Answers to Questions about Sex Therapy

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When do I need help for a sexual problem?

When should I go to therapy?

How do I get my spouse/partner to go to sex therapy?

What can I expect in and from Sex Therapy?

How do I find a good sex therapist?

When do I need help for a sexual problem?

Many problems, such as women unable to achieve orgasm, or men experiencing erection dysfunction, can be addressed successfully with self-help books.  "For Yourself" (female sexuality) by Lonnie Barbach, Ph.D. and Male Sexuality by Bernie Zilbergeld, Ph.D. are good examples.  You need a sex therapist when you have a sexual problem, or a relationship problem that is causing a sexual problem, that you are not able to "fix" by yourself. Common problems include sexual incompatibility, erection dysfunction (which the medical profession labels "impotence"), sexual desire discrepancy, vaginismus, and pain during intercourse.

Sometimes sexual problems are caused by, or are side effects of, other emotional factors, such as depression, or medicines.  Often they are caused by other psychodynamics in the relationship.  A competent sex therapist will assess the various components and suggest a course of action, which might be individual or couples therapy, assessment by a medical doctor in consideration of medication, or other interventions.

When should I go to therapy?

As soon as you determine that the problem is not getting better. For example, occasionally every guy cannot attain or maintain an erection. But if he worries about it, especially the next time he has an opportunity to be sexual, that can often guarantee that the erection loss will happen again, and the pattern starts. The longer that cycle of worry - erection problem - anxiety and embarrassment - and back to worry, goes on, the more established the problem gets.

Similarly, if a woman experiences a spastic clenching of the introitus -- the opening to the vagina -- repeatedly when penile penetration is attempted, the best course of action is to suspend further attempts until the problem can be alleviated by behavior modification.

In all cases, if the problem is repeated without change, it is better to stop that repetition and seek professional help.  The longer a problem goes on, the better "learned" it becomes, and the longer it will take to reverse that sequence in sex therapy.

How do I get my spouse/partner to go to therapy?

This is sometimes difficult. The best approach that I know is to focus on the rewards of attending therapy. It is quite common that men and women are resistant to coming into therapy -- for a variety of reasons. Often, the OFFERED "reason" is a cover-up for the "real" reason. American society places an awesome burden on men and women when it comes to sexuality,and the pain of acknowledging a sexual problem -- especially to a "stranger" -- is very real. The proverbial silver lining in the cloud, however, is that a vast majority of couples who complete a full course of sex therapy volunteer that they are NOT "just fixed" and returned to their sexual behavior before they had a problem; they are significantly more aware of what they find to be sexually stimulating, they are significantly less inhibited about announcing what they want, and they have enhanced communication skills on sexual matters.

If your spouse perceives the rewards of attending and completing therapy to be greater than the rewards of not presenting for therapy, he or she will go for the greater reward. The task is to make therapy more rewarding than not having therapy.  Some couples come in after one spouse has threatened divorce.

What can I expect in and from Sex Therapy?

Please keep in mind that different problems call for different solutions; that there are several schools of thought about how to conduct sex therapy; and that there are powerful and dramatic differences among therapists in wielding the tools of the trade. Considering some of the stories I have heard from patients, probably informing you of what SHOULD NOT HAPPEN is as important as describing what you can expect.

The thumbnail sketch of how I conduct sex therapy is:   An initial assessment to determine psychological versus medical factors.  If a referral to a medical doctor is not called for, I then meet with a couple 3-7 times to get an idea of how much sex is interfering with the relationship, and how much relationship conflicts are interfering with sex. That's why good sex therapy is also good marital/relationship therapy. I then meet with each of the partners individually to learn about their family of origin, relationship, and sexual histories. I will often assign readings (see "books the sexdoc finds interesting") and exercises to facilitate and "leverage" therapy -- that is to use time outside of the therapy session as effectively as possible. I am fond of telling patients: "My first job is to put myself out of a job as quickly as possible. I can accomplish that when you are able to do on your own what you are seeking help for in therapy."

I watch carefully to see how each person is responding to intervention. I role model communication and decision-making techniques. I explicitly identify and reward specific advances made in therapy.  I propose milestones and benchmarks for common agreement on assessing when we have accomplished our goals. And I will usually initiate a discussion of when we should part company for regular meetings (although I remain available for consultation in the future).

You can expect to be shy about describing your sexual behavior. After all, isn't it considered extremely rude to comment on your marital sex life to someone other than your spouse? In sex therapy, your honesty regarding what you do, how it feels, and what you want to do (or do more often) is necessary if you want your goals met (or determined to be unmeetable or unrealistic).

WHAT SHOULD NOT HAPPEN:  There should be no sexual contact. Many sex therapists will shake your hand. Some might give you an "upper body" hug.  I know of no ethical sex therapists who will kiss your cheek or let you kiss theirs. There should be no contact or exhibitionism or demonstrations or " ... touching so I can better understand ... ." A moment of humor is called for: In the mid-seventies I had a charming professional woman in her early 30's in the office. It was our third weekly meeting, and she continued to be imprecise as to why she wanted therapy. I gently reminded her that I would be pleased to help if I could but that she still had not identified why she was here. She stared at me defiantly for about a minute, crossed her arms in front of her, grabbed the edge of her blouse on either side of her body, and in one sudden deft movement she had raised her blouse to her neck, exposing her breasts, and demanded: "Do you think these are ugly?" Never breaking my gaze from her eyes I asked her to lower her blouse and to use words to describe her question. It turns out that she had inverted nipples and that her current boyfriend, young, immature, and inexperienced, had said that her nipples were ugly. When you are in your sex therapist's office, please use words and not actions.

WHAT ELSE SHOULD NOT HAPPEN:  Patients tell me that they have gone to therapists who listed "sexual problems" in their yellow pages advertising, but that whenever the subject of sex came up, the therapist changed the subject.  Fewer than 2% of psychotherapists are advanced specialty trained in the broad gamut of sexual problems.  One woman who had been sold into sexual slavery at the age of 12 told me during our fifth meeting that she had consulted about 15 therapists during the past two years, but each only once. When I asked what was different because this was our fifth meeting, she replied "You don't look like you're going to throw up when I tell you these things. All the others did." You should expect to talk about sexual material without either being diverted or having the therapist look distressed by what you say. SIMILARLY, but opposite, the therapist should not be "pulling" for more and more details for the purpose of his or her sexual amusement or stimulation. Clarification is important and precision is necessary and many of my patients have mislabeled body parts, but if you get the impression that the therapist is getting a charge, a thrill, or sexually excited about what you are saying, you're dealing with a less than competent sex therapist.

In summary: You should expect to be a bit nervous at first. You should expect to feel a little weird about telling a "stranger" your sexual history and current reason for asking for help. You should expect to be treated with respect and dignity. You should expect some set-backs -- just because you're now in therapy doesn't mean that the doc does all the work. You have to put forth effort. And you should expect the focus of attention and importance to be on you, not on the therapist (or his or her accomplishments). You should expect to know when progress is being made and to have an idea of the behavioral milestone(s) which will signal the successful completion of your therapeutic work.  Those who have mustered the courage to endure the process have earned my respect.

How do I find a good sex therapist?

There are no guarantees. A referral from a friend would be best but embarrassing. Call several Urologists (if it's a male sexual problem) or several OB-GYNs and ask who the doctor refers to. If the same names keep coming up, that should tell you something.

The term "psychotherapist" is defined and regulated state by state, but generally it applies to practitioners with a Master's degree or a doctoral degree (Ph.D. and M.D.).  Most of the practitioners at the master's level have a  Master of Science or a Master of Arts (M.S. or M.A.) degree in Psychology, with an emphasis on clinical psychology.  In California they were formerly titled MFCC:  Marriage, Family, and Child Counselor.  The new title is MFT: Marriage and Family Therapist.  Also at the Master's level are people with the title LCSW:  Licensed Clinical Social Worker.  At the doctoral level there are Ph.D.s (psychologists) and M.D.s (psychiatrists).

What degree level is best for you?  In my opinion, there are great sex therapists at all levels, and there are those at all levels who I think are unethical, simply ineffective, and/or border on malpractice.  So much of what goes into being a good sex therapist occurs after graduation that degree level is only a starting point.  Most folks at the master's level are good counselors -- that is they often have good advice and offer suggestions for solving and/or managing problems.  They often work with alcoholism, addictions, anger management, custody matters,  school learning and socialization problems, and family and marriage conflict, and their contact with patients is usually relatively brief. On average they have about 6 years of schooling after high school.

Psychologists earn a Ph.D. with an average of 13 years of schooling after high school, and are trained in helping people learn how to solve problems or acquire skills that last for a lifetime.  There is much more emphasis on differential diagnosis and on the subtleties between psychological factors and systemic (needing medical intervention) factors.  In addition they are required to conduct independent research for a doctoral dissertation.  In short, there are reasons why there are seven more years of schooling after a master's degree.  Some states allow someone with a Psy.D. (Doctor of Psychology) degree to apply for licensure as a psychologist.  The basic difference between a Ph.D. and a Psy.D. is that those with a Psy.D. did not conduct research leading to a dissertation.  The clinical -- dealing with patients -- training is virtually the same.

Psychiatrists are medical doctors with an average of 12 years of schooling after high school, and are trained in the biochemistry of mental illness.  Although the psychotic population is reserved for psychiatrists to treat, some psychiatrists see patients who are the domain of psychologists' training.  Not all psychiatrists are trained in "talk therapy" but many see patients who do not need medication.  Most psychologists work with one or two psychiatrists for "med reviews" of the psychologist's patients.

Fees:  In general, psychiatrists command higher fees per therapy session (usually 45 minutes) than psychologists, whose fees are usually higher than counselors.

Choice of a psychotherapist:  If someone is having a sexual problem and is clinically depressed or suffers from obsessive-compulsive disorder, they need the services of a psychiatrist.  If there is no  psychological disorder that needs medication, a psychologist who specializes in sex therapy is the psychotherapist of choice.  If fees are a matter of serious consideration, a counselor can be of some help.  But please remember -- there are great sex therapists at all levels, and there are incompetent people who claim to specialize in sex therapy.

In the State of California anyone can identify himself or herself as a "Sexologist."  They are not licensed or regulated and no insurance company will reimburse for their services.  That is a clear message that the consumer should exercise greater caution when considering such services.  There are some private for-profit commercial schools that offer a degree program in "Sexology."  It is not recognized as a profession by either the American Psychological Association or the American Psychiatric Association.

ALL OF THE ABOVE HAVING BEEN SAID, I started this with "There are no guarantees" because I have known people with master's degrees, Ph.D.s and M.D.s who are great sex therapists, and I have known people in all degree categories who I believe border on malpractice.  And that is why a referral from a respected source is so important.

Where else can you get help?

Many counties have a Psychological Association that makes referrals. Look in the White pages under your county's name followed by "county" or "parish"  (depending on what "counties" are called in your state), followed by "Psychological Association". Look in the Yellow Pages (tm) under "Psychologists", then alphabetically look for "referral services". NOTE:  Some "referral services" are private for-profit groups and do not represent the county's psych association. Because many county psych associations use an answering service to give out the number of the clinician on call, make sure you are speaking with a mental health professional before divulging anything intimate. I suggest asking the clinician on call for a pin point referral -- not "just" for an appointment with that person (who might or might not be specialty trained in intense sexual matters). If you think you're getting nowhere, ask for the name and the phone number of the current County Psychological Association President. Call him or her (the effort comes with the territory of the office).

If there is a University or College in or near where you live, call the Chair of the Department of Psychology, and ask for a referral to someone known to have a track record for dealing with sex therapy. Find out who teaches Human Sexuality and ask that person.

There are a number of referral sources on the Internet. One that I am sufficiently impressed with to list myself in their referral network is PsychScapes. Interested people might find their web page interesting:

See also the link to the PsychScapes Therapist Information Network on the sexdoc's home page.

Please remember that ethical sex therapy never involves sex with the therapist.

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