James Krehbiel is a therapist and he writes about a husband who "was dissatisfied with the relationship due to his wife’s physical appearance and had been pressuring her to have cosmetic surgery, including a face lift and liposuction. He felt the cosmetic changes would enhance the couple’s sex life and fill the void of what he was missing."

The wife very reluctantly went ahead with the face lift but it did not help the relationship. He goes on to say that the problem was a lack of intimacy, not the lack of sex and he lists the key signs of intimacy in a relationship.