Sex therapy is an area of specialization within the broader fields of psychotherapy and psychology. Unfortunately, very few graduate psych programs offer anything beyond introductory sexuality courses. Would-be sex therapists have to go out of their way to find the necessary training. Some students are able, as I was, to actively shape their studies by taking outside courses and asking experienced sex therapists to serve as mentors, advisors, and clinical supervisors. For practicing sex therapists, attending sexology conferences is essential for keeping up on the latest research and ideas. Since no state certifies sex therapists, anyone can call themselves one. So it's a consumer-beware situation.
Masters and Johnson, the founders of modern sex therapy, focused only on problems with basic sexual functioning. The field has grown tremendously since the 70s and today's sex therapists work with a much more complex array of concerns, such as waning or lost desire for sex, problematic attractions, and a host of what I call "troublesome turn-ons." A minority of people seek sex therapy not so much to solve problems, but to explore possibilities and potentials. Here's a brief survey of today's sex therapy landscape.
Arousal and Orgasm Concerns
For men, arousal problems are erection problems, now called erectile dysfunction. Arousal can be far more complex for women. For one thing, sexual excitement isn’t necessarily focused on the genitals. Tingling and warming sensations anywhere on the body may be more important signs of excitement, or arousal may spring from inner feelings or a particular mental response.
However sexual arousal is experienced, concerns arise when someone is consistently unable to become aroused—including the expected body reactions—when they want to. In some instances, arousal starts to build and then fades away without warning. Once sexual worries take hold, performance anxiety turns sex into an ordeal or a test. It's easy to say, "Don't worry." But when something causes distress for you and/or your partner, it's natural to become preoccupied and self-conscious about it.
Problems with orgasm are either focused on coming more quickly than desired (with few exceptions, this is a guy thing). Both men and women can have trouble coming at all, or just with partners, or only with a specific partner, or with certain types of stimulation, or feel they're taking too long to do it. The clock is ticking, seeking an orgasm turns into work, as pleasure evaporates.
Sexual Desire Concerns
Few experiences in life are more subjective than wanting sex. Even genital arousal isn’t a foolproof indicator of desire. But we do know this: Desire exists on a continuum, ranging from a definite urge for sex ("horniness") to a simple sense of "willingness"—being genuinely open to engaging in some kind of touch to see what might develop. A very common belief is that horniness is desire. This is unfortunate because so many people (some men, but many more women) don't experience a strong desire for sex until their bodies first become aroused. The notion that horniness is a prerequisite for sex is responsible for countless missed sexual opportunities.
Low or non-existence desire is now called hypoactive desire, and it happens to men and women alike, regardless of sexual orientation or age. Some feel apathy or indifference. But others have a distinct aversion toward sex. Some of these people actually experience panic when touched in a sexual way. In general, aversion-panic reactions result from one or more traumatic experiences such as childhood abuse, sexual assault, or other painful experiences like an STD or unwanted pregnancy. Too many women have acquiesced to intercourse when they didn't want it, or weren't sufficiently lubricated, resulting in abrasions or intense muscle spasms called vaginismus.
Some people have never felt much desire throughout their lives, while others once did but it's waned or died along the way. Since desire is so complex, many things can squelch it, including resentments or conflicts with a partner, losses of all kinds, drops in self-esteem, depression (or the medications to treat it), anxiety and stress, childbirth, or menopause.
While some lose their desire across the board—no fantasies, no sexual attractions, no masturbation, no erotic thoughts at all—others have desire, just not for their primary partner. The most common desire problems are desire discrepancies in which one partner wants significantly more sex than the other. Unless one partner is highly compliant and always says "yes," desire discrepancies are the norm—except in early romance when both partners may want as much sex as they can get.
Some couples adapt gracefully to their desire differences. But others fall into destructive chaser-chasee dynamics, in which the higher-desire partner begs, complains, pouts, gets pissed off, or manipulates for sex, thereby guaranteeing that the lower-desire partner will try even harder to avoid it, while feeling some combination of guilt and resentment themselves. No one wins this game.
Good Relationships with No Sex
There's a particular kind of couple which I see quite a bit in my practice: deeply bonded, highly committed partners who enjoy each other, cooperate well in daily living, are genuinely supportive, and often very affectionate—but the sex just isn't there. What's the deal? Well, there's such a thing as being too close. By too close I mean a lack of positive separateness. Many merge into an amorphous unit, completing each other's sentences, and losing the fascinating "otherness" that drew them to each other in the first place. These couples tend to downplay their differences, avoid conflict, and act nice even if it kills them. Some need a good fight. Others need to reclaim interests or friendships they abandoned for their togetherness.
In some cases, opening up the space between them, telling unspoken truths, and generally being more real might rekindle an erotic spark. Sometimes it's too late because they think of each other more like siblings and sex feels like incest. In other cases, sexual attraction never was the foundation of the relationship and never will be. What they have is a very special or romantic friendship. Here's the thing: not all close relationships are sexual, and not all sexual relationships are particularly close. It would be pretentious and silly for a sex therapist to tell these couples what to do. A courageous exploration of all the options is the best way to go.
Troublesome Turn-Ons
This is my name for a group of erotic conflicts that occur when a person's turn-ons cause them both excitement and distress. The most common troublesome turn-ons I see in my practice are:
- unworkable attractions
- love-lust splits
- struggles with unconventional turn-ons and identities
- sexual compulsions
Unworkable Attractions
Attractions, whether lusty or romantic, defy our best attempts to explain them. But one thing is clear: the pull we feel toward another to whom we're strongly attracted cannot be ignored. Some people have a predictable physical "type" that always grabs their attention. For others, certain perceived personality characteristics generate the chemistry. In either case, those whom we find most appealing aren't necessarily the ones with whom we can form the best relationships (as if we don’t have enough to deal with). People are most likely to question their attractions after a series of failed relationships with partners they found highly desirable. Few things are more painful than realizing that your deepest attractions may be working against you.
The question often arises: Can strong attractions be changed? My answer is a qualified “absolutely.” But keep this in mind: in all aspects of erotic life, it’s easier to cultivate new possibilities than to get rid of existing ones. Some people end up avoiding certain components of attraction (e.g., being drawn to unavailability or ambivalence) while embracing others (e.g., a taste for independent free-thinkers). But this approach won’t work if the problematic part of an attraction is the main source of the appeal. In these cases, accepting less intensity in exchange for more viability may be a necessary trade-off. Some can’t help seeing this as “settling,” while many others end up feeling liberated from a long ordeal.
Love-Lust Splits
When a person finds it difficult or impossible to feel sexually excited and emotionally attached at the same time, or with the same person—especially if this has happened with various partners—a love-lust split is probably at work. Generally, this problem begins in adolescence (sometimes much earlier) when turn-ons are shaped primarily through fantasies or porn, completely outside of the context of dating and relationships. As a result, one's capacities for lust and affection develop on separate tracks. When a person's lusty interests coalesce outside of the messy complexities of relating, they tend to remain separated because "disconnected lust" is extremely intense and is likely to be reinforced through countless repetitions over time.
People typically seek therapy for this problem when they fall in love or feel a deep emotional bond with someone quite special. They might enjoy sex for a while and then discover, quickly or gradually, that they're not getting turned on. What can be done? Quite a lot, actually. But learning about relational sex requires acceptance that it will never be like disconnected lust. The other key challenge is to tolerate awkward feelings while learning to be sexually engaged with another. In turn, this means that both partners must accept a natural waxing and waning of arousal, and perhaps not being orgasmic for a while.
Struggles with Unconventional Turn-Ons and Identities
Every society tries to shape and restrict the sexual behaviors and thoughts of its members. But even the most pluralistic societies don't embrace the multitude of sexual interests the human mind can invent. Families, institutions, and peers (the primary enforcers of sexual standards) can unleash an arsenal of psycho-social weapons—including shame, rejection, stigmatization, and threats of violence—against those considered perverted or weird.
It's sad, but not surprising, that those who don’t conform to mainstream sexual ideals typically grapple with some degree of inner turmoil, or even self-loathing, on their way to sexual self-acceptance (which remains tragically elusive for far too many). We can embrace or resist our attractions and turn-ons, but we don't choose them. In my book, The Erotic Mind, I argue that compelling erotic patterns spring from a blend of positive and negative experiences from our past and, over time, evolve into profoundly intimate expressions of our deepest selves.
In spite of a change in attitudes about sexual orientation throughout much of the developed world, coming out remains a difficult challenge. In spite of positive role models everywhere, most same-sex activity still occurs in the shadows where secrecy and shame prevail. One factor in the growing acceptance of gays and lesbians is the belief that they're born that way and can't help it. While there's good evidence that same-sex attraction is often an innate predisposition, multiple factors are inevitably involved in anything as complex as sexual orientation. It's worth noting that some people, especially women, become sexually involved with a particular partner based on the quality of their connection, not their gender.
What about other longstanding, highly consistent sexual interests such as BDSM or the vast array of sexual fetishes that captivate people in spite of the social costs, even if they don't want them? Many "kinky" sexual interests run so deep that they form the core of a person's sexual identity—just like a sexual orientation. Must we prove that each and every turn-on is inborn in order to find them acceptable? I certainly hope not.
If anything is supposed to be inborn, surely it's our gender. Isn't biological sex predetermined at conception and obvious from the moment of birth? Well no, not exactly. Approximately one percent of live births receive surgery for genital ambiguity. And many other types of intersexuality are more subtle or show up later on. A far greater number of people struggle to squeeze themselves into expected gender roles much too narrow to accommodate who they are.
Concerns over gender are gradually seeping into public awareness. Since the 1950s there have been occasional stories of people changing sex in mid-life, desperate to find inner peace. Some of us have read about berdaches and other "two-spirit" or "third-sex" people who have been somewhat accepted in other times and places. In the last couple of decades, those whose gender identities and/or behaviors are out of sync with binary ideas about male-female and masculine-feminine seem to be everywhere, especially in major cities of the developed world. Ironically, while a belief in the immutability of sexual orientation has helped to promote acceptance of gays and lesbians, an emerging awareness of gender ambiguity is actually helping transgendered or multi-gendered people to come out.
I believe that sex therapists have an obligation to help nudge social attitudes, in whatever tiny ways possible, toward a greater acceptance of all sexual minorities, especially those we have trouble understanding. Since social change is slow, the day-to-day work of sex therapy for those struggling with unconventional sexualities is to promote sexual self-acceptance among those who can't possibly find happiness without it. I have no doubt that doing so will eventually help improve the sexual health of the entire society.
Sexual Compulsions ("sex addiction")
Almost everyone knows from personal experience just how compelling sexual urges can be. In surveys, the majority of men (and more than a few women, too) say they think about sex almost constantly. But some people are so sexually driven that their sex lives are largely, if not completely, out of control. In its most grueling form, compulsive sex—similar to compulsive shopping, gambling, or overeating—can literally take over a person's life. The internet makes it especially easy to lose oneself for hours or days searching for whatever one seeks, with a virtually unlimited supply waiting to be tapped into 24/7.
Obviously there are many similarities with the substance addictions that can rob a person of choice and even lead to self-destruction. But I have two very practical concerns about the "sex addiction" concept. First, this label is terribly abused and often applied to completely normal sexual behavior. If someone likes porn but their partner doesn't approve, they're called—or may call themselves—a "sex addict." More than a few married people show up for "addiction" treatment because they also like to masturbate alone. Even those exploring their sexual orientation are frequently accused of addiction. And many therapists are guilty of applying the addiction label before they've even begun to understand what a client is dealing with.
The other problem with "sex addiction" can be even worse. Calling sex an addiction has an unmistakable tendency to instigate or escalate fighting with one's sexuality. This I can say for certain: If you go to war with you sexuality, you will lose, and end up in more trouble than before you started. I have never seen a single exception to this principle.
That said, out-of-control sex, like other serious compulsions, is real and fairly common. It offers a lot of diversion and excitation, but ultimately not much pleasure, and often leaves suffering and shame in its wake. Sex therapy can help by opening up an in-depth, compassionate exploration of a person's actual experience. Sometimes this means continuing with the problematic behavior, but with greater consciousness of what one is feeling at each point in time. Although it's not easy, this is definitely doable. Even a little more self-awareness changes the experience, especially since compulsive behaviors often involve a lot of "zoning out."
Making the choice to step away from automatic behaviors can, when a person is ready, usher in an unexpected level of clarity. As one client recently put it, "I had no idea how much I was hurting myself until I stopped doing it." To be of value, a "sexual moratorium" must be conducted in a spirit of self-discovery. No fighting. Breaking free of entrenched habits can be very difficult, it's true. Successful outcomes require support, persistence, and—perhaps most of all—a deepening self-respect and the erotic integrity that goes with it.
My Approach to Sex Therapy
Like any effective therapy, sex therapy is founded on a collaborative partnership between therapist and client(s). Another key ingredient is learning how to set aside judgments, or at least to recognize that we're having them. Because sexual problems are so often shrouded in shame, and our eroticism is so profoundly personal and multi-layered, deep truths must be explored for healing to occur. These truths simply won't reveal themselves to critical minds and judgmental hearts.
It helps a lot to realize that sexual problems are normal. So many people, including therapists, hold the belief that we'd all be better off without any sexual "hang-ups" and that healthy sexuality should be essentially problem free. Nonsense. Can you name any other important area of life that's problem free? Love? Family? Work? Of course not. Sexuality doesn't exist in a separate corner shielded from the conflicts and challenges that shape our existence. We have sexual problems, in part, simply because we're human.
When we delve into sexual problems, we often find unresolved struggles that have very little to do with sex. An example: Judy's husband, Pete, believes that a real man should be able to get a woman off by having intercourse with her for a long time. Her pleasure is his reward. Judy knows this because he makes such a big deal about it and she wants to make him feel good. Trouble is, she enjoys intercourse sometimes, but not for too long because her back hurts and her lubrication dries up. Besides, she's never been able to come that way, although she's very orgasmic from oral stimulation or certain kinds of touch. She visits me to fix her "orgasm problem." Luckily, she soon realizes that there's nothing wrong with her sexuality just as it is. But she can't shake the belief that a woman should be able to please her man.
When a sexual issue arises in the context of a relationship, as in the case of Judy and Pete, sex therapy with the couple has the best chance of success because they ultimately have to solve it together. But Pete refused to join us at first. Although I didn't want to support the notion that Judy was the problem person, we decided to have some individual sessions to explore her need to please Pete at her own expense. Needless to say, this lead to a deep well of emotion about her worth as a lover and a person.
Before long, Pete made the "mistake" of asking Judy how her therapy was going, so she took the risk of telling him about her lifelong rivalry with her "sexier" sister (which he kind of knew about) and her terror that he would leave her if she didn't orgasm the way he wanted. Not surprisingly, this launched a series of much-needed discussions that not only broke their impasse with sex, but also made Pete join us for couples work. Their greatest achievement was gradually moving from role-playing to genuine intimacy—the ability to be one's true self in the presence of the other. It turned out that Pete didn't like the endless fucking either, and keeping his erection required so much fantasizing that he wasn't even there half the time.
Building an Experimental Attitude
Sex therapists are noted for giving people "homework" that's supposed to lead to useful discoveries. The best-known of these is sensate focus, which involves taking turns massaging each other without any expectations or pressures to perform. This can be an excellent way to get out from under the self-consciousness, performance anxieties, and general lack of pleasure that goes with most sex problems. And by the way, taking-turns giving non-goal-oriented touch is a terrific way to be sexual, not just a therapeutic exercise. In actual practice, finding one's way back to pleasurable touch can be quite difficult, especially for those who have either been arguing about sex or avoiding it.
I encourage clients to adopt an experimental attitude from which they deliberately do things differently than usual at home, whether alone or with a partner. Failure isn't an option for the truly experimental, as long as something is observed or learned. From this perspective, not doing an agreed-upon experiment can be just as revealing as doing it, because it's crucial to see what's getting in the way—e.g., lack of time, overwhelming stress, patterns of non-engagement. For maximum benefit, the timing must be right, and the experiments must be an exact fit for the individual or couple, which means they should be actively involved in designing them.
Becoming More "Embodied"
Professional sex therapists don't ever touch their clients sexually. The potential for harm is just too great. Yet getting more in touch with one's senses, becoming aware of muscles, learning how to deliberately tense or relax them, and discovering the enlivening power of breathing are all crucial ingredients for sexual healing. Embodiment is a good word for this process.
Of course, there are many ways to cultivate a deeper connection with one's body. Conscious, extended masturbation—as opposed to the efficient get-off-quick variety—is highly beneficial and readily available for those who are open to it. Self-pleasuring is a wonderful way to discover how and where we like to be touched. It can also guide us to deeply satisfying, full-body orgasms, where waves of pleasure radiate in all directions far beyond the genitals.
Couples can explore these potentials together. Sharing masturbation is an intimate gift, as exciting as it is educational. The taking-turns model of touch I mentioned earlier offers another framework for uncovering each other's pleasure secrets. Naked holding and caressing where partners allow their breathing to naturally synchronize is, for some, a revelation—so different from the frenzied activity typically associated with passionate sex.
Sometimes I suggest involving the skills of an experienced massage therapist, especially one trained in the relatively new body work specialty called sexological bodywork. These practitioners are comfortable discussing sexual concerns and can gently show a client how to be more present for receiving touch and less lost in thoughts. This can be especially valuable for those whose sexuality is largely a "head trip." There are also benefits for those who have a hard time receiving, knowing what pleases them, or asking for it. The emphasis placed on breathing in this type of body work can be the key to truly letting go. A close collaboration between the body worker and sex therapist can create a unified growth experience.
From Problems to Possibilities
I mentioned earlier that some people consult a sex therapist because they wish to enhance the enjoyment they're already having. Common goals include:
