WHEN SELF-HELP ISN’T ENOUGH
A COUPLE’S GUIDE TO SEX THERAPY
Diane and Alan, both 41, had two sons and had been married 12 years when they first consulted Great Sex advisory board member Louanne Weston, Ph.D. They both loved each other and insisted they had a good marriage. But, they explained, they also had a problem: “It was a classic case of desire difference,” Weston explains. Diane was perfectly happy making love once or twice a month, and insisted that most of her friends did it no more than that; most less. Alan wanted sex twice a week or more, and insisted that anything less was “abnormal.”
The situation festered for many years. Alan and Diane talked about it periodically, sometimes calmly, sometimes angrily, but the discussion never brought them closer to any resolution. Finally, Alan insisted they see a sex therapist.
Diane consented to sex therapy reluctantly, fearing that Weston would take her husband’s side and urge her to have sex more often. Weston did no such thing. She explained that the couple had a very 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, Weston asked Alan and Diane about their sex life—and their lives in general. It turned out that their problem involved more than just a desire difference. Diane came from a family with fundamentalist religious beliefs. She was raised to view sex as dirty, especially oral sex. She was willing to perform oral sex on Alan, but refused to receive it, much to Alan’s chagrin. She considered her vulva dirty and not fit for her husband’s mouth. Alan very much wanted to give his wife oral sex, and felt rejected by her refusal.
Alan felt spurned in other ways as well. In addition to what he considered not enough sex, Diane was also reluctant to provide the nonsexual affection he craved—hugging, hand-holding, sitting with their arms around each other while watching TV. When he reached out to hug Diane, she often pushed him away, which hurt him. Alan was a successful contractor, but did not make as much money as Diane, a real estate attorney. She wanted to work less and spend more time with their children. She nagged Alan to make more money, which made him feel inadequate, insecure, and angry. When he felt insecure, he wanted the validation and reassurance that affection and sex provided him—which contributed to the strain around their desire difference.
THE NEWEST MENTAL HEALTH PROFESSION
Among the mental health professions, sex therapy is comparatively new, explains Great Sex advisory board member Dennis Sugrue, Ph.D. Sex therapy was born in the 1960s, when sex researchers William Masters, M.D., and Virginia Johnson showed that a combination of three approaches—basic sex education, whole-body sensuality, and instruction in specific sexual techniques—could resolve a surprisingly large proportion of common sex problems. Using the Masters-and-Johnson model and subsequent refinements, many women who had never had orgasms learned to express 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 followed automatically. “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.”
Initially, sex therapy caused controversy among mental health professionals. “There was a tendency,” Weston explains, “for the original sex therapists to say the opposite of what the marriage counselors had been saying—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 for today’s couples, this controversy is history. Relationship counselors and sex therapists have buried the hatchet. “These days sex therapy almost always involves relationship therapy as well,” says Michael Plaut, Ph.D., an associate professor of psychiatry at the University of Maryland School of Medicine and past president of the Society for Sex Therapy and Research, “Some sex problems are independent of the relationship, for example, involuntary ejaculation in young men. But for most sex problems, you have to deal with both the relationship and the sex.”
Weston agrees: “I wouldn’t say that sex therapy and relationship therapy have merged into one. I still call myself a sex therapist because I specialize in sex problems. But in addition to my sex therapy credentials, I’m also a licensed marriage and family therapist.”
What’s the difference between sex therapy and relationship counseling? “Couple’s counseling,” says Janet Hyde, Ph.D., a professor of psychology at the University of Wisconsin in Madison, and past president of the Society for the Scientific Study of Sex, “often deals with issues of communication and control—how the couple makes decisions and resolves differences of opinion. It may not deal with sex. But when couples consult a sex therapist, sex is always on the agenda.”
In addition, couples counselors and sex therapists have different training. Certification requirements vary from state to state, but in general, sex therapists must be licensed mental health professionals. In addition, they must obtain additional training in sexuality and provide several hundred hours of sex therapy supervised by a mentor sex therapist before they are permitted to provide sex therapy on their own.
Sex therapy has labored under some persistent misconceptions. Some people think those in therapy must have sex in front of—or with—their therapist or some other person, for example, a sex surrogate. Legitimate sex therapists never have sex with their clients. They do not ask clients to have sex in front of them. Some sex therapists work with surrogates, professionals trained to teach whole-body sensuality. The typical candidate for surrogate work is a man who is single, sexually inexperienced, uninformed about sensuality, and possibly phobic about sex and/or women. But very few sex therapists work with surrogates. Sex therapy is basically talk therapy, where couples sit down with a qualified professional to discuss problems that are primarily sexual in nature.
Of course, every marriage has sexual issues: disagreements over sexual frequency, repertoire, the pace of lovemaking, the mix of whole-body and genital caresses, and other issues (undressing for each other, lights on or off, use of sex toys or X-rated media, et cetera). How do you know if your disagreements are serious enough to warrant sex therapy? “It’s subjective,” Hyde says, “but typically people come in when they feel stuck, troubled by a persistent problem they can’t resolve on their own.”
There is no “typical” couple in sex therapy. Plaut has seen clients ranging in age from 18 to 82, in every stage of relationship—from dating couples just starting to get serious, to people who have been married for decades. But according to Sugrue, the greatest concentration of couples range in age from the late twenties to mid-forties.
WHAT HAPPENS DURING SEX THERAPY
Sex therapy begins with the clients and therapist getting acquainted. Many people feel uncomfortable talking about sex, so therapists typically ease into the subject by first taking couples’ medical histories. “Sexuality can be affected by chronic illness, medications, substance abuse, depression, and other medical issues,” Plaut explains. Next, therapists ask about clients’ family backgrounds and their relationship history.
Usually toward the end of the first session, the conversation turns to sex. Why are you here? How long has the problem been going on? When does it occur? How are each of you reacting to the problem? “I make it clear,” Plaut explains, “that I have no agenda for what their sexual relationship ‘ought’ to be in terms of what they do together, when they do it, or how often. That’s up to them. I see my job as helping them work out a sexual relationship they can both live with comfortably.”
Subsequent sessions usually begin with the therapist asking, “So, how are things?” From there, the therapy moves deeper into the couple’s problems, with discussion of both sexual and nonsexual issues that appear to be involved in the sex problem. The couple generally does most of the talking. Each one usually talks to the therapist but they may also talk to each other, sometimes at the suggestion of the therapist. The therapist asks questions, or asks for clarification of things the clients have said, or asks one spouse to react to something the other has said. “Couples often come in resenting each other,” Weston says. “They don’t see the other person’s perspective. They’re stuck. I try to get them unstuck. When one says something contentious, I try to offer new ways to look at the situation, ways that point to solutions. I try to help them make peace with each other.”
Unlike couples’ counseling, sex therapy often involves homework. If the couple has misconceptions about sexual basics, the therapist may provide reading material.
If issues emerge that require further discussion, the therapist may ask the couple to continue the discussion at home. If spouses are alienated from each other, the therapist may suggest that they go out on dates and simply have fun together. “For many couples, the first challenge is making time for each other,” Sugrue explains. “We live in a fast-paced society. Couples often get so caught up in work, or driving the kids to soccer practice, that they have little time or energy left for intimacy. I often encourage couples to spend quality time with each other.”
Homework often involves sensual—but nonsexual—intimacy. For example, hugging more often, cuddling while watching television, or trading massages. “Sensual massage without any genital contact,” Sugrue explains, “can be a great way for couples to rediscover the power of touch without getting caught up in performance concerns of sex.”
Sexual homework usually involves practicing techniques discussed in therapy. “I often encourage couples to try using a lubricant,” Weston says. “If I’m dealing with a man who has poor ejaculatory control or a woman who can’t express orgasm, homework typically involves various forms of focused masturbation.”
Weston recently worked with Susan, a 33-year-old kindergarten teacher who had never had an orgasm, and, after 5 years, got tired of faking them with her husband, Ted. “Usually, these women are so anxious that they can’t relax and let go enough to let their orgasms happen. This woman was like that.”
The therapy involved one sexual issue, Susan’s problem with orgasms, and one nonsexual issue, her guilt over deceiving her husband—and Ted’s hurt and anger over having been deceived for so long. With a lot of talking in therapy, Ted finally forgave Susan, which assuaged her guilt and allowed her to focus on her sex problem. Weston suggested a series of masturbation exercises for Susan to practice at home using a vibrator. With the vibrator’s help, and with support from Ted, over about a year, Susan learned to have orgasms.
Sometimes, however, the resolution of sex problems involves more sex education than relationship counseling. Jeanette, a 32-year-old homemaker and mother of three girls enjoyed sex and could express orgasm during masturbation, or when her husband, Peter, 36, caressed her clitoris by hand or orally—but she could not have orgasms during intercourse, and felt that something was wrong with her. Meanwhile, Peter felt there was something wrong with his lovemaking. They consulted Sugrue, who reassured them that their situation was by no means unusual. He explained that for most women, intercourse doesn’t provide enough clitoral stimulation to trigger orgasm. He reassured Jeanette that there was nothing wrong with her and Peter that his lovemaking was fine. If they wanted Jeanette to experience orgasm during intercourse, he suggested that they add a vibrator to intercourse, or that they try rear-entry (doggie style) intercourse with Peter reaching around and fondling Jeanette’s clitoris by hand. Jeanette and Peter felt reassured and grateful.
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, doctors often feel uncomfortable dealing with sexual issues. You may have to shop around for a physician comfortable with sexual medicine. 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 expressing orgasm, erection difficulties, or pain during intercourse.”
In the early days, sex therapy clients tended to be women unable to express orgasm, women with vaginal muscle spasms that prevented intercourse (vaginismus), men who lacked ejaculatory control, and men with erectile dysfunction. Sex therapists still treat these problems, but lack of orgasm (pre-orgasmia), vaginismus, and involuntary ejaculation can often be resolved by following the programs recommended by self-help materials, such as this book. (For others, see Resources.)
Today, the primary reasons couples consult sex therapists include:
Low or diminished sexual desire. There may be a medical cause, for example, antidepressant medication or low blood levels of testosterone—even in women. Relationship problems and other life stresses may also contribute to libido loss.
Desire differences. Both spouses have libidos 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 men always want sex more frequently than women. Not necessarily. “I’ve seen plenty of couples,” Weston says, “where the woman wanted sex more often than the man.”
Erection problems. In 1998, when Viagra was released, some sex therapists feared a loss of business. In fact, Viagra has been a boon to sex therapy. A recent British study shows that since Viagra’s arrival, British sex therapists have experienced increased demand for therapy. “Viagra put erection impairment in the news,” Hyde explains. “Famous men stepped forward and talked about their erection problems. That gave many men permission to admit they had the problem and get help. The research shows that Viagra works 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: incest, rape, or sexual exploitation.
Pain during intercourse. In addition to vaginismus, there are many other factors that contribute to painful intercourse for women, as discussed in chapter 9.
SEX THERAPY WORKS
Sex therapists claim considerable success treating all these problems. “In a cooperative relationship where both people are equally committed to working together,” Plaut explains, “sex problems usually improve with therapy. They may not resolve completely, but they usually improve noticeably.”
Studies of sex therapy outcomes support these claims. In a 1997 report published in the Journal of Sex and Marital Therapy, researchers at University of Pennsylvania School of Medicine in Philadelphia tracked 365 married couples who sought sex therapy for a variety of problems. In 65 percent of cases, sex therapy resolved the problem. Treatment outcome was unaffected by the specific problem, the gender of the person initially identified as having the problem, or that person’s history of sexual trauma. Among couples who did not respond to sex therapy, the reason often had to do with the presence of a sex-impairing illness, for example, heart disease or diabetes. The researchers concluded, “Sex therapy is effective in the real world.”
However, this study involved cooperative couples, both of whom participated in therapy. Sometimes, one spouse refuses. Then what? “Even when one person has the symptom or complaint,” Hyde explains, “the problem affects the couple, and its solution involves both of them. 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 spouse still flatly refuses, the one who wants sex therapy can be seen solo. “It’s usually not a good sign,” Plaut says. “It makes you wonder about the level of trust and cooperation in the relationship.” But sometimes, solo sex therapy helps. Researchers in Montreal, Quebec, worked with 50 single men who complained of a variety of sex problems. After 6 months to a year of treatment, they reported significant improvement. “I always prefer to see couples,” Weston explains, “but if only one is willing to come in, that person can still get valuable information, explore feelings, and take home new insights that might help resolve the problem, or persuade the other to join in.”
Some sex problems are easier to treat than others. Sex therapists agree that low libido and desire differences are often particularly challenging—but still treatable. British sex therapists worked with 60 couples troubled by the woman’s low libido. Fifty-seven percent reported improvement. “Some of my most personally satisfying cases have involved desire discrepancies,” Weston explains, “so there’s certainly hope for couples with this problem. But sometimes I see couples who simply refuse to compromise, who fear intimacy, and who prefer fighting to harmony. Then things are much less likely to work out.”
DURATION AND COST
For most issues, sex therapy typically takes 4 to 6 months of weekly, 1-hour sessions, plus homework. “My shortest course of therapy,” Plaut recalls, “took just seven sessions. My longest is still going on after 3 years. But on average, sex therapy takes 4 to 6 months, 16 to 24 sessions.”
Depending on location, sex therapy costs $75 to $175 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. “Some people prefer a male or female therapist, which is fine,” Sugrue says. “But the research shows that the therapist’s gender doesn’t matter. Men and women respond equally well to male or female therapists. What matters most is the rapport between the clients and the therapist. If you feel comfortable with the therapist, you’re likely to be helped. If you don’t like the therapist or feel uncomfortable, look for another therapist.”
A HAPPY ENDING
Alan and Diane saw Weston for 44 sessions. During their conversations, Diane revealed a great deal more than she’d ever told Alan about her sexually repressed upbringing and what a struggle it had been—and continued to be—for her to open up to him both sexually and emotionally. This was a revelation to Alan, who apologized for having been so sexually demanding, and expressed irritation and disappointment that his wife had kept such important information a secret. 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. They both also realized that when Diane carped about money, Alan became more sexually needy, which drove the wedge deeper between them. Weston also gave them some educational materials about oral sex, showing that it was hygienic and safe for women to receive, which helped Diane feel more comfortable about it.
Thanks to sex therapy, Diane stopped putting Alan down for making less money, and he became less sexually demanding. Their relationship became more affectionate, with more of the physical closeness that Alan wanted. Diane tried receiving oral sex, and after some awkwardness, began enjoying it. She still felt less interested in sex than Alan did, but their desire difference became a less thorny issue. They negotiated a compromise sexual frequency. Diane let go of limiting sex to once or twice a month, and Alan let go of insisting on twice a week. They decided to make love once a week, and made an evening of it, dining out at a nice restaurant beforehand—something Diane particularly liked. They enjoyed each other more, had more fun together, and took more pleasure in their lovemaking.
“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 your sex, but also deepens the trust and intimacy in your relationship.”
“Sex is like rubbing your stomach and patting your head at the same time,” Weston explains. “You have to pay attention to your own pleasure, while simultaneously paying attention to your partner’s. Some people don’t pay enough attention to themselves. Some don’t pay enough to their partner. Both situations can cause problems. But just as coaching can help people learn to rub their stomachs while patting their heads, sex therapy can usually help couples in loving relationships overcome their sex problems.”
▢Ask your family doctor, gynecologist, or urologist. Medical problems contribute to many sex problems, so it’s a good idea to begin with a check-up. If nothing turns up, ask the doctor for a referral to a sex therapist.
▢If you feel comfortable doing this, ask friends.
▢Call local or state psychological or social work organizations, and ask for referrals.
▢Contact any or all of the three leading professional sex-therapy organizations:
The American Association of Sex Educators, Counselors, and Therapists (AASECT), P.O. Box 5488, Richmond, VA 23220; (804) 644-3288; www.aasect.org.
The Society for the Scientific Study of Sex (SSSS), P.O. Box 416, Allentown, PA; (610) 530-2483, www.sexscience.org.
The Society for Sex Therapy and Research (SSTAR), 409 12th St., S.W., P.O. Box 96920, Washington, D.C. 20090; (202) 863-1645; www.sstarnet.org.
▢Once you have a short list of possible sex therapists, interview them briefly by phone. Ask about their experience dealing with your problem. Ask about their credentials, approach, when you might arrange sessions, and the cost. Select the one with whom you feel the best rapport.
▢If you have great difficulty forming relationships with women, have fears about relationships or women, or are sexually inexperienced and over 30, you might consider surrogate therapy. Most surrogates work in California, a few elsewhere around the United States and Canada. All professional surrogates work with sex therapists. For more information, contact the International Professional Surrogates Association, P.O. Box 4282, Torrance, CA 90510-4282; (323) 469-4720; ipsa1@aol.com