is no virtue if you can't stand the message. We help people to stand the message." He says couples don't get that from conventional therapy, which tends to pathologize relationships rather than work with their strengths. In the Crucible system, "we don't treat people like they're sick. We speak to the best in people, not their weaknesses. We're about developing resilience and standing up for yourself." People in a troubled marriage say they have grown apart. Schnarch says it's the opposite. "They're usually locked together, emotionally fused. More attachment doesn't make people happier, and it kills sex."

Schnarch uses the word crucible in two senses: metallurgical (a strong cauldron) and metaphorical (a test or trial). Both definitions can aptly describe the state of marriage. So in his therapy it's out with the elevator-music approach to saving marriages, in with the hard rock and harsh truths. Dare to tear apart the fuzzy, flabby, ego-suppressing dual personality that is your marriage and find your inner you. That effort will create a stronger individual, one who can deal with a partner with more integrity and authenticity.

Ken Wapman, 45, manager at a Bay Area software firm, and Margee, 45, a therapist, had been married 18 years when they signed up for Schnarch's program in 2001. Busy with their jobs and three kids, their marriage was somewhere between O.K. and icky. "The relationship was sustainable but not very satisfying," says Ken. And their sex life, he says, "was like your commute. You could practically do it with your eyes closed"--er, don't a lot of people do it that way?--"but you don't really look forward to it."

The Schnarch approach immediately appealed to Ken. "I liked that he didn't pull any punches," says Ken, who used to disagree with his wife and others just for the sake of it. "I used to use more imperative-type language. Schnarch helped me to think about developing more collaborative alliances." Working with Schnarch after trying other therapists, says Ken, was like "jumping into a Ferrari compared to driving a Toyota Celica."

At first the Crucible was a bit searing for Margee. "He forces you to see things in yourself that you haven't wanted to see. I used to think Ken's job was to take care of me by knowing how I felt. That's an idea embedded in the culture." Now, Margee says, she has learned to take care of herself. "I'm not dumping anything on him; I have worked my side of the issue. There is less unresolved tension. As a result, I feel love and want to move toward him."

The benefits of the weekend (cost: $925) inspired Margee to want to follow up with the Schnarch nine-day retreat ($2,400). Ken, less enthusiastic, offered a counterproposal. "I cut a deal with her. I said I would go with her to the retreat if I could go on a two-week bike trip in the French Alps." Sounds like Schnarchian self-differentiation in action.

--MAKE AN EFT TURN ON RED

Listen to enough marriage plaints, and you may conclude that Tolstoy was wrong: unhappy families really are all alike. They argue over sex, money, the kids, the lack of free time. After five years of marriage, Tom, 39, and Suzanne, 35, sparred with increasing frequency and rancor over the usual "spending" issues. He thought she was spending too much money; she thought he wasn't spending enough time with her and their two children. The counseling they tried didn't help. "It just made the situation artificial," says Suzanne. She's the verbal one; Tom, from a military family, is the strong, silent type. "So when we would argue, he gets sort of blasted out of the water by me, and he shuts down and shuts me out. It escalated to the point where he was, like, 'I'm out of here.'"

Hoping to break the pattern, they went last May to see Douglas Tilley, a Maryland clinical social worker who uses EFT--Emotionally Focused Therapy--a procedure that, in direct opposition to Schnarch's Crucible, focuses on the emotional need for connection and closeness with your spouse. EFT was devised about 20 years ago by Sue Johnson, a professor of psychology at Ottawa University, and Les Greenberg, now a professor at York University in Canada. "In our culture, we have this funny thing where we see maturity as being independent, not needing other people," says Johnson. "But when the Twin Towers came down in New York, what did people around the world do? They held on to the people they were with, they phoned the person they depend upon the most."

Modern life has overloaded marriage, says Johnson. "Our sister no longer lives next door, our mother phones us once a month, we're too busy at work to create lasting bonds there. So we're even more dependent on our spouses than ever before." In a distressed relationship, that bond is fraying. Typically, one person criticizes and complains, while the other falls into a pattern of defending and withdrawing. "The amazingly sad thing," says Johnson, speaking of the typical pattern in couples, "is they love each other. The man loves his wife so desperately that he has put up this huge wall because he's so terrified he's going to hear that she's disappointed in him. Unless they can find a way into a more secure bond, they'll split."

To re-create a sense of connection between the couple, the EFT therapist creates an environment in which both spouses feel safe talking about their feelings, needs and fears. Like Suzanne and Tom, most couples are pleasantly surprised to hear that the feelings behind apparently hostile behavior are not rejection but a need to connect with their partner. Without that emotional security, Johnson says, all the communication skills in the world won't rebuild a relationship. "You can teach people communication skills up the wazoo," she says, "but if they're afraid of losing the person they depend on, they don't use them."

EFT is one of three approaches that the Society of Clinical Psychology, a division of the American Psychological Association, has found to be backed up by empirical research. Yet it hasn't become a mass therapy in the U.S. One reason may be that no one has yet written a best seller about EFT. And Johnson says EFT is not for abusive marriages. She once turned away a couple in which the husband was so verbally abusive that Johnson decided she shouldn't force the wife to reveal her deepest emotions. "I'm not going to encourage one person to do that when the other is standing there with a machine gun in hand," she says.

EFT seems to have disarmed Suzanne and Tom. Suzanne knows little about its theoretical bases--she calls it "EFT, EMF, whatever"--but she likes the results. "Since we have been going to therapy, Tom says a huge burden has been lifted off him. He's never talked about this kind of stuff before in his life." He now spends much more time with Suzanne and the children and less time with his buddies at the sports bar. Twice a month the couple put the children to bed and have a date--either at home, over a delicious dinner, or out at a restaurant. "We're at the point where if we're having hard times," Suzanne says, "it brings us together rather than apart."

--BRING ON THE DIVORCE BUSTERS

In a studio session to record a CD, David Roth, 39, a Chicago-area sculptor turned singer-songwriter, was having trouble with the part-time bass player--his wife Heidi Meredith. Both had grown up in broken homes and hoped to avoid separation. But after more than a decade together, they had devolved into chronic arguers: how to make the bed, how to make music. "We were in this decaying orbit that was going to crash and burn," says Roth. Says Meredith, 39: "It was never a question of our not loving each other. We would just completely butt heads, and then we would analyze it to death. That just got us in deeper."

Roth suggested they get help. Meredith, who in her day job is a psychiatrist, was skeptical. "I can't tell you how many patients I have seen who have also been in marital therapy for a year or more," she says, "and all they do is scream at each other."

They booked sessions with Michele Weiner-Davis, author of Divorce Busting and The Sex-Starved Marriage, who practices in Woodstock, Ill., outside Chicago. While many marriage therapies last months or years, Weiner-Davis says, her patients were usually out in half a dozen visits. Her technique favors action, not introspection.

"Traditional approaches ask people to look at the past and figure out why they're stuck," says Weiner-Davis, whose graduate degree is in social work. "But that insight generally leads people only to be experts in why they're having a problem--and novices in what to do about it. People on the brink of divorce do not have the luxury of time to take this journey backward. They need an instant injection of hope." Weiner-Davis encourages a dose of what she calls "real giving"--asking couples to realize what their partner needs in certain situations and provide what he needs regardless of whether the giver understands it. For example, if your spouse prefers to be alone when he's upset, allow him quiet time, even if you prefer to talk when you're upset.

Weiner-Davis' action-oriented scheme suited Roth and Meredith. "It's really freeing to just focus on the solution and clear out all the muck," says Meredith. Weiner-Davis encourages couples to identify what they want the marriage to look like, then list actions they can take--dinner out once a week, playing tennis or golf together, help with the housework--to achieve those goals. "The concept of real giving is so simple, but it really gets at the heart of how to make a relationship work," says Meredith.

The approach appeals equally to both sexes. If a guy can be convinced that his marriage is like a rusty carburetor or a clogged kitchen sink, he may be stirred to fix it. "I think men are hesitant to go into therapy because they feel they're going to be targeted," Roth says. "Michele's approach is pragmatic and practical. That's refreshing for a lot of men."

Some of Weiner-Davis' recipes earn hoots from others in the fractious fraternity of couples therapists. Of her advice that troubled couples should "just do it!"--have sex to jump-start a passionless marriage--Schnarch retorts, "Telling low-desire spouses to just do something just pisses them off. Most couples seeking help are angry, and angry sex isn't very generous. These people would rather poke each other's eyes out than stroke each other's genitals."

But she has plenty of satisfied customers--the Roth-Merediths, for two. They work (at their marriage) and play (she's now his band's official bass player). And their son, 4, has noticed the difference. When his parents fought, he used to throw things and scream. Now he sees his parents hugging and delights in squishing himself in to share the love. "I think it has improved the quality of his life," says Roth. "There's a lot more laughter in our house."

--CAN GOOD MARRIAGE BE TAUGHT?

What if you could go to school instead of to a shrink? That's the idea behind Marriage Education. "It's less expensive and more effective than therapy," says Diane Sollee, 59, who gave up her marriage-therapy career to create the Coalition for Marriage, Family and Couples Education. "The therapy model is 'I'll treat you, and, voila, your marriage will work.' The education model is much more respectful. It assumes there's nothing wrong with you--you're not sick. You just need better information, and it assumes you can apply it to your situation. It's also not a long-term process."

Every system sounds great--until you ask other marriage specialists about it. "To say therapy isn't working is absolutely wrong," Gottman insists. "These psycho-education interventions are powerful; you have to be careful about applying them. Currently, people in the marriage movement aren't being careful. They go ahead with tremendous optimism and convince people that this is key to family stability. I worry that it will all collapse when couples see that it can't be done that way. This isn't like driver ed." No, but when experts start comparing claims and stats, you hear the cacophony of rival used-car salesmen.

Is it the therapists who need educating? Or is it the Marriage Ed folks who need therapy? Somewhere there has to be detente between the clinical remoteness of one group and the evangelical salesmanship of the other--a middle ground, perhaps even a common ground. "A lot of therapy is education," says Gottman, "and a lot of education is therapy." At a time when America's marrieds and soon-to-bes are eager for mediation, the bickering of the two sides is unhelpful. Maybe both sides should consider this advice--both priceless and free--from that sage counselor Ogden Nash:

To keep your marriage brimming,
With love in the loving cup,
Whenever you're wrong admit it;
Whenever you're right shut up.

— Reported by Amanda Bower and Deirdre van Dyk/New York and Wendy Cole/Chicago

Sexual Healing
What feels good is good for you too. Making love can boost the heart, relieve pain and help keep you healthy
By Alice Park

The "sex glow." Carrie Bradshaw and her Sex and the City trio may be the champions of detecting it, getting it and keeping it, but you don't need a closetful of Prada to appreciate the rosy radiance that follows a pleasant sexual encounter. The fact is, sex leaves its mark, not just on the mind but on the body as well. Researchers have begun to explore its effects on almost every part of the body, from the brain to the heart to the immune system.

Studies are showing that arousal and an active sex life may lead to a longer life, better heart health, an improved ability to ward off pain, a more robust immune system and even protection against certain cancers, not to mention lower rates of depression.

But finding mechanisms for these benefits and proving cause and effect are no easy matter. "The associations are out there, so there has to be an explanation for it," says Dr. Ronald Glaser, director of the Institute of Behavioral Medicine Research at Ohio State University. Thanks to a better understanding of the biochemistry of arousal, as well as advances in imaging techniques, doctors are closing in on some possibilities. Their efforts are leading them to the hormone oxytocin, which may be the key lubricant for the machinery of sex. Known for controlling the muscles of the uterus during childbirth, oxytocin surges up to five times as high as its normal blood level during orgasm. Studies in animals have also revealed oxytocin's softer side. It is responsible for helping individuals forge strong emotional bonds, earning its moniker as the cuddle hormone. Released in the brain, oxytocin works in the blood, where it travels to tissues as distant as the uterus, as well as along nerve fibers, where it regulates body temperature, blood pressure, wound healing and even relief from pain.

While it is unlikely that oxytocin alone is responsible for sex's wide-ranging effects on the body, researchers hope that by tracking the hormone they can expose the network of body systems affected by sexual activity and identify other biochemical players along the way. Here's what they have learned so far:

--THE HEART OF THE MATTER

The strongest case that can be made for the benefits of sex come from studies of aerobic fitness. The act of intercourse burns about 200 calories, the equivalent of running vigorously for 30 minutes. During orgasm, both heart rate and blood pressure typically double, all under the influence of oxytocin. It would be logical to conclude that sex, like other aerobic workouts, can protect against heart disease, but studies in support of this link have yet to be done. "Can we make the claim that having sex is equal to walking a mile or bicycling? We don't know," says Robert Friar, a biologist at Michigan's Ferris State University. "The data don't really exist."

At least not yet. A study conducted in Wales in the 1980s showed that men who had sex twice a week or more often experienced half as many heart attacks after 10 years as men who had intercourse less than once a month. The trial, however, did not include a parallel group of randomly chosen control subjects, the scientific gold standard. So it's unclear whether frequent intercourse was responsible for the lower rate of heart attacks or whether, for example, the men who were sexually active were healthier or less prone to heart disease to begin with.

More recent research has focused on the hormones dehydroepiandrostone (DHEA) and testosterone, both important for libido. They have been linked to reducing the risk of heart disease as well as protecting the heart muscle after an attack. That may explain why doctors maintain that sex after a heart attack is relatively safe.

--PAIN CONTROL

In the 1970s Dr. Beverly Whipple of Rutgers University identified the female G spot, the vaginal on-switch for female arousal, and stumbled upon one of oxytocin's more potent effects: its ability to dull pain. Whipple showed that gentle pressure on the G spot raised pain thresholds by 40% and that during orgasm women could tolerate up to 110% more pain. But she could not explain the link until the advent of functional magnetic resonance imaging (fMRI). Using fMRI to view the brains of easily orgasmic women as they climaxed, either with visual stimuli or by self-stimulation, Whipple found that the body's pain-killing center in the midbrain is activated during peak arousal. Signals from this part of the brain instruct the body to release endorphins and corticosteroids, which can temporarily numb the raw nerve endings responsible for everything from menstrual cramps to arthritis and migraine for several minutes. Activating this region also reduces anxiety and has a calming effect.

--HE HEALING POWER OF SEX

A trial involving more than 100 college students in 1999 found that the levels of immunoglobulin, a microbe-fighting antibody, in students who engaged in intercourse once or twice a week were 30% higher than in those who were abstinent. Curiously, those who had sex more than twice a week had the same levels as those who were celibate. Could there be an optimal rate of sexual frequency for keeping the body's defenses strong?

Researchers in Sweden are meanwhile exploring how sex affects another immunological function: the healing of wounds. Here again, oxytocin may lead the way. Using injections of oxytocin as a surrogate for arousal, Swedish investigators have found that sores on the backs of lab rats heal twice as fast under the influence of the hormone as without it.

To find out whether the hormone has the same healing effect in people, Ohio State's Glaser and his wife Janice Kiecolt-Glaser, a psychologist at the same institution, are enrolling married couples in an unorthodox study in which each spouse's arm is blistered and then covered with a serum-collecting device. Over a 24-hour observation period, the couples discuss positive aspects of their marriage and mates as well as points of contention, such as finances or in-laws. The Glasers will analyze how levels of oxytocin change during these discussions, along with rates of healing.

--A LONG, HAPPY LIFE?

It's well known that married folk tend to live longer and suffer less depression than singles do. But is this because of more frequent sex, simple companionship or some benign aspect of personality that lends itself to marriage? Teasing apart such matters is difficult, but sex itself appears to be factor. A study of 3,500 Scottish men, for example, found a link between frequent intercourse and greater longevity. A much smaller study of elderly men found that those who masturbated appeared to experience less depression than those who did not. In addition, frequent sexual activity has been tied to lower risk of breast cancer in women and prostate cancer in men, a relationship that is still not fully understood but may involve some interaction between oxytocin and the sex hormones estrogen and testosterone and their roles in cell signaling and cell division. "Scientifically, it's an exciting time that will lead to a lot of rethinking and reconceptualizing of human sexuality," says Dr. John Bancroft, director of the Kinsey Institute. As the answers come in, the human race may begin to appreciate that the "sex glow" stays with them a lot longer than they realized.

January 19, 2004 Health
Bondage Unbound
Growing numbers of Americans are experimenting with sadomasochistic sex. But is it always safe and sane?
By John Cloud/Clayton

It turns out that you call it "S and M" only if you don't do it or if you experiment only occasionally with those handcuffs you keep hidden at the back of the nightstand. If, on the other hand, you are seriously involved in the sadomasochistic subculture--if, say, you have attended one or more of the nation's 90 annual sadomasochistic events ("Beat Me in St. Louis," for instance) and own not only handcuffs but also a spanking bench, a flogger, some paraffin wax, an unbreakable Pyrex dildo and various other unmentionables--you call it, simply, SM.

The linguistic distinction between S&M and SM may seem tiny, but the pop-culture, peep-show version of S&M has little to do with the real lives of those who practice SM (which is why sexologists who study sadomasochism have now also adopted the shorter abbreviation). S&M is Madonna in kinky outfits, Anne Rice chapters that run to the louche--even a recent Dannon ad featuring a woman in a French-maid uniform. Such S&M imagery has become so common that our astonishment at Robert Mapplethorpe's photographs of leather and pain 20 years ago now seems quaint. Today you can watch Samantha on Sex and the City in virtually the same poses.

But those who practice sadomasochism--including those halting dabblers who tee-hee their way through spankings, hoping to paddle excitement into their marriage--know it's still taboo. (After all, if it weren't, it would lose its power to excite.) To reconcile the icons with the actual practice, I spent several weeks recently talking to SM practitioners around the U.S.--in New York City and San Francisco, yes, but also in North Carolina and New Mexico. Whether they were nervous novices or experienced dungeon masters leading some of the nation's 250 SM organizations, virtually all of them asked for anonymity. One man said he had lost a job when his boss found directions to a bondage workshop in his office. Others said they would be embarrassed if their families learned of their proclivities. We live in a culture in which sadomasochism is everywhere--from Versace billboards to at least a dozen college campuses where SM support groups have been established--but somehow it remains unseen and unspoken, just beyond the edge of respectability.

Given the silence, measuring SM's popularity is not a precise business, especially since it blurs into the larger category of BDSM, or bondage-discipline-sadomasochism. A 1990 Kinsey Institute report said researchers estimate that 5% to 10% of Americans occasionally engage in SM sex. "The lighter end of BDSM is penetrating bedrooms across America. It's restraint on bedposts, it's spanking, it's fantasy play--and it's all fairly common," says Barnaby Barratt, president-elect of the American Association of Sex Educators, Counselors and Therapists. In his quarter-century of private practice as a therapist in southeastern Michigan, Barratt says, "hundreds, if not thousands" of married couples have told him they want to bind, paddle or play teacher/pupil with each other.

Barratt and other therapists say that couples often hope that role playing or nipple clamps or quick-release bondage will rev up their sex lives. "Many people have this as part of reciprocal, consensual love relationships, and in those cases, we assure them it's not a problem," says Eli Coleman, director of the Program in Human Sexuality at the University of Minnesota. He also makes the point that "there's an element of domination or submission or pain involved in almost any sexual interaction. What sadomasochism does is take these elements of eroticism further toward their extreme."

Some couples experiment a few times but return to what serious SM-ers call "vanilla" sex. Others become more deeply involved in the SM scene; they use SM props or fantasies every time they have sex. The scene has become so large and varied that it encompasses the rich farrago of coupling practices known as BDSM, which includes not only SM--the erotic enjoyment of inflicting and/or receiving pain--but also BD (bondage/discipline) and DS (domination/submission). BD usually involves physical restraint and a punishment/reward setup (say, Nurse Ratched with a patient). DS relationships are often as emotional as they are carnal. Submissives relish transferring authority over aspects of their lives to others; the submissive might allow the dominant not only to tie her up but even to tell her when she must go to sleep.

A common misperception is that most DS relationships involve dominant women--dominatrices, in the parlance--ordering around submissive men. (As a result, some feminists have come to see BDSM lifestyles as not only transgressive but progressive.) And, indeed, among the many prostitutes who offer BDSM services, more are dominant than submissive, says Dr. Paul Federoff, a University of Ottawa psychiatrist who has studied sadomasochists. "You also might see a lot of dominant women at a BDSM nightclub," he says, but "although it's not the politically correct answer, more women in the scene are choosing the submissive role." In a study Federoff co-authored last year, he found that among 1,320 self-identified BDSM practitioners who anonymously completed a Web survey, 79% of women reported being "always or usually submissive"; only 35% of men did.

In one sense, then, "Doc" and "Surri" aren't so unusual. Married in July, they live in Clayton, N.C., in a just renovated home that--when I visited in November--had been overtaken by Christmas decorations. ("I'm a Christmas freak," says Surri.) She is Doc's wife, but she also thinks of herself as his "slave," and although she sometimes says the word just like that--using her fingers to create quotation marks in the air--their master/slave arrangement directs almost every aspect of their lives. Doc tells Surri what she can and can't wear every day, and when the three of us arrived at a steak house for dinner, Doc ordered: "She'll have a white Zinfandel and a glass of water." (Surri did choose the Robert Mondavi over the Sutter Home on her own.)

If Surri fails to accomplish something Doc asks--say, cleaning out the car or working in the garden--he might spank her or stand her in the corner as though she were a wayward child. When she succeeds, he might call her a "good girl" or give her a small gift. ("I filled out one of those online profiles that ask for your favorite quote, and mine was 'Good girl,'" says Surri. "Hearing [Doc] say that makes me happier than anything else in the world.") Surri, who turns 38 this month, particularly enjoys such "age play" when she's ill; at those times, Doc, 39, might bring her a Winnie-the-Pooh bear. In the bedroom, Surri likes Doc to flog her, but softly, in a light figure-eight pattern. She's not one of those slaves who enjoy the sting of a whip. Says Doc: "A lot of people in the life aren't into pain, despite everything you hear in the media."

Doc and Surri take BDSM much further than most practitioners, but they say they merely verbalize and theatricalize the unspoken power exchanges that exist in every relationship. "About 80% of how we live our lives is the way Mom and Dad did in the '50s," says Doc. "And the way most Baptists live their lives down here," says Surri, referring to the Southern Baptist Convention's resolution that wives should "submit" to their husbands.

But when does this theater go too far? Why would a grown woman let anyone tell her what to eat and wear? "Sometimes people do get lost in this behavior," says Coleman of the University of Minnesota. "It can become very, very powerfully erotic and mood altering." Because of this concern, "sexual sadism" and "sexual masochism" are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the psychiatry compendium. The latter diagnosis, for instance, might apply to someone who starts out wanting a playful smack but ends up begging to be beaten bloody.

BDSM activists--yes, there are BDSM activists--counter that any sexual activity can become overpowering. And few sexologists would argue that whips and stilettos, in and of themselves, cause sexual compulsion. That's why some mental-health professionals contend that the American Psychiatric Association should remove sadism and masochism from the DSM. "There are no data to support their inclusion," says Charles Moser of the Institute for Advanced Study of Human Sexuality in San Francisco. "There is no study that shows that having BDSM interests causes distress or dysfunction."

In addition, the chains, the hot wax, the boot-licking humiliation--they're all secondary for most BDSM practitioners. "Pain is a means to an end, but not the goal itself," says Federoff of the University of Ottawa. "People into this scene, all of them, will tell you that they want anesthetic when they go to the dentist as well as you do. What's different is what they use pain for." BDSM-ers like to use athletic analogies: marathoners endure the agony of the last miles so they can savor the accomplishment of finishing. SM, they say, is no different.

But that doesn't explain why people do it--a question that sexologists can't yet answer. "Tell me the etiology of heterosexuality or homosexuality," says Moser, "and I will tell you the etiology of SM." Federoff has compiled new online surveys from 2,000 women and 2,000 men who identified themselves as part of the BDSM scene. "We have only started to analyze the data," he says, "but the first impression is that the people we have looked at tend to look very much like regular people from all walks of life--that is, they tend to look like people who might fill out Web questionnaires on any topic. Second, by the measures of psychological health we were able to get, they tend not to look particularly psychologically impaired"--at least no more so than the general population.

At this point, we should make clear that the BDSM these researchers study is consensual. No one in the fledgling BDSM movement argues in favor of actual slavery or rape (though eroticized simulations of such crimes are common). Among the BDSM clubs and support groups, all the reputable ones preach the BDSM mantra: safe, sane and consensual. "Like every other subculture, we have a fringe, an element that doesn't follow the rules," says Susan Wright of the National Coalition for Sexual Freedom, a BDSM advocacy group formed in 1997 that claims 34 member organizations representing 10,000 people. "But every mainstream BDSM group has a mission statement that includes those words over and over: safe, sane, consensual."

More specific guidelines--always check bound limbs to ensure circulation, for instance--have developed over the decades, she says. BDSM has a rich history. In the 19th century, psychiatrist Richard von Krafft-Ebing famously applied a French literary term--le sadisme, which described the sexually violent writing style of the Marquis de Sade--to mental patients who exhibited an "association of lust and cruelty." Less famously, Krafft-Ebing named masochism after the bawdy novels of Leopold von Sacher-Masoch, whose most famous work, Venus in Furs (1870), describes the willing enslavement of a dreamy man by a beautiful widow.

More recently, the Internet has helped connect curiosity seekers with BDSM organizations. Doc and Surri, for instance, help lead a North Carolina group that started less than a year ago but already has nearly 700 people on its e-mail list. The calendar of BDSM social events now includes gatherings for every imaginable subgroup--everything from the International Deaf Leather Contest (scheduled in Dallas in August) to the Black Rose convention in the Washington area, a yearly weekend of workshops and parties that draws 1,000.

Host communities aren't always thrilled to learn that hundreds of kinky convention-goers will be dropping in. In 2002, after Baptist leaders heard that the Howard Johnson hotel in Bridgeton, Mo., had served as the site for Beat Me in St. Louis, the Southern Baptist Convention canceled reservations at the hotel. Last year the Kenner, La., police chief mailed letters to local hotels urging them not to provide accommodations for Fetish in the Fall, a four-day series of parties and educational demonstrations--Dances with Whips, for instance--set for November. Chief Nick Congemi was worried that the gathering's activities would be "borderline illegal"; organizers canceled the event to spare attendees embarrassing public scrutiny.

Congemi has a point about the law. It is a bedrock principle of common law that consent is no defense against assault charges, and many prosecutors see BDSM activities like flogging as assault. In the past half-century, many SM participants have been successfully prosecuted. But while most appellate judges have upheld those convictions, a 1999 New York State ruling is altering the landscape. In that case, an appeals court overturned the conviction of Oliver Jovanovic, a Columbia University grad student who had been sentenced to 15 years for kidnapping and sexually abusing an undergrad. Before the alleged assault, the woman had e-mailed her SM fantasies to Jovanovic. The trial judge had refused to admit the e-mail messages into evidence, but the appeals court held that while no one has a constitutional right to engage in SM, the e-mails would have shed light on whether Jovanovic reasonably believed that the woman had consented.

Of all the knotty issues swirling around BDSM, consent was the most difficult for me to understand. No means no, but does yes always mean yes? If you ask someone to pass a flame across your genitals or tie you up for hours or tell you what to eat, are you in your right mind? I pressed Surri repeatedly on these issues. Finally, after a robust drag on her cigarette (which she had asked Doc's permission to smoke), she answered, "What we worry about when we look at our own community and try to make sure abuse isn't happening is whether submissives are restricted in their speech. And I can always say what I want ... Yes, Doc makes the final decision about things. But if he said to me, 'Shave off your hair,' well, we would have some issues because there's not a chance in hell I would do that." Surri and Doc do take the master/slave relationship to elaborate lengths, but she can always end it. "Ultimately," she says, "I have more control in this relationship than he does."

But Surri admits that not all her SM relationships have been so balanced. After she left her second husband--Doc is her third--she "got tied into a very bad person," she says. One day the man told her to get into a dog kennel, and she willingly complied. But then he left her alone--a major no-no under the safe-sane-and-consensual guidelines taught at SM conferences. As it happened, the apartment building accidentally caught fire. Surri suffered burns and smoke inhalation. "I was nearly dead when the paramedics got to me," she says. When I ask what happened to the man, tears well in her eyes. "Nothing." Surri didn't press charges because she was worried that if the authorities discovered her dominant-submissive lifestyle, they would come for her daughter.

Surri's daughter, a polite, sunshiny 14-year-old, knows that her mom takes orders from her stepdad, but Doc and Surri keep their sexual relationship--along with the floggers and other apparatus--private. Surri says her daughter's most common response to any mention of the BDSM lifestyle is, "Ugh, Mom!" (The daughter's privacy is one reason I agreed not to use real names for Doc and Surri. Another is that there are no legal protections for BDSM; the home-improvement warehouse where Doc works could fire him.)

I left North Carolina unsure what to think about the couple. They seem madly in love--"because we have this kind of relationship, everything has to be spoken, so it's much deeper," says Doc. And they are hardly radicals. Doc is a Schwarzenegger Republican and a big fan of the Left Behind novels, the evangelical Christian thrillers that graphically depict the damnation of the sinful. Both Surri and Doc criticize the moral laxity of parents who allow kids to shirk their chores and sass their elders.

On the other hand, Surri's "biggest satisfaction in life" should probably be something other than "seeing [Doc's] approval." She says it's in her nature to submit--that, in a manner of speaking, she has no choice but to give up choice. But can such thorough submission truly be safe, sane and consensual? Wright says BDSM-ers debate such issues all the time. If SM is to become a more accepted part of the mainstream, those serious debates--and not just the titillating extremes of "S&M" iconography--will have to come out of the closet.

January 19, 2004 Health
The Porn Factor
In the Internet age, pornography is almost everywhere you look. But what is it doing to real-life relationships?
By Pamela Paul

In a Friends episode titled "The One with Free Porn," Chandler and Joey discover to their delight a free pornography TV channel, which they leave on and watch endlessly for fear it will go away. Later, a startled Chandler reports to Joey, "I was just at the bank, and there was this really hot teller, and she didn't ask me to go do it in the vault." Joey describes a similar cold shoulder from the pizza-delivery woman. "You know what?" Chandler concludes. "We have to turn off the porn."

Chandler may be on to something. Call it the porn factor. Whereas pornography was once furtively glimpsed at dimly lighted newsstands or seedy adult theaters, today it is everywhere. It pours in over the Internet, sometimes uninvited, sometimes via eagerly forwarded links (Paris Hilton, anyone?). It titillates 24/7 on steamy adult cable channels and on-demand services (the pay-per-view reality show Can You Be a Porn Star? made its debut this month). It has infiltrated mainstream cable with HBO's forthcoming documentary series Pornucopia: Going Down in the Valley. And in ways that have only begun to be measured, it is coloring relationships, both long-and short-term, reshaping expectations about sex and body image and, most worrisome of all, threatening to alter how young people learn about sex.

In recent years, a number of psychologists and sociologists have joined the chorus of religious and political opponents in warning about the impact of pervasive pornography. They argue that porn is transforming sexuality and relationships--for the worse. Experts say men who frequently view porn may develop unrealistic expectations of women's appearance and behavior, have difficulty forming and sustaining relationships and feeling sexually satisfied. Fueled by a combination of access, anonymity and affordability, online porn has catapulted overall pornography consumption--bringing in new viewers, encouraging more use from existing fans and escalating consumers from soft-core to harder-core material. Cyberporn is even giving rise to a new form of sexual compulsiveness. According to Alvin Cooper, who conducts seminars on cybersex addiction, 15% of online-porn habitues develop sexual behavior that disrupts their lives. "The Internet is the crack cocaine of sexual addiction," says Jennifer Schneider, co-author of Cybersex Exposed: Simple Fantasy or Obsession?

Yet most users say sex online is nothing more than good (if not quite clean) fun. According to a 2001 online survey of 7,037 adults, two-thirds of those who visit websites with sexual content say their Internet activities haven't affected their level of sexual activity with their partners, though three-quarters report masturbating while online. The vast majority of respondents--85% to 90%--according to Cooper, who heads the San Jose Marital and Sexuality Center, which conducted the study, are what he calls "recreational users," people who view pornography as a curiosity or diversion.

The question is, Can even recreational use be unhealthy? A 2003 online study by Texas Christian University found that the more pornography men watch, the more likely they are to describe women in sexualized terms and categorize women in traditional gender roles. Mark Schwartz, director of the Masters and Johnson clinic in St. Louis, Mo., says porn not only causes men to objectify women--seeing them as an assemblage of breasts, legs and buttocks--but also leads to a dependency on visual imagery for arousal. "Men become like computers, unable to be stimulated by the human beings beside them," he says. "The image of a lonely, isolated man masturbating to his computer is the Willy Loman metaphor of our decade."

Other psychologists are more tolerant. Most men use pornography in secret, and as long as it doesn't affect their relationships, some say that's O.K. "If a client is enjoying a healthy use of pornography without his wife's knowledge, I would counsel him not to tell her," says psychiatrist Scott Haltzman, who studies men and relationships. Yet many therapists say such behavior creates a breach of trust. Spouses often view porn as a betrayal or even as adultery. The typical reaction when a woman discovers her husband's habit is shock and "How dare he?" According to therapist Lonnie Barbach, based in Mill Valley, Calif., many such women "feel like they're not good enough. Otherwise, why would their mates be seeking this?"

Sometimes pornography tears couples apart. At the 2003 meeting of the American Academy of Matrimonial Lawyers, two-thirds of the 350 divorce lawyers who attended said the Internet played a significant role in divorces in the past year, with excessive interest in online porn contributing to more than half of such cases. "This is clearly related to the Internet," says Richard Barry, president of the association. "Pornography had an almost nonexistent role in divorce just seven or eight years ago."

Still, couples therapists sometimes suggest pornography as a way to refresh relationships or spark desire. Increasingly, women are game. Sociologist Michael Kimmel has found that each year more of his female college students approve of porn, which may reflect women's increased sexual empowerment. Nonetheless, he says, "their attitude is surprising to those of us who think it an impoverished view of liberation to construct your sex life the way men do." The key, therapists say, is for mutual consumption to be seductive to both partners and for material to be "erotic" rather than "pornographic." Most describe the difference this way: porn is objectifying and derogatory while erotica depicts mutually satisfying sex between equal partners. Others say it's a matter of taste.

Trouble is, often the taste is not shared. Jessica (not her real name), 28, a product manager in New York City, tolerates her boyfriend's pornography habit, but his admiration for bodies like that of porn queen Jenna Jameson has made her insecure, so she plans to get breast implants. "My boyfriend told me lots of his friends' girlfriends have done it," she says. "He said to me, 'Imagine what an awesome body you'll have!' I can't blame him for his preferences." But Jessica isn't sure that surgery will improve their sex life. "He tends to be selfish sexually," she says. "I think pornography has a lot to do with it. For him, porn is easy."

Jessica's experience is pretty typical, says Aline Zoldbrod, a sex therapist in Lexington, Mass. She says men's use of porn for undemanding relief often distracts them from the task of trying to please their real-life partners.

Porn doesn't just give men bad ideas; it can give kids the wrong idea at a formative age. Whereas children used to supplement sex education by tearing through National Geographic in search of naked aboriginals and leafing through the occasional Penthouse they stumbled across in the garage, today many are confronted by pornographic images on a daily basis. In a 2001 poll by the Kaiser Family Foundation, 70% of 15-to 17-year-olds said they had accidentally come across pornography online. Older teens may be aware of the effects of such images: 59% of 15-to-24-year-olds told the pollsters they believe seeing porn on the Internet encourages young people to have sex before they are ready; 49% said it promotes bad attitudes toward women and encourages viewers to think unprotected sex is O.K. "Pornography is affecting people at an increasingly young age," says sociologist Diana Russell, who has written several books on the subject. "And unfortunately for many kids growing up today, pornography is the only sex education they'll get."

Because children learn sexual cues early, boys may train themselves to respond only to images shaped by porn stars, while girls may learn that submission and Brazilian bikini waxes are the keys to pleasing men. Recent studies show a correlation between increased aggressiveness in boys and exposure to pornography, and a link between childhood use of porn and sexually abusive behavior in adulthood. "It's not easy to shock me," says Judith Coche, a therapist in Philadelphia who has been in practice for 25 years. "But one 11-year-old girl's parents discovered their daughter creating her own pornographic website because it's 'cool' among her friends." As such incidents multiply, more Americans--parents especially--may come to Chandler's conclusion: We have to turn off the porn.