Talking About Sex (in) Therapy: Why it Matters
By Miklos Hargitay, PsyD
When I was in graduate school, I was meeting with a young woman in therapy who had been sexually assaulted by an acquaintance. We were working on addressing the trauma she experienced, and during one of our sessions, I wanted to ask about what dating and sex have been like for her after the assault. However, I felt uncomfortable. I asked for permission to inquire about her sexual history and her response floored me: “You’ve learned about some of the most painful and awful moments of my life. It’s okay that you want to talk about sex.” She’s absolutely right.
Silence about sex in therapy
Therapists have been taught that it's necessary to process difficult experiences that our patients bring to therapy yet shy away from asking about some of the more pleasurable moments. A survey of therapists asked whether their graduate training focused on sex and survey results found that a majority of therapists had limited graduate training in sex. Furthermore, some of the reported barriers to addressing sex with patients were factors such as perceived ignorance and possible discomfort in speaking openly about it in session (Love & Farber 2017; Kleinplatz, 2010). Unfortunately, this lack of sex education and reluctance of therapists to bring up sex with patients can have significant implications. For gender and sexual minorities, not feeling seen in the therapy room in addition to existing social oppression when it comes to sexual identity can be especially painful. A same sex interracial couple I once worked with told me that they used to scan my office for books or resources that would give them clues as to whether I was sex-positive. Their previous couples therapist, while supportive and compassionate, never attempted to address sex with them. As a result, they felt that they had to cordon off parts of their lives to engage in therapy.
Sexual health and mental health are related
So what might it look like to incorporate talking about your sexual concerns in therapy? Your sex life may not be the primary reason that you’re in therapy, but sometimes our patients are not aware that their sexual health and experiences may be tied to their mental health. For instance, some patients who are taking medication to treat depression often find a decrease in their sex drive as a side effect, which ironically may hamper their treatment progress for depression (imagine feeling better, but not having the desire to be intimate with someone you care about). Monitoring the relationship between your mood levels and your sex drive can be an important part of successful therapy and your overall emotional wellness.
What is sex therapy?
What if you are interested in going to therapy specifically to address a sexual concern? Sex therapy may be what you’re looking for. While sex therapy is similar to other types of therapy, the key difference is that conversations, interventions, and goals have the primary focus of supporting an individual or couple's sexual functioning. Sexual concerns, such as anxiety about sex, beliefs or thoughts that make sexual intimacy challenging, or difficulty being connected to one's body during sexual activity may be addressed together with a sex therapist. Sex therapy can also include elements of personal exploration, sex education, and a specific safe space to discuss sex openly and positively - sometimes with the plan of learning to do so with others. Sessions may include discussing and planning for behavioral exercises outside of session to help an individual or partners to engage sexually in a way consistent with their goals.
What does sex therapy look like?
Here’s a hypothetical scenario.
James (24), a college student in a relationship, is having difficulty with managing his anxiety. He said that he often feels overwhelmed and panicky in moments when he feels a “loss of control”. This can happen during finals, socializing with new people, and going on dates with his new girlfriend. He often attempts to control situations as best as he can by either avoiding high anxiety situations or by getting drunk or smoking cannabis to calm his nerves.
While many therapists may start by exploring potential anxiety triggers at school and helping James learn and use coping strategies other than avoidance, a sex therapist will likely focus on asking questions about how his anxiety or avoidance affects his experience of sex. In doing so, a sex therapist may discover that James struggles with erectile dysfunction.
A sex therapist may encourage James to consider what kinds of behaviors he’s been using to manage his erectile dysfunction. If they have not been helpful - the therapist could provide information and identify what additional strategies might be. Techniques such as mindfulness to help James focus on his bodily sensations in a non-judgmental manner, helping him challenge or notice his unhelpful thoughts about his perceived sexual functioning, increasing communication with his girlfriend so they can make changes to their sexual repertoire, and generating self-compassion when he feels that his body is “letting him down” may all be discussions in sex therapy. Finally, some validation and continued education is vital. For James and even his partner to hear that it's not their fault that James loses his erection, but that they can help make the situation better can be life changing.
How do I find a sex therapist?
Good question! If you have ever had the experience of wanting to talk about sex, but feel unsure about it with a therapist, you are not alone.
If you are currently looking for a sex therapist (or a therapist who is sex-aware), one place to start is through the AASECT (American Association of Sexuality Educators, Counselors, and Therapists) directory. AASECT certified sex therapists must at minimum have a graduate degree and complete relevant coursework, specialized training, and a certain number of professional hours under supervision.
How do I bring up sex with my therapist?
If you have a current therapist and wish to address needs related to sexuality, I would suggest considering the following:
Ask yourself, what are your goals in addressing sex in therapy?
Are you looking to address something specific such a difficulty with sex and dating? Or exploring themes related to sexuality such as gender identity?
Recognize that sex can impact all forms of functioning, even if it’s subtle.
Anxiety, depression, trauma, substance abuse, relationship struggles are all disruptions in our daily life and can make it difficult for sexual functioning and expression. Even if it doesn’t feel top of mind, addressing if sex is being affected by the above concerns (or is actually a main cause or contributor to the concern!) can be clarifying.
Try bringing it up.
It may be hard, but saying something like “I know we haven’t talked about this yet, but can we talk about sex?” can be a powerful conversation starter. Keep in mind that even if sex has never been the focus of therapy, you can always introduce new topics or goals with your therapist. Your therapy should reflect what is most relevant and important to you in your life. It may also be a great way to check in with your therapist and discuss if therapy is going the way that you hope.
About the Author: Dr. Miklos Hargitay is an AASECT certified sex therapist. Contrary to popular belief, he doesn’t talk about his sex life with his clients or watch his clients have sex. Dr. Hargitay is committed to providing a safe, sex-positive, and informative space for individuals and couples to openly talk and work towards building sexually fulfilling lives.
References:
Kleinplatz, P. J. (2010). The profession of sex therapy. Systemic sex therapy, 42-62.
Love, M., & Farber, B. A. (2017). Let's not talk about sex. Journal of clinical psychology, 73(11), 1489-1498.