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In this chapter, we explore themes that emerge in psychoanalytic work with couples, particularly in those couples presenting with sexual problems, from the "ordinary" difficulties of anxiety about being intimate to the more pathological manifestations in perversion. We examine how unresolved conflict in the internal world, especially in relation to the internal couple, can lead to difficulties in the capacity for intimate relating. We suggest that intrusive projective identification and the use of "defensive sameness" and "defensive difference" serve as defenses against intimacy. These defenses function to obliterate the reality of the other, and it is in this sense we use the term perversion. Finally, we comment on the difficulties for the therapist who may feel drawn into a perverse arena when working with couples with sexual problems. We use the film Sex, Lies and Videotape (Soderbergh, 1988) to illustrate these themes. In this extraordinary film we can observe a set of characters demonstrating the range of these difficulties, with the advantage that we do not encounter any problems about confidentiality.