The great majority of my psychotherapy clients, regardless of whether or not they come to see me as individuals or couples, are experiencing difficulties with relationships. And in many instances, when I inquire (and because I’m a certified sex therapist in addition to a psychotherapist), I find that people are not happy with their sex lives.
This is remarkable given that many people come to therapy with the idea that their main problem is anxiety, depression or work stress. As we inquire more deeply it becomes apparent that relationships and sex are also of concern or related to their symptomology. Sometimes they struggle to find someone special or to keep a relationship thriving, and this is the reason for the anxiety or depression. Often, sexual intimacy is a core part of what’s not working in their relationship. Or they have beliefs about what kind of achievements they have to have to be worthy of a partner. Often there are misunderstandings, conflicts or hurt feelings.
One might wonder if my sample is skewed. After all, psychotherapists and sex therapists don’t usually meet with clients who are happy and satisfied. But if we are to consider the population data, it is apparent that sexuality concerns are commonplace. For example, approximately half of adult women and one-third of adult men in the U.S. struggle with a sexual disorder (Laumann, Paik, & Rosen, 1999). This means that the majority of people are likely to have issues with sexuality, desire discrepancy, or some related issue at some point in their lives (Frank, Anderson, & Rubinstein, 1978). There is evidence to support the idea that common arguments over who does the dishes, how to handle discipline with kids and a host of other common couples issues can be improved by improving the sexual side of the relationship (Zilbergeld & Kilmann, 1984).
Currently, sexual dysfunction is largely treated by two categories of professionals (if we don’t count the tarot readers, aura adjusters and other non-licensed professionals): medical professionals and sex therapists. Medical professionals can work wonders with pelvic pain, erectile dysfunction and endocrinology issues, IF these issues are rooted in a biomedical cause. However, so many sexuality issues are psychologically driven and are better solved by sex education, sex coaching and/or sex therapy.
How do I know if I need a sex therapist then?
Psychotherapists, psychologists and related professionals (licensed professional clinical counselors, marriage and family therapists, licensed social workers) are trained to address relationship issues and problematic behaviors and feelings. If they were trained before 2012, (most licensed clinicians were because it takes several years to get licensed) they were not required to take any courses specifically that addressed sexuality. Those who are recently trained have only been required to take 10 hours of coursework which ends up feeling like a drive-by tour of sexual behaviors, assessments and interventions. For the most part, these professionals will spend time working on the feelings, relationship conflicts and issues brought to their attention without addressing any of the issues of sexual dysfunction and dissatisfaction directly. They may ask about sexuality and may refer clients to their medical provider if they hear of pelvic pain, lack of desire or arousal. They may also inadvertently support clients who are experiencing desire discrepancies with partner(s) to exit a relationship that seems to not be working through supportive therapies.
Assuming there is no medical reason for the sexual issues (and a referral to a medical provider can quickly confirm this), a sex therapist would spend time understanding the specifics of the problem in context. When does it occur? What have you tried so far? Who initiates sex? How is this communicated? Are there stressors or anxieties about sex? What are they? Is each person aware of what they like or prefer? Can they communicate this successfully in the moment? Are there any beliefs that the parties have about this situation that are unfounded? Would some specific coaching be helpful (e.g. new positions, different lube, different birth control, types of touch)? Do they need to develop a stronger connection or some dynamic tension or eroticism in the relationship? Are there fantasies that may be helpful to explore? How do they touch one another, make eye contact, use voice and space to indicate intimacy or eroticism? What effect would there be to consider increasing, decreasing or changing porn use, masturbation behavior, substance use, medicines, and other factors that may be implicated in the quality of partner sexual experience? All of these would help the sex therapist work on the level of cognitions, beliefs, feelings, and behaviors to support a healthy and satisfying sexual relationship. In addition to these common issues, sex therapists would be skilled in addressing the needs of kinky clients, sex workers, LGBT people, poly and non-monogamous relationship structures and those who have experienced sexual trauma.
What if I don’t want to talk about sex or don’t think sex is the problem?
While sex therapy is not for every relationship issue (Sometimes the core problem is really anxiety, depression, work stress or the quality of the attachment or communication about other issues in the relationship), you’d be surprised how helpful a sex therapist can be. Sex therapists are skilled at supporting asexuality as an identity, addressing common conflicts that are not sexual in nature, or making people feel comfortable who typically are embarrassed or unwilling to talk about sex. And sex therapists are ALSO all trained as psychotherapists and couples therapists before they become sex therapists, so often with a sex therapist, you can address both the psychological and sexual components. And a sex therapist is best positioned (forgive the pun) to assess which area or how these two areas might relate.
In the end, psychotherapeutic relationships are complex. And while finding a good sex therapist may not be as difficult or as important as finding a good partner, there is a parallel process; not all sex therapists are the right fit for every couple. As a group we are competent providing a kind of a two-for-one double dip set of skills that is beneficial for addressing a wider range of relationship dynamics. However, the most important variable in successful therapy of any kind is still the therapeutic alliance itself. If you feel your therapist is competent, you are making progress, and you find you can talk about anything on your mind (and these are subjective perceptions located in the client) and you feel it just fits then you have a strong working therapeutic alliance. And if you can find a sex therapist, who is by implication also a psychotherapist, with whom you have a therapeutic alliance then you have the best we have to offer to support your sex life and relationship(s).
Frank, E., Anderson, C., & Rubenstein, D. (1978). Frequency of sexual dysfunction in normal couples. New England Journal of Medicine, 299, p. 211.
Laumann, E., Paik, A., & Rosen, R. (1999). Sexual function in the United States: Prevalence and predictors Journal of the American Medical Association, 281(1), p. 537.
Zilbergeld, B. Kilmann, P. (1984). The scope and effectiveness of sex therapy.
Psychotherapy: Theory, Research, Practice, Training, Vol 21(3), 1984, 319-326. http://dx.doi.org/10.1037/h0086092).