Sex Therapy

Diane, 46, and Alan, 51, had been married 16 years andhad two sons when they first consulted sex therapist Louanne Weston, Ph.D., of Fair Oaks, California. They loved each other, and insisted they had a good marriage. But they also had a festering problem: Alan wanted sex more often than Diane did—twice as often. She was perfectly happy making love once a week, and insisted that most of her friends did it less. Alan wanted sex twice a week or more.

Alan had insisted they see a sex therapist. Diane consented but reluctantly, fearing that Weston would take her husband’s side and urge her to have sex more than she wanted to. Weston did no such thing. She explained that they had a common problem, that there was no “right,” “wrong,” or “normal” sexual frequency, and that she would do her best to help them solve their problem by reaching a workable compromise that respected both of their feelings. Diane felt reassured.

During weekly sessions that lasted 18 months, Alan and Diane discussed their sex life—and the rest of their lives as well. It turned out that their problem involved more than just a desire difference. Diane came from a fundamentalist religious family. She was raised to view sex as dirty, especially oral sex, which she was willing to perform, but refused to receive, much to Alan’s chagrin. He very much wanted to give his wife this intimate gift, and felt rejected by her refusal. Alan had other feelings of rejection as well. In addition to his wife’s comparative lack of libido, Diane was also not as non-sexually affectionate as he wanted. He craved more hugging, hand-holding, and cuddling, and felt hurt when she pushed him away.  Alan was a successful contractor, but did not make as much money as Diane, a real estate broker. She wanted to work less and spend more time at home. She nagged Alan to make more money, which made him feel insecure, angry, and emotionally needy. When he felt needy, he want the validation and reassurance that sex provided him, which contributed to the strain around their desire discrepancy.

The Newest Mental Health Profession

Among the mental health professions, sex therapy is comparatively new, explains Bloomfield Hills, Michigan, sex therapist Dennis Sugrue, Ph.D., a past president of the American Association of Sex Educators, Counselors, and Therapists (aasect.org). It was born in the 1960s, when pioneering sex researchers William Masters, M.D., and Virginia Johnson showed that a combination of three approaches—sex education, whole-body sensual massage (which Masters and Johnson called “sensate focus”), and specific sexual techniques—could resolve many sex problems. Using the Masters-and-Johnson model and subsequent refinements, many women who had never had orgasms learned to enjoy them, and many men learned ejaculatory control and restored lost or flagging erections.

This was revolutionary. At the time of Masters’ and Johnson’s original work, marriage counselors generally believed that once traditional talk therapy improved troubled relationships, sexual improvement automatically followed. “Marriage counselors didn’t focus on sex,” Weston explains. “Masters and Johnson showed that by zeroing in on it, sex therapy could usually improve sexual functioning, often without much focus on the relationship.”

But sex therapy was also controversial. There was a tendency for early sex therapists to say the opposite of what the marriage counselors had said, that once the sex problems were resolved, the marriage would automatically improve. In reaction, marriage counselors accused sex therapists of a mechanical, “cookbook” approach, and of under-emphasizing the many relationship issues that contribute to sex problems and sexual fulfillment.

Fortunately, by the 1980s, this controversy was history. Relationship counselors and sex therapists have buried the hatchet. “These days,” says University of Maryland psychiatrist Michael Plaut, Ph.D., a past president of the Society for Sex Therapy and Research (sstarnet.org), “sex therapy almost always involves relationship therapy as well. Some sex problems are independent of the relationship, for example, rapid, uncontrolled (‘premature’) ejaculation in men. But for most sex problems, you have to deal with both the relationship and the sex.”

What’s the difference between sex therapy and relationship counseling? “Couple counseling,” says University of Wisconsin psychologist Janet Hyde, Ph.D., a past president of the Society for the Scientific Study of Sexuality (sexscience.org), “often deals with issues of communication and control—how the two people make decisions and resolve differences. It may not deal with sex. But when couples consult a sex therapist, sex is definitely on the agenda.”

Marital and sex therapists also have different training. Currently, the gold standard of sex therapy is AASECT certification. “To earn it,” Sugure says, “you must start out as a licensed mental health professional, and practice psychotherapy for at least 1,000 hours a year for several years. Then you obtain additional training in human sexuality, followed by 100 hours of sex therapy supervised by an AASECT-certified mentor, and then amass 500 hours of sex therapy practice.” Currently, there are some 650 AASECT-certified sex therapists in the U.S.

Of course, every marriage has sexual issues: disagreements over sexual frequency, the pace of lovemaking (extended or “quickies”), the mix of whole-body and genital caresses, types of sexual expression (oral sex, swallowing semen, etc.), and other issues (use of sex toys or x-rated media, etc.). How do you know if your disagreements are serious enough to warrant sex therapy?  “It’s subjective,” Hyde says. “People come in when they feel stuck, troubled by a persistent problem they can’t resolve on their own.”

Problems Sex Therapy Can Help

“The first step toward resolving sex problems,” Plaut explains, “is to consult your family doctor, and maybe a urologist or gynecologist. Many sex problems have medical elements. Unfortunately, many doctors are not very comfortable dealing with sexual issues. You may have to shop around for a physician who is. If medical treatment doesn’t resolve things to your satisfaction, then it’s time to consider sex therapy, especially if you experience a persistent loss of libido, difficulty becoming aroused, problems reaching orgasm, painful sex, or festering resentment around sexual issues.”

In the early days, sex therapists counseled many women unable to have orgasms, other women with vaginal muscle spasms that prevented intercourse (vaginismus), and many men who lacked ejaculatory control. Sex therapists still treat these problems, but they can often be resolved by reading self-help books (see end of article).

In addition to the problems that lend themselves to self-help, the issues couples typically bring to sex therapists include:

  • Low or diminished libido.  There may be a medical cause, for example, antidepressants (notably, the Prozac family of drugs), or low blood levels of testosterone—even in women. Testosterone is the “male” sex hormone, but both sexes have it, and it’s responsible for sex drive in both men and women. Relationship problems and other life stresses may also play a role in loss of libido.
  • Desire differences. Both spouses have libidos in the normal range, but, like Alan and Diane, one wants sex more often than the other.  Relationship problems and other life stresses may be involved, but in many cases, the people simply have different levels of desire. The stereotype is that compared with women, men want sex more frequently. But that’s not necessarily so. “I’ve seen plenty of couples,” Weston says, “where the woman wanted sex more often than the man.”
  • Erection problems. Many factors can contribute to erection impairment: illnesses (heart disease, diabetes, and chronic pain), drugs (alcohol, smoking, antidepressants, narcotics, and certain blood pressure medications), prostate surgery, and relationship problems or other life stresses. When the erection pill, Viagra, first became available, some sex therapists feared a loss of business. In fact, Hyde says, erection medications have been a boon to sex therapy: “It put erection impairment in the news. It gave men permission to admit they had a problem and get help. The research shows that the erection drugs work best when combined with the kind of talk therapy sex therapists provide.”
  • Sexual aversion. People with this condition not only have no libido, they feel a deep visceral fear of sex, and may not know why. Frequently, the cause is past sexual trauma, for example, incest, rape, or sexual abuse.
  • Pain on intercourse. Women’s pain may be caused by: endometriosis, reproductive tract infections, anxiety, relationship stress, an unusually low pain threshold, and a history of sexual trauma.
  • Virginity or minimal sexual experience in people over 30. For some people (more men than women) sex just doesn’t happen. As these people grow older, this problem becomes increasingly problematic.

Sex Therapy Works

Sex therapists claim considerable success treating all these problems. “In a cooperative relationship where both people are committed to working together,” Plaut explains, “sex problems usually improve with therapy.”

Studies of sex therapy outcomes support this claim. In a report published in the Journal of Sex and Marital Therapy, University of Pennsylvania researchers tracked 365 couples who sought sex therapy for a variety of problems. In two-thirds (65 percent), sex therapy resolved the problem. Treatment outcome was unaffected by the specific problem, the gender of the person with the main complaint, or that person’s history of sexual trauma. Among couples who did not respond to sex therapy, the reason often had to do with an illness, for example, heart disease or diabetes, both of which can impair sexual functioning. The researchers concluded, “Sex therapy is effective in the real world.”

Confirming this conclusion, a Penn State researcher surveyed sex therapists about their sex problems. Compared with the general population, sex therapists reported as many or more lifetime sex problems. But when asked about sex problems during the past 12 months, compared with the general population, sex therapists reported fewer problems. Conclusion: Despite initially experiencing as many sex problems as other Americans, the knowledge gained by training for sex therapy and practicing it reduced sex therapists’ sex problems to levels significantly lower than average. In other words, sex therapy works.

What If One Person Refuses To Go?

The outcome study involved cooperative couples. Sometimes, however, one spouse refuses to consult a therapist. Then what? “Even when one person has the symptom or complaint,” Hyde explains, “the couple has the problem. The solution involves them both. Sex therapy is not some awful experience. The spouse who wants it should appeal to the other saying it’s likely to improve their sex and strengthen their relationship, which helps both of them.”

If one lover still flatly refuses, the one who wants sex therapy can be seen solo. “I always prefer to see couples,” Weston explains, “but if only one is willing to come in, that person can still get information, explore feelings, and take home new information that might help or eventually persuade the other to come in.”

What Happens? Duration? Cost?

Sex therapy is very similar to talk psychotherapy. Clients never have sex with the therapist or in the presence of the therapist.

For most problems, sex therapy takes four to six months of weekly, one-hour sessions, often with “homework,” for example, conversations to gain experience in new communication skills, or sensual assignments in bed to practice new lovemaking techniques.  “My shortest course of therapy,” Plaut recalls, “took just seven sessions. My longest is still going on after three years. But on average, sex therapy takes four to six months, 16 to 24 sessions.”

Depending on location, sex therapy costs $100 to $200 an hour. Some health insurers cover it. Others don’t. And some place limits on the number of covered sessions, after which you pay out-of-pocket. Check your policy.

Some people wonder if the sex therapist’s gender affects the quality of the therapy. “People have personal preferences, which is fine,” Sugrue says. “But the research shows that the therapist’s gender doesn’t matter. Men and woman respond equally well to male or female therapists. What matters most is the rapport between the clients and therapist.”

A Happy Ending

Alan and Diane saw Weston for 44 sessions. Diane described her sexually repressed upbringing and what a struggle it had been—and continued to be—for her to open up to Alan sexually and emotionally.  This was a revelation to Alan, who apologized for having been so sexually demanding. Both Alan and Diane realized that her complaints about being the major breadwinner had less to do with the money than with her need to keep some emotional distance between them. Meanwhile, when she carped about money, he just became more sexually needy. Weston also gave them some educational materials about oral sex, showing that it was hygienic and safe for women to receive, which allayed Diane’s fears.

Thanks to sex therapy, Diane stopped putting Alan down for making less money, and he became less sexually demanding. They evolved toward a more affectionate relationship, with more of the cuddling that Alan wanted. Diane tried receiving oral sex and enjoyed it. She still felt less interested in sex than Alan did, but their desire discrepancy became a less thorny an issue. They enjoyed each other more, and they enjoyed sex more as well.

“Good sex is one of life’s greatest pleasures,” Sugrue says. “If you’re not enjoying it as much as you’d like, there’s no reason to feel inadequate, embarrassed, ashamed, or resentful of your partner. Sex therapy can usually help. The effort not only improves the quality of sex, but also deepens the trust and intimacy in the relationship.”

How to Find a Sex Therapist Near You

References:

Althof, S.E. et al. “Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction,” Journal of Sexual Medicine (2005) 2:793.

Blizter, J. et al. “Sexual Counseling in Elderly Couples,” Journal of Sexual Medicine (2008) 5:2027.

Corty, E.W. “Self-Reported Sexual Problems in American Sex Therapists,” presented at the 2009 annual meeting of the Society for Sex Therapy and Research, Washington, D.C.

Gehring, D. “Couple Therapy for Low Sexual Desire: A Systemic Approach,” Journal of Sex and Marital Therapy (2003) 29:25.

Leiblum SR and RC Rosen (eds). Principles and Practice of Sex Therapy, 3rd edition. Guildford Press, NY, 2000.

McCabe, M.P. “Evaluation of a Cognitive Behavior Therapy Program for People with Sexual Dysfunction,” Journal of Sex and Marital Therapy (2001) 27:259.

Sarwer, DB and JA Durlak. “A Field Trial of the Effectiveness of Behavioral Treatment for Sexual Dysfunctions,” Journal of Sex and Marital Therapy (1997) 23:87.

Wesley, S. and E.M. Waring. “A Critical Review of Marital Therapy Outcome Research,” Canadian Journal of Psychiatry (1996) 41:421.

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