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Sex Therapy and Counseling

To restore healthy sexual relations, most people need 
to resolve broader issues that underlie their sexual problems.

In many cases, sexual problems during menopause can’t be untangled from broader psychological and relationship issues. To restore healthy sexual relations, most people need to resolve the issues that underlie their sexual problems. Both individuals and couples can benefit from sessions with a licensed sex therapist.

Sex therapists are mental health providers who address emotional and relationship issues in the same way that other therapists do, but they use their special training to offer a more targeted approach that emphasizes learning to talk about sexual feelings openly. The goal is to empower couples to understand the nature and sources of their sexual problems, better express their sexual wants and needs, and broaden their menu of sensual and sexual expression. A frequent aim is to enhance the pleasure and intimacy of a couple’s sexual activity without the pressure to always have intercourse or achieve orgasm. 

What to expect. Sex therapy typically begins with a lot of talking and sharing. The therapist will help you and your partner assess the problem and identify factors, thoughts, and behaviors that might be contributing to it.

If you are troubled by low libido, for instance, the sex therapist will try to create an atmosphere in which you feel less pressured and eventually more receptive to sex. Often women with low libido don’t really miss sex or don’t believe much can be done about their sex drive, so they decide to seek therapy only when they feel the problem threatens their relationship. If that’s your case, the therapist may help you reframe the problem not as a shortcoming of either you or your partner but as a couple’s issue that warrants a joint solution. This may require that your partner express a clear commitment to the relationship and that both of you explore the relationship dynamics that might explain your differing levels of desire. Your therapist is also likely to ask how much time per week you and your partner spend just enjoying each other’s company. If you don’t spend much time alone together, the therapist will likely have you focus on giving more priority to your relationship first. This might involve identifying the strengths of your relationship in earlier days and working together to build on those strengths. The therapist can also help you explore ways of being more physically affectionate without feeling the pressure to have intercourse.

If you have orgasm difficulties, as another example, the therapist will ask whether you’ve ever been able to climax, either through masturbation or with a partner. If you haven’t, the therapist will likely explore possible sexual abuse in your past or negative attitudes about sex or masturbation. You’ll also be urged to become more familiar with what gives you sexual pleasure, perhaps by using a vibrator to stimulate yourself, with or without your partner present.

Your therapist will often serve as a sex educator, explaining physical causes of sexual problems, such as vaginal dryness, and helping you rethink unhelpful misconceptions about sex—for example, that foreplay isn’t real sex or is just for teenagers.

After the therapist’s initial assessment of your relationship and the problems you report, much of the relationship-building and behavioral portions of sex therapy are done as homework by you and your partner between sessions. These behavioral techniques are aimed at boosting trust and sensual awareness to help you and your partner enhance or restore physical intimacy. You’ll be asked to discuss your feelings, sensations, and thoughts during these techniques at your next therapy session.

Sensate focus exercises are designed to help couples increase their comfort with physical intimacy and familiarize themselves with each other’s (and their own) body.

Sensate focus exercises. The techniques that are often at the center of sex therapy involve a series of structured touching activities known as sensate focus exercises. These are designed to help couples increase their comfort with physical intimacy and familiarize themselves with each other’s (and their own) body.

Sensate focus techniques often are customized for individual couples, but they generally follow the four stages outlined in the table below. Sex therapists will often use other behavioral exercises and treatments (including treatments discussed later in this section) in addition to sensate focus, depending on a couple’s needs.

The stages of sensate focus technique
Stage 1       Each partner spends about 30 minutes caressing the other’s naked body, head to toe and front and back, except for the genitals and breasts. The emphasis is on the “giver” touching in a way that he or she enjoys. The aim is to focus on each sensation and the reaction to it. If this is too much too soon, couples can start with simple hand-holding or back rubs.
Stage 2 

The couple repeats the exercise from Stage 1, except this time the “receiver” tells the giver what kind of touching he or she wants and gives direction on what’s most enjoyable.

Stage 3  The couple expands the exercise from Stage 2 to include touching of the genitals and breasts, but not exclusively. The focus remains concentrating on sensations and expressing wants and pleasures without the goal of orgasm.
Stage 4  The couple now may engage in mutual touching and stimulation to the point of orgasm, including intercourse if mutually desired.

Sex therapy versus counseling; finding a therapist. If your sexual problem is rooted largely in relationship issues, you and your partner may benefit from standard couples counseling, especially if the techniques of sex therapy may be too much for you right away. Your individual or couples therapist is also a good source for referrals to a sex therapist if and when needed. Your gynecologist or other healthcare provider might also be able to refer you to a sex therapist, or you can visit the websites of the American Association of Sex Educators, Counselors, and Therapists (AASECT), the International Society for the Study of Women’s Sexual Health (ISSWSH), and the Society for Sex Therapy and Research (SSTAR) (see “Resources for More Information”).

If you do seek out a sex therapist, don’t be shy about calling in advance to ask about his or her treatment philosophy, techniques used, and training. And remember that an initial visit does not commit you to long-term therapy; if the fit with the therapist doesn’t feel right, try another.

How effective is sex therapy? The best scientific evidence for the effectiveness of sex therapy is in treating orgasm problems, sexual aversion (finding sex distasteful or disgusting), and vaginismus. There is not much scientific support for the effectiveness of sex therapy alone for treating low sexual desire unless it is mainly due to relationship issues or other emotional or psychological factors.

Keep in mind that sex therapy or counseling can yield benefits simply by leading you and your partner to focus afresh on intimacy and sexuality. In clinical studies of various medications for female sexual problems, the groups of women receiving placebo therapy saw improvements of up to 30% in their sexual function over the course of the study. This suggests that just paying greater attention to sexuality—as women do when enrolling in a clinical study, or when couples jointly seek counseling—can have positive effects even when no active treatment is used.

Solo sex therapy?

It’s not uncommon for a woman with low desire or arousal difficulties to seek out sex therapy alone, without her partner, because she believes the problem is hers alone. If that sounds like you, be aware that even if you don’t think your partner is part of the problem, he or she should be part of the solution.

Sometimes a partner is wary of participating in sex therapy. If that’s the case, urge your partner to attend at least one session of therapy since it will help the therapist appreciate his or her point of view. Your partner also may be won over and be willing to give it more of a chance, which can only help improve the therapy’s efficacy.

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