Sex Therapy

• What is sex therapy?
• Who uses sex therapy?
• Rationale behind sex therapy
• Approaches to sex therapy
• Effectiveness of different approaches to sex therapy
• Making an appointment with a sex therapist
• What happens during sex therapy?
  • Initial assessment
    • History taking
    • Physical examination
    • Investigations
  • Diagnosis
  • Treatment
    • Pharmaceutical treatments
  • Follow up to prevent relapse
• Assessing the outcomes of sex therapy
• Ethical principles of sex therapy

What is sex therapy?

Sex therapy refers to a group of treatments which are used to resolve sexual difficulties, for example difficulties relating to sexual desire, arousal and ability to orgasm. Current approaches to sex therapy are typically informed by a biopsychosocial framework, that is, a framework which recognises that biological (e.g. hormone levels), psychological (e.g. self esteem and body image) and sociocultural (e.g. the degree of social acceptance of women playing an active role in sexual encounters) factors all influence an individual’s sexual functioning. As such the various treatments which comprise sex therapy address biological, psychological and sociocultural factors which may underlie a particular sexual complaint. The treatments involved in sex therapy may include:

• Sexuality counselling sessions for couples, individuals or groups – sexuality counselling is a process that addresses sex education, values clarification, exploration of sexual attitudes and beliefs, self image, sexual identity, gender role development and relationship issues. It is an interactional process between counsellors and clients that facilitates exploration and understanding of connections between sexual desires, practices, attitudes, ideals and duties;
• Physical and sensual homework exercises which may or may not involve sensual stimulation of the genitals;
• Medications, for example prescription of PDE5 inhibitors for erectile dysfunction or antibiotics to treat sexually transmitted infections (STI) which contribute to sexual difficulties such as dyspareunia (pain during intercourse);
• Surgical interventions may also rarely be used to rectify problems contributing to sexual difficulties, for example urinary incontinence in women.

Sex therapy aims not only to help couples or individuals overcome difficulties relating to their sexual functioning but also to increase their pleasure, skill, comfort and confidence in sexual experiences. Individual therapists will vary in their approach to sex therapy. However, as a group, sex therapists take a non-judgmental stance (they do not judge individuals because of their sexual desires or fetishes, but rather recognise that all individuals are different and will desire different sexual experiences). When working with couples, which is generally preferred, sex therapists will also encourage the couple not to judge or blame each other for the sexual problems they are encountering.

Who uses sex therapy?

Individuals or couples who experience sexual difficulties might use sex therapy. There is no archetype for the person who will benefit from sex therapy. Instead, sex therapy can help individuals of various ages, cultural backgrounds, beliefs and abilities.

The sexual difficulties for which couples or individuals may seek sex therapy can be specifically identified as sexual problems or sexual dysfunctions. Sexual dysfunctions are impairments, either physical or psychological, of one of the three phases of the sexual response cycle, i.e. desire, arousal and orgasm. Additionally, there are the pain disorders. These sexual dysfunctions may include:

• Difficulty with sexual desire, in particular, a lack of sexual desire which is called Hypoactive Sexual Desire Disorder, but also hypersexual desire or sexual aversion.
• Arousal difficulties, such as erectile dysfunction in men and Female Sexual Arousal Disorder or Persistent Genital Arousal Disorder in women;
• Difficulty with orgasm, either achieving orgasm too quickly (which is called premature ejaculation in men), taking too long to achieve orgasm (which is called delayed ejaculation in men), or being unable to achieve orgasm (which is called anorgasmic disorder in males or female orgasmic disorder in women; and
• Sexual pain disorders, such as vaginismus in women (involuntary spasms of the vaginal muscles which cause pain during intercourse), and dyspareunia in both men and women.

Aside from these dysfunctions, people experience a wide range of other sexual difficulties for which they may like to seek sexuality counselling. They are referred to as sexual problems and range from dissatisfaction with sexual frequency and sexual boredom to incompatibility with respect to sexual activity and lack of sexual fulfilment. These more emotionally based problems also include exploration of the degree of passion that couples express sexually, the type of communication employed by each partner, and the level of commitment partners exhibit to work on the sexual aspect of their relationship.

Rationale behind sex therapy

Sex is an integral part of any intimate partnership, and sexual functioning within a partnership influences the relationship more generally. This is particularly true when sex is dysfunctional. Sexual dysfunction is a major cause of relationship breakdown and stress within a relationship. It also has a negative impact on an individual’s confidence and sense of wellbeing. Thus, just like other health problems, resolving sexual difficulties is important in maintaining individual health, but it also impacts on relationship health. Sex therapy can be expected not only to improve sexual satisfaction for the couple or individual being treated, but also to improve other areas of their life, and potentially avert distressing events such as marriage breakdown.

Approaches to sex therapy

Modern sex therapy is generally informed by a biopsychosocial framework. It ideally involves one or more distinct but related components which focus on biological, physical, psychological, relational and/or contextual factors. Ideally, a range of health professionals may be involved in the therapy, including general practitioners, sex therapists, relationship counsellors and specialist physicians. Distinct treatments may be prescribed by any one of these professionals (e.g. medication may be prescribed by a general practitioner to improve a man’s erectile function), but will be administered alongside treatments devised by professionals from other backgrounds (e.g. a sex therapist may provide counselling to the man and his partner at the same time). In reality however, sex therapy does not always combine a range of treatments.

Since the approval of PDE5 inhibitors (e.g. Levitra (vardenafil), Cialis (tadalafil), Viagra (sildenafil citrate)) for the treatment of erectile dysfunction, many men receive solely pharmaceutical interventions. Other approaches focus solely on psychological factors and provide only psychological interventions. For example, Masters and Johnson, who developed sex therapy as a profession in the 1960s and 1970s and laid the foundation for modern sex therapy, focused almost entirely on psychosocial causes of sexual difficulties. More recently new approaches which focus exclusively on psycho-social issues have also been developed, for example psychotherapy, a counselling technique which assists individuals to deeply explore their embarrassing or shameful experiences and feelings.

Effectiveness of different approaches to sex therapy

Assessing the relative effectiveness of various approaches to sex therapy can be difficult because sex therapy is applied to different sexual difficulties (e.g. erectile dysfunction or premature ejaculation in men and difficulty achieving orgasm and sexual pain in women). Each sexual difficulty will respond differently to different types of treatments (e.g. there are a range of medications which are effective in treating erectile dysfunction in men but none which have been demonstrated effective in helping women achieve orgasm).

There is also difficulty comparing the results of studies assessing the effectiveness of different approaches to sex therapy because many studies use different measures of success. For example, some may focus solely on whether or not the treatment resolved the individual or couples’ sexual complaint (e.g. inability to orgasm), while others might use broader measures of sexual functioning (e.g. extent of sexual enjoyment, regardless of whether orgasm was achieved). Sex therapists argue that holistic approaches, which incorporate a range of biopsychosocial approaches and attempt to address the problems underlying sexual dysfunctions (e.g. marital problems, systemic health issues) are more effective than those which focus solely on a particular sexual complaint (e.g. erectile dysfunction, anorgasmia).

There is some evidence to support claims that holistic approaches are more effective, particularly in relation to erectile dysfunction in men. The treatment of erectile dysfunction has been the focus of much research since the approval of PDE5 inhibitors. While PDE5 inhibitors have proven very successful in treating erectile dysfunction in clinical studies, their effectiveness as used in the real world, where factors such as self esteem, relationship and work stress also affect erectile function has not been heavily evaluated.

Available evidence suggests that many men who use medications to treat erectile dysfunction do not continue using them in the long term, and as these medications are only effective while they are being used, men are likely to re-experience erectile dysfunction when they cease to use PDE5 inhibitors. A number of studies which have compared the effectiveness of medication treatment of erectile dysfunction alone or in combination with non-pharmacological of sex therapies have reported better treatment outcomes with combined therapy, for example improved ability to achieve erection, greater sexual satisfaction amongst treated men and their partners and greater satisfaction with treatment. There is however evidence that the cost of treatment with medication is less than the cost of sex therapy involving counseling.

Making an appointment with a sex therapist

Appointments for sex therapy can be made by contacting the therapist directly. Both these organisations compile a directory of qualified sex therapists in Australia: the Society of Australian Sexologists and the Australian Society of Sex Educators, Researchers and Therapists.

When considering which therapist may be most appropriate to consult with, be aware that some specialise in particular types of therapy (e.g. sexuality after cancer treatment). Also consider the location in terms of its convenience and whether or not you would like to have face to face or telephone sessions.

Sex therapy services are not covered by the Medicare rebate scheme unless the therapist is a registered psychologist, so there is no need for a referral from a GP. Some private health insurance scheme provide rebates for sex therapy. The health insurance provider can give specific details of the rebates available for sex therapy with different levels of cover.

What happens during sex therapy?

Typically, sex therapy will involve a number of sessions with a therapist, who acts like a counsellor to facilitate the couples’ disclosure and discussion of the sexual problems which have lead them to seek therapy. Ideally, the couple are treated together although certain aspects of the treatment may involve only one member of the couple. In some instances individuals will also seek therapy and be treated as individuals.

Specialist sex therapists are often involved in the ongoing treatment of sexual difficulties, particularly when treatment involves psychosocial (as opposed to medication-only) therapies. In addition to assessing the couple’s situation, the therapist’s role is to provide motivation to the couple to change their sexual behaviours so that they are mutually satisfied. A therapist also tries to help a couple focus on the difficulties underlying their sexual difficulties and develop strategies which might help to overcome them. With the therapist’s assistance, couples engage in discussions about their sex life and sexuality and the factors which influence these. They may also practice physical exercises (for example sensual touching exercises), often as “homework” tasks. The therapist may also prescribe medications in appropriate situations, or counselling for broader issues affecting sexual functioning (e.g. marital counselling for couples with marital difficulties).

Initial assessment

Initial assessment of a couple visiting a sex therapist or other health professional with complaints of sexual difficulties generally includes a medical history (with a particular focus on the history of the sexual difficulty) and physical examination. A diagnosis of the complaint will then usually be made.

History taking

In order to assess the nature, severity and underlying causes of a sexual difficulty, a therapist or other health professional may ask the couple questions regarding the:

• history of the relationship, including when they first became attracted and sexually active;
• onset of sexual difficulties;
• nature of the sexual difficulties;
• couples’ explanation for why they are having sexual difficulties;
• attitudes towards sexuality; and
• previous treatment for sexual difficulties and response to that treatment.

Discussing the relationship and its history may be a difficult process, as many couples seeking sex therapy have relationship difficulties and the individuals may experience a range of negative emotions including shame, guilt and anger. Negative emotions will interfere with the treatment, and the sex therapist will therefore encourage couples to discuss events of the past and move on from them, leaving any negative emotions behind.

Therapists may also ask each member of the couple about childhood experiences which may be influencing their sexuality today, including questions regarding:

• their parents’ marriage, details of their parents’ level of intimacy, attitudes to sexuality, separations and extra-marital affairs; and
• childhood experience of incest or sexual abuse.

Physical examination

Physical examination also plays an important role in the assessment of a couple’s sexual difficulties. However, it is important to note that a physical examination cannot be conducted by a Sex Therapist who is not a GP, medical doctor, nurse or physiotherapist. A physical examination is generally considered essential in cases where the presenting complaint is:

• a sexual pain disorder (e.g. vaginismus, dyspareunia);
• erectile dysfunction; or
• thought to be underpinned by a neurological disorder.

For other presenting complaints, while not essential, physical examination often provides important insights into the underlying causes or nature of a range of sexual difficulties. It can also assist the doctor to select the most appropriate laboratory tests and other investigations to assist with diagnosis. For example:

• degeneration of the genital tissues in women may indicate oestrogen deficiency or a connective tissue disorder;
• erectile dysfunction in men might indicate cardiovascular problems, diabetes or a lower urinary tract problem; and
• the emotional or physical response to pelvic and/or genital examination of a man and woman, may provide insights regarding psychological issues underlying the sexual dysfunction.

Investigations

Laboratory assessment of hormone levels is often performed in the assessment of sexual disorders although such tests are not essential. For women, the hormones best known for influencing sexual functioning are testosterone (which affects sexual desire) and oestrogen (which affects sexual arousal, in particular vaginal lubrication and elasticity). Testosterone is also the key hormone affecting sexual desire and function in men. However, there is also evidence that psychosocial factors, in particular satisfaction with the relationship and partner, are more important determinants of sexual function than hormone levels.

Diagnosis

The information generated through history taking, examination and investigations is used by the doctor to develop:

1. a preliminary diagnosis regarding the causes underlying the couple’s sexual difficulties (particularly a determination of whether the difficulties are primarily underpinned by biological or psychological factors);
2. a strategy for resolving the sexual difficulties based on the above diagnosis; and
3. a strategy for resolving any related problems which may influence sexual difficulties (e.g. a referral to marriage or couples therapy to resolve relationship issues such as intimacy and trust).

Diagnosis is sometimes complicated by the terminology medical practitioners use to classify different sexual complaints. Complaints are commonly termed dysfunctions or disorders (rather than difficulties) in the medical field. However many professionals see this terminology as problematic, because it implies that individuals who do not live up to a particular sexual ideal (e.g. being able to achieve orgasm every time they have sex) are somehow dysfunctional. Many argue that the sexual ideals currently in existence are unrealistic, and that failure to achieve orgasm or an erection from time to time is absolutely normal, rather than dysfunctional.

Issues have also been raised with the categories biomedicine puts forward to classify sexual difficulties. For example, one classification system offers only a single diagnostic category for all disorders of female sexual arousal. However, health professionals have identified a number of distinct sub-categories of disorders of low sexual arousal in females, those related primarily to:

1. biological/physical factors;
2. psychosocial factors; or
3. a combination of the two.

They have also identified a further category, persistent genital arousal, although these categories are not included in current classification systems.

Treatment

Treatment of sexual difficulties has changed considerably in the past decade, in particular due to pharmacological advances. The approval of PDE5 inhibitors for the treatment of erectile dysfunction has resulted in increasing numbers of male patients receiving pharmacological sex therapies, often without concomitant counselling or education therapy. Despite the increasing prominence of PDE5 inhibitors in sex therapy, there is evidence that combined sex therapy is more effective in long term. Combined approaches to sex therapy involve a combination of cognitive-behavioural and systemic interventions including:

• sexual education;
• sexual permissiveness training (teaching couples to freely express their sexual feelings and behave in ways which they may previously thought of as unusual);
• communication training;
• assertiveness practice;
• couple counselling;
• non demand pleasuring (sensual activities between a couple which occur for their own sake, not as a lead up to sexual intercourse);
• physical awareness and sensuality exercises;
• exploration of past traumatic events that may influence current sexual experience;
• treatment of psychological problems (e.g. depression);
• treatment of systemic health problems including:
  • obesity and overweight;
  • fatigue;
  • eating disorders;
  • self esteem and body image difficulties,
  • sedentary lifestyle;
  • compulsive exercise;
  • sleep apnoea;
  • sexually transmitted infections (STI);
  • prostate disorders;
  • cardiovascular problems;
• surgical interventions to rectify congenital or other abnormalities of the genitals which may underpin sexual difficulties;and/or
• treatment with medications.

The exact combination of therapeutic measures will depend on the nature of the sexual difficulties and the individuals involved. Sex therapists will usually be familiar with many different treatment options and combine them to suit the particular needs of the couple being treated.

The sex therapist also helps motivate and guide the couple throughout the treatment. Typically sex therapy involves numerous visits to a therapist’s office, in which education and training are undertaken, issues discussed and response to medicines and other aspects of the treatment monitored. The couple may also be introduced to pleasuring exercises and asked to practice these as homework. The frequency and duration of sex therapy sessions will vary depending on the couple being treated. However, to prevent the reoccurrence of sexual difficulties, it is recommended that sessions continue even after improvements in sexual functioning are seen. Couples may also experience greater improvement if they continue with “homework” exercises after the conclusion of sex therapy sessions.

Pharmaceutical treatments

Pharmaceutical treatment of sexual difficulties has become particularly common for men, since PDE5 inhibitors became widely available for the treatment of erectile dysfunction. Evidence demonstrates that these drugs are, for the most part, safe and effective, particularly when there are no underlying psychological and relationship issues. However, the drugs provide relief from erectile dysfunction only whilst in use, and as many as 40-80% of men do not continue with medication treatment when it is used alone, without psychosocial treatment (e.g. counselling).

Unlike with men, there are no medications approved for the treatment of sexual difficulties in women, however some medications can improve female sexual response. For example, treatment of post menopausal women with oestrogen replacement improves sexual wellbeing although this is not the purpose for which it is prescribed. There is also evidence that surgically sterilised women experience increased sexual desire with testosterone treatment, although testosterone therapy is not approved for the treatment of sexual desire difficulties.

Follow up to prevent relapse

Couples who experience improved sexual functioning during sex therapy may still relapse into sexual difficulties once sex therapy sessions terminate. Ensuring that sex therapy is comprehensive and effectively addresses the biological, physical, psychological and social factors underpinning sexual difficulties tends to reduce the potential for difficulties to re-arise once therapy stops.

To ensure ongoing sexual satisfaction, it is also important that:

• couples have realistic goals about their future sexual performance, for example that they do not expect to have “perfect” sex every time;
• couples are prepared to deal with sexual “failures”, that is, sexual experiences which were difficult or less than satisfactory than was hoped;
• the couple continue to practice some of the techniques learnt during sex therapy, for example non-demand pleasuring sessions without intercourse and using alternative sexual scripts to consciously expand their sexual repertoire; and
• couples have follow up visits with the sex therapist every six months for one to two years after the treatment is complete.

Additionally, resistance to treatment and relapse may be signs of other sexual dysfunctions in the individual or couple, problems with communication, or relationship conflict.

Assessing the outcomes of sex therapy

There are a number of approaches which can be taken to measure the effectiveness of a sex therapy program. Evaluation typically focuses on objective, physical measures, such as achievement of orgasm or erection in an individual who previously had difficulty. This is partly because it is more difficult to assess subjective measures in circumstances where same outcomes may indicate either success or failure, depending on the couple. For example, in some cases sex therapy may result in the realisation that the relationship is deeply troubled. In such a case ending the relationship may constitute a more successful treatment outcome than achieving sexual performance within it.

It is generally recognised that the main measure on which the success of sex therapy should be measured is in terms of whether or not the therapy assisted the couple to achieve greater sexual satisfaction, regardless of whether, or in spite of the fact that, sexual performance actually changed. Achieving an orgasm is not necessarily a success, unless the couple perceive that achievement to have enhanced their sex life. In some cases expectations may change as a result of sex therapy rather than sexual performance. For example, sex therapy may teach couples not to expect “perfect” sexual performance at every encounter, and that imperfect sexual performance does not necessarily constitute unsatisfactory sex.

There are also questions surrounding what outcomes should be expected, for what individuals and for how long. For example, is it realistic for a post menopausal woman with low sexual desire or a 50 year old man with erectile dysfunction to expect to re-achieve the level of sexual function achieved in earlier life (e.g. in their 20s or 30s)? Should couples who respond immediately to therapy but relapse to sexual difficulties after treatment cessation be considered successfully treated or treatment failures?

Ethical principles of sex therapy

Some people wonder if sex therapy entails talk therapy only or whether treatment will involve sexual contact with the therapist or even between the couple while in the therapist’s office. In fact, no sexual contact between therapists and the couple or individual is permissible. Although, couples or individuals are often given homework assignments to practice at home and then to discuss in the following session, it would be unethical to have couples engage in sexual activity or touching with the therapist present.

Additionally, issues such as integrity, confidentiality, and avoiding dual relationships are particularly salient in sex therapy, given the vulnerability that couples or individuals generally feel in revealing highly taboo and often hidden material.

All sex therapists are expected to study and follow the codes of ethics of their respective disciplines. Therapists who are members of certain organisations or counselling bodies are required to adhere to the organisations’ code of ethics for sex therapists.

Kindly reviewed by Desiree Spierings BA (Psych) MHSc (Sexual Health); Sex Therapist and Relationship Counsellor; Director of Sexual Health Australia and Editorial Advisory Board Member of Virtual Medical Centre and Parenthub.

References

1. Lieblum, S.R. Sex therapy today: Current issues and future perspective. Chap 1. Principles and practice of sex therapy. 4^th ed. The Guilford Press; 2007. pp 3-22.
2. McCarthy, B. McDonald, D. Sex therapy failure: a crucial but ignored issue. J Sex Martial Therapy. 2009;35:320-9.
3. Ohl, L.E. Essentials of Female Sexual Dysfunction from a Sex Therapy Perspective. Urology. 2007;27(1):57-64.
4. McCarthy, B.W. Relapse prevention strategies and techniques in sex therapy. J Sex Marital Ther. 1993;19(2):142-6.
5. Klienplatz, P.J. Coming out of the sex therapy closet: using experiential psychotherapy with sexual problems and concerns. Am J Psychotherapy 2007;61(3):333-48.
6. Althof, S. Rosen, R. DeRogatis, L. et al. Outcome measurement in female sexual dysfunction clinical trials: review and recommendations. J Sex Marital Therapy. 2005;31:153-66.
7. Fichten, C.S. Libman, E. Brender, W. Methodological issues in the study of sex therapy. Effective components in the treatment of secondary orgasmic dysfunction. J Sex Marital Therapy. 1983;9(3):191-203.
8. Brock, C. McMahon, C. Chen, K. et al. Efficacy and safety of tadalafil for the treatment of erectile dysfunction: results of integrated analyses. J Urology. 2002;168(4):1332-6.
9. Aubin, S. Heiman, J. Berger, R. et al Comparing Sildenafil Alone Vs. Sildenafil Plus Brief Couple Sex Therapy on Erectile Dysfunction and Couples’ Sexual and Marital Quality of Life: A Pilot Study, J Sex  Marital Therapy. 2009. 35(2):122-43.
10. Baum, N. Randrup, D. Junot, D. Hass, S. Prostaglandin E versus sex therapy in the management of psychogenic erectile dysfunction. Int J Impotence Res. 2000;12:191-4.
11. Sarrel, P. Dobay, B, Witta, B. Estrogen and estrogen-androgen replacement in postmenopausal women dissatisfied with estrogen-only therapy, sexual behaviour and neuroendocrine responses. J Reprod Med. 1998;43:847-56.
12. Russell, L Sex and couples therapy: a method to enhance sexual and emotional intimacy. J Sex Marital Ther. 1990;16(2):111-20.
13. Metz, M., & McCarthy, B. (2007). The Good Enough Sex model for men’s and couple sexual satisfaction. Sexual and Relationship Therapy, 22, 351-62.
14. Long, LL, Burnett, JA & Thomas, RV. Sexuality Counseling. An Integrative Approach. Upper Saddle River, New Jersey, Pearson Education Inc.; 2006.
15. Hertlein, KM, Weeks, GR, Gambescia (eds). Systemic Sex Therapy. 1^st ed. New York, Routledge; 2009.