We explore a couple’s communication, personal history, and biological components of sex. We talk about therapeutic aspects of sex. We teach meditative and mindfulness techniques and we refer to physical therapists. You have to be willing to be curious for the rest of your life as a sex therapist because sex therapy has continued to evolve. But sex therapy most often resembles outpatient mental health counseling with individuals or couples.
Now that that’s cleared up, let’s start at the beginning. How does one go about getting into this field? Did you wake up one day and announce to your family, “Hey everybody, I’m going to become a sex therapist!”
I’ve been a sex therapist since 1985. I didn’t go looking for that job, it was actually the only job that was open in the medical center at the time. Up until then I had been an oncology social worker for many years. The new job combined OB/GYN and urology work with sex therapy training if I was willing to commit to two years. I ended up staying until 2010.
For the first 5 or 6 months I was getting trained by an established sex therapist on how to even approach patients. I mock-interviewed 40 people in the mental health field, cold calling them with sex questions: "Hey so-and-so, pretend to be anyone you want with a sexual problem and let me interview you." It got so bad that people would see me coming down the hall and would duck into rooms because they didn’t want to do another interview on erectile dysfunction.
I loved the intense work of being an oncology social worker, talking about grief and loss and how to use grief to grow. So then I became afraid that becoming a sex therapist would be like eating the frosting off a carrot cake.
Do you remember your very first client?
My first client was a woman with cancer and she needed to have her vulva removed. She wanted to know how to be orgasmic.
My second client was a man who was so traumatized from being sexually abused by his mother in childhood that he was unable to get close to women. He would have panic attacks.
My third client was a couple who'd been partnered for 15-20 years and because of vaginal pain they’d been unable to have penetrative vaginal sex.
I was quick to realize that this work was still about helping people with loss and helping people grow.
So what you learned and valued in oncology social work ended up coming into play in sex therapy.
At the time, I didn’t have any more education about sex than anybody else growing up in the ‘50s and ‘60s. I could barely even say "ma-ma-ma masturbate" and was stumbling over all the terms. I tried to use my old cancer jargon to be supportive and empathic but it didn’t translate into sex therapy. For instance, in oncology when a patient has difficult decisions to make, a social worker might say: “Sounds like you’re feeling stuck between a rock and a hard place.” The first time I tried that with a man with erectile dysfunction he said "Don’t I wish!”
And now that you’re’ comfortable using all the terms, it must make you a very interesting conversationalist.
I think it’s important to note that sex therapists are most believable if they walk the talk. A sex therapist gets very comfortable talking about sex. I can talk about sex with family and friends and I think that’s what we want to aim for- that sex is such a comfortable topic that we can turn to people we know and trust and say “I’m having some pain”, “I’m having trouble with arousal”, or “I can’t stop being aroused.”
It’s a lot like other important conversations we have with people we care about. We have to pitch it to the age of the person. I have three adult children but for many years, when they were young kids, we (my husband is a psychologist) simply told them we work with people who have problems. By the time they were in college they were good at saying “Not now mom.” Or, “Too much information!” Or, “I have a question about…”
At home, writing books can be a ‘jealous lover'. While working on Sex Matters for Women one evening, my handsome husband came into the study and asked "Am I going to get lucky tonight?” To which I couldn’t help but answer, "Hey, I don't actually 'do' sex, I just write about it!"
Knowing that others may not have the same comfort level about sex as you do, it seems like talking about sex would be a delicate dance. Whether you’re with family or with clients, knowing when the moment is right to laugh, when to teach, or when to just be present with people when they’re experiencing emotional pain.
It’s often very tough work for a therapist. We have to deliver some very hard choices to people. It’s very challenging to me to figure out how to reach an individual or a couple where they are. To pinpoint what’s troubling them - and here I refer to the wisdom of Martha Stark MD – to then use empathy, insight, and authenticity to speak to them where they are so they can take hold of the reigns.
I believe a fundamental part of mental health is education and education empowers people. They need to be with a professional who has a lot of training and isn’t self-absorbed. It’s for the client, nobody else, with a singular focus on that moment.
These moments sometimes require humor and lightness and people are taught early on that sex is so serious that they don’t know how to laugh, play, and enjoy themselves sexually.
You’ve been a sex therapist for nearly 30 years. What’s kept you going into the office each day?
What keeps me going every day is that combination of head and heart. Being present to witness people change as they become more empowered to take their journey into their own hands. It’s a commitment to knowing that change requires a presence and a connection.
Sex is different for all of us. One of my favorite writers, Margaret Nichols, who is a sex therapist in New Jersey says, "We're all queer." We’re as different in our interests in sex as we are about food and that makes this work very interesting.
Speaking of food, a client once read online that she could use egg whites as lubrication. But when it came time for sex, she contacted me with the urgent question, “Do I have to whip them first?” It’s great getting to that point of laughing with a client after so much of their story has been heartbreaking. They reach a point of reflection, growth, and mastery so they can joke about what once went wrong. They move from desperately wanting to make earth-moving sex to laughing about how they farted during their attempt!
I’ve heard about vibrators at security lines in airports accidentally setting off alarms or falling out of suitcases. It’s certainly a fast way to get your bag through security. How’s that for a travel tip!
What keeps me going is hearing their individual human stories. And I love when people bring in their stories. As people grow and change there are moments of great satisfaction and wonderful humor. Couples come in to my office who were never able to be present in their sexual relationship or never able to have an orgasm. I listen to their story and we work on changes. I remember one client calling me up in the middle of the night with the sheer joy of finally becoming orgasmic!
What about you personally? How do you maintain resilience when your job gets tough?
My job does get tough. It isn’t all laughter and happy endings. People have had heartbreaking experiences, trauma, abandonment and violence. Some days I leave the office - stand outside and breathe - and remind myself that I can be helpful to these people only if I take very good care of myself. So I go for a walk, meditate, make sure that I’m social and get out with friends. Nature helps; whether gardening or hiking or canoeing, there’s something about the natural world that brings healing when the work gets hard. I also remind myself that I choose to do this work every day and that it is very good work to do. I do love it.
I’m very happy doing all the things that I do- private practice, writing, teaching, and directing the University of Michigan Sexual Health Certificate program.
There is a lot of pressure helping guide new people into the field of sex therapy. There’s always a spike of interest when we get a pop culture movie that highlights sex therapy like Barbara Streisand in Meet the Fockers.
Speaking of the movies, I would think you have a special window into how pop culture and the media affect our attitudes about sex and sex therapy.
Recent movies like The Sessions and Hope Springs really speak to that and I really love talking to people about real life problems and their own adaptations. Sex therapy is about being real and honest. It’s also about celebrating where the pleasure really comes from. I have story after story about people who have adapted their bodies to become erogenous, from areas of pain to areas of pleasure. From earlobes to lips, from nipples to toes.
I’ve realized that when you talk to people about the quality of their sex life, we are talking about their embodied selves. This nearly 30 years has been a journey of learning how we adapt to our own issues. The best sex isn’t being had by people who live in perfect bodies, but by people who understand perfectly well that they need to have pleasure in the body they've got.
The more people engage in idealization of anyone, whether it’s their sex therapist or who they see in the media, the less they live in their real lives and the more they let yearning and anger replace actual living.
I don’t try to fill people in on my personal sex life; I try to fill them in on the actualization - the reality - that it’s not perfect for anyone. Like in the movies, it doesn’t exist that way for me as a sex therapist or anybody else whom you idealize.
Right up there with the idealization myth about perfect sex is the myth of spontaneity. As though people out there in the world somehow pause throughout their day for great spontaneous perfect sex. Actually, couples learn to read their partner’s cues and then have sex when they read the cue. Busy people are encouraged to schedule it in.
The Masters and Johnson sexual model of the ‘50s and ‘60s (desire-arousal-orgasm-resolution) is gradually being replaced with the contemporary model informed by the work of Rosemary Basson, PhD. She found that sex begins with a motivation and good intention to be sexual, followed by going into the bedroom, then beginning to touch/cuddle/snuggle, then arousal kicks in and more desire for sex follows. She found that not all women are necessarily interested in being orgasmic every time and that satisfaction during sex doesn’t need to include orgasm. It’s more about feeling contentment and pleasure with whatever they did in the bedroom and their comfort with their partner.
There’s a myth that sex is an either/or proposition. That a woman will enjoy orgasm with sex or they will enjoy an emotional intimacy. In our long-term partnerships we have to be willing to say what we consider, as sex therapist Barry McCarthy refers to as good-enough sex. And to spend more time enjoying all the aspects of what a sex life has to offer. Not to rate sexual performance or to determine if our partner is an “A” type or a “B” type, but to know that every time they enter the bedroom it’s going to be different and that it’s consensual.
People who come into my office are distressed. Perhaps part of their body is hurting or part of their history is hurting. It affects the sex because they can’t have that spontaneous sex every time. But even if both partners don’t share the same level of erotic focus, they may in about 15 or 20 minutes as it gradually develops. They can bring themselves to the erotic focus of touch, then experience sensation, then pleasure and arousal, then desire. Touch, touch, touch.... “Ooooh there’s something!” Touch, touch, touch… “Ooooh now I remember why I’m here!”
So a couple can plan for sex. They can deal with the grief of the loss of spontaneity due to changes in their busy lives. It’s better than saying I don’t feel aroused so I won’t have sex or I don’t want to get aroused because of my unhappiness with my partner. You don’t have to try to override annoyances with your partner, but if you’re at least in an okay place you can go into the bedroom and try. These are the realities that you don’t see in the movies.
Does the easy access to sexual material on the web make that even more challenging for you to teach?
We need to teach sex education throughout the lifespan. To get it into the ears of our young people. We are falling short and need to get creative on how to teach them about sex. You make a good citizen by not only teaching about the external political environment but by teaching them about their individual self. We don’t do a good job teaching that to young people.
Now the internet is a wonderful tool, and it can have problematic aspects. On one hand, the web has fabulous sites such as Scarlet Teen and Advocates For Youth.
But then a client will ask me if it’s bad for them as a couple if her husband is looking at porn on the internet and it turns into a fishhook question- a question that gets tangled with more and deeper questions. Here’s an example why:
Psychologist Jaak Panksepp researches the brain neurocircuitry that helps us attach to other people in activities like play and nurturing. We also have neurocircuitry that doesn’t contribute to attachment and one of those circuits is responsible for our "seeking" activity. So we can then look at this particular circuitry while it’s seeking/viewing porn on the web and see how that affects our connection with people. "Seeking" behaviors are not oriented to others and when activated in people can become dissociative in nature. If you are going off by yourself a lot to the computer, the therapist will be curious about your connection with human beings and your tendency towards dissociation. We look at this because our connection with humans is what accounts for our individual growth and of course our relational growth.
It’s a wonderful time to examine this “seeking” behavior on the internet and the resulting human attachment research. We have the skills to treat the problems that our advanced culture has created; we just have to be smart about educating people and helping people make wise decisions for themselves. That means providing better mental health services, providing better access to education, teaching mindfulness, teaching about sex, and making the human connection.
With all the research and technology, how has sex therapy and sex education changed and where is it headed?
There have been enormous changes and these are for the better. We are getting more client-centered and have more training to help.
Many years ago when I was training as a sex therapist one of the things I learned was that people born with sexual differences, at that time called ‘intersex’, were often not given any say over their own bodies. What resulted, sadly, was confusion, unnecessary surgeries, and trauma from the way in which individuals were cared for by the medical community.
A movement began to stop this treatment. Research, internet, consumer oriented health care, and the activism of GLBTQQI individuals and supporters has all helped this.
I’ve done work to help parents and physicians think differently about intersex conditions and to “educate rather than operate" where appropriate. (see ISNA.org and accordalliance.org for more information on this topic). People with intersex differences, parents of kids with intersex differences, and health care providers are all trying to be more collaborative and to think through what is in the best interests of that individual person. I should note also that the term “disorders of sex development” (DSD) is commonly used instead of “intersex” nowadays. Although that may be 'medically accurate' many persons with DSD prefer 'intersex' or have other preferences. The language is evolving.
There is a steadily increasing number of health care professionals who are integrating sexual counseling to their skill set. They don’t provide intensive therapy but can provide education and direction to their patients.
For women with vaginal penetrative pain, dilator therapy has been helpful. Historically, women would talk about the dilator therapy with a sex therapist and then have to go home and figure it out by themselves. Nowadays I refer people to a physical therapist who specializes in pelvic muscles who can be present with a client who needs dilator therapy and teach her. Clients will change at a much higher rate because the physical therapist is right there, showing them their muscles, guiding them through the process, teaching them, and connecting with them. That is a wonderful new development in the field over the past decade.
We are still a culture that doesn’t have enough education. Leader countries on the topic of sex education and sex research are Canada, Netherlands, and Scandinavia.
The sexual revolution was an evolution. Since then we have changed a lot- expanded the notion of sexuality being a part of everyone from birth until death. We understand trauma. We now have an understanding of polysexuality- the entire spectrum of sexual pleasure. The internet has been wonderful in providing that "you are not alone" connection. Yet we have also increased the number of people seeking treatment for problematic or compulsive sexual behavior.
What do you envision for the next leg of your career?
I want to keep practicing and teaching. I am curious about other cultures and collaborative research with other disciplines. This is a field where you never stop learning and you never grow old.
SallieFoley.com - An extensive and up-to-date repository of free sexual health information and resources maintained by Sallie Foley. Includes sexual health resource bibliographies for all ages, information on menopause and aging, vaginal health information, disorders of sex development resources, and more.
ISNA - Intersex Society of North America
Accord Alliance - Information and resources on Disorders of Sex Development (DSD)
AASECT - American Association of Sexuality Educators, Counselors, and Therapists. Information on becoming a sexuality educator or health/mental health professional.
UMSHCP - Information on how to earn sexual health training through the University of Michigan.
Scarlet Teen - "Sex ed for the real world: Inclusive, comprehensive and smart sexuality information and help for teens and 20s"
Advocates for Youth - "champions efforts to help young people make informed and responsible decisions about their reproductive and sexual health"
WebMD - Sexual Health Center - includes articles and videos on many common sexual health conerns
The latest edition of Sallie Foley’s co-authored book Sex Matters For Women: A Complete Guide to Taking Care of Your Sexual Self recently received the Society for Sex Therapy and Research (SSTAR) 2013 Consumer Book Award. Ms. Foley maintains a psychotherapy and consultation private practice in Ann Arbor, Michigan. She is an AASECT certified sexuality educator, supervisor, and diplomate of sex therapy. You can follow her on Facebook here.
Brad Waters MSW, LCSW provides career-life coaching and consultation to clients internationally via phone and Skype. He helps people explore career direction and take action on career transitions. Brad holds a Master's degree in social work from the University of Michigan and Master's certification in Holistic Health Care from Western Michigan University. Brad is also a personal development writer whose books are available on Amazon and BradWatersMSW.com
Copyright, 2013 Brad Waters. This article may not be reproduced or published without permission from the author. If you share it, please give author credit and do not remove embedded links.