(Created March 2010)
As sexual medicine has entered everyday discussion in America, the concept of sex therapy continues to be misperceived and misunderstood by many health care providers and patients. This fact sheet is designed to clarify what sex therapy is—and is not.
Sex therapy is a form of talk therapy comprised of a combination of counseling, cognitive-behavioral interventions, and treatment of concomitant psychiatric conditions such as depression and anxiety disorders.1,2 It certainly does not involve patients having sex in front of the therapist or the therapist acting as a sexual surrogate.
According to the American Association of Sexuality Educators, Counselors and Therapists (AASECT), certified sex therapists “are mental health professionals, trained to provide in-depth psychotherapy, who have specialized training in treating clients with sexual issues and concerns.” They handle both “simple sexual concerns” and “are prepared to provide comprehensive and extensive psychotherapy over an extended period of time in more complex cases.”3
Individual or couple psychotherapy may be offered, and clients meet with the sex therapist in an office setting. A history is taken, one or more diagnoses is established, and a treatment plan is developed.1,3
Sex therapists frequently treat clients with desire, arousal, performance, and satisfaction issues. They also counsel patients who have experienced sexual trauma or abuse, or who are struggling with gender identity or sexual orientation issues, fetishes, sexual pain, or sexual compulsions/addiction.3
The When and How of Referring a Patient for Sex Therapy
Most front-line providers will be comfortable treating a sexual issue—up to a point. They can certainly give the patient permission to discuss the problem, validate her concern as legitimate, and provide limited information and suggestions, as suggested by the PLISSIT Model of Intervention for Sexual Problems.1,4 For intensive therapy and any situation where a sexual issue exceeds their level of comfort or expertise, clinicians will want to refer a patient to qualified specialists, such as a sex therapist.2,4
It is important for primary care providers to become familiar with sex therapists in their area (see box on sex therapy resources) so they can readily and confidently refer patients and their partners as needed. The patient should be referred with the assurance that you are adding a team member to address her problem, and not just passing her off to another clinician. It is important to emphasize that you will continue to be involved with her ongoing care. Comprehensive and optimal sexual care often may require both a physical and mental health approach.5
Sex Therapy Interventions
Sex therapists can offer a variety of interventions that may help a patient reconnect emotionally and sexually with her partner. Common strategies include:
- Helping a patient develop realistic and appropriate goals. Patients may need help understanding female and male sexual response and what is arousing for them as individuals. They may not have explored their sexual responses, they may pretending to have orgasms, they may be anxious or inhibited about their sexuality, or they may engage in a set pattern of sexual activity that is not arousing or satisfying to them.1,2 Exploration of wants, needs sexual turn ons or turn offs may also be used. Education about a sexual problem is often the first step in the treatment process and helps the patient better define her needs, goals, and expectations.3,4
- Exploration of sexual fantasies. Fantasizing about sex is often a good step in recharging desire. Basson has suggested that many women (particularly those in long-term relationships) are not having spontaneous sexual thoughts or fantasies, but may be receptive to sex if mentally or physically stimulated.6,7 Sex therapists may recommend bibliotherapy or the use of erotic books or videos to spur fantasies. In addition, the sharing of fantasies with a partner can improve relationship communication about what a woman finds arousing and may help a couple revive an otherwise boring sexual script or repertoire.2,8
- Identifying contextual catalysts for sexual activity. Review of the context in which sexual activity typically occurs in a woman’s life—i.e. the sexual script—including the time of day, the interval between sexual encounters, and the way a partner indicates his/her desire for intimacy can be used by the sex therapist to make recommendations about how to increase a woman’s desire for sex, arousal, and satisfaction.1
- Cueing exercises. These exercises are designed to help a patient remember instances in her life when she felt sexy and had a good and satisfactory level of sexual desire. The patient is instructed to recall her physical appearance, the setting, the smells in the air, the music she was hearing, and the foods she was eating at that time and use these as “cues” for feeling sexual now.8
- Assigning sensate focus exercises. These behavioral exercises involve a couple taking turns pleasuring one another so each person has a heightened awareness of what types of strokes and caresses are most arousing and can convey that information to his/her partner. Sensate focusing can be both genital and non-genital in nature. It often begins with limited sensual massage of the face, hands and neck and progresses over time to include sexual intercourse. In fact, to reduce “performance anxiety” and help the couple establish emotional intimacy, the exercises are not goal-oriented (i.e., tied to intercourse) and intercourse is initially discouraged.8
- Teaching the practice of mindfulness. Most people have become multitaskers in an effort to keep up with everyday life. They may take this approach to their sexual life, and rush unfocused through intercourse as well, leaving little room for sufficient arousal, enjoyment, or satisfaction. Women with desire and arousal disorders are particularly vulnerable to being distracted by stressors during sexual encounters. The practice of mindfulness teaches the patient to focus on the here and now and on all of her sensations—sight, smell, hearing, touch, and taste—and to push distracting thoughts away. The technique can be particularly helpful in educating a woman about the way her body responds to sexual stimuli.1,8
- Exploring alternate forms of sexual expression. This can include education on sensual massage; fondling and caressing; mutual masturbation; manual, oral, and anal stimulation techniques; use of sexual enhancing toys (vibrators) and trying alternative sexual positions (other than the missionary position) for sexual intercourse.8
- Addressing sexual boredom. A couple who has been together for many years often falls into a sexual routine that is unimaginative and boring, often called a sexual rut, that can dampen desire. A sex therapist can offer a number of suggestions for reviving this type of a sexual life, such as changing the venue for sex (moving it out of the bedroom, for instance, and into the back seat of the car or to a hotel room), as well as sex education books and videos to cull for new techniques.2,8
- Discussing dilators or the EROS device. Sex therapists have a number of tools at their disposal to help patients. For a woman suffering from vaginismus, they can suggest vaginal dilators along with a functionalized program that can help reduce patient anxiety and help facilitate stretching of the vagina. Successful treatment hinges on the patient being taught how to insert and use dilators appropriately—e.g., using them three times a week to once daily for 10 to 15 minutes and progressing slowly through larger-sized dilators.8 For a woman with arousal and/or orgasm disorders, sex therapists may recommend the EROS Clitoral Stimulator, a prescription-only device that utilizes suction to draw blood to the clitoral region and has shown in limited clinical data to improve arousal in selected cases.8
For more information on this topic, refer to the other Sexual Health Fundamentals fact sheets, The Top 10 Things You Need to Know about Female Sexuality and Talking with Patients About Sexuality and Sexual Health.
- Various authors. In: Leiblum SR, ed. Principles and Practice of Sex Therapy. Fourth Edition. New York, NY: Guilford Press. 2007.
- Berman J, Berman L, Bumiller E. For Women Only: A Revolutionary Guide to Reclaiming Your Sex Life. 2nd ed. NY, NY: Holt. 2005.
- American Association of Sexuality Educators, Counselors, and Therapists. Frequently Asked Questions. Available at www.aasect.org/faqs.asp. Accessed 12/21/09.
- Albaugh JA, Kellogg-Spadt S. Sexuality and sexual health: The nurse’s role and initial approach to patients. Urologic Nursing. 2003;23:227-228.
- Kingsberg SA. Taking a sexual history. Obstet Gynecol Clin N Am. 2006;33:535-547.
- Basson R. Female sexual response: The role of drugs in the management of sexual dysfunction. Obstet Gynecol. 2001;98:350-353.
- Basson R. Women’s sexual dysfunction: Revised and expanded definitions. CMAJ. 2005;172:1327-1333.
- Krychman ML. 100 Questions & Answers About Women’s Sexual Wellness and Vitality. Sudbury, MA: Jones and Bartlett Publishers. 2010.
Sexual Health Fundamentals is a publication of the Association of Reproductive Health Professionals (ARHP) for health care professionals, educators, and researchers working in the field of reproductive health. This fact sheet is part of the Sexual Health Fundamentals for Patient Care Initiative, which was guided by principles established by a consensus committee of renowned experts in female sexuality, led by cochairs Michael Krychman, MD, and Susan Kellogg Spadt, CRNP, PhD. The goals of this initiative are to assist “frontline” members of the reproductive health care team with expert, evidence-based guidance on sexual function, health, and wellness, and to provide freely available needs assessment tools for professional societies to customize for their specific constituencies. Sexual Health Fundamentals are available at www.arhp.org/factsheets.