Erectile dysfunction, loss of libido, orgasm problems and arriving at school to talk about condoms � psychosexual therapist susan carr has plenty of material for embarrassing her teenage children By Julie Mackintosh

JUST like most parents, Susan Carr sometimes embarrasses her kids. And as one of Scotland's leading experts on sexual problems, the mother of four has more ammunition than most. "I went to their school to give a talk on sex and condoms and the only person absent in the whole of the fourth year was my son," she recalls with a mischievous laugh.

Between 20% and 40% of us are likely to suffer from a sex problem at some point in our lives, and Carr, who recently married for the second time, has pretty much seen them all.

Her psychosexual clinic at Glasgow's Sandyford Health Centre treats around 50 patients a week, many of whom attend for more than a year. Although Carr acknowledges that sexual problems can be physical as well as emotional, her team deals mainly with the emotional side, through counselling. "The most common problems in women are vaginismus - the inability to let anything penetrate the vagina - loss of libido, painful sex and difficulties such as inability to orgasm," she explains.

For men, premature ejaculation is the most common sexual complaint, followed by impotence, delayed ejaculation and loss of libido. The clinic also deals with fetishes (obsessions with using prostitutes and with high-heeled shoes are two that have entered Carr's casebook).

"Everyone with a physical problem that impinges on their sexuality and their relationship is going to have some kind of emotional knock-on," argues Carr. "For example, men with erectile dysfunction often go down the route of take some tablets and solve the problem', and no-one is looking at the emotional impact.

"Also a common scenario is that of post-menopausal women going to the doctor because they have no interest in sex and saying: But it's just my hormones.' Talking to her you discover she's been married for 20 years and her husband has had affairs. She's still with him for the sake of the children, then she goes through the menopause and isn't interested in sex, so she says: Give me some hormones and that will sort it out.' But of course it won't. And this is what we help the person look at."

That Carr's services are in high demand is evidenced by her three-month waiting list. Could the media's obsession with sex be responsible for making so many people dissatisfied with their own love lives? Carr is unconvinced. "People have always had sex so they've always been having problems with sex, but what we do at our clinic didn't really exist in Scotland until about 20 years ago. Before that everything fell under the remit of the old-fashioned family planning consultant, which didn't extend much beyond contraception."

It was while working as a family planning doctor in the early 1980s that Carr became interested in psychosexual medicine. "Patients mainly came for advice on contraception or menopausal issues," she recalls. "But I was always struck by the stories that lay behind. They often seemed to involve sex, relationships and emotions, and at that stage I just didn't know how to help."

Back then, psychosexual medicine was not well recognised, she says. "You were regarded as very unusual, weird even, if you wanted to get involved." By the end of the 1980s, attitudes had moved on and some counselling was available. "At the start it was demand-led, and today's clinic really evolved from that."

While Carr is encouraged by the increased openness in talking about sex, she still believes that "the west of Scotland male doesn't like to say I have a problem with sex'."

Many patients apparently panic at the "psychosexual" tag attached to the clinic and arrive assuring Carr they are not mad. "We've been stressing for years that it's not about mental illness. These are ordinary people with problems of a sexual nature," she says.

There is no "typical" patient in terms of age, class, occupation, gender (though women tend to be more willing to talk), marital status or sexual orientation. The youngest are around 18 but the clinic also treats couples into their 80s. Do people of that age still have sex? "Absolutely," replies Carr somewhat indignantly. "Why shouldn't they?"

But although people are increasingly more willing to seek help, some disguise problems for years. "Vaginismus is a purely emotional condition. There's nothing physically wrong with the vagina: it just can't let anything in," she explains. "A GP might have a patient in her 20s, married, on the Pill and everything seems to be fine, but she's avoiding a smear test. Eventually someone asks if there's a problem, and she gets very upset and admits she has never actually had sex."

Sexless marriages are surprisingly common, according to Carr, who says that if both partners are happy, this isn't necessarily a problem. "Not infrequently I treat women in their 30s who have been married for over a decade and have never had sex. Often they are only willing to talk about it now because they want a child.

"These are very ordinary people who are otherwise happy and successful in their lives, and I think it's a bit of a myth that women with vaginismus must have suffered trauma or abuse that prevents them from having sex. In fact, women with loving, over-sheltered backgrounds sometimes find it very hard to leave the scenario of being a wee girl cared for at home to become a sexual woman in an adult relationship.

"They are ashamed, embarrassed and can't talk to friends. Frequently they have supportive, loving partners, and the partnership almost colludes in allowing the problem to continue. If a husband is not supportive about the lack of sex, then the relationship is going to break up very quickly."

The tragedy, says Carr, is that vaginismus has a 90% cure rate when treated properly (through a mixture of counselling and gynaecological advice). "One of the nicest parts of this job is working with a woman or a couple for up to two years, then getting a wonderful card saying I'm pregnant' or I've had a baby'".

Does being constantly bombarded with images of the perfect sex life cause unnecessary anxiety about our own performance? "It can. About 15 years ago, when Cosmopolitan magazine was at its height, if an article about achieving simultaneous orgasm was published, then we had hundreds of girls at the clinic saying they were having 23 orgasms but they weren't simultaneous with their boyfriend, what can we do?"

Does she ever issue practical advice - tell patients to buy some nice lingerie perhaps? "I have never told anyone to buy underwear. I find that rather trite. Many television sex programmes seem unethical, almost like cheap pornography. You get two good-looking experts floating in and solving everything within half an hour and it's very unrealistic, and often trivialises sexual problems. Occasionally we get people frightened to come here because they think it will be like that - doctors watching them have sex or putting pressure on them.

"But sometimes, if a patient has a physical problem, I might suggest something more proactive. We have a wonderful library here with publications offering practical suggestions. Or if a woman has never had an orgasm, we would look at the emotional side - attitudes, upbringing. But there is also a vibrator called the Rabbit. It seems to work."

Surely she sees couples who simply don't fancy each other any more? "Yes, that's very common and sometimes you can see it as plain as day. But as clinicians we are completely non-directive. Rather, we reflect back to patients what they are telling us. Many people are in relationships that you and I might not think are ideal, but that's where they are and that is where they want to stay. Our role is to help them. Sometimes patients don't have a good partner, and unfortunately we can't provide partners here.

"What I find heartbreaking," she adds, "is the number of people abused as children, and the impact that has on them as adults. Also the amount of patients who've been affected by alcoholism in the family is staggering."

The melancholy of that last statement hangs in the air for a moment, until, returning once again to memories of her own family, the doctor recalls: "When my oldest daughter was going away to university, she said: Mum, I've got a question to ask you.' I put on my serious face and said What's that?' And she looked at me and said, "Oh, Mum, it's not about contraception or condoms. I don't know how to cook."