Sex and Therapy 6/6: How do Sex Therapists Work?

At one time sex therapists mainly worked with DSM sexual dysfunctions aimed at facilitating intercourse and orgasm, such as erectile difficulties, early or delayed ejaculation, painful intercourse and issues with desire, arousal and orgasm. However, the role of sex therapists has broadened out so that they may now work with sexual dependency, sexual identity issues, fertility problems, trauma, trust and commitment, for instance.

It’s common to refer to a specialist colleague before starting sex therapy – for instance, to treat relationship conflict, sexual trauma or a medical issue – or some therapists have additional training and qualifications themselves. Some are medically trained, most are experienced couple counsellors, and increasingly many have trauma training.

Since some form of anxiety is at the heart of many sexual problems, heteronormative outcomes – such as ‘successful’ erection, ejaculation, orgasm and vaginal penetration – are backgrounded in favour of more general goals, such as relaxed intimate experiences. In practice, the complained-of dysfunctions are also treated, but the emphasis is much more on personal experience than scary outcomes.

Though some therapists’ interventions only involve talking, many use a core cognitive-behavioural approach based on the work of sex researchers William Masters and Virginia Johnson. After an initial meeting with the couple to learn about their issues and discuss their options, most sex therapists book detailed history-taking sessions. The information enables them to understand both how the couple’s problems have developed and the thinking and behaviour which is maintaining and exacerbating them. They then meet with the couple again to discuss this and to review the couple’s wishes going forward.

As CBT is a stepped process, some couples step off even after the first session or following history taking if they have already experienced resumption or improvement in their sexual connection.

Those who continue into treatment are given individual and couple exercises, initially aimed at getting them reacquainted with their own and each other’s bodies. Very anxious clients, and those who haven’t been sexual together for a long time, are offered pre-sensate exercises that are performed clothed or only involve talking. More confident couples dive straight into sensate focus exercises that involve touching all body areas apart from breasts, buttocks and genitals, as there will be a sex ban in place. This allows couples to focus on what touch is possible rather than what isn’t. Gradually, over many weeks, more and different kinds of touch is introduced which becomes increasingly sexual.

The couple are normally urged to concentrate on their own experience and to avoid discussion. This helps reduce performance and response anxiety, as the couple learn to manage not knowing what the other is thinking or experiencing. Because the exercises are framed as experimental, and the couple are encouraged to discuss management of not-knowing, mutuality builds as they recognise similar feelings of anxiety and doubt.

Sex therapists are experienced in timing their interventions, anticipating and managing any problems that occur. Confidence grows as partners become able to show one another how they want to be touched, with a strong emphasis on consent. Throughout, they also have individual exercises and coaching which address their specific dysfunctions, body image, shame and anxiety, including awareness of the cultural, familial and societal influences on their thinking.

Individuals can also benefit from sex therapy, but couple work is able to tackle the apprehension associated with a close relationship and develop management of triggers around achievement and performance.

Several foundation courses are now available which prepare therapists for counselling with a sexual focus, also offering information about the much more in-depth training sex therapists receive.